Transforming Food Environments

Charlotte EL Evans, Charlotte E.L. Evans

• Publisher: CRC Press
• Year: 2022
• eBook ISBN:
  9781000544176
• Topic: Medicine
• Subtopic: Nutrition, Dietics & Bariatrics

We regularly find ourselves in food environments that promote the consumption of high fat and sugary foods rather than encouraging us to eat more fruit and vegetables. However, because of increased media attention, people are becoming more interested in alternative approaches to improving the many food-related decisions we make daily. Transforming Food Environments features evidence from several disciplines exploring initiatives that have improved food environments and discusses the importance of achieving success in equitable and sustainable ways.

The book presents information on diverse food environments followed by methods that help readers become aware of the design of interventions and food policies. It covers food environments in schools, workplaces, and community centres as well as fast food establishments and food marketing. The book presents methods to help encourage better food choices and purchase of healthier foods. It explores persuasion tactics used by health professionals such as changing availability and/or price, using nudging techniques, and food labelling.

Led by Editor Charlotte Evans, Associate Professor of Nutritional Epidemiology and Public Health Nutrition at the University of Leeds; and written by an international range of authors from countries including the US, Canada, Australia, New Zealand, Japan and the United Kingdom, this multidisciplinary book appeals to students, researchers, public health professionals and policy makers. It also raises awareness and provides a comprehensive treatment of the importance of our environments on food choice.

1 Introduction to the Food Environment

Charlotte E.L. Evans

University of Leeds

CONTENTS

1. 1.1 Introduction
2. 1.2 Relationships between Diet and Health
3. 1.3 Changing Dietary Behaviour
4. 1.4 Development of Food Environment Research
5. 1.5 Layout of the Book
   1. 1.5.1 Places
   2. 1.5.2 Methods
6. 1.6 Conclusions
7. Acknowledgements
8. References

DOI: 10.1201/9781003043720-1

1.1 Introduction

A definition of healthy food environments:

Environments in which the foods, beverages and meals that contribute to a population diet meeting national dietary guidelines are widely available, affordably priced and widely promoted.

(Swinburn et al., 2013).

Take a moment to look around your immediate environment. What food is easily available to you? Are you more likely to grab whatever is easiest and closest to you or are you willing to walk further, pay more or wait longer for something else you really want to eat? These questions highlight some of the important factors in the food environment. Most people make food-related decisions based on habits and don’t expect to spend much time and effort (referred to as agency) on choosing what to eat. We are therefore influenced by what we see and experience, whether it is an advert for a certain food, the availability or the cost of certain foods or cultural beliefs. The main aim of this book is to provide you with substantial evidence that improving our food environment is crucial to our health and well-being.

Although first documented in the 1980s, it is only in the last 10 years that wider interest in the food environment has spread amongst nutritional scientists, public health policy makers and stakeholders involved in manufacturing, selling and providing food. This chapter provides information on diet and health and the role of the food environment as well as how to make the most of this book.

1.2 Relationships between Diet and Health

Evidence from across the globe provides strong and consistent evidence that poor diet leads to higher rates of morbidity and premature death from non-communicable diseases (NCDs) such as cardiovascular disease and some cancers (World health Organization [WHO], 2014). This is true in low-, middle and high-income countries (Lachat et al., 2013). In a large global review of the burden of many diseases, low intakes of fruits, vegetables and wholegrain and high intakes of salt, sugars and fats were identified as the most important factors for good health in the world along with tobacco and alcohol (Lim et al., 2012). It has been estimated that up to 40% of premature NCD deaths could be avoided with a high-quality diet; and poor diet generates more deaths and Disability Adjusted Life Years (DALYs) than tobacco (≈19%), alcohol (≈9%) and physical inactivity (≈2%) combined (Steel et al., 2018).

