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BACKGROUND: Structural racism and economic marginalization shape dietary patterns in complex ways. Most research examining race and income inequities discount their interactions in shaping dietary intakes. An intersectional approach is needed to identify interconnected sources of social inequities and to more precisely locate dietary inequities. OBJECTIVES: We examined whether racial identity and perceived income adequacy independently and jointly shape dietary quality, defined using the Healthy Eating Index (HEI) 2015, among a large sample of adults in Canada. METHODS: Cross-sectional data from 2540 adults (≥18 years of age) in Canada who participated in the 2019 International Food Policy Study were analyzed. Multivariable linear regression models were executed to test the independent associations and interactions between racial identity and perceived income adequacy with HEI-2015 scores. Models were constructed to examine HEI-2015 total and component scores, adjusting for age, gender, and education. RESULTS: Perceived income adequacy, but not racial identity, was independently associated with HEI-2015 total scores. The interaction between racial identity and perceived income adequacy was significantly associated with HEI-2015 scores. Compared to the reference group (individuals identifying as White and reporting income adequacy), those identifying as Black and reporting income adequacy were associated with lower HEI-2015 scores (β, −7.30; 95% CI, −13.07 to −1.54) and those identifying as Black and reporting income inadequacy were associated with lower HEI-2015 scores (β, −6.37; 95% CI, −12.13 to −0.60). Individuals who identified as indigenous and reported neither income adequacy nor inadequacy had lower HEI-2015 scores (β, −8.50; 95% CI, −13.82 to −3.18) compared to the reference group. CONCLUSIONS: Findings suggest that racial identity and perceived income adequacy jointly shape dietary quality. Inequities in dietary quality may be missed when intersecting racial identities and socioeconomic positions are not explicitly investigated. To support healthier dietary patterns, strategies must reduce socioeconomic barriers that impose dietary constraints on some racialized groups.

The release of Canada’s Food Guide (CFG) in 2019 by Health Canada prompted the development of indices to measure adherence to these updated dietary recommendations for Canadians. This study describes the development and scoring standards of the Healthy Eating Food Index (HEFI-2019), which is intended to measure alignment of eating patterns with CFG-2019 recommendations on food choices among Canadians aged 2 years and older. Alignment with the intent of each key recommendation in the CFG-2019 was the primary principle guiding the development of the HEFI-2019. Additional considerations included previously published indices, data on Canadians’ dietary intakes from the 2015 Canadian Community Health Survey-Nutrition, and expert judgement. The HEFI-2019 includes 10 components: Vegetables and fruits (20 points), Whole-grain foods (5 points), Grain foods ratio (5 points), Protein foods (5 points), Plant-based protein foods (5 points), Beverages (10 points), Fatty acids ratio (5 points), Saturated fats (5 points), Free sugars (10 points), and Sodium (10 points). All components are expressed as ratios (e.g., proportions of total foods, total beverages, or total energy). The HEFI-2019 score has a maximum of 80 points. Potential uses of the HEFI-2019 include research as well as monitoring and surveillance of food choices in population-based surveys. Novelty: The Healthy Eating Food Index-2019 was developed to measure adherence to the 2019 Canada's Food Guide recommendations on healthy food choices. The HEFI-2019 includes 10 components, of which 5 are based on foods, 1 on beverages and 4 on nutrients, for a total of 80 points.

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

Precision public health is a relatively new field that integrates components of precision medicine, such as human genomics research, with public health concepts to help improve population health. Despite interest in advancing precision public health initiatives using human genomics research, current and future opportunities in this emerging field remain largely undescribed. To that end, we provide examples of promising opportunities and current applications of genomics research within precision public health and outline future directions within five major domains of public health: biostatistics, environmental health, epidemiology, health policy and health services, and social and behavioral science. To further extend applications of genomics within precision public health research, three key cross-cutting challenges will need to be addressed: developing policies that implement precision public health initiatives at multiple levels, improving data integration and developing more rigorous methodologies, and incorporating initiatives that address health equity. Realizing the potential to better integrate human genomics within precision public health will require transdisciplinary efforts that leverage the strengths of both precision medicine and public health.

Background Compared with those with a higher socio-economic position (SEP), individuals with a lower SEP have higher cancer morbidity and mortality. However, the contribution of modifiable risk factors to these inequities is not known. This study aimed to quantify the mediating effects of modifiable risk factors to associations between SEP and cancer morbidity and mortality. Methods This study used a prospective observational cohort design. We combined eight cycles of the Canadian Community Health Survey (2000/2001–2011) as baseline data to identify a cohort of adults (≥35 years) without cancer at the time of survey administration (n = 309 800). The cohort was linked to the Discharge Abstract Database and the Canadian Mortality Database for cancer morbidity and mortality ascertainment. Individuals were followed from the date they completed the Canadian Community Health Survey until 31 March 2013. Dates of individual first hospitalizations for cancer and deaths due to cancer were captured during this time period. SEP was operationalized using a latent variable combining measures of education and household income. Self-reported modifiable risk factors, including smoking, excess alcohol consumption, low fruit-and-vegetable intake, physical inactivity and obesity, were considered as potential mediators. Generalized structural equation modelling was used to estimate the mediating effects of modifiable risk factors in associations between low SEP and cancer morbidity and mortality in the total population and stratified by sex. Results Modifiable risk factors together explained 45.6% of associations between low SEP and overall cancer morbidity and mortality. Smoking was the most important mediator in the total population and for males, accounting for 15.5% and 40.2% of the total effect, respectively. For females, obesity was the most important mediator. Conclusions Modifiable risk factors are important mediators of socio-economic inequities in cancer morbidity and mortality. Nevertheless, more than half of the variance in these associations remained unexplained. Midstream interventions that target modifiable risk factors may help to alleviate inequities in cancer risk in the short term. However, ultimately, upstream interventions that target structural determinants of health are needed to reduce overall socio-economic inequities in cancer morbidity and mortality.

Objective To explore the impact of a capacity-building intervention (CBI) to support implementing provincial nutrition guidelines on food marketing in recreation facilities (RFs). Design Randomized controlled trial within a natural experiment: food marketing in RFs from 3 guideline provinces randomly assigned to intervention (GL+CBI) or comparison (GL-ONLY) was compared with facilities in 1 province without guidelines (NO-GL). Food marketing was assessed by the Food and Beverage Marketing Assessment Tool for Settings. Setting Canadian provinces with/without voluntary nutrition guidelines for RFs. Participants 51 RFs. Intervention 18-month CBI. Main Outcome Measures Change in Food and Beverage Marketing Assessment Tool for Settings scores and marketing features between baseline and follow-up across groups. Analysis Kruskal–Wallis with post hoc Mann–Whitney U tests. Results No significant differences in food marketing features between baseline and follow-up across groups except for a change in food marketing frequency (P = 0.045). The increase in frequency in NO-GL (median, 6.0; interquartile range, −2.0 to 8.5) was significantly greater than changes in the GL+CBI (P = 0.033) and GL-ONLY sites (P = 0.049). Conclusions and Implications Capacity-building was not associated with improved food marketing features potentially because of nonmandated nutrition guidelines, low priority for change, and vague or narrow facility goals and guidelines. Nutrition guidelines with specific unhealthy food marketing restrictions should be mandated and supported.

