Fatores associados ao nível de segurança alimentar e nutricional no município e estado de São Paulo e no Brasil: uma análise dos resultados obtidos pela escala brasileira de insegurança alimentar / Food and nutritional security level associated factors in the city and state of São Paulo and in Brazil: an analysis of obtained results from the Brazilian food insecurity scale

A falta de segurança alimentar e nutricional (SAN) consiste em um fenômeno multifatorial, que pode afetar o estado nutricional do indivíduo por ela acometido de diversas maneiras e em qualquer faixa etária. A falta de SAN pode desencadear tanto desnutrição, como obesidade e assim favorecer o aumento da prevalência de doenças crônicas não transmissíveis, o que diminui a qualidade de vida e se constitui um importante problema de saúde pública. Objetivo: Analisar e comparar a força da associação dos fatores socioeconômicos e demográficos à segurança alimentar e nutricional (SAN) no Brasil e áreas geográficas selecionadas. Metodologia: Trata-se de um estudo ecológico, transversal e analítico, que utilizou como base os microdados da Pesquisa de Orçamento Familiar (POF/IBGE), realizada nos anos de 2017-2018, envolvendo 757 famílias residentes no município de São Paulo (MSP), 3.406 famílias do estado de São Paulo (ESP) e 49.365 famílias do Brasil. Utilizou-se a técnica de regressão logística multinomial, do tipo ordinal, para o processamento do modelo de associação entre o nível de SAN (nSAN) e as variáveis demográficas, socioeconômicas e clínicas, utilizando o módulo survey do Stata versão 14. Adotouse o nível de significância estatística de 5% e o odds ratio proporcional para descrever as associações. Resultados: A grande maioria dos indivíduos de referência dos domicílios componentes da amostra é do sexo masculino, adulta, com obesidade, sem seguro saúde e que não fazem nenhum tipo de dieta, variando as características de raça/cor e escolaridade entre as três localidades analisadas. Para as três localidades estudadas, encontrou-se proporções elevadas da população com segurança alimentar e nutricional garantida (acima de 59%). As associações encontradas demonstraram que as famílias com pessoas de referência do sexo feminino apresentam maior chance de piora do nSAN, bem como aquelas com menores níveis de saneamento básico e estratos de renda mais pobres, para os quais a chance de piora do nSAN em relação aos estratos de renda mais ricos se eleva em até 12 vezes. Ser de raça branca foi fator protetor à IAN, bem como ter idade mais avançada e mais anos de escolaridade. Conclusão: As características sociodemográficas sexo, raçacor, idade e escolaridade, e socioeconômicas, renda e presença de saneamento básico, apresentam importante associação ao nível de SAN das famílias, quando este é analisado por meio da Escala Brasileira de Insegurança Alimentar (EBIA). Entretanto, faz-se necessária a construção de um instrumento que avalie todas as dimensões da SAN

Lack of food and nutrition security (FNS) is a multifactorial phenomenon, which can impact the nutritional status of individual affected by it in different ways and in any age group. The lack of FNS can trigger both malnutrition and obesity and thus favor the prevalence increase of chronic non-communicable diseases, which reduces lifes quality and constitutes an important public health problem. Objective: To analyze and compare the strength of association of socioeconomic and demographic factors with FNS in Brazil and selected geographical areas. Methodology: Ecological, crosssectional, and analytical study, which used the microdata of the Research as a basis Family Budget (POF / IBGE), carried out in 2017-2018, involving 757 families residing in São Paulo city (SPC), 3,406 families from São Paulo state (SPS) and 49,365 families from Brazil. Multinomial logistic regression technique, of the ordinal type, was used to process the association model between the FNS level (FNSl) and the demographic, socioeconomic and clinical variables, using the survey module of Stata version 14. It was adopted statistical significance of 5% and proportional odds ratio to describe the associations. Results: Most reference individuals in the sample's households are male, adult, obese, without health insurance and who do not follow any type of diet, varying the characteristics of race / color and education between the three locations analyzed. For the three locations studied, high proportions of the population were found with guaranteed FNS (above 59%). Associations found showed that families headed by female individuals are more likely to worsen FNSl, as well as those with lower levels of basic sanitation and poorer income strata, for which the chance of worsening FNSl in relation to strata wealthier income rises to 12 times. Being white was a protective factor for food insecurity, as well as being older and with more years of schooling. Conclusion: Sociodemographic characteristics of sex, race-color, age and education, and socioeconomic, income and presence of basic sanitation, present important association at the FNSl of families, when this is analyzed through the Brazilian Food Insecurity Scale (EBIA). However, it is necessary to build an instrument that assesses all dimensions of the FNS

