Development and testing of two tools to assess point-of-sale food and beverage marketing to children in restaurants.

OBJECTIVE: To describe the development and testing of two assessment tools designed to assess exterior (including drive-thru) and interior food and beverage marketing in restaurants with a focus on marketing to children and teens. DESIGN: A scoping review on restaurant marketing to children was undertaken, followed by expert and government consultations to produce a draft assessment tool. The draft tool was mounted online, and further refined into two separate tools: the Canadian Marketing Assessment Tool for Restaurants (CMAT-R) and the CMAT-Photo Coding Tool (CMAT-PCT). The tools were tested to assess inter-rater reliability using Cohen's Kappa and percent agreement for dichotomous variables, and intra-class correlation coefficients for continuous or rank order variables. SETTING: Waterloo, Ontario, Canada. PARTICIPANTS: Restaurants of all types were assessed using the CMAT-R (n = 57), and 30 randomly selected photos were coded using the CMAT-PCT. RESULTS: The CMAT-R collected data on general promotions and restaurant features, drive-thru features, the children's menu, and the dollar/value menu. The CMAT-PCT collected data on advertisement features, features considered appealing to children and teens, characters. The inter-rater reliability of the CMAT-R tool was strong (mean percent agreement was 92.4%, mean Cohen's κ = 0.82 for all dichotomous variables and mean ICC = 0.961 for continuous/count variables). Mean percent agreement for the CMAT-PCT across items was 97.3%, and mean Cohen's κ across items was 0.91, indicating very strong inter-rater reliability. CONCLUSIONS: The tools assess restaurant food and beverage marketing. Both showed high inter-rater reliability and can be adapted to better suit other contexts.

Food environment research in Canada: a rapid review of methodologies and measures deployed between 2010 and 2021.

Numerous research methodologies have been used to examine food environments. Existing reviews synthesizing food environment measures have examined a limited number of domains or settings and none have specifically targeted Canada. This rapid review aimed to 1) map research methodologies and measures that have been used to assess food environments; 2) examine what food environment dimensions and equity related-factors have been assessed; and 3) identify research gaps and priorities to guide future research. A systematic search of primary articles evaluating the Canadian food environment in a real-world setting was conducted. Publications in English or French published in peer-reviewed journals between January 1 2010 and June 17 2021 and indexed in Web of Science, CAB Abstracts and Ovid MEDLINE were considered. The search strategy adapted an internationally-adopted food environment monitoring framework covering 7 domains (Food Marketing; Labelling; Prices; Provision; Composition; Retail; and Trade and Investment). The final sample included 220 articles. Overall, Trade and Investment (1%, n = 2), Labelling (7%, n = 15) and, to a lesser extent, Prices (14%, n = 30) were the least studied domains in Canada. Among Provision articles, healthcare (2%, n = 1) settings were underrepresented compared to school (67%, n = 28) and recreation and sport (24%, n = 10) settings, as was the food service industry (14%, n = 6) compared to grocery stores (86%, n = 36) in the Composition domain. The study identified a vast selection of measures employed in Canada overall and within single domains. Equity-related factors were only examined in half of articles (n = 108), mostly related to Retail (n = 81). A number of gaps remain that prevent a holistic and systems-level analysis of food environments in Canada. As Canada continues to implement policies to improve the quality of food environments in order to improve dietary patterns, targeted research to address identified gaps and harmonize methods across studies will help evaluate policy impact over time.

The Influence of the School Neighborhood Food Retail Environment on Unhealthy Food Purchasing Behaviors Among Adolescents: A Systematic Review.

