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

Citizens' perspectives on healthy weight approaches in low SEP neighborhoods: a qualitative study from a systems perspective

BACKGROUND

The physical and the social environment are important predictors of healthy weight, especially in low socioeconomic position (SEP) neighborhoods. Many Dutch municipalities have implemented a healthy weight approach (HWA). Yet, there is room for improvement. This system science study examined what influences the utilization of HWA facilities and activities, and what aspects can help to achieve a desired systems change (also called leverage point themes (LPTs)) in the HWA system as perceived by citizens living in low SEP neighborhoods.

METHOD

All research phases were performed with four citizens co-researchers. Forty-seven citizens living in low SEP neighborhoods were semi-structurally interviewed about the neighborhood HWA facilities and municipal HWA activities. A rapid coding qualitative analysis approach was applied per topic. The topics were citizens' healthy living description, personal circumstances, and satisfaction with foot and cycle paths, sports facilities, playgrounds, green spaces, museums and theaters, community centers, churches, healthcare, school, food supplies, contact with neighborhood, unfamiliar and/or unused activities, familiar and used activities, unavailable but desired (lacking) activities, and reaching citizens.

RESULTS

The utilization of HWA facilities and activities was influenced by the overarching themes of social cohesion, familiarity, reaching citizens, maintenance, safety, physical accessibility, financial accessibility, social accessibility, fit with personal context, and fit with the neighborhood's specific needs. Different overarching themes stood out across different facilities and activities. LPTs indicated the overarching themes needed in combination with one another for a specific activity or facility to increase utilization. For example, the LPT regarding foot and cycle paths was "accessible, safe, and maintained foot and cycle paths". The LPTs regarding familiar and used activities were "customized activities; information provision (e.g., about possibilities to join without paying); social contact, meeting others, and everyone feels included".

CONCLUSION

Conducting inclusive qualitative research from a systems perspective among citizens living in low SEP neighborhoods has contributed valuable insights into their needs. This enables practical implementation of HWAs by providing a deeper understanding of the LPTs within the HWA system. LPTs can help HWA stakeholders to further develop current HWAs toward systems approaches. Future research could study the leverage points that may contribute to LPT implementation.

Exploring the multiple dimensions of perceived food access in the local food environment in Flanders: perceptions of adults in socioeconomically disadvantaged situations

Persons in socioeconomically disadvantaged situations are more susceptible and disproportionally exposed to unhealthy food environments, which results in limited access to healthy foods and poorer dietary outcomes. This qualitative paper examines the various dimensions of perceived food access to healthy and unhealthy foods (i.e., availability, affordability, accessibility, accommodation, desirability, convenience and acceptability) within the local food environment among persons in socioeconomically disadvantaged situations. A total of 23 participants in socioeconomically disadvantaged situations expressed their perceptions of food access within their local food environment and its role in their eating behaviour through participant-driven photo-elicitation in a focus group context (n=7) and researcher-driven photo-elicitation interviews (n=16). Reflexive thematic analysis has been used to analyse our data through an access framework. Four overarching themes were constructed. The first two themes concern barriers to perceived food access in respectively the home and community food environment - including the importance of kitchen infrastructure, household composition and transport options. The third theme encompasses the interaction of perceived food access with the sociocultural environment, highlighting its dual role as facilitator (e.g., through food sharing practices) and barrier (e.g., through social stigma and shame). The fourth theme concerns awareness and the ability to navigate within the information food environment, which has also been proposed as a novel dimension of food access. This study emphasizes the complexity of food access and the need for a multifaceted approach that integrates perceptions to ensure equitable access to healthy foods.

Food environments and association with household food insecurity: a systematic review

OBJECTIVE

We evaluated the available literature on the association between characteristics of the food environment and household food insecurity.

STUDY DESIGN

Systematic review.

METHODS

Studies published until January 9th, 2023, were searched in the PubMed, Web of Science, Science Direct, EMBASE and LILACS databases. The included studies were summarized with a narrative synthesis with information on the study location, population studied, prevalence and type of measure/instrument used to assess food (in)security, method of evaluating the food environment and measure between food insecurity and food environment.

RESULTS

Twenty-two articles were included. Different methods were used to measure food security and the food environment. Most food insecurity assessment tools assessed the dimension of access to food, more precisely economic access. The dimensions of the food environment most evaluated were food availability and affordability. An association between characteristics of the food environment and food insecurity was found in 18 of these studies. Homes with food insecurity have a greater availability of unhealthy foods, more frequent purchasing of foods in convenience stores and small markets as well as a lower availability of healthy foods, such as fruits and vegetables.

CONCLUSIONS

This review revealed that household food insecurity was associated with the food environment, highlighting the importance of policies to promote healthy diets, especially in vulnerable communities. Few studies were found in the Global South, demonstrating the gap in this knowledge in these locations.

Intake of Snacks and Sweets in a National Study of Built and Social Environments: the REasons for Geographic And Racial Differences in Stroke Study

BACKGROUND

Few national studies across the United States' rural-urban continuum examine neighborhood effects on snacks and sweets intake among adults.

OBJECTIVES

This study examines associations of urbanicity/rurality-tailored measures of food store availability and neighborhood socioeconomic status (NSES) with the intake of snacks and sweets in a national sample of middle and older age adults.

METHODS

This cross-sectional study used food frequency questionnaire data collected in the REasons for Geographic And Racial Differences in Stroke study (N = 21,204). What We Eat in America food group categorizations guided outcome classification into 1 main category (total snacks and sweets) and 4 subcategories (savory snacks and crackers; sweet bakery products; candy and desserts; nutrition bars and low-fat snacks and sweets). NSES and food store availability were determined using geographic information systems. Food store availability was characterized as geographic access to primary food stores (e.g., supermarkets, supercenters, and select food retailers) in urbanicity/rurality-tailored neighborhood-based buffers. Multiple linear regression was used to predict each outcome.

RESULTS

Living in neighborhoods with a high density of primary food stores was associated with 8.6%, 9.5%, and 5.8% lower intake of total snacks and sweets, sweet bakery products, and candy and desserts, respectively. Living in the highest NSES quartile was associated with 11.3%, 5.8%, and 18.9% lower intake of total snacks and sweets, savory snacks and crackers, and sweet bakery products, respectively. Depending on primary food store availability, higher household income was associated with significantly greater intake of nutrition bars and low-fat snacks and sweets. Living in a United States Department of Agriculture-defined food desert was not associated with intake.

CONCLUSIONS

In a geographically diverse sample of middle and older age United States adults, living in neighborhoods with no primary food stores or neighborhoods of low-SES was associated with higher intake of total snacks and sweets and subgroups of snacks and sweets.

Association between density of food retailers and fitness centers and gestational diabetes mellitus in Eastern Massachusetts, USA: population-based study

Background

Few studies have investigated the relationship between the food and physical activity environment and odds of gestational diabetes mellitus (GDM). This study quantifies the association between densities of several types of food establishments and fitness centers with the odds of having GDM.

Methods

The density of supermarkets, fast-food restaurants, full-service restaurants, convenience stores and fitness centers at 500, 1000 and 1500 m (m) buffers was counted at residential addresses of 68,779 pregnant individuals from Eastern Massachusetts during 2000-2016. The 'healthy food index' assessed the relative availability of healthy (supermarkets) vs unhealthy (fast-food restaurants, convenience stores) food retailers. Multivariable logistic regression quantified the cross-sectional association between exposure variables and the odds of having GDM, adjusting for individual and area-level characteristics. Effect modification by area-level socioeconomic status (SES) was assessed.

Findings

In fully adjusted models, pregnant individuals living in the highest density tertile of fast-food restaurants had higher GDM odds compared to those living in the lowest density tertile (500 m: odds ratio (OR):1.17 95% CI: [1.04, 1.31]; 1000 m: 1.33 95% CI: [1.15, 1.53]); 1500 m: 1.18 95% CI: [1.01, 1.38]). Greater residential density of supermarkets was associated with lower odds of GDM (1000 m: 0.86 95% CI: [0.74, 0.99]; 1500 m: 0.86 95% CI: [0.72, 1.01]). Similarly, living in the highest fitness center density tertile was associated with decreased GDM odds (500 m:0.87 95% CI: [0.76, 0.99]; 1500 m: 0.89 95% CI: [0.79, 1.01]). There was no evidence of effect modification by SES and no association found between the healthy food index and GDM odds.