Políticas alimentarias para prevenir la obesidad y las principales enfermedades no transmisibles en España: querer es poder / Food policies to prevent obesity and the main non-transmissible diseases in Spain: where there's a will there's a way

Introducción: En España, un tercio de los menores y dos tercios de los adultos padecen exceso de peso, una condición que genera un sobrecoste médico directo de 2000 millones de euros. El entorno alimentario obesogénico causa obesidad al promover el consumo de bebidas azucaradas y de alimentos ultraprocesados. Por ello, proponemos cinco políticas prioritarias con el PODER de revertir la epidemia de obesidad y de enfermedades no transmisibles asociadas a ella, mediante la creación de entornos alimentarios saludables. El PODER de las políticas alimentarias: P (Publicidad): regulación de la publicidad de alimentos y bebidas no saludables dirigida a menores por todos los medios y prohibición de patrocinios de congresos o eventos deportivos y avales de asociaciones científicas o profesionales de la salud. O (Oferta): promoción de una oferta 100% saludable en máquinas expendedoras de centros educativos, sanitarios y deportivos. D (Demanda): implantación de un impuesto, al menos del 20%, a las bebidas azucaradas, acompañado de subvenciones o bajadas de impuestos a alimentos saludables y disponibilidad de agua potable a coste cero en todos los centros y espacios públicos. E (Etiquetado): aplicación efectiva del Nutri-Score mediante el uso de incentivos, regulación y mecanismos de contratación pública. R (Reformulación): reformular los acuerdos de reformulación con la industria con objetivos más ambiciosos y de obligado cumplimiento. Reflexión final: Las cinco intervenciones propuestas, aplicadas con éxito en otros países, contribuirán a concienciar a la población y tendrán un impacto positivo en la salud y en la economía, por una reducción de los costes sanitarios de la obesidad y un aumento de la productividad laboral. Estas medidas deberían formar parte de una gran transformación del sistema alimentario, con políticas agroalimentarias que fomenten una producción sostenible de alimentos saludables

Introduction: In Spain, one third of all children and two-thirds of adults suffer from excess weight, a condition that generates a direct excess medical cost of 2000 million Euros. Obesogenic food environments cause obesity by promoting the consumption of sugar-sweetened beverages and ultra-processed foods. Accordingly, we propose five priority policies capable of reversing the epidemic of obesity and related non-communicable diseases through the creation of healthy food environments. The power (PODER in Spanish) of food policies: Advertising (Publicidad): regulation of unhealthy food and drink advertisements carried by all media and targeted at children, and prohibition of sponsorships of congresses, conferences or sports events and endorsements by scientific associations or health professionals. Supply (Oferta): promotion of a 100% healthy supply of goods on sale in vending machines sited at educational, health and sports centres. Demand (Demanda): levying a tax of at least 20% on sugar-sweetened beverages, accompanied by subsidies or reduced taxes on healthy foods and availability of drinking water free of charge at all public venues and areas. Labelling (Etiquetado): effective application of the Nutri-Score through the use of incentives, regulation and public-tender mechanisms. Reformulation (Reformulación): revising and redrawing reformulation agreements with the industry, setting more ambitious goals and mandatory compliance. A final thought: These five proposed interventions, all of which have been successfully applied in other countries, will serve to raise population awareness and have a positive impact on health and the economy, through reducing the health care costs of obesity and enhancing work productivity. These measures should form part of a wide-ranging transformation of the food system, with agri-food policies that foster the sustainable production of healthy foods

Prevalencia de anemia infantil y su asociación con factores socioeconómicos y productivos en una comunidad altoandina del Perú / Childhood anemia prevalence and its association with socioeconomic and productive factors in a high Andean community of Peru

