Who's cooking tonight? A time-use study of coupled adults in Toronto, Canada.

Understanding how coupled adults arrange food-related labor in relation to their daily time allocation is of great importance because different arrangements may have implications for diet-related health and gender equity. Studies from the time-use perspective argue that daily activities such as work, caregiving, and non-food-related housework can potentially compete for time with foodwork. However, studies in this regard are mostly centered on individual-level analyses. They fail to consider cohabiting partners' time spent on foodwork and non-food-related activities, a factor that could be helpful in explaining how coupled partners decide to allocate time to food activities. Using 108 daily time-use logs from seventeen opposite-gender couples living in Toronto, Canada, this paper examines how male and female partners' time spent on non-food-related activities impact the total amount of time spent on foodwork by coupled adults and the difference in time spent on foodwork between coupled women and men. Results show that both male and female partners took a higher portion of foodwork when their partner worked longer. When men worked for additional time, the couple-level duration of foodwork decreased. Without a significant impact on the gender difference in foodwork duration, women's increased caregiving duration was associated with a reduction of total time spent on foodwork by couples. An increase in caregiving and non-food-related chores by men was associated with an increased difference in duration of foodwork between women and men, which helped secure a constant total amount of foodwork at the couple level. These behavioral variations between men and women demonstrate the gender differences in one's responsiveness to the change of partners' non-food-related tasks. The associations found among non-food-related activities and foodwork are suggestive of a need to account for partners' time allocation when studying the time-use dynamics of foodwork and other daily activities.

Are stress-related pathways of social status differentiation more important determinants of health inequities in countries with higher levels of income inequality?

We explored socioeconomic gradients in self-rated overall health (SROH) using indicators of materialist (educational attainment and perceived income adequacy) and psychosocial perspectives (subjective social status (SSS)) among adults living in countries with varying levels of income inequality, and the importance of psychosocial stress in mediating these associations. If psychosocial processes at the individual and societal levels correspond, associations between SSS and SROH should be higher among adults in countries with higher income inequality, and psychosocial stress should be a more important mediator of these associations. We used multigroup structural equation models to analyse cross-sectional data from the International Food Policy Study of adults (n = 22,824) in Australia, Canada, Mexico, the UK and the United States. Associations between SSS and SROH were not higher in more unequal countries, nor was psychosocial stress a more important mediator of these associations. Inequities in SROH in more unequal countries may not predominantly reflect stress-related pathways of social status differentiation.

Stress-Related Poor Diet Quality Does Not Explain Socioeconomic Inequities in Health: A Structural Equation Mediation Analysis of Gender-Specific Pathways.

BACKGROUND: Psychosocial stress and diet quality individually mediate associations between socioeconomic position (SEP) and health; however, it is not known whether they jointly mediate these associations. This is an important question because stress-related unhealthy eating is often invoked as an explanation for diet-related health inequities, particularly among women, seemingly with no empirical justification. OBJECTIVE: This study examined whether psychosocial stress and diet quality jointly mediated associations between SEP and self-rated health in women and men. DESIGN: Multiple mediating pathways were modeled using data from the cross-sectional International Food Policy Study. PARTICIPANTS AND SETTING: Data were collected from 5,645 adults (aged 18 years or older) in Canada during 2018 and 2019. MAIN OUTCOME MEASURES: Participants reported SEP using indicators of materialist (educational attainment and perceived income adequacy) and psychosocial pathways (subjective social status), along with psychosocial stress, dietary intake (to assess overall diet quality via Healthy Eating Index-2015 scores), and self-rated health. STATISTICAL ANALYSES PERFORMED: Structural equation modeling modeled pathways linking SEP (ie, educational attainment, perceived income adequacy, and subjective social status) with self-rated health mediated by psychosocial stress and diet quality, stratified by gender. RESULTS: There was no evidence that psychosocial stress and diet quality jointly mediated associations between SEP and self-rated health in women or men. Diet quality mediated associations between educational attainment and self-rated health in women and men, with some evidence that it mediated associations between subjective social status and self-rated health in men (P = 0.051). Psychosocial stress mediated associations between perceived income adequacy and self-rated health in women and men, and between subjective social status and self-rated health in women. CONCLUSIONS: Although often invoked as an explanation for diet-related health inequities, stress-related poor diet quality did not mediate associations between SEP and self-rated health in women or men. Psychosocial stress and diet quality individually mediated some of these associations, with some differences by gender.

