Improve Food Environments Research Articles

Improved food environments for healthy diets and enhanced nutrition

Improved food environments for healthy diets and enhanced nutrition

Eat, play, live: a randomized controlled trial within a natural experiment examining the role of nutrition policy and capacity building in improving food environments in recreation and sport facilities

BackgroundRecreation and sport facilities often have unhealthy food environments that may promote unhealthy dietary patterns among children. In response, some Canadian provinces have released voluntary nutrition guidelines for recreation and sport facilities, however implementation has been limited. Organizational capacity building may overcome barriers to implementing guidelines. Eat, Play, Live was a randomized controlled trial embedded within a natural experiment that tested the impact of an 18 month capacity building intervention (CBI) in enhancing implementation of provincial nutrition guidelines, and whether nutrition guidelines were associated with positive changes. Primary outcomes were facility capacity, policy development and food environment quality.MethodsRecreation and sport facilities in three guideline provinces were randomized into a guideline + CBI (GL + CBI; n = 17) or a guideline only comparison condition (GL-ONLY; n = 15). Facilities in a province without guidelines constituted a second comparison condition (NO-GL; n = 17). Facility capacity, policy development, and food environment quality (vending and concession) were measured and compared at baseline and follow-up across conditions using repeated measures ANOVA and Chi-square statistics. Healthfulness of vending and concession items was rated as Do Not Sell (least nutritious), Sell Sometimes or Sell Most (most nutritious).ResultsThere were significant time by condition effects, with significant increases in facility capacity (mean ± SD: 30.8 ± 15.6% to 62.3 ± 22.0%; p < 0.01), nutrition policy development (17.6% developed new policies; p = 0.049), overall quality of the concession food environment (14.7 ± 8.4 to 17.5 ± 7.2; p < 0.001), and in the proportion of Sell Most (3.7 ± 4.4% to 11.0 ± 9.0%; p = 0.002) and Sell Sometimes vending snacks (22.4 ± 14.4% to 43.8 ± 15.8%; p < 0.001) in GL + CBI facilities, with a significant decline in Do Not Sell vending snacks (74.0 ± 16.6% to 45.2 ± 20.1%; p < 0.001).ConclusionsSignificant improvements in facility capacity, policy development and food environment quality occurred in recreation and sport facilities that were exposed to nutrition guidelines and participated in a CBI. Outcomes did not improve in facilities that were only passively or not at all exposed to guidelines. Ongoing capacity building may enhance implementation of voluntary nutrition guidelines, however food environments remained overwhelmingly unhealthy, suggesting additional scope to enhance implementation.Trials registrationClinical trials registration (retrospectively registered): ISRCTN14669997 Jul 3, 2018.

An Examination of Failed Grocery Store Interventions in Former Food Deserts.

Background. Implementing food stores in deprived neighborhoods to improve access to healthy food is a debated topic. Aims. To uncover important contributors to the closure of grocery store interventions in urban food deserts. Method. We systematically reviewed both peer-reviewed and gray literature for publications on the failure of grocery store interventions. Results. We found nine articles on six different failed food stores. The reasons stated for closure included low sales, a lack of food retail experience, poor marketing, and difficulty in attracting and retaining a high volume of consumers from the local market. Discussion. Current literature on the topic of the closure of inner-city grocery stores does not have a concise rationale to explain why inner-city grocery store interventions were not successful. Conclusion. We must consider the most appropriate interventions to improve food environments in food deserts using local and national policies to address the social determinants of health.

Evaluating the impact of a healthy corner store initiative on food access domains

Healthy Corner Store Initiatives (HCSIs) are one food access strategy that aims to improve food environments by supporting local food stores in expanding their healthy offerings. This study presents the evaluation results from one such HCSI. Fresh Foods Here evaluated its network of eight stores in Columbus, Ohio between November 2013 and August 2014. Data from invoices, inventories, rapid market assessments, and customers surveys were analyzed for evidence of impact on the service delivery and personal domains of food access. For some indicators, initial gains were concentrated between pre- and interim evaluation periods, followed by either a leveling off or decline between interim and post. However, overall results were promising, with increases noted in the number of healthy items ordered by store owners, in daily foot traffic and transactions, and in consumer confidence for certain healthy behaviors. Lessons learned concerning the operation and evaluation of HCSIs are shared.