INTRODUCTION: Adolescents are often exposed to food retailers selling unhealthy food items during their lunch breaks and school commutes. This systematic review examines the influence of school neighborhood food retail environments on adolescent food purchasing. METHODS: A systematic search of 6 databases. Observational studies published from January 2012 to December 2022 that measured food availability, accessibility, or exposure, measured food purchasing, and focused on adolescents (aged 10-19 years) were eligible for inclusion. RESULTS: Twelve studies with 97 findings were included. Thirty-one findings indicated that a school neighborhood with a high density of unhealthy food retail, a school with unhealthy food retail nearby, or exposure to unhealthy food retail on the journey to/from school was associated with higher prevalence and frequency of unhealthy food purchases. DISCUSSION: Adolescents' food purchasing behaviors may be meaningfully affected by their school neighborhood food retail environment; however, the included studies have many methodological shortcomings. IMPLICATIONS FOR RESEARCH AND PRACTICE: Results identify the need for new studies that measure food purchasing, use comprehensive definitions of food retail environments, and adopt more rigorous methods to approximate exposure to food retail. More robust evidence would strengthen the rationale for policy or program interventions and potentially indicate specific targets for intervention.

The British Columbia Farmers' Market Nutrition Coupon Program Reduces Short-Term Household Food Insecurity Among Adults With Low Incomes: A Pragmatic Randomized Controlled Trial.

BACKGROUND: The British Columbia Farmers' Market Nutrition Coupon Program (BC FMNCP) provides households with low incomes with coupons to purchase healthy foods from farmers' markets. OBJECTIVE: To examine the impact of the BC FMNCP on the short-term household food insecurity, malnutrition risk, mental well-being, sense of community (secondary outcomes), and subjective social status (exploratory outcome) of adults with low incomes post-intervention and 16 weeks post-intervention. DESIGN: Secondary analyses from a pragmatic randomized controlled trial conducted in 2019 that collected data at baseline, post-intervention, and 16 weeks post-intervention. PARTICIPANTS/SETTING: Adults ≥18 years with low incomes were randomized to an FMNCP group (n = 143) or a no-intervention control group (n = 142). INTERVENTION: Participants in the FMNCP group received 16 coupon sheets valued at $21 Canadian dollars (CAD)/sheet over 10 to 15 weeks to purchase healthy foods from farmers' markets and were eligible to participate in nutrition skill-building activities. MAIN OUTCOME MEASURES: Outcomes included short-term household food insecurity (modified version of Health Canada's 18-item Household Food Security Survey Module), malnutrition risk (Malnutrition Universal Screening Tool), mental well-being (Warwick-Edinburgh Mental Well-Being Scale), sense of community (Brief Sense of Community Scale), and subjective social status (MacArthur Scale of Subjective Social Status community scale). STATISTICAL ANALYSIS: Mixed-effects linear regression and multinomial logistic regression examined between-group differences in outcomes post-intervention and 16 weeks post-intervention. RESULTS: The risk of marginal and severe short-term household food insecurity was lower among those in the FMNCP group compared with those in the control group (relative risk ratio [RRR] 0.15, P = 0.01 and RRR 0.16, P = 0.02) post-intervention, with sustained reductions in severe household food insecurity 16 weeks post-intervention (RRR 0.11, P = 0.01). No statistically significant differences were observed in malnutrition risk, mental well-being, sense of community, or subjective social status post-intervention or 16 weeks post-intervention. CONCLUSIONS: The BC FMNCP reduced short-term household food insecurity but was not found to improve malnutrition risk or psychosocial well-being among adults with low incomes compared with a no-intervention control group.

"No one went into pharmacy to sell a lot of Coca-Cola. It's just sort of a necessary evil" - Community pharmacists' perceptions of front-of-store sales and ethical tensions in the retail environment.

Background: Community pharmacists are expected to uphold ethical duties to patients and society while maintaining independent businesses or fulfilling expectations of corporate owners. Canadian pharmacy colleges provide only indirect guidance on the retail setting of the profession. Little is known about whether pharmacists identify ethical issues in retail pharmacy or around the sales of non-drug products. Objective: This study sought to examine pharmacists' perceptions of their roles in health promotion, the factors that influence the selection of front-of-store products, and ethical issues relating to their dual roles as health care providers and retailers. Methods: In 2020, 25 Canadian pharmacists participated in semi-structured phone interviews. Interviews were audio-recorded, anonymized, transcribed verbatim, and thematically analyzed using qualitative methods. Results: Almost all participants described their role primarily as a health care provider, though some described themselves as 50-50 health care providers and retailers. Most staff pharmacists reported little control over front-of-store product selection. Where participants reported some control, external factors such as business viability and profitability impacted their choices, though some reported selecting products based on the needs of their patient community or their personal beliefs. The dominant tensions described stemmed from participants' dual roles as health care providers and retailers, though specific issues and situations were varied, ranging corporate targets, to service provision, to the sales of unproven or unhealthy products. Participants suggested solutions to the issues they described, ranging from a complete overhaul of the licensing structure of community pharmacies, down to one-on-one conversations with patients. Conclusion: Our findings suggest that the retail setting of community pharmacy produces unique ethical tensions: the imposition of retail sales standards and targets are commonplace, and business viability is a primary driving force in front-of-store product selection. Clear guidance from Canadian pharmacy colleges and legislators to address these tensions and issues may be necessary.

