ArticlePDF AvailableLiterature Review

Abstract

The authors provide a conceptual model of a healthy nutrition environment, then review the types of measures required to assess various aspects of this environment. Measures fall into priority categories of consumer and community environments.
330 American Journal of Health Promotion
THE
S
CIENCE OF HEALTH PROMOTION
Critical Issues and Trends
Healthy Nutrition Environments:
Concepts and Measures
Karen Glanz, PhD, MPH; James F. Sallis, PhD; Brian E. Saelens, PhD; Lawrence D. Frank, PhD
INTRODUCTION
The widespread prevalence of obesity is poorly ex-
plained by individual-level psychological and social corre-
lates of diet and physical activity behaviors. Moreover, ad-
vice to simply ‘eat less and move more’ ignores the com-
plex influences of the social and built environments on
individuals’ access to affordable, healthful food and activi-
ty-friendly communities. Although the body of research
on active living environments has recently grown expo-
nentially,
1–4
the same cannot be said for our understand-
ing of healthy nutrition environments.
Eating, or ‘‘nutrition environments,’ are widely be-
lieved to contribute to the increasing epidemics of child-
hood and adult obesity in the United States and globally.
Numerous authors and agencies, including the World
Health Organization,
14
the Institute of Medicine,
5,15
the
International Obesity Task Force,
16
and the Centers for
Disease Control,
11
have identified environmental and poli-
cy interventions as the most promising strategies for creat-
ing population-wide improvements in eating, physical ac-
tivity, and weight status.
5–13
To make significant progress
in this area of inquiry, and to inform public health policy,
well-defined concepts and valid, reliable measures of nu-
trition environments are needed. The purposes of this ed-
itorial are to provide a brief selective overview of the liter-
ature on food environments, propose a conceptualization
of nutrition environments, and describe our work to de-
velop and test measures of nutrition environments.
Karen Glanz is with the Rollins School of Public Health, Emory
University, Atlanta, Georgia. James F. Sallis is at San Diego
State University, San Diego, California. Brian E. Saelens is at
the University of Cincinnati, Cincinnati, Ohio. Lawrence D.
Frank is with the University of British Columbia, Vancouver,
British Columbia, Canada.
Send reprint requests to Dr Karen Glanz, Rollins School of Public
Health, Emory University, 1518 Clifton Road, NE, Room 526, Atlanta,
GA 30322; kglanz@sph.emory.edu.
This manuscript was an invited submission.
Am J Health Promot 2005;19(5):330–333.
Copyright
q
2005 by American Journal of Health Promotion, Inc.
0890-1171/05/$5.00
1
0
SUMMARY OF THE LITERATURE ON
NUTRITION ENVIRONMENTS
Several studies have examined schools as important
sources of children’s food.
17–20
For example, fruit and veg-
etable availability and school lunch selection correlate
with youth fruit and vegetable consumption.
21–26
The nutrition environment might explain some of the
racial/ethnic and socioeconomic disparities in nutrition
and health outcomes. For instance, fast-food restaurants
are more prevalent in minority neighborhoods, whereas
supermarkets are less prevalent.
27–29
Some healthy foods,
such as low-fat dairy products
30
and fruits and vegetables,
are less available or of poorer quality in minority and low-
er income areas.
28,31
A recent, important publication re-
ported that African-American adults’ fruit and vegetable
intake increased with each additional supermarket in a
census tract.
27
The nutrition environment in the United States has
been changing rapidly. The increasing popularity of din-
ing out over the past two decades has raised the propor-
tion of nutrients obtained at away-from-home food sourc-
es.
32
Away-from-home foods typically contain more fat and
saturated fat and less fiber than foods prepared at
home.
32
Expanding portion sizes appear to be contribut-
ing to the obesity epidemic.
33
Price and availability are influential features of the nu-
trition environment—and the influences are not necessar-
ily health promoting. Cost has been reported as the sec-
ond most important factor in food decisions, behind
taste.
34
Government regulations that affect price are con-
sistent influences on the purchase of fruits, vegetables,
beef, and pork.
35
Vending machine purchases have also
been shown to relate to price. A recent study showed a
93% increase in low-fat snack sales after a 50% price re-
duction.
36
Although the literature to date is limited, di-
verse studies support the principle that nutrition environ-
ments might be important influences on eating behavior
and could help explain disparities in behavior and dis-
ease. In the context of an obesity epidemic,
37
it is essen-
tial to improve our understanding of food environments
as rapidly as possible.
CONCEPTUALIZING AND MEASURING
NUTRITION ENVIRONMENTS
We propose a conceptual model for the study of nutri-
tion environments based on an ecological model of health
May/June 2005, Vol. 19, No. 5 331
Figure 1
Model of Community Nutrition Environments
behavior
6,38
and ongoing work by the authors supported
by the Robert Wood Johnson Foundation. The model in-
corporates constructs found or hypothesized to be related
to the healthy eating outcomes from the fields of public
health, health psychology, consumer psychology, and ur-
ban planning. The model in Figure 1 identifies four types
of nutrition environments that need to be studied, and
those environments are affected by policies of govern-
ments and other organizations. Food environments are
shown as having two pathways of influence on eating pat-
terns. Environmental effects can be moderated or mediat-
ed by demographic, psychosocial, or perceived environ-
ment variables. Environmental, social, and individual fac-
tors influence eating patterns, which in turn affect risk of
many chronic diseases.
This model has been used to guide the development of
nutrition environment measures that are needed to sup-
port studies of environments and eating behaviors. Be-
cause of the large number of potential variables that
could be measured, we have identified the ‘‘community
nutrition environment’’ and the ‘consumer nutrition en-
vironment’ as highest priority because they have been less
studied and could have broad effects.
At the general community environment level, we can
observe the distribution of food sources, that is the num-
ber, type, and location and accessibility of food outlets.