Socioeconomic inequities in diet quality among a nationally representative sample of adults living in Canada: an analysis of trends between 2004 and 2015.

BACKGROUND: Socioeconomic inequities in diet quality are stable or widening in the United States; however, these trends have not been well characterized in other nations. Moreover, purpose-developed indices of inequities that can provide a more comprehensive and precise perspective of trends in absolute and relative dietary gaps and gradients using multiple indicators of socioeconomic position (SEP) have not yet been used, and can inform strategies to narrow dietary inequities. OBJECTIVES: We quantified nationally representative trends in absolute and relative gaps and gradients in diet quality between 2004 and 2015 according to 3 indicators of SEP among adults in Canada. METHODS: Adults (≥18 y old) who participated in the nationally representative, cross-sectional Canadian Community Health Survey-Nutrition in 2004 (n = 20,880) or 2015 (n = 13,970) were included. SEP was classified using household income (quintiles), education (5 categories), and neighborhood deprivation (quintiles). Dietary intake data from 24-h recalls were used to derive Healthy Eating Index-2015 (HEI-2015) scores. Dietary inequities were quantified using absolute and relative gaps (between the most and least disadvantaged) and absolute [Slope Index of Inequality (SII)] and relative gradients (Relative Index of Inequality). Overall and sex-stratified multivariable linear regression and generalized linear models examined trends in HEI-2015 scores between 2004 and 2015. RESULTS: Mean HEI-2015 scores improved from 55.3 to 59.0 (maximum: 100); however, these trends were not consistently equitable. Whereas inequities in HEI-2015 scores were stable in the total population and in females, the absolute gap [from 1.60 (95% CI: 0.09, 3.10) to 4.27 (95% CI: 2.20, 6.34)] and gradient [from SII = 2.09 (95% CI: 0.45, 3.73) to SII = 4.84 (95% CI: 2.49, 7.20)] in HEI-2015 scores for household income, and the absolute gradient for education [from SII = 8.06 (95% CI: 6.41, 9.71) to SII = 10.52 (95% CI: 8.73, 12.31)], increased in males. CONCLUSIONS: Absolute and relative gaps and gradients in overall diet quality remained stable or widened between 2004 and 2015 among adults in Canada.

Trends in Socioeconomic Inequities in Diet Quality between 2004 and 2015 among a Nationally Representative Sample of Children in Canada.

BACKGROUND: Dietary inequities in childhood may shape dietary and health inequities across the life course. Quantifying the magnitude and direction of trends in absolute and relative gaps and gradients in diet quality according to multiple indicators of socioeconomic position (SEP) can inform strategies to narrow these inequities. OBJECTIVES: We examined trends in absolute and relative gaps and gradients in diet quality between 2004 and 2015 according to 3 indicators of SEP among a nationally representative sample of children in Canada. METHODS: Data from children (aged 2-17 y; n = 18,670) who participated in the cross-sectional Canadian Community Health Survey-Nutrition in 2004 or 2015 were analyzed. SEP was based on total household income, household educational attainment, and neighborhood deprivation. Dietary intake data from 1 interviewer-administered 24-h dietary recall were used to derive a Healthy Eating Index-2015 (HEI-2015) score for each participant as a measure of diet quality. Inequities in diet quality were quantified using 4 indices: absolute and relative gaps (between highest and lowest SEP) and absolute (Slope Index of Inequality) and relative gradients (Relative Index of Inequality). Overall and age-stratified multivariable linear regression and generalized linear models examined trends in HEI-2015 scores between 2004 and 2015. RESULTS: Although mean HEI-2015 total scores improved from 52.3 to 57.3 (maximum 100 points; P < 0.001), absolute and relative gaps and gradients in diet quality remained mostly stable for all 3 SEP indicators. However, among children aged 6-11 y, absolute and relative gradients in diet quality according to household educational attainment and neighborhood deprivation widened. CONCLUSIONS: The diet quality of children in Canada was poor and inequitably patterned in 2004 and 2015. Although mean diet quality improved between 2004 and 2015, absolute and relative gaps and gradients in diet quality persisted, with some evidence of widening absolute and relative gradients among 6- to 11-y-olds.