Breakfast Consumption and Diet Quality of Teens in Southwestern Ontario.

Background: Breakfast skipping has previously been associated with worse diet quality among adolescents; the latter increases the risk of chronic disease. However, many studies do not consider diet quality as a function of calories, which is problematic as skippers tend to consume less energy than consumers. Additionally, due to the lack of one accepted definition of both breakfast skipping and diet quality, it is unclear how differences found may change when using varying definitions. Objectives: We aimed to compare the Healthy Eating Index-2015 (HEI-2015) scores and nutrient intakes of teen breakfast skippers and consumers in Southwestern Ontario, Canada. Methods: Cross-sectional, baseline data were used from SmartAPPetite, an ongoing nutrition intervention study. Singular 24-h dietary recalls and sociodemographic data from 512 adolescents aged 13-19 y were used to compare HEI-2015 scores and nutrient intakes via multivariable linear regression. Results: Previous day breakfast skippers had significantly lower HEI-2015 scores (-4.4; 95% CI: -8.4, -0.4) and significantly lower intakes of calories, saturated fat, and vitamin C, as well as significantly higher intake of sodium and total fat. Conclusions: Previous day breakfast consumers had significantly higher diet quality scores and better nutrient intakes than breakfast skippers, although, on average, both had poor diet quality. Consequently, it is unlikely that simply advising teens to consume breakfast will result in meaningful change in diet quality, and more effort should be placed on promoting nutritious breakfasts.

The contribution of modifiable risk factors to socioeconomic inequities in cardiovascular disease morbidity and mortality: A nationally representative population-based cohort study.

This study examined the individual and joint effects of modifiable risk factors mediating the associations between socioeconomic position (SEP) and morbidity and mortality from cardiovascular diseases (CVD) in a nationally representative sample of adults in Canada. Participants in the Canadian Community Health Survey (n = 289,800) were followed longitudinally for CVD morbidity and mortality using administrative health and mortality data. SEP was measured as a latent variable consisting of household income and individual educational attainment. Mediators included smoking, physical inactivity, obesity, diabetes and hypertension. The primary outcome was CVD morbidity and mortality, defined as the first fatal/nonfatal CVD event during follow-up (median 6.2 years). Generalized structural equation modeling tested the mediating effects of modifiable risk factors in associations between SEP and CVD in the total population and stratified by sex. Lower SEP was associated with 2.5 times increased odds of CVD morbidity and mortality (OR: 2.52, 95% CI: 2.28, 2.76). Modifiable risk factors mediated 74% of associations between SEP and CVD morbidity and mortality in the total population and were more important mediators of associations in females (83%) than males (62%). Smoking mediated these associations independently and jointly with other mediators. The mediating effects of physical inactivity were through joint mediating effects with obesity, diabetes or hypertension. There were additional joint mediating effects of obesity through diabetes or hypertension in females. Findings point to modifiable risk factors as important targets for interventions along with interventions that target structural determinants of health to reduce socioeconomic inequities in CVD.

Neighborhood Fast-Food Environments and Hypertension in Canadian Adults.