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.

The objective of this study was to evaluate the construct validity and reliability of the Healthy Eating Food Index-2019 (HEFI-2019), which was developed to measure adherence to Canada’s Food Guide 2019 (CFG-2019) recommendations on healthy food choices. Dietary intake data from 24-hour dietary recalls in the 2015 Canadian Community Health Survey-Nutrition were used for that purpose. Multidimensionality was examined using principal component analysis. Mean scores were compared among subgroups of the population. The association between scores and energy intake was assessed using Pearson correlations. Cronbach’s alpha was calculated to assess reliability. The estimated mean HEFI-2019 score (/80) was 43.1 (95% CI, 42.7 to 43.6) among Canadians aged 2 years and older. The first and 99th percentiles were 22.1 and 62.9 points. The mean HEFI-2019 score for smokers was 7.2 points lower than for non-smokers (95% CI, –8.5 to –5.9). The HEFI-2019 was weakly correlated with energy intake (r = –0.13; 95% CI, –0.20 to –0.06). The principal components analysis revealed at least 4 dimensions. Cronbach’s alpha was 0.66 (95% CI, 0.63 to 0.69). Evidence of construct validity and internal consistency support the use of the HEFI-2019 to assess adherence to CFG-2019’s recommendations on healthy food choices. Novelty: Examination of the HEFI-2019’s psychometric properties is needed prior to implementation. Analyses support the construct validity and internal consistency of the HEFI-2019. Interpretation of the total HEFI-2019 score must be accompanied by its components’ scores, considering it assesses multiple dimensions of food choices.

Unhealthy food and beverage availability and sponsorship undermine healthy food practices in sport and recreation. We conducted a focused ethnography with reflexive photo-interviewing to examine parents’ awareness, reactions, and experiences of food and beverage marketing in and around their children’s physical activity in public sport and recreation facilities. Eleven parents took photos of what they thought their facility was ‘saying about food and eating’. Photos guided semi-structured interviews on the ‘4Ps’ of marketing (product, pricing, placement, promotion). Thematic analysis was conducted by holistic coding followed by in vivo, versus, and value coding. Photo-taking increased parents’ awareness of food marketing in facilities. Reactions to food and beverage marketing were positive or negative depending on parents’ perspectives of healthy food availability (choice), marketers’ motives, and mixed messages within the facility. Parents experienced their children requesting ‘junk’ food at the facility leading to parents actively attempting to reduce the frequency of these requests. Healthy eating promotion in sport and recreation facilities was misaligned with the foods and beverages available which contributed to parents’ distrust of social marketing initiatives. Critically evaluating the alignment of commercial and social marketing in recreation and sport may help inform effective healthy eating interventions that are accepted and supported by parents.

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.

The British Columbia Farmers' Market Nutrition Coupon Program (FMNCP) is a farmers' market food subsidy program that provides low-income households with coupons valued at $21/wk for 16 weeks to purchase healthy foods at participating BC Association of Farmers' Markets members' markets.This study aimed to explore changes, differences, and similarities in participants' experiences and perceived short-term outcomes during and after participating in the FMNCP.A longitudinal qualitative research approach was used to conduct a recurrent cross-sectional analysis. Data generation and analysis were guided by Freedman et al's theoretical framework of nutritious food access. Data generation occurred during 2019 FMNCP program (time 1) and 4 to 7 weeks after (time 2) the program year ended. Data at each time point were analyzed separately using directed content analysis, followed by a comparative analysis to identify changes, differences, and similarities between time points.Twenty-eight adult participants were interviewed during the program; 24 were re-interviewed post program.Three communities in British Columbia, Canada.Three themes were generated: temporary relief and engagement; lasting experiences and outcomes; enhancing participant experiences and outcomes. The first theme related to how participants' experiences and perceived outcomes, such as increased financial support and improved diet quality and health, were temporary. The second theme reflected positive lasting experiences and outcomes from participating in the FMNCP, including increased food and nutrition knowledge and enhanced social ties. The third theme focused on enhancing participants' program experiences and outcomes, including increasing the duration of food subsidies.The FMNCP temporarily enhanced access to nutritious foods and had lasting positive effects on participants' nutrition-related knowledge and social outcomes. Nevertheless, participants struggled to maintain healthy eating practices post program due to financial constraints. Expanding farmers' market subsidy programs may improve access to nutritious foods; maintain positive dietary, social, and health outcomes for participants; and reach more low-income households.

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.

Language focused on individual dietary behaviors, or alternatively, lifestyle choices or decisions, suggests that what people eat and drink is primarily a choice that comes down to free will. Referring to and intervening upon food consumption as though it were a freely chosen behavior has an inherently logical appeal due to its simplicity and easily defined targets of intervention. However, despite decades of behavioral interventions, population-level patterns of food consumption remain suboptimal. This debate paper interrogates the manner in which language frames how problems related to poor diet quality are understood and addressed within society. We argue that referring to food consumption as a behavior conveys the idea that it is primarily a freely chosen act that can be ameliorated through imploring and educating individuals to make better selections. Leveraging practice theory, we subsequently propose that using the alternative language of eating practices and patterns better conveys the socially situated nature of food consumption. This language may therefore point to novel avenues for intervention beyond educating and motivating individuals to eat more healthfully, to instead focus on creating supportive contexts that enable sustained positive dietary change. Clearly, shifting discourse will not on its own transform the science and practice of nutrition. Nevertheless, the seeds of change may lie in aligning our terminology, and thus, our framing, with desired solutions.

Summary As providers of community-based physical activity programs, recreation and sports facilities serve as an important resource for health promotion. Unfortunately, the food environments within these settings often do not reflect healthy eating guidelines. This study sought to describe facilitators and barriers to implementing provincial nutrition guidelines in recreation and sports facilities in three Canadian provinces with nutrition guidelines. Semi-structured interviews were analysed thematically to identify facilitators and barriers to implementing provincial nutrition guidelines. Facilitators and barriers were then categorised using a modified “inside out” socio-ecological model that places health-related and other social environments at the centre. A total of 32 semi-structured interviews were conducted at two time-points across the three guideline provinces. Interview participants included recreation staff managers, facility committee or board members and recreation volunteers. Eight facilitators and barriers were identified across five levels of the inside out socio-ecological model. Facilitators included provincial or municipal expectations of guideline implementation, clear communication to staff around guideline directives and the presence of a champion within the community or facility who supported guideline implementation. Barriers included unhealthy food culture within community, competition from other food providers and issues within food service contracts that undermined healthy food provision. Findings reinforce the importance of top down (clear expectations regarding guideline implementation at the time of approval) and bottom up (need for buy-in from multiple stakeholders) approaches to ensure successful implementation of nutrition guidelines. The application of a modified socio-ecological model allowed for a more nuanced understanding of leverage points to support successful guideline implementation. Lay summary Healthy eating is an important behaviour for preventing chronic diseases. Supporting people to access healthy foods in places where they live, learn, work or play is a public health priority. Recreation and sports facilities are a setting where people can be physically active. Unfortunately, the food environment in these settings may not reflect nutrition guidelines. In this study, we interviewed key stakeholders from recreation and sports facilities in three Canadian provinces who had put guidelines for healthy eating in place. We used a specific framework to do this called the inside out socio-ecological model. Eight facilitators and barriers were identified using this model. Facilitators included provincial or municipal expectations of guideline implementation, clear communication to staff around guideline directives and the presence of a champion within the community or facility who supported guideline implementation. Barriers included unhealthy food culture within community, competition from other food providers and issues within food service contracts that undermined healthy food provision. Our findings can help people working in recreation and sports facilities to identify issues that may help or hinder healthy food provision in these settings.