FUNDAMENTOS: La anemia infantil es un problema crítico en zonas altoandinas del Perú por su asociación con la morbi-mortalidad materno infantil e impacto negativo en el desarrollo emocional, cognitivo y motor de los niños. Se ha realizado un estudio para determinar la prevalencia de anemia en la población infantil del distrito de Tunanmarca y establecer su relación con factores socioeconómicos y productivos. MÉTODOS: Se encuestó a 48 familias campesinas del distrito de Tunanmarca. Se midió el contenido de hemoglobina de sus hijos menores de 5 años, previo consentimiento informado. Las asociaciones entre variables se determinaron con pruebas de Chi cuadrado y Rde Spearman, con un p<0,05 en el SPSS 23. RESULTADOS:La prevalencia de anemia infantil fue 86%, distribuidos en 34,9% de anemia leve, 46,5% de anemia moderada y 4,7% de anemia severa. Las prevalencias de enfermedades diarreicas y respiratorias agudas fueron 16,7 y 25%. La anemia infantil se asocia con algunas variables socioeconómicas y productivas. CONCLUSIONES: En la comunidad altoandina de Tunanmarca, Jauja-Perú se observó una alta prevalencia de anemia infantil, asociada inversamente con la educación materna, hogares adecuadamente constituidos, propietarios de la vivienda, mayor frecuencia de consumo de pescado, habas y crianza de animales domésticos

BACKGROUND: Infantile anemia is a critical problem in high Andean areas of Peru due to its association with maternal and infant morbidity and mortality and negative impact on the emotional, cognitive and motor development of children. A study was carried out to determine the prevalence of anemia in the child population of the Tunanmarca district and establish its relationship with socioeconomic and productive factors. METHODS: A survey to 48 peasant families of Tunanmarca district was applied, and the hemoglobin content of their children under 5 years old was measured, with prior informed consent. Associations between the variables were determined with Chi square tests and Spearman's R, with a p <0.05 in the SPSS 23. RESULTS:Infant anemia prevalence was 86%, distributed in 34.9% mild anemia, 46.5% moderate anemia and 4.7% severe anemia. Prevalence of diarrheal and acute respiratory diseases were 16.7 and 25%. Infant anemia prevalence is associated with some socioeconomic and productive variables. CONCLUSIONS: In the high Andean community of Tunanmarca, Jauja-Peru a high prevalence of childhood anemia was observed, inversely associated with maternal education, adequately constituted households, owning the home, with the highest frequency of consumption of fish, beans and the raising of domestic animals

Food Insecurity Is Associated with an Increased Prevalence of Comorbid Medical Conditions in Obese Adults: NHANES 2007-2014.

BACKGROUND: Numerous studies have examined if food insecurity (FI) leads to increased weight gain, but little is known about how FI affects obese participants. OBJECTIVE: Our objective was to determine if obese, food-insecure adults are more likely to have medical comorbidities than obese, food-secure adults. DESIGN: We conducted a cross-sectional study using the 2007-2014 National Health and Nutrition Examination Survey (NHANES). PARTICIPANTS: All obese participants (≥ 20 years) in NHANES were eligible. Participants who were pregnant or missing FI data were excluded. MAIN MEASURES: The primary exposure was household FI, and the primary outcome was the total number of obesity-related comorbidities. Secondary outcomes evaluated the association between FI and individual comorbidities. Propensity score weighting was used to improve covariate balance. We used negative binomial regression to test the association between FI and the total number of comorbidities. We used logistic regression to test the association between FI and individual comorbidities. KEY RESULTS: Of the 9203 obese participants, 15.6% were food insecure. FI (ß = 0.09, 95% CI: 0.02, 0.15; p = 0.01) and very low food security (ß = 0.17, 95% CI: 0.07, 0.28; p = 0.003) were associated with an increased number of comorbidities. In secondary analyses, FI was associated with increased odds of coronary artery disease (OR: 1.5, 95% CI: 1.1, 2.0) and asthma (OR: 1.3, 95% CI: 1.1, 1.6). Very low food security was associated with increased odds of coronary artery disease, diabetes, and asthma. CONCLUSION: Obese adults living in food-insecure households were more likely to have an increased number of comorbid conditions than obese adults living in food-secure households. Clinicians should be aware of the association between FI and comorbid medical conditions when treating patients with obesity.

Measuring and Understanding Food Insecurity in Australia: A Systematic Review.

The number of Australians seeking food aid has increased in recent years; however, the current variability in the measurement of food insecurity means that the prevalence and severity of food insecurity in Australia is likely underreported. This is compounded by infrequent national health surveys that measure food insecurity, resulting in outdated population-level food insecurity data. This review sought to investigate the breadth of food insecurity research conducted in Australia to evaluate how this construct is being measured. A systematic review was conducted to collate the available Australian research. Fifty-seven publications were reviewed. Twenty-two used a single-item measure to examine food security status; 11 used the United States Department of Agriculture (USDA) Household Food Security Survey Module (HFSSM); two used the Radimer/Cornell instrument; one used the Household Food and Nutrition Security Survey (HFNSS); while the remainder used a less rigorous or unidentified method. A wide range in prevalence and severity of food insecurity in the community was reported; food insecurity ranged from 2% to 90%, depending on the measurement tool and population under investigation. Based on the findings of this review, the authors suggest that there needs to be greater consistency in measuring food insecurity, and that work is needed to create a measure of food insecurity tailored for the Australian context. Such a tool will allow researchers to gain a clear understanding of the prevalence of food insecurity in Australia to create better policy and practice responses.