Life stories of food agency, health, and resilience in a rapidly gentrifying urban centre: Building a multidimensional concept of food access.

Few studies examine how geographic and non-geographic elements of food access intersect. The purpose of this qualitative study is to explore the relationship between food access, food security, health, and gentrification in the rapidly gentrifying urban centre of Kitchener, Ontario, Canada. Semi-structured interviews were conducted with 20 low-income, longtime residents of Kitchener-Waterloo, and five key informants in the region. This study complicates concepts of food access that focus on density or proximity of (un)healthy food outlets and illustrates the complex decision-making processes of residents in procuring healthy, affordable, and appropriate foods. Race, equity, and food justice-based analysis also illuminate the disproportionate effects of gentrification on racialized residents, who face barriers to obtaining culturally-appropriate foods. These findings expand food access research by showing how individuals creatively cope with and adapt to changes within their food environments. To achieve a multidimensional concept of food access under conditions of gentrification, it is important to build an understanding of individuals' diverse priorities, adaptation strategies, motivations, and behaviours related to food procurement within the context of structural barriers to food security (including urban development practices and social assistance benefit levels). By supporting residents' food agency and food justice in gentrifying cities, it might be possible to develop more effective interventions to support food security and health.

Quantifying the contribution of modifiable risk factors to socio-economic inequities in cancer morbidity and mortality: a nationally representative population-based cohort study.

BACKGROUND: Compared with those with a higher socio-economic position (SEP), individuals with a lower SEP have higher cancer morbidity and mortality. However, the contribution of modifiable risk factors to these inequities is not known. This study aimed to quantify the mediating effects of modifiable risk factors to associations between SEP and cancer morbidity and mortality. METHODS: This study used a prospective observational cohort design. We combined eight cycles of the Canadian Community Health Survey (2000/2001-2011) as baseline data to identify a cohort of adults (≥35 years) without cancer at the time of survey administration (n = 309 800). The cohort was linked to the Discharge Abstract Database and the Canadian Mortality Database for cancer morbidity and mortality ascertainment. Individuals were followed from the date they completed the Canadian Community Health Survey until 31 March 2013. Dates of individual first hospitalizations for cancer and deaths due to cancer were captured during this time period. SEP was operationalized using a latent variable combining measures of education and household income. Self-reported modifiable risk factors, including smoking, excess alcohol consumption, low fruit-and-vegetable intake, physical inactivity and obesity, were considered as potential mediators. Generalized structural equation modelling was used to estimate the mediating effects of modifiable risk factors in associations between low SEP and cancer morbidity and mortality in the total population and stratified by sex. RESULTS: Modifiable risk factors together explained 45.6% of associations between low SEP and overall cancer morbidity and mortality. Smoking was the most important mediator in the total population and for males, accounting for 15.5% and 40.2% of the total effect, respectively. For females, obesity was the most important mediator. CONCLUSIONS: Modifiable risk factors are important mediators of socio-economic inequities in cancer morbidity and mortality. Nevertheless, more than half of the variance in these associations remained unexplained. Midstream interventions that target modifiable risk factors may help to alleviate inequities in cancer risk in the short term. However, ultimately, upstream interventions that target structural determinants of health are needed to reduce overall socio-economic inequities in cancer morbidity and mortality.

Impact of a farmers' market nutrition coupon programme on diet quality and psychosocial well-being among low-income adults: protocol for a randomised controlled trial and a longitudinal qualitative investigation.

