Evidence on the determinants of dietary patterns, nutrition and physical activity, and the interventions to maintain or to modify them:

A systematic review

Submitted by the International Food Policy Research Institute to the World Cancer Research Fund

by Corinna Hawkes Abay Asfaw Adrian Bauman Fiona Bull Cara Eckhardt Jef Leroy Marika Smith

July 31, 2006

Summary
This report presents the evidence on the determinants of dietary patterns, consumption of foods and contaminants, key diet-related health risks, and physical activity, as they relate to cancer, and the evidence on the effectiveness of interventions to maintain or modify them. The evidence presented in this report was obtained through a systematic review of the literature. To identify the evidence, a range of databases were searched. The articles retrieved were scanned, sorted and selected for inclusion in this review based on a series of criteria. This report, which is global in scope, comprises three parts and five chapters. Part A reviews the evidence on the determinants of dietary patterns, food consumption and dietrelated health risks. It is divided into two chapters. Chapter One reviews the environmental, economic and political determinants, and Chapter Two, the socioeconomic and cultural determinants. Part B reviews the evidence of the effectiveness of interventions concerning diet, and is likewise divided into two chapters. Chapter Three reviews the effectiveness of interventions for dietary prevention of cancer in North America, Australia/New Zealand, and Europe. Chapter Four reviews the effectiveness of interventions for diet and diet-related health risks in the rest of the world. Part C reviews the evidence of the determinants and interventions for physical activity. Both of these components are included in Chapter Five. This summary presents the conclusions for each Part. Part A: Determinants of diet The environmental, economic and political determinants reviewed were the natural environment, agriculture, globalization, food retailing, food advertising and promotion, and food price. This attempt to systematically review, in one report, such distal, upstream determinants of diets is unprecedented. The distal nature of the determinants introduced many methodological challenges into the review, not least the lack of literature measuring associations. To make the most of a complex and challenging body of literature, the review examined the impact of these determinants on dietary indicators, dietary precursors and/or dietary outcomes. Since the evidence base varied considerably between the different determinants, each produced different types of conclusions. On the natural environment, there is little evidence on if and how the environment determines diet. The review did find evidence that factors in the natural environment are determinants of the consumption of two contaminants associated with cancer: arsenic and aflatoxins. Agricultural production practices are also determinants of arsenic and aflatoxin contamination. On agriculture, the review succeeded in identifying some key agricultural issues relevant to cancer prevention: a series of agricultural production practices (crop

fertilisation practices, livestock feeding practices, crop breeding and diversity of cropping system), and agricultural policies that create incentives or disincentives to the production and marketing of foods associated with cancer. Agricultural production practices are potential determinants because they affect food nutrient quality (and contamination). Research in this area has focused on the nutrient quality of fruits, vegetables, meat and staple crops. Agricultural policies are potential determinants because they affect food availability and price. Evidence from different geographical regions suggests that in some contexts, agricultural policy influences dietary outcomes. But overall, evidence is either is conflicting or not available to confirm if and how these practices and policies are actually associated with dietary outcomes. Still, the evidence base is growing, and given their position at the base of the food supply chain, these agricultural practices and policies warrant closer attention from public health policymakers. On globalization, it was widely reported that globalization policies and processes are playing an important role in the development of dietary patterns linked with the increasing prevalence of chronic diseases, such as cancer, in the developing world. The growth of transnational food companies (including supermarkets), trade liberalisation and global food advertising and promotion, were the most widely implicated determinants. Recent analysis shows that it is possible to link specific globalization policies and processes to changes in food availability and price, but no studies measuring associations nor cause and effect are available to confirm these findings. More policy-oriented research on the link between globalization policies and processes and diet would help inform the debate around the merits and problems of globalization from a chronic disease perspective. For food retailing, the evidence reviewed allowed one probable conclusion to be drawn: socio-economically disadvantaged groups in the United States have less access to supermarkets relative to more advantaged groups, and less access to supermarkets is associated with lower quality diets. The nature of the evidence base prevents this conclusion from being applied to other parts of the world. More evidence is needed to determine if this association is the result of cause or effect. The most conclusive evidence can be drawn about food advertising and promotion. Existing systematic reviews conclude that food promotion can have and is having an effect on children, particularly in the areas of food preferences, purchase behaviour and consumption. These effects are significant, independent of other influences and operate at both brand and category level. Among many factors, therefore, food advertising and promotion influences the preferences and purchase requests of children, influences consumption at least in the short term, is a likely contributor to less healthful diets, and may contribute to negative diet-related health outcomes and risks among children and youth. The actual effect of food promotion relative to other factors influencing the consumption of these foods remains unclear. The evidence base on price is made up almost exclusively of economic studies of price elasticities. It is difficult to draw conclusions from this literature

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because variations in price elasticities often reflect differences between the models used to estimate them, rather than actual differences in consumer responses to price. But the number of studies included in the review did allow some conclusions to be drawn. First, while consumers are often not very responsive to changes in food prices, there is convincing evidence that they are more sensitive to changes in the prices of meat, eggs and milk, fish and fruits relative to other food groups. In most cases, consumers are more sensitive to the price of fruit than vegetables. Second, there is convincing evidence that low income consumers are more sensitive to the price of meat, eggs and milk, fish, fruits and vegetables than higher income consumers. Also, consumers in lower income countries tend to be more price sensitive to all foods than consumers in higher income countries. Third, if the price of a particular food changes, consumers are generally more likely to respond by changing consumption of that food rather than compensating by changing consumption of another food (since cross-price elasticities are generally lower than own-price elasticities). The socio-economic and cultural determinants reviewed were income, socioeconomic status, poverty and food insecurity, employment and occupational status, education, race and ethnicity, urban/rural residence, household size and composition, marital status, religion, neighbourhood and family. This review made a particular effort to cover developing countries. Nevertheless, most of the evidence on the socio-economic and cultural determinants of diet came from developed countries. Poor study design led to many of the papers being excluded, and was very limited on fruits and vegetables for all countries. The evidence base does allow probable conclusions to be drawn about red and processed meat consumption. The evidence suggests that there is a moderate positive association between income and dietary intake of red and processed meat in developed countries, but there is a moderate negative association with education. The conclusion for education is supported by the results of household expenditure studies, but for income, the results of household expenditure studies indicate that as income increases the quality of red meat consumption increases, not quantity. This difference could be explained by changes in intrahousehold allocation. There is also probable evidence that in the United States, blacks and Hispanics consume more red and processed meat (independent of income or education) than whites, and consume fewer vegetables. Limited evidence in developing countries suggests that urban living is associated with higher red meat and vegetable intakes. This was not found for developed countries. Limited evidence also suggests that the meat and vegetable intake among ethnic groups from developing countries is likely to be different if they are born in a developed country (more red meat, less vegetables). For obesity, low socio-economic status is associated with higher levels of obesity in developed countries. In developing countries, an inverse association is found in the poorest countries, but as the level of obesity increases, the burden of obesity shifts to groups of lower socio-economic status.

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Part B. Dietary interventions The first review of interventions (which was covered by a research team independent of the rest of this review) examined the effects of programmes and interventions promoting dietary changes believed to prevent cancer in North America, Europe and Australia and New Zealand. It is the first known systematic review of dietary interventions which focuses on groups, communities and populations (the review does not cover obesity). The great variety in study design, target population, types of intervention activities and outcome measurement tools made the evaluation of effectiveness a difficult process. In view of the complexity of most study designs, it was not possible to draw firm conclusions about the effectiveness of individual intervention components. But certain common intervention activities could be classified as more successful than others. These included the use of printed materials, events such as health fairs and contests, cafeteria point-of-purchase displays, and mass media approaches. The review found that evidence of effectiveness was strongest for the interventions intended to increase fruit and vegetable consumption. It also found that dietary strategies among socio-economically deprived groups in supportive settings can contribute to strategies addressing health inequalities. Resourceintensive modes of intervention, such as detailed advice in healthcare settings are appropriate for high-risk individuals, but not the general, healthy population. Implementing organisational, environmental and policy changes in addition to intervention activities in worksites and communities contributed to effectiveness, as did longer duration (interventions which lasted for more than one year). Valuable dietary changes were measured in the relatively short term in the studies reviewed, but there was inadequate evidence of how these may be sustained over the long-term given the multiple influences on food consumption behaviour in developed societies. Inadequate evaluation of population-based interventions also prevented further conclusions from being drawn about their effectiveness. The review concluded that population and community programmes have the potential to make a major contribution to diet-related cancer prevention. The second review of interventions concerned diet and obesity in the rest of the world (i.e., developing countries plus high-income countries outside of North American, Europe and Australia and New Zealand). It is also the first review of its kind since it focuses explicitly on the developing world. The review found that there is a paucity of well-designed and evaluated interventions geared toward improving diet with the overt goal of preventing chronic disease in developing countries. It was thus not possible to draw any convincing conclusions regarding interventions to address diet in the context of cancer in developing countries.

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That said, several key conclusions can thus be drawn from this review. The review found that interventions have had some success in increasing fruit and vegetable consumption in developing countries. Further, interventions carried out in China, Chile, Israel, Japan, Mauritius, Pakistan, Turkey and Singapore all showed a degree of success improving diets or nutritional knowledge, and reducing obesity. Efforts to increase production and consumption of fruits and vegetables through home gardens and nutrition education have been quite successful among poor communities with high rates of micronutrient deficiency. These types of successful programmes could be redesigned and expanded to reach the less poor, the urban, and other populations at higher risk for cancers. As such, these interventions may represent the option with the highest potential for reducing cancer risk through diet in developing countries. Virtually all of the interventions reviewed incorporated education components to successful effect. The ways in which the education was provided varied and included individual or group counselling, cooking demonstrations, demonstration gardens, and other strategies. Overall, the education component appeared essential for maximizing the effect. While a positive finding, the focus on education reflects the fact that many of the interventions were implemented at the individual level, and that more environmentally based strategies lack evaluation. This review identified some positive trends with regard to ongoing and future interventions. Although many of the interventions reviewed were implemented at the individual level, many were actually community-based. Of the 17 interventions evaluated and reviewed, 2 were individual-level interventions, 12 were community-level, and two were population-level. Many up-and-coming interventions are also underway and are taking population or community-wide approaches. This indicates a growing trend towards national attention to dietrelated chronic diseases and a growing motivation to institute broad policies to counter rising levels of risk. This context of raised awareness and motivation should provide researchers with the opportunity to design and evaluated a broad range of interventions in the near future so that more concrete conclusions can be drawn about what approaches are the most effective among developing country populations. The limitations of the studies reviewed indicate what is needed for future evaluations. Few interventions in any of the categories were randomized and control groups were often not included in the design. Many studies did not include baseline measures, another important component for measuring impact. The interventions targeting target overweight or obese subjects at the individuallevel do not provide information on obesity prevention or which can be expanded to the population level. Community- and population-level interventions were often designed to incorporate multiple approaches to address multiple disease risk factors, making it difficult to quantify the independent effects of the various intervention strategies.

Part C. Physical activity The review of physical activity reviewed existing reviews of physical activity determinants (defined as correlates of associations) and interventions worldwide. It is the first time in at least ten years that a review using systematic methods has covered the literature on both correlates and interventions, and for both adults and children. In this past ten years, the evidence base has grown dramatically. Unlike most other reviews, the review also makes a concerted effort to take on board the broader, more distal environmental correlates and interventions literature. The review on correlates found that the most important correlates of physical activity were intra-individual factors, such as age, gender and educational attainment, as well as cognitive variables such as self-efficacy. Other important theoretical intrapersonal variables included measures of motivational readiness to be active and inter-personal variables such as social support. The review also found that there were consistent associations between aspects of the physical environment, especially urban form attributes of walkable environments that were related to physical activity in adults and children. More specifically, among adults, there are consistent demographic factors associated with physical activity in populations. These include age and gender, with most leisure-time physical activity measures showing lower prevalence among women and older adults, compared to men and young adults. In addition, some socio-economic individual level attributes, especially educational attainment and income are positively related to leisure-time physical activity. The most consistent intrapersonal factor consistently associated with physical activity is self efficacy. On the other hand, obesity and tobacco use were reasonably consistently and inversely associated with physical activity. Among children and adolescents, consistent associations were noted for gender (males more active), and for age, with declines in physical activity through adolescence. Some intrapersonal perceptions, such as body image and self perceptions (inverse) and self-esteem (direct) are associated in some studies. Intention to be active and preferences are important in younger children, but not in adolescents. Previous physical activity and membership of community sports associations were associated with being active in adolescence. Depression and psychological distress, as well as increased sedentary pursuits are inversely related to physical activity among adolescents. At the social/cultural level, in adults, social support is associated with physical activity, particularly among older adults, women, and some minority populations. Cultural factors have some influence, but it is not consistent; for some groups, promoting dance or other active cultural expression is useful for promoting activity, but this is not universal. Among younger children, social influences are quite important. Consistently, parental and other adult role models are important, but this becomes less important among adolescents. Peer influences and teacher modelling of active behaviours is unrelated to youth physical activity.

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At the environment and policy level, for adults, environmental characteristics consistently associated with physical activity include urban density, mixed land use and street connectivity and destinations close by, which are elements of the walkability of a neighbourhood. In addition, aesthetic factors, safety (for older adults) and paths/ infrastructure appear important. Some of these are at the local level (street scale), whereas others are part of the larger urban environment. Children who are active report greater access to local facilities, paths and recreation opportunities than les active children. For younger children, parental transport and parental affluence are correlated with participation, especially in organised sport and recreation. Policies that promote physical activity are often linked to environmental changes. For example, policies that influence zoning ordinances, play equipment, transport policy and urban planning policies might contribute to active-friendly environments; however, these are theoretical, rather than based on much longitudinal data. Research on correlates has been carried out almost exclusively in developed countries. Understanding of the correlates of physical activity in developing countries is very limited, and no clear patterns are available. In order to develop strategies to influence physical activity, correlates and determinants research will need to be broadened to include these settings. Reviews of physical activity interventions were assessed across settings and population groups. Research efforts to promote physical activity are limited by imperfect measures, and small, non-generalisable study populations. Reviews often reach different conclusions, and attempts to standardise physical activity measurement, designs, and to encourage systematic reviews would help develop the evidence base further, and provide a platform for evidence-based population wide change. Still, this review did enable some conclusions to be drawn about interventions to promote physical activity. Overall, the most effective interventions to promote physical activity are community-wide interventions, specialised behaviour change programmes tailored to individual needs, and primary care advice to be more active. Comprehensive school based programmes are effective for children, but curriculum-based or physical education-based interventions are less effective. For children and youth, integrated school-based programmes are effective. These are comprehensive approaches, including information, environmental change, regulatory change (such as mandatory physical education) and encouraging out-of-school and family engagement in activity. An integrated approach is more effective that physical education classes or curriculum changes alone. There is very little evidence on what works to promote physical activity in young adults. For all age groups, interventions that emphasise social support, either through engagement of primary care providers, family or peers show positive outcomes on physical activity participation.

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For older adults, group programmes and primary care advice are effective interventions, but show short lived effects; home-based programmes appear not as effective, but the effects may persist for longer on physical activity adherence. There is limited evidence for walking interventions, although they may appeal and be achievable for elderly adults. Individual level interventions can be effective in influencing physical activity in the short term. Specialised behaviour change focused interventions are effective, including those that tailor interventions to individuals. Among older adults, primary care and general practice-based brief advice, and individually tailored interventions can produce positive and short term change in physical activity. There is limited evidence of the effectiveness of environmental interventions to promote physical activity, despite a large volume of cross-sectional association between the physical environment and physical activity levels. Some interventions areas, such as stair-use promotions, and increasing access to facilities are evidence based and appear effective. However, other aspects of environmental intervention seem best suited to integration into multi-strategy, well resourced community-wide interventions. The maintenance of facilities used for physical activities, and better transport systems with adequate cycling/walking infrastructure may be useful, especially in developing countries at risk of losing this infrastructure through development. The environment holds much promise, but evidence on effectiveness of intervention at this scale is lacking. Overall, limited evidence exists for worksite interventions, mass media campaigns alone, and primary care exercise referral programmes on physical activity outcomes. There is very little specific information on physical activity interventions from developing countries. Examples of good practice models can be used to describe quality programmes, but an evidence base for is lacking for promoting physical activity.

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Review Team
Project leader and lead author Corinna Hawkes PhD Research Fellow Food Consumption and Nutrition Division International Food Policy Research Institute Washington DC, USA Contact: c.hawkes@cgiar.org Responsibility: Overall coordinator and editor; environmental, economic and political determinants Research team Dr Abay Asfaw Post-Doctoral Research Fellow Food Consumption and Nutrition Division International Food Policy Research Institute Washington DC, USA Responsibility: Food price Dr Jef L. Leroy Post-Doctoral Research Fellow Nutrition and Health Research Center National Institute of Public Health Cuernavaca, Mexico Responsibility: Socio-economic and cultural determinants of diet Dr Fiona Bull CoDirector, National Centre for Physical Activity and Health Reader, Physical Activity & Health School of Sport and Exercise Sciences Loughborough University Loughborough United Kingdom Responsibility: Determinants (correlates) of physical activity Dr Cara Eckhardt Post-Doctoral Research Fellow Food Consumption and Nutrition Division International Food Policy Research Institute Washington DC, USA Responsibility: Dietary interventions in the rest of the world Ms. Marika C. Smith Research Assistant Department of Health Economics National Institute of Public Health Cuernavaca, Mexico Responsibility: Socio-economic and cultural determinants of diet Dr Adrian Bauman Sesqucentenary Professor, Behavioural Epidemiology and Health Promotion Director, Centre for Physical Activity & Health School of Public Health, University of Sydney Sydney, Australia Responsibility: Interventions for physical activity

Note that Chapter Three was authored by a group entirely independent of this review and so the authors are not listed here.