Aims To summarize methods used to account for antihyperglycemic medication changes in randomized controlled trials evaluating the effect of dietary and physical activity interventions on glycemia among adults with diabetes. Methods Using studies included in two recently published systematic reviews of randomized controlled trials examining the glycemic effects of dietary and physical activity interventions, we evaluated how each study accounted for antihyperglycemic medication changes. Data were analyzed using summary statistics, stratified by the type of intervention studied, and each was assigned a score from 0 to 6 reflecting the strength of medication controls employed. Results We evaluated 22 physical activity focused and 27 dietary focused articles. Our scoring system yielded a mean concurrent medication adjustment score of 3.9/6 for the physical activity studies and a score of 1.7/6 ( p < 0.001) for the dietary studies. Conclusions We found that randomized controlled trials included in recent systematic reviews of physical activity and dietary interventions did not robustly account or control for changes in antihyperglycemic medications, with physical activity interventions doing so more robustly than dietary interventions. This is a threat to the validity of study findings, as observed glycemic changes may in fact be attributable to imbalances in concurrent medication adjustments between groups.

Sarah Downer and colleagues review new efforts to incorporate food and nutrition into prevention, management, and treatment of diet related disease in healthcare systems

Background Increasing inequalities in rates of obesity and chronic disease may be partly fuelled by increasing dietary inequalities, however very few nationally representative analyses of socioeconomic trends in dietary inequalities exist. The release of the 2011–13 Australian National Nutrition and Physical Activity Survey data allows investigation of change in dietary intake according to socioeconomic position (SEP) in Australia using a large, nationally representative sample, compared to the previous national survey in 1995. This study examined change in dietary intakes of energy, macronutrients, fiber, fruits and vegetables among Australian adults between 1995 and 2011–13, according to SEP. Methods Cross-sectional data were obtained from the 1995 National Nutrition Survey, and the 2011–13 National Nutrition and Physical Activity Survey. Dietary intake data were collected via a 24-h dietary recall (n = 17,484 adults) and a dietary questionnaire (n = 15,287 adults). SEP was assessed according to educational level, equivalized household income, and area-level disadvantage. Survey-weighted linear and logistic regression models, adjusted for age, sex/gender and smoking status, examined change in dietary intakes over time. Results Dietary intakes remained poor across the SEP spectrum in both surveys, as evidenced by high consumption of saturated fat and total sugars, and low fiber, fruit and vegetable intakes. There was consistent evidence (i.e. according to ≥2 SEP measures) of more favorable changes in dietary intakes of carbohydrate, polyunsaturated and monounsaturated fat in higher, relative to lower SEP groups, particularly in women. Intakes of energy, total fat, saturated fat and fruit differed over time according to a single SEP measure (i.e. educational level, household income, or area-level disadvantage). There were no changes in intake of total sugars, protein, fiber or vegetables according to any SEP measures. Conclusions There were few changes in dietary intakes of energy, most macronutrients, fiber, fruits and vegetables in Australian adults between 1995 and 2011–13 according to SEP. For carbohydrate, polyunsaturated and monounsaturated fat, more favorable changes in intakes occurred in higher SEP groups. Despite the persistence of suboptimal dietary intakes, limited evidence of widening dietary inequalities is positive from a public health perspective. Trial registration Clinical trials registration: ACTRN12617001045303. Electronic supplementary material The online version of this article (10.1186/s12966-018-0666-4) contains supplementary material, which is available to authorized users.

Background Dietary patterns that align with recommended guidelines appear to minimize long-term weight gain in the general population. However, prospective associations between diet quality and weight change in disadvantaged adults have not been examined. This study examined associations between concurrent change in diet quality and body mass index (BMI) over 5 years among women living in socioeconomically disadvantaged neighbourhoods. Methods Dietary intake and BMI were self-reported among 1242 women living in disadvantaged neighbourhoods in Victoria, Australia, at three time points from 2007/08 to 2012/13. Diet quality was evaluated using the Australian Dietary Guideline Index (DGI). Associations between concurrent change in diet quality and BMI were assessed over the three time points using fixed effects and mixed models. Models were adjusted for age, smoking, menopausal status, education, marital status, number of births, urban/rural location and physical activity. Results Average BMI increased by 0.14 kg/m2 per year increase in age in the fixed effects model, and by 0.13 kg/m2 in the mixed model (P

KEY POINTS Most Canadians consume diets that are inconsistent with Health Canada’s recommendations.[1][1] Problems related to poor diet quality are particularly evident among Canadians with a lower social position (i.e., as shown by lower levels of education and household income), as both overall

As currently conceived, precision public health is at risk of becoming precision medicine at a population level. This paper outlines a framework for precision public health that, in contrast to its current operationalisation, is consistent with public health principles because it integrates factors at all levels, while illuminating social position as a fundamental determinant of health and health inequities. We review conceptual foundations of public health, outline a proposed framework for precision public health and describe its operationalisation within research and practice. Social position shapes individuals’ unequal experiences of the social determinants of health. Thus, in our formulation, precision public health investigates how multiple dimensions of social position interact to confer health risk differently for precisely defined population subgroups according to the social contexts in which they are embedded, while considering relevant biological and behavioural factors. It leverages this information to uncover the precise and intersecting social structures that pattern health outcomes, and to identify actionable interventions within the social contexts of affected groups. We contend that studies informed by this framework offer greater potential to improve health than current conceptualisations of precision public health that do not address root causes. Moreover, expanding beyond master categories of social position and operationalising these categories in more precise ways across time and place can enrich public health research through greater attention to the heterogeneity of social positions, their causes and health effects, leading to the identification of points of intervention that are specific enough to be useful in reducing health inequities. Failure to attend to this level of particularity may mask the true nature of health risk, the causal mechanisms at play and appropriate interventions. Conceptualised thus, precision public health is a research endeavour with much to offer by way of understanding and intervening on the causes of poor health and health inequities.As currently conceived, precision public health is at risk of becoming precision medicine at a population level. This paper outlines a framework for precision public health that, in contrast to its current operationalization, is consistent with public health principles because it integrates factors at all levels, while illuminating social position as a fundamental determinant of health and health inequities. We review conceptual foundations of public health, outline a proposed framework for precision public health and describe its operationalization within research and practice. Social position shapes individuals’ unequal experiences of the social determinants of health. Thus, in our formulation, precision public health investigates how multiple dimensions of social position interact to confer health risk differently for precisely defined population subgroups according to the social contexts in which they are embedded, while considering relevant biological and behavioural factors. It leverages this information to uncover the precise and intersecting social structures that pattern health outcomes, and to identify actionable interventions within the social contexts of affected groups. We contend that studies informed by this framework offer greater potential to improve health than current conceptualizations of precision public health that do not address root causes. Moreover, expanding beyond master categories of social position and operationalizing these categories in more precise ways across time and place can enrich public health research through greater attention to the heterogeneity of social positions, their causes and health effects, leading to identification of points of intervention that are specific enough to be useful in reducing health inequities. Failure to attend to this level of particularity may mask the true nature of health risk, the causal mechanisms at play and appropriate interventions. Conceptualized thus, precision public health is a research endeavour with much to offer by way of understanding and intervening on the causes of poor health and health inequities.