Interpretation

In Eastern Massachusetts, living near a greater density of fast-food establishments was associated with higher GDM odds. Greater residential access to supermarkets and fitness centers was associated with lower the odds of having GDM.

Funding

NIH.

Understanding food choice: A systematic review of reviews

The topic of consumer food choice has received much attention among researchers and stakeholders within the food industry. However, in order to better facilitate food consumption towards a more sustainable direction, we need increased knowledge and understanding of factors that influence consumers' food choice. This study is a systematic review of reviews conducted between 2017 and 2021, summarising and synthesising reviews on food choice. The aim is to provide an update of the current knowledge on consumer food choice, point out what is already known, and identify knowledge gaps to enable a prioritisation for future research. The analysis highlights decisive factors in food choice, i.e. product, available information, price, context, personal and group influences and sensory perceptions. The synthesis of findings follows a socioecological model, integrating four different levels of the social and environmental systems: the physical food environment, the social and community level, interpersonal relations and, finally, individual characteristics such as psychological and behavioural factors. Results show that behavioural patterns, influenced by strong informal institutions, such as culture and norms, can be difficult to break; for example, changing into more sustainable food behaviour. The findings suggest that more interdisciplinary research and studies in real-life settings are needed to grasp the complexity of food choice. This would allow for us to better understand consumers as social beings shaped by, among other things, the physical environment, social interactions, and culture.

Associations of role, area deprivation index, and race with health behaviors and body mass index among localized prostate cancer patients and their partners

PURPOSE

To examine the associations of role (localized prostate cancer (PCa) patient vs. their intimate partner), area deprivation index (ADI-higher scores indicating higher neighborhood deprivation levels), and race (Black/African American (AA) vs. White) with health behaviors and body mass index (BMI) among PCa patients and partners. The behaviors include smoking, alcohol consumption, diet quality, sedentary behaviors, and physical activity (PA).

METHODS

This study used the baseline data collected in a clinical trial. Given the nested structure of the dyadic data, multi-level models were used.

RESULTS

Significant role-race interaction effects on smoking, ADI-race effects on alcohol consumption, and role-ADI effects on BMI were found. Meanwhile, patients smoked more cigarettes, decreased alcohol consumption, had less healthful diets, spent longer time watching TV, did fewer sedentary hobbies, had more confidence in PA, and had higher BMIs than their partners. High ADI was independently associated with lower odds of drinking alcohol, using computer/Internet, and doing non-walking PA, and higher BMI compared to low ADI controlling for role and race. Black/AA dyads had less smoking amount and alcohol consumption and higher sedentary time and BMI than White dyads when adjusted for role and ADI.

CONCLUSIONS

This study identified significant interaction and main effects of role, ADI, or race on health behaviors and BMI.

IMPLICATIONS FOR CANCER SURVIVORS

Future behavioral interventions should address divergent individual needs between patients and partners, social and neighborhood barriers, and cultural indicators of racial groups to promote healthful behaviors and improve the quality of survivorship for PCa patients and partners.

The relationship between the price and demand of alcohol, tobacco, unhealthy food, sugar-sweetened beverages, and gambling: an umbrella review of systematic reviews

BACKGROUND

The WHO highlight alcohol, tobacco, unhealthy food, and sugar-sweetened beverage (SSB) taxes as one of the most effective policies for preventing and reducing the burden of non-communicable diseases. This umbrella review aimed to identify and summarise evidence from systematic reviews that report the relationship between price and demand or price and disease/death for alcohol, tobacco, unhealthy food, and SSBs. Given the recent recognition as gambling as a public health problem, we also included gambling.

METHODS

The protocol for this umbrella review was pre-registered (PROSPERO CRD42023447429). Seven electronic databases were searched between 2000-2023. Eligible systematic reviews were those published in any country, including adults or children, and which quantitatively examined the relationship between alcohol, tobacco, gambling, unhealthy food, or SSB price/tax and demand (sales/consumption) or disease/death. Two researchers undertook screening, eligibility, data extraction, and risk of bias assessment using the ROBIS tool.

RESULTS

We identified 50 reviews from 5,185 records, of which 31 reported on unhealthy food or SSBs, nine reported on tobacco, nine on alcohol, and one on multiple outcomes (alcohol, tobacco, unhealthy food, and SSBs). We did not identify any reviews on gambling. Higher prices were consistently associated with lower demand, notwithstanding variation in the size of effect across commodities or populations. Reductions in demand were large enough to be considered meaningful for policy.

CONCLUSIONS

Increases in the price of alcohol, tobacco, unhealthy food, and SSBs are consistently associated with decreases in demand. Moreover, increasing taxes can be expected to increase tax revenue. There may be potential in joining up approaches to taxation across the harm-causing commodities.

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

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

Determinants of iron-rich food deficiency among children under 5 years in sub-Saharan Africa: a comprehensive analysis of Demographic and Health Surveys

BACKGROUND

Iron deficiency is a major public health problem that affects the physical and cognitive development of children under 5 years of age (under-5 children) in sub-Saharan Africa (SSA). However, the factors associated with the limited consumption of iron-rich foods in the region are poorly understood.

OBJECTIVE

This study examined the prevalence and determinants of iron-rich food deficiency among under-5 children in 26 SSA countries.

DESIGN

This nationally representative quantitative study employed pooled data from Demographic and Health Surveys conducted between 2010 and 2019.

METHODS

Representative samples comprising 296 850 under-5 children from the various countries were used. Bivariate and multivariate logistic regression models were used to determine the associations between the lack of iron-rich food uptake and various sociodemographic factors.

RESULT

The overall prevalence of iron-rich food deficiency among the children in the entire sample was 56.75%. The prevalence of iron-rich food deficiency varied widely across the 26 countries, ranging from 42.76% in Congo Democratic Republic to 77.50% in Guinea. Maternal education, particularly primary education (OR 0.62, 95% CI 0.57 to 0.68) and higher education (OR 0.58, 95% CI 0.52 to 0.64), demonstrated a reduced likelihood of iron-rich food deficiency in the sample. Likewise, paternal education, with both primary education (OR 0.69, 95% CI 0.63 to 0.75) and higher education (OR 0.66, 95% CI 0.60 to 0.73) showed decreased odds of iron-rich food deficiency. Postnatal visits contributed significantly to reducing the odds of iron-rich food deficiency (OR 0.90, 95% CI 0.83 to 0.95), along with antenatal visits, which also had a positive impact (OR 0.84, 95% CI 0.74 to 0.95). Finally, residents in rural areas showed slightly higher odds of iron-rich food deficiency (OR 1.12, 95% CI 1.10 to 1.28).

CONCLUSION

Based on the findings, interventions targeting iron-food deficiency in the SSA region should take into strong consideration the key determinants highlighted in this study.

The Influence of the School Neighborhood Food Retail Environment on Unhealthy Food Purchasing Behaviors Among Adolescents: A Systematic Review

INTRODUCTION

Adolescents are often exposed to food retailers selling unhealthy food items during their lunch breaks and school commutes. This systematic review examines the influence of school neighborhood food retail environments on adolescent food purchasing.

METHODS

A systematic search of 6 databases. Observational studies published from January 2012 to December 2022 that measured food availability, accessibility, or exposure, measured food purchasing, and focused on adolescents (aged 10-19 years) were eligible for inclusion.

RESULTS

Twelve studies with 97 findings were included. Thirty-one findings indicated that a school neighborhood with a high density of unhealthy food retail, a school with unhealthy food retail nearby, or exposure to unhealthy food retail on the journey to/from school was associated with higher prevalence and frequency of unhealthy food purchases.

DISCUSSION

Adolescents' food purchasing behaviors may be meaningfully affected by their school neighborhood food retail environment; however, the included studies have many methodological shortcomings.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Results identify the need for new studies that measure food purchasing, use comprehensive definitions of food retail environments, and adopt more rigorous methods to approximate exposure to food retail. More robust evidence would strengthen the rationale for policy or program interventions and potentially indicate specific targets for intervention.