Obesity is a risk factor for cardiovascular disease as well as some cancers (Riaz et al., 2018) and rates continue to increase in many countries. Overweight and obesity affect 59% of adults in the European region (WHO, 2020) and over 67% of adult males and 60% of adult females in the UK. Furthermore, childhood obesity increases risk of obesity (Ward et al., 2017) and high blood pressure (Umer et al., 2017) in adulthood, and thus reducing childhood obesity has become a major focus of government policy in many countries. In England, obesity now affects over 10% of children starting school (4–5 year olds), and over 20% by the end of primary school (10–11 year olds) (NHS Digital, 2020) and rates are higher for children in poorer households. The recent COVID-19 pandemic highlighted that obesity increased hospital and death rates in people infected with severe respiratory disease (Bornstein et al., 2020), further highlighting the importance of improving health.

An additional diet-related health outcome of particular concern in children includes severe dental decay which reflects high and frequent intakes of dietary sugars and is a common cause of hospital admissions in young children in the UK, particularly children living in low-income households (Public Health England (PHE), 2019). There are high costs associated with these different burdens of disease as a result of consuming poor-quality diets, which add to the costs of our already over-burdened health systems and which could be avoided.

The World Health Organization (WHO) defines healthy diets as diets based on nutrient-rich foods, including vegetables, fruits, whole grains, pulses (beans), nuts and seeds, with limited intake of energy-dense foods high in fats (particularly trans and saturated fats), free sugars and salt (WHO, 2014). These foods are also known as discretionary or non-core foods. Many countries have recommendations in place, for example in the UK there is The Eatwell Guide (PHE, 2016) shown in Figure 1.1 and in the US the American Heart Association (AHA) has diet and lifestyle recommendations (American Heart Association (AHA), 2017).

FIGURE 1.1 The Eatwell Guide is sourced from Public Health England in association with the Welsh government, Food Standards Scotland and the Food Standards Agency in Northern Ireland. It is reprinted under the open government licence under crown copyright. (Available from https://www.gov.uk/government/publications/the-eatwell-guide.)

1.3 Changing Dietary Behaviour

Although we might know that eating fruits and vegetables are good for us, that doesn’t mean that we eat enough of them; highlighting more than education is needed. Many populations in the world do not currently consume a healthy diet despite the consistent advice and promotion from WHO and other health organisations. In Europe, average intakes of fruits and vegetables in 22 of the 28 EU Member States are currently below the daily 400 g, recommended by WHO (EPHA, 2016) while the average consumption of meat and dairy products remains above recommended levels (EHN, 2017). Although the 5-a-day recommendation to eat five portions of fruit and vegetables per day was introduced in the UK in 2003, nearly 20 years later only about a quarter of the UK population meets the recommendation (Castiglione, 2019).

For the last few decades, much of the attention has been on individuals improving their diets which has had some success, mainly in managing existing obesity or type 2 diabetes but less so in prevention. Economists believe that most of us are time inconsistent, in that even though we plan to consume less in the future or make healthier choices, when the time comes we choose not to (Institute for Fiscal Studies, 2010). On a global scale, huge technological improvements, economic development and globalisation have taken place. In many countries, particularly more recently in low- and middle-income countries, the traditional diet of staple grains, legumes and fruits and vegetables has changed to a dietary pattern that is more reliant on processed foods, foods from outside the home, animal products, refined carbohydrates, edible oils and sugar-sweetened beverages (Popkin, 2015).

There are additional issues related to equity with inequalities in diet and health increasing in many high-income countries. In the UK, intake of fruits and vegetables is only half of the national average in lower-income communities. There are stark inequalities in obesity. In Europe, 20% of adults with a lower education level are obese compared with 12% of those with a higher education (OECD, 2019). In English children, rates of obesity are twice as high for children living in the most deprived areas than in the most affluent areas (PHE, 2020). Worse still, this gap has consistently widened since 2006 in England. The exposure to unhealthy food environments by young people is of particular concern as their health will be disproportionately affected if they experience poor diet over a longer period of their lives.

