Store-specific grocery shopping patterns and their association with objective and perceived retail food environments

OBJECTIVE

To explore store-specific grocery shopping patterns and assess associations with the objective and perceived retail food environment (RFE).

DESIGN

This cross-sectional study used principal component analysis and hierarchical cluster analysis to identify grocery shopping patterns and logistic regression models to assess their associations with the RFE, while adjusting for household characteristics.

SETTING

The Montpellier Metropolitan Area, France.

PARTICIPANTS

To be eligible for inclusion, participants had to be 18 years of age or older and reside in the Montpellier Metropolitan Area. Analyses were carried out on 415 households.

RESULTS

Households of cluster 'Supermarket' (49 % of households) primarily shopped at supermarkets and were less likely to live near a convenience store. Households of cluster 'Diversified' (18 %) shopped mostly at organic stores, at markets, at specialised stores, and from producers and were more likely to have a market in their activity space. Households of cluster 'Discount' (12 %) primarily shopped at discounters and were less likely to perceive a producer in their activity space. Households of cluster 'Convenience' (12 %) mostly shopped online or in convenience stores. Finally, households of cluster 'Specialized' (9 %) had high expenditures in greengrocers and in other specialised food stores and were more likely to live near a specialised food store.

CONCLUSIONS

This study highlighted the importance of considering both perceived and objective RFE indicators, as well as assessments around the home and in activity space. Understanding how people buy food and interact with their RFE is crucial for policymakers seeking to improve urban food policies.

Dietary environmental impacts of French adults are poorly related to their income levels or food insecurity status

PURPOSE

Recent global-scale analysis showed the extent of inequality in terms of carbon emissions related to overall consumption, with richer households emitting significantly more greenhouse gases than poorer ones. While socio-economic status is a known determinant of food consumption, and despite the urgent need to move towards more sustainable diets, very few studies have explored socio-economic differences regarding the environmental impacts of diets. The objective of the present study was to compare the environmental impacts of French adults' diets according to food insecurity (FI) status and income level.

METHODS

The environmental impacts of diets of a representative sample of adults living in France (n = 1964) were assessed using data from the last National Individual Food Consumption Survey (INCA3) and the Agribalyse® v3.0.1 environmental database. Fifteen impact indicators were estimated, including climate change, eutrophication (freshwater, marine, terrestrial), resource depletion (energy, minerals, water), and the single EF score. First, the mean diet-related impact (per day per person) was estimated for each environmental indicator by decile of environmental impact. Second, the environmental impacts of diets of individuals living in food-insecure households (severe and moderate FI, as measured by the Household Food Security Survey Module) were compared with those of individuals living in food-secure households, the latter being divided by income decile. Differences in environmental impacts of diets (total and by food group) between these 12 sub-populations were tested by ANOVA after adjustment for age, gender, energy intake and household size.

RESULTS

The 10% of the population with the highest environmental impact has a mean impact approximately 3-6 times higher than the 10th with the lowest environmental impact, depending on the indicator. Individuals living in households with severe and moderate FI represented 3.7% and 6.7% of the studied population, respectively. Results showed a high variability in impacts within each of the 12 sub-population and no difference in environmental impacts of diets between sub-populations, except for water use (p < 0.001) and freshwater eutrophication (p = 0.02). The lowest water use and freshwater eutrophication were observed for individuals living in households with severe FI and the highest for high-income sub-populations, with differences mainly explained by the level of fruit and vegetable intakes and the type of fish consumed, respectively. Low-income populations, in particular individuals living in households with severe FI, had relatively high intakes of ruminant meat but for most indicators, the high environmental impact of this food group was offset by low consumption of other high impacting food groups (e.g., fruits and vegetables), and/or by high consumption of low impacting food groups (e.g., starches), resulting in no difference in the impact at the diet level.

CONCLUSION

While there is a high inter-individual variability in the environmental impacts of diets, this variability was not related to income level or FI status for most indicators, except higher water use and freshwater eutrophication in higher-income populations. Overall, our results underline the importance of considering individual dietary patterns and thinking at the whole diet level, and not only considering specific food or food groups impacts, when designing educational tools or public policies to promote more sustainable diets.

A natural experiment to assess how urban interventions in lower socioeconomic areas influence health behaviors: the UrbASanté study

BACKGROUND

Mechanisms underlying the associations between changes in the urban environment and changes in health-related outcomes are complex and their study requires specific approaches. We describe the protocol of the interdisciplinary UrbASanté study, which aims to explore how urban interventions can modify environmental exposures (built, social, and food environments; air quality; noise), health-related behaviors, and self-reported health using a natural experiment approach.

METHODS

The study is based on a natural experiment design using a before/after protocol with a control group to assess changes in environmental exposures, health-risk behaviors, and self-reported health outcomes of a resident adult population before and after the implementation of a time series of urban interventions in four contiguous neighborhoods in Paris (France). The changes in environmental exposures, health-related behaviors, and self-reported health outcomes of a resident adult population will be concurrently monitored in both intervention and control areas. We will develop a mixed-method framework combining substantial fieldwork with quantitative and qualitative analytical approaches. This study will make use of (i) data relating to exposures and health-related outcomes among all participants and in subsamples and (ii) interviews with residents regarding their perceptions of their neighborhoods and with key stakeholders regarding the urban change processing, and (iii) existing geodatabases and field observations to characterize the built, social, and food environments. The data collected will be analyzed with a focus on interrelationships between environmental exposures and health-related outcomes using appropriate approaches (e.g., interrupted time series, difference-in-differences method).

DISCUSSION

Relying on a natural experiment approach, the research will provide new insights regarding issues such as close collaboration with urban/local stakeholders, recruitment and follow-up of participants, identification of control and intervention areas, timing of the planned urban interventions, and comparison of subjective and objective measurements. Through the collaborative work of a consortium ensuring complementarity between researchers from different disciplines and stakeholders, the UrbASanté study will provide evidence-based guidance for designing future urban planning and public health policies.