Critical Success Factors for Promoting Healthy Food Environments and Healthy Eating Through Local Policy Changes: Learning From Canada

Background and context: Policies implemented at the local level can create healthier environments that enable individuals to engage in healthier, cancer preventive behaviors - such as healthy eating. Policies support cancer preventive behaviors in a sustainable and often cost-effective manner. Many theoretical frameworks exist to describe the policy process; however in practice, policy development is often considered a complex and unfamiliar mechanism to the cancer prevention and health promotion community. Aim: To identify and better understand the critical success factors underlying cancer prevention policy success, the Canadian Partnership Against Cancer analyzed the policy outcomes - focused on food environments and healthy eating - from their pan-Canadian funding initiative Coalitions Linking Action and Science for Prevention (CLASP). Strategy/Tactics: Four projects funded through the CLASP initiative, from 2009 to 2016, have yielded 260 policy outcomes related to improving food environments and healthy eating. The policy changes were the result of evidence-based interventions implemented at the local level (i.e., municipalities, schools/child care, and workplaces). Program/Policy process: Over 220 knowledge products and evaluation documents were reviewed to identify food environment and healthy eating policy outcomes and key lessons learned. The policy outcomes were analyzed and categorized according to: a) implementation setting (municipality, school/child care, workplace); and b) policy lever addressed. Policy lever categories were sourced from the World Cancer Research Fund's (WCRF) NOURISHING Framework. Ten key informant interviews were conducted with former project members to refine and validate the lessons learned. Lessons learned were organized into a final list of critical success factors and themed into overarching categories. Outcomes: The majority of the food environment and healthy eating policy outcomes from CLASP occurred in workplace settings (n=133) and municipalities (n=111), and the least in schools/child care settings (n=16). The most frequent NOURISHING policy lever was “Offer healthy food and set standards in public institutions and other specific settings” primarily through policies to ban the sale of energy drinks (n=83) and implementing nutrition standards (n=58). Ten critical success factors were identified and described within three categories: people (n=3); tools (n=3); and approaches and ways of working (n=4). What was learned: A key takeaway from this work was a combination of cross-sectoral partnerships, tools and evidence, and collaborative ways of working were crucial to advance food environment and healthy eating policy change in municipalities, schools and child care settings, and workplaces. By utilizing the international WCRF NOURISHING Framework, it is intended that the lessons learned from this policy work in a Canadian context can inform local-level cancer prevention policy efforts around the world.

Unexpected Neighborhood Sources of Food and Drink: Implications for Research and Community Health

Studies of neighborhood food environments typically focus on select stores (especially supermarkets) and/or restaurants (especially fast-food outlets), make presumptions about healthfulness without assessing actual items for sale, and ignore other kinds of businesses offering foods/drinks. The current study assessed availability of select healthful and less-healthful foods/drinks from all storefront businesses in an urban environment and considered implications for food-environment research and community health. Cross-sectional assessment in 2013 of all storefront businesses (n=852) on all street segments (n=1,253) in 32 census tracts of the Bronx, New York. Investigators assessed for healthful items (produce, whole grains, nuts, water, milk) and less-healthful items (refined sweets, salty/fatty fare, sugar-added drinks, and alcohol), noting whether items were from food businesses (e.g., supermarkets and restaurants) or other storefront businesses (OSB, e.g., barber shops, gyms, hardware stores, laundromats). Data were analyzed in 2017. Half of all businesses offered food/drink items. More than one seventh of all street segments (more than one third in higher-poverty census tracts) had businesses selling food/drink. OSB accounted for almost one third of all businesses offering food/drink items (about one quarter of businesses offering any healthful items and more than two thirds of businesses offering only less-healthful options). Food environments include many businesses not primarily focused on selling foods/drinks. Studies that do not consider OSB may miss important food/drink sources, be incomplete and inaccurate, and potentially misguide interventions. OSB hold promise for improving food environments and community health by offering healthful items; some already do.

Healthiness of Food and Beverages for Sale at Two Public Hospitals in New South Wales, Australia.