Accessibility can include drive-through windows and hours
of operation. Stores and restaurants are the most numer-
ous food outlets. We term other sources of food, such as
homes and cafeterias in schools, worksites, and other loca-
tions such as churches and healthcare facilities as ‘‘organi-
zational nutrition environments’ that generally are avail-
able to defined groups rather than to the general popula-
tion. Several sources of data could be used for identifying
food outlets in communities: GIS-based analyses of land
use data, census data, food license lists from health and
agriculture departments, Web site searches, and online
Yellow Pages and phone books. Each method has advan-
tages and limitations, and a combination is probably the
best way to assure coverage.
The home environment could be the most complex
and dynamic food source. Food at home is affected by
food availability at other outlets. Frequency of shopping
can affect the environment’s effect on food choice. The
primary food shopper and preparer has particular influ-
ence on the eating patterns of others in the household,
so there is a strong social influence component. The avail-
ability of food and parental influence are especially strong
for children.
15
Several recently reported studies examined community-
level access to food sources, such as grocery stores and
fast-food restaurants, and have found community-level as-
sociations related to socioeconomic, racial, and ethnic
health patterns.
29,30,39
Others have found correlations of
neighborhood characteristics with individual food pur-
chasing or consumption behaviors.
27,40
Although these re-
lationships are particularly intriguing, such ecological
studies might oversimplify complex systems.
41
They sug-
gest broad policy opportunities for health promotion, but
such efforts might be misdirected if the root causes are
not examined more closely. These findings are consistent
with the ‘‘gravity model,’ which is employed in transpor-
tation and urban planning research; it predicts aggregate
human behaviors related to spatial interaction, such as
traffic flow and shopping activities.
42
Recent results also
support the usefulness of Zipfs Principle of Least Effort,
332 American Journal of Health Promotion
which suggests that relative proximity in space of healthy
vs. unhealthy food products affects the odds of a healthy
vs. an unhealthy diet.
43
Consumer environment data reflect what consumers
encounter within and around a retail food outlet (i.e.,
store or restaurant), and most of these characteristics also
will apply to food sources in organizational environments,
although the home might be a special case. Relevant char-
acteristics can include nutritional qualities, price, promo-
tions, placement, range of choices, freshness, and nutri-
tional information. In retail food stores, the target catego-
ries of food of broadest interest would be those most
closely related to obesity and other chronic diseases (i.e.,
those that contribute most to fat and calories
44
and those
that are most recommended for healthful eating
45,46
and
are consistent with the Dietary Guidelines for Americans
and the Food Guide Pyramid
47,48
). Therefore, the categories
of foods of highest priority are proposed as dairy products,
meat and poultry, fruits and vegetables, packaged main
dishes, and baked goods/sweets.
Our current work developing environmental assess-
ments in retail food stores (grocery/supermarket and
convenience stores) measures two factors for fresh and
packaged food products: availability of healthy food op-
tions (low-fat, vegetables, fruits or unsweetened fruit juic-
es) and cost. Cost is assessed per pound for fruits and veg-
etables and for ‘‘healthy’ vs. ‘regular’ options for compa-
rable products, such as low-fat dairy products, lean meats,
and prepackaged main dishes. Specific criteria for what is
‘healthful’’ have been suggested by various health re-
searchers and community and government agen-
cies,
45,46,49,50
and these criteria should be adapted for use
in consumer nutrition environment indicators.
Some of the earliest published measures of availability
were reported by Cheadle and others,
51–53
who calculated
the percentage of shelf space used for healthy food op-
tions, such as low-fat milk and cheese and lean meats.
These measures are theoretically robust but could be
more difficult to apply in contemporary grocery stores
that are larger and more varied in layout than they were a
decade ago. Other opportunities for consumer-level mea-
sures in stores include assessing product promotion and
placement related to children (e.g., store displays market-
ing energy-dense foods; unhealthy products on lower
shelves). These issues have been found to be important in
tobacco control efforts.
54
Assessments of the consumer nutrition environment at
restaurants, including fast-food restaurants, are more chal-
lenging than food store measures, and there are few pub-
lished examples.
55,56
We propose restaurant evaluations
initially focus on four indicators of the availability of
healthy choices or options: healthy main dish choices
(low-fat, low-calorie, healthy main dish salads), availability
of fruit (without added sugar or sauce), availability of
nonfried vegetables (and vegetables without fat-laden
sauces), and portion sizes (availability of small portions
and, for chain restaurants, presence of ‘super-sizing’’).
These selected key variables are recognized in the descrip-
tive literature as contributing to consumer food choice
and are most likely to affect weight and cardiovascular
risk factors. Because many restaurant chains and most fast-
food restaurants publish their menus and nutrient values,
it is possible to obtain nutritional information from books
or on the internet. However, an important caveat is that
such information is seldom available at the point of
choice, where it would be most informative to customers.
Other key data sources for restaurant environments in-
clude reviewing menus, interviewing managers or making
inquiries to waiters, and visual scanning of the restaurant
environment. Although it might be easy to determine
whether restaurants offer super-sized items, other dimen-
sions of restaurant offerings are more difficult to evaluate
if nutrition information is not provided.
We identify the ‘‘information environment’’ as a
fourth, independent type of environment whereby media
reports and advertising are affected by government and
industry policies, and could in turn affect attitudes and
the appeal of certain foods and food sources. The infor-
mation environment is unique because it can operate on
a national or regional level, as well at the neighborhood
and store or restaurant level.
Although there are an increasing number of reports of
various dimensions of nutrition environments, there is no
guidance in the literature on how best to measure nutri-
tion environments in a comprehensive manner. Our typol-
ogy is based on an ecological model, our field experience,
criteria put forward by authoritative health groups, and
preliminary studies. Our Nutrition Environment Measure-
ment Study (NEMS), currently underway, is an effort to
develop a comprehensive set of tools that is reliable and
demonstrates criterion validity to characterize nutrition
environments in neighborhoods. In defining these mea-
sures, we have been attentive to the nutritional meaning-
fulness of indicators, relevance and feasibility of measures,
and potential for linking environmental and individual as-
sessments in subsequent studies.