INTRODUCTION: Low-income populations have poorer diet quality and lower psychosocial well-being than their higher-income counterparts. These inequities increase the burden of chronic disease in low-income populations. Farmers' market subsidies may improve diet quality and psychosocial well-being among low-income populations. In Canada, the British Columbia (BC) Farmers' Market Nutrition Coupon Programme (FMNCP) aims to improve dietary patterns and health among low-income participants by providing coupons to purchase healthy foods from farmers' markets. This study will assess the impact of the BC FMNCP on the diet quality and psychosocial well-being of low-income adults and explore mechanisms of programme impacts. METHODS AND ANALYSIS: In a parallel group randomised controlled trial, low-income adults will be randomised to an FMNCP intervention (n=132) or a no-intervention control group (n=132). The FMNCP group will receive 16 coupon sheets valued at CAD$21/sheet over 10-15 weeks to purchase fruits, vegetables, dairy, meat/poultry/fish, eggs, nuts and herbs at farmers' markets and will be invited to participate in nutrition skill-building activities. Overall diet quality (primary outcome), diet quality subscores, mental well-being, sense of community, food insecurity and malnutrition risk (secondary outcomes) will be assessed at baseline, immediately post-intervention and 16 weeks post-intervention. Dietary intake will be assessed using the Automated Self-Administered 24-hour Dietary Recall. Diet quality will be calculated using the Healthy Eating Index-2015. Repeated measures mixed-effect regression will assess differences in outcomes between groups from baseline to 16 weeks post-intervention. Furthermore, 25-30 participants will partake in semi-structured interviews during and 5 weeks after programme completion to explore participants' experiences with and perceived outcomes from the programme. ETHICS AND DISSEMINATION: Ethical approval was obtained from the University of Calgary Conjoint Health Research Ethics Board, Rutgers University Ethics and Compliance, and University of Waterloo Office of Research Ethics. Findings will be disseminated through policy briefs, conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT03952338.

Socioeconomic Disadvantage across the Life Course Is Associated with Diet Quality in Young Adulthood.

Socioeconomic position (SEP) is a key determinant of diet quality across the life course. Young adulthood is a unique period of transition where dietary inequities between groups with lower and higher SEP may widen. This study investigated associations between SEP in both childhood and young adulthood and diet quality in young adulthood. Data from 1949 Canadian young adults aged 18⁻30 who participated in the Canada Food Study were analyzed. Healthy Eating Index⁻2015 (HEI-2015) scores were calculated based on one 24-hour dietary recall. Childhood and young adult SEP were represented by self-report of participants' parent(s)' and their own highest educational level, respectively. Linear regression was used to examine associations between childhood and adult SEP and adult HEI-2015 score. Mediation analyses examined whether adult SEP mediated the relationship between childhood SEP and adult HEI-2015 score. Lower SEPs in childhood and adulthood were each associated with lower HEI-2015 scores in young adulthood. Adult SEP mediated up to 13.0% of the association between childhood SEP and adult HEI-2015 scores. Study findings provide support for key life course hypotheses and suggest latent, pathway, and cumulative effects of SEP across the early life course in shaping the socioeconomic patterning of diet quality in young adulthood.

School Food Policies and Student Eating Behaviors in Canada: Examination of the 2015 Cancer Risk Assessment in Youth Survey.

BACKGROUND: Limited evidence exists on effects of school-based nutrition policies. This study explored the influence of mandatory versus voluntary provincial school nutrition policies on student eating behaviors. METHODS: A cross-sectional, school-based survey assessed student eating behaviors using self-report survey measures in a representative sample of Canadian high school students from 7 provinces (N = 12,110). Provincial school nutrition policies were characterized as mandatory or voluntary. Healthful and nonhealthful eating behaviors were analyzed across sociodemographic characteristics. Regression models were used to assess the association between policy type and eating behaviors, and to explore potential moderating variables. RESULTS: Healthful and nonhealthful eating behaviors differed significantly across several sociodemographic characteristics. Overall, neither healthful nor nonhealthful eating behaviors differed significantly between schools with voluntary and mandatory nutrition policies (odds ratio [OR] = 0.83, 95% confidence interval [CI] 0.64-1.08; OR = 1.16, 95% CI 0.83-1.64). Frequency of buying lunch at school and buying lunch out moderated the association between policy enforcement level and healthful eating behaviors (p = .0472, p = .0119). Frequency of buying lunch out moderated the association between policy enforcement levels and nonhealthful eating behaviors (p = .0009). CONCLUSIONS: This study documents nonhealthful components of Canadian adolescents' diets, and the results highlight important areas for future research in assessing the effectiveness of school nutrition policies.