TRIAL REGISTRATION

This research was registered at the ClinicalTrial.gov (NCT05743257).

Which Dietary Changes to Achieve Nutritional Adequacy While Reducing Diet Cost in the French West Indies?

Objectives

The French West Indies are facing increasing rates of obesity and diet-related chronic diseases. Food prices are ∼30% higher in these territories compared with mainland France, while a large part of their populations is socioeconomically disadvantaged. Economic affordability of a healthy diet is a key issue in this region. Our objective was to identify dietary changes that would allow Guadeloupean and Martinican adults to achieve nutritional adequacy while reducing the cost of their diets.

Methods

Dietary intakes of 1061 adults were obtained from a cross-sectional survey (2013–2014) conducted on a representative sample of the Guadeloupean and Martinican populations. Diet cost was based on mean prices of 1357 foods compiled from a Martinican supermarket website. For each adult, optimized diets respecting all nutritional recommendations and with minimized departure from initial diet were designed with linear programming under 3 scenarios: 1) all nutritional constraints, 2) all nutritional constraints without exceeding initial diet cost, and 3) all nutritional constraints while reducing diet cost by 30%.

Results

When cost was not constrained, achieving nutritional adequacy while departing the least from individual food intakes induced an increase in cost for most adults (74%). When cost was not allowed to increase, achieving nutritional adequacy induced an increase in the consumption of fruit & vegetables, unrefined starches, dairy products (especially milk), eggs and vegetable fats, and a decrease in sweetened beverages (especially for &lt; 30 y), refined starches, sweetened products, meat and fish. When a 30% reduction of cost was imposed, achieving nutritional adequacy induced the same types of dietary changes than with scenario 2, but modified their magnitude (and thus the effort for consumers), notably a smaller increase in vegetables (+7 vs. +86g/d) but a larger increase in dairy (+90 vs. +72 g/d) and starchy foods (+112 vs. +54 g/d), and a larger reduction in meat (−48 vs. −12 g/d). Increases in fruits (∼+80g/d) and unrefined starches (+127 g/d) and decrease in sweetened beverages (∼−100 g/d) were still observed.

Conclusions

Nutrition prevention programs promoting the affordable dietary changes identified in this study could help improve nutritional adequacy of the Guadeloupean and Martinican populations.

Funding Sources

French National Research Agency.

Associations Between Retail Food Environment and Nutritional Quality of Food Purchases in French Households: The Mont'Panier Cross-Sectional Study

Objectives

The purpose of this study was to assess whether the retail food environment, measured by multiple indicators around home and in activity space, was associated with 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 nutritional quality of food purchases. Food environment indicators (presence, number, relative density and proximity of food outlets) were calculated around home and in activity space (around home, work, other places of activity and along commuting journeys) 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 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

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

Conclusions

Greengrocers might be an efficient food store type to promote 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.

Funding Sources

Région Occitanie; Institut national de recherche pour l'agriculture, l'alimentation et l'environnement (INRAE); ANR (the French National Research Agency).

Changes in Food Purchasing Practices of French Households During the First COVID-19 Lockdown and Associated Individual and Environmental Factors

Objectives

This study aimed to explore changes in food purchasing practices (FPP) of French households during the first COVID-19 lockdown and associations with individual and environmental factors.

Methods

In April of 2020 households from the Mont'Panier cross-sectional study (n = 306), a quota sampling survey conducted in the south of France, were asked to complete an online questionnaire about their FPP during lockdown and related factors, including perceived food environment (FE) (distance to closest food store, perception of increased food prices etc.). Objective FE (presence, number, proximity and density of food outlets) was assessed around participant's home using a geographical information system. Multiple correspondence analysis based on changes in frequency of use and quantity of food purchased by food outlet, followed by a hierarchical cluster analysis resulted in the identification of clusters. Logistic regression models were performed to assess associations between identified clusters and household's sociodemographic characteristics, perceived and objective FE.

Results

Five clusters were identified. Cluster “Supermarket” (38% of the total sample), in which households reduced frequency of trips, but increased quantity bought in supermarkets during lockdown, was associated with lower incomes. Cluster “E-supermarket” (12%), in which households increased online food shopping, was associated with higher incomes. Cluster “Diversified” (22%), made up of households who reduced frequency of trips to diverse food outlet types, was associated with the perception of increased food prices. Cluster “Organic Food Store” (20%), in which households did not change frequency of trips, nor quantity purchased in organic food stores, was associated with being older (35–50 y vs < 35 y). Finally, cluster “Producer” (8%), including households who regularly purchased food from producers, but mostly reduced these purchases during lockdown, was associated with the presence of an organic food store within a 1-km walking distance around home.

Conclusions

This study highlighted diverse changes in FPP during lockdown and overall more significant associations with perceived than with objective FE indicators.

Funding Sources

ANR, INRAE, Région Occitanie.

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.

Changes in Food Purchasing Practices of French Households During the First COVID-19 Lockdown and Associated Individual and Environmental Factors

Background

To limit the spread of COVID-19, a strict lockdown was imposed in France between March and May 2020. Mobility limitations and closure of non-essential public places (restaurants, open-air markets, etc.) affected peoples' food environment (FE) and thus their food purchasing practices (FPPs). This study aimed to explore changes in FPPs of French households during lockdown and associations with individual and environmental factors.