CONCLUSION
The model in Figure 1 is presented as a starting point
for conceptualizing nutrition environment variables that
are believed to be related to eating behaviors. On the ba-
sis of a broad consideration of nutrition environments,
our group prioritized specific variables in the community
and consumer environments. Measures are being devel-
oped that will allow associations between environments
and eating behavior to be tested. It is likely other investi-
gators will prioritize other food environment variables, so
additional measures will need to be developed. More set-
ting-specific models might be needed as well. The com-
plexity of the research area is clear, but given the public
health imperative to improve eating behaviors in the pop-
ulation,
37
greater priority needs to be given to under-
standing the role of food environments on individual’s
eating patterns.
Acknowledgment
This work was supported in part by a grant from the Robert Wood Johnson Founda-
tion for the Nutrition Environment Measures Study (NEMS).
May/June 2005, Vol. 19, No. 5 333
References
1. Humpel N, Owen N, Leslie E. Environmental factors associated with
adults’ participation in physical activity: a review. Am J Prev Med. 2002;22:
188–199.
2. Saelens BE, Sallis JF, Frank LD. Environmental correlates of walking and
cycling: findings from the transportation, urban design, and planning lit-
erature. Ann Behav Med 2003;25:80–91.
3. Owen N, Humpel N, Leslie E, et al. Understanding environmental influ-
ences on walking: review and research agenda. Am J Prev Med. 2004;27:
67–76.
4. Frank LD, Schmid T, Sallis JF, et al. Linking objectively measured physical
activity with objectively measured urban form: findings from SMARTRAQ.
Am J Prev Med. 2005;28(suppl 2):117–125.
5. Institute of Medicine. Health and Behavior: The Interplay of Biological, Behav-
ioral, and Societal Influences. Washington, DC: National Academy Press;
2001.
6. Booth SL, Sallis JF, Ritenbaugh C, et al. Environmental and societal fac-
tors affect food choice and physical activity: rationale, influences, and le-
verage points. Nutr Rev. 2001;3:21–39.
7. Hill JO, Wyatt, HR, Reed GW, Peters JC. Obesity and the environment:
where do we go from here? Science. 2003;299:853–855.
8. Killingsworth R, Earp J, Moore R. Supporting health through design:
challenges and opportunities. Am J Health Promot. 2003;18:1–3.
9. Glanz K, Lankenau B, Foerster S, et al. Environmental and policy ap-
proaches to cardiovascular disease prevention through nutrition: opportu-
nities for state and local action. Health Educ Q. 1995;22:512–527.
10. Glanz K, Hoelscher D. Increasing fruit and vegetable intake by changing
environments, policy and pricing: restaurant-based research, strategies,
and recommendations. Prev Med. 2004;39:S88–S93.
11. Koplan JP, Dietz WH. Caloric imbalance and public health policy. JAMA
2000;282:1579–1581.
12. Nestle M, Jacobson, MF. Halting the obesity epidemic: a public health
policy approach. Public Health Rep. 1999;115:12–24.
13. Stokols D, Grzywacz JG, McMahan S, Phillips K. Increasing the health
promotive capacity of human environments. Am J Health Promot. 2003;18:
4–13.
14. World Health Organization. Global strategy on diet, physical activity, and
health. Available at: http://www.who.int/dietphysicalactivity/. Accessed
December 6, 2004.
15. Koplan JP, Liverman CT, Kraak VI, eds. Preventing Childhood Obesity: Health
in the Balance. Washington, DC: Institute of Medicine; 2004.
16. Kumanyika SK, Jeffery RW, Morabia A, et al. Obesity prevention: the case
for action. A report of the Public Health Approaches to the Prevention
of Obesity Working Group of the International Obesity Task Force. Avail-
able at: http://www.iotf.org. Accessed: November 2000.
17. Zive MM, Elder JP, Prochaska JJ, et al. Sources of dietary fat in middle
schools. Prev Med. 2002;35:376–382.
18. French SA, Story M, Fulkerson JA, Gerlach AF. Food environment in sec-
ondary schools: a la carte, vending machines, and food policies and prac-
tices. Am J Public Health. 2003;93:1161–1167.
19. Kubik MY, Lytle LA, Hannan PJ, et al. The association of the school food
environment with dietary behaviors of young adolescents. Am J Public
Health. 2003;93:1168–1173.
20. Lytle LA, Fulkerson JA. Assessing the dietary environment: examples
from school-based nutrition interventions. Public Health Nutr. 2002;5:893–
899.
21. Osganian SK, Ebzery MK, Montgomery DH, et al. Changes in the nutri-
ent content of school lunches: results from the CATCH Eat Smart food
service intervention. Prev Med. 1996;25:400–412.
22. Story M, Neumark-Sztainer D, French S. Individual and environmental in-
fluences on adolescent eating behaviors. J Am Diet Assoc. 2002;102:S40–
S51.
23. Cullen KW, Baranowski T, Rittenberry L, Olvera N. Social-environmental
influences on children’s diets: results from focus groups with African-,
Euro- and Mexican-American children and their parents. Health Educ Res.
2000;15:581–590.
24. Kratt P, Reynolds K, Shewchuk R. The role of availability as a moderator
of family fruit and vegetable consumption. Health Educ Behav. 2000;27:
471–482.
25. Gibson EL, Wardle J, Watts CJ. Fruit and vegetable consumption, nutri-
tional knowledge and beliefs in mothers and children. Appetite. 1998;31:
205–228.
26. Edmonds J, Baranowski T, Baranowski J, et al. Ecological and socioeco-
nomic correlates of fruit, juice, and vegetable consumption among Afri-
can-American boys. Prev Med. 2001;32:476–481.
27. Morland K, Wing S, Diez Roux A. The contextual effect of the local food
environment on residents’ diets: the Atherosclerosis Risk in Communities
(ARIC) study. Am J Public Health. 2002;92:1761–1767.