How are intra-household dynamics, gender roles and time availability related to food access and children's diet quality during the Covid-19 lockdown?

The association between food access and children's diet quality has been documented mainly from its external dimension (e.g., availability, prices, food properties, and marketing). However, existing research has underscored that the external food environment cannot fully account for variations in children's diet quality, even amid the COVID-19 lockdown. It is increasingly evident that elements within the domestic food environment also play a crucial role in shaping this relationship. Specifically, gender roles influence how food is procured and consumed, along with challenges related to time constraints. This study explores the influence of the domestic time-gender axis and household dynamics in food access and children's dietary quality in 14 female-headed households in Santiago, Chile, during the COVID-19 lockdown. Employing a photo-elicitation exercise, we engaged with families residing in the same urban neighborhood but exhibiting varying levels of dietary quality among their children. Our analysis utilized a framework incorporating both socio-ecological food environment and gender theories. Our findings show that within these households, only one unit of "person-time" was available to address all food and caregiving tasks. Due to an unequal gender system, this limited time allocation was disproportionately absorbed by women, who were already burdened with multiple responsibilities. The lack of time favors the consumption of ultra-processed foods and hinders the intake of fresh foods. Other associated intrahousehold dynamics, such as children's fussiness and special diets, accentuates these time scarcity consequences. These difficulties were further exacerbated by strategies adopted in response to the COVID-19 lockdown, however, in families where food-related responsibilities were shared more equitably the lockdown was less disrupting. These results indicate that on top of external food environment policies, comprehensive gender-transformative policies that include food socialization processes are needed to promote healthier diets among all.

Ready-to-Eat Food Environments and Risk of Incident Heart Failure: A Prospective Cohort Study

BACKGROUND

Food environments have been linked to cardiovascular diseases; however, few studies have assessed the relationship between food environments and the risk of heart failure (HF). We aimed to evaluate the association between ready-to-eat food environments and incident HF at an individual level in a large prospective cohort.

METHODS

Exposure to ready-to-eat food environments, comprising pubs or bars, restaurants or cafeterias, and fast-food outlets, were individually measured as both proximity and density metrics. We also developed a composite ready-to-eat food environment density score by summing the densities of 3 types of food environments. Cox proportional analyses were applied to assess the associations of each single type and the composite food environments with HF risk.

RESULTS

Closer proximity to and greater density of ready-to-eat food environments, particularly for pubs and bars and fast-food outlets (P<0.05 for both proximity and density metric) were associated with an elevated risk of incident HF. Compared with those with no exposure to composite ready-to-eat food environments, participants in the highest density score category had a 16% (8%-25%; P<0.0001) higher risk of HF. In addition, we found significant interactions of food environments with education, urbanicity, and density of physical activity facilities on HF risk (all Pinteraction<0.05); the ready-to-eat food environments-associated risk of HF was stronger among participants who were poorly educated, living in urban areas, and without physical activity facilities.

CONCLUSIONS

Exposure to ready-to-eat food environments is associated with a higher risk of incident HF, suggesting the potential importance of minimizing unfavorable food environments in the prevention of HF.

What North American retail food environment indices miss in Guatemala: Cultural considerations for the study of place and health

We evaluated the cross-context validity and equivalence of the US- and Canada-originated Retail Food Environment Index (RFEI) and modified RFEI (mRFEI) against a retail food environment dataset from the indigenous-majority city of Quetzaltenango (Xela), Guatemala. The RFEI/mRFEI failed to identify 77% of retailers and misclassified the healthiness of 42% of the remaining retailers in Xela, inaccurately labeling the city a food swamp. The RFEI/mRFEI are not currently suitable for mapping retail food environments in places like Quetzaltenango. Alternative functional and temporal classifications of retail food environments may provide measures with greater contextual fit, highlighting important cultural considerations for the study of place and dietary health.

The interaction between the community food environment and cooking skills in association with diet-related outcomes in Dutch adults

OBJECTIVE

We examined whether associations between the food environment, frequency of home cooking, diet quality and BMI were modified by the level of cooking skills.

DESIGN

Cross-sectional study using linear and modified Poisson regression models adjusted for age, sex, energy intake, education, income, household size and urbanisation. The frequency of home cooking was categorised into <6 and 6-7 d. Diet quality was based on a validated Dutch healthy diet index (0-150 points). Count of restaurants and food stores were determined by their count in a 1000m buffer around home and work. Cooking skills (score 1-5) were assessed using a validated questionnaire and added as interaction term.

SETTING

The Netherlands.

PARTICIPANTS

1461 adults aged 18-65 years.

RESULTS

Count of restaurants and food stores were not associated with the frequency of home cooking. A 10-unit higher count of food stores was associated with a higher diet quality (β: 0·58 (95 % CI (0·04, 1·12)), and a 10-unit higher count of restaurants was associated with a lower BMI kg/m2 (β: -0·02 (95 % CI (-0·04, -0·004)). Better cooking skills were associated with a higher likelihood of cooking 6-7 d compared with <6 d (risk ratio: 1·24 (95 % CI (1·16, 1·31)) and a higher diet quality (β: 4·45 (95 % CI (3·27, 5·63)) but not with BMI. We observed no interaction between the food environment and cooking skills (P-for-interaction > 0·1).

CONCLUSIONS

Exposure to food stores was associated with a higher diet quality and exposure to restaurants with a lower BMI. Better cooking skills were associated with a higher frequency of home cooking and better diet quality but did not modify associations with the food environment. Future studies should explore different approaches to understand how individuals interact with their food environment.

Socioeconomic differences in associations between living in a 20-min neighbourhood and diet, physical activity and self-rated health: Cross-sectional findings from ProjectPLAN

The 20-min neighbourhood (20MN) concept aims to enable residents to meet daily needs using resources within a 20-min trip from home noting that there is no single definition of what services and amenities are required for daily needs nor what modes of transport constitute a 20 min trip. Whether 20MNs promote better health and whether associations differ by socio-economic status (SES) is unknown. Using cross-sectional data from adults randomly sampled in 2018-19 from Melbourne or Adelaide, Australia, we examined whether associations between neighbourhood type (20MN/non-20MN) and diet, physical activity or self-rated health vary according to individual- or area-level SES. We found no consistent patterns of interactions. The results do not consistently support the often assumed belief that 20MNs support more healthful behaviour and that these relationships vary by SES.

Quality appraisal of spatial epidemiology and health geography research: A scoping review of systematic reviews

A scoping review of peer-reviewed literature was conducted to understand how systematic reviews assess the methodological quality of spatial epidemiology and health geography research. Fifty-nine eligible reviews were identified and included. Variations in the use of quality appraisal tools were found. Reviews applied existing quality appraisal tools with no adaptations (n = 32; 54%), existing quality appraisal tools with adaptations (n = 9; 15%), adapted tools or methods from other reviews (n = 13; 22%), and developed new quality appraisal tools for the review (n = 5; 8%). Future research should focus on developing and validating a quality appraisal tool that evaluates the spatial methodology within studies.

Social inequities in the food retail patterns around schools in Recife, Brazil

This study aimed to describe the community food environment surrounding schools and its association with territorial socio-environmental vulnerability in the city with the highest intraurban social inequity index in Brazil.

METHODS

this ecological observational study includes data on the presence and type of food retail in a 400 m buffer surrounding public and private schools in Recife. We have also described the Health Vulnerability Index (HVI) of census tracts and conducted multivariate analyses.

RESULTS

through factor analysis, we observed two grouping patterns of food retail. The "diverse food outlets" pattern was positively associated with middle HVI (β 0.14, 95% confidence interval [CI] - 0.11; 0.16) and higher HVI areas (β 0.15, 95%CI - 0.11; 0.17), while "the large food retail chains" pattern was inversely associated with middle HVI (β -0.42, 95% CI - 0.53; -0.30) and high HVI areas (β -0.32, 95%CI - 0.45; -0.18) and positively associated with private schools (β 0.15, 95%CI - 0.030; 0.27).