Methods

In April of 2020 households from the Mont'Panier cross-sectional study (n = 306), a quota sampling survey conducted in the south of France, were asked to complete an online questionnaire about their FPPs during lockdown and related factors, including perceived FE (distance to closest general food store, perception of increased food prices, etc.). Objective FE (presence, number, proximity, and density of food outlets) was assessed around participant's home using a geographical information system. Multiple correspondence analysis based on changes in frequency of use and quantity of food purchased by food outlet, followed by a hierarchical cluster analysis, resulted in the identification of clusters. Logistic regression models were performed to assess associations between identified clusters and household's sociodemographic characteristics, perceived, and objective FE.

Results

Five clusters were identified. Cluster “Supermarket” (38% of the total sample), in which households reduced frequency of trips, but increased quantity bought in supermarkets during lockdown, was associated with lower incomes and the perception of increased food prices. Cluster “E-supermarket” (12%), in which households increased online food shopping with pickup at supermarket, was associated with higher incomes. Cluster “Diversified” (22%), made up of households who reduced frequency of trips to diverse food outlet types, was associated with the perception of increased food prices. Cluster “Organic Food Store” (20%), in which households did not change frequency of trips, nor quantity purchased in organic food stores, was associated with being older (35–50 y vs. <35 y). Finally, cluster “Producer” (8%), which includes households who regularly purchased food from producers, but mostly reduced these purchases during lockdown, was associated with the presence of an organic food store within a 1-km walking distance around home.

Conclusion

This study highlighted diverse changes in FPPs during lockdown and overall more significant associations with perceived than with objective FE indicators.

Advantages and limitations of the methodological approaches used to study dietary shifts towards improved nutrition and sustainability

Acting on diet is one of the changes required - in combination with actions on food production, transformation, and waste - to address the challenges of reducing the environmental impact of our food systems and eliminating all forms of malnutrition. The number of studies exploring how to move towards a more sustainable diet has exploded over the past decades, but there is a need to facilitate their understanding and use by policy makers and all other stakeholders possibly influencing diet sustainability. The aim of the present article is to propose a categorization of studies into 4 approaches, based on the type of methodology used to explore diet sustainability, and to highlight the principles, advantages, and limitations of each approach in order to help study users in their interpretation. The 4 approaches are: assessment of sustainability characteristics of hypothetical diets (approach 1) or existing diets (approach 2), identification of existing "positive deviants" (approach 3), and design of more sustainable diets with constrained optimization (approach 4). Specificities and key findings drawn from each approach are described, and challenges for future studies are discussed.

Meeting nutritional adequacy in the Brazilian population increases pesticide intake without exceeding chronic safe levels

Achieving nutritional adequacy requires an increase in fresh foods consumption, which may increase pesticide intakes. This study aimed to identify required dietary modifications to achieve nutritional adequacy without exceeding the acceptable daily intake (ADI) for pesticides. Data from the National Dietary Survey 2017-2018 were linked to the pesticide database from the Program on Pesticide Residue Analysis in Food. We performed linear programming models to design nutritionally adequate diets constrained by food preferences for different constraints on pesticide intake at the least cost increment. Nutritional adequacy led to an increase in pesticide intakes without exceeding their ADI. Modifications in diets varied according to the model, but, in general, consisted in an increase in fruits and vegetables, dairy, and seafood, and a reduction in rice, red meat, and sugar-sweetened beverages quantities. In conclusion, meeting nutritional adequacy increases pesticide intake compared to the observed diets, without representing a health concern to consumers.

Demographic and socio-economic shifts partly explain the Martinican nutrition transition: an analysis of 10-year health and dietary changes (2003-2013) using decomposition models

OBJECTIVE

The Caribbean has seen a dramatic shift in the obesity and chronic disease prevalence over the past decades, suggesting a nutrition transition. Simultaneously, Martinique has faced a demographic transition marked by significant population ageing. We aimed to differentiate the contribution of changes in health status and dietary intakes due to shifts in demographic and socio-economic characteristics (DSEC) from that due to unobserved factors.

DESIGN

Two cross-sectional surveys conducted in 2003 (n 743) and 2013 (n 573) on representative samples were used. Dietary intakes were estimated by 24-h recalls. The contribution of changes in health status and dietary intakes due to shifts in observed DSEC was differentiated from that due to unobserved factors over a 10-year interval, using Oaxaca-Blinder decomposition models.

SETTING

Martinique, French region in the Caribbean.

PARTICIPANTS

Martinican adults (≥16 years).

RESULTS

Over the study period, health status deteriorated, partly owing to shifts in DSEC, explaining 62 % of the change in the prevalence of hypertension (+13 percentage points (pp)) and 48 % of waist circumference change (+3 cm). Diet quality decreased (mean adequacy ratio -2pp and mean excess ratio + 2 pp) and energy supplied by ultra-processed food increased (+4 pp). Shifts in DSEC marginally explained some changes in dietary intakes (e.g. increased diet quality), while the changes that remained unexplained were of opposite sign, with decreased diet quality, lower fruits, tubers and fish intakes and higher energy provided by ultra-processed foods.

CONCLUSION

Explained dietary changes were of opposite sign to nutrition transition conceptual framework, probably because unobserved drivers are in play, such as food price trends or supermarkets spread.

Correction to: Improving lifestyles sustainability through community gardening: results and lessons learnt from the JArDinS quasi-experimental study

An amendment to this paper has been published and can be accessed via the original article.

Improving lifestyles sustainability through community gardening: results and lessons learnt from the JArDinS quasi-experimental study

BACKGROUND

Despite an increasing number of studies highlighting the health benefits of community gardening, the literature is limited by cross-sectional designs. The "JArDinS" quasi-experimental study aimed to assess the impact of community garden participation on the adoption of more sustainable lifestyles among French adults.