(1) Background: Our aim was to conduct objective, baseline food environment audits of two major western Sydney public hospitals and compare them to recently revised state nutritional guidelines. (2) Methods: A cross-sectional assessment was conducted (June–July2017) across 14 fixed food outlets and 70 vending machines in two hospitals using an audit tool designed to assess the guideline’s key food environment parameters of availability, placement, and promotion of ‘Everyday’ (healthy) and ‘Occasional’ (less healthy) products. (3) Results: Availability: Overall, Everyday products made up 51% and 44% of all products available at the two hospitals. Only 1/14 (7%) fixed outlets and 16/70 (23%) vending machines met the guideline’s availability benchmarks of ≥75% Everyday food and beverages. Proportion of Everyday products differed among different types of food outlets (café, cafeteria, convenience stores). Placement: On average, food outlets did not meet recommendations of limiting Occasional products in prominent positions, with checkout areas and countertops displaying over 60% Occasional items. Promotion: Over two-thirds of meal deals at both hospitals included Occasional products. (4) Conclusion: Baseline audit results show that substantial improvements in availability, placement, and promotion can be made at these public hospitals to meet the nutrition guidelines. Audits of other NSW hospitals using the developed tool are needed to investigate similarities and differences in food environment between sites. These findings highlight the need for ongoing tracking to inform whether the revised guidelines are leading to improved food environments in health facilities.

Voluntary nutrition guidelines to support healthy eating in recreation and sports settings are ineffective: findings from a prospective study.

Interventions to support healthy eating among populations are needed to address diet-related chronic disease. Recreation and sport settings are increasingly identified as ideal settings for promoting overall health, particularly for children, through creation of environments that support positive health behaviours. These publicly funded settings typically support health through physical activity promotion. However, the food environment within them is often not reflective of nutrition guidelines. As more jurisdictions release nutrition guidelines in such settings, the purpose of this study was to assess whether voluntary nutrition guidelines, released in 2015 in the Canadian province of Nova Scotia, had any impact on food environments in these settings. Baseline and follow-up audits of food environments were conducted one year before (in 30 facilities) and one year after guideline release (in 27 facilities). Audits involved classifying all foods and beverages within vending machines and concessions as Do Not Sell, Minimum, Moderate, or Maximum nutrition, using criteria provided in the guidelines. The proportion of items within each category was calculated, and differences from pre- to post-guideline release were assessed using Chi-squared statistics. Results indicated limited change in food and beverage provision from pre- to post- guideline release. In fact, from pre- to post-guideline release, the proportion of Do Not Sell vending beverages and concession foods increased significantly, while Maximum concession beverages decreased, suggesting a worsening of the food environment post-guideline release. Findings suggest that voluntary guidelines alone are insufficient to improve food environments in recreation and sport settings. For widespread changes in the food environment of these settings to occur, more attention needs to be paid to reducing social, cultural, political and economic barriers to change (real and perceived) that have been identified in these settings, alongside developing leadership and capacity within facilities, to ensure that positive changes to food environments can be implemented and sustained.

PROTOCOL: Impact of the food environment on diet-related health outcomes in school-age children and adolescents in low- and middle-income countries: a systematic review.

PROTOCOL: Impact of the food environment on diet-related health outcomes in school-age children and adolescents in low- and middle-income countries: a systematic review.

Improving food environments and tackling obesity: A realist systematic review of the policy success of regulatory interventions targeting population nutrition.

BackgroundThis systematic review (PROSPERO: CRD42015025276) employs a realist approach to investigate the effect of “real-world” policies targeting different aspects of the food environment that shape individual and collective nutrition.ObjectivesWe were interested in assessing intermediate outcomes along the assumed causal pathway to “policy success”, in addition to the final outcome of changed consumption patterns.Data sourcesWe performed a search of 16 databases through October 2015, with no initial restriction by language.Study eligibility criteriaWe included all publications that reported the effect of statutory provisions aimed at reducing the consumption of energy-dense foods and beverages in the general population. We allowed all methodological approaches that contained some measure of comparison, including studies of implementation progress.Study appraisal and synthesis methodsWe reviewed included studies using the appraisal tools for pre-post and observational studies developed by the National Heart, Lung, and Blood Institute. Given the considerable heterogeneity in interventions assessed, study designs employed, and outcome measures reported, we opted for a narrative synthesis of results.Results and implicationsResults drawn from 36 peer-reviewed articles and grey literature reports demonstrated that isolated regulatory interventions can improve intermediate outcomes, but fail to affect consumption at clinically significant levels. The included literature covered six different types of interventions, with 19 studies reporting on calorie posting on chain restaurant menus. The large majority of the identified interventions were conducted in the US. Early results from recent taxation measures were published after the review cut-off date but these suggested more favorable effects on consumption levels. Nevertheless, the evidence assessed in this review suggests that current policies are generally falling short of anticipated health impacts.