CONCLUSION

the greatest variety in food retail is in high HVI areas, and large food retail chains prevail around private schools, especially in low HVI areas.

Effects of school indoor visual environment on children's health outcomes: A systematic review

Children's visual perceptions are critical for their comfort and health. This review explores the impacts of school indoor visual environment on children's health outcomes. A systematic search yielded 5704 articles, of which 32 studies were reviewed. Five environmental themes were identified: lighting, access to nature, window characteristics, art/environmental aesthetics, and ergonomics/spatial arrangement. Results affirm that visual environment affects children's health. There are disparities across environmental themes, with more extensive evidence for lighting and access to nature, but relatively limited in other areas. This study suggests a need for multi-disciplinary collaboration to develop a holistic perspective.

The FLY-project: study protocol for mixed methods research to explore the complex social dynamics of sustainable food-related lifestyles in youth in practical education

BACKGROUND

The present-day food system is a key driver of climate change and biodiversity loss, making it imperative for populations to shift towards more sustainable diets. The involvement of youth in this transition is vital because they are in a formative period where their identities, values, and norms, including their food behaviours, are being shaped. Special attention should be paid to youth in practical education because they are often overlooked in existing studies, yet evidence suggests they may lack the necessary resources to support dietary changes, resulting in lower levels of pro-environmental food-related behaviours. The aim of the FLY (Food-related Lifestyles in Youth) project is to study how sustainable food-related lifestyles and underlying factors develop in early adolescence, particularly in Dutch youth in practical education, how these spread in social networks, and to develop community-level intervention strategies to support youths' transition to sustainable food-related behaviours.

METHODS/DESIGN

The FLY-project adopts a mixed-method approach. First, two literature reviews are conducted. A systematic review assesses how capabilities, opportunities and motivation are associated with sustainable food behaviours in youth, and how these elements interrelate in determining sustainable food-related lifestyles. A scoping review studies community-level interventions that target sustainable and healthy food-related behaviours. Second, focus groups are conducted to explore the barriers and facilitating factors concerning capabilities, opportunities, and motivations that Dutch youth in practical-level education experience to transition to more sustainable food-related lifestyles. Third, a cohort survey study is conducted to track the dynamic interplay between capabilities, opportunities, motivation, and changes in specific sustainable food behaviours over time, and to assess the diffusion of sustainable food-related lifestyles via social (media) networks. Fourth, an experimental research programme tests promising intervention approaches, some of which are co-created with youth, targeting relevant underlying factors.

DISCUSSION

This paper describes the rationale, conceptual framework, design and methods of the FLY-project. The FLY-project contributes to an understanding of underlying factors of sustainable food-related behaviours in adolescence and results in a multi-component intervention toolkit, with a particular focus on youth in practical education programmes.

Unhealthy food availability, prominence and promotion in a representative sample of supermarkets in Flanders (Belgium): a detailed assessment

INTRODUCTION

The supermarket food environment is a key setting for potential public health interventions. This study assessed food availability, prominence and promotion in a representative sample of supermarkets in Flanders (Belgium).

METHODS

A sample of 55 supermarkets across five chains and 16 Flemish municipalities was selected in 2022, about 64% in the most deprived socioeconomic areas. Healthiness indicators related to food availability (ratio of cumulative linear shelf length for healthy versus unhealthy foods), prominence (proportion of unhealthy foods at check-outs and end-of-aisle endcaps), and promotion (food marketing on food packages) were measured.

RESULTS

Overall, the average ratio of healthy/unhealthy foods in supermarkets in Flanders was 0.36, meaning that for every 10m of shelf length of unhealthy foods there was 3.6m of healthy foods. There was a large variation in ratio's across supermarket chains. Of all foods available, 97.5% were ultra-processed at the check outs, while 72.2% and 58.5% were ultra-processed at the front and back end-of-aisle end-caps, respectively. Confectionery and sweet biscuits were the food categories with on average the highest number of marketing messages on pack per 10m of shelf length.

CONCLUSION

Supermarket in-store food environments in Flanders were found generally unhealthy, with those located in low income areas having unhealthier in-store food environments than supermarkets located in medium and high income areas. Despite commitments of all large supermarket chains in Flanders to promote and create healthier in-store food environments, our findings indicate that currently consumers are incentivized to buy unhealthy rather than healthy food products.

Food access, domestic environments, and dietary quality of low-middle income Chilean children during the COVID-19 pandemic

Introduction

Food access is associated with dietary quality; however, people living in similar physical environments can have different food access profiles. Domestic environments may also influence how food access relates to dietary quality. We studied food access profiles of 999 low-middle income Chilean families with children during the COVID-19 lockdown and how these profiles relate to dietary quality; secondarily, we also explore the role of the domestic environment in this relationship.

Materials and methods

Participants of two longitudinal studies conducted in the southeast of Santiago, Chile, answered online surveys at the beginning and end of the COVID-19 pandemic lockdown. Food access profiles were developed by a latent class analysis considering food outlets and government food transfers. Children's dietary quality was estimated by self-reported compliance with the Chilean Dietary Guidelines of Americans (DGA) and daily ultra-processed food (UPF) consumption. Logistic and linear regressions were used to assess the association between food access profiles and dietary quality. Domestic environment data (i.e., the sex of the person who buys food and cooks, meal frequency, cooking skills, etc.) were incorporated in the models to assess their influence on the relationship between food access and dietary quality.

Results

We have categorized three food access profiles: Classic (70.2%), Multiple (17.9%), and Supermarket-Restaurant (11.9%). Households led by women are concentrated in the Multiple profile, while families from higher income or education levels are focused on the Supermarket-Restaurant profile. On average, children presented poor dietary quality, with a high daily UPF consumption (median = 4.4; IQR: 3) and low compliance with national DGA recommendations (median = 1.2; IQR: 2). Except for the fish recommendation (OR = 1.77, 95% CI:1.00-3.12; p: 0.048 for the Supermarket-Restaurant profile), the food access profiles were poorly associated with children's dietary quality. However, further analyses showed that domestic environment variables related to routine and time use influenced the association between food access profiles and dietary quality.

Conclusion

In a sample of low-middle income Chilean families, we identified three different food access profiles that presented a socioeconomic gradient; however, these profiles did not significantly explain children's dietary quality. Studies diving deeper into household dynamics might give us some clues on intra-household behaviors and roles that could be influencing how food access relates to dietary quality.

Better understanding determinants of dietary guideline adherence among Dutch adults with varying socio-economic backgrounds through a mixed-methods exploration

OBJECTIVE

Low dietary guideline adherence is persistent, but there is limited understanding of how individuals with varying socio-economic backgrounds reach a certain dietary intake. We investigated how quantitative and qualitative data on dietary guidelines adherence correspond and complement each other, to what extent determinants of guideline adherence in quantitative data reflect findings on determinants derived from qualitative data and which of these determinants emerged as interdependent in the qualitative data.

DESIGN

This mixed-methods study used quantitative questionnaire data (n 1492) and qualitative data collected via semi-structured telephone interviews (n 24). Quantitative data on determinants and their association with total guideline adherence (scored 0-150) were assessed through linear regression. Directed content analysis was used for qualitative data.

SETTING

Dutch urban areas.

PARTICIPANTS

Adults aged 18-65 years.

RESULTS

A range of determinants emerged from both data sources, for example higher levels of cognitive restraint (β 5·6, 95 % CI 4·2, 7·1), habit strength of vegetables (β 4·0, 95 % CI 3·3, 4·7) and cooking skills (β 4·7, 95 % CI 3·5, 5·9), were associated with higher adherence. Qualitative data additionally suggested the influence of food prices, strong dietary habits and the social aspect of eating, and for the determinants cognitive restraint, habit strength related to vegetables, food prices and home cooking, some variation between interviewees with varying socio-economic backgrounds emerged in how these determinants affected guideline adherence.

CONCLUSIONS

This mixed-methods exploration provides a richer understanding of why adults with varying socio-economic backgrounds do or do not adhere to dietary guidelines. Results can guide future interventions promoting healthy diets across populations.