Socioeconomic position (SEP) is a key determinant of diet quality across the life course. Young adulthood is a unique period of transition where dietary inequities between groups with lower and higher SEP may widen. This study investigated associations between SEP in both childhood and young adulthood and diet quality in young adulthood. Data from 1949 Canadian young adults aged 18⁻30 who participated in the Canada Food Study were analyzed. Healthy Eating Index⁻2015 (HEI-2015) scores were calculated based on one 24-hour dietary recall. Childhood and young adult SEP were represented by self-report of participants' parent(s)' and their own highest educational level, respectively. Linear regression was used to examine associations between childhood and adult SEP and adult HEI-2015 score. Mediation analyses examined whether adult SEP mediated the relationship between childhood SEP and adult HEI-2015 score. Lower SEPs in childhood and adulthood were each associated with lower HEI-2015 scores in young adulthood. Adult SEP mediated up to 13.0% of the association between childhood SEP and adult HEI-2015 scores. Study findings provide support for key life course hypotheses and suggest latent, pathway, and cumulative effects of SEP across the early life course in shaping the socioeconomic patterning of diet quality in young adulthood.

Background There is considerable uncertainty regarding the impact of tableware size on food consumption. Most existing studies have used small and unrepresentative samples and have not followed recommended procedures for randomised controlled trials, leading to increased risk of bias. In the first pre-registered study to date, we examined the impact on consumption of using larger versus smaller plates for self-served food. We also assessed impact on the underlying meal micro-structure, such as number of servings and eating rate, which has not previously been studied. Methods The setting was a purpose-built naturalistic eating behaviour laboratory. A general population sample of 134 adult participants (aged 18–61 years) was randomly allocated to one of two groups varying in the size of plate used for self-serving lunch: large or small. The primary outcome was amount of food energy (kcal) consumed during a meal. Additionally, we assessed impact on meal micro-structure, and examined potential modifying effects of executive function, socio-economic position, and sensitivity to perceptual cues. Results There was no clear evidence of a difference in consumption between the two groups: Cohen’s d = 0.07 (95% CI [− 0.27, 0.41]), with participants in the large plate group consuming on average 19.2 (95% CI [− 76.5, 115.0]) more calories (3%) compared to the small plate group (large: mean (SD) = 644.1 (265.0) kcal, versus small: 624.9 (292.3) kcal). The difference between the groups was not modified by individual characteristics. There was no evidence of impact on meal micro-structure, with the exception of more food being left on the plate when larger plates were used. Conclusions This study suggests that previous meta-analyses of a low-quality body of evidence may have considerably overestimated the effects of plate size on consumption. However, the possibility of a clinically significant effect – in either direction – cannot be excluded. Well-conducted trials of tableware size in real-world field settings are now needed to determine whether changing the size of tableware has potential to contribute to efforts to reduce consumption at population-level. Trial registration The study protocol (https://osf.io/e3dfh/) and data analysis plan (https://osf.io/sh5u7/) were pre-registered on the Open Science Framework. Electronic supplementary material The online version of this article (10.1186/s12966-019-0826-1) contains supplementary material, which is available to authorized users.

Background: Recreation and sport facilities often have unhealthy food environments that may promote unhealthy dietary patterns among children. In response, some Canadian provinces have released voluntary nutrition guidelines for recreation and sport facilities, however implementation has been limited. Organizational capacity building may overcome barriers to implementing guidelines. Eat, Play, Live was a randomized controlled trial embedded within a natural experiment that tested the impact of an 18 month capacity building intervention (CBI) in enhancing implementation of provincial nutrition guidelines, and whether nutrition guidelines were associated with positive changes. Primary outcomes were facility capacity, policy development and food environment quality. Methods: Recreation and sport facilities in three guideline provinces were randomized into a guideline + CBI (GL + CBI; n = 17) or a guideline only comparison condition (GL-ONLY; n = 15). Facilities in a province without guidelines constituted a second comparison condition (NO-GL; n = 17). Facility capacity, policy development, and food environment quality (vending and concession) were measured and compared at baseline and follow-up across conditions using repeated measures ANOVA and Chi-square statistics. Healthfulness of vending and concession items was rated as Do Not Sell (least nutritious), Sell Sometimes or Sell Most (most nutritious). Results: There were significant time by condition effects, with significant increases in facility capacity (mean ± SD: 30.8 ± 15.6% to 62.3 ± 22.0%; p

Background Emerging evidence shows sedentary behaviour may be associated with mental health outcomes. Yet, the strength of the evidence linking sedentary behaviour and stress is still unclear. This study aimed to synthesise evidence regarding associations between time spent in sedentary behaviour and stress in adults. Methods A systematic search was conducted (January 1990 – September 2019). Following PRISMA guidelines, an evaluation of methodological quality, and best-evidence synthesis of associations between time in sedentary behaviour (including sitting time, TV viewing, computer use) and stress were presented. Twenty-six studies reporting on data from n = 72,795 people (age 18-98y, 62.7% women) were included. Results Across the studies (n = 2 strong-, n = 10 moderate- and n = 14 weak-quality), there was insufficient evidence that overall time spent in sedentary behaviour and sitting time were associated with stress, particularly when using self-report measures of sedentary behaviour or stress. There was strong evidence of no association between TV viewing, or computer use and stress. Amongst studies using objective measures of sedentary behaviour and/or stress there was also strong evidence of no association. Conclusion Although previous research suggested sedentary behaviour may be linked to mental health outcomes such as depression and anxiety, the evidence for an association between various types of sedentary behaviour and stress is limited in quality, and associations are either inconsistent or null. High-quality longitudinal/interventional research is required to confirm findings and determine the direction of associations between different contexts (i.e. purpose) and domains (i.e. leisure, occupational, transport) of sedentary behaviour and stress.

Enhancing food skills and nutrition knowledge may help promote healthy eating among people who are food insecure. FoodMateFor evaluation purposes, SecondBiteMajor qualitative themes included program enjoyment; perceived positive long-term program impact on participants' eating and related attitudes and skills; barriers to cooking; suggested program modifications; and impact on others. In descriptive quantitative analyses, participants' diet; confidence to cook using basic ingredients, follow simple recipes and try new foods; cooking and food-related skills; social engagement and life satisfaction all improved between T1 and T3.Overall, FoodMate

ObjectiveFFQs are a popular method of capturing dietary information in epidemiological studies and may be used to derive dietary exposures such as nutrient intake or overall dietary patterns and diet quality. As FFQs can involve large numbers of questions, participants may fail to respond to all questions, leaving researchers to decide how to deal with missing data when deriving intake measures. The aim of the present commentary is to discuss the current practice for dealing with item non-response in FFQs and to propose a research agenda for reporting and handling missing data in FFQs.ResultsSingle imputation techniques, such as zero imputation (assuming no consumption of the item) or mean imputation, are commonly used to deal with item non-response in FFQs. However, single imputation methods make strong assumptions about the missing data mechanism and do not reflect the uncertainty created by the missing data. This can lead to incorrect inference about associations between diet and health outcomes. Although the use of multiple imputation methods in epidemiology has increased, these have seldom been used in the field of nutritional epidemiology to address missing data in FFQs. We discuss methods for dealing with item non-response in FFQs, highlighting the assumptions made under each approach.ConclusionsResearchers analysing FFQs should ensure that missing data are handled appropriately and clearly report how missing data were treated in analyses. Simulation studies are required to enable systematic evaluation of the utility of various methods for handling item non-response in FFQs under different assumptions about the missing data mechanism.