INTRODUCTION: Hypertension is a leading cause of cardiovascular disease and premature death worldwide. Neighborhoods characterized by a high proportion of fast-food outlets may also contribute to hypertension in residents; however, limited research has explored these associations. This cross-sectional study assessed the associations between neighborhood fast-food environments, measured hypertension, and self-reported hypertension. METHODS: Data from 10,700 adults living in urban areas were obtained from six Canadian Health Measures Survey cycles (2007-2019). Each participant's blood pressure was measured at a mobile clinic six times. Measured hypertension was defined as having an average systolic blood pressure ≥140 or a diastolic blood pressure ≥90 mm Hg or being on blood pressure-lowering medication. Participants were also asked whether they had been diagnosed with high blood pressure or whether they take blood pressure-lowering medication (i.e., self-reported hypertension). The proportion of fast-food outlets relative to the sum of fast-food outlets and full-service restaurants in each participant's neighborhood was obtained from the Canadian Food Environment Dataset, and analyses were conducted in 2022. RESULTS: The mean proportion of fast-food outlets was 23.3% (SD=26.8%). A one SD increase in the proportion of fast-food outlets was associated with higher odds of measured hypertension in the full sample (OR=1.17, 95% CI=1.05, 1.31) and in sex-specific models (women: OR=1.14, 95% CI=1.01, 1.29; men: OR=1.21, 95% CI=1.03, 1.43). Associations between the proportion of fast-food outlets and self-reported hypertension were inconclusive. CONCLUSIONS: Findings suggest that reducing the proportion of fast-food restaurants in neighborhoods may be a factor that could help reduce hypertension rates.

Impact of a farmers' market healthy food subsidy on the diet quality of adults with low incomes in British Columbia, Canada: a pragmatic randomized controlled trial.

BACKGROUND: Adults with low incomes have lower diet quality than their higher income counterparts. In Canada, the British Columbia Farmers' Market Nutrition Coupon Program (FMNCP) provides coupons to low-income households to purchase healthy foods in farmers' markets. OBJECTIVE: The objective of this study was to examine the impact of the FMNCP on the diet quality of adults with low incomes. METHOD: In a pragmatic randomized controlled trial conducted in 2019, adults with low incomes (≥18 y) were randomly assigned either to an FMNCP intervention (n = 143) or a no-intervention control group (n = 142). The FMNCP group received 16 coupon sheets valued at $21 per sheet over 10-15 wk to purchase healthy foods from farmers' markets. Participants completed a questionnaire and 2 24-h dietary recalls at baseline (0 wk), immediately post-intervention (10-15 wk), and 16-wk post-intervention (26-31 wk). Diet quality was calculated using the Healthy Eating Index-2015 (HEI-2015). Linear mixed-effects regression assessed differences in HEI-2015 total (primary outcome) and component scores (secondary outcomes) between the FMNCP and control groups at post-intervention and 16-wk post-intervention. Subgroup analyses examined program impacts by sex and age group (18-59 y, ≥60 y). RESULTS: There were no significant differences in HEI-2015 total scores between the FMNCP and control groups at post-intervention (-0.07; 95% CI: -4.07, 3.93) or 16-wk post-intervention (1.22; 95% CI: -3.00, 5.44) overall or between subgroups. There were no significant between-group differences in HEI-2015 component scores at post-intervention, although there were significant differences in component scores for dairy and fatty acids at 16-wk post-intervention. CONCLUSION: The FMNCP did not significantly improve diet quality among adults with low incomes over the study period. Further research is needed to explore whether higher subsidy amounts or a longer intervention period is needed to meaningfully improve diet quality among adults with low incomes. This trial was registered at [clinicaltrials.gov] as [NCT03952338].

Implementation of a food retail intervention to reduce purchase of unhealthy food and beverages in remote Australia: mixed-method evaluation using the consolidated framework for implementation research.