Street-view and traditional greenness metrics with adults' sitting time in high-density living in Hong Kong: Comparing associations, air pollution and noise roles, and population heterogeneity

BACKGROUND

Emerging evidence suggests neighborhood greenness is associated with physical activity; however, the sitting-specific associations with multi-source greenness metrics remain unclear, especially in high-density cities.

OBJECTIVES

This cross-sectional study examined: 1) the associations of street-view greenness (SVG) and traditional greenness metrics (i.e., Normalized Difference Vegetable Index (NDVI) and park density) with sitting time; 2) the potential moderating/mediating roles of objective/perceived air pollution and perceived roadside noise; and 3) how the associations vary by demographics and socioeconomic status.

METHODS

Interview survey data of 1977 adults in Hong Kong from 2014 and 2015 was linked to environmental data. Using an object-based image classification algorithm, SVG was derived from Google Street View images, capturing human-viewed street-level greenery. NDVI was derived from Landsat 8 satellite images using the normalized difference between the near-infrared and red bands. Park density was calculated by point density. In the main analyses including regressions, parallel mediation, interaction, and stratified models, the environmental metrics were measured within a 1000-m Euclidean buffer of residence.

RESULTS

SVG and park density were negatively associated with sitting time after adjusting for covariates including physical activity while NDVI was not significantly associated with sitting time, and results were robust with 800-1800 m Euclidean and 1400-1800 m network distance. Greenness-sitting associations were not moderated/mediated by perceived air pollution/roadside noise while SVG-sitting associations were moderated by objective NO₂, O₃, and PM_2.5 and mediated by O₃. SVG-sitting associations differed by age, having under-school-aged children, birthplace, education, and occupation type while associations between traditional greenness metrics and prolonged sitting showed no significant population heterogeneity.

CONCLUSIONS

SVG appears to be more accurate in estimating exposure than traditional metrics to reflect greenness-sitting associations, objective air pollution moderating and mediating roles, and population heterogeneity, which emphasizes the importance of street-level greenness planning for health promotion in terms of reducing sitting time.

Factors associated with fruit and vegetable consumption among Burmese refugees

OBJECTIVE

The Burmese population is one of the fast-growing refugee populations in the USA. This study investigated behavioural and environmental factors associated with fruit and vegetable (FV) consumption among Burmese refugees.

DESIGN

We conducted a cross-sectional interview survey in 2018-2019. The 24-h recall was used to assess dietary behaviour. Multivariable logistic regression models were constructed with meeting the daily FV consumption recommendation (two or more servings of fruits and three or more servings of vegetables) as the outcome variable. We selected socio-economics, nutritional knowledge, food shopping frequency, ethnicity of preferred food store owners, perceived neighbourhood food environment and network distance to preferred food stores as potential explanatory variables.

SETTING

Two Upstate New York counties.

PARTICIPANTS

Burmese refugees (n 173) aged ≥18 years.

RESULTS

Forty-five percentage of respondents met the daily FV consumption recommendation, and nearly all respondents identified ethnic (Burmese, Chinese/pan-Asian, or South Asian/halal) stores as their preferred stores to purchase FV. In the best-fit model, age (OR 1·08, 95 % CI (1·04, 1·12)) and shopping frequency (OR 1·51, 95 % CI (1·01, 2·26)) were positively associated, and network distance to preferred stores in kilometres (OR 0·81, 95 % CI (0·73, 0·90)) was negatively associated with meeting the daily FV consumption recommendation. No significant effect modifications by car ownership, poverty, length of stay in the USA and Supplemental Nutrition Assistance Program participation were detected.

CONCLUSIONS

The findings suggested that having Asian ethnic food stores within a short, walkable distance from home and shopping at these stores often can promote healthy dietary behaviour among Burmese refugees.

The Association between the School Environment and Adolescent Alcohol Drinking Behavior in Six Cities in China

Drinking alcohol during adolescence has short-term and long-term effects on physical and mental health. At this stage, teenagers are greatly influenced by their schoolmates and friends. We conducted a multicenter cross-sectional study to investigate the association between school environment factors and adolescents’ drinking behavior in China. Using multistage stratified cluster sampling, the study investigated 27,762 middle school students from six cities in China. The logistic regression model was used to explore the association between the school environment and adolescent alcohol drinking behaviors after adjusting for confounders, including gender, age, city, location, and smoking status. Compared with students with none of their close friends drinking, students with more than half of their close friends drinking were more likely to drink in a year (OR = 20.148, 95% CI: 17.722−22.905, p < 0.001) and in a month (OR = 13.433, 95% CI: 11.779−15.319, p < 0.001). In addition, classmates’ drinking behaviors, friends’ persuasion, and attending parties were risk factors for adolescents’ drinking behavior, while the propaganda and regulations of banning drinking in school were protective factors. The school environment, especially friends drinking, is associated with students’ drinking behavior. It is necessary to mobilize the strength of schools and peers to strengthen the prevention and control of adolescent drinking.

Digital health interventions to improve eating behaviour of people with a lower socioeconomic position: a scoping review of behaviour change techniques

Specific approaches are needed to reach and support people with a lower socioeconomic position (SEP) to achieve healthier eating behaviours. There is a growing body of evidence suggesting that digital health tools exhibit potential to address these needs because of its specific features that enable application of various behaviour change techniques (BCTs). The aim of this scoping review is to identify the BCTs that are used in diet-related digital interventions targeted at people with a low SEP, and which of these BCTs coincide with improved eating behaviour. The systematic search was performed in 3 databases, using terms related to e/m-health, diet quality and socioeconomic position. A total of 17 full text papers were included. The average number of BCTs per intervention was 6.9 (ranged 3-15). BCTs from the cluster 'Goals and planning' were applied most often (25x), followed by the clusters 'Shaping knowledge' (18x) and 'Natural consequences' (18x). Other frequently applied BCT clusters were 'Feedback and monitoring' (15x) and 'Comparison of behaviour' (13x). Whereas some BCTs were frequently applied, such as goal setting, others were rarely used, such as social support. Most studies (n = 13) observed a positive effect of the intervention on eating behaviour (e.g. having breakfast) in the low SEP group, but this was not clearly associated with the number or type of applied BCTs. In conclusion, more intervention studies focused on people with a low SEP are needed to draw firm conclusions as to which BCTs are effective in improving their diet quality. Also, further research should investigate combinations of BCTs, the intervention design and context, and the use of multicomponent approaches. We encourage intervention developers and researchers to describe interventions more thoroughly, following the systematics of a behaviour change taxonomy, and to select BCTs knowingly.

Food Environment around Schools: A Systematic Scope Review

The present systematic scope review intended to compile state-of-the-art information about the food environment around schools, exploring the main methods used to describe the food environment around schools as well as the possible effects that this environment can promote on the health of children and adolescents. The preferred reporting items for systematic reviews and meta-analyses-extension for scoping reviews (PRISMA-ScR) checklist and guidelines were followed to ensure a robust and repeatable methodological process. A systematic search was performed in the following electronic databases: MEDLINE, Embase, Science Direct, Web of Science, LILACS, and Scopus, as well as in related articles, a manual search of reference lists and gray literature. Forty-six studies were selected. There was no standardization regarding distances from food establishments to schools, methods of analysis, and software used. The food environment around the schools was characterized by the wide availability of food establishments, especially fast food, convenience stores, supermarkets, and grocery stores known for offering a wide variety of unhealthy foods. Regarding the correlations with the health of children and adolescents, the evidence points to possible interferences of the food environment known as obesogenic, but it cannot be related only to the school environment since most of the acquisition and consumption of food usually happens around family homes. Conducting standardized and comprehensive studies evaluating food choices in the school environment and their interrelationships is very important to ensure children's food and nutrition security and minimize negative health outcomes in the medium and long term.

The Availability and Price of Healthy Food in Seattle by Neighborhood Sociodemographic Characteristics

INTRODUCTION

Unequal access to healthy food in the local food retail environment contributes to diet quality disparities. We assessed whether in-store availability and prices of healthy foods differ by neighborhood-level income and racial and ethnic composition in a representative sample of food stores in Seattle, Washington.