Is food store type associated with the consumption of ultra-processed food and drink products in Brazil?

OBJECTIVE: To analyse the association between food store type and the consumption of ultra-processed products in Brazil. DESIGN: Data from the 2008-2009 Household Budget Survey involving a probabilistic sample of 55 970 Brazilian households. Food stores were grouped into nine categories. Foods and drinks were grouped according to characteristics of food processing. The contribution of each food store type to the total energy acquired from each food processing group, and according to quintiles of consumption of ultra-processed products, was estimated. Exploratory factor analysis was conducted to identify a pattern of food store usage. Linear regression models were performed to estimate the relationship between the purchase pattern and the consumption of ultra-processed products. RESULTS: In line with their larger market share, supermarkets accounted for 59 % of total energy and participated most in acquisition for three food groups, with emphasis on ultra-processed products (60·4 % of energy). The participation of supermarkets in total purchase tended to increase in populations with higher consumption of ultra-processed products, while the participation of small markets and small producers tended to decrease. The purchase pattern characterized by use of traditional retail (street fairs and vendors, small markets, small farmers, butcheries) was associated with a smaller consumption of ultra-processed products. CONCLUSIONS: Food policies and interventions aiming to reduce the consumption of ultra-processed products should consider the influence of supermarkets on the consumption of these products. A purchase pattern based on traditional retail constitutes an important tool for promoting healthy eating in Brazil.

Does unmeasured confounding influence associations between the retail food environment and body mass index over time? The Coronary Artery Risk Development in Young Adults (CARDIA) study.

Background: Findings in the observational retail food environment and obesity literature are inconsistent, potentially due to a lack of adjustment for residual confounding. Methods: Using data from the CARDIA study (n = 12 174 person-observations; 6 examinations; 1985-2011) across four US cities (Birmingham, AL; Chicago, IL; Minneapolis, MN; Oakland, CA), we used instrumental-variables (IV) regression to obtain causal estimates of the longitudinal associations between the percentage of neighbourhood food stores or restaurants (per total food outlets within 1 km network distance of respondent residence) with body mass index (BMI), adjusting for individual-level socio-demographics, health behaviours, city, year, total food outlets and market-level prices. To determine the presence and extent of bias, we compared the magnitude and direction of results with ordinary least squares (OLS) and random effects (RE) regression, which do not control for residual confounding, and with fixed effects (FE) regression, which does not control for time-varying residual confounding. Results: Relative to neighbourhood supermarkets (which tend to be larger and have healthier options than grocery stores), a higher percentage of grocery stores [mean = 53.4%; standard deviation (SD) = 31.8%] was positively associated with BMI [ß = 0.05; 95% confidence interval (CI) = 0.01, 0.10] using IV regression. However, associations were negligible or null using OLS (ß = -0.001; 95% CI = -0.01, 0.01), RE (ß = -0.003; 95% CI = -0.01, 0.0001) and FE (ß = -0.003; 95% CI = -0.01, 0.0002) regression. Neighbourhood convenience stores and fast-food restaurants were not associated with BMI in any model. Conclusions: Longitudinal associations between neighbourhood food outlets and BMI were greater in magnitude using a causal model, suggesting that weak findings in the literature may be due to residual confounding.

Identifying food deserts and swamps based on relative healthy food access: a spatio-temporal Bayesian approach.

