Neighbourhood food environments, diet and health

Martin White MRC Epidemiology Unit & CEDAR

4th November 2014

• What is a neighbourhood?

• What is a neighbourhood food environment?

• How have these changed over time?

• What are the emerging challenges for public health?

• What are the implications for public health research?

Overview

The rise of the car

Does food retailing influence dietary intake? FSA ‘food deserts’ study

• Setting: city of Newcastle upon Tyne, 2001-2

• Cross-sectional survey of all retail outlets selling food in the city (n=530), using food basket method (33 items)

• Cross-sectional surveys of:

• food purchasing behaviour, kitchen facilities and socio-economic factors at household level (n=2500)

• diet, health, other health related behaviours, knowledge, attitudes and socio-economic factors at individual level (n=4500)

• Spatial and statistical analyses

Travel to and from main food store

Journeys FROM main food store by:

Car Bus Metro Taxi Bicycle Foot All Modes

Jo

urn

eys T

O m

ain

foo

d

sto

re b

y:

Car 1909 (63.7)

1 (0.0)

2 (0.1)

1 (0.0)

1913 (63.9)

Bus 11 (0.3)

320 (10.7)

1 (0.0)

60 (2.0)

7 (0.2)

399 (13.3)

Metro 1 (0.0)

3 (0.1)

28 (0.9)

11 (0.3)

43 (1.4)

Taxi 34 (1.1)

34 (1.1)

Bicycle 12 (0.4)

12 (0.4)

Foot 13 (0.4)

52 (1.7)

1 (0.0)

48 (1.5)

481 (16.1)

595 (19.9)

All Modes

1934 (64.6)

376 (12.6)

30 (1.0)

155 (7.8)

12 (0.4)

489 (16.3)

2996 (100.0)

Travel distance to main food store

Distance from home to main food shop (metres)

Main shop type Number of households

Median Inter-quartile range

Multiple supermarkets 2440 2081 1020-3846

Asda 677 2569 1330-4053

Co-op 214 1389 570-3431

Morrison 106 7712 6661-8627

Safeway 633 1356 781-2205

Sainsbury 13 9726 8781-10420

Tesco 753 2555 1138-3808

Discount supermarkets 435 1077 539-1965

Kwiksave 284 879 412-1707

Netto 114 1393 806-2491

Department stores 82 3418 2302-4653

All other stores 47 1060 539-1965

All types of store 2988 1865 885-3701

Number (%) of households trip-chaining usually or sometimes by household composition

Visiting family/ friends

Via school Via non-

food shopping

Via gym Via work Via other activity

Via any location / activity

1 adult 374 (35.0) 11 (1.0) 492 (46.0) 105 (9.8) 364 (34.1) 270 (25.3) 332 (31.1)

2 adults 335 (31.8) 27 (2.6) 531 (50.4) 115 (10.9) 396 (37.6) 272 (25.8) 285 (27.0)

3 or more adults

109 (33.1) 13 (4.0) 189 (57.4) 29 (8.8) 171 (52.0) 86 (26.1) 94 (28.6)

1 adult, 1 or more children

71 (47.0) 72 (47.7) 87 (57.6) 23 (15.2) 60 (39.7) 30 (19.9) 73 (48.3)

2 or more adults, 1 or more children

204 (37.1) 208 (37.8) 342 (62.2) 64 (11.6) 278 (50.5) 136 (24.7) 176 (32.0)

All 1093 (34.7) 331 (10.5) 1641 (52.0) 336 (10.7) 1269 (40.2) 794 (25.2) 960 (30.4)

Proximity to all shops selling food

<250m

<500m

<750m

<1000m

>1000m

% of shops selling all items in basket (median number of basket items available)*

No. of stores

All items (33) ‘Healthier’ basket (21)

‘Less Healthy’ basket (10)

All F&V (14) Fresh F&V (10)

Multiple Supermarket

20 70.0 (33) 95.0 (21) 75.0 (10) 100 (14) 100 (10)

Discount supermarket

18 22.2 (32) 27.8 (20) 50.0 (9.5) 44.4 (13) 50.0 (10)