METHODS

We developed and validated an in-store survey tool and surveyed 134 stores. We measured availability and prices of 19 items. For each store, we calculated a healthy food availability score (range, 0-25), and mean prices within each category. Using census tract data, we identified the median household income and proportions of Black and Hispanic residents for each store's neighborhood and grouped them by tertiles of these neighborhood characteristics across Seattle census tracts. We used Wald tests to compare mean availability scores and prices between tertiles and applied postestimation weights to reflect store-type distributions within each tertile.

RESULTS

Neighborhoods with lower income and a larger proportion of Black residents had lower healthy food availability scores compared with neighborhoods with higher income (8.06 [95% CI, 7.04-9.07] vs 12.40 [95% CI, 10.63-14.17], P < .001) and fewer Black residents (8.88 [95% CI, 7.79-9.98] vs 12.32 [95% CI, 10.51-14.14], P = .003). Availability did not differ by Hispanic population proportions. Mean prices of grains, eggs, and meat were lower in neighborhoods with larger proportions of Black residents.

CONCLUSION

We found systematic differences in healthy food availability based on neighborhood-level income and racial composition. In-store assessments of the food retail environment can inform local, tailored strategies to improve healthy food access.

Differential Associations Between Changes in Food Environment and Changes in BMI Among Adults Living in Urban, Low-Income Communities

BACKGROUND

Food environments can contribute to excess weight gain among adults, but the evidence is mixed.

OBJECTIVES

This longitudinal study investigated the associations between changes in the food environment and changes in BMI in adults and whether changes in the food environment differentially impact various subgroups.

METHODS

At 2 time points, BMI was calculated using self-reported height and weight data from 517 adults (mean age, 41 years) living in 4 New Jersey cities. The counts of different types of food outlets within 0.4, 0.8, and 1.6 km of respondents' residences were collected at baseline and tracked until follow-up. A binary measure of social standing (social-advantage group, n = 219; social-disadvantage group, n = 298) was created through a latent class analysis using social, economic, and demographic variables. Multivariable linear regression modeled the associations between changes in BMI with measures of the food environment; additionally, interaction terms between the measures of food environment and social standing were examined.

RESULTS

Overall, over 18 months, an increase in the number of small grocery stores within 0.4 km of a respondent's residence was associated with a decrease in BMI (β = -1.0; 95% CI: -1.9, -0.1; P = 0.024), while an increase in the number of fast-food restaurants within 1.6 km was associated with an increase in BMI (β = 0.1; 95% CI: 0.01, 0.2; P = 0.027). These overall findings, however, masked some group-specific associations. Interaction analyses suggested that associations between changes in the food environment and changes in BMI varied by social standing. For instance, the association between changes in fast-food restaurants and changes in BMI was only observed in the social-disadvantage group (β = 0.1; 95% CI: 0.02, 0.2; P = 0.021).

CONCLUSIONS

In a sample of adults living in New Jersey, changes in the food environment had differential effects on individuals' BMIs, based on their social standing.

The CIVISANO protocol: a mixed-method study about the role of objective and perceived environmental factors on physical activity and eating behavior among socioeconomically disadvantaged adults

BACKGROUND

Overweight and obesity have a strong socioeconomic profile. Unhealthy behaviors like insufficient physical activity and an unbalanced diet, which are causal factors of overweight and obesity, tend to be more pronounced in socioeconomically disadvantaged groups in high income countries. The CIVISANO project aims to identify objective and perceived environmental factors among different socioeconomic population groups that impede or facilitate physical activity and healthy eating behavior in the local context of two peri-urban Flemish municipalities in Belgium. We also aim to identify and discuss possible local interventions and evaluate the participatory processes of the project.

METHODS

This study (2020-2023) will use community-based participatory tools, involving collaborative partnerships with civic and stakeholder members of the community and regular exchanges among all partners to bridge knowledge development and health promotion for socioeconomically disadvantaged citizens. Furthermore, a mixed-methods approach will be used. A population survey and geographic analysis will explore potential associations between the physical activity and eating behaviors of socioeconomically disadvantaged adults (25-65 years old) and both their perceived and objective physical, food and social environments. Profound perceptive context information will be gathered from socioeconomically disadvantaged adults by using participatory methods like photovoice, walk-along, individual map creation and group model building. An evaluation of the participatory process will be conducted simultaneously.

DISCUSSION

The CIVISANO project will identify factors in the local environment that might provoke inequities in adopting a healthy lifestyle. The combination of perceived and objective measures using validated strategies will provide a robust assessment of the municipality environment. Through this analysis, the project will investigate to what extent community engagement can be a useful strategy to reduce health inequities. The strong knowledge exchange and capacity-building in a local setting is expected to contribute to our understanding of how to maximize research impact in this field and generate evidence about potential linkages between a health enhancing lifestyle among socioeconomically disadvantaged groups and their physical, food and social environments.

Changes in neighborhood environments and the increasing socioeconomic gap in child obesity risks: Evidence from Singapore

Most empirical research studying the link between neighborhood environments and child obesity risks are conducted in contexts such as the U.S., with pronounced patterns of residential segregation, making it difficult to extrapolate how far built environment characteristics contribute to socioeconomic disparities in obesity risks in less segregated contexts. Using a large national dataset of almost 625,000 students' height and weight data collected at ages 7, 11 and 14, between 2004 and 2015, this paper explores whether differences in eight neighborhood characteristics measuring access to different type of food outlets, parks and other active spaces, and public transport infrastructure might be responsible for socioeconomic differences in child obesity risks in Singapore, a city-state with relatively low levels of residential segregation. Through descriptive analyses we find that socioeconomic disparities in child BMIz in Singapore widened from 2004 onwards. However, while longitudinal regression models with individual and time fixed effects suggest that family socioeconomic status modified the relationship between environmental exposures and BMIz, there does not seem to be a clear, unequivocal relationship between built environment changes and the observed widening of the socioeconomic obesity gap.

Systematic literature review of instruments that measure the healthfulness of food and beverages sold in informal food outlets

BACKGROUND

Informal food outlets, defined as vendors who rarely have access to water and toilets, much less shelter and electricity, are a common component of the food environment, particularly in many non-Western countries. The purpose of this study was to review available instruments that measure the quality and particularly the healthfulness of food and beverages sold within informal food outlets.

METHODS

PubMed, LILACS, Web of Science, and Scopus databases were used. Articles were included if they reported instruments that measured the availability or type of healthy and unhealthy foods and beverages by informal food outlets, were written in English or Spanish, and published between January 1, 2010, and July 31, 2020. Two trained researchers reviewed the title, abstract and full text of selected articles; discrepancies were solved by two independent researchers. In addition, the list of references for selected articles was reviewed for any additional articles of relevance. The quality of published articles and documents was evaluated using JBI Critical appraisal checklist for analytical cross-sectional studies.

RESULTS

We identified 1078 articles of which 14 were included after applying the selection criteria. Three additional articles were considered after reviewing the references from the selected articles. From the final 17 articles, 13 measurement tools were identified. Most of the instruments were used in low- and middle-income countries (LMIC). Products were classified as healthy/unhealthy or produce/non-produce or processed/unprocessed based on availability and type. Six studies reported psychometric tests, whereas one was tested within the informal food sector.

CONCLUSIONS

Few instruments can measure the healthfulness of food and beverages sold in informal food outlets, of which the most valid and reliable have been used to measure formal food outlets as well. Therefore, it is necessary to develop an instrument that manages to measure, specifically, the elements available within an informal one. These actions are extremely important to better understand the food environment that is a central contributor to poor diets that are increasingly associated with the obesity and Non-communicable disease (NCD) pandemic.