ObjectiveThe present study aimed to: (i) examine associations between food store patronage and diet and weight-related outcomes; and (ii) explore consumer motivations for visiting different types of food store.DesignA stratified probability sample of residents completed household and individual-level surveys in 2009/2010 on food purchasing patterns and motivations, dietary intake, waist circumference (WC), weight and height. Diet quality was calculated using the Healthy Eating Index for Canada from a subset of participants (n 1362). Generalized estimating equations were created in 2015 to examine how frequency of patronizing different types of food store was associated with diet quality, intake of fruits and vegetable, mean intake of energy (kcal) sodium and saturated fat, WC and BMI.SettingThree mid-sized urban municipalities in Ontario, Canada.SubjectsA representative sample of residents (n 4574).ResultsParticipants who shopped frequently at food co-ops had significantly better diet quality (β=5·3; 99 % CI 0·3, 10·2) than those who did not. BMI and WC were significantly lower among those who frequently shopped at specialty shops (BMI, β=−2·1; 99 % CI −3·0, −1·1; WC, β=−4·8; 99 % CI −7·0, −2·5) and farmers’ markets (BMI, β=−1·4; 99 % CI −2·3, −0·5; WC, β=−3·8; 99 % CI −6·0, −1·6) compared with those who did not. Relative importance of reasons for food outlet selection differed by large (price, food quality) v. small (proximity, convenient hours) shopping trip and by outlet type.ConclusionsFindings contribute to our understanding of food store selection and have implications for potentially relevant retail food intervention settings.

IntroductionLow-income populations have poorer diet quality and lower psychosocial well-being than their higher-income counterparts. These inequities increase the burden of chronic disease in low-income populations. Farmers’ market subsidies may improve diet quality and psychosocial well-being among low-income populations. In Canada, the British Columbia (BC) Farmers’ Market Nutrition Coupon Programme (FMNCP) aims to improve dietary patterns and health among low-income participants by providing coupons to purchase healthy foods from farmers’ markets. This study will assess the impact of the BC FMNCP on the diet quality and psychosocial well-being of low-income adults and explore mechanisms of programme impacts.Methods and analysisIn a parallel group randomised controlled trial, low-income adults will be randomised to an FMNCP intervention (n=132) or a no-intervention control group (n=132). The FMNCP group will receive 16 coupon sheets valued at CAD$21/sheet over 10–15 weeks to purchase fruits, vegetables, dairy, meat/poultry/fish, eggs, nuts and herbs at farmers’ markets and will be invited to participate in nutrition skill-building activities. Overall diet quality (primary outcome), diet quality subscores, mental well-being, sense of community, food insecurity and malnutrition risk (secondary outcomes) will be assessed at baseline, immediately post-intervention and 16 weeks post-intervention. Dietary intake will be assessed using the Automated Self-Administered 24-hour Dietary Recall. Diet quality will be calculated using the Healthy Eating Index-2015. Repeated measures mixed-effect regression will assess differences in outcomes between groups from baseline to 16 weeks post-intervention. Furthermore, 25–30 participants will partake in semi-structured interviews during and 5 weeks after programme completion to explore participants’ experiences with and perceived outcomes from the programme.Ethics and disseminationEthical approval was obtained from the University of Calgary Conjoint Health Research Ethics Board, Rutgers University Ethics and Compliance, and University of Waterloo Office of Research Ethics. Findings will be disseminated through policy briefs, conference presentations and peer-reviewed publications.Trial registration numberNCT03952338.

The Automated Self-Administered Dietary Assessment Tool (ASA24) is a web-based tool that guides participants through completion of a 24-h dietary recall and automatically codes the data. Despite the advantages of automation, eliminating interviewer contact may diminish data quality. Usability testing can assess the extent to which individuals can use the ASA24 to report dietary intake with efficiency, effectiveness, and satisfaction. This mixed-methods study evaluated the usability of the ASA24 to quantify user performance and to examine qualitatively usability issues in a sample of low-income adults (85% female, 48.2 years on average) participating in a nutrition coupon program. Thirty-nine participants completed a 24-h dietary recall using the ASA24. Audio and screen recordings, and survey responses were analyzed to calculate task times, success rates, and usability issue frequency. Qualitative data were analyzed thematically to characterize usability issues. Only one participant was able to complete a dietary recall unassisted. We identified 286 usability issues within 22 general usability categories, including difficulties using the search function, misunderstanding questions, and uncertainty regarding how to proceed to the next step, 71.4% of participants knowingly misentered dietary information at least once. Usability issues may diminish participation rates and compromise the quality of ASA24 dietary intake data. Researchers should provide on-demand technical support and designers should improve the intelligence and flexibility of the ASA24&rsquo, s search functionality.

Background Children’s recreational sport settings typically sell energy dense, low nutrient products; however, it is unknown whether the same types of food and beverages are also marketed in these settings. Understanding food marketing in sports settings is important because the food industry often uses the promotion of physical activity to justify their products. This study aimed to document the ‘exposure’ and ‘power’ of food marketing present in public recreation facilities in Canada and assess differences between provinces with and without voluntary provincial nutrition guidelines for recreation facilities. Methods Food marketing was measured in 51 sites using the Food and beverage Marketing Assessment Tool for Settings (FoodMATS). The frequency and repetition (‘exposure’) of food marketing and the presence of select marketing techniques, including child-targeted, sports-related, size, and healthfulness (‘power’), were assessed. Differences in ‘exposure’ and ‘power’ characteristics between sites in three guideline provinces (n = 34) and a non-guideline province (n = 17) were assessed using Pearson’s Chi squared tests of homogeneity and Mann-Whitney U tests. Results Ninety-eight percent of sites had food marketing present. The frequency of food marketing per site did not differ between guideline and non-guideline provinces (median = 29; p = 0.576). Sites from guideline provinces had a significantly lower proportion of food marketing occasions that were “Least Healthy” (47.9%) than sites from the non-guideline province (73.5%; p