BACKGROUND: Adoption of health-enabling food retail interventions in food retail will require effective implementation strategies. To inform this, we applied an implementation framework to a novel real-world food retail intervention, the Healthy Stores 2020 strategy, to identify factors salient to intervention implementation from the perspective of the food retailer. METHODS: A convergent mixed-method design was used and data were interpreted using the Consolidated Framework for Implementation Research (CFIR). The study was conducted alongside a randomised controlled trial in partnership with the Arnhem Land Progress Aboriginal Corporation (ALPA). Adherence data were collected for the 20 consenting Healthy Stores 2020 study stores (ten intervention /ten control) in 19 communities in remote Northern Australia using photographic material and an adherence checklist. Retailer implementation experience data were collected through interviews with the primary Store Manager for each of the ten intervention stores at baseline, mid- and end-strategy. Deductive thematic analysis of interview data was conducted and informed by the CFIR. Intervention adherence scores derived for each store assisted interview data interpretation. RESULTS: Healthy Stores 2020 strategy was, for the most part, adhered to. Analysis of the 30 interviews revealed that implementation climate of the ALPA organisation, its readiness for implementation including a strong sense of social purpose, and the networks and communication between the Store Managers and other parts of ALPA, were CFIR inner and outer domains most frequently referred to as positive to strategy implementation. Store Managers were a 'make-or-break' touchstone of implementation success. The co-designed intervention and strategy characteristics and its perceived cost-benefit, combined with the inner and outer setting factors, galvanised the individual characteristics of Store Managers (e.g., optimism, adaptability and retail competency) to champion implementation. Where there was less perceived cost-benefit, Store Managers seemed less enthusiastic for the strategy. CONCLUSIONS: Factors critical to implementation (a strong sense of social purpose; structures and processes within and external to the food retail organisation and their alignment with intervention characteristics (low complexity, cost advantage); and Store Manager characteristics) can inform the design of implementation strategies for the adoption of this health-enabling food retail initiative in the remote setting. This research can help inform a shift in research focus to identify, develop and test implementation strategies for the wide adoption of health-enabling food retail initiatives into practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN 12,618,001,588,280.

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.

Urban design and adolescent mental health: A qualitative examination of adolescent emotional responses to pedestrian- and transit-oriented design and cognitive architecture concepts.

With the continued migration of people into cities, urban environments are becoming increasingly important determinants of health. However, the study of how precise environmental designs are linked to mental health are generally lacking, especially among adolescent populations. Using a qualitative approach featuring 23 go-along interviews with adolescents, we investigated the relationships between specific urban designs as outlined in pedestrian- and transit-oriented design (imageability, enclosure, scale, transparency, complexity) and cognitive architecture (biophilic architecture, symmetries, fractals) concepts and adolescent mental health indicators (i.e., emotional responses). Central findings from the subsequently undertaken framework analysis include considerably different perceptions regarding natural versus built enclosure and landmarks, significantly more expressed emotional engagement with visually rich and transparent urban designs relative to grey/concrete and windowless designs, and strong positive reactions to the three cognitive architecture concepts. Additional exploratory gender-based analyses were conducted and found potential differences in perceptions of design concepts between boys and girls. We note the broader relevance of these findings by discussing their implications for practitioners and suggesting how they can advance certain UN Sustainable Development Goals.

A systematic review of trucking food, physical activity, and tobacco environments and tractor-trailer drivers' related patterns and practices in the United States and Canada, 1993-2021.

Truckers in the United States (U.S.) and Canada are at high risk for noncommunicable disease. Although trucking built environments have been highlighted for intervention, no systematic review has assessed aspects of trucking environments that may influence food, physical activity (PA), and smoking patterns/practices. The purpose of this systematic review was to characterize the state of the science on trucking food, PA, and tobacco environments and to examine truckers' food, PA, and tobacco patterns/practices. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used. Five databases were selected for searching in April 2020 and 2021 using key terms constructed by a librarian. Peer-reviewed research with data about U.S. and Canadian truckers' (i.e., drivers operating 18-wheelers or tractor trailers) food, PA, and/or tobacco environments and related patterns/practices were included. Quality was assessed using the Mixed Method Appraisal Tool. Thirty-eight studies were identified. Results included data from at least 16,600 truckers and 282 trucking settings in the U.S. (n = 32) and Canada (n = 6). Most studies were classified as quantitative descriptive and of poor quality (average score 3 of 7). The few studies (n = 4) that measured trucking food and PA environments characterized trucking sites as poor. Fifteen (47%) presented data about truckers' perceptions of food or PA environments and highlighted prominent environmental barriers. Truckers' food, PA, and smoking patterns and practices suggested poor diet quality, sedentary practices, and a high prevalence of smoking. The science of trucking food, PA, and tobacco environments is underdeveloped and requires much more focus using validated measures.