A Census of Midsize to Large Supermarkets in Toronto: A Cross-Sectional Analysis of the Consumer Nutrition Environment.

OBJECTIVE: Assess the consumer nutrition environment in midsize to large supermarkets by supermarket type and area-level socioeconomic variables. DESIGN: Cross-sectional census of 257 supermarkets using the Toronto Nutrition Environment Measures Survey in Stores. SETTING: Toronto, Canada. VARIABLES MEASURED: Availability; price and linear shelf space of fruits and vegetables vs energy-dense snack foods by supermarket type; after-tax, low-income measure; and neighborhood improvement area. ANALYSIS: Multivariate linear regression. RESULTS: There was a high availability of fruits (7.7 of 8) and vegetables (9.5 of 11). There was similar linear shelf space for fruits and vegetables vs energy-dense snack foods (ratio, 1.1 m). Adjusted fruit prices were lowest in quintiles 1 (ß = -$1.30; P = .008), 2 (ß = -$1.41; P = .005), and 3 (ß = -$1.89; P < .001) vs quintile 5 (lowest percentage of people living with low income) and in ethnic (ß = -$3.47; P < .001) and discount stores (ß = -$5.64; P < .001) vs conventional. Adjusted vegetable prices were lowest in quintiles 2 (ß = -$1.87; P = .04), 3 (ß = -$1.78; P = .03), and 4 (ß = -$2.65; P = .001) vs quintile 5 and in ethnic (ß = -$7.10; P < .001) and discount (ß = -$5.49; P < .001) stores. They were highest in other (ß = + $3.08; P = .003) vs conventional stores. Adjusted soda and chips prices were lower in discount (ß = -$1.16; P < .001) and higher in other stores (ß = + $0.67; P < .001) vs conventional. CONCLUSIONS AND IMPLICATIONS: Findings do not indicate inequities in shelf space, availability, or price across diverse neighborhoods. Practitioners can use findings to help consumers navigate supermarkets to make healthy choices.

Exploring sales data during a healthy corner store intervention in Toronto: the Food Retail Environments Shaping Health (FRESH) project. / Analyse de données sur les ventes lors d'une intervention axée sur un dépanneur santé de Toronto : le projet FRESH sur l'environnement de la vente d'aliments au détail comme déterminant de la santé.

INTRODUCTION: Population health interventions in the retail food environment, such as corner store interventions, aim to influence the kind of cues consumers receive so that they are more often directed toward healthier options. Research that addresses financial aspects of retail interventions, particularly using outcome measures such as store sales that are central to retail decision making, is limited. This study explored store sales over time and across product categories during a healthy corner store intervention in a lowincome neighbourhood in Toronto, Ontario. METHODS: Sales data (from August 2014 to April 2015) were aggregated by product category and by day. We used Microsoft Excel pivot tables to summarize and visually present sales data. We conducted t-tests to examine differences in product category sales by "peak" versus "nonpeak" sales days. RESULTS: Overall store sales peaked on the days at the end of each month, aligned with the issuing of social assistance payments. Revenue spikes on peak sales days were driven predominantly by transit pass sales. On peak sales days, mean sales of nonnutritious snacks and cigarettes were marginally higher than on other days of the month. Finally, creative strategies to increase sales of fresh vegetables and fruits seemed to substantially increase revenue from these product categories. CONCLUSION: Store sales data is an important store-level metric of food environment intervention success. Furthermore, data-driven decision making by retailers can be important for tailoring interventions. Future interventions and research should consider partnerships and additional success metrics for retail food environment interventions in diverse Canadian contexts.

