Toward Heart-Healthy and Sustainable Cities: A Policy Statement From the American Heart Association.

Nearly 56% of the global population lives in cities, with this number expected to increase to 6.6 billion or >70% of the world's population by 2050. Given that cardiometabolic diseases are the leading causes of morbidity and mortality in people living in urban areas, transforming cities and urban provisioning systems (or urban systems) toward health, equity, and economic productivity can enable the dual attainment of climate and health goals. Seven urban provisioning systems that provide food, energy, mobility-connectivity, housing, green infrastructure, water management, and waste management lie at the core of human health, well-being, and sustainability. These provisioning systems transcend city boundaries (eg, demand for food, water, or energy is met by transboundary supply); thus, transforming the entire system is a larger construct than local urban environments. Poorly designed urban provisioning systems are starkly evident worldwide, resulting in unprecedented exposures to adverse cardiometabolic risk factors, including limited physical activity, lack of access to heart-healthy diets, and reduced access to greenery and beneficial social interactions. Transforming urban systems with a cardiometabolic health-first approach could be accomplished through integrated spatial planning, along with addressing current gaps in key urban provisioning systems. Such an approach will help mitigate undesirable environmental exposures and improve cardiovascular and metabolic health while improving planetary health. The purposes of this American Heart Association policy statement are to present a conceptual framework, summarize the evidence base, and outline policy principles for transforming key urban provisioning systems to heart-health and sustainability outcomes.

A comparative national-level analysis of government food system resilience activities across four developed countries at varying stages of planning.

BACKGROUND: The COVID-19 pandemic, extreme weather events, and the Russian invasion of Ukraine have highlighted global food system vulnerabilities and a lack of preparedness and prospective planning for increasingly complex disruptions. This has spurred an interest in food system resilience. Despite the elevated interest in food system resilience, there is a lack of comparative analyses of national-level food system resilience efforts. An improved understanding of the food system resilience landscape can support and inform future policies, programs, and planning. METHODS: We conducted a cross-country comparison of national-level food system resilience activities from Australia, Aotearoa New Zealand, Sweden, and the United States. We developed upon and adapted the resilience framework proposed by Harris and Spiegel to compare actions derived from thirteen national food system resilience documents. We coded the documents based on the actions taken by the governments including: the food system resilience attributes utilized, the part of the food supply chain, the specific shocks or stressors, the implementation level, the temporal focus of action, and the expected impact on food security. We analyzed and compared countries' coded categories and subcategories, and category combinations. RESULTS: The results showed that these countries are addressing some of the same issues, are using multi-pronged policy actions to address food system resilience issues, and are focused on both retrospective reviews and prospective models of disruptive events to inform their decisions. Some work has been done towards preparing for climate change and other natural disasters, and less preparing has been done for other shocks or stressors. CONCLUSIONS: This paper develops and applies a framework rooted in literature to understand the content of national-level food system resilience documents. The analysis identified potential gaps, concentrations, and themes in national food systems resilience. The framework can be applied to augment existing policy, create new policy, as well as to supplement and complement other existing frameworks.

Aquatic food loss and waste rate in the United States is half of earlier estimates.

Food loss and waste (FLW) is a major challenge to food system sustainability, including aquatic foods. We investigated aquatic FLW in the food supply of the United States, the largest importer of aquatic food globally, using primary and secondary data and life cycle methodology. We show that there are significant differences in FLW among species, production technology, origin and stage of supply chain. We estimate total aquatic FLW was 22.7%, which is 43-55% lower than earlier estimates reported in the literature, illustrating the importance of applying a disaggregated approach. Production losses associated with imported food contribute over a quarter of total FLW, and addressing these losses requires multinational efforts to implement interventions along the supply chain. These findings inform prioritization of solutions-including areas of need for innovations, government incentives, policy change, infrastructure and equity.

Commercial weight-loss diets, greenhouse gas emissions and freshwater consumption.

