#428: Food Environments

1. Key Ideas
2. Detailed Study Notes
3. Transcript

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Danny’s Key Ideas in this Episode:

1. Food choices are shaped by the contexts within which they are made
2. Solutions: The need for policy and structural changes
3. Behaviour change also needed at individual and “bottom-up” level

1) Food choices are shaped by the contexts within which they are made

Dietary behaviours are not simply a result of wanting to eat a certain way. Many, if not most, of our dietary choices are habitual and driven by environmental factors. This is why, by default, in the modern day it is extremely easy to eat in a manner that is harmful for our health in the long-term.

European Public Health Alliance states: “Food environments are the physical, economic, political and socio-cultural contexts in which people engage with the food system to make their decisions about acquiring, preparing and consuming food… The food environment concept shows us that the choices we make about food are, to a significant degree, shaped by the contexts within which they are made.”

So what are these ‘contexts’ that are shaping choices?

A number of contexts and factors impacting food choices were discussed in the episode:

1. The home environment shapes preferences and liking
2. Friends, relationships and social cues; with social and cultural norms playing a role in preference learning
3. Advertising
4. Food deserts
   1. Areas where the access to affordable, healthy food options is limited/non-existent due to grocery stores being too far away. Given their limited options, people living in food deserts therefore often end up disproportionally turning to fast-food and convenience outlets for meals. Within the US, socially-deprived areas have 2.5x the density of fast-food outlets nearby, than those living in affluent areas
5. Income/purchasing power
   1. In order to comply with Eatwell Guide (the UK’s dietary guidelines), households in the lowest 10% of income in the UK would need to spend 73.6% of disposable income on food. Whereas households in the top 10% would only have to spend 6%.

More details on each of the above is laid out in the Detailed Study Notes below.

2) Solutions: The need for policy and structural changes

“The food environment concept shows us that the choices we make about food are, to a significant degree, shaped by the contexts within which they are made. Following from that is the recognition that the most effective and equitable way to change food behaviours is to change the structural factors that drive food choice.” – EPHA

In order to counter the problematic aspects of the modern food environment, solutions may be needed from both a top-down and bottom-up direction. In this sense, top-down being at the level of public health policy and food industry regulation. And bottom-up being actions individuals, practitioners, community groups, etc. can take to modify the environment at a grassroots level.

As it was put by Swinburn et al., 2015 in a paper in the Lancet: “Arguments are often reduced to a debate between individual and collective responsibilities, and between hard regulatory or fiscal interventions and soft voluntary, education-based approaches. Genuine progress lies beyond the impasse of these entrenched dichotomies”

Hawkes et al., 2015 highlight four of the key mechanisms through which food policies can work, namely by:

• providing an enabling environment for healthy preference learning
• overcoming barriers to the expression of healthy preferences
• encouraging people to reassess existing unhealthy preferences
• stimulating a positive food-systems response

Public health policy options tend to fall into six categories, adapted from Gorski & Roberto 2015:

1. Mandates
2. Restrictions
3. Economic incentives
4. Marketing limits
5. Information provision
6. Environmental defaults

Descriptions of the above categories is given in the Detailed Study Notes section below.

Policy interventions with evidence do exist. And it should be theoretically possible for someone to keep whatever political affiliation they desire, while acknowledging the best evidence for changing population health through dietary change is through a combination of various public health nutrition policies. And these policies act on various levels; from regulation of industry down to environmental nudges.

3) Behaviour change at individual and “bottom-up” level

Bottom-up level is where individuals, nutritionists and medical professionals can focus their attention. Here we can think about what way can an individual design the environment around them to be more conductive to healthy behaviours and/or decrease the reliance on will power to avoid behaviours they do not wish to follow. This can include:

• thinking about what foods are available in the home
• planning when/where meals will be consumed ahead of time
• finding health-promoting behaviours they enjoy
• finding foods/meals that are both nutritious and that they like the taste of
• developing cooking skills
• etc.

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What are Food Environments?