INTRODUCTION: Les interventions en santé de la population dans le secteur de l'alimentation de détail, comme celles réalisées dans les dépanneurs, visent à transformer le type de signaux envoyés aux consommateurs afin qu'ils choisissent des aliments plus sains. Peu de recherches abordent les aspects financiers des interventions réalisées dans le milieu de la vente au détail, en particulier les mesures de résultat comme les ventes en magasin, pourtant au centre du processus décisionnel de la vente au détail. Cette étude examine l'évolution des ventes en magasin et les ventes par catégories de produits dans le cadre d'une intervention axée sur un dépanneur santé situé dans un quartier à faible revenu de Toronto (Ontario). MÉTHODOLOGIE: Les données sur les ventes effectuées entre août 2014 et avril 2015 ont été regroupées par catégories de produits et par jour. Nous avons utilisé des tableaux croisés dynamiques Excel afin de résumer et de présenter visuellement les données sur ces ventes. Nous avons mené des tests t afin d'étudier les différences au niveau des ventes de chaque catégorie de produits en fonction des jours de vente « de pointe ¼ (jours d'affluence) par rapport aux autres jours de vente. RÉSULTATS: Les ventes globales du magasin culminaient les derniers jours de chaque mois, soit à la période à laquelle les prestations d'assistance sociale sont versées. La hausse des revenus lors des jours de pointe était principalement imputable aux ventes de laissez-passer de transports en commun. La moyenne des ventes de collations non nutritives et de cigarettes était légèrement plus élevée lors des jours de pointe par rapport aux autres jours. Les stratégies novatrices employées pour augmenter les ventes de fruits et légumes frais ont semblé accroître considérablement les revenus générés par ces catégories de produits. CONCLUSION: Les données sur les ventes en magasin constituent un paramètre important de mesure du succès des interventions en environnement alimentaire. De plus, les prises de décision des détaillants fondé sur ces données peuvent se révéler déterminantes lors de l'adaptation des interventions. Les responsables des recherches et des interventions futures devraient envisager d'établir des partenariats et d'utiliser d'autres indicateurs de rendement lors des interventions ciblant l'environnement de la vente au détail d'aliments dans divers contextes canadiens.

An introduction to the healthy corner store intervention model in Canada.

SETTING: The majority of Canadians' food acquisition occurs in retail stores. Retail science has become increasingly sophisticated in demonstrating how consumer environments influence population-level diet quality and health status. The retail food environment literature is new but growing rapidly in Canada, and there is a relative paucity of evidence from intervention research implemented in Canada. INTERVENTION: The healthy corner store model is a comprehensive complex population health intervention in small retail stores, intended to transform an existing business model to a health-promoting one through intersectoral collaboration. Healthy corner store interventions typically involve conversions of existing stores with the participation of health, community, and business sector partners, addressing business fundamentals, merchandising, and consumer demand. OUTCOMES: This article introduces pioneering experiences with the healthy corner store intervention in Canada. First, we offer a brief overview of the state of evidence within and outside Canada. Second, we discuss three urban and one rural healthy corner store initiatives, led through partnerships among community food security organizations, public health units, academics, and business partners, in Manitoba, Ontario, and Newfoundland and Labrador. Third, we synthesize the promising practices from these local examples, including aspects of both intervention science (e.g., refinements in measuring the food environment) and community-based practice (e.g., dealing with unhealthy food items and economic impact for the retailer). IMPLICATIONS: This article will synthesize practical experiences with healthy corner stores in Canada. It offers a baseline assessment of promising aspects of this intervention for health and health equity, and identifies opportunities to strengthen both science and practice in this area of retail food environment work.

Prospective associations between diet quality and body mass index in disadvantaged women: the Resilience for Eating and Activity Despite Inequality (READI) study.

Background: Dietary patterns that align with recommended guidelines appear to minimize long-term weight gain in the general population. However, prospective associations between diet quality and weight change in disadvantaged adults have not been examined. This study examined associations between concurrent change in diet quality and body mass index (BMI) over 5 years among women living in socioeconomically disadvantaged neighbourhoods. Methods: Dietary intake and BMI were self-reported among 1242 women living in disadvantaged neighbourhoods in Victoria, Australia, at three time points from 2007/08 to 2012/13. Diet quality was evaluated using the Australian Dietary Guideline Index (DGI). Associations between concurrent change in diet quality and BMI were assessed over the three time points using fixed effects and mixed models. Models were adjusted for age, smoking, menopausal status, education, marital status, number of births, urban/rural location and physical activity. Results: Average BMI increased by 0.14 kg/m2 per year increase in age in the fixed effects model, and by 0.13 kg/m2 in the mixed model (P < 0.0001). BMI decreased by 0.014 kg/m2 for a woman of average age with each unit increase in DGI score in the fixed effects model (p < 0.0001), and by 0.012 kg/m2 in the mixed model (P = 0.001). The rate of change in BMI with age was greater for those with a lower DGI score than for those with a higher score (P < 0.10). Conclusions: Positive change in diet quality was associated with reduced BMI gain among disadvantaged women. Supporting disadvantaged women to adhere to population-level dietary recommendations may assist them with long-term weight management.