BACKGROUND: Obesity and other adverse health outcomes are influenced by individual- and neighbourhood-scale risk factors, including the food environment. At the small-area scale, past research has analysed spatial patterns of food environments for one time period, overlooking how food environments change over time. Further, past research has infrequently analysed relative healthy food access (RHFA), a measure that is more representative of food purchasing and consumption behaviours than absolute outlet density. METHODS: This research applies a Bayesian hierarchical model to analyse the spatio-temporal patterns of RHFA in the Region of Waterloo, Canada, from 2011 to 2014 at the small-area level. RHFA is calculated as the proportion of healthy food outlets (healthy outlets/healthy + unhealthy outlets) within 4-km from each small-area. This model measures spatial autocorrelation of RHFA, temporal trend of RHFA for the study region, and spatio-temporal trends of RHFA for small-areas. RESULTS: For the study region, a significant decreasing trend in RHFA is observed (-0.024), suggesting that food swamps have become more prevalent during the study period. For small-areas, significant decreasing temporal trends in RHFA were observed for all small-areas. Specific small-areas located in south Waterloo, north Kitchener, and southeast Cambridge exhibited the steepest decreasing spatio-temporal trends and are classified as spatio-temporal food swamps. CONCLUSIONS: This research demonstrates a Bayesian spatio-temporal modelling approach to analyse RHFA at the small-area scale. Results suggest that food swamps are more prevalent than food deserts in the Region of Waterloo. Analysing spatio-temporal trends of RHFA improves understanding of local food environment, highlighting specific small-areas where policies should be targeted to increase RHFA and reduce risk factors of adverse health outcomes such as obesity.

Availability, Price, and Quality of Fruits and Vegetables in 12 Rural Montana Counties, 2014.

We assessed the consumer food environment in rural areas by using the Nutrition Environment Measures Survey for Stores (NEMS-S) to measure the availability, price, and quality of fruits and vegetables. We randomly selected 20 grocery stores (17 rural, 3 urban) in 12 Montana counties using the 2013 US Department of Agriculture's rural-urban continuum codes. We found significant differences in NEMS-S scores for quality of fruits and vegetables; of 6 possible points, the mean quality score was 4.5; of rural stores, the least rural stores had the highest mean quality scores (6.0). Intervention strategies should aim to increase fruit and vegetable quality in rural areas.

Lack of Healthy Food in Small-Size to Mid-Size Retailers Participating in the Supplemental Nutrition Assistance Program, Minneapolis-St. Paul, Minnesota, 2014.

INTRODUCTION: The US Department of Agriculture has stocking criteria for healthy foods among Supplemental Nutrition Assistant Program (SNAP)-authorized retailers. Increased access to healthy food could improve diet quality among SNAP participants, which has implications for chronic disease prevention. The objective of this study was to quantify healthy foods stocked in small-size to mid-size retailers who are authorized under SNAP but not under the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). METHODS: We used formative, cross-sectional data from a large policy evaluation to conduct secondary analyses. Store audits were conducted in 2014 in 91 randomly selected, licensed food stores in Minneapolis and St. Paul, Minnesota. Supermarkets and retailers participating in WIC, which are required to stock healthy foods, were excluded as were other stores not reasonably expected to stock staple foods, such as specialty stores or produce stands. Availability of milk, fruits, vegetables, and whole-grain-rich foods was assessed. RESULTS: The 91 stores studied were corner stores, food-gas marts, dollar stores, and pharmacies. More than half carried 1 or more varieties of fat-free or low-fat milk, fresh or canned fruit, and whole-grain-rich cereal. However, only one-third stocked 1 or more varieties of fresh vegetables and only one-quarter stocked whole-grain-rich products, such as whole-grain-rich bread (26%) or tortillas (21%) or brown rice (25%). Few stores stocked at least 2 varieties of each product. CONCLUSIONS: Many stores did not stock a variety of healthy foods. The US Department of Agriculture should change policies to improve minimum stocking requirements for SNAP-authorized retailers.

A randomized controlled study of a healthy corner store initiative on the purchases of urban, low-income youth.

OBJECTIVE: Although many initiatives exist to improve the availability of healthy foods in corner stores, few randomized trials have assessed their effects. This study evaluated, in a randomized controlled trial, the effects of a first-generation healthy corner store intervention on students' food and beverage purchases over a 2-year period. METHODS: Participants (n = 767) were fourth-, fifth-, and sixth-grade students. Ten schools and their nearby corner stores (n = 24) were randomly assigned to the healthy corner store intervention or an assessment-only control. Intercept surveys directly assessed the nutritional characteristics of students' corner store purchases at baseline, 1 and 2 years. Students' weight and heights were measured at baseline, 1 and 2 years. RESULTS: There were no differences in energy content per intercept purchased from control or intervention schools at year 1 (P = 0.12) or 2 (P = 0.58). There were no differences between control and intervention students in BMI z score (year 1, P = 0.83; year 2, P = 0. 98) or obesity prevalence (year 1, P = 0.96; year 2, P = 0.58). CONCLUSIONS: A healthy corner store initiative did not result in significant changes in the energy content of corner store purchases or in continuous or categorical measures of obesity. These data will help to inform future interventions.