Nutrient profiling for front of pack labelling: how to align logical consumer choice with improvement of products?

The primary goal of front of pack (FOP) labelling is to help consumers make healthier choices through communication. A secondary goal is to encourage producers to improve the nutritional composition of their products. Evidence has shown that (FOP) labelling can help consumers to make healthier food choices and has been an incentive for producers to improve product composition. As FOP labelling is seen as an important tool to improve food environments for public health purposes, the WHO supports initiatives of governments to implement an FOP labelling system. Based on the experiences of a wide range of countries over many years, possible success factors for such an FOP system have been defined, six of which are discussed in the present paper and used to evaluate the Dutch Choices Programme that was started in 2006. In the course of time a large number of producers joined the programme and the logo was recognised by more than 90 % of the consumers, but by 2016 the Dutch consumer organisation argued on the basis of their own research that a quarter of the consumers did not understand the colour coding of the logo and as a result the Dutch government decided to no longer support this logo and to introduce a nutrition app. The challenge that remains is to find a system that consumers understand well and that still encourages manufacturers of food to improve product composition. New technology-based data collecting initiatives might provide the right tools to develop such a system.

Food in My Neighborhood: Exploring the Food Environment through Photovoice with Urban, African American Youth

ABSTRACTThis study adapted Photovoice methodology for younger participants to better understand the perceptions of urban African American youth on their food environments and diets. Youth (n = 17, ages 10–13 years) photographed and described, using novel narrative-based activities, the myriad places they regularly acquired “junk food” from environments saturated with such but differed in their assessments of the availability and desirability of more nutritious alternative foods. Youth often discussed specific foods as well as peers and adults in their lives as either entirely “healthy” or “unhealthy.” This concrete thinking should be considered when designing messaging strategies to improve diets in similar populations. Overall, Photovoice is an engaging and effective method to engage youth in efforts to improve food environments and diets.

Nutrition in Children and Adolescents.

Nutrition is a critical factor for appropriate child and adolescent development. Appropriate nutrition changes according to age. Nutrition is an important element for prevention of disease development, especially for chronic diseases. Many children and adolescents live in environments that do not promote optimum nutrition. Families must work to provide improved food environments to encourage optimum nutrition. Early primordial prevention of risk factors for chronic disease, such as cardiovascular disease, is important, and dietary habits established early may be carried through adult life.

Agents of Change: How Immigrant-Run Ethnic Food Retailers Improve Food Environments

ABSTRACTImmigrant-run ethnic food retail stores, which are often located in urban neighborhoods, are reported to provide healthy foods. Yet, there is little research on how these stores manage to operate successfully in low-resource environments, which are reported to have poor access to healthy foods, and the challenges they must overcome in a broken food system. Based on a qualitative pilot case study of Middle Eastern stores in Buffalo, New York, the authors report factors that enable immigrant entrepreneurs to operate healthy food retail stores in low-income urban neighborhoods and the challenges they must overcome in the process. Factors for success include store owners’ membership in ethnic networks, prior business experience, and understanding of niche market opportunities. This article reports policy suggestions for how local governments can help ethnic food retailers to create healthier food environments and foster economic and community development.