BACKGROUND: Weight-loss attempts are widespread in the United States, with many using commercial weight-loss diet plans for guidance and support. Accordingly, dietary suggestions within these plans influence the nation's food-related environmental footprint. METHODS: We modelled United States (US) per capita greenhouse gas emissions (GHGe) and water footprints associated with seven commercial weight-loss diets, the US baseline, and selected other dietary patterns. We characterised consumption in commercial weight-loss diets both via modelling from provided guidelines and based on specific foods in 1-week meal plans. Cradle-to-farmgate GHGe and water footprints were assessed using a previously developed model. GHGe results were compared to the EAT-Lancet 2050 target. Water footprints were compared to the US baseline. RESULTS: Weight-loss diets had GHGe footprints on average 4.4 times the EAT-Lancet target recommended for planetary health (range: 2.4-8.5 times). Bovine meat was by far the largest contributor of GHGe in most diets that included it. Three commercial diets had water footprints above the US baseline. Low caloric intake in some diets compensated for the relative increases in GHGe- and water-intensive foods. CONCLUSIONS: Dietary patterns suggested by marketing materials and guidelines from commercial weight-loss diets can have high GHGe and water footprints, particularly if caloric limits are exceeded. Commercial diet plan guidance can be altered to support planetary and individual health, including describing what dietary patterns can jointly support environmental sustainability and weight loss.

A Mixed-Methods Approach to the Development of a Disaster Food Security Framework.

BACKGROUND: Limited research on food systems and food insecurity (FI) following disasters finds contextual differences in post-disaster food systems that shape dimensions of FI. Measurement limitations make it difficult to address FI and develop effective practices for disaster-affected communities. OBJECTIVE: To develop, validate, and test a Disaster Food Security Framework (DFSF). DESIGN: Mixed-methods approach was used, including in-depth interviews to understand lived experiences during disasters; expert panel input to validate DFSF designed using responses from in-depth interviews; and quantitative testing of robustness of DFSF using the coronavirus disease 2019 pandemic as a disaster example. PARTICIPANTS AND SETTING: The in-depth interviews included participants from Vermont (n = 5), North Carolina (n = 3), and Oklahoma (n = 2) who had been living in those states during Hurricane Irene (2011), Hurricane Florence (2018), the Moore tornadoes (2013), and coronavirus disease 2019 pandemic (2020). The expert panel consisted of researchers and practitioners from different US geographical regions and food-related disciplines (n = 18). For the quantitative testing survey, data from 4 US states (New York, New Mexico, Vermont, and Maryland; n = 3,228) from the National Food Access and COVID Research Team was used. MAIN OUTCOME MEASURES: The outcomes from the in-depth interviews were dimensions of disaster FI, those from the expert panel was a content validity ratio, and those from the quantitative testing was the number of items and components to be included. ANALYSES PERFORMED: Inductive and deductive reasoning were using when reporting on the in-depth interviews and expert panel results, including frequencies. The quantitative testing was conducted using multiple correspondence analysis. RESULTS: The in-depth interviews revealed four dimensions of FI: availability (supply and donation), accessibility (economic, physical, and social), acceptability (preference and health), and agency (infrastructure and self-efficacy). The panel of experts reported high content validity for the DFSF and its dimensions (content validity ratio >0.42), thus giving higher credibility to the DFSF. Multiple correspondence analysis performed on 25 food-related variables identified one component with 13 indicators representing three of the four dimensions: availability, acceptability, and accessibility, but not agency.

COVID-19, Climate Change, and Conflict in Honduras: A food system disruption analysis.

In Honduras, as in many settings between 2020 and 2022, food security was affected by the COVID-19 pandemic, climate change, and conflicts-what some refer to as "The Three Cs." These challenges have had overlapping impacts on food supply chains, food assistance programs, food prices, household purchasing power, physical access to food, and food acceptability. This article applies a food system disruption analysis-adapted from a fault tree analysis originally developed for a municipal context in the United States-to the context of Honduras to systematically examine how the Three Cs affected food availability, accessibility, and acceptability. This article demonstrates the value of approaching food security through a disruption analysis, especially for settings impacted by multiple, interconnected, ongoing crises.

When increasing vegetable production may worsen food availability gaps: A simulation model in India.