28. Sloane DC, Diamant AL, Lewis LB, et al. Improving the nutritional re-
source environment for healthy living through community-based partici-
patory research. J Gen Intern Med. 2003;18:568–575.
29. Block JP, Scribner RA, DeSalvo KB. Fast food, face/ethnicity, and income:
a geographic analysis. Am J Prev Med. 2004;27:211–217.
30. Wechsler H, Basch CE, Zybert P, et al. The availability of low-fat milk in
an inner-city Latino community: implications for nutrition education. Am
J Public Health. 1995;85:1690–1692.
31. Horowitz CR, Colson KA, Hebert PL, Lancaster K. Barriers to buying
healthy foods for people with diabetes: evidence of environmental dispar-
ities. Am J Public Health. 2004;94:1549–1554.
32. Lin BH, Frazao E, J Guthrie. Away-From-Home Foods Increasingly Important to
Quality of American Diet. Washington, DC: Agriculture Information Bulletin
749; 1999.
33. Young LR, Nestle M. The contribution of expanding portion sizes to the
US obesity epidemic. Am J Public Health. 2002;92:246–249.
34. Glanz K, Basil M, Maibach E, et al. Why Americans eat what they do:
taste, nutrition, cost, convenience, and weight control as influences on
food consumption. J Am Diet Assoc. 1998;98:1118–1126.
35. Ralston K. How government policies and regulations can affect food
choices. In: Frazao, E, ed. America’s Eating Habits: Changes and Consequenc-
es. Washington, DC: Agriculture Information Bulletin 750; May 1999.
36. French SA, Jeffery RW, Story M, et al. Pricing and promotion effects on
low-fat vending snack purchases: the CHIPS study. Am J Public Health.
2001;91:112–117.
37. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death
in the United States, 2000. JAMA. 2004;291:1238–1245.
38. Sallis JF, Owen N. Ecological models of health behavior. In Glanz K, Rim-
er BK, Lewis FM, eds. Health Behavior and Health Education: Theory, Re-
search, and Practice. 3rd ed. San Francisco, Calif: Jossey-Bass; 2002:462–484.
39. Morland K, Wing S, Roux AD, Poole C. Neighborhood characteristics as-
sociated with the location of food stores and food service places. Am J
Prev Med. 2001;22:23–29.
40. Turrell G, Blakely T, Patterson C, Oldenburg B. A multilevel analysis of
socioeconomic (small area) differences in household food purchasing be-
havior. J Epidemiol Community Health. 2004;58:208–215.
41. Ham SA, Levin S, Zlot AI, et al. Ranking of cities according to public
health criteria: pitfalls and opportunities. Am J Public Health. 2004;94:546–
549.
42. Erlander S, Steward NF. The Gravity Model in Transportation Analysis—Theo-
ry and Extensions: Topics in Transportation. Philadelphia, Pa: Coronet Books;
1990.
43. Zipf, GK. Human Behavior and the Principle of Least Effort. Cambridge,
Mass: Addison-Wesley; 1949.
44. Peeters A, Barendregt JJ, Willekens F, et al. Obesity in adulthood and its
consequences for life expectancy: a life-table analysis. Ann Intern Med.
2003;138:24–32.
45. World Cancer Research Fund, American Institute for Cancer Research.
Food, Nutrition and the Prevention of Cancer: A Global Perspective. Washington,
DC: American Institute for Cancer Research; 1997.
46. California Center for Public Health Advocacy. School Nutrition Consensus
Panel: Competitive Food Standards Recommendations. Davis, Calif: California
Center for Public Health Advocacy; 2002.
47. US Departments of Agriculture and Health and Human Services. Nutri-
tion and Your Health: Dietary Guidelines for Americans. 5th ed. Washington,
DC: US Depts of Agriculture and Health and Human Services; 2000.
Home and Garden Bulletin 232. Also available at: http://
www.ars.usda.gov/dgac.
48. US Department of Agriculture. The Food Guide Pyramid. Home and Gar-
den Bulletin 252. Washington, DC: US Government Printing Office; 1992.
49. US Food and Drug Administration, Center for Food Safety and Applied
Nutrition. Reference values for nutritional labeling, revised June 1999;
and Nutrition information on restaurant menus, July 1996. Available at:
http://www.cfsan.fda.gov. Accessed February 24, 2003.
50. Sallis JF, Nader PR, Rupp JW, et al. San Diego surveyed for heart-healthy
foods and exercise facilities. Publ Health Rep. 1986;101:216–219.
51. Cheadle A, Psaty BM, Curry S, et al. Community-level comparison be-
tween the grocery store environment and individual dietary practices.
Prev Med. 1991;20:250–261.
52. Cheadle A, Psaty B, Wagner E, et al. Evaluating community-based nutri-
tion programs: assessing the reliability of a survey of grocery store prod-
uct displays. Am J Public Health. 1990;80:709–711.
53. Cheadle A, Wagner E, Koepsell T, Kristal A, Patrick D. Environmental in-
dicators: a tool for evaluating community-based health promotion pro-
grams. Am J Prev Med. 1992;8:345–350.
54. Feighery EC, Ribisl KM, Schleicher N, et al. Cigarette advertising and
promotional strategies in retail outlets: results of a statewide survey in
California. Tob Control. 2001;10:184–188.
55. Cheadle AD, Psaty BM, Curry S, et al. Assessing the validity of a survey of
the restaurant health environment. Am J Health Promot. 1994;9:88–91.
56. Cassady D, Houseman R, Dagher C. Measuring cues for healthy choices
on restaurant menus: development and testing of a measurement instru-
ment. Am J Health Promot. 2004;18:444–449.
A fusion of the best of science and the best of practice —
together, to produce the greatest impact.
Stay on top of the science and art of health promotion with
your own subscription to the American Journal of
Health Promotion.