Background: Current methods for evaluating food marketing to children often study a single marketing channel or approach. As the World Health Organization urges the removal of unhealthy food marketing in children’s settings, methods that comprehensively explore the exposure and power of food marketing within a setting from multiple marketing channels and approaches are needed. The purpose of this study was to test the inter-rater reliability and the validity of a novel settings-based food marketing audit tool. Methods: The Food and beverage Marketing Assessment Tool for Settings (FoodMATS) was developed and its psychometric properties evaluated in five public recreation and sport facilities (sites) and subsequently used in 51 sites across Canada for a cross-sectional analysis of food marketing. Raters recorded the count of food marketing occasions, presence of child-targeted and sports-related marketing techniques, and the physical size of marketing occasions. Marketing occasions were classified by healthfulness. Inter-rater reliability was tested using Cohen’s kappa (κ) and intra-class correlations (ICC). FoodMATS scores for each site were calculated using an algorithm that represented the theoretical impact of the marketing environment on food preferences, purchases, and consumption. Higher FoodMATS scores represented sites with higher exposure to, and more powerful (unhealthy, child-targeted, sports-related, large) food marketing. Validity of the scoring algorithm was tested through (1) Pearson’s correlations between FoodMATS scores and facility sponsorship dollars, and (2) sequential multiple regression for predicting “Least Healthy” food sales from FoodMATS scores. Results: Inter-rater reliability was very good to excellent (κ = 0.88–1.00, p

Women living in socioeconomically disadvantaged neighbourhoods are at heightened risk of experiencing psychological stress. Therefore, identifying potential risk factors for stress is important to support positive mental health. A growing body of research has linked sedentary behaviour with mental ill-health (e.g., depression and anxiety); however, little research has specifically investigated potential linkages between sedentary behaviour and stress. Therefore, the aim of this study was to investigate the association between common types of sedentary behaviour and objectively-measured stress (as measured by hair cortisol levels) amongst women living in socioeconomically disadvantaged neighbourhoods. During 2012–2013, 72 women (aged 18–46 years) living in socioeconomically disadvantaged neighbourhoods self-reported sedentary behaviour (TV viewing, computer use, overall sitting time) and provided hair samples. Hair cortisol levels were measured using enzyme-linked immunosorbent assay. Linear regression models examined cross-sectional associations between sedentary behaviour and hair cortisol levels. There was no association between any type of sedentary behaviour (TV viewing, computer use, or overall sitting time) and hair cortisol levels in either crude or adjusted models. Sedentary behaviour may not be linked to hair cortisol level (stress) in women living in socioeconomically disadvantaged neighbourhoods. Further studies utilising objective measures of both sedentary behaviour and stress are required to confirm these findings.

Community sports settings are often sources of unhealthy foods for children. Many managers in these settings are reluctant to increase availability of healthy food options because they perceive that healthy foods are not profitable. This study assessed the independent contribution of increased availability of healthy foods to their sales in a community sport, commercial context. Change in revenues per patron was also examined.The availability of healthy items was increased from 9.1% at baseline (35 days) to 25.0% during the intervention period (40 days), returning to 9.1% postintervention (6 days). Purchases of all patrons who bought foods/beverages (n=17,262 items sold) from two concessions at an outdoor community pool were assessed from baseline to postintervention. Chi-square analyses assessed differences in the proportion of healthy and unhealthy items sold, as well as in the proportion of total revenues per patron across periods. A trained observer also recorded qualitative observations pertaining to a subset of patrons' (n=221) dietary behaviors and activities.Healthy items represented 7.7%, 22.7%, and 9.8% of sales during the preintervention, intervention, and postintervention periods, respectively (p0.01). Sales of healthy beverages exceeded sales of all other product types. The proportion of total revenues per patron did not differ by period.Food availability was an important environmental determinant of food purchasing behaviors in this community commercial context, given that sales of healthy foods closely mirrored their availability. Increased availability of healthy foods in community and commercial settings is important because concurrent changes within multiple environments will be required to improve children's dietary behaviors.

Background Men of low socioeconomic position (SEP) are less likely than those of higher SEP to consume fruits and vegetables, and more likely to eat processed discretionary foods. Education level is a widely used marker of SEP. Few studies have explored determinants of socioeconomic inequalities in men’s eating behaviours. The present study aimed to explore intrapersonal, social and environmental factors potentially contributing to educational inequalities in men’s eating behaviour. Methods Thirty Australian men aged 18–60 years (15 each with tertiary or non-tertiary education) from two large metropolitan sites (Melbourne, Victoria; and Newcastle, New South Wales) participated in qualitative, semi-structured, one-on-one telephone interviews about their perceptions of influences on their and other men’s eating behaviours. The social ecological model informed interview question development, and data were examined using abductive thematic analysis. Results Themes equally salient across tertiary and non-tertiary educated groups included attitudes about masculinity; nutrition knowledge and awareness; ‘moralising’ consumption of certain foods; the influence of children on eating; availability of healthy foods; convenience; and the interplay between cost, convenience, taste and healthfulness when choosing foods. More prominent influences among tertiary educated men included using advanced cooking skills but having relatively infrequent involvement in other food-related tasks; the influence of partner/spouse support on eating; access to healthy food; and cost. More predominant influences among non-tertiary educated men included having fewer cooking skills but frequent involvement in food-related tasks; identifying that ‘no-one’ influenced their diet; having mobile worksites; and adhering to food budgets. Conclusions This study identified key similarities and differences in perceived influences on eating behaviours among men with lower and higher education levels. Further research is needed to determine the extent to which such influences explain socioeconomic variations in men’s dietary intakes, and to identify feasible strategies that might support healthy eating among men in different socioeconomic groups. Electronic supplementary material The online version of this article (10.1186/s12889-018-6162-6) contains supplementary material, which is available to authorized users.

Background The impacts of supermarket-based nutrition promotion interventions might be overestimated if participants shift their proportionate food purchasing away from their usual stores. This study quantified whether participants who received price discounts on fruits and vegetables (FV) in the Supermarket Healthy Eating for Life (SHELf) randomized controlled trial (RCT) shifted their FV purchasing into study supermarkets during the intervention period. Methods Participants were 642 females randomly assigned to a 1) skill-building (n = 160), 2) price reduction (n = 161), 3) combined skill-building and price reduction (n = 160), or 4) control (n = 161) group. Participants self-reported the proportion of FV purchased in study supermarkets at baseline, 3- and 6-months post-intervention. Fisher’s exact and χ2 tests assessed differences among groups in the proportion of FV purchased in study supermarkets at each time point. Multinomial logistic regression assessed differences among groups in the change in proportionate FV purchasing over time. Results Post-intervention, 49% of participants purchased ≥50% of their FV in study supermarkets. Compared to all other groups, the price reduction group was approximately twice as likely (RRR: 1.8-2.2) to have increased proportionate purchasing of FV in study supermarkets from baseline to post-intervention (p

Dietary patterns were examined in a convenience sample of 36 female University of Alberta students, all of whom had completed at least one nutrition course. Data from a validated food frequency questionnaire were used to determine if students had a dietary pattern similar to that recommended in Eating Well with Canada's Food Guide (EWCFG) or by the Traditional Healthy Mediterranean Diet Pyramid (THMDP), as measured using a Mediterranean Diet Quality Index Score. No student consumed the THMDP minimum number of portions of legumes, seeds, and nuts, of olive oil, or of whole grains. The majority did not meet the minimum EWCFG recommendations for any food group. The results suggest that nutrition education alone may be insufficient to ensure optimal dietary patterns among female university students. The methodology reported in this study is novel in assessing whether dietary patterns resemble the THMDP or the EWCFG.