Translating agricultural productivity into food availability depends on food supply chains. Agricultural policy and research efforts promote increased horticultural crop production and yields, but the ability of low-resource food supply chains to handle increased volumes of perishable crops is not well understood. This study developed and used a discrete event simulation model to assess the impact of increased production of potato, onion, tomato, brinjal (eggplant), and cabbage on vegetable supply chains in Odisha, India. Odisha serves as an exemplar of vegetable supply chain challenges in many low-resource settings. Model results demonstrated that in response to increasing vegetable production 1.25-5x baseline amounts, demand fulfillment at the retail level fluctuated by + 3% to -4% from baseline; in other words, any improvements in vegetable availability for consumers were disproportionately low compared to the magnitude of increased production, and in some cases increased production worsened demand fulfillment. Increasing vegetable production led to disproportionately high rates of postharvest loss: for brinjal, for example, doubling agricultural production led to a 3% increase in demand fulfillment and a 19% increase in supply chain losses. The majority of postharvest losses occurred as vegetables accumulated and expired during wholesale-to-wholesale trade. In order to avoid inadvertently exacerbating postharvest losses, efforts to address food security through agriculture need to ensure that low-resource supply chains can handle increased productivity. Supply chain improvements should consider the constraints of different types of perishable vegetables, and they may need to go beyond structural improvements to include networks of communication and trade.

Exploring U.S. Food System Workers' Intentions to Work While Ill during the Early COVID-19 Pandemic: A National Survey.

With "stay at home" orders in effect during early COVID-19, many United States (U.S.) food system workers attended in-person work to maintain national food supply chain operations. Anecdotally, many encountered barriers to staying home despite symptomatic COVID-19 illness. We conducted a national, cross-sectional, online survey between 31 July and 2 October 2020 among 2535 respondents. Using multivariable regression and free-text analyses, we investigated factors associated with workers' intentions to attend work while ill (i.e., presenteeism intentions) during the early COVID-19 pandemic. Overall, 8.8% of respondents intended to attend work with COVID-19 disease symptoms. Almost half (41.1%) reported low or very low household food security. Workers reporting a higher workplace safety climate score were half as likely to report presenteeism intentions (adjusted odds ratio [aOR] 0.52, 95% confidence interval (CI) 0.37, 0.75) relative to those reporting lower scores. Workers reporting low (aOR 2.06, 95% CI 1.35, 3.13) or very low (aOR 2.31, 95% CI 1.50, 3.13) household food security levels had twice the odds of reporting presenteeism intentions relative to those reporting high/marginal food security. Workplace culture and safety climate could enable employees to feel like they can take leave when sick during a pandemic, which is critical to maintaining individual and workplace health. We stress the need for strategies which address vulnerabilities and empower food workers to make health-protective decisions.

Dietary Behaviors among New Users of Meal-Kit Services during the Early Months of the COVID-19 Pandemic.

The COVID-19 pandemic changed the way people acquired food, including increased use of meal-kit delivery services. Investigators analyzed data from a national survey of US adults collected between July 2020 and September 2020, to describe new users of meal-kit services during the pandemic and explore associations between new use of meal-kits and dietary behaviors. Bivariate and multivariate regression analyses were conducted to identify differences in demographic characteristics and reported dietary behaviors between new and never meal-kit users. Nearly all new meal-kit users were under the age of 55 years (92.5%), lived in urban areas (90.1%), and reported having children in their households (82%). A higher proportion of new users were current SNAP participants (32.8%) compared to never users (17.1%). Compared to never users, new users of meal-kit services reported eating more fruits and vegetables (PR: 1.95, 95% CI: 1.42, 2.68), and more red and processed meats (PR: 2.39, 95% CI: 1.49-3.85) since the pandemic began. Results suggest that meal-kit services may have been a useful resource for certain populations during the early months of COVID-19 and are potentially associated with increased consumption of certain foods. Further research examining the continued use and the influence of meal-kit services on diet is needed.

Consumer Seafood Waste and the Potential of a 'Direct-from-Frozen' Approach to Prevention.

Few food waste interventions focus on drivers distinct to particular food groups, such as seafood. Given suggestive evidence that seafood may be wasted at exceptionally high rates, and given its environmental, economic and nutritional value, this research provides insights into seafood-specific consumer food waste interventions. We performed three complementary sub-studies to examine consumer and retailer views regarding seafood waste and frozen seafood as well as perceptions of an intervention providing chef-created recipes to promote cooking frozen seafood without defrosting. The findings indicated an openness to a direct-from-frozen intervention among many consumers and retailers, and suggested seven potential barriers to adoption, along with ways to address them. Underlying the potential for this intervention, and more broadly contributing to addressing consumer seafood waste, the research formed the basis of a new "4 Ps" concept model to characterize the drivers of discarded seafood: proficiency, perceptions/knowledge, perishability, and planning/convenience. These factors shape waste through pathways that include behavioral protocols; taste preferences; waste-prevention efforts; and food safety concerns, precautions, and errors. This research suggested the benefit of testing a larger-scale direct-from-frozen intervention using insights from the concept model and, more broadly, the benefits of exploring approaches to food waste prevention rooted in specific food groups.