Key Definitions

• “Food environments are the physical, economic, political and socio-cultural contexts in which people engage with the food system to make their decisions about acquiring, preparing and consuming food.” – High Level Panel of Experts on Food Security and Nutrition (HLPE) report
  —
• “The food environment is the interface that mediates people’s food acquisition and consumption within the wider food system. It encompasses external dimensions such as the availability, prices, vendor and product properties, and promotional information; and personal dimensions such as the accessibility, affordability, convenience and desirability of food sources and products” – European Commission, Group of Chief Scientific Advisors (2020)

“Today’s food environments exploit people’s biological, psychological, social, and economic vulnerabilities, making it easier for them to eat unhealthy foods.” – The Lancet – Obesity series (2015)

One of the key points from this discussion is the realization that food choices are shaped by the contexts within which they are made.

Another term that comes up in such conversations is “obesogenic environment”. This was a term first coined by researcher Boyd Swinburn, who at the time was working at the NIH doing medical research, studying health outcomes in the Pima Indians, specifically those living in a Native American reservation outside Phoenix, Arizona.

The “obesogenicity” of an environment was defined by Swinburn et al., (1999) as “the sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations.”

How do Environmental Factors & Context Impact Food Choices?

“The key elements of the food environment that influence consumer food choices, food acceptability and diets are: physical and economic access to food (proximity and affordability); food promotion, advertising and information; and food quality and safety.” – High Level Panel of Experts on Food Security and Nutrition (HLPE) report

This episode included a discussion of the following…

Food Preferences and Exposure to Food Cues

• Some aspects of food preferences are innate; for example, human infants have a liking for sweetness (see podcast episode with Prof. Marion Hetherington). But most aspects of food preferences are malleable and learned over time.
• A major determinant of food preferences is the familiarity of the taste.
• The home environment has been shown to be particularly important in the influencing of preferences for energy-dense foods (Fildes et al., 2014)
• Similarly our friends and relationships influence our food choice (Cunningham, 2012). This appears to be more pronounced depending on how close the relationship is, how likely we are to imitate them or compare our own preferences.
• Psychobiology of appetite, evidence for visual stimulation to prompt desire to eat certain foods.
• Single-parent households associated with high energy-density diets, independent of socio-economic status.
• How social media is changing our relationship with food (e.g. Chung, 2021)
• Social and cultural norms also play a role in preference learning (Sobral et al.)

Advertising

• Advertising has a direct effect on preferences by creating familiar and positive associations (Cairns et al., 2013)
• Estimated that children and adolescents see food marketing 30 and 189 times on average per week on social media apps, respectively (Potvin Kent et al., 2018)
• In line with much of the other food preference research, childhood is a critical time for this food preference development.

Socioeconomics

A number of socioeconomic factors are intertwined and involved in shaping the food environment and individual choices. Some impotant examples to highlight this include food deserts, density of fast-food outlets by area, and the impact of income/purchasing power.

Food Deserts & Fast-Food Outlet Density

• “Food deserts” = areas where the access to affordable, healthy food options is limited/non-existent due to grocery stores being too far away
• Given their limited options, people living in food deserts therefore often end up disproportionally turning to fast-food and convenience outlets for meals.
• In the UK, Fraser et al. (2010) showed that the density of McDonald’s, Pizza Hut, Burger King, and KFC, were each linearly associated with increasing social deprivation.
• A cross-sectional study (Burgoine et al., 2014) on people in Cambridge, UK
  • Participants’ home and work addresses were mapped by postcode.
  • 48% more takeaway food outlets at work than at home
  • Found that the combination of 1) highest fast-food outlet exposure and 2) lowest household income, was associated a 143% greater odds of obesity, compared to those with the lowest fast-food outlet exposure and highest incomes.
• Within the US, socially-deprived areas have 2.5x the density of fast-food outlets nearby, than those living in affluent areas (Yeh & Katz, 2015, pg. 106)
• It should be noted that some researchers, such as Wilkins et al. (2019), have reported that there is a large diversity of methods used to measure the retail food environment and the associations with obesity vary by the measurement method used.