We used our experience assisting in the development of and evaluating the Alberta Nutrition Guidelines for Children and Youth (ANGCY) as a basis for exploring roles that registered dietitians (RDs) can play within health promotion, and how others perceive the RD role. Data were generated via 12 key informant interviews and observations during a multiple case study of recreation facilities that had and had not adopted the ANGCY. We also drew on dialogue and personal observations during development of the ANGCY. Dietitians working in government, academia, community settings, private practice, and industry played an important role throughout the development and implementation of the ANGCY. Some sectors proactively sought RD expertise, while others with less ability to pay accessed RDs’ services less. Informants generally regarded RDs in a positive light. Findings indicate the profession should incrementally adjust training models to reflect emerging areas of practice, and highlight the need for RDs to proactively seek new avenues in which to apply their skills. These actions will help RDs remain the trusted source of food and nutrition information, not only in health care, but also within health promotion settings.

Background Food manufacturers have made public statements and voluntary commitments, such as the Healthier Australia Commitment (HAC), to improve the nutritional quality of foods. However, limited information about the nutritional quality or healthfulness of new products makes it difficult to determine if manufacturers are doing this. The purpose of this study was to assess the healthfulness of new food products released into the Australian retail market in 2015, and whether those companies who were HAC members released healthier food options compared to non-HAC members. Methods This cross-sectional study assessed the healthfulness of all new retail food products launched in Australia in 2015 as indexed in Mintel’s Global New Products Database. Healthfulness was assessed using three classification schemes: Healthy Choices Framework Victoria, Australian Dietary Guidelines and NOVA Food Classification System. Descriptive statistics and chi-squared tests described and compared the number and proportions of new foods falling within each of the food classification schemes’ categories for companies that were and were not HAC members. Results In 2015, 4143 new food products were launched into the Australian market. The majority of new products were classified in each schemes’ least healthy category (i.e. red, discretionary and ultra-processed). Fruits and vegetables represented just 3% of new products. HAC members launched a significantly greater proportion of foods classified as red (59% vs 51% for members and non-members, respectively) discretionary (79% vs 61%), and ultra-processed (94% vs 81%), and significantly fewer were classified as green (8% vs 15%), core foods (18% vs 36%) and minimally processed (0% vs 6%) (all p

Disadvantaged communities provide adverse psychosocial exposures that have been linked to high levels of stress, and this may provide one explanatory pathway linking socioeconomic disadvantage to obesity. This study used hair cortisol analysis to quantify associations between stress and body mass index (BMI), and between hair cortisol and perceived psychological stress levels, in women and children living in socioeconomically disadvantaged neighborhoods. Participants were a volunteer sample of 70 women from the Resilience for Eating and Activity Despite Inequality study, including 30 maternal-child pairs. Women self-reported body weight, height and perceived psychological stress using the Perceived Stress Scale (PSS), and provided hair samples for themselves and their child. Children's body weight and height were measured. Following extraction, hair cortisol levels were measured using enzyme-linked immunosorbent assay. Multiple linear regression models examined associations between stress and BMI, and between hair cortisol and perceived stress levels in women and children. Women's hair cortisol levels were not associated with their BMI or PSS scores. Women's PSS scores were positively associated with their BMI (p = 0.015). Within maternal-child pairs, mothers and children's hair cortisol levels were strongly positively associated (p = 0.006). Maternal hair cortisol levels and PSS scores were unrelated to their child's zBMI. Children's hair cortisol levels were not associated with their zBMI or with their mother's PSS score. Findings suggest that cortisol-based and perceived psychological measures of stress may be distinct among women and children living in disadvantaged neighborhoods. Perceived psychological measures may be more important predictors of weight-related risk.

Supermarket Healthy Eating for Life (SHELf) was a randomized controlled trial that operationalized a socioecological approach to population-level dietary behaviour change in a real-world supermarket setting. SHELf tested the impact of individual (skill-building), environmental (20 % price reductions), and combined (skill-building + 20 % price reductions) interventions on women’s purchasing and consumption of fruits, vegetables, low-calorie carbonated beverages and water. This process evaluation investigated the reach, effectiveness, implementation, and maintenance of the SHELf interventions. RE-AIM provided a conceptual framework to examine the processes underlying the impact of the interventions using data from participant surveys and objective sales data collected at baseline, post-intervention (3 months) and 6-months post-intervention. Fisher’s exact, χ 2 and t-tests assessed differences in quantitative survey responses among groups. Adjusted linear regression examined the impact of self-reported intervention dose on food purchasing and consumption outcomes. Thematic analysis identified key themes within qualitative survey responses. Reach of the SHELf interventions to disadvantaged groups, and beyond study participants themselves, was moderate. Just over one-third of intervention participants indicated that the interventions were effective in changing the way they bought, cooked or consumed food (p

Summary Background & aims This study assessed the effects of administering a lipid emulsion containing eicosapentaenoic and docosahexaenoic acid before and after open-heart surgery on cytokine production and length of hospital stay in infants. Methods Thirty-two infants (40 ± 2.3 weeks gestational age; 10.6 days at time of surgery) undergoing open-heart surgery with cardiopulmonary bypass were randomized to receive an intravenous lipid emulsion with (treatment) or without (control) eicosapentaenoic and docosahexaenoic acid in this prospective, randomized, double-blind, controlled trial. Results Mean plasma TNF-α concentration was significantly (p = 0.003) lower in the treatment (5.9 pg/mL) compared to the control group (14.8 pg/mL). In infants without sepsis, plasma TNF-α did not differ according to treatment, however when sepsis developed, mean plasma TNF-α was 21.1 pg/mL and 1.5 pg/mL (p = 0.0007) in control and treatment groups, respectively. Plasma TNF-α was positively correlated with length of hospital stay in the control group (p = 0.01), and negatively correlated with length of stay in the treatment group (p = 0.004), with a significant time by treatment interaction (p = 0.02). Conclusions Providing a lipid emulsion containing eicosapentaenoic and docosahexaenoic acid reduces TNF-α concentrations in infants undergoing open-heart surgery. Lipid emulsions containing eicosapentaenoic and docosahexaenoic acid may ameliorate the inflammatory response among critically ill infants. This trial was registered at clinicaltrials.gov as NCT00336908.

Background Sugar-sweetened beverage consumption is associated with morbidity and mortality. The retail food environment influences food and beverage purchasing and consumption. This study assesses the impact of a community pharmacy’s removal of sweet beverages on overall community sales of carbonated soft drinks (CSD) in a rural setting. We also examined whether the pharmacy intervention affected CSD sales in the town’s other food stores. Methods Weekly CSD sales data were acquired from the three food retailers in the town of Baddeck, Nova Scotia (January 1, 2013 to May 8, 2015, n = 123 weeks). Autoregressive integrated moving average (ARIMA) analysis was used to analyse the interrupted time series data and estimate the impact of the pharmacy intervention (September 11, 2014) on overall CSD sales at the community level. Data were analysed in 2015. Results Before the intervention, the pharmacy accounted for approximately 6 % of CSD sales in the community. After the intervention, declines in total weekly average community CSD sales were not statistically significantly. CSD sales at the other food stores did not increase after the pharmacy intervention. Conclusions This study was among the first to examine the impact of a restrictive retail food environment intervention, and found a non-significant decline in CSD sales at the community level. It is the first study to examine a retail food environment intervention in a community pharmacy. Pharmacies may have an important role to play in creating healthy retail food environments.