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Contents
Summary ...................................................................................................................... i Review Team ............................................................................................................. ix Introduction..................................................................................................................1

PART A: Dietary Determinants

Chapter 1 Environmental, Economic, and Political Determinants of Diet Food Consumption and Obesity: A Global Perspective........................................... 1-1 1.1 Scope, Structure, and Methodology................................................................... 1-1 1.1.1 Scope..................................................................................................... 1-1 1.1.2 Chapter structure................................................................................... 1-4 1.1.3 Methodology ......................................................................................... 1-5 1.2 Results: Agriculture and Environment............................................................... 1-9 1.2.1 Characterising and classifying the literature......................................... 1-9 1.2.2 Environment, agricultural production practices and food quality (contaminants).................................................................................... 1-13 1.2.3 Environment, agricultural production practices and food quality (nutrient quality)................................................................................. 1-17 1.2.4 Agricultural policy and food availability and price ............................ 1-25 1.2.5 Summary, discussion and conclusions................................................ 1-42 1.3 Results: Globalization...................................................................................... 1-46 1.3.1 Searching, characterising and classifying the literature...................... 1-46 1.3.2 Conceptual models of globalization as a dietary determinant ............ 1-48 1.3.3 Globalization policies and processes and dietary indicators............... 1-50 1.3.4 Linking globalization policies and processes to specific dietary indicators ................................................................................................58 1.3.5 Globalization policies and processes and dietary outcomes ............... 1-62 1.3.6 Summary, discussion and conclusions................................................ 1-65 1.4 Results: Food retailing ..................................................................................... 1-67 1.4.1 Searching, characterising and classifying the literature...................... 1-67 1.4.2 Food purchasing patterns in food retailers in developing countries ... 1-70 1.4.3 Food retail environment as a dietary indicator ................................... 1-70 1.4.4 Food retail environment and dietary precursor or outcomes .............. 1-73 1.4.5 Summary, discussion, and conclusions............................................... 1-85 1.5 Results: Food Advertising and Promotion....................................................... 1-87 1.5.1 Searching and classifying the literature .............................................. 1-87 1.5.2 Impact of food advertising promotion on childrens diets.................. 1-88 1.5.3 Summary, discussion and conclusions................................................ 1-91

1.6 Results: Food Price .......................................................................................... 1-91 1.6.1 Characterising and classifying the literature....................................... 1-91 1.6.2 Impact of food price on dietary precursors/intake (foods).................. 1-96 1.6.3 Impact of food price on dietary precursors/intake (nutrients) .......... 1-118 1.6.4 Impact of food price on diet-related health....................................... 1-124 1.6.5 Summary, discussion and conclusions.............................................. 1-127 1.7 Conclusions.................................................................................................... 1-131 Appendix 1.1. Conceptual framework of impact of food price and on food expenditure, body weight and diet-related health ................................................ 1-133 Appendix 1.2: Search record................................................................................ 1-135 Appendix 1.3: Summary of food retailing studies reviewed ............................... 1-139 Appendix 1.4: Summary of food price studies reviewed..................................... 1-153 Chapter 1 References ........................................................................................... 1-180 Chapter 2 Socio-economic and Cultural Determinants of Diet ....................................... 2-1 2.1 Scope and Methodology .................................................................................... 2-1 2.1.1 Scope..................................................................................................... 2-1 2.1.2 Methodology ......................................................................................... 2-2 2.2 Summary of results from the Brug and van Lenthe review ............................... 2-7 2.2.1 Determinants of fruit and vegetable intake in children......................... 2-7 2.2.2 Determinants of fruit and vegetable intake in adolescents ................... 2-7 2.2.3 Determinants of fruit and vegetable intake in adults ............................ 2-8 2.3 Results of the current review ............................................................................. 2-8 2.3.1 Description of the studies included....................................................... 2-8 2.3.2 Determinants of dietary intake............................................................ 2-34 2.3.3 Determinants of obesity ...................................................................... 2-46 2.4 Conclusions...................................................................................................... 2-47 Appendix 2.1: Search record.................................................................................. 2-51 Appendix 2.2: Summary of descriptive quantitative studies using direct measures of dietary intake reviewed...................................................................... 2-65 Appendix 2.3: Summary of descriptive quantitative studies using indirect measures of dietary intake reviewed...................................................................... 2-75

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Appendix 2.4: Summary of reviews on socio-economic and cultural determinants of obesity reviewed .................................................................................................... 2-81 Chapter 2 References ............................................................................................... 2-5

PART B: Dietary Interventions

Chapter 3 Effectiveness of Interventions for Dietary Prevention of Cancer in Australasia, Europe, and North America......................................................... 3-1 Chapter 4 Effectiveness of Interventions for Dietary Prevention of Cancer in the Rest of the World......................................................................................................... 4-1 4.1 Scope and Methodology .................................................................................... 4-1 4.1.1 Scope..................................................................................................... 4-1 4.1.2 Methodology ......................................................................................... 4-1 4.2 Results: Community-level interventions with the primary purpose of targeting specific foods, food groups or dietary constituents that have established links with cancer ....................................................................................................................... 4-4 4.2.1 Characterisation of the literature........................................................... 4-4 4.2.2 Interventions in the context of chronic disease prevention................... 4-5 4.2.3 Interventions in the context of micronutrient deficiencies ................... 4-8 4.2.4 Summary and conclusions .................................................................. 4-13 4.3 Results: Individual-level and community-level interventions explicitly targeting the prevention or reduction of overweight and obesity ......................... 4-15 4.3.1 Characterisation of the literature......................................................... 4-15 4.3.2 Interventions targeting children and adolescents................................ 4-15 4.3.3 Interventions targeting adults.............................................................. 4-18 4.3.4 Summary and conclusions .................................................................. 4-20 4.4 Individual-level, community-level, and population-based interventions with the goal of chronic disease prevention........................................................... 4-21 4.4.1 Characterisation of the literature......................................................... 4-21 4.4.2 Individual-level interventions ............................................................. 4-22 4.4.3 Community-level interventions .......................................................... 4-23 4.4.4 Population-level interventions ............................................................ 4-26 4.4.5 Summary and conclusions .................................................................. 4-28 4.5 Community-level interventions addressing the contamination of foods with aflatoxin ......................................................................................................... 4-29 4.5.1 Characterisation of the literature......................................................... 4-29 4.5.2 Interventions ....................................................................................... 4-30 4.5.3 Summary and conclusions .................................................................. 4-31

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4.6 Nutrition during early childhood and cancer risk ............................................ 4-31 4.6.1 Overview............................................................................................. 4-31 4.7 Conclusions...................................................................................................... 4-33 Appendix 4.1: Search record.................................................................................. 4-39 Appendix 4.2: Inclusion/exclusion criteria ............................................................ 4-43 Appendix 4.3. Summary of intervention and evaluations designs of studies reviewed ................................................................................................................. 4-45 Appendix 4.4: Summary of interventions identified through database search that did not meet the inclusion/exclusion criteria ............................................................... 4-55 Appendix 4.5: Examples of unpublished, unevaluated and up-and-coming interventions........................................................................................................... 4-65 Chapter 4 References ............................................................................................. 4-53

PART C: Physical Activity

Chapter 5 Physical Activity: Correlates and Interventions............................................. 5-1 5.1 Scope of the Report............................................................................................ 5-1 5.1.1 What is physical activity? ..................................................................... 5-1 5.1.2 Prevalence and trends in physical activity levels.................................. 5-3 5.1.3 Health benefits of physical activity....................................................... 5-4 5.2 Correlates of Physical Activity .......................................................................... 5-5 5.2.1 Introduction........................................................................................... 5-5 5.2.2 Methods................................................................................................. 5-5 5.2.3 Results................................................................................................... 5-8 5.2.4 Analysis................................................................................................. 5-8 5.2.3 Conclusions: correlates. 5-29 5.3 Interventions on Physical Activity................................................................... 5-33 5.3.1 Introduction......................................................................................... 5-33 5.3.2 Methods............................................................................................... 5-34 5.3.3 Results................................................................................................. 5-36 5.3.4 Conclusions: interventions.................................................................. 5-54 Appendix 5.1: Summary of included review papers on correlates of physical activity.............................................................................................. 5-59

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Appendix 5.2: Summary of coverage of potential correlates of physical activity by review adult populations ................................................................... 5-61 Appendix 5.3: Summary of coverage of potential correlates of physical activity by review older adult populations....................................................................... 5-63 Appendix 5.4: Summary of correlates for children and adolescents ..................... 5-65 Appendix 5.5: Review papers of intervention studies to increase physical activity.................................................................................................................... 5-67 Chapter 5 References ............................................................................................. 5-83

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Introduction
This report presents the evidence on the determinants of dietary patterns, consumption of foods and contaminants, key diet-related health risks, and physical activity, as they relate to cancer, and the evidence on the effectiveness of interventions to maintain or modify them. The evidence was obtained through a systematic review of the literature. The World Cancer Research Fund (WCRF) recently updated the scientific evidence on the associations between diet and cancer. The underlying objective of this review, which was commission by WCRF, is to inform the translation of this science into recommendations for policy actions needed to control and prevent diet-related cancers and their risk factors. The review provides a significant contribution to the evidence on which to base these recommendations by, firstly, reviewing the evidence on the environmental, economic, political, socio-economic and cultural determinants of diet and physical activity, and to some extent the personal determinants, and, secondly, reviewing the evidence from past interventions to promote healthy diets and physical activity at all scales. This report thus addresses four key questions: What is the evidence on the determinants of dietary patterns, consumption of foods and contaminants, and key diet-related health risks, as they relate to cancer? What is the evidence on the determinants of physical activity? What is the evidence on the effectiveness of dietary interventions? What is the evidence on the effectiveness of physical activity interventions?

Note that throughout this review, where the term diet is used, it refers generically to dietary patterns, consumption of foods and contaminants, and key diet-related health risks. This review is global in scope. It is structured to examine the determinants and interventions at a range of scales. The review on the determinants proceeds on the understanding that determinants operate at three broad levels: the environmental, economic and political (basic, distal determinants), the socio-economic and cultural (underlying determinants), and the personal (immediate determinants). It assumes that different environmental, economic or political circumstances create the conditions conducive (or not) to healthy diets and physical activity, but that these only ultimately affect diets through their interaction with peoples socio-economic and cultural circumstances and personal behaviour and psychology. This concept is depicted in the figure Conceptual Approach to Review of Determinants. Due to the need to focus on the determinants most amendable to policy recommendations, this review deals with the personal factors in a rather limited way. Personal factors are dealt with most extensively for in the physical activity review.

Conceptual Approach to Review of Determinants

Conceptual Approach to Review of Interventions

The interventions review is likewise carried out at a variety of levels (which equate to those in the determinants review): the population level, the community level and the individual level. This conceptual approach is depicted on the figure Conceptual Approach to Review of Interventions. In taking this approach, this report presents an unprecedented review of the literature. The (distal) environmental, economic and political determinants have never been reviewed together in this way using systematic methodologies. Nor has a review of socioeconomic and cultural determinants ever made such an effort to cover developing countries. This report also includes the first known systematic review of dietary interventions which focuses on groups, communities and populations (this component of the review was conducted by a separate study team). The review of diet and obesity interventions in the developing world is also the first review of its kind because of its focus on developing countries. On physical activity, this is the first time in at least ten years that a review using systematic methods has covered the literature on both correlates and interventions, and for both adults and children. In this past ten years, the evidence base has grown dramatically. Unlike most other reviews, the review also makes a concerted effort to take on board the broader, more distal environmental correlates and interventions literature. The review presented here review focuses on the risk factors associated with diet-related cancers, including physical activity. With regard to the foods of concern, it is important to note that the review was conducted before the final conclusions on the association between diet and cancer were made by WCRF in 2006. Thus the original basis of the foods selected here was the 1997 WCRF report Food, Nutrition and the Prevention of Cancer: a Global Perspective. These foods and dietary constituents are listed in the Table. Diet-related risks for cancer (here termed diet-related health risks) such as obesity were also included in all food-related reviews. To take account of the fact that evidence may have changed in the past ten years, efforts were made to keep track of the most recent evidence on the associations between diet and cancer as it was collected by WCRF. This led to some further risks being accounted for in this current review, but this varies between the different parts of the review since they were conducted at different times. For example, emerging evidence on the importance of processed meat led to its emphasis in the review of socio-economic and cultural determinants, while the new evidence on arsenic led to its inclusion in one review. Also, awareness that the latest WCRF approach was to focus on foods rather than nutrients led to a dominant focus on foods rather than nutrients. Note that this report excludes alcohol. Though significant effort was made initially to review the literature on alcohol, the complexity and lack of expertise within the research team precluded its inclusion in the end.

Foods, food groups and dietary constituents associated with cancer risk according to the WCRF Report Food, Nutrition and the Prevention of Cancer: a Global Perspective (1997) Association with Cancer Reduces Risk Dietary Constituents and Contaminants (highest level of evidence) Carotenoids (probable) Vitamin C (probable) Vitamin E (possible) Selenium (possible) Allium compounds (possible) Aflatoxin compounds (probable) Sugar (possible) Fat (possible) Cholesterol (probable) Salt (probable) Foods and Food Groups (highest level of evidence) Whole grain cereals (possible) Fruits and vegetables (especially green and cruciferous) (convincing)

Increases Risk

Meat (probable) Eggs (possible) Milk and dairy products (possible)

This report comprises three parts and five chapters. Part A reviews the evidence on the determinants of dietary patterns, food consumption and diet-related health risks. It is divided into two chapters. Chapter One reviews the environmental, economic and political determinants, and Chapter Two, the socio-economic and cultural determinants. Part B reviews the evidence of the effectiveness of interventions concerning diet, and is likewise divided into two chapters. Chapter Three reviews the effectiveness of interventions for dietary prevention of cancer in North America, Australia/New Zealand, and Europe (this report was written by another team of researchers so is not included here). Chapter Four reviews the effectiveness of interventions for diet and diet-related health risks in the rest of the world. Part C reviews the evidence of the determinants and interventions for physical activity. Both of these components are included in Chapter Five. References and appendices appear at the end of each chapter. Each chapter also draws conclusions. These conclusions are tentative and should be considered in that light.

PART A: Dietary Determinants

Chapter 1 Environmental, Economic, and Political Determinants of Diet Food Consumption and Obesity: A Global Perspective
Corinna Hawkes and Abay Asfaw International Food Policy Research Institute

1.1 Scope, Structure, and Methodology

1.1.1 Scope This aim of this chapter is to present a systematic review of the literature on the environmental, economic and political determinants of the consumption of foods and contaminants, and the diet-related health risks, associated with cancer. Environment, economics and politics are distal, upstream determinants of diet, characterised by their breadth of scale and encompassing a vast array of components. The first stage of this review was thus to define these determinants. To define these determinants, the review follows a food supply chain approach. Earlier conceptual work has characterised the food supply chain the passage of food from field to fork globally, nationally and locally as playing a critical role in the food we eat. According to Lang and Heasman (1), the twentieth century saw a food supply chain revolution (p.140) (still continuing today) which affected how food is grown, produced, sold, marketed and eaten, often as a result of globalization processes. For the purposes of this review, five components of this supply chain were conceptualised as dietary determinants (listed on Table 1.1): the natural environment agriculture globalization food retailing food advertising and promotion

These determinants are defined as processes, not actors e.g., food retailing, not food retailers. Still, it is implicit throughout this review that global and national actors, including the food industry, international organizations, and regional and national governments, play an important role in determining these processes. And in fact, orienting these determinants to encourage the consumption of diets associated with the prevention of cancer is likewise the responsibility of these large-scale political and economic actors.