Do marginalized neighbourhoods have less healthy retail food environments? An analysis using Bayesian spatial latent factor and hurdle models.

BACKGROUND: Findings of whether marginalized neighbourhoods have less healthy retail food environments (RFE) are mixed across countries, in part because inconsistent approaches have been used to characterize RFE 'healthfulness' and marginalization, and researchers have used non-spatial statistical methods to respond to this ultimately spatial issue. METHODS: This study uses in-store features to categorize healthy and less healthy food outlets. Bayesian spatial hierarchical models are applied to explore the association between marginalization dimensions and RFE healthfulness (i.e., relative healthy food access that modelled via a probability distribution) at various geographical scales. Marginalization dimensions are derived from a spatial latent factor model. Zero-inflation occurring at the walkable-distance scale is accounted for with a spatial hurdle model. RESULTS: Neighbourhoods with higher residential instability, material deprivation, and population density are more likely to have access to healthy food outlets within a walkable distance from a binary 'have' or 'not have' access perspective. At the walkable distance scale however, materially deprived neighbourhoods are found to have less healthy RFE (lower relative healthy food access). CONCLUSION: Food intervention programs should be developed for striking the balance between healthy and less healthy food access in the study region as well as improving opportunities for residents to buy and consume foods consistent with dietary recommendations.

Youth retail tobacco access in Canada: regional variation, perceptions, and predictors from YSS 2010/2011.

PURPOSE: Retail tobacco access is an important determinant of youth smoking prevalence. This study examines perceptions of ease in obtaining cigarettes and how prevalence of self-reported retail tobacco access among youth smokers varies by province in Canada. Additionally, relevant retail experiences, such as being asked for identification by a store clerk, are described. METHODS: Data from grades 9-12 students who participated in the 2010/2011 Youth Smoking Survey, a nationally generalizable sample of Canadian students (n=31396) were used to examine retail tobacco access and related experiences. Logistic regression models were used to examine differences in retail tobacco access and retail tobacco experiences by sociodemographic and regional characteristics. RESULTS: 79% of students who never smoked thought it would be easy to get cigarettes. About one-quarter of smokers reported usually buying cigarettes from stores, and the percent of student smokers usually buying cigarettes in stores ranged from 16% in British Columbia to 36% in Quebec. Compared to grade 9 students, grade 12 students had higher odds of report being asked for identification (OR=6.3, 95% CI 1.9-21.5). CONCLUSIONS: Retail tobacco access appears to be a significant source of cigarette access among Canadian youth. Retail tobacco access varies significantly by province, which suggests provincial policies should be strengthened.

Flavored tobacco use among Canadian students in grades 9 through 12: prevalence and patterns from the 2010-2011 youth smoking survey.

INTRODUCTION: This study examined patterns of use of flavored tobacco products in a nationally generalizable sample of Canadian students in grades 9 through 12 after the implementation of a national ban on certain flavored tobacco products. METHODS: Data from the 2010-2011 Youth Smoking Survey, a nationally generalizable sample of Canadian students in grades 9 through 12 (n = 31,396), were used to examine tobacco product use. Logistic regression models were used to examine differences in use of flavored tobacco products (cigarettes, pipes, little cigars or cigarillos, cigars, roll-your-own cigarettes, bidis, smokeless tobacco, water pipes, and blunt wraps) by sociodemographic and regional characteristics. RESULTS: Approximately 52% of young tobacco users used flavored products in the previous 30 days. Flavored tobacco use varied by product type and ranged from 32% of cigarette smokers reporting menthol smoking to 70% of smokeless tobacco users reporting using flavored product in the previous 30 days. The percentage of last-30-day users who used flavored tobacco was significantly higher in Quebec than in Ontario and significantly higher among youths who received weekly spending money than among those who received no money. CONCLUSION: More than half of tobacco users in grades 9 through 12 in Canada use flavored tobacco, despite a national ban on certain flavored tobacco products.

