Food availability and affordability in a Mediterranean urban context: associations by store type and area-level socio-economic status.

OBJECTIVE: Although food environments have been highlighted as potentially effective targets to improve population diets, evidence on Mediterranean food environments is lacking. We examined differences in food availability and affordability in Madrid (Spain) by store type and area-level socio-economic status (SES). DESIGN: Cross-sectional study. Trained researchers conducted food store audits using the validated Nutrition Environment Measures Survey in Stores for Mediterranean contexts (NEMS-S-MED) tool to measure the availability and price of twelve food groups (specific foods = 35). We computed NEMS-S-MED scores and summarised price data with a Relative Price Index (RPI, comparing prices across stores) and an Affordability Index (normalising prices by area-level income). We compared the availability and affordability of 'healthier-less healthy' food pairs, scores between food store types (supermarkets, specialised, convenience stores and others) and area-level SES using ANOVA and multi-level regression models. SETTING: City of Madrid. 2016 and 2019 to cover a representative sample. PARTICIPANTS: Food stores within a socio-economically diverse sample of sixty-three census tracts (n 151). RESULTS: Supermarkets had higher food availability (37·5/49 NEMS-S-MED points), compared to convenience stores (13·5/49) and specialised stores (8/49). Supermarkets offered lower prices (RPI: 0·83) than specialised stores (RPI: 0·97) and convenience stores (RPI: 2·06). Both 'healthy' and 'less healthy' items were more available in supermarkets. We found no differences in food availability or price by area-level SES, but affordability was higher in higher-income areas. CONCLUSIONS: Supermarkets offered higher food availability and affordability for healthy and less healthy food items. Promoting healthy food availability through supermarkets and specialised stores and/or limiting access to convenience stores are promising policy options to achieve a healthier food environment.

Urban environment and dietary behaviours as perceived by residents living in socioeconomically diverse neighbourhoods: A qualitative study in a Mediterranean context.

Scholars have determined that low socioeconomic status (SES) is associated with unhealthy dietary behaviours and that local food environments shape food inequality. Less is known about how residents' perceptions of their food environment affect their dietary behaviours. We conducted 37 semistructured interviews and 29 focus groups in three socioeconomically distinct neighbourhoods in Madrid. We identified the following main categories related to social and physical food environments: (a) perceptions of healthy and unhealthy dietary behaviours, (b) children's relationships with food, (c) precariousness and (d) residential food retailer types. Older adults were perceived as healthier consumers, whereas younger people were identified as fast-food consumers. In the low- and middle-SES neighbourhoods, residents saw home-cooked legume-based stews as healthy food. In the high-SES neighbourhood, television cooking programs were highlighted as a positive influence. In the low- and middle-SES neighbourhoods, grandparents played an essential role in the transmission of healthy eating habits to their grandchildren. In the high-SES neighbourhood, children's diets at home were determined by school menus. In the low- and middle-SES neighbourhoods, participants talked about a black market where food could be purchased. Food retailers with low-quality foods were also highlighted. In all neighbourhoods, residents missed traditional food stores, and in the low- and middle-SES neighbourhoods, immigrant-run food stores were not well accepted. Our study presents the concepts shaping how neighbourhood SES differences affect dietary behaviours according to residents of a large Mediterranean city.

Residents' perceptions of their local food environment in socioeconomically diverse neighborhoods: A photovoice study.

The influence of unhealthy food environments on residents' eating behaviors has been previously documented. Yet, socioeconomic differences across areas are less studied. Participatory studies provide relevant knowledge to better inform future nutrition interventions. We conducted a participatory Photovoice project in which residents interpreted the influence of the local food environment on eating behaviors across three neighborhoods of contrasting area-level socioeconomic status (SES) in Bilbao, Spain. From April to July 2017, a total of 23 residents participated in the three Photovoice groups. Each group critically discussed their photographs (N = 110) in groups of 6-9 participants along six group sessions. Through a consensus-building process, participants identified 27 emerging categories choosing finally 39 related photographs, which followed six conceptual main themes characterizing their local food environment: 1) unhealthy eating behaviors, 2) cultural diversity, 3) retail transformation, 4) social relationships, 5) precariousness, and 6) healthy eating. Although high food quality and fresh products may portray a general healthy food environment in all three neighborhoods, participants discussed why some residents still adopt unhealthy eating behaviors characterized by an excessive consumption of alcohol (high-SES area), sugar loaded foods (high- and middle-SES) and fast food (middle and low-SES). This photovoice participatory methodology helps highlighting important similarities and differences regarding food environment perceptions in the whole socioeconomic spectrum of any given city. This type of participatory approach helps guiding local policies and interventions promoting healthier local food environments.