Avaliação da segurança alimentar e nutricional de famílias beneficiárias do Programa Bolsa Família / Food security status of beneficiary families of the brazilian 'Bolsa Família' Program

Objetivo: Avaliaram-se par�metros socioecon�micos e seguran�a alimentar e nutricional (SAN) de fam�lias benefici�rias do Programa Bolsa Fam�lia (PBF) residentes em um munic�pio do norte de Minas Gerais. M�todos: Foram investigadas 150 fam�lias e obtidos dados sobre as suas condi��es socioecon�micas (idade do titular, n�vel de escolaridade, situa��o no mercado de trabalho, renda gasta com alimenta��o e n�mero de filhos). Mediu-se o n�vel de seguran�a alimentar utilizando-se a Escala Brasileira de Medida da Inseguran�a Alimentar, com 15 quest�es que refletem a inseguran�a alimentar em diferentes n�veis de intensidade. Aplicou-se o teste de Fisher para avaliar a associa��o entre seguran�a alimentar e as vari�veis socioecon�micas. Resultados: A grande maioria das fam�lias era jovem, empregada e com at� tr�s filhos menores de 18 anos; 60% gastavam menos de 160 reais mensais com alimenta��o. Observou-se que 72,0% dos entrevistados sofriam de inseguran�a alimentar, sendo 50,0% em um grau leve, 14,7% moderada e 7,3% grave. Os dados de inseguran�a alimentar n�o se associaram �s vari�veis socioecon�micas. Conclus�o: As fam�lias contempladas pelo Programa Bolsa Fam�lia ainda vivem em condi��es de vulnerabilidade social e a seguran�a alimentar e nutricional ainda n�o � garantida para essa popula��o.

Objective: The present study evaluated the socioeconomic and food and nutrition security (FNS) parameters of families assisted under the ?Bolsa Fam�lia? Program in a municipality of northern Minas Gerais state, Brazil. Methods: Data on socioeconomic conditions (age and educational level of the head of family, labor market position, expenses with food, and number of children) were collected from a sample of 150 families. Food security status was measured using the Brazilian Food Insecurity Scale with 15 questions that indicate different levels of food insecurity. Association between food security and socioeconomic variables were assessed by the Fisher?s exact test. Results: Most families were young, with employed parents, and up to 3 underage children; 60% spent less than R$160.00/month on food. It was possible to observe that 72.0% of the families investigated suffered with food insecurity: 50.0% with mild insecurity, 14.7% with moderate insecurity, and 7.3% with severe insecurity. Data on food insecurity were not associated with the socioeconomic variables assessed. Conclusion: The families assisted by the ?Bolsa Fam�lia? Program still live under social vulnerability and do not have their food and nutritional security ensured.

The geography of diabetes by census tract in a large sample of insured adults in King County, Washington, 2005-2006.

INTRODUCTION: Identifying areas of high diabetes prevalence can have an impact on public health prevention and intervention programs. Local health practitioners and public health agencies lack small-area data on obesity and diabetes. METHODS: Clinical data from the Group Health Cooperative health care system were used to estimate diabetes prevalence among 59,767 adults by census tract. Area-based measures of socioeconomic status and the Modified Retail Food Environment Index were obtained at the census-tract level in King County, Washington. Spatial analyses and regression models were used to assess the relationship between census tract-level diabetes and area-based socioeconomic status and food environment variables. The mediating effect of obesity on the geographic distribution of diabetes was also examined. RESULTS: In this population of insured adults, diabetes was concentrated in south and southeast King County, with smoothed diabetes prevalence ranging from 6.9% to 21.2%. In spatial regression models, home value and college education were more strongly associated with diabetes than was household income. For each 50% increase in median home value, diabetes prevalence was 1.2 percentage points lower. The Modified Retail Food Environment Index was not related to diabetes at the census-tract level. The observed associations between area-based socioeconomic status and diabetes were largely mediated by obesity (home value, 58%; education, 47%). CONCLUSION: The observed geographic disparities in diabetes among insured adults by census tract point to the importance of area socioeconomic status. Small-area studies can help health professionals design community-based programs for diabetes prevention and control.

Assessing the food environment of a rural community: baseline findings from the heart of New Ulm project, Minnesota, 2010-2011.