The American Journal of Health Promotion provides a forum for that rare commodity
practical and intellectual exchange between researchers and practitioners. ”
Kenneth E. Warner, PhD
Avedis Donabedian Distinguished University Professor of Public Health
School of Public Health, University of Michigan
“ The contents of the American Journal of Health Promotion are timely, relevant, and
most important, written and reviewed by the most respected researchers in our field. ”
David R. Anderson, PhD
Vice Programs and Technology, StayWell Health Management
Definition of Health Promotion
“Health Promotion is the science and art of helping people
change their lifestyle to move toward a state of optimal
health. Optimal health is defined as a balance of physical,
emotional, social, spiritual and intellectual health. Lifestyle
change can be facilitated through a combination of efforts
to enhance awareness, change behavior and create
environments that support good health practices. Of the
three, supportive environments will probably have the
greatest impact in producing lasting change.”
(O’Donnell, American Journal of Health Promotion, 1989, 3(3):5.)
DIMENSIONS OF
OPTIMAL HEALTH
Subscribe today...
Editor in Chief
Michael P. O’Donnell, PhD, MBA, MPH
Associate Editors in Chief
Bradley J. Car
dinal, PhD
Diane H. Morris, PhD, RD
Judy D. Sheeska, PhD, RD
Mark G. Wilson, HSD
SECTION EDITORS
Interventions
Fitness
Barry A. Franklin, PhD
Medical Self-Care
Donald M. Vickery, MD
Nutrition
Karen Glanz, PhD, MPH
Smoking Control
Michael P. Eriksen, ScD
Weight Control
Kelly D. Brownell, PhD
Stress Management
Cary Cooper, CBE
Mind-Body Health
Kenneth R. Pelletier, PhD, MD (hc)
Social Health
Kenneth R. McLeroy, PhD
Spiritual Health
Larry S. Chapman, MPH
Strategies
Behavior Change
James F. Prochaska, PhD
Culture Change
Daniel Stokols, PhD
Health Policy
Kenneth E. Warner, PhD
Applications
Underserved Populations
Ronald L. Braithwaite, PhD
Health Promoting Community Design
Jo Anne L. Earp, ScD
Research
Data Base
David R. Anderson, PhD
Financial Analysis
Ron Z. Goetzel, PhD
Method, Issues, and Results in Evaluation
and Research
Lawrence W. Green, DrPH
Qualitative Research
Marjorie MacDonald, BN, PhD
Measurement Issues
Shawna L. Mercer, MSc, PhD
The Art of Health Promotion
Larry S. Chapman, MPH
ANNUAL SUBSCRIPTION RATES: (Good through 12/31/05)
Individual Institution
U.S. $99.95 $144.85
Canada and Mexico $108.95 $153.85
Other Countries $117.95 $162.95
CALL 800-783-9913 (U.S. ONLY) or 818-760-8520
OR FIND US ON THE WEB AT
http://www.HealthPromotionJournal.com
... Efforts have been made to translate concepts and constructs about the food environment into measurement tools that can generate empirical evidence [1][2][3][4][5][6] . The consumer food environment 1 , which was the object of interest in the present study, includes factors related to the food itself, i.e., the way in which it is provided or presented and the price, nutritional quality and nutritional labeling (including nutrition claims), among other factors. ...
... The consumer food environment 1 , which was the object of interest in the present study, includes factors related to the food itself, i.e., the way in which it is provided or presented and the price, nutritional quality and nutritional labeling (including nutrition claims), among other factors. The consumer's food environment may be inserted into organizational environments, such as companies and universities 1 . In the literature, the most commonly reported method for evaluating the consumer food environment is the auditing of establishments that sell food. ...
... The university food environment, which was the scenario of interest of this study, can be characterized by the availability of foods, preparations and beverages (FPB), physical and financial accessibility, the promotion of FPB, nutritional information and advertising within the campus and may also include the campus surroundings. It is known that this environment influences the eating habits of the individuals who are exposed to it 10 , since it can act as a facilitator of or barrier to healthy choices 1,10 given that meals consumed at the university may be an important part of the diet of students, teachers and employees 11,12 . ...
Article
Full-text available
This study aimed to evaluate the content validity and reliability of an instrument for evaluating the university food environment. A checklist was developed to assess establishments that sell food and beverages in the university environment. The content validation encompassed the development of the instrument, expert evaluation and pretest performance. Reliability was evaluated using a convenience sample (n=64) of establishments distributed across seven campuses of three public universities and was carried out using interobserver (IO) and test-retest (TR) evaluations. Categorical and count variables were analyzed by calculating the percentage agreement (PA), kappa coefficient (k) and prevalence-adjusted , bias-adjusted kappa (ka), and continuous variables were analyzed by the intraclass correlation coefficient (ICC). The checklist consisted of 204 items distributed in seven domains. The in-strument's performance was considered excellent or very good for 91.3% (PA) of the items when evaluated. For IO, 68.3% (k) and 96.5% (ka) had excellent, very good or good agreement, while for TR, 65% (k) and 96.5% (ka) had excellent agreement. The instrument showed satisfactory content validity and reliability for characterizing the food environment at Brazilian universities.
... Obtaining recommended energy intake would have positive impacts not only on the environment but also on Ontarians' health by reducing excess calories that lead to increased body mass and associated non-communicable diseases. However, it has always been extremely challenging to get individuals to change their eating habits due to the influence of nutrition environments [47], which reflect consumer interactions with food outlets, such as restaurants or grocery stores, and their social environment, including family and social influencers [47]. For example, for low-income consumers, dietary choices are significantly impacted by cost compared to other factors [48,49]. ...
... Obtaining recommended energy intake would have positive impacts not only on the environment but also on Ontarians' health by reducing excess calories that lead to increased body mass and associated non-communicable diseases. However, it has always been extremely challenging to get individuals to change their eating habits due to the influence of nutrition environments [47], which reflect consumer interactions with food outlets, such as restaurants or grocery stores, and their social environment, including family and social influencers [47]. For example, for low-income consumers, dietary choices are significantly impacted by cost compared to other factors [48,49]. ...