Acute Terminal Ileitis in Children: A Retrospective Study in a Pediatric Emergency Department.

OBJECTIVES: This study aims to describe the clinical presentation and outcome of patients diagnosed with acute ileitis in our pediatric emergency department. METHODS: We performed a retrospective study of all patients diagnosed with terminal ileitis by abdominal ultrasonography findings in our pediatric emergency department, over the years 2013 and 2014. Patients with previous diagnosis of inflammatory bowel disease (IBD) were excluded. Data collected were clinical, radiological, and laboratory data at diagnosis; outcome including hospitalization care; and outpatient follow-up in pediatric gastroenterology and/or primary care. RESULTS: A total of 20 cases were retrieved and studied. All of them presented with abdominal pain, 65% located in the right lower quadrant. Leukocyte count, C-reactive protein, and fibrinogen levels (means, 12,889; 4/µL; 50.1 mg/L; and 575 mg/dL, respectively) were above normal range. Hemoglobin and platelet count were normal. A microbial cause of ileitis was found in 3 cases (Yersinia enterocolitica, Campylobacter jejuni, and Adenovirus). Nine patients were referred to a pediatric gastroenterology unit. No cases of IBD were found. CONCLUSIONS: Acute ileitis is a rare and benign cause of abdominal pain in the pediatric emergency department. The main intervention on initial assessment is to rule out potentially severe causes of abdominal pain that could benefit of an emergency surgical procedure. In contrast with adults and adolescents, acute ileitis in children does not have a clear association with development of IBD.

Photovoice and empowerment: evaluating the transformative potential of a participatory action research project.

BACKGROUND: Photovoice is a visual research methodology with the intention to foster social change. Photovoice has been used to investigate change in empowerment in vulnerable communities, However, the individual experience of participants involved in Photovoice projects is seldom scrutinized. Our aim was to explore and describe the individual experiences of the female individuals who participated in a previous Photovoice project. We analyzed a change in the women's empowerment in terms of: 1) gain in knowledge and skills, 2) change in self-perception, and 3) access to and use of resources. METHODS: This qualitative study took place in the low-income District of Villaverde (Madrid, Spain), from January-June 2016. We conducted 10 semi-structured interviews with the female residents who had participated in the previous Photovoice project. We also collected field notes. We analyzed these data through a direct qualitative content analysis. The three outlined dimensions of empowerment provided guidance for the analysis of the results. RESULTS: We found positive changes in the three dimensions of empowerment: 1) participants acquired new knowledge and developed critical awareness of their community; 2) the social recognition participants received transformed their self-perception; and 3) the project allowed them to expand their social networks and to build new links with different actors (research partners, local decision makers, media and the wider public). CONCLUSIONS: Photovoice projects entail the opportunity for empowering participants. Future research using Photovoice should assess the influence it has on participants' empowerment changes and how to sustain these individual and social changes.

The mismatch between observational measures and residents' perspectives on the retail food environment: a mixed-methods approach in the Heart Healthy Hoods study.

OBJECTIVE: To gain a deeper understanding of the retail food environment by investigating similarities and differences between objective measures and residents' perspectives. DESIGN: The study incorporated Geographic Information System (GIS)-based measures, in-store surveys and the results from a larger photovoice project. We combined these data using a convergent parallel mixed-methods approach. SETTING: We conducted this study in a low-income neighbourhood in Madrid (Spain) in 2016. SUBJECTS: We assessed healthy food availability, accessibility and affordability using GIS-based measures and in-store audits. We also analysed the photographs and discussions from twelve participants who engaged in a photovoice project on their food environment. RESULTS: Quantitative results depicted a widely served and highly accessible retail food environment, in which supermarkets scored highest in terms of healthy food availability (36·5 out of 39) and 98·9 % of residents could access a healthy food store within a walking travel distance of less than 15 min. Qualitative results showed that participants preferred small local businesses over supermarkets, and revealed built environment obstacles for elderly residents. They also highlighted how the socio-economic context constrained residents' food choices. CONCLUSIONS: People's experienced retail food environment is different from the one quantitatively analysed. Results show the potential of using a mixed-methods approach to enrich food environment research and enhance public health interventions.

