Monitoring and benchmarking government policies and actions to improve the healthiness of food environments : a proposed Government Healthy Food Environment Policy Index

Government action is essential to increase the healthiness of food environments and reduce obesity, diet-related non-communicable diseases (NCDs), and their related inequalities. This paper proposes a monitoring framework to assess government policies and actions for creating healthy food environments. Recommendations from relevant authoritative organizations and expert advisory groups for reducing obesity and NCDs were examined, and pertinent components were incorporated into a comprehensive framework for monitoring government policies and actions. A Government Healthy Food Environment Policy Index (Food-EPI) was developed, which comprises a ‘policy’ component with seven domains on specific aspects of food environments, and an ‘infrastructure support’ component with seven domains to strengthen systems to prevent obesity and NCDs. These were revised through a week-long consultation process with international experts. Examples of good practice statements are proposed within each domain, and these will evolve into benchmarks established by governments at the forefront of creating and implementing food policies for good health. A rating process is proposed to assess a government's level of policy implementation towards good practice. The Food-EPI will be pre-tested and piloted in countries of varying size and income levels. The benchmarking of government policy implementation has the potential to catalyse greater action to reduce obesity and NCDs.

Family food environment and dietary behaviors likely to promote fatness in 5-6 year-old children

Background: The family food environment (FFE) is likely to exert important influences on young children's eating. Examination of multiple aspects of the FFE may provide useful insights regarding which of these might most effectively be targeted to prevent childhood obesity.

Objective: To assess the associations between the FFE and a range of obesity-promoting dietary behaviors in 5–6-year-old children.

Design: Cross-sectional study.

Subjects: Five hundred and sixty families sampled from three socio-economically distinct areas.

Measurements: Predictors included parental perceptions of their child's diet, food availability, child feeding practices, parental modeling of eating and food preparation and television (TV) exposure. Dietary outcomes included energy intake, vegetable, sweet snack, savory snack and high-energy (non-dairy) fluid consumption.

Results: Multiple linear regression analyses, adjusted for all other predictor variables and maternal education, showed that several aspects of the FFE were associated with dietary outcomes likely to promote fatness in 5–6-year-old children. For example, increased TV viewing time was associated with increased index of energy intake, increased sweet snack and high-energy drink consumption, and deceased vegetable intake. In addition, parent's increased confidence in the adequacy of their child's diet was associated with increased consumption of sweet and savory snacks and decreased vegetable consumption. 

Conclusion:  This study substantially extends previous research in the area, providing important insights with which to guide family-based obesity prevention strategies.

Associations between the home food environment and obesity-promoting eating behaviors in adolescence

Objective: This study examines relationships between multiple aspects of the home food environment and obesity-promoting characteristics of 12- to 13-year-old adolescents' diets, specifically frequency of consumption of high-energy fluids, sweet snacks, savory snacks, and take-out foods.

Research Methods: This was a cross-sectional study including 347 adolescents 12 to 13 years of age and their parents. Data were collected via self-completed surveys. The adolescents' diets were assessed using a Food Frequency Questionnaire derived from existing age-appropriate National Nutrition Survey data. An extensive range of domains within the home food environment were assessed. Bivariate linear regression analyses were run split by gender. Forced entry multiple linear regression analyses (adjusting for all variables significant in bivariate analyses as well as for maternal education) were also performed, stratified by the sex of the child.

Results: The influence of mothers, either as models for eating behaviors or as the providers of food, was pervasive. Mothers' intake of high-energy fluids (p = 0.003), sweet snacks (p = 0.010), savory snacks (p = 0.008), and take-out food (p = 0.007) was positively associated with boys' intake of all these foods. In addition, mothers' intake of high-energy fluids was positively associated with daughters' consumption of these drinks (p = 0.025). Furthermore, availability of unhealthy foods at home was positively associated with girls' sweet snack (p = 0.001), girls' savory snack (p < 0.001), boys' savory snack (p = 0.002), and, in the bivariate analyses, girls' high-energy fluid consumption (p = 0.002).

Discussion: This study of home food environment influences on adolescent diet highlights the pervasive influence of mothers in determining adolescents' obesity-promoting eating, providing direction for obesity prevention strategies and future research.