Despite poor diet choices being potentially avoidable, there are many barriers preventing us making healthy food choices. Different approaches need to be taken and improving the food environment is one method of tackling this complex issue. How research in this area has evolved is described in the next section.

1.4 Development of Food Environment Research

The WHO’s ‘healthy settings’ initiative embraced a more holistic or ecosystem approach to health promotion based on the ‘Health for all’ report in 1980, and defined a ‘setting’ as the place or social context in which people engage in daily activities in which environmental, organisational, and personal factors interact to affect health and well-being (WHO 2021). This holistic or ecosystem approach to health promotion increased in popularity after the ‘move towards a new public health’ outlined in the Ottawa Charter of 1986, following the first International Conference on Health Promotion (Anonymous, 1986). It stated that ‘Health is created and lived by people within the settings of their everyday life; where they learn, work, play, and love’. As Porter wrote in 2007, ‘Ottawa steered health promotion away from dominant health education models of individual behaviour change towards a ‘socio-ecological’ version of health promotion that addresses structural determinants of health’ (Porter, 2007). However, due to the polarisation of views on health promotion with systems-based views on the one side and education on the other (Green, 1988), this more holistic ethos has taken time to become universally embedded in public health systems in many countries, particularly where food choice is concerned.

In the UK, a large mapping exercise was carried out to look at the different domains that have an impact on obesity, including diet and physical activity. It quickly became evident that food was influenced by a huge number of interlocking factors (Foresight, 2007). Some of the main domains in the Foresight Report included the physical environment, food consumption and individual psychology but, interestingly, not the food environment. Further progress on defining the food environment as a key policy area was made in 2008 when Story et al. (2008) visually represented the key factors that impact on food choice including individual and social networks and physical and macro environments depicted in Figure 1.2. The latter two levels are the main topics covered in this book. Physical environments include places such as school, work and retail environments and macro environments include national policies such as taxes on sugary drinks and reformulation by the food industry.

FIGURE 1.2 Ecological framework for influencers of eating behaviour. (Reproduced with permission from Story et al. 2008. Creating healthy food and eating environments: policy and environmental approaches. Annu Rev Public Health, 29, 253–272. https://www.annualreviews.org/doi/abs/10.1146/annurev.publhealth.29.020907.090926.)

Swinburn et al. (2013) further refined more precisely what we mean by the food environment. Their socio-ecological (rather than individual) approach gave further credence to the importance of food environments on health which can be defined as ‘T...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication Page
• Table of Contents
• Preface
• Acknowledgements
• Editor
• Contributors
• Chapter 1 Introduction to the Food Environment
• Chapter 2 The Home Food Environment
• Chapter 3 The School Food Environment
• Chapter 4 The Workplace Food Environment
• Chapter 5 The Retail Food Environment
• Chapter 6 Role of the Food Industry in Improving the Food Environment: Reformulation and Logistical Considerations
• Chapter 7 The Role of the Food Industry in Public Health Nutrition
• Chapter 8 Fast Food and Out-of-Home Food Environments
• Chapter 9 Community Food Environments
• Chapter 10 The Role of Places of Worship in the Food Environment
• Chapter 11 Food Insecurity, Poverty and the Very Low-Income Food Environment
• Chapter 12 Nutrition Communication in Public Health and the Media
• Chapter 13 Nutrition Labelling on Food Products and Menus
• Chapter 14 Commercial Marketing Food Environment for Young People
• Chapter 15 Portion and Serving Size of Energy- and Nutrient-Dense Foods
• Chapter 16 Choice Architecture and Nudging for Better Food Choice
• Chapter 17 Financial Incentives to Promote Healthier Diets
• Chapter 18 Importance of Sustainable Food Environments
• Chapter 19 Evaluation of Interventions, Programmes and Policies in Food Environments
• Chapter 20 Systems Approaches to Improve the Food Environment for Disease Prevention
• Chapter 21 Conclusions and Next Steps in Improving Food Environments
• Index