Understanding differences in the local food environment across countries: A case study in Madrid (Spain) and Baltimore (USA).

Places where we buy food influence dietary patterns, making local food environments a good example of a mass influence on population diets. Cross-cultural studies, using reliable methods, may help understanding the relationship between food environments and diet-related health outcomes. We aimed to understand cross-national differences in the local food environment between Madrid and Baltimore by comparing an average neighborhood in each city in terms of food store types, healthy food availability, and residents' pedestrian access. During 2012-2013, we assessed one neighborhood (~15,000 residents) in each city selecting median areas in terms of socio-demographic characteristics (segregation, education, aging, and population density). We collected on-field data on (a) number and types of all food stores, (b) overall healthy food availability and (c) specific availability of fruits & vegetables. Throughout a street network analysis (200m, 400m and 800m) of food stores with high healthy food availability, we estimated residents' pedestrian accessibility. We found 40 stores in Madrid and 14 in Baltimore. Small food stores carrying fresh foods in Madrid contrasted with the high presence of corner and chain convenience stores in Baltimore. In Madrid, 77% of the residents lived within less than 200m from a food store with high healthy food availability. In contrast, 95% of Baltimore's residents lived further than 400m from these stores. Our results may help promoting interventions from local city agencies to allocate resources to existing small-sized food stores, and to improve walkable urban environments. These actions may influence food choices, especially for those residents lacking access to private vehicles.

Population cardiovascular health and urban environments: the Heart Healthy Hoods exploratory study in Madrid, Spain.

BACKGROUND: Our aim is to conduct an exploratory study to provide an in-depth characterization of a neighborhood's social and physical environment in relation to cardiovascular health. A mixed-methods approach was used to better understand the food, alcohol, tobacco and physical activity domains of the urban environment. METHODS: We conducted this study in an area of 16,000 residents in Madrid (Spain). We obtained cardiovascular health and risk factors data from all residents aged 45 and above using Electronic Health Records from the Madrid Primary Health Care System. We used several quantitative audit tools to assess: the type and location of food outlets and healthy food availability; tobacco and alcohol points of sale; walkability of all streets and use of parks and public spaces. We also conducted 11 qualitative interviews with key informants to help understanding the relationships between urban environment and cardiovascular behaviors. We integrated quantitative and qualitative data following a mixed-methods merging approach. RESULTS: Electronic Health Records of the entire population of the area showed similar prevalence of risk factors compared to the rest of Madrid/Spain (prevalence of diabetes: 12 %, hypertension: 34 %, dyslipidemia: 32 %, smoking: 10 %, obesity: 20 %). The food environment was very dense, with many small stores (n = 44) and a large food market with 112 stalls. Residents highlighted the importance of these small stores for buying healthy foods. Alcohol and tobacco environments were also very dense (n = 91 and 64, respectively), dominated by bars and restaurants (n = 53) that also acted as food services. Neighbors emphasized the importance of drinking as a socialization mechanism. Public open spaces were mostly used by seniors that remarked the importance of accessibility to these spaces and the availability of destinations to walk to. CONCLUSION: This experience allowed testing and refining measurement tools, drawn from epidemiology, geography, sociology and anthropology, to better understand the urban environment in relation to cardiovascular health.

Characterizing physical activity and food urban environments: a GIS-based multicomponent proposal.

BACKGROUND: Healthier urban environments influence the distribution of cardiovascular risk factors. Our aim was to design and implement a multicomponent method based on Geographic Information Systems to characterize and evaluate environmental correlates of obesity: the food and the physical activity urban environments. METHODS: Study location comprised a socio-demographically average urban area of 12 contiguous census sections (≈16,000 residents), in Madrid, Spain. We conducted on-field audits on all food stores and street segments. We designed a synthetic index integrating continuous measures of both environments, by kernel density analyses. Index ranges from 0 to 100 (least-most healthy). RESULTS: We found a heterogeneous distribution with 75 and 50 % of the area scoring less than 36.8 and 25.5, respectively. Census sections of study area were categorized by Jenks intervals as high, medium-high, medium-low and low. 41.0 % of residents lived in an area with a low score, 23.6 % medium-low and 31.1 % medium-high and 4.2 % in a high. CONCLUSION: The proposed synthetic index may be a relevant tool to inform urban health interventions, providing a feasible way to integrate different measures of barriers and facilitators of healthy urban environments in terms of food and physical activity.