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This review also includes a sixth determinant: food price. The different components of the food supply chain all affect food price; in turn, food prices are one of the key economic factors via which people decide what and how much to consume. Food price is thus a medium though which the other determinants affect diet. A conceptual framework of the relationship between food prices and dietary outcomes is presented in Appendix 1.1. The six identified determinants are quite different in nature to each other, and are thus each treated slightly differently in this systematic review. As a group, they are also quite different from the socio-economic and cultural determinants (reviewed in Chapter 2 and listed in Table 1.1). These differences arise from the nature of the evidence base. For the more distal determinants, it is methodological challenging to obtain evidence on associations, or cause and effect, between exposures and dietary outcomes. To paraphrase Marmot (2), the further upstream we go in search for causes, the less likely is there to be a measured association with dietary outcomes. (The actual quote is: The further upstream we go in search for causes, the less applicable is the randomized control trial.). As had been expected, this limitation emerged in the early phases of this systematic review. It became clear that dietary outcomes were rarely measured if at all in studies of the most distal determinants of the natural environment, agriculture and globalization. Studies of the more proximal determinants of food retailing, food advertising and promotion and food price, were more likely to include some measure of food consumption or dietary outcome, but even then, the number of studies on dietary intake was relatively small, and the study designs precluded conclusions being drawn about cause and effect. In contrast, there was a more substantive body of work on the association between the socio-economic and cultural determinants and dietary outcomes. This is a clear reflection of the nature of the determinants: examining distal, upstream factors usually requires measuring a factor in the environment outside of the household (e.g., the price of the food, the retailers situated in a neighbourhood, the agricultural systems that provide the food sold by the retailers etc) whereas it is possible to collect data on socio-economic and cultural factors within a household and combine them with data on consumption, diet or diet-related health in the same household. It is noteworthy that in the case where the environmental factor can also be measured in a household television food advertising there are more studies (and it is also noteworthy that there are very few studies on advertising and promotion not measurable within the household). In approaching this review, it was therefore necessary to make a decision from the outset about the scope of this chapter: whether to exclude the distal determinants for which research on associations or cause and effect is not available (as would normally be done in a systematic review) or to take a more inclusive approach. Given the perceived need to improve our understanding of the impact of more distal determinants on diet, it was

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decided to take a more inclusive approach, but one which reflected the differences in the evidence base. A hierarchical approach to the evidence base was therefore devised and adopted. This approach divides the dietary measures included in the studies of the determinants into a hierarchy: dietary indicators, dietary precursors, and dietary outcomes. For papers on the more distal determinants, the impact of the determinant on dietary indicators was examined (as already depicted in the Figure in the introduction to this report). These indicators are aggregate measures at the level of the food supply chain and are defined as: food availability, food accessibility, food quality (i.e., nutrient quality and degree of contamination), food price, and food desirability. Where the evidence is available, the impact of the more proximal determinants on dietary precursors and/or dietary outcomes was examined. Dietary precursors are measures that indicate what will be consumed but do not directly measure actual intake, body weight etc (these can also be termed indirect measures of dietary intake as they are in much of Chapter Two). They include measures such as food expenditure and food preferences, and are commonly (but not always) measured at the household level. Dietary outcomes are defined as measures of direct dietary intake or of diet-related health at the individual level. Table 1.1 maps this hierarchy of dietary measures. Depending on the nature of the literature, between one and three hierarchal levels were examined for each determinant. The table shows clearly that as the determinants become closer and closer to the consumer (e.g., food retailing relative to agriculture), more and more studies take measurements of dietary precursors and outcomes in households and individuals. It is assumed throughout that the highest quality studies are those which measure dietary outcomes at the individual level, and that studies which measure cause and effect between exposures and dietary outcomes are more powerful than those which measure associations. It is also recognized that studies which only examine dietary indicators would not normally be included in systematic reviews. But as already noted, the lack of substantive research on the more distal factors made reviewing these papers in full awareness of their limitations a first and essential step in understanding their role as dietary determinants. Owing to the nature of the literature, detailed descriptions of the studies are only included in the text and accompanying appendices when they examine dietary precursors and outcomes. Taking a global approach, this report thus reviews if and how each of these determinants affects dietary indicators, precursors and outcomes. It attempts to answer the question: Are the natural environment, agriculture, globalization, food retailing, food advertising and promotion, and food price determinants of diet, and if so, how do they affect diet?

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Table 1.1. Determinants, and the dietary indicators, precursors and outcomes associated with these determinants, included in this review (chapters 1 and 2)
Dietary measure Determinant category Determinant Dietary indicators in the food supply chain Food availability, quality (contaminants) Food availability, food quality (nutrient & contaminants), price Food availability, accessibility, price, desirability Food availability, accessibility, price, desirability _ Dietary precursors . _ _ Dietary outcomes in individuals _ _

Environmental, Natural environment economic & political Agriculture determinants (chapter 1) Globalization

Food retailing

Food expenditure

Dietary intake, dietrelated health

Food advertising & promotion Food price

Food preferences, food Food consumption purchasing behaviour, dietary intake, diet-related health Dietary intake, dietFood expenditure, related health household food consumption, per capita food availability Food expenditure, food purchasing, household food consumption As above Dietary intake

Socio-economic Income & cultural determinants (chapter 2) Socio-economic status, poverty & food insecurity Employment & occupational status Education Race & ethnicity Urban/rural residence Household size & composition Marital status Religion Neighbourhood Family

Dietary intake, obesity*

As above As above As above As above

Dietary intake Dietary intake Dietary intake Dietary intake Dietary intake Dietary intake Dietary intake Dietary intake Dietary intake

As above As above As above As above As above

* Owing to the methodology used in Chapter 2, the papers included on obesity only covered the relationship with socio-economic status; papers were not identified that addressed the other socio-economic and cultural determinants

1.1.2

Chapter structure

This chapter is structured as follows: first, the general methodology is set out for each of the environmental, economic and political determinants. For the reason given above that each determinant varies from another the methodology is reported determinant by determinant. The results of each determinant are then reported separately and sub-divided

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in different ways according to the nature of the evidence. Each results section starts with a characterisation of the literature which includes a rationale for the development of the inclusion and/or exclusion criteria for the determinant and for the way that the results are subsequently written up. Though the basic structure is the same, there are differences in the way each results section is organized. Tables listing the inclusion and/or exclusion criteria are included at the beginning of each results section rather than in the methodology section below (section 1.1.3). Each results section ends with a brief summary and conclusion. Throughout the text, tables and figures are used where they can help communicate information more easily, and the relevant appendices for each section are referenced in the specific sections. The core results sections are as follows: Agriculture and environment (section 1.2) Globalization (section 1.3) Food retailing (section 1.4) Food advertising and promotion (section 1.5) Food price (section 1.6)

The chapter ends with a section drawing conclusions from the review. 1.1.3 Methodology

1.1.3.1 Methods for environment and agriculture Databases. The literature was identified through a structured electronic database search of three databases: PubMed, ISI Web of Science, and CAB Direct. The grey literature was also searched (not systematically) for relevant papers and, where relevant, papers added in from reference lists of studies identified through the database search. All citations were uploaded into Reference Manager software. Search terms. For each determinant, a list of exposure and determinant terms were prepared, tested and refined several times until the most useful combinations were identified (i.e., the terms which identified the fullest range of the most relevant papers). The final search strings used within each database are listed in Appendix 1.2. It transpired during this process that using very broad terms was the most useful approach; though this generated an extremely large numbers of papers, most of which were irrelevant, it avoided the problem of narrower searches that potentially relevant papers and groups of papers were excluded. This is due to the relative disparate nature of the literature. Searches. The databases were searched in all languages for papers published onward from 1980 to the date of the particular search. Three sets of literature searches

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contributed to the agriculture and environment review. First, environment was searched in general using the search strings listed in Appendix 1.2. The terms used, derived through experimentation, aimed to identify literature on the impact of spatial variations and temporal change in the natural environment on indicators of dietary patterns. They did not aim to identify papers on the relationship per se between environment and food production (i.e., papers that did not consider the consumption implications), nor those which dealt with foods and contexts not associated with cancer. On the basis of this search, 353 articles were retrieved by the databases and were subjected to a title and abstract scan for content and relevancy. Somewhat surprisingly, this process revealed only two possible papers. Efforts to capture more literature using broader terms were unsuccessful. Thus the original intention of including environment as the first section of this review was changed, and the environment section combined with agriculture. Second, then, agriculture was searched using the search strings listed in Appendix 1.2. On the basis of this search, 3218 articles were retrieved by the databases and were subjected to a title and abstract scan for content and relevancy. Though a very large number of papers, extensive experimentation with search terms confirmed that this was the best approach since alternative, more targeted approaches had the result of excluding potentially relevant papers. Third, it was clear from an initial abstract scan that these two searches had inadequately identified papers on the two contaminants linked to cancer known to have environmental and agricultural sources: arsenic and aflatoxins. These were thus searched separately using the terms listed in Appendix 1.2, which yielded a total of 194 and 108 papers respectively. A summary of the literature selection process for environment and agriculture can be found in Tables 1.5 and 1.6. 1.1.3.2 Methods for globalization Databases. The literature was identified through a structured electronic database search of three databases: PubMed, ISI Web of Science, and CAB Direct. All citations were uploaded into Reference Manager software. Search terms. For each determinant, a list of exposure and determinant terms were prepared, tested and refined several times until the most useful combinations were identified (i.e., the terms which identified the fullest range of the most relevant papers). The final search strings used within each database are listed in Appendix 1.2. Searches. The databases were searched in all languages for papers published onward from 1980 to the date of the particular search. Three sets of literature searches contributed to the globalization review. First, globalization and related terms were
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searched using the search strings listed in Appendix 1.2. On the basis of this search, 174 articles were retrieved by the databases. The same search was carried out again in April 2006 to identify any papers published in the months extending back to the first search (October 2005). Second, using the search strings listed in Appendix 1.2, an additional search was conducted for international trade, a determinant originally intended to be included separately. On the basis of this search, 355 articles were retrieved by the databases. An initial title and abstract scan revealed that some of the papers were duplicates of those identified in the globalization search, and the vast majority of the others did not satisfy the inclusion criteria. Since the trade search provided so few additional papers and because international trade is an integral component of globalization it was thus decided to merge the trade and globalization searches. Third, after the first draft of the globalization review had been completed, it was noted that none of the identified papers measured the association between globalization and consumer food prices. Thus a third search was conducted in an attempt to identify additional papers on this subject using the search strings in Appendix 1.2. The search retrieved 258 papers. In total, when the searches were combined and duplicates accounted for, a total of 751 papers were retrieved and subject to a title and abstract scan. Papers were also added in from the re-run of the original globalization search. A summary of the literature selection process for environment and agriculture can be found in Table 1.11. 1.1.3.3 Methods for food retailing Databases. The literature was identified through a structured electronic database search of three databases: PubMed, ISI Web of Science, and CAB Direct. All citations were uploaded into Reference Manager software. Search terms. For each determinant, a list of exposure and determinant terms were prepared, tested and refined several times until the most useful combinations were identified (i.e., the terms which identified the fullest range of the most relevant papers). This process took particular account of attempts to identify papers from developing countries. The final search strings used within each database are listed in Appendix 1.2. Though search generated an extremely large numbers of papers, most of which were irrelevant, it avoided the problem of narrower searches that potentially relevant papers and groups of papers were excluded. Searches. Food retailing was searched using the search strings listed in Appendix 1.2. Searches were made for papers in all languages published onward from 1980 to the date of the particular search (November 2005). On the basis of this search, 1221 articles were retrieved by the databases. The same search was carried out again in June 2006 to

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identify any papers published in the months extending back to the first search. A summary of the literature selection process for environment and agriculture can be found in Table 1.14. 1.1.3.4 Methods for food advertising and promotion Unlike the other determinants, the literature on the impact of food advertising and promotion was not subject to a systematic search. This is because three high-quality systematic reviews of this literature have been carried out over the past four years. One of the reviews was published in 2006, and another was conducted in 2006 and is awaiting publication. The recent publication and high quality of these existing reviews meant that this section took the approach of reviewing the reviews. 1.1.3.5 Methods for food price Databases. The literature was identified through a structured electronic database search of three databases in the field of economics: Econlit, CAB Direct, and AgEcon. Experimentation revealed that databases of the economic literature were more useful in identifying the relevant studies (tests were carried out in PubMed but found not to be useful). Search terms. Two sets of search strings, listed in Appendix 1.2, were used to search the databases. The first set focused on identifying papers on the impact of food price on dietary precursors and dietary outcomes in general; the second set focused on identifying papers specifically on food price elasticities. Searches. Food price was searched using the search strings listed in Appendix 1.2. Searches were made for papers in all languages published onward from 1980 to the date of the particular search. On the basis of this search, 620 articles were retrieved by the databases. After the completion of these searches, some more targeted searches were made for papers from developing countries in Google Scholar, but no additional papers were identified through this process.

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1.2 Results: Agriculture and Environment

1.2.1 Characterising and classifying the literature 1.2.1.1 Characterisation of the literature Two related aspects of the literature on the environmental and agricultural determinants of diet influenced the review process. First, the natural environment and agriculture are very broad determinants and have the potential to affect diet through a large number of pathways: agriculture encompasses an enormous number of policies, processes and actors, and, combined with the natural environment, forms the base of the entire food supply chain. This made it necessary to identify the active agents and specific pathways through which each of these determinants affect diet. This process, in fact, proved just as important as identifying the results. It also became clear at the outset that many of the papers in this subject area are conceptual in nature, simply presenting arguments on how and why the determinants affect diet. These conceptual papers do not add empirical understanding but are helpful in identifying the specific pathways through which these determinants affect diet. These papers were therefore also considered for inclusion. For the natural environment search, it was anticipated that the search would identify papers on the relationship between spatial variations and temporal change in the natural environment and dietary patterns. But out of the 353 papers identified through the database search, just two could be considered for inclusion (both fundamentally conceptual papers on biodiversity). Papers on subjects such as the risks of climate change for the staple crop production, the relationship between environmental factors and the diets of animals, the impact of the human diet on the environment, and the impact of environmental factors on dietary contaminants (except for arsenic and aflatoxins) were considered irrelevant for the purposes of this review. Factors in the natural environment did emerge as critical in the separate review of arsenic and aflatoxins. In total, the arsenic database search identified 194 papers and the aflatoxins database search 108 papers. The environmental themes included in this review are listed in Table 1.2. In the agriculture search, the initial scan resulted in the exclusion of a large number of irrelevant papers. Many of the papers dealt with agriculture and nutrition in rural, developing country contexts, mainly with respect to agricultures contribution to calorie availability. Given the focus of this review on dietary patterns and foods associated with cancer, these papers were excluded. Other themes emerging from the literature were likewise excluded: papers on plant, crop, animal or microbial nutrition, on agricultural pests and pesticides, animal and environmental conservation, occupational health risks of farming, the influence of agriculture in prehistoric diets and the impact of diets on agriculture.

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None of the remaining papers presented the results of studies on the association or cause and effect between agricultural determinants and dietary outcomes (as already discussed in section 1.1.1, likely a reflection of the distal nature of agriculture as a dietary determinant in modern contexts). But two basic themes linking agriculture to dietary indicators did emerge from the abstract scan: the impact of agricultural production practices on food quality (nutrient quality and contamination)

the impact of agricultural policy on food availability and food price Under each general theme, different sub-themes emerged. These are listed in Table 1.2. Under the agricultural production practices theme, several different practices were identified as important, while under the agricultural policy theme, the literature focused on several geographical regions. The fact that there was coherence around particular practices and particular policies in particular regions strengthened the evidence base by allowing papers to be brought together and considered as a whole. Each sub-theme also tended to deal with specific foods or nutrients, so increasing their cohesiveness. Papers which focused on other practices or regions were excluded (provided they were not of high quality) because they did not benefit from being considered alongside a broader body of work. The literature falling under these themes were dealt with differently, according to the nature of the literature: In the case of environment, agricultural production practices and arsenic and aflatoxins, the database search revealed several existing review papers. Given that a systematic review of original papers was not possible in the time available for this review, the review papers, plus particularly relevant studies, were surveyed and summarised. Apart from general relevancy, they were subject to no particular inclusion or exclusion criteria (there is thus no table listing inclusion/exclusion criteria). In the case of agriculture production practices and food nutrient quality, there were several existing review papers as well as individual relevant papers. Many of these papers were conceptual in nature. These papers were thus subject to some general inclusion and exclusion criteria and summarised en masse. These inclusion and exclusion criteria are listed in Table 1.3. In the case of agricultural policy and dietary indicators, the literature consisted mainly of original studies that attempted some form of quantitative or qualitative impact analysis of agricultural policy on food availability and price. The quality of the impact analyses did not tend to be particularly high. These papers were thus subject to some general inclusion and exclusion criteria and brought together into a narrative flow. These inclusion and exclusion criteria are listed in Table 1.4.

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Table 1.2. Agriculture, environment and diet: categorization of themes emerging from the database search*
General theme Food/nutrient/contaminant /diet-related health outcome of concern General Arsenic Aflatoxins Arsenic

Determinant Environment

Sub-theme Biodiversity

Dietary indicator Food availability

Natural & human pollution Food quality (contamination) Climate & weather Agriculture Agricultural production practices Irrigation Food quality (contamination) Food quality (contamination) Food quality (contamination) Food nutrient quality Food nutrient quality Food nutrient quality Foods availability & nutrient quality Food availability & price Food availability & price

Multiple (e.g., cropping frequency) Fertilisation (organic vs. conventional production) Feed (livestock) Crop breed/variety Degree of agrobiodiversity Agricultural policy Central Europe and the former Soviet Union EUs Common Agricultural Policy

Aflatoxins Fruits & vegetables Fat quantity and quality Provitamin A carotenoid & other micronutrients General Meat, dairy, fruits and vegetables Dairy fats, vegetable fats, fruits & vegetables

Norways farm-foodFood availability & price Dairy products & dairy fat nutrition policy Agricultural subsidies in Food availability & price Dairy products, meat, obesity North America *Note: papers presenting the results of agriculture-based interventions to increase consumption of micronutrient-rich foods in resource-poor settings are not included here but in Chapter 4 on interventions.

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Table 1.3. Inclusion criteria for review of agricultural production practices and dietary indicators Study characteristic Focus Inclusion criteria - Studys main focus was conceptualizing or measuring the impact of crop fertilisation technique, livestock feed type, crop breed/variety, and degree of agrobiodiversity on food nutrient quality - At least one of the food or nutrients related to cancer as described in the introduction - No particular quality criteria beyond main focus Exclusion criteria - Studys main focus was undernutrition in the developing world

Foods

- Main concern of the paper was staple foods - For organic vs. conventional agriculture, reviews that were highly selective in their choice of papers - For crop breed, papers by authors which repeated what they had said in other papers

Quality

Table 1.4. Inclusion criteria for review of agricultural policy and dietary indicators Study characteristic Focus Inclusion criteria - Studys main focus was a qualitative or quantitative impact analysis of agricultural policy on availability and price of foods or diet-related health -At least one of the food or nutrients related to cancer as described in the introduction Eastern Europe and former Soviet Union, European Union, Norway, United States and Canada - No particular general quality criteria beyond main focus Exclusion criteria - Studys main focus was undernutrition in the developing world - Main concern of the paper was staple foods - Regions dealt with by only one paper

Foods

Geographical regions Quality

- Papers which just discussed the results of earlier published papers

1.2.1.2 Classification of the literature The literature selection process for the agriculture search is summarised in Table 1.5. Following a title and abstract review to exclude clearly irrelevant papers, 176 of the original 3218 articles from the basic agriculture search were requested in their full paper form for a second level of selection. These papers were examined in more detail for relevancy and for adherence to the inclusion criteria. Thirty seven of these articles met the inclusion criteria. A surprisingly large number of additional papers 23 were also identified either from the grey literature, reference lists of the identified papers, or from the authors own knowledge of the academic literature. These were added into the database, making a total of 60 papers. Twenty six were on agricultural production practices (3-28) and 34 were on agricultural policy (29-62).