METHODS

Individuals entering a community garden in Montpellier (France) in 2018 (n = 66) were compared with pairwise matched individuals with no experience in community gardening (n = 66). Nutritional quality, environmental impact and cost of monthly household food supplies, level of physical activity measured by accelerometers, as well as mental and social well-being, sensitivity to food waste, and connection with nature were evaluated at baseline (t0) and 12 months later (t1) to explore sustainability of lifestyles in social/health, environmental and economic dimensions. Linear mixed models were used to determine the independent effect of community gardening on investigated lifestyles components. In-depth interviews were conducted at t1 with 15 gardeners to better understand changes that may have occurred in gardeners' lives during the first year of gardening.

RESULTS

At t0, gardeners had lower education level, lower BMI and their household reported lower percentage of meals consumed outside of the home compared to non-gardeners (p <  0.05). Participating in the community garden had no significant impact, in spite of sufficient statistical power, on fruit and vegetables supplies (main outcome), nor on physical activity parameters, nor on others of the social/health, environmental and economic lifestyles components investigated. Qualitative interviews suggested the existence of pre-established health and environmental consciousness in some gardeners and revealed several barriers to the participation such as lack of time, lack of gardening knowledge, physical difficulty of gardening, health problems and conflicts with other gardeners.

CONCLUSIONS

The health benefits of community gardening previously reported by cross-sectional studies might be confounded by selection bias. The JArDinS study highlights the need to identify solutions to overcome barriers related to community garden participation when designing relevant public health interventions for the promotion of sustainable lifestyles.

TRIAL REGISTRATION

The study was registered at clinicaltrials.gov as NCT03694782 . Date of registration: 3rd October 2018, retrospectively registered.

Nutritional Quality of Vegetarian and Non-Vegetarian Dishes at School: Are Nutrient Profiling Systems Sufficiently Informative?

In France, school canteens must offer a vegetarian meal at least once per week. The objective was to evaluate the nutritional quality of school main dishes. A database of main dishes served in primary schools was first split into non-vegetarian (n = 669) and vegetarian (n = 315) categories. The latter has been divided into three sub-categories: vegetarian dishes containing cheese, vegetarian dishes containing eggs and/or dairy products but no cheese and vegetarian dishes without any eggs, cheese or other dairy products (vegan). Categories and sub-categories were compared based on nutrient adequacy ratios for "protective" nutrients (proteins, fibres, vitamins, minerals, essential fatty acids), the contents of nutrients to be limited (saturated fatty acids (SFA), sodium, free sugars) and on two nutrient profiling systems (SAIN,LIM and Nutri-Score). The vegetarian category and the non-vegetarian category displayed "adequate" levels (≥5% adequacy for 100 kcal) on average for almost all "protective" nutrients. The three sub-categories of vegetarian dishes displayed good SAIN,LIM and Nutri-Score profiles on average, although key nutrients were lacking (vitamin B12, vitamin D and DHA) or were present in insufficient amounts (vitamin B2 and calcium) in the vegan sub-category. The sub-category containing eggs and/or dairy products other than cheese was a good compromise, as it provided protective nutrients associated with eggs and fresh dairy products, while the sub-category containing cheese provided higher levels of SFA. Nutrient profile algorithms are insufficiently informative to assess the nutritional quality of school dishes.

Caribbean nutrition transition: what can we learn from dietary patterns in the French West Indies?

PURPOSE

Despite the urgency regarding increasing rates of obesity and chronic diseases in the Caribbean, few studies described the nutrition transition. We aimed to provide such information by identifying dietary patterns in the French West Indies and their characteristics.

METHODS

This cross-sectional analysis included 1144 Guadeloupeans and Martinicans from a multistage sampling survey conducted on a representative sample. Dietary patterns were identified using principal component analysis followed by a clustering procedure, and described using multivariable regression models.

RESULTS

Four patterns were identified: (i) a "prudent" pattern characterized by high intakes of fruits, vegetables, legumes, seafood and yogurts, low intakes of fatty and sweet products, and a high Diet Quality Index-International (DQI-I); (ii) a "traditional" pattern characterized by high intakes of fruits, vegetables, tubers and fish, low intakes of red and processed meat, snacks, fast foods, and sweetened beverages, with a high DQI-I, mostly shaped by women and older persons; (iii) a "convenient" pattern characterized by high intakes of sweetened beverages, snacks, and fast foods, with the lowest DQI-I, principally shaped by young participants; (iv) a "transitioning" pattern characterized by high consumptions of bread, processed meat, sauces, alcoholic and sweetened beverages, but also high intakes of tubers, legumes, and fish, mainly shaped by men, middle aged, of whom 35% had metabolic syndrome.

CONCLUSION

The co-existing dietary patterns in the French West Indies, marked by a generational contrast, seem to reflect different steps in dietary change as described in the literature, suggesting an ongoing nutrition transition.

Socioeconomic inequalities in metabolic syndrome in the French West Indies

BACKGROUND

Obesity and metabolic diseases represent a major health burden in the Caribbean, particularly since a large part of the population is disadvantaged. However, socioeconomic inequalities in chronic diseases are poorly explored in this region. We investigated the association between socioeconomic position and metabolic syndrome (MetS) prevalence and explored the contribution of diet quality to explain this association, among adults in the French West Indies.

METHODS

This cross-sectional analysis included 1144 subjects (≥16 y) from a multistage sampling survey conducted in 2013-2014 on a representative sample of the Guadeloupean and Martinican population. MetS prevalence was assessed using the Joint Interim Statement. Dietary intakes were estimated from 24 h-dietary recalls, and diet quality was assessed through the Diet Quality Index-International (DQI-I). Associations between socioeconomic indicators (education, employment, social assistance benefits) and MetS prevalence, and the potential contribution of diet quality in this association were assessed using multivariable logistic regression models, adjusted for sociodemographic characteristics.