OBJECTIVES: The field of retail food environments research is relatively new in Canada. The objective of this scoping review is to provide an overview of retail food environments research conducted before July 2015 in Canada. Specifically, this review describes research foci and key findings, identifies knowledge gaps and suggests future directions for research. METHODS: A search of published literature concerning Canadian investigations of retail food environment settings (food stores, restaurants) was conducted in July 2015 using PubMed, Web of Science, Scopus, PsychInfo and ERIC. Studies published in English that reported qualitative or quantitative data on any aspect of the retail food environment were included, as were conceptual papers and commentaries. SYNTHESIS: Eighty-eight studies were included in this review and suggest that the field of retail food environments research is rapidly expanding in Canada. While only 1 paper was published before 2005, 66 papers were published between 2010 and 2015. Canadian food environments research typically assessed either the socio-economic patterning of food environments ( n = 28) or associations between retail food environments and diet, anthropometric or health outcomes ( n = 33). Other papers profiled methodological research, qualitative studies, intervention research and critical commentaries ( n = 27). Key gaps in the current literature include measurement inconsistency among studies and a lack of longitudinal and intervention studies. CONCLUSION: Retail food environments are a growing topic of research, policy and program development in Canada. Consistent methods (where appropriate), longitudinal and intervention research, and close partnerships between researchers and key stakeholders would greatly advance the field of retail food environments research in Canada.

Publicly funded recreation and sports facilities provide children with access to affordable physical activities, although they often have unhealthy food environments that may increase child obesity risk. This study evaluated the impact of a capacity-building intervention (Healthy Food and Beverage Sales; HFBS) on organizational capacity for providing healthy food environments, health of vending machine products, and food policy development in recreation and sport facilities in British Columbia, Canada.Twenty-one HFBS communities received training, resources, and technical support to improve their food environment over 8 months in 2009-2010, whereas 23 comparison communities did not. Communities self-reported organizational capacity, food policies, and audited vending machine products at baseline and follow-up. Repeated-measures analysis of variance evaluated intervention impact.Intervention and comparison communities reported higher organizational capacity at follow-up; however, improvements were greater in HFBS communities (p0.001). Healthy vending products increased from 11% to 15% (p0.05), whereas unhealthy products declined from 56% to 46% (p0.05) in HFBS communities, with no changes in comparison communities. At baseline 10% of HFBS communities reported having a healthy food policy, whereas 48% reported one at follow-up. No comparison communities had food policies.This is the first large, controlled study to examine the impact of an intervention to improve recreation and sport facility food environments. HFBS communities increased their self-rated capacity to provide healthy foods, healthy vending product offerings, and food policies to a greater extent than comparison communities. Recreation and sport settings are a priority setting for supporting healthy dietary behaviors among children.

Background Few children meet physical activity (PA) recommendations, and are therefore at increased risk for overweight/obesity and adverse health outcomes. To increase children’s opportunities for PA, several Canadian provinces have adopted school-based daily PA (DPA) policies. It is not clear why some jurisdictions have adopted DPA policies, and others have not, nor whether these policies have been implemented and have achieved their intended outcomes. The purpose of this study was to understand the processes underlying adoption and diffusion of Canadian DPA policies, and to review evidence regarding their implementation and impact. Methods We adopted a multiple case history methodology in which we traced the chronological trajectory of DPA policies among Canadian provinces by compiling timelines detailing key historical events that preceded policy adoption. Publicly available documents posted on the internet were reviewed to characterize adopter innovativeness, describe the content of their DPA policies, and explore the context surrounding policy adoption. Diffusion of Innovations theory provided a conceptual framework for the analyses. A systematic literature search identified studies that had investigated adoption, diffusion, implementation or impact of Canadian DPA policies. Results Five of Canada’s 13 provinces and territories (38.5%) have DPA policies. Although the underlying objectives of the policies are similar, there are clear differences among them and in their various policy trajectories. Adoption and diffusion of DPA policies were structured by the characteristics and capacities of adopters, the nature of their policies, and contextual factors. Limited data suggests implementation of DPA policies was moderate but inconsistent and that Canadian DPA policies have had little to no impact on school-aged children’s PA levels or BMI. Conclusions This study detailed the history and current status of Canadian DPA policies, highlighting the conditional nature of policy adoption and diffusion, and describing policy and adopter characteristics and political contexts that shaped policy trajectories. An understanding of the conditions associated with successful policy adoption and diffusion can help identify receptive contexts in which to pioneer novel legislative initiatives to increase PA among children. By reviewing evidence regarding policy implementation and impact, this study can also inform amendments to existing, and development of future PA policies. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1669-6) contains supplementary material, which is available to authorized users.

Despite their wellness mandate, many publicly funded recreational facilities offer primarily unhealthy foods. Governments have developed programs and resources to assist facilities to improve their food offerings, however the challenge to incent preferential sale of healthier foods remains substantial. In the Canadian province of Alberta, uptake of government-issued voluntary nutrition guidelines for recreational facilities has been limited, and offers of free assistance to implement them as part of a research study were not embraced. Financial constraints appear to be the most important barrier to offering healthier items in Alberta's recreational facilities, as facility and food service managers perceive that selling healthier foods is unprofitable and might jeopardize sponsorship agreements. Mandatory government regulation may therefore be required to overcome the barriers to offering healthier foods in this setting. The advantages of a regulatory approach appear to outweigh any disadvantages, with benefits for population health, more effective use of public funds, and greater equity for the public and industry. Adverse effects on corporate profitability and freedom of choice are expected to be limited. Regulation may offer an efficient, effective and equitable means of ensuring that recreational facilities support child health and do not undermine it by exposing children to unhealthy food environments.

ObjectiveTo assess agreement among three nutrient profiling systems used to evaluate the healthfulness of vending machine products in recreation and sport settings in three Canadian provinces. We also assessed whether the nutritional profile of vending machine items in recreation and sport facilities that were adhering to nutrition guidelines (implementers) was superior to that of facilities that were not (non-implementers).DesignTrained research assistants audited the contents of vending machines. Three provincial nutrient profiling systems were used to classify items into each province’s most, moderately and least healthy categories. Agreement among systems was assessed using weightedκstatistics. ANOVA assessed whether the average nutritional profile of vending machine items differed according to province and guideline implementation status.SettingEighteen recreation and sport facilities in three Canadian provinces. One-half of facilities were implementing nutrition guidelines.SubjectsSnacks (n531) and beverages (n618) within thirty-six vending machines were audited.ResultsOverall, the systems agreed that the majority of items belonged within their respective least healthy categories (66–69 %) and that few belonged within their most healthy categories (14–22 %). Agreement among profiling systems was moderate to good, withκwvalues ranging from 0·49 to 0·69. Implementers offered fewer of the least healthy items (PConclusionsThe policy outcomes of the three systems are likely to be similar, suggesting there may be scope to harmonize nutrient profiling systems at a national level to avoid unnecessary duplication and support food reformulation by industry.