The impact of a pricing and communications intervention on stocking and sales of healthier foods in small Baltimore City food stores

Improving food environments and increasing access to healthy foods has been identified as a key strategy for obesity prevention and reduction. B'More Healthy Retail Rewards was a 6‐month factorial randomized controlled trial that tested the impact of a communications and pricing intervention on the stock and sales of healthier foods, including drinks, staple foods, and snacks, at multiple levels of the local food system. Twenty‐four small food stores in low‐income areas of Baltimore City were randomized to one of four treatment groups: pricing only (G1), communications only (G2), combined pricing and communications (G3), and control (G4). Pricing stores (n=12) received a 10–30% discount on promoted foods from their local wholesaler. Communications stores (n=12) received signage, small refrigerators, and other materials to help increase stock and sales of promoted foods. Regression‐based difference‐in‐difference models using linear generalized estimating equations were used to estimate treatment effects from baseline to post‐intervention (Δ outcome for treatment group ‐Δ outcome for control). Intervention effects were observed for stocking scores of promoted foods for all treatment groups verses control group, with the greatest effects seen among the two pricing interventions (G1: β=3.6, 95% CI 1.3–5.9; G2: β=2.5, 95% CI 0.7–4.3; G3: β=3.5, 95% CI 0.8–6.2). There was a significant treatment effect for daily unit sales of healthy snacks for the combined pricing and communications intervention (β=6.4, 95% CI 0.9–11.9) versus control, but not for other intervention groups. These findings suggest that store‐directed pricing interventions are most effective in motivating store owners to stock healthier foods, with additional integration of targeted communication strategies further motivating customers to purchase these foods.Support or Funding InformationFunding was received by National Heart, Lung &amp; Blood Institute (Grant #1R21HL102812‐01A1), the Abell foundation, and Johns Hopkins Global Obesity Prevention Center.

Comparison of Food Availability in School Stores in Seoul, South Korea Before and After Implementation of Two National Food‐ and Nutrient‐Based Policies

Public health interest in preventing childhood obesity and chronic diseases by improving school food environments has been growing around the world. As part of this movement, the South Korean government implemented two policies restricting unhealthy food sales in school stores: 1) a food‐based policy enacted in 2007 restricts specific food sales (e.g., soft drinks), and 2) a nutrient‐based policy enacted in 2009 restricts energy‐dense, nutrient‐poor (EDNP) food sales in school stores. The purpose of the study was to assess the effects of the two policies on the school store food environment.Foods sold in stores located in middle and high schools in Seoul, South Korea were observed before (2006, 15 stores) and after (2013, 12 stores) implementation of the two school store policies. After controlling for the total number of food types offered in school stores and school characteristics (school level, private/public, students’ sex, and income level), numbers and percentages of food types in each category were compared between 2006 and 2013. Also, number and percentage of EDNP foods in 2013 were examined using mixed models with school districts as random effects. All statistical analyses were conducted using SAS 9.4 (SAS Institute, Inc., Cary, NC).The mean number of food types offered in school stores was significantly higher in 2013 (102.3 items) than in 2006 (41.1 items; p&lt;0.001), even after adjusting for school characteristics (p=0.022). When controlling for the total number of food types and school characteristics, the mean number of soft drinks offered in a school store in 2013 (0.3 items) was significantly lower than in 2006 (1.9 items, p=0.032). Soft drinks, the target of the 2007 policy, were still available in 50% of school stores observed in 2013, while 60% of school stores observed in 2006 offered soft drinks. In contrast, EDNP foods, the target of the 2009 policy, were available in all school stores observed in 2013, and represented about 7.6% of food types offered.In school stores in South Korea, a food‐based policy that prohibits soft drinks appears to have been more effective for decreasing availability of restricted items than a nutrient‐based policy. Neither of the two policies, however, eliminated access to unhealthy foods in school stores. To improve school store food environments, alternative strategies such as requiring healthy food sales are likely needed.Support or Funding InformationThis study was supported by the Walker Institute of International and Area Studies, University of South Carolina.

The Healthy Communities Study Nutrition Assessments: Child Diet and the School Nutrition Environment.