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Table 1.5. Agriculture: Summary of the literature selection process Papers identified through initial database search Papers requested in full paper form for second-level review Papers obtained in time for potential inclusion in review Papers from second-level review that met inclusion/exclusion criteria and are included in the review Papers obtained through other means and included in the review Total papers included that met inclusion/exclusion criteria and are included in the review Sub-classification of these papers Agricultural production practices Agricultural policy 3,218 176 168 37 23 60 26 34

Table 1.6 summarises the results of the environment and arsenic and aflatoxins searches. Two papers were included from the environment search (63;64), and to summarise available knowledge on arsenic, nineteen papers were referenced (66-84), and one for aflatoxins (65).
Table 1.6. Environment, Arsenic and Aflatoxins: Summary of the Literature Selection Process Papers identified through initial database search for environment Papers selected for inclusion Papers identified through initial database search for arsenic Papers referred to in summary Papers identified through initial database search for aflatoxins Papers referred to in summary 353 2 194 19 108 1

1.2.2

Environment, agricultural production practices and food quality (contaminants)

1.2.2.1 Arsenic, environment, and agriculture Arsenic is an element found in the environment from natural and human sources. Nineteen papers are referred to selectively in the following summary to illustrate the impact of the environment, and also agriculture, on arsenic contamination. The papers revealed that drinking water is a major pathway of contamination from environment to humans. According to Chou and Rosa (66), drinking water is one of the most important sources of arsenic exposure and is linked with many cases of arsenic poisoning. Arsenic enters drinking water largely from water leaching through soil and rock naturally high in

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arsenic. It can also enter drinking water as a result of human activities, including those related to agriculture, such as drawdown through the use of groundwater for irrigation (67) and leaching from fertilizers containing arsenic, such as poultry litter (68) and phosphates (69). Food is another potential pathway of contamination, though outbreaks have rarely directly been traced to food (66). Papers identified three potential pathways through which food could become contaminated during agricultural production: the use of contaminated water as irrigation water on food crops (70); the use of pesticides containing arsenic (e.g., sodium arsenite) on horticultural crops (71); and the use of contaminated animal feed for livestock raised for human consumption (72). Worldwide, the most notable cases of arsenic contamination are in Asia: Bangladesh, India (West Bengal), and China (Shanxi Province and Taiwan). Several papers reported on the degree and extent of arsenic contamination of drinking water and the health affects in these areas (67;73-80). The papers concluded that there is a clear association between factors in the natural environment, drinking water contamination and human health outcomes. As described by Chou and De Rosa (66), in these areas, the soil naturally contains, high levels of arsenic which leaches into groundwater that is used for drinking water Arsenic is released into groundwater when the oxygen levels in the aquifer become low and iron and manganese oxyhydroxides that bind arsenic dissolve and release it into the surrounding water (p.383). Hossain (67) comprehensively reviewed arsenic contamination in Bangladesh in 2006, reporting that there is a strong correlation between the occurrence of arsenic and the surface geology and geomorphology [within Bangladesh] (p.4). Skin cancer has been reported in all these endemic regions (66). It can be said that, in poor communities where resources are lacking, there appears to be an association between environmental factors, arsenic concentration in drinking water and human health outcomes. The food-agriculture pathway is less clear. According to Chakraborti et al. (79) in 2002 while arsenic in drinking water is being highlighted, there have been almost no studies on how additional arsenic is introduced through the food chain (p.3). Recently published studies from endemic areas are attempting to fill this gap (as reviewed by Hossain (67)). Three papers identified examined arsenic concentration in rice. In a greenhouse experiment, Abdein et al. (72) studied the effects of arsenic contaminated irrigation water on the uptake of arsenic by the dominant rice species grown in Bangladesh. The study found the level of contamination of rice grain (i.e., the part consumed by humans) did not exceed recommended levels. The study did find high concentrations in rice straw, which is often fed to cattle, suggesting that there may also be a pathway of contamination from plants to animals to humans. In a pot experiment, Ghoshal et al. (81) examined the effect of arsenic contamination of the rice plant. The study found that arsenic accumulation and concentration significantly increased in the straw and roots of the plants grown in soil

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irrigated with arsenic-contaminated water (but not the grain). Meharg and Rahman (82) measured rice grain concentrations in several districts in Bangladesh, finding that two of the districts had high arsenic concentrations the highest recorded to date in the scientific literature. Three further papers examined arsenic concentration in locally produced vegetables and fish. Alam et al. (70) measured arsenic accumulation in vegetables frequently consumed by local communities around Samta village, Bangladesh. He found that arsenic did accumulate in local vegetables sufficiently to provide a significant additional source of arsenic in the diet, though the total amount was less than the recommended daily intake. Das et al. (83) measured the degree of arsenic accumulation in rice, vegetables and fish grown in several different areas of Bangladesh known to suffer from arsenic contamination. The study found that rice grain and fish were not contaminated above the food safety limit, though some selected vegetables did exceed the limit. Roychowdhury et al. (84) examined the arsenic concentration of several foods areas in West Bengal, India, finding that in arsenic-contaminated areas, mean arsenic concentrations in vegetables, cereals and spices were between four and seven times higher than control areas, although they did not specify whether this exceeded the recommended food safety limits. In conclusion, there is no clear association between irrigation, food contamination and arsenic intake, but in endemic areas, it appears that small amounts of arsenic accumulate in rice grains, much more so in the roots, and that some green leafy vegetables accumulate arsenic. In his review Hossain (67) concludes that two of the key unanswered questions on the determinants of arsenic contamination are whether the increased use of groundwater for irrigation purposes causes arsenic to be mobilized and enter groundwater, and whether there is an risk that arsenic in irrigation water will enter the food chain. 1.2.2.2 Aflatoxins, environment and agriculture Out of the 108 papers identified from the database search on aflatoxins, one was identified which presented a very comprehensive and recent (2004) review of the literature on the agroecological determinants of aflatoxin exposure. This paper was thus used as the basis for the summary provided here. Aflatoxin is a fungal metabolite which contaminates staple crops during production, harvest, and storage. Proliferation occurs predominantly in developing countries with hot and humid climates. Crops mainly affected are maize, groundnuts, rice and cassava, as well as tree nuts. The association with hot and humid climates stems from the fungal biology: aflatoxins are produced by certain types of fungi when the ambient temperature is between 24-35C and when the moisture content of the crops exceeds about 7%. While aflatoxin contamination does occur in developed countries, it is well controlled through a

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variety of methods that are not feasible in less developed countries where small-scale operations and subsistence farming are more common. Thus, aflatoxin contamination in many developing countries remains prevalent. Cardwell and Henry (65) review the agroecological determinants of aflatoxin exposure. They identify a series of generic environment and agricultural risk factors for exposure: climatic and edaphic factors, agricultural management systems, insect pest pressure, and food processing customs. Specific risk factors are identified as follows: Presence of toxigenic fungus in the soil Soil infertility Drought stress Striga, a parasitic weed Crop diseases, particularly vascular disease Insect damage Excessive heat during kernel development Delayed harvest Harvest and postharvest damage to kernel/grain Sanitation and management of harvested produce Dry down and moisture in storage Postharvest insect feeding

Cardwell and Henry note that in agro-ecosystems with one or more of the risks, crops are likely to contain aflatoxin, increasing the potential for human exposure. They then review the degree of exposure in three key agroecological zones: temperate zones, humid tropics, and mid-altitudes: Temperate Zones. In cool temperate zones, the risk of aflatoxin contamination of indigenous food supplies is very low since the fungus is less competitive in zones with lower temperatures and more available water. In warm zones of the United States, problems of aflatoxin contamination sporadically occur in maize, groundnut, and pistachio nut primarily in drought years. Humid Tropics. Aflatoxins are most prevalent in the humid tropics. Evidence from sub-Saharan Africa indicates that the degree of contamination varies considerably within this climatic zone. In the humid coastal savannas and forested areas, several studies indicate that contamination is low, possibly because adequate rainfall in these zones makes the crop less susceptible to invasion. In the savannah grassland areas, contamination is more common, though there is again variation between the different types of savannah. In the Southern Guinea Savannah, there is a nine-month rainy season, continuous

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maize planting is common, soil fertility levels are typically low, and pre- and postharvest insect pressure is high. Maize and groundnuts are also consumed frequently. Thus the risk of chronic dietary exposure to aflatoxin is high: aflatoxin-albumin blood levels in children in this zone have been measured as higher than other the agro-ecological zones. In the Northern Guinea Savannah, where cropping systems are more advanced, aflatoxin levels are lower. But where crop management systems are less developed, this zone is similar to the Southern Guinea Savannah in grain aflatoxin concentration. The Sudan Savannah, is another agroecological zone and has high temperatures and a short rainfall period. Growing conditions are often poor, with temperature and drought stress common, and postharvest storage often exposes the crop to humidity. Thus high toxin levels can be found in foods in this zone Mid-Altitudes. Agro-ecological zones 800 meters and more above sea level tend to have very low aflatoxin contamination as a result of a cooler climate and less stressful conditions during production and storage.

In conclusion, in parts of sub-Saharan Africa and other parts of the world with similar agro-ecologies in where there are limited food options, the chances for chronic dietary exposure to unsafe levels of aflatoxin are high. The degree of exposure varies with climatic and soil conditions and a range of different agricultural production practices.

1.2.3

Environment, agricultural production practices and food quality (nutrient quality)

Agricultural production practices that affect food nutrient quality can be categorized as follows (following Welch and Graham (25) and Goldman et al. (85)): Field site selection (e.g., soil type, climate) Crop fertilisation practices (e.g., use of conventional chemical fertiliser relative to organic) Livestock feeding practices (e.g., feeding livestock with grain or corn) Choice of crop/animal breed/variety (e.g., high yielding varieties bred though agricultural research) Diversity of cropping system (e.g., monocropping versus inclusion of many varieties) Postharvest handling (e.g., conditions of storage and distribution)

Twenty six papers were selected for this review that examined four of these factors in the context of human nutrition: crop fertilisation practices; livestock feeding practices; crop breed/variety; and diversity of cropping system.

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1.2.3.1 Crop fertilisation practices Agronomic research has examined how fertilisation practices affect plant yield and crop nutrient quality. The database search identified one aspect of this research relevant to this review: the comparison between the nutrient qualities of food produced by organic versus conventional practices (fertilisation practices are just one difference between organic and conventional agriculture, but this aspect was the most commonly assessed in the literature). The context of this research is the debate about whether organic foods are of higher nutritional quality relative to foods produced using conventional methods. There is a certain amount of rhetoric embedded in this debate. As noted by Magkos et al. (86) probably the greatest historical assertion of the organic movement is the ability of organic foods to cure cancer (p.358), an assertion that has been denied by the medical community, including WCRF. The database search originally identified seven reviews of the literature on the differences between organic and conventionally produced foods. Five were excluded because they did not actually review the core literature or were highly selective in the use of the literature. This left two review papers (87;88); a further four papers were added from the reference lists of these papers (6;15;27;28). One of these papers was a systematic review (i.e., it took the methodological quality of the original studies into account and had clear inclusion and exclusion criteria). It was published by the Soil Association a Britishbased non-governmental organization (NGO) concerned with promoting organic food and farming. Another of the reviews was also published by a special interest group. Since they were published by special interest groups with a clear mandate to promote organic food production, these two reviews are summarised separately, following the review of the four papers published by independent academics. The four papers were generally cautious in drawing conclusions. They emphasised above all that the existing evidence is very mixed but agreed that two clear conclusions could be drawn on nutrient quality differences: Organic leafy green vegetables and potatoes have a tendency to have a higher vitamin C content relative to conventional (reasonably consistent evidence) Organic leafy green vegetables have a tendency to have a lower nitrate content relative to conventional (strongest evidence) (a food safety rather than nutritional concern)

The papers did not present sufficient evidence, or did not agree that clear conclusions could be drawn on essential and non-essential micronutrients (including provitamin A carotenoid), secondary metabolites, nor for any other foods. Several quality issues need to be considered when evaluating this literature. First and foremost, the papers do not provide any indication of whether producing foods using

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organic relative to conventional methods actually affects human nutrition or diets (e.g., whether the availability of organic food makes any different to overall fruit and vegetable consumption, or whether consuming organic food is associated with higher intakes of bioavailable nutrients). The studies rarely measured any differences in the bioavailability of those nutrients between the foods produced through different production practices. Secondly, research papers are difficult to compare owing to differences in study design and quality that do not necessarily account for the many sources of potential variation in the nutrient content of a food not necessarily controlled for in the studies i.e., differences between the source of the compared foods (wide potential for error exists when foods are sourced in a supermarket, far less so when foods are grown specifically for the purpose of the study); the study variables (e.g., duration, sampling frame, nutritional analyses); plant breed (cultivar); production methods (e.g., soil, plant and harvest date); and farm location (e.g., climate, seasonal variation, storage conditions). Thus actual differences may be missed because these variations are not accounted for, or vice versa. Thirdly, though the four papers reviewed here presented comprehensive reviews of the literature, none of them used systematic techniques, so reducing the strength of their conclusions. The Soil Association attempted to take account of the differences in study design and quality by conducting a systematic review (15). Their report, published in 2001, starts out by noting that the lack of conclusiveness of past reviews. The one exception was the other paper published by a special interest group included here. Worthington (28) examined 1,230 individuals nutrient comparisons, finding that 56% showed higher nutrient levels in organically grown crops, whereas 37% favoured conventionally produced crops. Data average 10-20% in favour of organic, leading the author to conclude that there is more iron, magnesium, phosphorus, and vitamin C and less nitrates in organic crops as compared to conventional crops. The Soil Association believed that the lack of agreement between previous reviews, and their general lack of conclusiveness, stemmed from differences between the qualities of the reviewed studies, and thus that the evidence required re-examining. They therefore reviewed the literature based on a strict set of inclusion and exclusion criteria to ensure study validity (further details can be found in their report on pages 31-33). On the basis of these criteria, the review rejected over two-thirds of the 99 papers originally selected for review. From these remaining papers, the report concluded that (cited directly from page 4 of their report): On primary nutrients Vitamin C and dry matter contents are higher, on average, in organically grown crops. Mineral contents (e.g., calcium, magnesium, iron and chromium) are also higher, on average, in organically grown crops, although the small number and

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heterogeneous nature of the studies included mean that more research is needed to confirm this finding. On secondary nutrients Research is beginning to confirm the expectation that organic crops contain an increased range and volume of naturally occurring compounds known variously as secondary plant metabolites or phytonutrients. Further research is needed in this field.

The Soil Association also recently published a review of the evidence on organic milk (89). The review concluded that, on the basis of the differences between the diets of organic relative to conventional cows, the compounds in organic milk have a range of nutritional benefits, including cancer and disease prevention which they list as increased levels of vitamin E, carotenoids and omega 3 essential fatty acids. 1.2.3.2 Livestock feeding practices Four papers discussed the role of livestock feeding practices in the nutrient quality of meat (and made brief mention of fish) and its implication for obesity and diet-related chronic diseases (7;9;12;20). Uniting these papers was a concern that modern intensive animal husbandry practices were degrading meat nutrient quality, especially with regard to fat. In a review of the dietary and chronic disease implications of the development of modern agriculture in the United States, Cordain et al. (9) advance the idea that feeding corn (rather than grass) to cattle has led to increased saturated fat content and increase of n-6 fatty acids relative to n-3 fatty acids in beef. They argue that this tendency has been strengthened through the development of intensive feedlot operations in the United States. Ghebremeskel and Crawford (12) take up this line of argument. In a review paper, they present the hypothesis that breeding livestock (and fish) to encourage rapid weight gain, along with associated aspects of intensive livestock production such as feed type, has been accompanied by increased deposition of meat fat relative to protein, an increase of saturated fatty acids relative to polyunsaturated fatty acids, and naturally lower stores of vitamin A and beta-carotene. To support their argument, they compare the fat content of domestically bred livestock with wild animals. They report that pigs fed on a high energy diet produce pork chops with over 40% of energy from fat and a ratio of polyunsaturated to saturated fatty acids of only 0.2-1, relative 20% and a ratio of 2 in wild pigs. A more recent (unpublished) paper by the same research group follows up this work. Wang et al. (20) evaluate the changes in energy from fat, protein and fatty acid composition in poultry in the United Kingdom. The context is the increase of intensive

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poultry operations in the United Kingdom since the 1970s, when British medical authorities recommended increased poultry consumption (because of its low fat content). The study examined historical records for past data on fat content, and compared this with test results on meat samples obtained from several supermarkets and organic food suppliers. The results indicate that as of 2004, chicken had nearly 100 more calories and more than double calorie fat to protein ratio as compared to 1950. Since poultry consumption in the United Kingdom has increased more than 25 times between 1950 to 2000, they estimate that fat calories from chicken has increase over 40-fold. Thus eating the same weight of chicken today compared to 30 years ago involves eating 100 more calories and 3 to 8 times less the long chain omega 3 fatty acids. It was unclear whether the study design was rigorous enough to support this conclusion given potential problems in comparing data over time, and the sampling of the modern meat samples. The study did also not take account of increasing consumer preferences for leaner poultry cuts. A report published by the Union of Concerned Scientists (a US-based NGO concerned with applying science to solving environmental and social problems) in 2006 is the most comprehensive study on this issue. Clancy (7) reviewed and analysed all existing scientific literature in the English language that compares differences in fat content between grass-fed (i.e., raised on open pastures) and conventionally raised (i.e., corn-fed in intensive feedlots) dairy and beef cattle. The report examines four fats: total fat; saturated fat; the omega-3 fatty acids alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA); and conjugated linoleic acid (CLA). The resulting analysis found statistically significant differences in fat content between pasture-raised and conventional products. Specifically (citing directly from page 2 of the report): Steak and ground beef from grass-fed cattle are almost always lower in total fat than steak and ground beef from conventionally raised cattle. Steak from grass-fed cattle tends to have higher levels of the omega-3 fatty acid ALA. Steak from grass-fed cattle sometimes has higher levels of the omega-3 fatty acids EPA and DHA. Ground beef from grass-fed cattle usually has higher levels of CLA. Milk from pasture-raised cattle tends to have higher levels of ALA. Milk from pasture-raised cattle has consistently higher levels of CLA.