RESULTS

MetS prevalence adjusted for age and sex was 21 and 30% among Guadeloupean and Martinican, respectively. Compared to high-educated participants, low-educated subjects were more likely to be at risk of MetS (OR = 2.4; 95%CI = [1.3-4.4], respectively), as were recipients of social assistance benefits compared to non-recipients (OR = 2.0; 95%CI = [1.0-4.0]). The DQI-I explained 10.5% of the overall variation in MetS due to education.

CONCLUSIONS

Socioeconomic inequalities in MetS prevalence, reflected by education and social assistance benefits, were found. However, diet quality contributed only to socioeconomic inequalities due to education underlining that education may impact health through the ability to generate overall dietary behavior, long-term beneficial. Our work identified subgroups with higher risk of MetS, which is needed when implementing public health measures, particularly in this Caribbean population with of high poverty rates. Further prospective studies are needed to improve our understanding of the mechanisms of social inequalities in MetS in a high poverty rates context.

Opticourses: promoting healthier food purchases at no additional cost in low-income households

Introduction

Healthy diets are generally more expensive than unhealthy diets, explaining why socially disadvantaged individuals perceive food prices as a barrier to improve their diets. It is thus crucial to develop strategies enabling the achievement of good nutritional quality with a low budget, taking into account actual beliefs and expectations of the target population. A co-construction approach is thus recommended, involving participants at each step of the intervention to maximize its impact.

Methods

The “Opticourses” program was launched in 2010 with a feasibility study, followed by an intervention research in 2012-2014, in order to develop and evaluate a prevention program aiming at improving the nutritional quality of food purchases at no additional cost in a socioeconomically disadvantaged population. In order to implement activities tailored to the target population, participants were involved in the development of the protocol and the tools of the intervention and evaluation processes.

Results

Opticourses’s workshops (8 to 12 participants) include different activities displayed in four 2h sessions around real food purchases of participants, and games and exchanges aimed at promoting food and food choices of good nutritional quality for their price. The intervention research showed improvements in food purchasing behaviors of Opticourses participants. A transferability phase was conducted in 2015-2017. Since 2017, Opticourses is spreading in several regions of France, through training of professionals, in particular the courses organized by the Health Education Regional Committee (CRES) in the South of France.

Discussion

Bringing an original, concrete, co-constructed and scientifically based response to an everyday life problem is the main strength of the program. One important risk of failure for such prevention program is the underestimation of the requirements of the intervention research, in terms of time and human and budgetary resources.

Key messages

From a research point of view, getting access to new food purchasing data will allow a continuous refinement and innovation in the improvement of the diet for people with budgetary constraints. By focusing on food purchasing, a familiar activity that most adults feel able to handle, the Opticourses program is engaging and pragmatic, in accordance with health promotion principles.

Does diet quality mediate socioeconomic differences in metabolic syndrome in the French West Indies?

Background

Obesity and metabolic diseases represent a major health burden in the Caribbean, particularly since a large part of the population is disadvantaged. However, socioeconomic inequalities in chronic diseases are poorly explored in this region, and the contribution of diet to explain these inequalities has not yet been studied. We investigated the association between socioeconomic position and the prevalence of metabolic syndrome (MetS), and explored whether this association was mediated by diet quality in the French West Indies.

Methods

This cross-sectional analysis included 1,144 adults (≥16 y) from a multistage sampling survey, representative of the Guadeloupean and Martinican population. The prevalence of MetS was assessed using the Joint Interim Statement. Dietary intakes were estimated using 24hours dietary recalls, and diet quality was assessed through the Diet Quality Index-International (DQI-I). Associations between socioeconomic indicators (education, employment, social assistance benefits) and prevalence of MetS, and the potential mediating effect of diet quality in this association were assessed using multivariable logistic regression models adjusted for sociodemographic factors.

Results

MetS prevalence adjusted for age and sex was 21% and 30% among Guadeloupean and Martinican, respectively. Compared to those with a high education level, low- and middle-educated subjects were more likely to be at risk of MetS (OR = 1.9; 95%CI = [1.0-3.6] and OR = 2.7; 95%CI = [1.4-5.1], respectively), as were recipients of social assistance benefits compared to non-recipients (OR = 2.2; 95%CI = [1.1-4.2]). The DQI-I explained 11% of the overall variation in MetS due to education.

Conclusions

Socioeconomic inequalities in MetS prevalence were found in a Caribbean population but diet quality contributed only to socioeconomic inequalities due to education. Future public health measures need to target specifically populations with limited financial resources and low education.

Key messages

Our work identified subgroups with higher risk of MetS, which is needed when implementing public health measures, particularly in this Caribbean population with of high poverty rates. Diet quality contributed only to socioeconomic inequalities due to education underlining that education may impact health through the ability to generate overall dietary behavior, long-term beneficial.

What can dietary patterns tell us about the Caribbean nutrition transition?

Background

Given the public health urgency facing the increasing rates of obesity and chronic diseases in the Caribbean, characterization of the nutrition transition and population groups at higher nutritional risk is needed. We identified dietary patterns in the French West Indies (FWI) and their association with individual characteristics.

Methods

This cross-sectional analysis included 1,144 Guadeloupeans and Martinicans from a representative survey. To identify dietary patterns, principal component analysis was performed using 25 food groups, followed by a clustering procedure classifying subjects in independent clusters. Their associations with health status, Diet Quality Index-International (DQI-I), food supply behaviors, sociodemographic and economic characteristics were studied using multivariable models.

Results

Four dietary patterns were identified, representing 25%, 24%, 31% and 20% of the sample: (1) a “healthy” cluster characterised by a high DQI-I, composed of high educated individuals; (2) a “traditional” cluster with a high DQI-I and high intakes of traditional dishes, formed mostly by women and older persons, with a high obesity prevalence (26%); (3) a “western” cluster with a low DQI-I, high intakes of sweetened beverages, snacks and fast foods, composed mainly of young subjects, buying their fruits, vegetables and tubers only or mainly in supermarkets; and (4) a “transitional” cluster with high intakes of bread, processed meat, sauces, alcoholic and sweetened beverages but conversely high intakes of tubers, legumes, fish and low intakes of biscuits and cakes, formed mainly by middle age men, self-employed or manual workers, and 35% had metabolic syndrome.