Multifaceted community interventions directed at improving food environments are emerging, but their impact on dietary change and obesity prevalence has not been adequately documented. The Healthy Communities Study (HCS) is seeking to identify characteristics and combinations of programs and policies that are associated with children's diets and obesity-related outcomes in various types of communities across the U.S. The purpose of this paper is to describe the methods used in 2013-2015 in the HCS to assess dietary intake, school nutrition environments, and other nutrition-related behaviors. The conceptual framework of the HCS is based on the socioecological model and behaviors shown in previous studies to be related to obesity in children guided selection of domains. Nine domains were identified as essential measures of nutrition in the HCS: (1) intake of selected foods and beverages; (2) food patterns and behaviors; (3) social support; (4) home environment; (5) school environment; (6) community environment; (7) breastfeeding history; (8) household food insecurity; and (9) dieting behaviors and body image. Children's dietary intake was assessed using a dietary screener and up to two automated 24-hour recalls. Dietary-related behaviors were assessed by a survey administered to the parent, child, or both, depending on child age. School nutrition measures were obtained from a combination of school staff surveys and researcher observations. Information from these measures is expected to contribute to a better understanding of "what is working" to improve the dietary behaviors that are likely to prevent obesity and improve health in children.

Consumer support for healthy food and drink vending machines in public places

Objective:To investigate the feasibility of introducing vending machines for healthier food into public places, and to examine the effectiveness of two front‐of‐pack labelling systems in the vending machine context. Methods:A survey was conducted with 120 students from a university and 120 employees, patients and visitors of a hospital in regional NSW, Australia. Questions explored vending machine use, attitudes towards healthier snack products and price, and the performance of front‐of‐pack labelling formats for vending machine products. Results:Most participants viewed the current range of snacks and drinks as “too unhealthy” (snacks 87.5%; drinks 56.7%). Nuts and muesli bars were the most liked healthier vending machine snack. Higher proportions of participants were able to identify the healthier snack in three of the five product comparisons when products were accompanied with any type of front‐of‐pack label (all p<0.01); however, participants were less likely to be able to identify the healthier product in the drinks comparison when a front‐of‐pack guide was present. Conclusion:Respondents were interested in a range of healthier snacks for vending machines. Front‐of‐pack label formats on vending machines may assist consumers to identify healthier products. Implications:Public settings, such as universities and hospitals, should support consumers to make healthy dietary choices by improving food environments.

Fast-food fights: news coverage of local efforts to improve food environments through land-use regulations, 2001-2013. [corrected

Zoning and other land-use policies are a promising but controversial strategy to improve community food environments. To understand how these policies are debated, we searched existing databases and the Internet and analyzed news coverage and legal documentation of efforts to restrict fast-food restaurants in 77 US communities in 2001 to 2013. Policies intended to improve community health were most often proposed in urban, racially diverse communities; policies proposed in small towns or majority-White communities aimed to protect community aesthetics or local businesses. Health-focused policies were subject to more criticism than other policies and were generally less successful. Our findings could inform the work of advocates interested in employing land-use policies to improve the food environment in their own communities.

A Q methodology study of stakeholders’ views about accountability for promoting healthy food environments in England through the Responsibility Deal Food Network

In March 2011, the United Kingdom’s (UK’s) Government launched five Public Health Responsibility Deal Networks to address public health priorities. The Networks used voluntary partnerships to influence peoples’ choice architecture to move them toward healthier behaviors. The purpose of this research was to conduct an exploratory study of diverse stakeholders’ perspectives about perceived responsibility and accountability expectations to improve food environments in England through the Food Network partnerships. A purposive sample of policy elites (n=31) from government, academia, food industry and non-government organizations sorted 48 statements related to improving food environments in England. Statements were grounded in three theoretical perspectives (i.e., legitimacy, nudge and public health law). PQMethod 2.33 statistical software program used factor analysis to identify viewpoints based on intra-individual differences for how participants sorted statements. The results revealed three distinct viewpoints, which explained 64% of the variance for 31 participants, and emphasized different expectations about responsibility. The food environment protectors (n=17) underscored government responsibility to address unhealthy food environments if voluntary partnerships are ineffective; the partnership pioneers (n=12) recognized government–industry partnerships as legitimate and necessary to address unhealthy food environments; and the commercial market defenders (n=1) emphasized individual responsibility for food choices and rejected government intervention to improve food environments. Consensus issues included: protecting children’s right to health; food industry practices that can and should be changed; government working with industry on product reformulation; and building consumer support for economically viable healthy products. Contentious issues were: inadequacy of accountability structures and government inaction to regulate food marketing practices targeting children. We conclude that understanding different viewpoints is a step toward building mutual trust to strengthen accountability structures that may help stakeholders navigate ideologically contentious issues to promote healthy food environments in England.