1.2.3.3 Choice of crop breed/variety The literature on crop breeding and diet is largely concerned with the role of breeding in increasing crop yield (and therefore calorie availability) in the context of undernutrition

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in the developing world. These papers were excluded. But the search did reveal 15 papers on the relationship between crop breeding and food nutrient quality that were in some way relevant to the cancer context (3-5;10;14;16;18;19;21-25;90;91). The two relevant themes were carotenoids in staple crops and the nutrient quality of fruits and vegetables. All these papers, bar one, were conceptual in nature (explaining the relatively large number). Most of the papers discuss crop breeding as an aspect of agricultural research, a term traditionally used to describe the appliance of science and technology to breed crops for higher yield. Before addressing the two themes, it is illustrative to gain a sense of how agricultural research has been conceptualized to affect nutrition in the context of undernutrition. Drawing on a wide body of earlier research, Pinstrup-Andersen (18) argues that agricultural research influences human nutrition by affecting (among other factors) the quality of diet composition and food nutrient quality. With regard to diet composition, he suggests that the decisions made about the commodities in which to invest agricultural research affects the incentives farmers have to produce them and their cost. He illustrates his point with the Green Revolution (i.e., the breeding and adoption of high-yielding cereal varieties in developing countries, mainly in South Asia, in the 1960s and 1970s). He credits the Green Revolution with significantly increasing rice and wheat production in these regions and, consequently, increasing energy availability and so reducing undernutrition. Yet at the same time, he notes that relatively speaking, production of pulses declined, and thus consumption of pulses fell, so changing diet quality. PinstrupAndersen suggests this took place because the adoption of high-yielding breeds and other technologies made rice and wheat more profitable to produce, whereas minimal technological changes were made in pulse production, largely because research resources were not invested in those crops (p.15). On this subject, Welch and Graham (23) go further, arguing that the problem with the Green Revolution was that since the main consideration was high yield, little thought was given to nutritional value and human health in the new cereal cultivars being bred (p.3). Pinstrup Andersen (18) also noted the challenge presented by the dual burden of underand over-nutrition for agricultural research. He used the example of livestock breeding, which he suggests has had the result of increasing the quantity of available meat and decreasing its price. This, he contends, has had the positive impact of providing more easily accessible protein and essential micronutrients to poor people, but has also made meat more affordable in larger quantities for everyone, thus facilitating excessive consumption and increasing the risk of obesity and diet-related diseases. (Two papers did discuss livestock breeding in the context of obesity and diet-related chronic diseases (12;20), and have already been reviewed under livestock feeding practices above).

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On the carotenoids theme, Pinstrup-Anderson (18), Welch and Graham (23), and others, propose that crop breeding can affect the nutritional quality of crops positively through deliberate intervention. A total of 14 papers (many of which contain similar arguments) argue that the process of deliberate biofortification (i.e., breeding food crops to increase their content of bioavailable micronutrients) has the potential to increase micronutrient intake in general, and carotenoids in particular, in resource-poor populations in developing countries (3-5;10;14;16;18;19;21-25;92;93). These arguments are as follows: It is scientifically possible substantially increase of carotenoid content in several staple crops. Foods naturally high in bioavailable carotenoids, such as fruits and vegetables, are unaffordable for the poor in developing countries. Since staple food are already consumed in large quantities by the malnourished poor, switching to biofortified varieties would not require major behavioural changes by food consumers or food producers. Relative to the standard approaches of food fortification and supplementation, breeding staple crops for enhanced carotenoid content has the potential to lead to sustainable, long-term adoption after the initial investment.

The papers emphasise that to assess its potential, the process of breeding carotenoids into crops needs to be evaluated in terms of its direct impact on human nutrition (i.e., rather than just assuming that increased availability will improve nutrition), especially from the perspective of bioavailability. Some evaluations are currently being undertaken (see Appendix 4.5, Chapter 4), but none has yet been published in the peer-reviewed literature. One paper identified in this review did attempt an empirical analysis of the nutritional impacts of crop breeding (though not concerning carotenoids). Weinberger (21) modelled the nutritional impacts of the introduction of high-yielding varieties of (naturally ironrich) mungbean in Pakistan. The author found that the adoption of higher-yielding mungbean varieties led to an increase of annual per capita availability from 453g to 739g between 1984 (the year of adoption) and 2000, with associated increase of total bioavailable iron of 1.1% between 1984 and 1995. However, a commentary following the article noted that the model was based on a large number of assumptions, which are unlikely to be true in reality (94). On the nutrient quality of fruits and vegetables theme, Davis et al. (10) examine nutrient content data for garden crops in the United States between 1950 and 1999. The study compared nutrient content data published by the United States Department of Agriculture (USDA) in 1950 and 1999 for 13 nutrients and water in 43 garden crops, mostly vegetables. (Note that the quality of this study has not been evaluated here and so the following results should be interpreted in that light.) After adjusting for differences in

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moisture content, they calculated ratios of nutrient contents, R (1999/1950), for each food and nutrient. To evaluate the foods as a group, the study calculated median and geometric mean R-values for the 13 nutrients and water. The results indicate that the 43 foods show apparent, statistically reliable declines (R < 1) for 6 nutrients (protein, Ca, P, Fe, riboflavin and ascorbic acid), but no statistically reliable changes for 7 other nutrients. Declines in the medians range from 6% for protein to 38% for riboflavin. When evaluated for individual foods and nutrients, R-values were usually not distinguishable from 1 with current data. The authors point out that this is consistent with the results of a study conducted by Mayer (95) in the United Kingdom which also showed marked reductions of the nutrient content of some fruits and vegetables between the 1930s and 1980s. Davis et al. (10) then hypothesise that decades of breeding vegetables and fruits for high yields has been the cause of these declines, with the resultant trade-off of reduced nutrient concentrations It is well-accepted in agricultural research they say, that selection for one resource-using function may take resources away from other resource-using functions (p.678). The authors support their assertion by documenting examples from a number of horticultural crops (e.g., tomatoes, broccoli) that choice of cultivar can have a significant influence on its nutrient quality, changes that are more significant than could have been caused by changes in soil type and fertilisation practices alone. 1.2.3.4 Diversity of plant and cropping systems Two papers identified in the environment review and one in the agriculture review identified biodiversity as a potentially important environment factor in promoting the availability of food variety, and high food nutrient quality. The two environmental papers present hypotheses linking biodiversity to healthy diets. Wahlqvist (64) proposes that biodiversity captures the spectrum of biologically active food components required for optimal health in an omnivorous species (p.59) and is the biological underpinning of the food variety needed for a healthy diet. Johns and Sthapit (96) likewise argue that biodiverse cropping systems that incorporate species often indigenous species rich in essential and non-essential micronutrients can provide benefits for human nutrition. They note that farming systems rich in agrobiodiversity tend to produce indigenous, neglected, and underutilized food crops and gathered foods rich in nutrient quality. Improving accessibility to this range of crops could, they argue, offer nutritional benefits to the rural and urban poor at risk for undernutrition and chronic diseases. One paper was identified which examine these linkages from an empirical perspective. Frei and Becker (11) examined the dietary implications of agrobiodiversity in an upland farming system in the Philippines. The study tested indigenous rice and vegetable varieties for nutrient quality, and questioned local people about their dietary practices.

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They found that the indigenous varieties produced in the agrobiodiverse system were rich in nutrients (especially beta-carotene) and that peoples regular diets incorporate many of these diverse crops. This diversity thus appeared to increase peoples micronutrient intake and the food security of local communities. The quality of this study has not been evaluated. The study did not actually measure the specific relationship between the consumption of the crops and nutritional outcomes. 1.2.4 Agricultural policy and food availability and price

Thirty four papers were included that assessed the role of agricultural policy as a dietary determinant, all set in the context of the consumption of foods or nutrients associated with diet-related chronic diseases. Some were explicitly set in the context of the growth of obesity. All examined the implications of agricultural policy for the dietary indicators of food availability or price. Most attempted some form of impact analysis, though some were purely conceptual in nature. In a conceptual paper, Nugent (47) categorises the types of agricultural policies relevant to the context of the global increased of diet-related chronic diseases. She defines three categories: input policies, production policies and trade policies and provides some examples of how they could affect diet via food availability (listed in Table 1.7). The remainder of the policy papers centre around four specific settings (below) and focus on the availability and price of specific foods or nutrients (see also Table 1.2): Centrally-planned agricultural policies in Eastern Europe and the former Soviet Union during the communist era, and their replacement by market-led policies during the subsequent transition; foods/nutrients of concern are meat, dairy, saturated fats, fruits and vegetables. Norways farm-food-nutrition policy developed and implemented during the 1970-80s.; foods/nutrients of concern are dairy products and dairy fats. The European Unions Common Agricultural Policy; foods/nutrients of concern are dairy fats, vegetable fats, fruits and vegetables. Agricultural subsidy programmes in North America. Food/nutrients of concern are mainly (not exclusively) dairy products and meat, along with obesity.
Types of policies Subsidies on irrigation, fertilisers and pesticides Investment in infrastructure (agricultural extension services, road building) Agricultural research Production policies Price support (i.e., agricultural subsidies) Meat production, and therefore availability, rises at a faster rate due to guaranteed prices Example of potential dietary impact Support for irrigation can encourage farmers to use water-intensive crops, such as sugar, and thus promote production and availability

Table 1.7. Agricultural policies with implications for diet change according to Nugent (47)
Category Input policies

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Direct payments Agricultural marketing reforms (e.g., dismantling of markets boards) Trade policies Import tariffs Export incentives Lower trade barriers for vegetable oils increases availability

Following Nugents (47) categorisation in Table 1.7, these policy papers mainly examine production policies, especially agricultural subsidies (Agricultural subsidies is a collective term for the financial assistance provided to farmers through governmentsponsored price-support programmes, including minimum price guarantees and export subsidies). Input and trade policies are referenced in some places more than others, but are largely treated as a secondary concern. Agricultural research, as an input policy affecting choice of crop breed, was included briefly in the above section on agricultural production practices (section 1.2.3.3). Trade policies are also included in the section on globalization (sections 1.3.3.2 and 1.3.4). 1.2.4.1 Agricultural policy in Eastern Europe and the former Soviet Union Thirteen papers refer in someway to the dietary impact of centrally-planned agricultural policies in Eastern Europe and the former Soviet Union during the communist era, and their replacement by market-led policies during the subsequent transition (33;37;38;42;48;49;53-55;59;97-99). Five of these papers were identified through the database search (33;38;53;55;59), and a further eight were added in from personal knowledge. Three of these added papers, on Poland, were interrelated and came from the medical literature (100-102) (the database search failed to identify these papers because agriculture was not referred to in the abstract or as a keyword, but the papers are oft-cited in the context of the role of agricultural policies in chronic disease prevention). A fourth addition was a background paper previously prepared on this subject for the World Health Organization Regional office for Europe by the lead author of this report (37). This background paper drew on a wider range of literature than that identified through the systematic literature review. The remaining four papers (42;48;49;54), which in someway discussed both production and consumption issues, were drawn from the reference list of this background paper. Some of the papers made only brief reference to the issues at hand; it was only by bringing the papers together that a picture began to emerge. Taken together, the identified papers indicate that the experience of Eastern Europe and the former Soviet Union provides a unique example of the apparent impact of a set of agricultural policies on dietary patterns, in particular with regard to red meat, dairy products, saturated animal fat, and, to a lesser extent, fruits and vegetables. Still, it is difficult to disentangle the impact of the agricultural polices relative to the other measures taken to dismantle the state economy during the transition era (e.g., the removal of consumer price subsidies, increased trade). In reality, all of these measures interacted

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to affect food availability and price, alongside changes in income. Below, the 13 papers are brought together into a narrative, to tease out some of the dynamics of agricultural policies in the context of other policy shifts, changes in food availability, prices and the consumption of meat, dairy product and fruits and vegetables. During the communist era, agriculture was an integral part of the centrally planned economy in Eastern Europe and the former Soviet Union. Food production, distribution, price and trade were generally organised in a nationalised system of state and collective farms and state monopolies. Both food production and food prices were heavily subsidised, particularly meat and dairy. (As well as being a direct intervention to make foods more affordable, food price subsidies were also implicitly an agricultural policy since they offset the price-rising effect of production subsidies, and may stimulate demand for domestically produced food.) Trade was also relatively closed: countries imported food but only from other communist countries. During the communist period, the amount of available food and household incomes improved relative to the World War II years, and food consumption increased overall. During this period, production and consumption subsidies are believed to have strongly influenced the consumption of meat, eggs and dairy (milk, butter) above and beyond other foods (48;49;59). Between 1950 and 1989, consumption of meat and milk products increased by around 250% in the former Soviet Union, and there were similarly large increases in the consumption of eggs (49). At the same time, there were large decreases in the consumption of bread and potatoes, the staples of the traditional Russian diet (49). According to Osborne and Trueblood (48), the livestock expansion policy in the former Soviet Union succeeded in raising per capita meat consumption above and beyond what would be expected due to income given that in 1990 [meat consumption] was equal to or higher than that in the United Kingdom, despite the fact that per capita income in the United Kingdom was over two times that of the USSR (p.5) (as shown in Chapter 2, increases in income tend to be associated with increased red meat consumption). Similar changes took place in Eastern Europe. In the former Yugoslavia, agricultural production and trade polices combined with consumer price subsidies (and higher household incomes) were attributed with increasing the per capita consumption of meat between 1952/53 and 1975/76 by 242% relative to 169% for fresh vegetables (55). In Poland, meat and milk production was effectively controlled by the state, and these products received over 60% of all food price subsidies, creating considerable incentives for both production and consumption (38). Following the fall of communism, governments implemented radically different agrofood policies. Their aim was to transform agriculture into an efficient, market-based system. These policies were implemented to differing degrees at different times in each country, but generally involved de-collectivising and privatising state farms, dismantling

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monopolies, reducing agricultural subsidies and government control over food prices, and liberalising trade (54). Of these agricultural policies, three had particularly important implications for food availability and price, particularly of meat and dairy products: Reduction or elimination of agricultural subsidies (price supports). Reducing price supports had the effect of reducing the price received by farmers for producing livestock, and the subsidies they received for feed and fertiliser. This reduced their incentive to produce and production of all commodities fell. Owing to the previously high levels of support, declines were most marked for meat and dairy: in 2001, for example, Russia and Ukraine produced 2.35 million metric tons of beef and pork annually, a decline from 6.17 million tons in 1988 (48). This had the direct impact of reducing the availability of these products. Agricultural trade liberalisation. Trade liberalisation resulted in an increase in the amount of food imports. During the communist period, nothing was imported except from other communist countries; yet by 2001 meat imports into the Russian Federation amounted to 19% of total world meat imports by volume (48). A high proportion of the meat imports poultry were low-priced, lowquality chicken legs from the United States. Poultry meat exports from the United States to Eastern Europe reached US$83 million in 2001 (4% of total United States poultry meat exports). Most countries also became net importers of fruits and vegetables. Elimination of food price subsidies. Removing price subsidies almost uniformly led to higher food prices, especially for the previously heavily subsidised meat and dairy, thus reducing the ability of the population (many of whom now had lower incomes) to afford these now relatively more expensive products.

Combined, these policy changes affected the types of foods available, their absolute prices, and, importantly, their relative prices. Under communism red meat and dairy had been cheap relative to other foods; after the transition they became relatively more expensive (33). Also, as shown by the price review (section 1.6), the price elasticity of meat and dairy fats increase relative to other during this period (i.e., expenditure is more responsive to changes in price), indicating that the rise in prices has a disproportionate influence on consumption of these products. It has thus been suggested that these prices changes were important determinants of changing dietary patterns in the region in the immediate aftermath of the transition. Indeed, as exemplified here, consumption of red meat and dairy products declined relative to cereals, bread, potatoes and consumption of fruits and vegetables: Between 1990 and 2000 in the Russian Federation, per capita consumption of meat fell overall by 45%, milk by 44%, sugar by 26%, cereals by 1%, fruits and vegetables by 3%, while consumption of potatoes increased by 11% (42) In Lithuania, per capita consumption of beef, pork and eggs fell by more than 40% between 1990 and 1996, milk by 36%, whereas per capita consumption of bread and fruits and vegetables increased by almost 20% each.