Frequency of Workplace Controls and Associations With Safety Perceptions Among a National Sample of US Food Retail Workers During the COVID-19 Pandemic.

OBJECTIVES: Explore workplace control frequencies and factors associated with US food retail workers' safety perceptions during COVID-19. METHODS: An online, cross-sectional survey captured working conditions and safety perceptions among a large, national sample of US food retail workers from July to October 2020. RESULTS: Overall, 40.3% reported feeling "not so" or "not protected" by COVID-19 controls. Administrative controls were more commonly reported (56.8% reported ≥5 controls) than engineering (19.5% reported ≥3). Fomite-related controls were more common than those reducing interpersonal contact. After adjustment, organizational safety climate (prevalence ratio (PR): 1.53, 95% CI: 1.24, 1.89), and perceived strict prevention measure enforcement (PR: 0.60, 95% CI: 0.46, 0.78) were associated with safety perceptions. CONCLUSIONS: Many workers do not feel well-protected by COVID-19 controls. Safety climate and control enforcement are associated with workers' COVID-19 safety perceptions.

Impact of Messaging Strategy on Consumer Understanding of Food Date Labels.

OBJECTIVE: Explore consumer understanding of the food industry's 2-date labeling system and the relative effectiveness of messages in increasing understanding. DESIGN: Participant understanding of date labels assessed before and after random assignment to 1 of 7 messages explaining the meaning of the labels. SETTING: US online survey through Amazon Mechanical Turk collected responses from July 29, 2019, to August 5, 2019. PARTICIPANTS: Adults aged 18 years or older who speak English (n = 2,607). INTERVENTION: Seven message variations. VARIABLES MEASURED: Behaviors, awareness, and understanding of date labeling, and effectiveness of messages and opportunities for improving them. ANALYSIS: Pearson's chi-square test of independence, Wald chi-square test of association, McNemar's test of marginal homogeneity, and logistic regression. RESULTS: The majority of respondents use date labels to make decisions and believe they know what the labels mean; however, only 64.0% and 44.8% knew the general meaning of the Best If Used By and Use By labels, respectively. Even fewer understood their specific meanings. Overall, education increased general understanding to 82.0% for Best If Used By and 82.4% for Use By (P < 0.001). The effectiveness of the educational message did not vary significantly by message variation. CONCLUSIONS AND IMPLICATIONS: Consumer education is needed to improve understanding of the 2-date labeling system, ultimately improving food safety and decreasing wasted food. This study highlights opportunities for effective educational communication.

"Maybe it's still good?" A qualitative study of factors influencing food waste and application of the E.P.A. Food recovery hierarchy in U.S. supermarkets.

About 31% of post-harvest food available for human consumption is lost or wasted annually in the United States. Roughly one third (43 billion lbs.) of food loss occurs in grocery and other retail food stores. Supermarkets engage in food waste reduction, rescue, and recycling strategies, but little is known about frontline workers' and department managers' perspectives on food discards and strategies to limit waste. We aimed to increase understanding of factors influencing grocery retail employees' food waste decision-making at the store level, and of the perspectives of those frontline supermarket workers and managers responsible for food waste prevention and mitigation. We conducted 20 qualitative semi-structured interviews and used thematic analysis to explore how grocery workers and managers view food waste decision drivers, and how these impact the feasibility and effectiveness of waste reduction and food rescue and recycling in their stores. Workers and managers report personalized discard decision-making and confusion between quality and safety indicators. Interviewees described in-store policies, resources and trainings as lacking or inconsistently applied, leading to variability in food waste prevention, rescue, and recycling. Overall, interview participants considered waste reduction strategies that rescue profitable goods more feasible than other food rescue and recycling efforts like donation and composting. Workers' and managers' perceptions of in-store food waste drivers and views on extant food waste prevention and mitigation efforts point to areas for future research and intervention.

Preschool Healthy Food Policy Did Not Increase Percent of Food Wasted: Evidence from the Carolinas.