Exploring low-income families' financial barriers to food allergy management and treatment.

Objectives. Low-income families may face financial barriers to management and treatment of chronic illnesses. No studies have explored how low-income individuals and families with anaphylactic food allergies cope with financial barriers to anaphylaxis management and/or treatment. This study explores qualitatively assessed direct, indirect, and intangible costs of anaphylaxis management and treatment faced by low-income families. Methods. In-depth, semistructured interviews with 23 participants were conducted to gain insight into income-related barriers to managing and treating anaphylactic food allergies. Results. Perceived direct costs included the cost of allergen-free foods and allergy medication and costs incurred as a result of misinformation about social support programs. Perceived indirect costs included those associated with lack of continuity of health care. Perceived intangible costs included the stress related to the difficulty of obtaining allergen-free foods at the food bank and feeling unsafe at discount grocery stores. These perceived costs represented barriers that were perceived as especially salient for the working poor, immigrants, youth living in poverty, and food bank users. Discussion. Low-income families report significant financial barriers to food allergy management and anaphylaxis preparedness. Clinicians, advocacy groups, and EAI manufacturers all have a role to play in ensuring equitable access to medication for low-income individuals with allergies.

Construct validation of 4 food-environment assessment methods: adapting a multitrait-multimethod matrix approach for environmental measures.

Few studies have assessed the construct validity of measures of neighborhood food environment, which remains a major challenge in accurately assessing food access. In this study, we adapted a psychometric tool to examine the construct validity of 4 such measures for 3 constructs. We used 4 food-environment measures to collect objective data from 422 Ontario, Canada, food stores in 2010. Residents' perceptions of their neighborhood food environment were collected from 2,397 households between 2009 and 2010. Objective and perceptual data were aggregated within buffer zones around respondents' homes (at 250 m, 500 m, 1,000 m, and 1,500 m). We constructed multitrait-multimethod matrices for each scale to examine construct validity for the constructs of food availability, food quality, and food affordability. Convergent validity between objective measures decreased with increasing geographic scale. Convergent validity between objective and subjective measures increased with increasing geographic scale. High discriminant validity coefficients existed between food availability and food quality, indicating that these two constructs may not be distinct in this setting. We conclude that the construct validity of food environment measures varies over geographic scales, which has implications for research, policy, and practice.

Objective food environments and health outcomes.

BACKGROUND: Pathways by which food environments affect residents' diet-related outcomes are still unclear. Understanding pathways may help decision makers identify food environment strategies to promote healthy diets. PURPOSE: To examine the hypothesis that residents' perceptions mediate the relationship between objective food environment and residents' diet quality and weight status. METHODS: In the Waterloo Region, Ontario, objective food environment data were collected from 422 food stores and 912 restaurants using the Nutrition Environment Measure Survey in Stores and Restaurants, a shelf-space measure of fruits and vegetables, and the Retail Food Environment Index. Waterloo Region households (n=2223) completed a subjective food environment perception survey; household members (n=4102) self-reported weight, height, and waist circumference. A subsample (1170 individuals within 690 households) completed diet records. Food environment data were collected in 2010; respondent data were collected from 2009-2010; and data were analyzed in 2012. A series of gender-specific models were conducted to test mediation, adjusting for household income, car ownership, age, and education level. RESULTS: Residents' perceptions did not mediate the relationship between objective measures and diet-related outcomes; instead, results revealed the direct effect of several objectively measured factors of the food environment (notably food access and relative food affordability) on outcomes. Perceptions generally were not associated with diet-related outcomes. CONCLUSIONS: These results reveal that in this setting, strategies aimed at improving residents' perceptions may be less effective than those acting directly on food environments to improve food access and relative food affordability.