Conclusions

The dietary patterns identified reflect different steps of dietary change as described by Popkin, suggesting an ongoing nutrition transition in the FWI. This characterization provides useful information for public health actions regarding population groups at higher nutritional risk.

Key messages

Four diversified dietary patterns were identified suggesting an ongoing nutrition transition in the French West Indies. Demographic and socioeconomic characteristics associated with dietary patterns, especially age, reflecting a generational contrast, provided needed information to guide future public health measures.

Impact of community gardens on the sustainability of lifestyles: baseline data of the JArDinS study

Introduction

Despite growing evidence for the multiple health benefits of community gardening, longitudinal studies based on quantitative data are needed. JArDinS is a quasi-experimental study aimed at assessing the impact of community garden participation in the adoption of more sustainable lifestyles.

Materials and

Methods

Gardeners starting gardening in a community garden in Montpellier (France) were recruited in 2018. Volunteers with no experience in community gardening and matched for age range, gender, household income and household composition were recruited in a control group. A recruitment goal of 80 participants per group was determined to detect a 30% increase in F&V supply in the gardeners group. Participant were issued with three tools: a Food Supply Dairy to collect data on monthly household’s food supply, a triaxial accelerometer to measure physical activity and an online questionnaire on mental and social health, sensitivity to food waste, and connection with nature. Measures have been collected at baseline and will be repeated 12 months later. Data collected are examined conjointly to assess the sustainability of lifestyles in its social/health, environmental and economic dimensions. Change of outcomes after 1 year will be compared between the natural experiment and the control groups, to evaluate the effect of access to a community garden on the sustainability of lifestyles.

Results

A final number of 77 participants per group were enrolled at baseline, which is 4% less the original recruitment goal. Baseline data for the natural experiment group and the control group are currently being analysed and will be presented.

Discussion

This study will provide valuable information about the potential of community gardens to favor sustainable lifestyles, based on a robust quasi-experimental design allowing causality evaluation. Findings could help developing policies toward more sustainable urban planning favoring both human and environmental health.

Key messages

For the first time, the JArDinS study will allow testing, the impact of community gardens on the sustainability of lifestyles. Results will help orient urban planning decisions towards healthier options.

Does participating in community gardens promote sustainable lifestyles in urban settings? Design and protocol of the JArDinS study

Background

Despite growing evidence for the multiple health benefits of community gardening, longitudinal studies based on quantitative data are needed. Here we describe the protocol of JArDinS, a quasi-experimental study, aimed at assessing the impact of community garden participation (a natural experiment) in the adoption of more sustainable lifestyles.

Methods

Gardeners (n = 80) starting gardening in a community garden in Montpellier (France) will be recruited. Volunteers with no experience in community gardening and matched for age range, gender, household income and household composition will be recruited in a control group (n = 80). The sustainability of lifestyles in its social/health, environmental and economic dimensions will be assessed from a food supply diary (recording type, quantity and price of foods acquired in a 1-month period and the carbon impact of relevant food trips), a triaxial accelerometer (measuring physical activity) and online questionnaires on mental and social health, sensitivity to food waste, and connection with nature. Change of outcomes after 1 year will be compared between the natural experiment and the control groups.

Discussion

This study will provide information on the impact of participation in a community garden on the different dimensions of sustainability, based on a robust quasi-experimental design allowing causality evaluation.

Trial registration

The JArDinS study was registered at clinicaltrials.gov as NCT03694782. Date of registration: 3rd October 2018, retrospectively registered.

Integrating nutrient bioavailability and co-production links when identifying sustainable diets: How low should we reduce meat consumption?

Background

Reducing the consumption of meat and other animal-based products is widely advocated to improve the sustainability of diets in high-income countries. However, such reduction may impair nutritional adequacy, since the bioavailability of key nutrients is higher when they come from animal- vs plant-based foods. Meat reduction may also affect the balance between foods co-produced within the same animal production system.

Objective

The objective was to assess the impact of introducing nutrient bioavailability and co-production links considerations on the dietary changes needed − especially regarding meat ‒ to improve diet sustainability.

Methods

Diet optimization with linear and non-linear programming was used to design, for each gender, three modeled diets departing the least from the mean observed French diet (OBS) while reducing by at least 30% the diet-related environmental impacts (greenhouse gas emissions, eutrophication, acidification): i) in the nutrition-environment (NE) model, the fulfillment of recommended dietary allowances for all nutrients was imposed; ii) in the NE-bioavailability (NEB) model, nutritional adequacy was further ensured by accounting for iron, zinc, protein and provitamin A bioavailability; iii) in the NEB-co-production (NEB-CP) model, two links between co-produced animal foods (milk–beef and blood sausage–pork) were additionally included into the models by proportionally co-constraining their respective quantities. The price and environmental impacts of individual foods were assumed to be constant.

Results

‘Fruit and vegetables’ and ‘Starches’ quantities increased in all modeled diets compared to OBS. In parallel, total meat and ruminant meat quantities decreased. Starting from 110g/d women’s OBS diet (168g/d for men), total meat quantity decreased by 78%, 67% and 32% for women (68%, 66% and 62% for men) in NE, NEB and NEB-CP diets, respectively. Starting from 36g/d women’s OBS diet (54g/d for men), ruminant meat quantity dropped severely by 84% and 87% in NE and NEB diets for women (80% and 78% for men), whereas it only decreased by 27% in NEB-CP diets (38% for men). The share of energy and proteins of animal origin was similar for the 3 modeled diets (approximately 1/5 of total energy, and 1/2 of protein) and lower than in OBS diet (approximately 1/3 of total energy, and 2/3 of protein).