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In Bulgaria, households reduced the consumption of meat and fish in the 1990s by 39.3% and 73.5% respectively, while increasing the consumption of inexpensive lard by 88.9% In Romania, in 1998, meat consumption was 73% of the amount consumed in 1990 (i.e., 27% lower), milk 70%, sugar 93%, vegetables 92% and fruits 80%

Similar changes have also been reported for Armenia (53) and Estonia (33). Data from Estonia shows that expenditure on meat remained stable, but since prices increased, this implies that actually consumption declined. Across the region, there was a general trend in substituting red meat for the now cheaper (and largely imported) poultry meat. A particularly interesting change took place in Poland. As elsewhere, during the transition period, the removal and agricultural and consumer price subsidies led to huge price increases of previously subsidised foods, which induced major shifts in the relative prices of individuals foods. At the same time, trade liberalisation facilitated the entry of new products into the market place, such as citrus fruits (now available all year round) and margarine, which was far cheaper than the now unsubsidised butter, and heavily advertised by the industry. Consumption of animal fats fell dramatically from 8.8kg per head in 1988 to 3.7kg in 1996. Between 1990 and 1999, consumption of saturated fat in 1999 fell by 7%, polyunsaturated fat increased by 57% and the ratio between the two increased by 70% (103). Fruit availability also increased, much of it from imports: consumption of imported fruit rose from 2.8kg/yr in 1990 to 8.8kg per year in 1991 and 10.4kg in 1999. Three papers from the medical literature credit these dietary shifts with explaining the decline of coronary heart disease CHD) in Poland during that time period. Zatonski et al. (104) present the results of an ecological study investigating the reasons for the sharp decline in deaths attributed to coronary heart disease between 1991 and 1994. The study reviews possible causes, concluding that the switch from saturated to polyunsaturated fat, combined with an increased on fruit and vegetable consumption, are the most likely explanation (they note that the margarine sold in Poland was low in trans fatty acids). In a later paper, Zatonski and Willet (105) described continuing declines of mortality from CHD in Poland subsequent to 1994, further declines in saturated fat consumption, and increases in polyunsaturated fat and fruit and vegetable consumption. On the basis of previous epidemiological evidence, they conclude that increased fruit and vegetable consumption is insufficient to explain the degree of decline of mortality. They therefore conclude that the increasing ratio of saturated:polyunsaturated fat intake is a more likely explanation. This conclusion is partly disputed by Lock and McKee (106) in a commentary following the paper. The authors argue that the study underestimates the positive role of fruit and vegetable intake by considering only imports, where as many non-traditional produce is now grown locally.

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Together these papers concerned with agricultural policy in eastern Europe and the former Soviet Union support the hypothesis that the transition of agricultural policies was an important determinant of changing consumption of red meat, animal fats, and fruits and vegetables, via the intermediary indicators of food availability and price. No definite conclusions can be drawn since none of the studies explicitly measured the impact of agricultural policies on dietary outcomes. The influence of agricultural policy on food availability and prices vis a vis other determinants (e.g., income, changing preferences etc) on food consumption is not clear. 1.2.4.2 Norways farm-food-nutrition policy Norway is a rare example of a country that has developed and attempted to implement an integrated agriculture-food-nutrition policy with dietary improvements as one of its goals. The policy, adopted by the Norwegian parliament in 1975/76, had the aims of (107): Encouraging a health-promoting diet by reducing overall fat consumption, and replacing saturated fats with polyunsaturated fats, whole grains, and vegetables. (Targets were set to decrease fat consumption from the then 42% of calories to 35% and shift the ratio of polyunsaturated to saturated fats in the diet ranged from 0.35 to 0.5.) Promoting domestic food production and reducing food imports. (Targets were set to increase the countrys self-sufficiency from 39% of total calories to 52% by 1990, and increase farmer incomes to parity with industrial workers.). Diet was also embedded in this goal though the low-fat milk policy. Promoting agricultural development in Norways less advantaged, outlying regions with due regard for preserving the environmental resource base. Contributing to world food security, promoting food production and consumption in poor countries.

As noted in Chapter 3, there has been no systematic dietary evaluation of this policy. Still, the three papers included here attempted to assess the dietary impacts of this policy via the intermediary indicators of food availability and price (40;45;108). The planned implementation strategy of the farm-food-nutrition policy over the first five years (1975-80) involved three components: joint setting of producer and consumer prices so providing incentives to produce more health promoting foods (the one explicit agricultural policy); education and research (including agricultural research); and food regulation. In fact, in this first phase, the linked agriculture-diet component was very limited: some agricultural research was conducted to breed cows for lower fat milk; and food price subsidies were altered (109) (as already noted for Eastern Europe and the former Soviet Union, food price subsidies can be viewed as agricultural policy). Food price subsidies were slowly shifted to favour some foods over others such as skimmed
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over whole milk, poultry relative to pork, and margarine to butter (specifically, the food price subsidy for skimmed milk increased more than for whole milk, the new subsidy for poultry in 1977 was set higher than for pork, the fish subsidy was increased to moderate the long term price rise of fish compared with beef, a new margarine subsidy was introduced to avoid butter becoming relatively too cheap, and no consumer sugar price subsidy was granted when import prices soared in mid-1970s). According to Milio (110), using this policy instrument effectively to meet dietary objectives proved difficult in the face of agricultural objectives. For example, during the wage-price freeze in 1977/78 (implemented to control inflation) farmers were paid an increased price for beef to help achieve the goal of wage parity with industrial workers. But because the price freeze prevented the cost of the production subsidy being passed on to consumers, the food price subsidy for beef was increased significantly. Given the general real improvements in income over the decade, beef then became cheap in relation to disposable income, and consumption increased beyond what was expected even in 1990. Beyond this, no household budget or dietary surveys were carried out during this period to enable the dietary outcomes to be evaluated. After the first five years, policy implementation shifted from a dietary perspective. By this time, according to Milio (45), fat had become a contentious question owing to the overwhelming evidence of the link between fat and health. This fat-health issue challenged the legitimacy of the extensive subsidies to the dairy industry, producing a conflict between an industry accustomed to the emphasis being on producing more, and a nutrition community concerned with producing less. Post-1980, then, production subsidies changed: in 1983, a policy was introduced to stabilise milk production by granting production subsidies for milk only up to a given volume; earlier, in 1980, the maximum price per litre was made contingent on the protein content being increased relatively more than the fat content, and farmers were granted production subsidies to grow their own grass fodder as an incentive to feed cattle grass (which results in lower fat milk) rather than with imported feed. Specifically, the policy was designed to economically penalise farmers if they produced either too much milk, or milk with more than 3.8% fat. Yet ironically, since farmers received added support for growing their own grass fodder, this created an incentive for more dairy cattle and more milk production. Through the 1980s, the nutrition community made efforts to align production and food price subsidies with nutrition policy guidelines. But they met with limited success. Food price subsidies for meat were phased out by 1987 (following the recommendations), but overall, subsidies for dairy products almost doubled, and little distinction was made between full-fat and semi-skimmed or skimmed milk. Contrary to the guidelines, all consumer subsidies for fish and margarine ceased. In fact, combined price support (i.e., production and food price subsidies) for nutritionally less-desired dairy-fat foods, when

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compared with subsidies for margarine, fish, flour and skimmed milk subsidies, gradually made higher-fat foods cheaper. Compared with 1980, subsidies on fat foods in 1987 were six times higher than on those favoured in the policy guidelines. Further, the 1987 subsidies for dairy-fat foods and meat combined were six times larger than the amount for the policy favoured foods, while in 1980 they were only twice as large. It was during this period in 1984 that semi-skimmed milk was introduced into the Norwegian market. Household budget surveys indicate that diets in Norway did change during this period (45). Between 1980 and 1985, the consumption of grains increased by 2.2%, vegetables by 1%, fruit by 9%, soy-based margarine by 13% and skimmed milk by 10%. By 1990 the consumption of semi-skimmed milk had increased tenfold since its introduction in 1984. Favourable declines occurred for whole milk (20%), butter (11%) and hard margarines (25%). There was also a net fall of 4% in the total energy derived from fat in the diet, and the policy goal of reducing total energy from fat was attained: the percentage of food energy derived from fat declined from 40% in 1977/79 to 35% in 1989. Further, the ratio of polyunsaturated to saturated fats in the diet increased from 0.35 in the late 1970s to 0.44 in 1989, not quite reaching the desired 0.5 ratio. Though there were also negative dietary shifts (such as the increased consumption of high-fat snacks), this compares favourably with neighbouring Sweden, where saturated fat intake rose during the same time period. But it is far from clear if (or how much) of these changes can be attributed to the farmfood-nutrition policy, or its different components. Due partly to the conflicts that emerged between the agriculture and nutrition sectors, the most extensively implemented nutrition component of the policy was actually the provision of consumer information, not the more structural agricultural policy component (40;45). And it is perfectly possible that consumer education was the most important influence on positive dietary changes. Related changes in market forces could have also played the most important role. Kjaernes (40), in fact, argues that it was market forces that stimulated the agricultural sector to start producing semi-skimmed milk in 1984, not any particularly policy decision (its introduction cannot be traced to ay particular policy). The subsequent dramatic shift from full-fat milk to semi-skimmed milk consumption appears, he argues, to have had far more impact than government efforts to stimulate lower-fat milk production through agricultural and food price policies. The lack of a comprehensive dietary evaluation of the Norwegian farm-food-nutrition policy means that its affects on dietary outcomes will never be fully understood. The fact that is implementation was so complex and arguable incomplete makes it even more difficult to understand its true impacts. The clearest conclusion that can be drawn actually

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concerns implementation: it is clearly extremely challenging to implement agricultural policies as a dietary intervention in a democratic political environment. 1.2.4.3 European Unions Common Agricultural Policy (CAP) An agricultural policy which has been examined specifically for its dietary impacts is the European Unions Common Agricultural Policy (CAP). The CAP was established in the 1950s to promote food security in Europe post-World War II by several means: (i) increasing agricultural productivity; (ii) stabilising markets; (iii) improving standards of living in agriculture; (iv) ensuring the availability of supplies; and (v) ensuring that supplies reach consumers at reasonable prices. It underwent reform in 1996 and 2000. While the specific mechanisms to achieve these goals have varied from product-toproduct (and have changed as the CAP has been reformed), they have generally involved: Price supports in the form of a minimum price guarantee (intervention price). If the price falls below the intervention price, the EU buys the product to remove it from the market. Import tariffs to reduce imports of cheaper products from non-member countries. Export subsidies, to bridge the gap between the high internal price and the lower world price, enabling the disposal of intervention stocks. Promotion of consumption as a means of disposing of surplus stocks and making up for the higher product prices resulting from price supports and import tariffs.

Eleven papers were included in this review on the CAP and diet (31-34;39;5052;57;58;60). None of these studies are of the quality required to draw clear conclusions on dietary outcomes. Still, they raise a number of important questions with regard to the intermediary factors of food availability and food price, and, to a lesser extent, food desirability (though promotion). Interestingly, the papers can be categorised according to the discipline of the author and theme: seven papers were authored by agricultural economists based in Germany, Greece and the United Kingdom and focused on food price; six papers were authored by nutritionists and advocates from public health agencies, organizations and university departments in the Netherlands, Sweden and the United Kingdom and focused on food availability. As described below, the papers written by economists and nutritionists also came to different conclusions. (Of note, five of the 11 papers were added in from reference lists of identified papers, indicating a combination of flaws in indexing these papers in databases and the relatively high proportion of grey literature.) All the studies are mainly concerned with the impacts of these policies on the availability and/or price of dairy fats, vegetable fats, and/or fruits and vegetables. The policies in the

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CAP on these foods are summarised in Table 1.8. Others foods are included in some of the studies, but only briefly.
Table 1.8. Policies in the EUs common agricultural policy affecting dairy fats, vegetable fats, and fruits and vegetables Food Dairy Butterfat and skimmed milk Policies - Significant intervention though at least 14 different measures, including intervention measures, export subsidies, quotas, and support to promote consumption - Import tariffs - Minimum price guarantees through intervention buying and withdrawal when market price falls below a set level (withdrawal support) - Disposal of withdrawn stocks though reduced price schemes or donation (sale at reduced prices to food and feed industry for incorporation into ice cream and bakery products; sales to non-profit-making organizations and persons on social assistance; free distribution to deprived persons; subsidised exports) - Milk quotas to limit production - School milk policy - Annual area payment decoupled from total production. - Import tariffs - Minimum price guarantees through intervention buying and withdrawal when market price falls below a set level (withdrawal support)

Milk Oilseeds Fruits and vegetables

Sources: (31;57;60).

The papers by economists argue that these policies have affected food price in two ways: (i) raising overall food prices in the EU relative to world market prices (because the CAP provides a minimum guaranteed price which is higher than the world market price); and (ii) changing the relative prices of those foods (because the differences between the policies applied to different products means their prices are affected to differing degrees). In three related papers, Ritson (50-52), ranks different foods according to the degree to which the CAP has raised prices, and therefore, he argues, discouraged consumption ((50) p.846). At the top are the products for which the CAP has had a very substantial impact on price: butter, milk and other dairy products; sugar; and red meat, mainly beef, but also lamb and pork. In the middle category are cereals and cereal fed livestock (poultry and eggs). The final group, for which the CAP has made minimal difference to price, are vegetable oils and fruits and vegetables. Based on this analysis, Ritson (52) argues that the EU CAP has succeeded in pushing the diet of EU consumers in the direction that the medical profession would now regard as more healthy (p.261). He supports his analysis with the conclusions of the relatively small number of studies which have looked specifically at the impact of the CAP on the UK diet which have all broadly come to the same conclusion that the main effect has been via food prices and that this effect has been (at least mildly) positive with respect to healthy eating ((50) p.846).

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Drawing on their own earlier work and of others, Traill and Henson (57) examine how these price changes are likely to affect consumption. They estimate that the CAP has the effect of reducing the consumption of cheese (-39.5%), beef (-43.2%), and butter (31.6%). These estimates do not take substitution effects into account (i.e., changes in relative prices between beef and chicken may lead consumers to substitute one for another, as opposed to leading to an overall decline of meat consumption). Two other studies estimate the impact of CAP-induced price changes on food consumption, both of which are concerned with the impact of EU-membership on food consumption. Georgakopoulos (34) estimates the food consumption impact of the entry of Greece into the European Union. The study first estimates, using the residuals method, the impact of the adoption of the CAP on food prices, and then calculates price elasticities for these foods. By combining these estimates, the study concludes that EU entry led to a decline in the consumption of meat by -8.7% and of sugar by -6.4%, whereas consumption of vegetables increased by 5.8% and of citrus fruits by 2.0% (consumption of other fruits fell by -0.4%). Fock (33) models the potential food consumption impact of CAP of the entry of Estonia into the EU. The study simulated two different CAP scenarios the 1997 CAP and CAP following the 2000 reform using a calibrated demand system analysis. The study estimates the changes of retail food prices for nine food groups on the basis of estimations from OECD and EU statistics, and then calculates price elasticities for each group. In both cases, the study finds that beef consumption would fall significantly as a result of higher prices (-44.9% or -23.0% depending on the scenario). Poultry consumption would also fall (-8.1% or -9.1%), but pork consumption would increase (+13.7% or +11.6%). Milk consumption would decline by -12.3% or -9.0% and sugar by -7.7% or -8.8%, whereas consumption of eggs, cereal products and potatoes would rise by up to 3%. As noted by Traill (57), all these estimates are likely to overstate the price impacts because: They assume that the price rises caused by the CAP are the equivalent of the difference between the farmgate prices (i.e., the price paid for raw materials) paid in the EU, and the (lower) farmgate prices paid on the world market. This assumption is likely to significantly overstate the difference, since the CAP also has the effect of making the world prices lower. They assume that the differences in farmgate prices resulting from the CAP changes are passed onto consumers, where as it is well known, especially in high-income countries, that manufacturers and retailers do not necessarily pass on price changes to consumers.