Income/purchasing Power

In order to comply with Eatwell Guide (the UK’s dietary guidelines), households in the lowest 10% of income in the UK would need to spend 73.6% of disposable income on food. Whereas households in the top 10% would only have to spend 6%. – Living Cost & Food Survey

The same data shows that on average, the poorest half of the UK population would have to spend ~30% of disposable income to meet Eatwell Guide targets, while the top 50% would have to spend 12%.

As per a report by Foresight (Foresight is a project run by the UK’s Government Office for Science), the real cost of fruits and vegetables as a proportion of food budgets increased by nearly 40%, while the real cost of sugar-sweetened drinks as a proportion of food budgets declined by nearly 25%.

Some of the above surveys (and wider issues) have been cause for much debate politically. Below is a recent example of reports on food insecurity being raised by an MP in the UK:

At the DWP Select Committee, I questioned Theresa Coffey. I was frankly embarrassed and left frustrated by the Minister’s lack of an answer. There was no recognition of the impact of UK Tory welfare policies on food insecurity and challenges with the cost of living. pic.twitter.com/o02RmeG16k

— Chris Stephens MP (@ChrisStephens) February 9, 2022

In the podcast discussion, the work of Professor Martin Caraher was mentioned in relation to purchasing power, socioeconomics and food insecurity. Prof. Caraher discussed this in detail in episode 344 of the podcast.

Differences Based on Geography & Culture

Most of the evidence on the food environment that uses proximity or density measures of food retailers remains focused on western population and urban settings. So it’s important not to automatically extrapolate such findings to other populations or rural areas.

For example, the GLOBE study conducted in a Dutch population, while showing a detrimental impact of “high financial strain”, also found that the greater density of fast-food outlets was associated with lower BMI. This is in opposition to the data in UK, US, and other Western populations.

Qualitative research on a neighbourhood in Madrid, Spain looked at workers and food traders in the area in an attempt to capture social aspects related to food purchasing. It suggested that the most important drivers of purchasing decisions were:

1. traditions
2. the trust and relationship between customers and the food traders
3. time scarcity due to modern life pressures; i.e. younger residents depended more on supermarkets that had greater ranges of products, were more convenient and had longer opening hours

Non-Diet Environmental Characteristics

SLOPE (Studying Lifecourse Obesity PrEdictors) study:

• Population-based cohort in Southampton, UK
• Examined how environmental characteristics, including greenspace, walkability, supermarket density, unhealthy food outlet relative density, spaces for social interaction and air quality at birth are associated with overweight and obesity in school-aged children (14,084 children aged 4–5 years and 5,637 aged 10–11 years).
• Increased access to greenspace may have a role in early prevention of childhood obesity. While effects were often small, at a population level these effect sizes could be pragmatically meaningful.

Modifying Food Environment for a Healthier Population: How?

Given that food choices are shaped by the contexts within which they are made, “the most effective and equitable way to change food behaviours is to change the structural factors that drive food choice.” – European Public Health Alliance

In a 2015 paper published in The Lancet, Swinburn et al. stated: “… dramatic actions are needed to improve the healthiness of food environments. Substantial debate surrounds who is responsible for delivering effective actions and what, specifically, these actions should entail. Arguments are often reduced to a debate between individual and collective responsibilities, and between hard regulatory or fiscal interventions and soft voluntary, education-based approaches. Genuine progress lies beyond the impasse of these entrenched dichotomies. We argue for a strengthening of accountability systems across all actors to substantially improve performance on obesity reduction”

One of the world’s leading researchers in food policy and public health is Professor Corinna Hawkes. Prof. Hawkes is Director of the Centre for Food Policy at City, University of London. If you’re interested in digging into food policy and food systems, then it’s recommended to listen to episode 339 of the podcast where Prof. Hawkes was the guest.