Conclusions

Decreasing meat content was strictly needed to achieve more sustainable diets for French adults, but the reduction was less severe when nutrient bioavailability and co-production links were taken into account.

Co-construction and Evaluation of a Prevention Program for Improving the Nutritional Quality of Food Purchases at No Additional Cost in a Socioeconomically Disadvantaged Population

Background: Food prices influence food choices. Purchasing foods with higher nutritional quality for their price may help improve the diet quality of socioeconomically disadvantaged individuals. Objective: This study aimed to describe the co-construction and evaluation of the Opticourses prevention program, which promotes healthy eating among participants in socioeconomically deprived situations by improving the nutritional quality of their household food purchases with no additional cost. Methods: Individuals were recruited in poor districts of Marseille, France. The intervention and evaluation tools and protocols were co-constructed with 96 individuals. Then, 93 adults willing to participate in a standardized intervention comprising 5 participative workshops on diet and budget were enrolled. Impact on food purchases was estimated with experimental economics: 2-d experimental food purchase intents were observed at baseline and endline for workshop participants (WPs, n = 35) and controls (n = 23), with the use of monetary incentives to limit social-desirability bias. Changes in food and nutrient content and energy cost (expressed in €/2000 kcal) of experimental purchases were assessed. Results: The co-constructed participative workshops included playful activities around food purchase practices and the nutritional quality, taste, and price of foods. Experimental purchases contained a large amount of energy at baseline for both WPs and controls (5114 and 4523 kcal ⋅ d-1 ⋅ person-1, respectively). For WPs only, the mean energy content decreased between baseline and endline (-1729 kcal ⋅ d-1 ⋅ person-1; P < 0.01; medium effect size: Cohen's d = 0.5), and the percentage of energy from free sugars and from foods high in fat, sugar, and salt also decreased (both P < 0.05 and medium effect sizes), whereas energy cost remained unchanged. No significant changes between baseline and endline were observed for the controls. Conclusions: After the intervention, the energy content of participants' experimental purchases was closer to their needs, suggesting that the workshops helped them plan and rationalize their food purchases better. The nutritional quality of the experimental purchases increased but energy cost did not, showing that the co-constructed Opticourses prevention program can favorably change food purchasing behaviors of socioeconomically disadvantaged individuals with no additional cost. This trial was registered at clinicaltrials.gov as NCT02383875.

Improving diet sustainability through evolution of food choices: review of epidemiological studies on the environmental impact of diets

The Food and Agriculture Organization defines sustainable diets as nutritionally adequate, safe, healthy, culturally acceptable, economically affordable diets that have little environmental impact. This review summarizes the studies assessing, at the individual level, both the environmental impact and the nutritional quality or healthiness of self-selected diets. Reductions in meat consumption and energy intake were identified as primary factors for reducing diet-related greenhouse gas emissions. The choice of foods to replace meat, however, was crucial, with some isocaloric substitutions possibly increasing total diet greenhouse gas emissions. Moreover, nutritional adequacy was rarely or only partially assessed, thereby compromising the assessment of diet sustainability. Furthermore, high nutritional quality was not necessarily associated with affordability or lower environmental impact. Hence, when identifying sustainable diets, each dimension needs to be assessed by relevant indicators. Finally, some nonvegetarian self-selected diets consumed by a substantial fraction of the population showed good compatibility with the nutritional, environmental, affordability, and acceptability dimensions. Altogether, the reviewed studies revealed the scarcity of standardized nationally representative data for food prices and environmental indicators and suggest that diet sustainability might be increased without drastic dietary changes.

The bioavailability of iron, zinc, protein and vitamin A is highly variable in French individual diets: Impact on nutrient inadequacy assessment and relation with the animal-to-plant ratio of diets

Nutritional adequacy depends on nutrient intakes and bioavailability which strongly varies with the plant- or animal-origin of foods. The aim was to estimate iron, zinc, protein and vitamin A bioavailability from individual diets, and investigate its relation with the animal-to-plant ratio (A/P) of diets. Bioavailability was estimated in 1899 French diets using diet-based algorithms or food-group specific conversion factors. Nutrient inadequacy was estimated based on i) bioavailability calculated in each individual diet and ii) average bioavailability assumed for Western-diets. Mean iron absorption, zinc absorption, protein quality and β-carotene conversion factor were 13%, 30%, 92%, and 17:1, respectively. Bioavailability displayed a high variability between individual diets, poorly explained by their A/P. Using individual bioavailability led to different inadequacy prevalence than with average factors assumed for Western-diets. In this population, the A/P does not seem sufficient to predict nutrient bioavailability and the corresponding recommended intakes. Nutritional adequacy should be assessed using bioavailability accounting for individual diets composition.

A methodology to compile food metrics related to diet sustainability into a single food database: Application to the French case

The holistic approach required to assess diet sustainability is hindered by lack of comprehensive databases compiling relevant food metrics. Those metrics are generally scattered in different data sources with various levels of aggregation hampering their matching. The objective was to develop a general methodology to compile food metrics describing diet sustainability dimensions into a single database and to apply it to the French context. Each step of the methodology is detailed: indicators and food metrics identification and selection, food list definition, food matching and values assignment. For the French case, nutrient and contaminant content, bioavailability factors, distribution of dietary intakes, portion sizes, food prices, greenhouse gas emission, acidification and marine eutrophication estimates were allocated to 212 commonly consumed generic foods. This generic database compiling 279 metrics will allow the simultaneous evaluation of the four dimensions of diet sustainability, namely health, economic, social and environmental, dimensions.