Investigating the association between the socioeconomic environment of the service area and fast food visitation: A context-based crystal growth approach

Fast food consumption is one of the major causes of rising obesity rates. Fast food consumers are mostly residents located in the service area-the fast food outlet's surrounding area. Conventional buffer approaches may exhibit bias in measuring service areas by ignoring the local community's detailed spatial configuration and transportation preferences. This study uses fast food outlets and their visits provided by a mobile phone-based dataset named SafeGraph and applies a novel context-based crystal growth algorithm (CG) to delineate improved service areas of fast food outlets in Chicago. We also explore how socioeconomic variables in service areas by CG and buffer-based approaches are related to visits to fast food outlets. Results show that compared to conventional buffers, CG produces improved service areas as it excludes inaccessible barriers and adjusts the accessible areas by transportation preferences. Further, the model using service areas of public transport users by CG yields the best performance. Additionally, the rate of single-mother households and the number of other fast food outlets nearby are positively related to fast food visits in all models. Findings acknowledge the advantages of CG and help make policy interventions to reduce fast food consumption.

The Association Between Family Environment and Adolescent Alcohol Drinking Behavior: A Cross-Sectional Study of Six Chinese Cities

Objective

Adolescents' alcohol consumption has lifetime adverse physical and mental health effects. Family environment factors have a significant influence in shaping adolescents' beliefs and habits. We conducted the multicenter cross-sectional study aiming to investigate the association between family environment factors and adolescent drinking behavior in China.

Methods

The study investigated 27,762 middle school students from Beijing, Shanghai, Guangzhou, Jinan, Chengdu, and Harbin. A logistic regression model was used to explore the association between family environmental factors and adolescent drinking behavior. Participants were asked to self-report previous experiences of drinking and getting drunk to access their drinking status. Factors of family environment related to alcohol consumption included: parents' educational level, family economic status, family composition, the number of times parents drank alcohol in the past 30 days, and parents' attitudes toward their drinking behavior. The logistic regression model was used to adjust the demographic confounders, including gender, age, city, location, and smoking status, and to explore the association between family environmental factors and adolescent alcohol drinking behaviors.

Results

Compared with students whose parents prohibited drinking, students who were approved drinking were more likely to drink in this year (OR = 16.544, 95%CI:15.265–17.929, P < 0.001; Full adjustment: OR = 13.111, 95% CI: 12.031–14.288, P < 0.001), drink in this month (OR = 7.791, 95% CI: 7.077–8.565, P < 0.001; Full adjustment: OR = 6.010, 95% CI: 5.439–6.641, P < 0.001). In addition, Low family economic status, not living with the mother, parents' ambivalent attitudes toward their children's drinking and parental drinking were risk factors for drinking among middle school students.

Conclusion

The family environment, especially parents' attitudes, is associated with students' drinking and drunken behavior. Mobilizing the power of parents may play a positive role in the effective prevention and control of adolescent drinking.

Can in-store interventions reduce the socioeconomic gap in fruit and vegetable purchases in grocery stores? A descriptive study of volume sales from 2012 to 2020 in Norway's largest grocery store chain

Fruits and vegetable (FVs) consumption is an essential determinant of health, and intake is strongly patterned by socioeconomic status (SES). Inside grocery store interventions have increasingly been explored to promote healthier diets, especially for people with lower SES. This study describes how the supermarket chain Kiwi used a combination of in-store interventions to increase annual sales of FVs between 2012 and 2020. In particular, this study examined how sales developed in counties with different demographic characteristics (e.g., education, income, overweight and obesity, and self-reported FVs consumption level) in order to evaluate whether the effect differs between different populations. The primary outcome measurement was annual volume sales, adjusted for new stores opening and closing during the study period, also called like-for-like sales. The study has used a descriptive study design. The chain used interventions such as better placement, promoting healthy foods, giving out discounts, and placing "on the go" FVs and cups with portioned FVs at the cash registry. Results show that like-for-like volume sales of FVs grew by 34.1% during the study period. The increase was especially strong for vegetables, which increased by 41.8%, compared to fruits and berries, which increased by 25%. Sales increased for all eleven counties in Norway. Using the Spearman correlation, a moderately positive association was found between the number of overweight or obese people in counties and the development in FVs sales. To conclude, in-store interventions positively impacted FVs sales. More research in an experimental context is needed to determine if interventions may reduce the socioeconomic gap in FVs consumption.

Where do Dutch adults obtain their snack foods? Cross-sectional exploration of individuals' interactions with the food environment

We investigated frequency of consumption and location of obtaining snack foods and sociodemographic differences therein. Data: cross-sectional survey data (N = 1784 Dutch adults 18-65 years) on the frequency of consumption of 10 snack foods and where they obtained them. Adjusted logistic regression analyses revealed notable differences in the frequency of snack food consumption between younger and older adults and between those with low vs. high socioeconomic position (SEP). The location of obtaining snack foods also differed between sociodemographic groups with supermarkets forming an important point-of-purchase for snack foods, especially for those with low SEP and with children in their household.

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.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Large-scale diet tracking data reveal disparate associations between food environment and diet

An unhealthy diet is a major risk factor for chronic diseases including cardiovascular disease, type 2 diabetes, and cancer1-4. Limited access to healthy food options may contribute to unhealthy diets5,6. Studying diets is challenging, typically restricted to small sample sizes, single locations, and non-uniform design across studies, and has led to mixed results on the impact of the food environment7-23. Here we leverage smartphones to track diet health, operationalized through the self-reported consumption of fresh fruits and vegetables, fast food and soda, as well as body-mass index status in a country-wide observational study of 1,164,926 U.S. participants (MyFitnessPal app users) and 2.3 billion food entries to study the independent contributions of fast food and grocery store access, income and education to diet health outcomes. This study constitutes the largest nationwide study examining the relationship between the food environment and diet to date. We find that higher access to grocery stores, lower access to fast food, higher income and college education are independently associated with higher consumption of fresh fruits and vegetables, lower consumption of fast food and soda, and lower likelihood of being affected by overweight and obesity. However, these associations vary significantly across zip codes with predominantly Black, Hispanic or white populations. For instance, high grocery store access has a significantly larger association with higher fruit and vegetable consumption in zip codes with predominantly Hispanic populations (7.4% difference) and Black populations (10.2% difference) in contrast to zip codes with predominantly white populations (1.7% difference). Policy targeted at improving food access, income and education may increase healthy eating, but intervention allocation may need to be optimized for specific subpopulations and locations.

OUP accepted manuscript

Context

Online grocery services are an emerging component of the food system with the potential to address disparities in access to healthy food.

Objective

We assessed the barriers and facilitators of equitable access to healthy foods in the online grocery environment, and the psychosocial, purchasing, and dietary behaviors related to its use among low-income, diverse populations.

Data Sources

Four electronic databases were searched to identify relevant literature; 16 studies were identified.

Results

Barriers to equitable access to healthy food included cost and limited availability of online grocery services in food deserts and rural areas. The expansion of online grocery services and the ability to use nutrition assistance benefits online were equity-promoting factors. Perceived low control over food selection was a psychosocial factor that discouraged online grocery use, whereas convenience and lower perceived stress were facilitators. Findings were mixed regarding healthfulness of foods purchased online. Although few studies assessed diet, healthy food consumption was associated with online grocery use.

Conclusion

Researchers should assess the impact of online grocery shopping on low-income families’ food purchases and diet.

Systematic Review Registration

PROSPERO registration no. CRD: 42021240277

Digital Health Coaching for Type 2 Diabetes: Randomized Controlled Trial of Healthy at Home

Digital health coaching is an intervention for type 2 diabetes mellitus (T2DM) that has potential to improve the quality of care for patients. Previous research has established the efficacy of digital interventions for behavior change. This pilot study addresses a research gap in finding effective and accessible behavioral interventions for under-resourced individuals with T2DM. We examined the impact of Healthy at Home, a 12-week phone and SMS-based (short message service) digital health coaching program, on insulin resistance which is an upstream marker for T2DM progression. We compared this intervention to usual diabetic care in a family medicine residency clinic in a randomized controlled trial. Digital health coaching significantly improved participants' calculated Homeostatic Model Assessment for Insulin Resistance (HOMA2-IR) by −0.9 ± 0.4 compared with the control group (p = 0.029). This significance remained after controlling for years diagnosed with T2DM, enrollment in Medicaid, access to food, baseline stage of change, and race (p = 0.027). Increasing access to digital health coaching may lead to more effective control of diabetes for under-resourced patients. This study demonstrates the potential to implement a personalized, scalable, and effective digital health intervention to treat and manage T2DM through a lifestyle and behavioral approach to improve clinical outcomes (http://clinicaltrials.gov, NCT04872647).