Article
Full-text available
Many studies have evaluated the life cycle environmental impacts of diets based on a single period, but few studies have considered how environmental impacts of diets change over time, even though dietary patterns (DPs) change due to policy and socio-demographic factors. This study evaluated changes in the global warming potential (GWP) of DPs in the province of Ontario, Canada, using a life cycle assessment. We quantified the farm-to-fork GWP of six DPs (Omnivorous, No Pork, No Beef, No Red Meat, Pescatarian, and Vegetarian), using dietary intake data from a 2014 and 2015 survey. Throughout this period, the biggest decrease in GWP was for DPs containing beef, even though these DPs still have the highest GWP (3203 and 2308 kg CO2e, respectively, based on the annual energy intake of one individual). Across all DPs, plant-based proteins contributed less than 5% to GWP, while meat and fish contributed up to 62% of the total GWP. Ten-year GWP reductions are insufficient to meet climate change and other sustainability goals, and major dietary shifts are needed, particularly substituting animal-based proteins with plant-based proteins. To design effective interventions for shifting towards sustainable diets, research is needed to understand how socio-demographic and regional differences influence individuals’ food choices.
... Emotions evoked by UPF may automatically elicit high levels of approach motivation and influence individuals' eating behavior, including the motivation to consume UPF rather than unprocessed/minimally processed foods (UMPF). High exposure and easy access to UPF in different food environments, such as communities and organizations, may intensify their appeal to consumers, which affects consumer behavior (28)(29)(30)(31). Thus, it is likely that emotions elicited by UPF available in food environments play a significant role in creating unhealthy and unsustainable diets. ...
Article
Full-text available
Background Ultra-processed foods (UPF) are becoming extensively available in the food environments. UPF are industrial formulations that are designed to maximize palatability and consumption through a combination of calorie-dense ingredients and chemical additives. UPFs are also aggressively marketed, which may make them more attractive than unprocessed/minimally processed foods (UMPF). Since consumers' purchase decisions are guided by food-evoked emotions, we aimed to provide evidence that UPF visual cues trigger higher emotional responses and approach motivation than UMPF visual cues, with potential impacts on individuals' intention to consume the UPF over the UMPF.Methods Participants (n = 174; 144 women; mean age = 20.7 years; standard deviation = 4.35) performed two tasks. In the first task, 16 pictures of foods (8 UPF and 8 UMPF), and 74 pictures from other affective categories, were presented. After viewing each picture, the participants rated it along two basic dimensions of emotion through the Self-Assessment Manikin scale: pleasantness and arousal. In the second task, the participants viewed the same food pictures, and they rated their intention to consume the foods depicted in the pictures. Each picture was plotted in terms of its mean pleasantness and arousal ratings in a Cartesian plane, which resulted in an affective space.ResultsPictures of UPF and UMPF were positioned in the upper arm of the boomerang-shaped affective space that represents approach motivation. Pictures containing UPF triggered higher approach motivation and intention to consume than pictures containing UMPF. We also found a stronger association between emotional responses and intention to consume UPF relative to UMPF.Conclusion These results shed new light on the role of ultra-processed foods evoked emotions that contribute to less healthy and sustainable food environments.
Article
Resumo O objetivo deste artigo é caracterizar os apelos publicitários presentes no ambiente alimentar para comercializar alimentos ultraprocessados e analisar o perfil nutricional desses alimentos segundo critérios da OPAS e presença de aditivos alimentares. Estudo transversal, com dados auditados em 20 pequenos supermercados de São Paulo. O protocolo INFORMAS foi utilizado para classificar as mensagens publicitárias. Os alimentos foram classificados segundo a NOVA. O perfil nutricional da OPAS foi utilizado para classificar os alimentos elevados em nutrientes críticos. Os padrões de publicidade foram identificados por análise fatorial. A associação entre os padrões e os grupos de alimentos foi investigada por regressão linear. Mais de 95% dos alimentos ultraprocessados tinham pelo menos um nutriente crítico em excesso. Verificou-se associação positiva entre o padrão nova marca, divertido e vantajoso com salgadinhos, produtos pré-prontos, lácteos e biscoitos, e entre o padrão nova marca e uso sugerido com lácteos. A padronização da publicidade de alimentos nos pequenos comércios varejistas está associada à oferta de salgadinhos, produtos lácteos, alimentos pré-prontos e biscoitos, produtos que excedem em nutrientes críticos.
Article
This article aims to characterize the advertising appeals present in the food environment to market ultra-processed foods and to analyze the nutritional profile of these foods according to PAHO criteria and the presence of food additives. Cross-sectional study, with data audited in 20 small supermarkets in São Paulo. The INFORMAS protocol was used to classify the advertising messages. The foods were classified according to NOVA. The PAHO profile model was used to classify foods high in critical nutrients. Advertising patterns were identified by factor analysis. The association between patterns and food groups was investigated by linear regression. More than 95% of the ultraprocessed foods had at least 1 critical nutrient in excess. There was a positive association between the new brand, fun and advantageous pattern with snacks, ready-made products, dairy products and cookies; between the new brand and suggested use pattern with dairy products. The standardization of food advertising in small retail stores is associated with offering snacks, dairy products, ready-to-eat foods and cookies, products that exceed critical nutrients.
Article
Resumo Avaliar possíveis diferenças nas trajetórias alimentares de estudantes segundo assiduidade ao Restaurante Universitário (RU) e forma de ingresso na universidade. Experimento natural com graduandos (n=1.131) de uma universidade pública brasileira. Em 2011 e 2013 foram aplicados questionários identificados e autopreenchidos presencialmente sobre consumo regular de alimentos marcadores de alimentação saudável ou não saudável, realização do almoço, jantar e substituição de almoço e/ou jantar por lanche. A variação das práticas alimentares regulares foi avaliada pela trajetória individual de cada estudante obtida pela combinação das respostas nos dois questionários. A análise da associação entre a assiduidade ao RU e a trajetória (positiva ou negativa) foi feita por meio de modelos de regressão logística múltipla. Observou-se associação (IC95% não sobrepostos) entre maior assiduidade ao RU e maior chance de trajetória positiva para realização de jantar e de almoço e para consumo de feijão, hortaliças, hortaliças cruas, frutas, biscoito de pacote, hambúrguer/embutidos e guloseimas e menor chance de trajetória negativa para feijão, hortaliças cruas e salgados fritos. A implementação do RU promoveu significativa melhoria da alimentação dos estudantes assíduos a ele, tanto cotistas quanto não cotistas.