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.

A pan-Canadian dataset of neighbourhood retail food environment measures using Statistics Canada's Business Register.

BACKGROUND: The objective of this study was to create the Canadian Food Environment Dataset (Can-FED) and to demonstrate its validity. DATA AND METHODS: Food outlet data were extracted from Statistics Canada's Business Register (BR) in 2018. Retail food environment access measures (both absolute and relative measures) were calculated using network buffers around the centroid of 56,589 dissemination areas in Canada. A k-medians clustering approach was used to create categorical food environment variables that were easy to use and amenable to dissemination. Validity of the measures was assessed by comparing the food environment measures from Can-FED with measures created using Enhanced Points of Interest data by DMTI Spatial Inc. and data from a municipal health inspection list. Validity was also assessed by calculating the geographic variability in food environments across census metropolitan areas (CMAs) and assessing associations between CMA-level food environments and CMA-level health indicators. RESULTS: Two versions of Can-FED were created: a researcher file that must be accessed within a secure Statistics Canada environment and a general-use file available online. Agreement between Can-FED food environment measures and those derived from a proprietary dataset and a municipal health inspection list ranged from rs=0.28 for convenience store density and rs=0.53 for restaurant density. At the CMA level, there is wide geographic variation in the food environment with evidence of patterning by health indicators. INTERPRETATION: Can-FED is a valid and accessible dataset of pan-Canadian food environment measures that was created from the BR, a data source that has not been explored fully for health research.

Built environment influences on healthy eating and active living: The NEWPATH study.

OBJECTIVE: The Neighbourhood Environments in Waterloo: Patterns of Active Transportation and Health (NEWPATH) study examined built environment influences on travel, physical activity, food consumption, and health. This collaboration between researchers and practitioners in health and transportation planning is the first, to our knowledge, to integrate food purchasing, diet, travel, and objectively measured physical activity into a trip-destination protocol. This study simultaneously examines diet and physical activity relationships with BMI and waist circumference (WC). METHODS: Individual diet and travel diary data were linked to objective built-environment measures of walkability and retail food environments. BMI and WC were self-reported (n = 1,160). Some respondents wore accelerometers to objectively measure physical activity (n = 549). Pathways from the built environment through behavior (walking and eating) to BMI and WC were assessed using path analysis. RESULTS: Walkability was associated with lower BMI and WC through physical activity and active travel. Healthy retail food environments were associated with healthy eating and lower BMI and WC, whereas walkability and healthy retail food environments were insignificant (p < 0.05). Walkable neighborhoods had less healthy food environments, but active travel was not associated with healthy eating or caloric intake. CONCLUSIONS: Findings highlight the importance of neighborhood walkability and food environments in shaping physical activity, diet, and obesity.

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.

How Do Urban Environments Affect Young People's Mental Health? A Novel Conceptual Framework to Bridge Public Health, Planning, and Neurourbanism.

Childhood and adolescence are crucial periods for mental and social development. Currently, mental illness among young people is a global epidemic, and rates of disorders such as depression and anxiety are rising. Urban living, compared with rural living, is linked with a higher risk of serious mental illness, which is important because the world is urbanizing faster than ever before. Urban environments and their landscapes, designs, and features influence mental health and well-being. However, no conceptual frameworks to date have detailed the effect of urban environments on young people's mental health, and few studies have considered the growing role of digital and social media in this relationship, leading to calls for the development of holistic approaches to describe this relationship. This article synthesizes existing knowledge on urban places (both built and natural environments) and mental health in the public health and urban planning literature and examines the emerging field of neurourbanism (a multidisciplinary study of the effect of urban environments on mental health and brain activity) to enhance current practice and research. We developed 2 novel conceptual frameworks (1 research-oriented, 1 practice-oriented), adapted from Bronfenbrenner's socioecological model, that focus on the relationship between urban environments and young people's mental health. We added a digital and social media contextual level to the socioecological model, and we applied a multilayer concept to highlight potential cross-field interactions and collaborations. The proposed frameworks can help to guide future practice and research in this area.

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.

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.