Department store

2 50.0 (31) 50.0 (20) 50.0 (9) 100 (14) 100 (10)

Convenience store

216 1.4 (17) 1.4 (8) 13.9 (8) 2.3 3) 2.6 (0)

Freezer centre 13 0 (18) 0 (8) 15.4 (7) 0 (3) 0 (0)

Greengrocer 47 0 (13) 0 (11) 0 (1) 0 (10) 87.2 (10)

Specialist and Ethnic food stores

16 0 (3) 0 (2) 0 (3) 6.3 (1) 6.3 (0)

Market stall 3 0 (10) 0 (10) 0 (0) 0 (10) 66.7 (10)

News Agency or Post Office

58 0 (4) 0 (1) 0 (4) 0 (0,0) 0 (0)

All shops 560 3.9 (11) 5.0 (5) 10.2 (5) 6.4 (3) 14.6 (0)

Availability of food items by type of store

Proximity to shops selling 10/10 fruit &

veg of good quality & less than median

basket price (£6.35)

<250m

<500m

<750m

<1000m

>1000m

Newcastle: Townsend Deprivation Score

quintiles for Enumeration Districts

5km

N

What factors are associated with dietary intake at individual, household and community levels? Results of MLMs

Fruit & veg consumption

Age

Female

Physical activity

Dietary knowledge

Non-smoker

Alcohol

Vegetarian

Not on benefits

White/car, non-white/foot (interaction)

Total variance explained 11.7% Unexplained variance Individual 66% Household 32% Neighbourhood 0%

Fat consumption

Age

Male

Dietary knowledge

Smoker

Alcohol

Meat eater

Eating out

Cost of weekly shopping (per adult equivalent)

Total variance explained 9.6%

Unexplained variance

Individual 76%

Household 23%

Neighbourhood 5%

Food retail access and diet: interpretation

• Overall food availability very good - 99% had access to 14 F&V, at usual main food store or within 500m

• Most households bought their food at stores with good availability (e.g. 78% - all 33 items, 90% - 10 F&V) - but availability was socio-economically patterned (rich = more)

• The poor live as close to shops selling most basket items (e.g. Multiple supermarkets) as the more affluent, but are more likely to shop where the prices are lower (e.g. discounters), and thus where the availability and quality are also poorer

• Food choice appears to be most strongly associated with dietary knowledge, socio-demographic factors, attitudes to retailing and issues of cost, rather than local availability

• Better methods are needed to analyse complex multilevel data sets on the relationship between diet and the retail environment

The rise of internet food shopping

Food at checkouts

• 15% of outdoor advertising was for food

• Adverts tended to be for less healthy (HFSS) foods

• Significantly more adverts and food adverts in poorer areas

• No differences in types of food advertised by IMD 0

100

200

300

400

500

600

700

800

Least affluent Most affluent

Square metres of food adverts by IMD tertile

Food adverts in weekly magazines

• Adverts made up 23% of magazine pages in 118 issues

of 30 magazines with readership >500k/week in 1

month (Nov 2007)

• 443/2829 (15.7%) adverts were for food

• ‘meals, combination foods, soups and sauces’ - 26% /

‘foods containing fat/sugar’ - 23% of food adverts

• HFSS food adverts significantly more common in least

affluent tertile of magazines (by ratio of ABC1: C2DE)

Adams J, White M. Eur J Public Health 2009; 19(2): 144-9

Food adverts in monthly women’s magazines

• Adverts made up 40% of magazine pages in 213 issues

of 18 magazines with readership >500k/month in 12

months (2008-9)

• 1380/35053 (3.9%) adverts were for food

• ‘food and drinks high in fat and/or sugar’ - 28.0% of

food adverts / ‘fruits & vegetables’ - 2.0% of food

adverts

• HFSS food significantly adverts more common in least

affluent tertile of magazines (by ratio of ABC1: C2DE)

Adams J, Simpson E, White M. BMC Public Health 2011, 11:368

Obesity, TV & food advertising

Effects of food promotion

“…food promotion does have a modest

impact on nutrition knowledge, food

preferences & consumption...The evidence

that food promotion influences purchasing

behaviour is of modest strength.”