How low can dietary greenhouse gas emissions be reduced without impairing nutritional adequacy, affordability and acceptability of the diet? A modelling study to guide sustainable food choices

OBJECTIVE

To assess the compatibility between reduction of diet-related greenhouse gas emissions (GHGE) and nutritional adequacy, acceptability and affordability dimensions of diet sustainability.

DESIGN

Dietary intake, nutritional composition, GHGE and prices were combined for 402 foods selected among those most consumed by participants of the Individual National Study on Food Consumption. Linear programming was used to model diets with stepwise GHGE reductions, minimized departure from observed diet and three scenarios of nutritional constraints: none (FREE), on macronutrients (MACRO) and for all nutrient recommendations (ADEQ). Nutritional quality was assessed using the mean adequacy ratio (MAR) and solid energy density (SED).

SETTING

France.

SUBJECTS

Adults (n 1899).

RESULTS

In FREE and MACRO scenarios, imposing up to 30 % GHGE reduction did not affect the MAR, SED and food group pattern of the observed diet, but required substitutions within food groups; higher GHGE reductions decreased diet cost, but also nutritional quality, even with constraints on macronutrients. Imposing all nutritional recommendations (ADEQ) increased the fruits and vegetables quantity, reduced SED and slightly increased diet cost without additional modifications induced by the GHGE constraint up to 30 % reduction; higher GHGE reductions decreased diet cost but required non-trivial dietary shifts from the observed diet. Not all the nutritional recommendations could be met for GHGE reductions ≥70 %.

CONCLUSIONS

Moderate GHGE reductions (≤30 %) were compatible with nutritional adequacy and affordability without adding major food group shifts to those induced by nutritional recommendations. Higher GHGE reductions either impaired nutritional quality, even when macronutrient recommendations were imposed, or required non-trivial dietary shifts compromising acceptability to reach nutritional adequacy.

Reaching Nutritional Adequacy Does Not Necessarily Increase Exposure to Food Contaminants: Evidence from a Whole-Diet Modeling Approach

BACKGROUND

Dietary guidelines are designed to help meet nutritional requirements, but they do not explicitly or quantitatively account for food contaminant exposures.

OBJECTIVE

In this study, we aimed to test whether dietary changes needed to achieve nutritional adequacy were compatible with acceptable exposure to food contaminants.

METHODS

Data from the French national dietary survey were linked with food contaminant data from the French Total Diet Study to estimate the mean intake of 204 representative food items and mean exposure to 27 contaminants, including pesticides, heavy metals, mycotoxins, nondioxin-like polychlorinated biphenyls (NDL-PCBs) and dioxin-like compounds. For each sex, 2 modeled diets that departed the least from the observed diet were designed: 1) a diet respecting only nutritional recommendations (NUT model), and 2) a diet that met nutritional recommendations without exceeding Toxicological Reference Values (TRVs) and observed contaminant exposures (NUTOX model). Food, nutrient, and contaminant contents in observed diets and NUT and NUTOX diets were compared with the use of paired t tests.

RESULTS

Mean observed diets did not meet all nutritional recommendations, but no contaminant was over 48% of its TRV. Achieving all the nutrient recommendations through the NUT model mainly required increases in fruit, vegetable, and fish intake and decreases in meat, cheese, and animal fat intake. These changes were associated with significantly increased dietary exposure to some contaminants, but without exceeding 57% of TRVs. The highest increases were found for NDL-PCBs (from 26% to 57% of TRV for women). Reaching nutritional adequacy without exceeding observed contaminant exposure (NUTOX model) was possible but required further departure from observed food quantities.

CONCLUSIONS

Based on a broad range of nutrients and contaminants, this first assessment of compatibility between nutritional adequacy and toxicological exposure showed that reaching nutritional adequacy might increase exposure to food contaminants, but within tolerable levels. However, there are some food combinations that can meet nutritional recommendations without exceeding observed exposures.

Current MUAC Cut-Offs to Screen for Acute Malnutrition Need to Be Adapted to Gender and Age: The Example of Cambodia

Background

Early identification of children <5 yrs with acute malnutrition is a priority. Acute malnutrition is defined by the World Health Organization as a mid-upper-arm circumference (MUAC) <12.5 cm or a weight-for-height Z-score (WHZ) <-2. MUAC is a simple and low-cost indicator to screen for acute malnutrition in communities, but MUAC cut-offs currently recommended by WHO do not identify the majority of children with weight-for-height Z-score (<-2 (moderate malnourished) or r<-3 (severe malnourished). Also, no cut-offs for MUAC are established for children >5 yrs. Therefore, this study aimed at defining gender and age-specific cut-offs to improve sensitivity of MUAC as an indicator of acute malnutrition.

Methods

To establish new age and gender-specific MUAC cut-offs, pooled data was obtained for 14,173 children from 5 surveys in Cambodia (2011–2013). Sensitivity, false positive rates, and areas under receiver-operator characteristic curves (AUC) were calculated using wasting for children <5yrs and thinness for children ≥5yrs as gold standards. Among the highest values of AUC, the cut-off with the highest sensitivity and a false positive rate ≤33% was selected as the optimal cut-off.

Results

Optimal cut-off values increased with age. Boys had higher cut-offs than girls, except in the 8–10.9 yrs age range. In children <2yrs, the cut-off was lower for stunted children compared to non stunted children. Sensitivity of MUAC to identify WHZ<-2 and <-3 z-scores increased from 24.3% and 8.1% to >80% with the new cut-offs in comparison with the current WHO cut-offs.

Conclusion

Gender and age specific MUAC cut-offs drastically increased sensitivity to identify children with WHZ-score <-2 z-scores. International reference of MUAC cut-offs by age group and gender should be established to screen for acute malnutrition at the community level.