INTRODUCTION: Changes in the food environment in the United States during the past few decades have contributed to increased rates of obesity, diabetes, and heart disease. Improving the food environment may be an effective primary prevention strategy to address these rising disease rates. The purpose of this study was to assess the consumer food environment of a rural community with high rates of obesity and low levels of fruit and vegetable consumption. Findings were used to identify food environment intervention strategies to be implemented as part of a larger community-based heart disease prevention program. METHODS: We used the Nutrition Environment Measures Survey for Restaurants (NEMS-R) and Stores (NEMS-S) to assess 34 restaurants, 3 grocery stores, and 5 convenience stores in New Ulm, Minnesota. RESULTS: At least half of the restaurants offered nonfried vegetables and 100% fruit juice. Only 32% had at least 1 entrée or 1 main dish salad that met standards for "healthy." Fewer than half (41%) had fruit available and under one-third offered reduced-size portions (29%) or whole-grain bread (26%). Grocery stores had more healthful items available, but findings were mixed on whether these items were made available at a lower price than less healthful items. Convenience stores were less likely to have fruits and vegetables and less likely to carry more healthful products (except milk) than grocery stores. CONCLUSION: Baseline findings indicated opportunities to improve availability, quality, and price of foods to support more healthful eating. A community-wide food environment assessment can be used to strategically plan targeted interventions.

A survey of foodstuffs fortified with vitamins available on the market in Warsaw.

BACKGROUND: Foodstuffs fortified with vitamins and/or minerals are nowadays continually being developed, leading to an increasing diversity of these products being available on the market. This contributes to increased consumption of added nutrients, which can be an effective tool for improving public health. OBJECTIVES: To identify and characterise products fortified with vitamins, available on the Warsaw foodstuff market, which can thereby be used as a source of information for the assessment of dietary micronutrient intake. MATERIAL AND METHODS: Data were gathered using the information provided on labels from foodstuff products found in 14 Warsaw supermarkets during March to October 2012. RESULTS: There were 588 products found to be fortified with vitamins. The number of vitamins added ranged from one in 193 products to twelve in 14 products. The group of vitamins used for enrichment consisted of: A, D, E, B1, B2, B6, B12, C, niacin, pantothenic acid, folic acid and biotin. Juices, non-alcoholic beverages (29.4%) and cereal products (18.9%) constituted the largest product groups. In addition, fortified vitamins were also significantly present in sweets (15.8%), instant beverages and desserts (13.6%), milk products, fat spreads and soy products. The most frequently added vitamins were: vitamin C (58% products), vitamin B6 (46%) and B12 (45%), whilst the least frequently added was biotin (16%). The highest content of vitamins A and D were seen in fat spreads, whereas the highest levels of B vitamins, vitamin C and E were observed in certain sweets. CONCLUSIONS: The wide range of fortified products available can serve to increase vitamin intake in many population groups, especially in children and teenagers. In order that consumers can make informed choices in buying these product types, appropriate education is necessary to raise public awareness of the health issues involved.

Classification bias in commercial business lists for retail food stores in the U.S.

BACKGROUND: Aspects of the food environment such as the availability of different types of food stores have recently emerged as key modifiable factors that may contribute to the increased prevalence of obesity. Given that many of these studies have derived their results based on secondary datasets and the relationship of food stores with individual weight outcomes has been reported to vary by store type, it is important to understand the extent to which often-used secondary data correctly classify food stores. We evaluated the classification bias of food stores in Dun & Bradstreet (D&B) and InfoUSA commercial business lists. METHODS: We performed a full census in 274 randomly selected census tracts in the Chicago metropolitan area and collected detailed store attributes inside stores for classification. Store attributes were compared by classification match status and store type. Systematic classification bias by census tract characteristics was assessed in multivariate regression. RESULTS: D&B had a higher classification match rate than InfoUSA for supermarkets and grocery stores, while InfoUSA was higher for convenience stores. Both lists were more likely to correctly classify large supermarkets, grocery stores, and convenience stores with more cash registers and different types of service counters (supermarkets and grocery stores only). The likelihood of a correct classification match for supermarkets and grocery stores did not vary systemically by tract characteristics whereas convenience stores were more likely to be misclassified in predominately Black tracts. CONCLUSION: Researches can rely on classification of food stores in commercial datasets for supermarkets and grocery stores whereas classifications for convenience and specialty food stores are subject to some systematic bias by neighborhood racial/ethnic composition.

The foodscape: classification and field validation of secondary data sources across urban/rural and socio-economic classifications in England.