Measuring the `obesogenic` food environment in New Zealand primary schools

Childhood obesity is an increasing health problem in New Zealand and many other countries. Information is needed to guide interventions that reduce the ‘obesogenic’ (obesity-promoting) elements of school environments. The aim of this study was to identify and measure the obesogenic elements of the school environment and the canteen sales of energy-dense foods and drinks. A self-completion questionnaire was developed for assessing each school's nutrition environment and mailed to a stratified random sample of New Zealand schools. The responses from primary schools (n = 200, response rate 61%) were analysed. Only 15.5% of schools had purpose-built canteen facilities and over half ran a food service for profit (31% profit to the school, 24.5% profit for the contractors). Only 16.5% of schools had a food policy, although 91% of those rated the policy as effective or very effective. The most commonly available foods for sale were pies (79%), juice (57%) and sausage rolls (54.5%). Filled rolls were the most expensive item (mean $1.79) and fruit the least expensive (mean $0.47). The ratio of ‘less healthy’ to ‘more healthy’ main choices was 5.6:1, for snacks it was 9.3:1 and for drinks it was 1.4:1. In contrast, ~60% of respondents said that nutrition was a priority for the school. Only 50% felt there was management support for healthy food choices and only 39% agreed that mainly nutritious food was offered by the food service. ‘Less healthy’ choices dominated food sales by more than 2:1, with pies being the top selling item (>55 000 per week). We found that the food environment was not conducive to healthy food choices for the children at New Zealand schools and that this was reflected in the high sales of relatively unhealthy foods from the school food services. Programmes that improve school food through policies, availability, prices and school ethos are urgently needed.

Children's fruit and vegetable intake : Associations with the neighbourhood food environment

Objective : To examine associations between availability of different types of food outlets and children's fruit and vegetable intake.
Method : Parents of 340 5–6 and 461 10–12 year-old Australian children reported how frequently their child ate 14 fruits and 13 vegetables in the last week in 2002/3. A geographic information system (GIS) was used to determine the availability of the following types of food outlets near home: greengrocers; supermarkets; convenience stores; fast food outlets; restaurants, cafés and takeaway outlets. Logistic regression analyses examined the likelihood of consuming fruit ≥ 2 times/day and vegetables ≥ 3 times/day, according to access to food outlets.
Results : Overall, 62.5% of children ate fruit ≥ 2 times/day and 46.4% ate vegetables ≥ 3 times/day. The more fast food outlets (OR = 0.82, 95%CI = 0.67–0.99) and convenience stores (OR = 0.84, 95%CI = 0.73–0.98) close to home, the lower the likelihood of consuming fruit ≥ 2 times/day. There was also an inverse association between density of convenience stores and the likelihood of consuming vegetables ≥ 3 times/day (OR = 0.84, 95%CI = 0.74–0.95). The likelihood of consuming vegetables ≥ 3 times/day was greater the farther children lived from a supermarket (OR = 1.27, 95%CI = 1.07–1.51) or a fast food outlet (OR = 1.19, 95%CI = 1.06–1.35).
Conclusion : Availability of fast food outlets and convenience stores close to home may have a negative effect on children's fruit and vegetable intake.

The school food environment : associations with adolescent soft drink and snack consumption

Background
Because students may purchase food and drinks in and around their schools, the school food environment may be important for obesity-related eating behaviors such as soft drink and snack consumption. However, research exploring the associations between school environments and specific eating behaviors is sparse.

Methods
Associations of the availability of canteen food and drinks, the presence of food stores around schools, and individual cognitions (attitudes, norms, modeling, perceived behavioral control, and intentions) with soft drink and snack consumption were examined in a cross-sectional study (2005–2006) among 1293 adolescents aged 12–15 years. Soft drink and snack consumption and related cognitions were assessed with self-administered questionnaires. The presence of food stores and the distance to the nearest food store were calculated within a 500-meter buffer around each school. Data on the availability of soft drinks and snacks in school canteens were gathered by observation. In 2007, multilevel regression models were run to analyze associations and mediation pathways between cognitions, environmental factors, and behaviors.

Results
Adolescents' attitudes, subjective norms, parental and peer modeling, and intentions were positively associated with soft drink and snack consumption. There was an inverse association between the distance to the nearest store and the number of small food stores with soft drink consumption. These effects were mediated partly by cognitions.

Conclusions
This study provided little evidence for associations of environmental factors in the school environment with soft drink and snack consumption. Individual cognitions appeared to be stronger correlates of intake than physical school-environmental factors. Longitudinal research is needed to confirm these findings.

Socioeconomic variations in women's diets : what is the role of perceptions of the local food environment

Objectives : To test the contribution of perceived environmental factors (food availability, accessibility and affordability) to mediating socioeconomic variations in women’s fruit, vegetable and fast food consumption.

Methods : A community sample of 1580 women from 45 neighbourhoods provided survey data on their socioeconomic position (SEP) (education and income); diet (fruit, vegetable and fast food consumption); and the perceived availability of, access to and cost of healthy food in their local area.

Results : Once perceived environmental variables were considered, the associations between SEP and diet were weak and non-significant, suggesting that socioeconomic differences in diet were almost wholly explained by perceptions of food availability, accessibility and affordability.

Conclusions : Strategies to decrease socioeconomic inequalities in diet could involve promoting inexpensive ways to increase fruit and vegetable consumption, and ensuring that people of low SEP are aware that many healthy foods are available at relatively low cost. Future research should also confirm if perceptions match objective measures of food availability, accessibility and affordability, in order to address the real and/or perceived lack of healthy options in low SEP neighbourhoods.