A Systematic Review of Health Promotion Programs to Improve Nutrition for People with Intellectual Disability

PURPOSE OF REVIEW

To investigate the type and effectiveness of health promotion programs designed to improve nutrition for people with intellectual disability. This review also sought to highlight gaps in the evidence by mapping interventions to the socio-ecological model.

RECENT FINDINGS

To date, reviews on health promotion programs for people with intellectual disability have focused on individualised weight management interventions and behaviour change techniques. No reviews have focused solely on nutrition or considered a broader range of interventions and policies targeted beyond the individual. This review found that health promotion interventions to date were predominantly at the individual level of the socio-ecological model and of varying effectiveness. Of the non-individually focused interventions, those targeting the physical environment or considering multiple socio-ecological levels achieved the greatest improvements in nutrition outcomes. Nutrition and obesity prevention research and policy need to include intellectual disability as part of equity considerations, while intellectual disability policy needs to consider the broader food environment.

Associations between online food outlet access and online food delivery service use amongst adults in the UK: a cross-sectional analysis of linked data

BACKGROUND

Online food delivery services facilitate 'online' access to food outlets that typically sell lenergy-dense nutrient-poor food. Greater online food outlet access might be related to the use of this purchasing format and living with excess bodyweight, however, this is not known. We aimed to investigate the association between aspects of online food outlet access and online food delivery service use, and differences according to customer sociodemographic characteristics, as well as the association between the number of food outlets accessible online and bodyweight.

METHODS

In 2019, we used an automated data collection method to collect data on all food outlets in the UK registered with the leading online food delivery service Just Eat (n = 33,204). We linked this with contemporaneous data on food purchasing, bodyweight, and sociodemographic information collected through the International Food Policy Study (analytic sample n = 3067). We used adjusted binomial logistic, linear, and multinomial logistic regression models to examine associations.

RESULTS

Adults in the UK had online access to a median of 85 food outlets (IQR: 34-181) and 85 unique types of cuisine (IQR: 64-108), and 15.1% reported online food delivery service use in the previous week. Those with the greatest number of accessible food outlets (quarter four, 182-879) had 71% greater odds of online food delivery service use (OR: 1.71; 95% CI: 1.09, 2.68) compared to those with the least (quarter one, 0-34). This pattern was evident amongst adults with a university degree (OR: 2.11; 95% CI: 1.15, 3.85), adults aged between 18 and 29 years (OR: 3.27, 95% CI: 1.59, 6.72), those living with children (OR: 1.94; 95% CI: 1.01; 3.75), and females at each level of increased exposure. We found no association between the number of unique types of cuisine accessible online and online food delivery service use, or between the number of food outlets accessible online and bodyweight.

CONCLUSIONS

The number of food outlets accessible online is positively associated with online food delivery service use. Adults with the highest education, younger adults, those living with children, and females, were particularly susceptible to the greatest online food outlet access. Further research is required to investigate the possible health implications of online food delivery service use.

Perceived Produce Availability and Child Fruit and Vegetable Intake: The Healthy Communities Study

Children eat more fruits and vegetables when more are available at home, but less is known about how the neighborhood food environment relates to children's diet and weight outcomes. The goal of this study was to determine whether parental perception of the food environment (neighborhood and home) is associated with children's fruit and vegetable (F&V) intake and weight outcomes, and to assess differences by household food security status and household income. Cross-sectional data from the 2013-2015 U.S. Healthy Communities Study included 5138 children, aged 4 to 15 years old, from 130 U.S. communities. Neighborhood and home food environments were assessed with parent-reported, perceived F&V availability scores. Associations were tested with multi-level linear regression models. Parents' perception of produce availability was associated with household F&V availability ratings (β = 0.09 points, p < 0.001). Household F&V availability was associated with child F&V intake (β = 0.32 cups/day or 25.6 g/day, p < 0.001). A higher child F&V intake was associated with a lower child BMI z-score (β = -0.05, p = 0.002). Weaker relationships were seen for children living in food insecure or low-income households. Optimizing neighborhood and home access to F&V may help children improve diet quality, but may not be as effective for children living in food insecure or low-income households.

Nonalcoholic Fatty Liver Disease Prevalence Trends Among Adolescents and Young Adults in the United States, 2007-2016

Understanding the burden of NAFLD among adolescents and young adults has become increasingly relevant. Our aim was to estimate the prevalence of NAFLD among adolescents and young adults in the United States. Data were obtained from National Health and Nutrition Examination Survey from 2007-2016. Adolescents and young adults aged 12 to 29 years were included. NAFLD was determined by the U.S. Fatty Liver Index in the absence of secondary causes of liver disease, and the differences in prevalence trends were analyzed based on age, gender, and race. Complete data were available for 4,654 adolescents and young adults (mean age 21 years; 50.9% male; 56.8% White, 20.9% Hispanic, and 13.3% Black). The overall prevalence of NAFLD among adolescents and young adults was 18.5%, ranging from 13.2% among early and middle adolescents (12-17 years) to 18.7% among late adolescents and young adults (18-24 years), to 24.0% among older young adults (25-30 years) (trend P < 0.001). The prevalence of NAFLD was higher for boys than for girls (aged 12-17: 15.1% vs. 11.3%; aged 18-24: 21.1% vs. 16.2%; aged 25-30: 28.7% vs. 19.2%, all P < 0.030). Among all age groups, Hispanics had a higher prevalence of NAFLD than Whites and Blacks (pairwise P < 0.001). Over the study time period, the prevalence of NAFLD among early and middle adolescents and young adults did not change (trend P > 0.80). In contrast, NAFLD prevalence among late adolescents increased (trend P = 0.018). In fact, White and Hispanic late adolescents were the drivers behind this increase in the prevalence of NAFLD. Conclusion: These data indicate an increasing trend in NAFLD prevalence among 18-24-year-olds. These data have important public health and policy implications.

Residents' Insights on Their Local Food Environment and Dietary Behaviors: A Cross-City Comparison Using Photovoice in Spain

Perceptions of local food environments and the ability of citizens to engage in participatory research may vary, even if participants share similar cultural and socioeconomic contexts. In this study, we aimed to describe participants’ narratives about their local food environment in two cities in Spain. We used the participatory methodology of Photovoice to engage participants in Madrid (n = 24) and Bilbao (n = 17) who took and discussed photographs about their local food environment (Madrid; n = 163 and Bilbao; n = 70). Common themes emerged across both cities (food insecurity, poverty, use of public spaces for eating and social gathering, cultural diversity and overconsumption of unhealthy foods); however, in Bilbao citizens perceived that there was sufficient availability of healthy foods despite that living in impoverished communities. Photovoice was a useful tool to engage participating citizens to improve their local food environments in both cities. This new approach allowed for a photovoice cross-city comparison that could be useful to fully understand the complexity and diversity of residents’ perceptions regardless of their place of residence.

National nutrition policy in high-income countries: is health equity on the agenda?

OBJECTIVE

Equity-oriented policy actions are a key public health principle. In this study, how equity and socioeconomic inequalities are represented in policy problematizations of population nutrition were examined.

DATA SOURCES

We retrieved a purposive sample of government nutrition-policy documents (n = 18) from high-income nations.

DATA SYNTHESIS

Thematic analysis of policy documents was informed by a multitheoretical understanding of equitable policies and Bacchi's "What's the Problem Represented to be?' analysis framework. Despite common rhetorical concerns about the existence of health inequalities, these concerns were often overshadowed by greater emphasis on lifestyle "problems" and reductionist policy actions. The notion that policy actions should be for all and reach everyone were seldom backed by specific actions. Rhetorical acknowledgements of the upstream drivers of health inequalities were also rarely problematized, as were government responsibilities for health equity and the role of policy and governance in reducing socioeconomic inequalities in nutrition.

CONCLUSION

To positively influence health equity outcomes, national nutrition policy will need to transition toward the prioritization of actions that uphold social justice and comprehensively address the upstream determinants of health.