BACKGROUND: In recent years, alongside the exponential increase in the prevalence of overweight and obesity, there has been a change in the food environment (foodscape). This research focuses on methods used to measure and classify the foodscape. This paper describes the foodscape across urban/rural and socio-economic divides. It examines the validity of a database of food outlets obtained from Local Authority sources (secondary level & desk based), across urban/rural and socio-economic divides by conducting fieldwork (ground-truthing). Additionally this paper tests the efficacy of using a desk based classification system to describe food outlets, compared with ground-truthing. METHODS: Six geographically defined study areas were purposively selected within North East England consisting of two Lower Super Output Areas (LSOAs; a small administrative geography) each. Lists of food outlets were obtained from relevant Local Authorities (secondary level & desk based) and fieldwork (ground-truthing) was conducted. Food outlets were classified using an existing tool. Positive predictive values (PPVs) and sensitivity analysis was conducted to explore validation of secondary data sources. Agreement between 'desk' and 'field' based classifications of food outlets were assessed. RESULTS: There were 438 food outlets within all study areas; the urban low socio-economic status (SES) area had the highest number of total outlets (n = 210) and the rural high SES area had the least (n = 19). Differences in the types of outlets across areas were observed. Comparing the Local Authority list to fieldwork across the geographical areas resulted in a range of PPV values obtained; with the highest in urban low SES areas (87%) and the lowest in Rural mixed SES (79%). While sensitivity ranged from 95% in the rural mixed SES area to 60% in the rural low SES area. There were no significant associations between field/desk percentage agreements across any of the divides. CONCLUSION: Despite the relatively small number of areas, this work furthers our understanding of the validity of using secondary data sources to identify and classify the foodscape in a variety of geographical settings. While classification of the foodscape using secondary Local Authority food outlet data with information obtained from the internet, is not without its difficulties, desk based classification would be an acceptable alternative to fieldwork, although it should be used with caution.

Improving data accuracy of commercial food outlet databases.

PURPOSE. Assessing food environments often requires using commercially available data. Disparate methods used for classifying food outlets in these databases call for creating a classification approach using common definitions. A systematic strategy for reclassifying food stores and restaurants, as they appear in commercial databases, into categories that differentiate the availability of healthy options is described here. DESIGN AND SETTING. Commercially available data on food outlets including names, addresses, North American Industry Classification System codes, and associated characteristics was obtained for five New Jersey communities. ANALYSIS. A reclassification methodology was developed using criteria and definitions from the literature to categorize food outlets based on availability of healthy options. Information in the database was supplemented by systematic Internet and key word searches, and from phone calls to food outlets. RESULTS. The methodology resulted in 622 supermarket/grocery stores, 183 convenience stores, and 148 specialty stores in the original data to be reclassified into 58 supermarkets, 30 grocery stores, 692 convenience stores, and 115 specialty stores. Outlets from the original list of 1485 full-service restaurants and 506 limited-service restaurants were reclassified as 563 full-service restaurants and 1247 limited-service restaurants. Reclassification resulted in less than one-seventh the number of supermarkets and grocery stores, more than three times the number of convenience stores, and twice as many limited-service restaurants-a much less healthy profile than the one generated by using exclusively the commercial databases. CONCLUSION. An explicit and replicable strategy is proposed for reclassifying food outlets in commercial databases into categories that differentiate on the basis of healthy food availability. The intent is to contribute towards building a consensus among researchers on definitions used in public health research for characterizing different types of food outlets.

Validation of 3 food outlet databases: completeness and geospatial accuracy in rural and urban food environments.

Despite interest in the built food environment, little is known about the validity of commonly used secondary data. The authors conducted a comprehensive field census identifying the locations of all food outlets using a handheld global positioning system in 8 counties in South Carolina (2008-2009). Secondary data were obtained from 2 commercial companies, Dun & Bradstreet, Inc. (D&B) (Short Hills, New Jersey) and InfoUSA, Inc. (Omaha, Nebraska), and the South Carolina Department of Health and Environmental Control (DHEC). Sensitivity, positive predictive value, and geospatial accuracy were compared. The field census identified 2,208 food outlets, significantly more than the DHEC (n = 1,694), InfoUSA (n = 1,657), or D&B (n = 1,573). Sensitivities were moderate for DHEC (68%) and InfoUSA (65%) and fair for D&B (55%). Combining InfoUSA and D&B data would have increased sensitivity to 78%. Positive predictive values were very good for DHEC (89%) and InfoUSA (86%) and good for D&B (78%). Geospatial accuracy varied, depending on the scale: More than 80% of outlets were geocoded to the correct US Census tract, but only 29%-39% were correctly allocated within 100 m. This study suggests that the validity of common data sources used to characterize the food environment is limited. The marked undercount of food outlets and the geospatial inaccuracies observed have the potential to introduce bias into studies evaluating the impact of the built food environment.