This research evaluates the effects of a South Carolina (SC) policy, which changed the nutrition standards for foods served in early care and education (ECE) settings, on wasted food. A two-group pre-test/post-test evaluation was performed in ECE centers serving children age 3-5 from households with lower incomes in SC (n = 102 children from 34 centers, intervention) and North Carolina (NC; n = 99 children from 30 centers, comparison). Direct observation was performed to assess the quantity and kcal of food served and quantity and percent of food discarded, by food group and nutrient, enabling assessment of waste in the absence of intervention. Mixed-effects linear models were fit to estimate, by state, differences in change from baseline to post-implementation at the center level. Covariates were selected a priori, including center enrollment, racial composition, director educational attainment, years in operation, for-profit status, and Child and Adult Care Food Program (CACFP) participation. Waste of food was high across states and time points. The policy was not associated with a change in percent of food discarded in SC compared to NC in adjusted analyses.

The Early Food Insecurity Impacts of COVID-19.

COVID-19 has disrupted food access and impacted food insecurity, which is associated with numerous adverse individual and public health outcomes. To assess these challenges and understand their impact on food security, we conducted a statewide population-level survey using a convenience sample in Vermont from March 29 to April 12, 2020, during the beginning of a statewide stay-at-home order. We utilized the United States Department of Agriculture six-item validated food security module to measure food insecurity before COVID-19 and since COVID-19. We assessed food insecurity prevalence and reported food access challenges, coping strategies, and perceived helpful interventions among food secure, consistently food insecure (pre-and post-COVID-19), and newly food insecure (post COVID-19) respondents. Among 3219 respondents, there was nearly a one-third increase (32.3%) in household food insecurity since COVID-19 (p < 0.001), with 35.5% of food insecure households classified as newly food insecure. Respondents experiencing a job loss were at higher odds of experiencing food insecurity (OR 3.06; 95% CI, 2.114-0.46). We report multiple physical and economic barriers, as well as concerns related to food access during COVID-19. Respondents experiencing household food insecurity had higher odds of facing access challenges and utilizing coping strategies, including two-thirds of households eating less since COVID-19 (p < 0.001). Significant differences in coping strategies were documented between respondents in newly food insecure vs. consistently insecure households. These findings have important potential impacts on individual health, including mental health and malnutrition, as well as on future healthcare costs. We suggest proactive strategies to address food insecurity during this crisis.

Healthy Eating Policy Improves Children's Diet Quality in Early Care and Education in South Carolina.

Policies to promote healthy foods in early care and education (ECE) in the United States exist, but few have been prospectively evaluated. In South Carolina, a statewide program serving low-income children in ECE enacted new policies promoting healthy foods. We conducted an evaluation to measure changes in dietary intake among children in ECE exposed and not exposed to the new policy. Using direct observation, we assessed dietary intake in 112 children from 34 ECE centers in South Carolina and 90 children from 30 ECE centers in North Carolina (a state with no policy). We calculated Healthy Eating Index-2015 (HEI) scores to measure diet quality consumed before and after the policy was enacted. We fit mixed-effects linear models to estimate differences in HEI scores by state from baseline to post-policy, adjusting for child race, number of children enrolled, director education, center years in operation, participation in the Child and Adult Care Food Program (CACFP), and center profit status. The policy increased HEI scores for whole fruits, total fruits, and lean proteins, but decreased scores for dairy. Thus, the policy was associated with some enhancements in dietary intake, but additional support may help improve other components of diet.

Food Sources and Expenditures for Seafood in the United States.

The aim of this study was to explore United States (U.S.) seafood consumption patterns, food sourcing, expenditures, and geography of consumption. We analyzed seafood intake and food sourcing using the National Health and Nutrition Examination Survey (NHANES) cycles 2007-2008 to 2015-2016 for US adults ≥19 years old (n = 26,743 total respondents; n = 4957 respondents consumed seafood in the past 24 h). Seafood expenditures were extrapolated by combining NHANES with three other public datasets. U.S. adults consumed 63% of seafood (by weight) at home. The top sources of seafood (by weight) were food retail (56%), restaurants (31%), and caught by the respondent or someone they know (5%). Sixty-five percent of consumer expenditures for seafood were at restaurants and other "away from home" sources while 35% were at retail and other "at home" sources. Slightly less than half of overall U.S. food expenditures are "away from home," which is much lower than for seafood, suggesting that consumers have very different spending habits for seafood than for an aggregate of all foods.