Longitudinal examination of the family food environment and weight status among children

Objective. To examine whether aspects of the family food environment were associated with body mass index (BMI) z-score and weight status in children, cross-sectionally and prospectively over 3 years.

Methods. Four aspects of the family food environment (breakfast eating patterns, food consumption while watching television, parental provision of energy-dense foods and child consumption of energy-dense food at home and away from home) were assessed with a questionnaire completed by parents of 161 children aged 5-6 years and 132 children aged 10-12 years in Melbourne, Australia in 2002/03. In 2002/03 and 2006, children's BMI z-score and weight status (non-overweight or overweight) was calculated from measured height and weight. Results. At baseline, 19% of younger and 21% of older children were overweight. Three years later, a greater proportion of younger (now aged 8-9 years) compared with older (aged 13-15 years) children were classified as overweight (28% versus 18%). Few of the family food environment variables were associated with children's BMI z-score and weight status cross-sectionally and longitudinally. However, among older children, more frequent dinner consumption while watching television was associated with a higher BMI z-score longitudinally (B = 0.3, 95% CI = 0.0, 0.6), less frequent breakfast consumption was associated with higher odds of overweight longitudinally (OR = 2.2, 95% CI = 1.1-4.7), and more frequent fast food consumption at home was associated with higher odds of overweight cross-sectionally (OR = 3.1, 95% CI = 1.4-7.0).

Conclusions. This study found few significant associations between aspects of the family food environment and BMI z-score or weight status in a sample of Australian children.

Children's takeaway and fast-food intakes: associations with the neighbourhood food intakes : associations with the neighbourhood food environment

Objective: The present study aimed to examine associations between availability of outlets where takeaway or fast food could be purchased and consumption of takeaway or fast food among children.

Design Cross-sectional: Parents completed a questionnaire regarding the frequency per week their child usually ate takeaway or fast foods. The availability of outlets where these foods could be purchased close to home and en route to school was determined with a Geographic Information System (presence of any outlets and density of outlets within 800 m from home and along the route to school, and distance from home to closest outlet).

Setting: Greater Melbourne and Geelong, Australia.

Subjects: Three hundred and fifty-three children aged 5–6 years and 463 children aged 10–12 years.

Results: Overall, 69·4 % of children consumed takeaway or fast foods once weekly or more often. Only one measure of availability of outlets close to home was associated with consumption; each additional outlet within 800 m was associated with 3 % lower odds of consuming takeaway or fast foods at least once weekly (OR = 0·97, 95 % CI 0·95, 1·00). There were no associations between availability en route to school and the likelihood of consuming takeaway or fast food at least once weekly.

Conclusions:  Access to outlets where takeaway or fast food could be purchased did not predict frequency of consumption of takeaway or fast food in the expected direction. Such relationships appear to be complex and may not be adequately captured by the measures of access included in the current study.

Evidence-informed process to identify policies that will promote a healthy food environment in the Pacific Islands

Objective: To implement a systematic evidence-informed process to enable Fiji and Tonga to identify the most feasible and targeted policy interventions which would have most impact on diet-related non-communicable diseases.

Design: A multisectoral stakeholder group of policy advisers was formed in each country. They used participatory approaches to identify the problem policies and gaps contributing to an unhealthy food environment. Potential solutions to these problems were then identified, and were assessed by them for feasibility, effectiveness, cost-effectiveness and side-effects. Data were gathered on the food and policy environment to support the assessments. A shortlist of preferred policy interventions for action was then developed.

Results: Sixty to eighty policy problems were identified in each country, affecting areas such as trade, agriculture, fisheries and pricing. Up to 100 specific potential policy solutions were then developed in each country. Assessment of the policies highlighted relevant problem areas including poor feasibility, limited effectiveness or cost-effectiveness and serious side-effects. A shortlist of twenty to twenty-three preferred new policy options for action in each country was identified.

Conclusions: Policy environments in these two countries were not conducive to supporting healthy eating. Substantial areas of potential action are possible, but some represent better choices. It is important for countries to consider the impact of non-health policies on diets.

Towards understanding the new food environment for refugees from the Horn of Africa in Australia

The study explored how African migrant communities living in North-West Melbourne, Australia, conceptualise and interpret the Australian food system from an intergenerational perspective and how this impacts on their attitudes and beliefs about food in Australia. Using a qualitative approach that involved 15 adolescents and 25 parents, the study found significant intergenerational differences in four themes that characterised their new food environment: (1) an abundance of cheap and readily available processed and packaged foods, (2) nutrition messages that are complex to gauge due to poor literacy levels, (3) promotion of a slim body size, which contradicts pre-existing cultural values surrounding body shapes and (4) Australian food perceived as being full of harmful chemicals. In order to develop effective culturally competent obesity prevention interventions in this sub-population, a multigenerational approach is needed.