Assessing Walking and Cycling Environments in the Streets of Madrid: Comparing On-Field and Virtual Audits.

Audit tools are useful for exploring the urban environment and its association with physical activity. Virtual auditing options are becoming increasingly available potentially reducing the resources needed to conduct these assessments. Only a few studies have explored the use of virtual audit tools. Our objective is to test if the Madrid Systematic Pedestrian and Cycling Environment Scan (M-SPACES) discriminates between areas with different urban forms and to validate virtual street auditing using M-SPACES. Three areas (N = 500 street segments) were selected for variation in population density. M-SPACES was used to audit street segments physically and virtually (Google Street View) by two researchers in 2013-2014. For both physical and virtual audits, all analyzed features score significantly different by area (p < 0.05). Most of the features showed substantial (ICC = 0.6-0.8) or almost perfect (ICC ≥ 0.8) agreement between virtual and physical audits, especially neighborhood permeability walking infrastructure, traffic safety, streetscape aesthetics, and destinations. Intra-rater agreement was generally acceptable (ICC > 0.6). Inter-rater agreement was generally poor (ICC < 0.4). Virtual auditing provides a valid and feasible way of measuring residential urban environments. Comprehensive auditor training may be needed to guarantee good inter-rater agreement.

Diet Quality Changes by Educational Level among Adults in Spain from 2017 to 2021.

Despite increasing attention on addressing socioeconomic disparities in diet quality, longitudinal studies are scarce. Furthermore, the effects of the COVID-19 pandemic on diet-related outcomes are yet to be fully understood. We examined changes in diet quality by educational level among adults in Madrid, Spain. We used data from recruitment (in 2017) and from 2021. At baseline, our sample included 1358 adults aged 40-75 years who were free of cardiovascular disease and completed a validated diet quality screener. Of them, 931 answered the survey in the follow-up visit in 2021. We used participants' diet quality index scores (range: 18-54; higher scores indicate better diet quality) as the dependent variable. As our independent variable, we assessed participants' educational levels (low, medium, and high). We fitted a multinomial regression using the categories of educational level as the main predictor, adjusting for age, sex, country of origin, and household composition. During the study period, 78.0% of participants sustained their diet quality, 11.6% improved it, and 10.4% moved away from a healthier dietary pattern. In descriptive analyses, we observed an increase in diet quality among less-educated females. Unadjusted multinomial models showed that a lower educational level predicted both increases and decreases in diet quality over the period. Even though the median diet quality scores did not change significantly, we observed heterogeneous changes over the four years. Variability within diet, with some improving and some worsening, seems to have increased among participants with lower educational levels. Future studies should look at the determinants of change in these population subgroups.

Correlates of eating behaviors in adolescence: a systematic review of qualitative studies.

CONTEXT: Nutrition plays a critical role in adolescence. Adolescents are vulnerable to the impact of different factors that distance them from healthy habits, increasing their risk of chronic diseases in adulthood. Qualitative methodologies allow for a better understanding of these factors. OBJECTIVE: This systematic review aims to consolidate qualitative research evidence from the past 10 years to analyze the facilitators and barriers influencing adolescents' eating behaviors. DATA SOURCES: Databases searched for relevant studies were Scopus, Medline/PubMed, PsycINFO, and Web of Science. DATA EXTRACTION: A total of 4176 records were identified. The authors used the GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative Research) quality-assessment tool. RESULTS: Fifty articles with qualitative or mixed methodologies were finally included. The most applied techniques were focus groups and semi-structured interviews. The factors influencing adolescents' diets were classified into 4 dimensions: individual, social, community, and macrosystem factors. The most influential were the following-(1) at the individual level: gender (facilitator or barrier), taste and appearance of food (barrier), and lack of time (barrier); (2) at the social level: parents' and caregivers' influence (facilitator or barrier), peer group influence (barrier), and socioeconomic position (barrier); (3) at the community level: school food environment (facilitator or barrier), neighborhood food environment (barrier), household food environment (facilitator or barrier), food insecurity (barrier), and availability and affordability of ultra-processed foods (barrier); and (4) at the macrosystem level: digital tools (facilitator or barrier). CONCLUSIONS: This systematic review identified several facilitators and barriers influencing eating behaviors among adolescents. Qualitative research provides a rich source of knowledge to inform interventions aimed at improving adolescents' diets. Qualitative research is very useful for collecting researches that help to implement intervention programs that improve adolescent nutrition.