The relationship between joining a US free trade agreement and processed food sales, 2002-2016: a comparative interrupted time-series analysis.

OBJECTIVE: To examine changes in sales of highly processed foods, including infant formulas, in countries joining free trade agreements (FTAs) with the US. DESIGN: Annual country-level data for food and beverage sales come from Euromonitor International. Analyses are conducted in a comparative interrupted time-series (CITS) framework using multivariate random-effects linear models, adjusted for key confounders: gross domestic product (GDP) per capita, percent of the population living in urban areas and female labor force participation rate. Memberships in other FTAs and investment treaties are also explored as possible confounders. SETTING: Changes are assessed between 2002 and 2016. PARTICIPANTS: Ten countries joining US FTAs are compared with eleven countries without US FTAs in force; countries are matched on national income level, world region and World Trade Organization membership. RESULTS: After countries join a US FTA, sales are estimated to increase by: 0·89 (95 % CI 0·16, 1·6; P = 0·016) kg per capita per annum for ultra-processed products, 0·81 (95 % CI 0·47, 1·1; P < 0·001) kg per capita per annum for processed culinary ingredients and 0·17 (95 % CI 0·052, 0·29; P = 0·005) kg per capita under age 5 per annum for baby food. No significant change is estimated for minimally processed foods. In statistical models, large unexplained variations in country-specific trends suggest additional unmeasured country-level factors also impact sales trends following entry into US FTAs. CONCLUSIONS: These findings strongly support the conclusion that joining US FTAs can contribute to detrimental changes in national dietary consumption that increase population risk of non-communicable diseases.

Understanding and addressing waste of food in the Kingdom of Saudi Arabia.

INTRODUCTION: Multiple estimates suggest the Kingdom of Saudi Arabia (KSA) may have one of the highest rates of wasted food globally. The KSA has limited arable lands and scarce water and thus relies on extensive imports and food subsidies to meet food demand. Accordingly, waste and loss of food are a significant concern for food security. MATERIALS AND METHODS: A narrative literature review was performed to identify the available information relevant to characterizing the context, magnitude of food wasted in the KSA, key contributing factors, and existing interventions and recommendations. RESULTS: Estimates of annual per capita waste of food ranged from 165 kg to 511 kg. Given the country's relatively limited agricultural production, the consumer and retail levels are primary targets for intervention. Key contributors to waste include culture, food valuation, policy and industry factors, and awareness and concern. The country is at an early stage of developing responses. We build upon existing approaches and recommendations, with particular emphasis on the potential role of agricultural extension staff in addressing the issue, and highlight research needs. CONCLUSIONS: Given the potentially exceptional levels of wasted food in the KSA and the extensive evidence gaps, there is a great need for further research and action. Our review and synthesis presents numerous opportunities to advance innovative waste reduction approaches in the country, with particular relevance for other parts of the Middle East and other areas early in their efforts to address waste of food.

World Trade Organization membership and changes in noncommunicable disease risk factors: a comparative interrupted time-series analysis, 1980-2013.

OBJECTIVE: To investigate the relationship between joining the World Trade Organization (WTO) and the availability of several commodities with both harmful and protective effects for the development of noncommunicable diseases. METHODS: We used a natural experiment design to compare trends in the domestic supply of tobacco, alcohol and seven food groups, between 1980 and 2013, in 21 countries or territories joining WTO after 1995 and 26 non-member countries, using propensity score weights. We applied a comparative interrupted time-series framework, by using multivariate random-effects linear models, adjusted for gross domestic product per capita, the percentages of urban population and female labour force participation. In the tobacco model, we controlled for Member States that had ratified the Framework Convention on Tobacco Control and in the alcohol model, the percentage of the population identifying themselves as Muslim. FINDINGS: Following accession to WTO, member states experienced immediate increases in the domestic supply of fruits and vegetables of 55 g per person per day on average, compared to non-member countries. The analysis showed gradual increases in the geometric mean of the supply of tobacco and alcohol of 6.2% and 3.6% per year, respectively. We did not detect any significant changes in the availability of red meats and animal fats; seafood; nuts, seeds and legumes; starches; or edible oils; and results for sugars were inconsistent across model variations. CONCLUSION: The results suggest that WTO membership may lead to increases in both harmful and protective factors for noncommunicable disease, but further exploration of country-specific variation is warranted.