Cairns et al (2009)

who.int/dietphysicalactivity/Evidence_Update_2009.pdf

2007 Ofcom scheduling restrictions on TV food advertising to children

• Prohibition of:

»advertisements for HFSS foods

»during & around programmes “of

particular appeal to” children

• Phased introduction April 2007 - January

2009

• Aim to: “reduce significantly the exposure of

children under 16 to HFSS advertising”

Advertisements for HFSS foods

Results – all viewers

All ads Food ads HFSS food ads

PMV PMV % of all

OR (95% CI) PMV % of all

OR (95% CI)

Wk 1 704,426 14.8 1.00 5.7 1.00

Wk 2 967,991 14.5 0.96 (0.95-0.98) 8.7 1.54 (1.51-1.57)

Both 1,672, 417 14.6 - 7.5 -

Adams J, Tyrrell R, Adamson AJ, White M. PLoS ONE 2012; 7(2): e31578

Results – viewers aged 4-15 years

All ads Food ads HFSS food ads

PMV PMV % of all

OR PMV % of all

OR

Wk 1 84,264 14.2 1.00 6.1 1.00

Wk 2 106,691 12.6 0.85 (0.82-0.89) 7.0 1.05 (0.99-1.12)

Both 190,955 13.3 - 6.6 -

Adams J, Tyrrell R, Adamson AJ, White M. PLoS ONE 2012; 7(2): e31578

Summary of results

• Proportion of ads viewed that were for food

» decreased in children & all people

• Proportion of ads viewed that were for HFSS food

» didn’t change in children

» increased by 50% in all people

> No evidence that scheduling restrictions achieved aim to: “reduce significantly the exposure of children under 16 to HFSS advertising”

Adams J, Tyrrell R, Adamson AJ, White M. PLoS ONE 2012; 7(2): e31578

Industry tactics: context

Do TV foods advertisements portray advertised foods in a ‘healthy’ context?

Adams J, Tyrrell R, White M. Do television food advertisements portray advertised foods in a ‘healthy’ food context? British Journal of Nutrition, 2011; 105: 810-815

Brand awareness and advergaming

Access to the internet and social media

• 91% of the UK adult population owns an internet-ready mobile phone

• Coverage among the most deprived households is 87%

• Coverage among the 75+ age group is 58%

• 71% of UK households have access to the internet via PC

• Facebook has >900 million users and Twitter >500 million users worldwide

Corporate social responsibility

Conversation changing

Redefining the food environment

• Expansion of our physical reach through

easy access to mechanised transport

• Expansion of our virtual world through

radio, television, cinema, internet and

mobile devices

• Globalisation of economies, including the

food industry

• A subtle range of food industry influences

on our awareness of brands and products

What are the challenges for public health?

• To understand better the role of the food industry in determining what we eat

• To determine the best ways to engage with industry

• To focus on upstream, large scale interventions to change diet

• To develop programmes of research that embrace this wider concept of the food environment

Some research questions

• Where should we focus our energies?

• How important are each of the environmental influences on diet?

• How are these influences changing over time?

• What is the food industry thinking? What is their next move?

• What is the relationship between the food industry and regulatory bodies?

• Can the food industry be regulated effectively?

• What population level interventions can be pursued cost-effectively at a local level?

Acknowledgements Particular thanks to Jean Adams, who led our work on food advertising. Thanks also

to other colleagues in Newcastle, including Ashley Adamson, John Mathers, Simon

Raybould, Sarah Sowden, Emma Simpson, Rachel Tyrrell and Ellie Ganniti.

Work presented here was undertaken by members of Fuse, the Centre for

Translational research in Public Health at Newcastle University, and the Centre for

Diet and Activity Research (CEDAR), UKCRC Public Health Research Centres of

Excellence.

Funding from the British Heart Foundation, Cancer Research UK, Economic and

Social Research Council, Medical Research Council, the National Institute for Health

Research, and the Wellcome Trust, under the auspices of the UK Clinical Research

Collaboration, is gratefully acknowledged.