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Henson and Traill (39) (also reported by Traill and Henson (57)) attempt to quantify the impact of the CAP on the relative quantities of butter (as an unhealthy fat) and margarine (as a healthy fat) consumed in four different European countries: Denmark, Ireland the Netherlands, and the United Kingdom. The study uses empirical modelling techniques (a demand analysis and a supply analysis and simulations) and starts with the assumption that the CAP has had a significant impact on the price of butter (as a result of the minimum price guarantee for butter fat) and a negligible impact on the price of margarine (because support for oilseeds is decoupled from production) (Table 1.8). The study presents data showing that in all the countries the relative price difference between butter and margarine increased during the period of the progressive implementation of the CAP in the 1970s and 1980s. In the United Kingdom, they show that over the same period the consumption of butter declined relative to margarine. They therefore hypothesise that the CAP widened the gap between retail butter and margarine prices in the EU. Unfortunately, their subsequent analysis to test this hypothesis is confused and difficult to interpret. They estimate the price elasticities for butter and margarine, finding them to be all less than -0.5 (with one exception of -0.82 for butter in the Netherlands). They thus conclude at this point that the impact of changes of retail prices arising from the CAP is likely to be limited and vary between countries depending on their elasticities. But they later conclude that the CAP has exerted a significant downwards pressure on the demand for butter in the UK. This interpretation possibly stems from the fact that the butter prices are higher enough to dampen demand even with price elasticities lower than -0.5. Their model also indicates that the price of margarine is in fact indirectly affected by the CAP, because manufacturers and retailers take into account the price of butter when establishing the price of margarine, thereby making it more expensive (an increase by 10 pence in the price of butter leads to an increases of 3.3 pence in the price of margarine). The study also examines the effect of the EU schemes which offer butterfat withdrawn from the market for sale at reduced prices. They estimate that each kilogram of reduced-price sales increases the demand for butter by 0.31 kg, but at the same time displaces 0.69 kg of full-priced sales. Thus in practice, reduced-price butter schemes are relatively ineffective at stimulating the demand for butter, tending to displace full-price sales rather than generating new sales. The papers by public health nutritionists come to different conclusions. Schfer Elinder (32) argues that in general, the CAP is leading to overproduction, in turn encouraging food availability surplus to need, and consequently, excess consumption and obesity. Specifically, in the report Public Health Aspects of the EU Common Agricultural Policy, she raises questions about the impact of the dairy policy regime on the consumption of dairy fats (31). The study starts by noting that 25% of milk produced in the EU is withdrawn from the market and disposed of using reduced price schemes or donation (see

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Table 1.8); 90% of this butter fat is disposed of through reduced price sale to the food industry for use in pastry and ice cream. Since this lowers the relative costs for the food industry, the study hypothesises that the reduced price sales of butter fat withdrawn from the market increases the availability of butter fat and thereby promotes consumption. Because it appears to subsidise the consumption of saturated fat (via encouraging the use of butter rather then vegetable fat), Schfer Elinder considers this policy counter to public health. This conclusion is limited in scope, since the study does not in any way measure or model the impact of the policy. The analysis also assumes that if milk producers were not given the incentive to produce through minimum price supports and promotional measures, less milk-fat products would be produced and less would be consumed. Yet this is not necessarily the case since withdrawing these measures may have the result of lowering prices and promoting imports of cheaper milk-fat products. (The conclusion also contrasts with the assessment made by Henson and Traill (39)). Schfer Elinder (31) also voices concern about the EU School Milk measure, which provides schools with subsidised milk. The source of the concern is that the subsidy is higher for full-fat milk relative to skimmed or semi-skimmed milk. A European Commission report concluded that the measure has a very small, positive impact on milk availability in schools. Three papers examined the impact of the withdrawal support mechanism on fruit and vegetable consumption. Whitehead and Nordgren (60) reported in 1996 that withdrawal has become endemic in the fruit and vegetable sector to the extent that some farmers only grow for withdrawal (p.q). In 1993/94, for example, around 2.5 billion kilos of fruits and vegetables were withdrawn from the market, leading the authors to conclude that the withdrawal scheme raises prices to consumers and reduces supply, thus reducing the ability of consumers particularly those on low incomes from increasing their fruit and vegetable intake. In a follow up study taking into account the 1996 CAP reform, Schfer Elinder (31), came to the same conclusion. She noted that although the 1996 reform resulted in a reduction of withdrawals by around 50% (mainly due to compensated grubbing-up of orchards so reducing production volume), just over one million tonnes (1.4% of total production) of fruits and vegetables were still withdrawn in 2001, and most was destroyed. She thus concludes that the programme continues to increase the supply and reduce the availability of fruits and vegetables, and that this acts to discourage increased fruit and vegetable consumption among Europeans. This finding is disputed by Ritson (52), who argues that withdrawal support has had a minimal impact on fruit and vegetable production because of the relatively small amounts of withdrawn, and because, in the absence of the support, it is likely that farmers would not have grown the excess produce.

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Veerman et al. (58) attempt to add to this analysis by developing a simple mathematical multi-state life table model to quantify any diet and health gain for the Dutch population if the CAP withdrawal intervention scheme was eliminated. The study simulates the effects of making this increased supply (estimated from historical data at 1.27 million tonnes per year) available to the Dutch population. The distribution of the increased availability throughout the population was modelled following the most recent nutrition survey. The model found that if the withdrawal scheme were abolished, the average increase in consumption of fruits and vegetables among the Dutch population would be 1.80% (at a 95% uncertainty interval), amounting to 5-6g per person per day on average. The study then models the impact on the risks of selected chronic diseases, including several cancers, on the basis of estimates of the link between fruit and vegetables and cancer incidence by Riboli and Norat (2003). The results indicated that the annual number of incident cases prevented per 100000 person years would decline by between 0.0-0.5, with the greatest decline (0.5) seen for male lung cancer. Overall, then, the authors conclude that the result of ending the fruit and vegetable component of the CAP would be modest in terms of increased intake and health gain. Moreover, their model is likely to considerably overestimate the health gain for several reasons: It estimates a maximum effect because it assumes that all produce previously withdrawn would be sold and eaten by consumers (minus wastage). This includes the assumption that ending the withdrawal scheme would lead the price to fall to a level where consumers would purchase all the fruits and vegetables, whereas in fact, ending the guaranteed price is likely to reduce production because of the reduced price incentive, thus leading to higher prices to consumers. It assumes the amount withdrawn is a reflection of past data whereas there is a great deal of uncertainty in the amount of fruits and vegetables that would actually become available as a result of ending the withdrawal subsidies. The model ignores the role of the retail sector in distributing fruits and vegetables. There is a great deal of uncertainty about who would consume the extra fruits and vegetables; if they were consumed by people already consuming the recommended 400g per day, rather than the people consuming far less, then the health gains would be minimal, and vice versa. There is large uncertainty in the quantified estimates linking fruits and vegetable consumption to disease incidence.

As a result of these limitations, the authors conclude that ending withdrawal support could have, at a minimum, zero effect. Its most likely effect would be to increase fruit and vegetable consumption to between 0g 5/6g per day.

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1.2.4.4 Agricultural policies in North America Six papers discuss the implications of North American (Canada and the United States) agricultural policy on diet and obesity (29;30;35;36;41;56). Two papers identify specific agricultural (production and trade) policies likely to have an impact on food consumption (30;35); three empirically model the impact of specific policies on the consumption of specific foods and nutrients (35;36;41); and two papers discuss the implications for obesity (29;56) (this adds up to seven papers because one paper does both). Five of the six papers are authored by economists. Collins (30) identifies five specific agricultural policies in place in the United States in the late 1990s as limiting the supply of foods recommended or discouraged by the United States dietary guidelines, and hypothesises the impact this may have on the consumption of these foods. Likewise Goddard et al. (35) for Canada. These policies and their dietary implications are described in Table 1.9. LaFrance models the effects of the United States dairy programme (which covered around 70% of farm-gate milk sales in the late 1990s) on dairy prices and food and nutrient consumption in the United States (41). As indicated on Table 1.9, the minimum price guarantee mechanisms results in a higher price being paid to milk producers for fluid milk (i.e., sold to consumers) relative to milk used in food processing. Using a farm-level partial equilibrium model, he compares the real price of milk during the period 1949-1994, with a price simulated without the minimum price guarantee (competitive market equilibrium). The model estimates that, during the time period, the dairy programme led to an increase of fluid milk prices by an average of 6.5%, and to a decrease of butter, ice cream and canned and powdered milk prices by an average of 4.6%, 3.8%, 2.6% and 1.9% respectively. This resulted in an average decrease in fluid milk consumption by 2.5%, and average increase in butter, frozen dairy products, and canned/powdered milk consumption by 3.3%, 7.7%, and 5.8% respectively (cheese consumption was negligibly effected). These changes in consumption led to changes in nutrient intakes of between 0-1.1% (e.g., calories and protein increase by less than 0.2%; vitamin A decreases by 0.6%; cholesterol decreases by 1.1%). The author concludes that these orders of magnitude are sufficiently small that, for all practical purposes, the nutritional consequences of the dairy programme may not be a primary concern in the ongoing policy debate (p.25). Gray (36) models the consumption impact of the dairy programme in Canada, focusing on production quotas. As in the United States, the programme results in a higher price being paid for fluid milk relative to industrial milk used for processing (see Table 1.9). Using linear marginal cost and demand equations based on a single weighted average price for fluid and industrial milk, the model compares the difference between the quantity of fluid and industrial milk produced with and without the presence of the quota.
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Table 1.9. North American Agricultural Policies with Implications for Food Consumption (according to Collins (30) and Goddard et al. (35))
Food UNITED STATES Dairy (US Dairy Programme) Price supports: one guaranteed minimum price for fluid milk (i.e., milk sold to consumers) and a (lower) guaranteed price for milk sold to processors Import tariffs on selected fruits and vegetables Raises price of fluid milk and reduces price of manufactured dairy products such as cheese and ice cream, so eliminating dairy programme would increase the supply of fresh milk which represents a movement towards the Dietary Guidelines and raise cheese, butter and powdered milk prices. Reduces supply of lower cost fruit and vegetable imports but unclear what eliminating the tariffs would have because generally they are very low minimum import quality requirements on selected fruits and vegetables May promote consumption by increasing consumer confidence in fruits and vegetables, or decrease consumption by increasing prices (though cost of compliance) Unclear if eliminating this policy would affect fruit and vegetable production and therefore move the food supply closer towards dietary guidelines Reduces supply of sugar and peanuts; eliminating quotas would move the food supply further away from dietary guidelines and possibly encourage greater peanut and sugar consumption Lower consumption of fluid milk since provides incentives to continue to produce butterfat relative to milk solids; shift consumption towards processed milk products (e.g., ice cream) and away from milk solids Expanded production and availability of low costs vegetables; irrigated land for cattle increases red meat consumption Sugar a lower cost ingredient in processed foods Reduce white meat consumption and higher consumption of red meats Policy Implications for food supply, prices, consumption?

Fruits and vegetables

Minimum import quality requirements on selected fruits and vegetables Penalty imposed on cereal producers for growing fruits and vegetables Sugar and peanuts Quotas (for domestic production and imports)

CANADA Dairy (Canadian dairy programme) Production quotas, import tariffs, administered dairy prices guarantee higher minimum price for fluid milk relative to industrial milk for processing Federal and provincial support for irrigation Sugar subsidies Import and production quotas

Fruits and vegetables Sugar Poultry

The model assumes that the non-quota price will be the same as the world market price (CAN$0.39 per kilo), which is lower than the Canadian price (CAN$0.53 per kilo), and that the demand elasticity for raw milk of is -0.72. The model estimates that production quota reduces milk production by 7.202 MKg and consequently, reduces consumption of butter fat. Gray then models the impact of the reduced consumption of butter fat on health care costs via the reduction of CHD. The relationship between dairy fat consumption and CHD was estimated from medical studies on the relationship between serum cholesterol and CHD. The results indicate that the production quota reduces health care costs in Canada by around $13 million per year. Owing to the large numbers of assumptions in the model (perfect competition beyond the farmgate, imports tariffs remain in place, comparison price being world market price), Gray conducts a sensitivity analysis, finding that the results were very sensitive to the parameters included. The author thus concludes that no conclusive statement can be made about the effect of the dairy production quotas
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on health care costs, but because of the increased prices resulting from the dairy quota, it can be reasonably assumed that dairy quotas have a positive impact by reducing the amount of dairy fats consumed in Canada. Goddard et al. (35) model the effect of the Canadian poultry policy on consumption in Canada (see Table 1.9), based on the hypothesis that the poultry production quota means that poultry prices are higher in Canada than world market prices. Using an estimated integrated demand system, they simulate the impact of consumer subsidy equivalents (CSEs) (an index of the financial burden of supply-side agricultural policies, which in the case of poultry CSEs, reflect the impact of production import quotas) on turkey and chicken meat consumption between 1979 and 2003. The model results indicate that in the years in which CSEs were high, consumption of chicken and turkey, and associated protein, energy and fats were lower as a result of higher prices. As for Gray, the authors note that the quantitative changes are simply tentative approximations, suggesting direction and general magnitude rather than firm estimates (p.27), but conclude that there is enough evidence that poultry production quotas influence the consumption of the affected foods. Three papers discussion the implications of agricultural policies on obesity, all from the United States. Like Schfer Elinder (32), Tillotson (56) argues that, historically, the implementation of policies in the United States to (successfully) increase agricultural productivity (e.g., through subsidies, marketing assistance programmes, commodity programmes and trade policies) has led to a plentiful and low cost food supply which favors the occurrence of Americas obesity problem (p.625). This argument has also been proposed by journalists (111;112) and advocacy groups (113) in the United States. They argue that the high agricultural subsidies provided to corn and oilseeds increase the supply and use of derivatives of these commodities in energy-dense processed foods and soft drinks, thus increasing their availability, lowering their costs and encouraging consumption. Echoing the differences of opinion on this issue in Europe, economists disagree. With a focus on price, Alston et al. (29) plot trends in farmgate prices between 1960 and 2002, the time period when obesity increasing significantly in the United States. The study finds that the prices received by farmers has indeed declined steadily, which they attribute the agricultural policies such as subsidies (commodity programmes) and policies on agricultural research and development. But the study then goes on to show that these lower farmgate prices have not translated into lower consumer prices. This leads to them to conclude that the influence of agricultural policies on obesity is negligible. A paper released as this review was being completed agreed with these findings. Miller and Coble (46) econometrically evaluated the impact of direct government payments on the affordability of foods in the United States in the context of the debate about agricultural policy and obesity. The models find that direct payments do

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not significantly affect the affordability of food either in the aggregate or across specific food groups (though they have a very small affect on increasing the price of fresh fruit and lowering the price of vegetable oils). They therefore conclude that agricultural policies cannot be attributed with contributing to the obesity epidemic in the United States. 1.2.5 Summary, discussion and conclusions

This section has presented a survey of the literature on the relationship between agriculture, and, to a lesser extent, the environment, and the human diet. It has attempted to answer the question: Are the natural environment and agriculture determinants of diet, and if so, how do they affect diet? In conducting this review, teasing out what could be learned from this literature in a cancer prevention context proved a genuine challenge. First, the nature of agriculture and the environment as distal determinants presented a challenge in clarifying the pathways of influence. Second, no studies examine the association between agriculture and diet, let alone cause an effect. Third, study quality was overall quite weak, and tended to be compromised by methodological weaknesses and untested assumptions. These quality issues can be characterised as follows: On agricultural production practices and food nutrient quality, assumptions were made about the sources of the changing quality, but was generally not confirmed by experimentation. The studies also tended to make the assumption that changes in nutrient quality affect the overall nutrient quality of peoples diets, but this is not really the case when people can choose between different foods and offset any changes by eating additional or alternative foods. On agricultural policy and dietary indicators, the evidence base suffered from a lack of studies that evaluated impact even on the basic dietary indicators of food availability and price. More specifically, the economic models developed were rife with assumptions that were either inadequately explained or tested, or that tended to oversimplify the causal pathway from agriculture to dietary outcomes. One notable problem was the assumption that the impact of agricultural policies on farmgate prices translated directly into retail prices. Another was that the studies that were concerned with the price transmission through the food supply chain did not account the potential importance of food availability as a dietary indicator. And in turn, the studies that were concerned with food availability did not quantify the impact, and failed to consider the potential importance of price. These limitations meant that even when the models and studies were considered together, it was not possible to accurately quantify the impact of agriculture on dietary indicators.

Another important observation is the multidisciplinary nature of this research. Agronomists, agricultural economists, nutritionists, epidemiologist and public health professionals have all contributed. While this provides the benefit of a range of perspectives, it also highlights that different disciplinary approaches can lead to different
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results, especially in the absence of high quality methodological approaches. The clearest example of this is the difference of opinion between agricultural economists and the public health community on the role of agricultural policy in the development of unhealthy diets and obesity. Overall, then, what emerges from a quality perspective is (i) a lack of evaluation of agricultural production practices and policies on dietary indicators, precursors or outcomes; (ii) in the studies that do exist, too many are poorly designed and/or rely on untested or overly sweeping assumptions; (iii) a lack of understanding of if these factors actually affect what people eat relative to other factors and, therefore, whether they should demand the attention of health policy makers. While the nature of the evidence base and the quality issues limit the conclusions that can be drawn, the process of reviewing the literature succeeded in identifying the agricultural issues of relevance to the prevention of diet-related cancers, and to a more limited extent, some environmental issues. Identifying these issues represents the real contribution of this review to understanding the environment and agriculture as dietary determinants. In summary, the agri-environmental issues of relevance to cancer prevention comprise some specific factors in the natural environment, a series of agricultural production practices, and agricultural policies that create incentives or disincentives to the production and marketing of foods associated with cancer. But the question nevertheless remains of if and how these factors affect diet via the intermediary dietary indicators. The review of the literature prevents convincing or even probable conclusions to be drawn in most cases, but the following observations can be made from a policy perspective: In poor communities in poor countries, where facilities for water treatment are not available, living in areas where arsenic is prevalent in the natural environment is associated with arsenic poisoning through drinking water. Given arsenic poisoning is associated with cancers, and affects millions of people, this association demands urgent policy attention. It is possible that the presence of this problem among the poor in developing countries has led to inadequate attention being paid to the problem from a cancer perspective relative to dietrelated risks in developed countries. More research is also needed to better understand if increased use of groundwater for irrigation purposes encourages the entry of arsenic into groundwater used for drinking water. No conclusions can yet be drawn on whether contaminated food poses a threat, but research is urgently needed to build on existing research which suggests that small amounts of arsenic accumulate in rice grains, much more so in the roots, and that some green leafy vegetables accumulate arsenic. This is especially important since the consumption green leafy vegetables should not be discouraged from a cancer prevention perspective.