Who benefits from green spaces? Surrounding greenness and incidence of cardiovascular disease in a population-based electronic medical records cohort in Madrid.

The objective was to study the association between surrounding greenness and the incidence of cardiovascular diseases (CVD) with a four years follow-up in almost half a million high CVD-risk women and men, as well as its differential effect by area-level deprivation in Madrid. We analyzed 2015-2018 primary healthcare electronic medical records for 437,513 high CVD risk individuals representing more than 95% of the population of that age range residing in Madrid. The outcome variable was any cardiovascular event. We measured surrounding residence greenness at 200 m, 300 m, 500 m, and 1000 m through the Normalized Difference Vegetation Index (NDVI). We assessed socioeconomic deprivation through a census-based deprivation index. We estimated the 4-year relative risk of CVD by an increase in 0.1 units of NDVI and then stratified the models by quintiles of deprivation (Q5 the most deprived). We found that for every increase in 0.1 units of NDVI at 1000 m there was a 16% decrease in CVD risk (RR = 0.84 95% CI 0.75-0.94). CVD risk for the remaining distance exposures (at 200 m, 300 m, and 500 m) were none statistically significant. In general, the protective effect of green spaces was present in medium-deprivation areas and males, but the associations were inconsistent across deprivation levels. This study highlights the relevance of evaluating the interaction between physical and social urban components to further understand possible population prevention approaches for cardiovascular diseases. Future studies should focus on the mechanisms of context-specific interactions between social inequalities and green spaces' effects on health.

Socio-Spatial Segregation of Unhealthy Food Environments across Public Schools in Santiago, Chile.

Santiago, Chile is a very segregated city, with higher childhood obesity rates observed in vulnerable areas. We compared the counts and proximity of unhealthy food outlets (UFOs) around a 400 m buffer of 443 public schools (municipal and subsidized) located in socioeconomically diverse neighborhoods in 14 municipalities of Santiago. This was a cross-sectional study in which the socioeconomic status (SES) of the population living inside the buffer was classified as middle-high, middle, and low. We used the Kruskal-Wallis test for comparisons of density and proximity between type of school, SES, and population density. We used a negative binomial model (unadjusted and adjusted by population density) to determine the expected change in counts of UFOs by SES, which was compared to the reference (middle-high). Low SES neighborhoods had significantly more counts of UFOs, and these were located much closer to schools. Low and middle SES neighborhoods had an 88% and 48% higher relative risk of having UFOs compared to middle-high SES areas; (IRR = 1.88; 95% CI 1.59-2.23) and (IRR = 1.48; 95% CI 1.20-1.82), respectively. A socio-spatial segregation of UFOs associated with childhood obesity across public schools was observed in Santiago.

Factors influencing dietary inequalities among adolescents in Madrid and Bilbao: a qualitative research project.

OBJECTIVE: To describe the design and methodology of a qualitative study to explore the main factors influencing dietary inequalities in adolescents in Madrid and Bilbao, Spain. METHOD: The study area included six neighborhoods (three in each city) of different socioeconomic status (SES): low, medium, and high. We sampled 12 secondary schools (six in each city: two per socioeconomic level). Our methodology comprised: 1) developing an ad hoc index to classify all neighborhoods according to their SES; 2) selecting the study area and sample; 3) conducting semi-structured interviews (n=36) and focus groups (n=24). Grounded theory and phenomenological analysis will be employed in data analysis. Initially, we found factors influencing in adolescents' diet such as gender, family environment, and SES. CONCLUSIONS: Systematizing the selection of neighborhoods and secondary schools, along with using appropriate methods, could serve as a foundation for future studies on health inequalities among adolescents.

Time-Varying Food Retail and Incident Disease in the Cardiovascular Health Study.