Article
Foodscape conceptualizes the dynamic human–food–place nexus. Tourism provides a cross-cultural context where tourists can consume different destination foods and places, during which multiple types of destination foodscapes are produced. However, few studies explore how to frame the types and connotations of destination foodscape. Tourists’ travelogues provide a rich database to examine this question. Through netnography, this study collects and analyzes 86 posts of travelogues published from 2012 to 2019 in Mafengwo, a famous Chinese online travel community, about Chinese tourists’ food experiences in Chiang Mai, Thailand. We summarize five types of destination foodscapes, globalized recreational foodscape, staged local foodscape, glocalized foodscape, authentic local foodscape, and overseas ethnic foodscape in which tourists obtain different familiar-novelty hybrid experiences. This study contributes to interdisciplinary dialogue between food and tourism literature by proposing a coordinate framework with two axes, the spectrum of cultural distance and the spectrum of serving tourists/locals, to classify destination foodscape and a six-dimensional network construct to reveal the connotations of destination foodscape. Relevant strategies for promoting destination food and tourism development are also provided.
Article
Objective Characterize the community food environment through the different types of food outlets in the city of Fortaleza and associate their distribution according to sociodemographic indicators. Methods This is an ecological study carried out in the city of Fortaleza in which data from the Health Surveillance Service were used with the location of all licensed food stores in the city in the years 2018 and 2019. Georeferenced maps were set up to illustrate the spatial distribution of the establishments. Correlation analyses were performed to verify the association between food outlets and socioeconomic data. Values of p≤0.005 were considered significant. Results We identified a greater concentration of food stores in the neighborhoods with better socioeconomic levels. Snack bars (n=2051; 27.7%) and restaurants (n=1945; 26.3%), were in greater quantity and exhibited a positive correlation with the Human Development Index and average income. Supermarkets and hypermarkets (n=288; 3.9%) and street markets (n=81; 1.1%) were in a smaller number and had the worst spatial distribution. Conclusion We observed socioeconomic inequalities in the distribution of different types of food outlets. The little diversity and the limited number of establishments in peripheral neighborhoods, besides the centralization of outlets that sell food that is harmful to health, constitute obstacles for the population to make healthy food choices.
Article
The aim of this study was to analyze the availability of food stores in the territory of schools. Ecological study conducted in Viçosa, Minas Gerais, Brazil, with all schools (N=42) and food stores (N=656). Data were collected through the objective evaluation of the environment, and the stores were categorized into healthy, unhealthy, mixed and supermarkets. Bivariate Ripley´s K function assessed the existence of clustering of categories of stores in the territory of schools. All the schools had at least one food store in their territory. Unhealthy stores were the most common and closest to the schools. There were more stores around private schools, offering high school education, located in the central region and in the highest per capita income tercile. The bivariate Ripley´s K function showed evidence of clustering of stores at all analyzed distances (400 to 1.5 km) with up to 3 times more establishments than would be expected if they were randomly distributed. Therefore, schoolchildren were likely exposed to unhealthy food environments, regardless of neighborhood income and location, which may contribute to inadequate food choices.
Article
Objective To assess the validity of the Market Basket Analysis Tool (MBAT) for food environment quality within various retail environments compared to the Nutrition Environment Measures Survey in Stores (NEMS-S). Methods In-store assessments using the MBAT and the NEMS-S on the same day in a given store were conducted in grocery stores, corner stores, pharmacies, and dollar stores in a metropolis, and urban and rural counties across 4 states: Louisiana, Mississippi, North Carolina, and Virginia. Descriptive statistics, correlations, and ANOVAs were used to assess store location, store type differences, and MBAT and NEMS-S scores. Results Market Basket Analysis Tool and NEMS-S data were collected from 114 stores. Market Basket Analysis Tool and NEMS-S total and all individual component scores were significantly correlated (r = 0.84, P ≤ 0.0001; r range, 0.51–0.88; P ≤ 0.0001). Conclusions and Implications The MBAT offers a methodology to measure the food retail environment focusing on the availability of healthful food items with a reduced training time and streamlined data collection compared with the NEMS-S. Future work can assess the completion time of the MBAT compared with the NEMS-S and the ability of the MBAT to detect changes in food environment quality post healthy food retail interventions.
Article
Full-text available
The health of children and youth in US faces a dangerous setback regarding the epidemic of obesity. More than 9 million children over the age of 6 are considered obese, which means that they face serious immediate and long-term health risks. Schools are one of the primary locations for reaching children and youth, so it is important that the total school environment be structured to promote healthy eating habits and physical activity. Parents, the primary caretakers have profound effect on their children by fostering values and attitudes, rewarding specific behaviors and serving as role models. Preventing childhood obesity requires a comprehensive science-based approach that involves government, industry, communities, schools and families.