“Food policies should aim not just to make the healthy choice the easy choice, but the healthy choice the preferred choice” – Hawkes et al., 2015

Professor Tom Robinson from Stanford University referred to similar interventions as “stealth interventions” (4:06). In other words, can we have interventions that incentivise people to follow behaviours that are good for them, for reasons other than them being good for them, i.e. incentives that don’t appeal to “do this because it’s good for you”. What things are enjoyable, appealing, etc.? (e.g. enrolling kids in after school hip-hop dance programs vs. nutrition education – Stanford GEMS pilot study).

Hawkes et al., 2015 highlight four of the key mechanisms through which food policies can work, namely by:

1. providing an enabling environment for healthy preference learning
2. overcoming barriers to the expression of healthy preferences
3. encouraging people to reassess existing unhealthy preferences
4. stimulating a positive food-systems response

Public health policy options tend to fall into six categories (adapted from Gorski & Roberto, 2015):

1. Mandates: required policies for industries or individuals designed to protect against the adverse effects of an unhealthy substance or environment
   —
2. Restrictions: designed to limit access to an unhealthy substance or environment. An example could be prohibiting the sale of sugar-sweetened beverages to children/adolescents under a certain age.
   —
3. Economic incentives: aim to better align price incentives with health outcomes, encouraging lower consumption of unhealthy products. An example could be a tax on sugar-sweetened beverages. There is a potential role for taxes and subsidies, depending on how they are rolled out.
   —
4. Marketing limits: try to limit advertising and promotion of an unhealthy substance or environment. Regulation of food advertising would be a good example. Taillie et al. 2020: Combining front-of-pack labelling with marketing restrictions.
   —
5. Information provision: provide the public with important health information, including encouraging healthy behaviours and warning about the dangers of an unhealthy substance or environment. For example, education campaigns to promote eating fruits and vegetables.
   —
6. Environmental defaults: these policies preserve the freedom of individuals to expose themselves. So this is where interventions such as “nudging” could be used; for example, changing the default restaurant side dish from French fries to salad. Or as discussed in episode 292 of the podcast with Prof. Alexandra Johnstone, nudging as been researched as a means of reducing meat intake in Scottish populations (McBey et al., 2019).

Based on work by Lloyd-Williams et al. (2014), public health officials across 30 European countries considered mandatory regulation to be the most effective route.

Further reading on public health nutrition reports for those interested:

• WHO – Public Procurement for Health Policies: ensuring all foods available in public settings (schools, hospitals, prisons etc) contribute to the promotion of a health diet – this is interesting, lots of policies but no implementation.
• EU Commission: Farm 2 Fork Strategy – Building alternative food environments – protein alternative and sustainable farming.
• The Healthy Food Environment Policy Index (Food-EPI)

Behaviour Change at the Individual Level

Although the focus of this episode was on public health policy and changing the food environment at a population level, it should be noted there is also a role for behaviour change and alteration of the food environment at the individual level.

It’s important to again realize that, as Atkins & Michie (2015) put it: “Behaviour does not occur in a vacuum, it occurs within constantly evolving systems and contexts.” The below image gives an example of the interaction of a number of behaviours related to healthy eating.

Michie et al., 2011 proposed the Behaviour Change Wheel as a method of designing behaviour change interventions. As you can see below this shows an interaction between various policy interventions and an individual’s capability, opportunity and motivation to make behaviour change (the COM-B model). This idea was discussed more in episode 327 with David Dunne.

This is where individuals, those in guidance roles (coaches, nutritionists, doctors, etc.), and local inititatives can have an impact. This can include a whole host of factors, that are best discussed in their own episode, but just a short, non-exhaustive list includes:

• thinking about what foods are available in the home
• planning when/where meals will be consumed ahead of time
• finding health-promoting behaviours they enjoy
• finding foods/meals that are both nutritious and that they like the taste of
• developing cooking skills
• etc.

For more on behaviour change, see episodes with James Clear (249), Kyra Bobinet, MD (335), David Dunne (327), and Gab Fundaro, PhD (367).

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