INTRODUCTION: Natural experiments can strengthen evidence linking neighborhood food retail presence to dietary intake patterns and cardiometabolic health outcomes, yet sample size and follow-up duration are typically not extensive. To complement natural experiment evidence, longitudinal data were used to estimate the impacts of neighborhood food retail presence on incident disease. METHODS: The Cardiovascular Health Study recruited adults aged 65+ years in 1989-1993. Analyses conducted in 2021-2022 included those in good baseline health, with addresses updated annually through the year of death (restricted to 91% who died during >2 decades of cohort follow-up). Baseline and annually updated presence of 2 combined food retail categories (supermarkets/produce markets and convenience/snack focused) was characterized using establishment-level data for 1-km and 5-km Euclidean buffers. Cox proportional hazards models estimated associations with time to each incident outcome (cardiovascular disease, diabetes), adjusting for individual and area-based confounders. RESULTS: Among 2,939 participants, 36% with baseline supermarket/produce market presence within 1 km had excess incident cardiovascular disease (hazard ratio=1.12; 95% CI=1.01, 1.24); the association was attenuated and no longer statistically significant after adjustment for sociodemographic characteristics. Adjusted associations were robustly null for time-varying supermarket/produce market or convenience/fast food retail presence across analyses with outcomes of cardiovascular disease or diabetes incidence. CONCLUSIONS: Food environment changes continue to be studied to provide an evidence base for policy decisions, and null findings in this longitudinal analysis add literature that casts doubt on the sufficiency of strategies targeting food retail presence alone of an elderly cohort for curtailing incident events of clinical importance.

Trends and determinants of social inequities in cardiovascular risk factors in Spain: a mixed-methods study.

This sequential mixed-methods study aims to: 1) assess spatial and temporal trends in cardiovascular risk factors by socioeconomic position from 2001 to 2020 in Spain; 2) explore public health professionals' perspectives regarding interventions that might have impacted these inequities; and 3) analyze determinants on social inequities in cardiovascular risk factors. First, we will measure the change in absolute and relative social inequities in eight cardiovascular risk factors through time trend analysis using repeated cross-sectional data from both National and European Health Surveys for Spain from 2001 to 2020. Second, we will interview key informants -both at the regional and national level-, to contextualize data obtained in phase 1 and capture the content and variation of policies across regions. Third, we will use econometric methods to analyze how these identified interventions have impacted these social inequities within and across regions.

Retail Food Environment around Schools in Barcelona by Neighborhood Socioeconomic Status: Implications for Local Food Policy.

Childhood obesity is a relevant public health problem. The school food environment has been identified as an important factor for promoting healthy eating behaviors. This study assessed the availability of and proximity to unhealthy food stores around schools (n = 22) in the city of Barcelona and its association with neighborhood socioeconomic status (NSES). We conducted this cross-sectional study between 2019 and 2020. First, we identified all food retailers (n = 153) within a 400-m buffer around each school and identified those selling unhealthy food products. Then, we used Poison regression models to measure the association between NSES and the healthy food availability index (HFAI), adjusting for population density and distance. A total of 95% of the food establishments studied were classified as unhealthy (n = 146). In all, 90% of schools that had, at least, two unhealthy retailers in their proximity. There were significant differences in the mean distance to unhealthy establishments according to neighborhood SES and population density (p < 0.05). We found a positive association between schools located in higher SES neighborhoods and a higher availability and affordability of healthy food products (IIR = 1.67, 95% CI = 1.45−1.91 p = 0.000). We found strong social inequalities in the supply of healthy foods in Barcelona. Local food policy interventions addressing retail food environment around schools should consider socioeconomic inequalities.

Influence of home/school environments on children's obesity, diet, and physical activity: the SUECO study protocol.

OBJECTIVE: The SUECO study examines the relationship between urban obesogenic environments and health outcomes among school-age children in the city of Madrid, Spain. We will study how features of the urban environment (related to the food- and the physical activity environment) associate with children's anthropometrics, eating habits, and physical activity levels. METHOD: We describe the study protocol of this multilevel study in a representative sample of school-age children in the city of Madrid (2017; n=5,961 children ages 3-12). Main outcome variables include anthropometrics (body mass index, waist circumference, and body fat), healthy and unhealthy consumption measures, and physical activity measures. The primary explanatory variables are grouped into food environment (e.g., unhealthy food retailers' density) and physical activity environment (e.g., walkability, physical activity opportunities) variable categories. Multilevel models will be used to calculate the associations between each indicator and obesity and physical inactivity.