Article
Full-text available
Objective To examine the self-reported importance of taste, nutrition, cost, convenience, and weight control on personal dietary choices and whether these factors vary across demographic groups, are associated with lifestyle choices related to health (termed health lifestyle), and actually predict eating behavior.Design Data are based on responses to 2 self-administered cross-sectional surveys. The main outcomes measured were consumption of fruits and vegetables, fast foods, cheese, and breakfast cereals, which were determined on the basis of responses to questions about usual and recent consumption and a food diary.Subjects/setting Respondents were a national sample of 2,967 adults. Response rates were 71% to the first survey and 77% to the second survey (which was sent to people who completed the first survey).Statistical analyses Univariate analyses were used to describe importance ratings, bivariate analyses (correlations and t tests) were used to examine demographic and lifestyle differences on importance measures, and multivariate analyses (general linear models) were used to predict lifestyle cluster membership and food consumption.Results Respondents reported that taste is the most important influence on their food choices, followed by cost. Demographic and health lifestyle differences were evident across all 5 importance measures. The importance of nutrition and the importance of weight control were predicted best by subject's membership in a particular health lifestyle cluster. When eating behaviors were examined, demographic measures and membership in a health lifestyle cluster predicted consumption of fruits and vegetables, fast foods, cheese, and breakfast cereal. The importance placed on taste, nutrition, cost, convenience, and weight control also predicted types of foods consumed.Applications Our results suggest that nutritional concerns, per se, are of less relevance to most people than taste and cost. One implication is that nutrition education programs should attempt to design and promote nutritious diets as being tasty and inexpensive. J Am Diet Assoc. 1998;98:1118-1126.
Article
Full-text available
We are pleased that our article ( [1][1] ) has stimulated Butte and Ellis ( [2][2] ) to ask the question, “How much change in energy balance would be required to prevent weight gain in children?” The primary point of our article was that we need to set more realistic and specific goals for
Article
Research in transportation, urban design, and planning has examined associations between physical environment variables and individuals' walking and cycling for transport. Constructs, methods, and findings from these fields can be applied by physical activity and health researchers to improve understanding of environmental influences on physical activity. In this review, neighborhood environment characteristics proposed to be relevant to walking/cycling for transport are defined, including population density, connectivity, and land use mix. Neighborhood comparison and correlational studies with nonmotorized transport outcomes are considered, with evidence suggesting that residents from communities with higher density, greater connectivity, and more land use mix report higher rates of walking/cycling for utilitarian purposes than low-density, poorly connected, and single land use neighborhoods. Environmental variables appear to add to variance accounted for beyond sociodemographic predictors of walking/cycling for transport. Implications of the transportation literature for physical activity and related research are outlined. Future research directions are detailed for physical activity research to further examine the impact of neighborhood and other physical environment factors on physical activity and the potential interactive effects of psychosocial and environmental variables. The transportation, urban design, and planning literatures provide a valuable starting point for multidisciplinary research on environmental contributions to physical activity levels in the population.
Article
Environmental factors may contribute to the increasing prevalence of obesity, especially in black and low-income populations. In this paper, the geographic distribution of fast food restaurants is examined relative to neighborhood sociodemographics.Methods Using geographic information system software, all fast-food restaurants within the city limits of New Orleans, Louisiana, in 2001 were mapped. Buffers around census tracts were generated to simulate 1-mile and 0.5-mile “shopping areas” around and including each tract, and fast food restaurant density (number of restaurants per square mile) was calculated for each area. Using multiple regression, the geographic association between fast food restaurant density and black and low-income neighborhoods was assessed, while controlling for environmental confounders that might also influence the placement of restaurants (commercial activity, presence of major highways, and median home values).ResultsIn 156 census tracts, a total of 155 fast food restaurants were identified. In the regression analysis that included the environmental confounders, fast-food restaurant density in shopping areas with 1-mile buffers was independently correlated with median household income and percent of black residents in the census tract. Similar results were found for shopping areas with 0.5-mile buffers. Predominantly black neighborhoods have 2.4 fast-food restaurants per square mile compared to 1.5 restaurants in predominantly white neighborhoods.Conclusions The link between fast food restaurants and black and low-income neighborhoods may contribute to the understanding of environmental causes of the obesity epidemic in these populations.
Article
Background: Investigators have reported that the availability of foods in local grocery stores correlated with consumption when using large geopolitical units of analysis, e.g., zip codes. Associations across smaller geopolitical units, e.g., census tracts, have not been tested, nor has this work focused on restaurant availability, child consumption, or specific ethnic groups. Methods: This study examined whether median family income and fruit, juice, and vegetable (FJV) availability in grocery stores, restaurants, and homes in 11 census tracts correlated with FJV consumption among 11- to 14-year-old African-American Boy Scouts. FJV consumption was measured in 90 scouts using two 24-h food recalls. Instruments were developed to measure the availability of FJV at area grocery stores, restaurants, and homes where troop members resided. Results: Median household income (from 1990 census) was significantly correlated with restaurant fruit availability. Significant correlations were found between restaurant juice and vegetable availability and Boy Scout reported consumption of juice and vegetables. Conclusion: Census tract may be a useful unit when studying restaurant, but not grocery store, FJV availability. Within a census tract, restaurant FJV availability may be a significant target for community intervention and process evaluation.
Article
Background: The Child and Adolescent Trial for Cardiovascular Health (CATCH) tested the effectiveness of a multilevel intervention aimed at promoting a healthful school environment and positive eating and physical activity behaviors in children. The CATCH Eat Smart Program targeted the school food service staff and aimed to lower the total fat, saturated fat, and sodium content of school meals. Methods: The Eat Smart intervention was conducted in 56 intervention schools over a 2(1/2)-year period.+Five consecutive days of school menu, recipe, and vendor product information were collected from intervention and control schools at three intervals, Fall 1991, Spring 1993, and Spring 1994, to assess the nutrient content of school menus as offered. Results: There was a significantly greater mean reduction in the percentage of calories from total fat (adjusted mean difference -4.1%; P < 0.0001) and saturated fat (adjusted mean difference -1.3%; P = 0.003) in intervention compared with control schools from baseline to follow-up. Although the sodium content of school lunches increased in both conditions, the mean increase was significantly lower in intervention schools (adjusted mean difference -89 mg; P = 0.034). There were no statistically significant differences for total amounts of cholesterol, carbohydrate, protein, dietary fiber, total sugars, calcium, iron, vitamin A value, and vitamin C. Average total calories decreased significantly; however, the mean total calories (683 kcal) for intervention schools remained above one-third of the Recommended Dietary Allowances for this age group. Conclusions: The CATCH Eat Smart intervention successfully lowered the total fat and saturated fat content of school lunches as offered, while maintaining recommended amounts of calories and essential nutrients.