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Aflatoxin exposure remains a health threat in poor communities in poor countries where methods to reduce the growth of aflatoxins are not available or implemented, and where there are limited food options. Numerous environmental factors and agricultural production practices are associated with the degree of exposure including the presence of the fungus in the soil, drought stress, insect damage, and postharvest storage conditions. Differences between agroecosystems lead to higher risks in some regions relative to others, especially in the humid tropics. Thus in parts of the world with distinct agro-ecologies, such as parts of sub-Saharan Africa, the chances of chronic dietary exposure to unsafe levels of aflatoxins are high. As for arsenic, this likewise demands policy attention and it is possible that the presence of this problem among the poor in developing countries has led to inadequate attention being paid to the problem thus far. The subject of whether organic food contains relatively more nutrients than conventionally produced foods remains contentious. There is now reasonably consistent data to show that organically produced green leafy vegetables have higher vitamin C content than those produced using convention methods. Evidence for differences between organically and conventionally produced foods has also been advanced for fruits and vegetables in general, and for other micronutrients, but it is agreed that more research is needed to confirm this finding. The impact of actually consuming organic foods on human nutrition is not known. Though it is unlikely that this question will be resolved in the near future, it is likely that this debate will continue, and as such, will demand policy attention from a health perspective. The most recent review of the evidence appears to confirm the assertion that grass-fed beef is lower in fat and usually has higher levels of omega-3 fatty acids relative to corn-fed beef produced in intensive feedlots. The quality of this systematic review has not been independently validated. It is also unclear if and how these differences actually affect human fat intake. Though it is asserted that animal breeding has led to fattier meat, the fact that animals have been bred specifically for leaner meat (e.g., chicken breasts, lean pork) has not been addressed. The impact of crop breeding on dietary outcomes has not been adequately researched. Still two areas of crop breeding were identified with some relevance to cancer prevention. First, it has been proposed that breeding crops to enrich their micronutrient content (biofortification) can increase intake of carotenoids and other micronutrients in developing countries where foods naturally high in micronutrients such as fruits and vegetables are not affordable by the poor. Some evaluations of this approach are currently being undertaken, but none has yet been published in the peer-reviewed literature. Second, the evidence is building that nutrient quality of fruits and vegetables has declined in developed countries over past decades, and that this can be explained by decades of breeding for high yield varieties. The influence of different agricultural production practices on this apparent trend requires further investigation.

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No conclusions can be drawn about the role of biodiversity, including agrobiodiversity, on dietary outcomes, but the hypotheses that have been proposed on their association warrant further investigation. Though this has never been confirmed through specifically-designed studies, heavily interventionist agricultural policies aimed (and implemented) to increase production and consumption in national environments closed to outside influences appear to have the effect of influencing dietary outcomes. Likewise, radical and sudden changes in such policies can influence dietary outcomes (alongside changes in related policies). This is illustrated by the unique case of eastern Europe and the former Soviet Union before and during the transition era, a shift which had particular implications for red meat consumption. This experience allows some firm hypotheses to be developed on how agricultural policy affects diet. One is that agricultural policies can affect the consumption of foods produced directly by agriculture (i.e., subject to minimal transformation) such as meat, milk and fruits and vegetables, if these policies create marked incentives for increased production and availability, significantly affect food prices, and are not offset by food imports. Another is that the foods most likely to be affected are those with higher price elasticities. A third is that major economic transitions have implications for dietary changes above and beyond people choosing to consume different types of foods. A fourth is that trade liberalisation can alter the food supply and in so doing shape dietary choices. Such lessons can be learned from the situation in eastern Europe and the former Soviet Union, but the experience is unique in space and time and is unlikely ever to be repeated. The generalisability of the situation is therefore very limited. Moreover, the precise impact of agricultural policies on dietary outcomes (e.g., on red meat versus poultry consumption), the relative role of different agricultural policies (e.g., as they affect saturated fat versus fruits and vegetables), and their influence relative to other policy changes (e.g., food price subsidies), is difficult to identify, and has not been studied adequately to draw decisive conclusions. For example, the hypothesis that changing fat consumption in Poland is the result of changing agricultural policies in the region is well founded, and, indeed, rigorously argued but the nature of the evidence means it remains a hypothesis. Where countries are less closed to outside influences, where policies are less interventionist and targeted, and where the rates of change are less radical in other words, in more representative situations it is more difficult to assess whether agricultural policy affects what people eat. Even in the heavily domestically-oriented agricultural policy environment of Norway in the 1970s and 1980s, it is far from clear if (or how much) the decline of fat consumption during that period can be attributed to the agricultural components of the farmfood-nutrition policy or to any aspect of the policy. The clearest conclusion that can be drawn from the experience is that it is clearly challenging to implement agricultural policies as a dietary intervention in a democratic political environment. The lack of a comprehensive evaluation of this policy represents a

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missed opportunity for understanding of the role of agricultural policies as a dietary determinant. The EUs CAP has been more systematically evaluated for its dietary impacts, but the evidence is mixed. The complexity of the CAP make it extremely difficult to estimate to what extent the prices of individual foods have been changed by the policy, but there appears to be consensus among economists that the policy has had the effect of raising the farmgate price of beef, animal fats and sugar. Their analysis and modelling is not of sufficient quality to allow conclusions to be drawn about any impacts on consumer food prices or dietary outcomes. The public health literature continues to voice concern about the impact of the policy on availability of dairy fats and fruits and vegetables but the only paper that attempted to model the impact on fruits and vegetables showed that the effects of the policy was very small. Thus no real conclusions can be drawn except that, in the words of Veerman (58), a more comprehensive effort is needed to quantify the impact of the CAP on the consumption of different foods and subsequent health effects. This needs to take into account the genuine disagreement between the different researchers and research methods by developing a co-ordinated methodological approach drawing on techniques common to epidemiology and economics. This effort is needed given the rise of this issue on the agenda of European policy makers. The literature on North America likewise reflects different methodological approaches. Although policies have been identified in the United States and Canada that have dietary implications, the models do not agree if the magnitude and direction of their effects are significant for food consumption or obesity. The main source of the different results between these papers appears to be the transmission of price effects from the farmgate to the consumer. But as for the EUs CAP, it is likely that this will issue will grow as a live policy issue, and therefore should be considered in developing recommendations for policy makers.

1.3 Results: Globalization

1.3.1 Searching, characterising and classifying the literature 1.3.1.1 Characterisation of the literature It became clear from the abstract scan that the literature on globalization and diet is neither substantive nor well advanced methodologically. As already indicated in Table 1.1, no single paper was identified that measured the association between globalization and measurable dietary outcomes in a study specifically designed for that purpose. This likely reflects the fact that, as put by Popkin (114) it is impossible at this time, with the available databases, to fully link each aspect of globalization exactly to each one of these elements [of diet] (p.X). This is not necessarily surprising since globalization is an amorphous concept which can only be measured through the policies and processes which drive it. Yet likewise, there were few papers that explicitly made the link, using an

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adequately designed study, between a globalization process or policy, the change or spatial variation in the process, and intermediate dietary indicators. Moreover, many of the papers reflected little understanding of how the different aspects of globalization operate. Still, the abstract scan did indicate that there are ways through which the published research can further the understanding of globalization as a dietary determinant: By developing conceptual models of the relationship between globalization and diet By identifying globalization policies and processes which affect dietary indicators By linking these policies or processes to specific changes in dietary indicators over time or space By analysing dietary outcomes in the context of particular globalization policies or processes

As already discussed in section 1.1.1, though usually excluded in systematic reviews, reviewing these papers was a first and essential step in the process of understanding globalization as a dietary determinant, and taken together, provide a stronger basis for the development of clear hypotheses on the relationship between globalization and diet. The inclusion and exclusion criteria were therefore set following this logic (see Table 1.10). Papers were excluded if they simply mentioned globalization as a potential dietary determinant, made cursory reference to a particular process (e.g., advertising, fast food) or which briefly cited evidence and opinions presented in earlier papers without adding anything new to the literature.
Table 1.10. Inclusion and exclusions criteria for review of globalization and dietary indicators Study characteristic Focus Inclusion criteria - Study presented a conceptual model of the relationship between globalization and diet - Study identified globalization policies and processes which affect diet - Study linked these policies or processes to specific dietary changes over time or space - Study analysed food availability or diet data in the context of particular globalization policies or processes - At least one of the food or nutrients related to cancer as described in the introduction - No particular general quality criteria beyond main focus Exclusion criteria - Study not primarily focused on the relationship between globalization and diet - Study made just a cursory reference to a particular globalization process - Study briefly cited evidence and opinions on the subject without adding anything new to the literature - Study dealt solely with food insecurity and/or undernutrition - Main concern of the paper was staple foods

Foods

Quality

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Papers that only presented conceptual models or identified policies and processes were classified as conceptual and summarised en masse, with no assessment for quality. Papers that attempted to link one of these policies or processes to specific dietary changes over time or space or which analysed food availability or diet data in the context of a particular globalization process were classified as descriptive and each summarised separately in the text, including a brief consideration of the core weaknesses of the study. (These papers were still not of high enough quality to warrant summarizing their outcomes in a table and ranking each for quality.) 1.3.1.2 Classification of the literature On the basis of the exclusion and inclusion criteria, 113 articles were requested in their full paper form for a second level of selection and 97 obtained for potential inclusion in the review. These papers were examined in more detail for relevancy and for adherence to inclusion and exclusion criteria. Thirty-nine of these articles met the inclusion/exclusion criteria. Five of the papers presented conceptual models (115-119). All 39 attempted to identify the policies and processes of globalization which affect diet (114-116;118-153). Four of these latter papers attempted to link these policies and processes to a specific dietary change (128;133;146;154), and four of them (120;121;137) analysed food availability or diet data in the context of a particular globalization process. These statistics are summarised in Table 1.11.
Table 1.11. Globalization: Summary of the literature selection process Papers identified through initial database search for globalization terms 174 Papers identified through initial database search for trade terms 355 258 Papers identified through initial database search for food price terms 751 Total after removing duplicates Papers requested in full paper form for second-level review from globalization 96 search 4 Additional papers requested in full paper form for second-level review from trade search Additional papers requested in full paper form for second-level review from 3 food price search 8 Additional papers from grey literature from authors own knowledge 2 Additional papers from update of globalization search 113 Total requested Papers obtained for potential inclusion in review 97 Papers that met inclusion/exclusion criteria and are included in the review 39

1.3.2

Conceptual models of globalization as a dietary determinant

Five papers presented models that conceptualized the relationship between globalization and diet (115;116;118;119;155). Uniting the models was a focus on globalization as a cause of changing dietary patterns and associated increases of obesity and diet-related

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chronic diseases in developing countries. The models conceptualised globalization as a major driver behind the development of diets containing high levels of energy-dense, nutrient poor foods, including fats (animal fats and/or vegetable oils), sweeteners, processed foods and fast foods. The first (and most commonly known) is the nutrition transition model proposed by Drewnowksi and Popkin (115) (the nutrition transition is described in other papers by Popkin, but these were not identified through the database search). This model, which has been widely applied to many different countries and contexts, emphasises changing food availability, and the homogenizing and negative impact of globalization on dietary patterns, though the authors also note that the transition is associated with greater dietary diversity. Among the emerging trends in the global diet they note, are a greater dietary diversity and an increased proportion of vegetable fats and, to a lesser extent, sugars (p.40). According to an earlier paper (not identified through the database search) by Popkin (156), the nutrition transition proceeds in five temporal stages: collecting food (when diets were high in carbohydrates and fibre and low in fat); famine (which still characterises diets in some low income countries); receding famine (consumption of fruit, vegetables and animal protein increases, and starchy staples become less important in the diet); dietary patterns associated with diet-related chronic diseases (increase of fats, sweeteners, decline of fibre the stage popularly referred to as the nutrition transition); and behavioural change (when populations desire a healthier diet and change accordingly). The stage popularly known as the nutrition transition is, according to the model, driven in large part by globalization through its affect on economic growth, urbanisation, technological changes, food processing and the development of the mass media. Numerous other papers (not included here) describe the nutrition transition around the world and frequently suggest that globalization is a important determinant of dietary changes. A further two models build on the nutrition transition concept by engaging with globalization more comprehensively and attempting to encapsulate the coexistence of homogenization and diversification. A model proposed by Pingali and Khwaja (119) divides the changing dietary patterns into two time stages, one first positive, the second more negative. The first income-induced diet diversification stage is associated with improved and diversified diets as a result of higher incomes, while the second diet globalization stage is characterised by the convergence towards excessive consumption of proteins, sugars and fats. This model was developed through an examination of food availability in India, where diets diversified during the 1980s as a result of markedly higher consumption of animal and vegetable-source foods (including rice and pulses), and then globalized in the 1990s through increased consumption of animal fats,

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vegetable oils, sweeteners and fruits, and decreased consumption of rice, pulses and cereals. A third model, proposed in different forms by Fonte (116), Kennedy et al. (118) and Hawkes (157) further emphasises the coexistence of dietary diversification and dietary convergence over space as well as time. Fonte (116) notes that dietary convergence should not be seen solely in terms of what is eaten, but where food is acquired and eaten. She argues that although diets appear to diversify with globalization, this is simply a reflection of greater concentration of food products in one space, rather than an absolute increase in food variety. Drawing on the results of a series of case studies of globalization and nutrition, Kennedy, Nantel and Shetty (118) suggest that dietary convergence and diversification (which they term adaptation) occur at the same time as a result of different globalization processes. Convergence is largely driven by increasing incomes and lower food prices, while diversification is driven by lifestyle changes coupled with changing food availability, the emergence of new food retail outlets, and advertising. Hawkes (158) terms this the convergence-divergence model of dietary change on the basis that it unites the apparently contradictory observations that, on the one hand, global market integration homogenizes diets and, on the other, brings greater food variety (since it does both). The former is clear from food availability data of basic commodities, the latter through observation. The paper argues that dynamic, competitive forces unleashed as a result of globalization inherently produce both convergent and divergent dietary outcomes because market integration increases the incentive for TFCs to sell cheap and/or standardized food around the world, while simultaneously increasing their incentive to create market niches. It also stresses that this duality could be encouraging the uneven development of new dietary habits between rich and poor, since high-income groups in developing countries are able to accrue the benefits of a more dynamic marketplace, while lower-income groups may experience convergence towards poor quality obseogenic diets, as has been observed in western countries. This point about inequalities is also articulated by Leatherman and Goodman (137) in their paper on Mexico (described section 1.3.5). They argue that the shift towards commoditized foods systems in Mexico has increased the influence of household income and market prices as dietary determinants, and thus provided a context in which inequalities in access to adequate diets increase. 1.3.3 Globalization policies and processes and dietary indicators

All 39 papers attempted to identify policies and processes of globalization that affect diet (114-116;118-130;132-142;144-153;159;160). As for the conceptual models, these policies and processes were viewed as major drivers behind the development of diets containing high levels of energy-dense, nutrient poor foods. Not all the papers focused

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solely on negative associations, though: several papers suggested that globalization has played a positive role in increasing the diversity of diets. By bringing the papers together, it was possible to identify some consensus on the key globalization processes driving these changes dietary patterns. Nine inter-related processes were identified. These globalization processes are listed on Table 1.12, ranked by the number of times they are identified in the papers. Also on Table 1.12 is a list of the papers that identified these processes, the consensus rationale of their role in diet in terms of their dietary indicators, and an indication of where each is discussed in this document. As shown on Table 1.12, the most commonly identified processes are the rise of transnational food companies (TFCs), followed closely by international food trade liberalisation and then the related factors of global food advertising and promotion and the growth of transnational supermarkets. Other factors were cultural influences, the development of new forms of global food governance, technological developments, the liberalisation of foreign direct investment (FDI) and domestic agricultural liberalisation. Along with the brief rationale provided in Table 1.12, the reasons these papers identified these processes as potentially important dietary determinants are summarised in the next following subsections.

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Table 1.12. Dietary determinants of globalization according to the papers identified in the globalization review Dietary determinant Growth of transnational food companies (TFCs) Papers referencing the globalization process (116;118127;130;135;136;138;1 44;147;150;152;161) (114;119;121;122;125; 128;129;133135;139;142;146;148;1 49;151;162) (118;119;122125;130;134;135;144;1 50;163) (114;118;119;125;127; 129;134;136;144;145;1 64) (125;127;135137;140;148;152;153) (125;128;135;136;138) Rationale for inclusion as dietary determinant and link with dietary indicators Increases availability of processed foods (fast foods, snacks, soft drinks) through growth of fast food outlets, supermarkets and food advertising/promotion; driven by trade and FDI Imports change availability of foods and/or their price Where included in this report Role of TFCs, trade FDI, supermarkets, advertising summarised here in section 1.3.3; food advertising and promotion also included as a separate review of earlier systematic reviews in section 1.5 Here, in sections 1.3.3 and 1.3.4; also referenced in section 1.2.4 on agricultural policy

Liberalisation of international food trade

Global food advertising and promotion Development of supermarkets

Shapes food preferences by affecting desirability of different foods Growth of transnational supermarkets changes food availability (increases diversity of available products), accessibility, price, and way food is marketed Migration, TNCs, and tourism introduce and popularize new foods (changes food availability and desirability) New forms of global food governance limits the ability of countries to implement policies to restrict availability and alter price of foods associated with negative dietary change Changes type of foods available, their price and the way they are sold and marketed Affects ability to transport, store and process foods, which affects their availability, accessibility and price Changes way food is produced, type of foods available, their price and the way they are sold and marketed

Here, in sections 1.3.3 and 1.3.4; food advertising and promotion also included as a separate review of earlier systematic review in section 1.5 Growth of supermarkets here in sections 1.3.3 and 1.3.4; plus, specific effects of food retail environment on diet subject to full systematic review section 1.4 Here, in sections 1.3.3 and 1.3.5

Cultural influences

Development of new forms of global food governance Liberalisation of foreign direct investment (FDI) Technological developments Domestic agricultural liberalisation

Here, in section 1.3.3

(126;132;149;165) (114;115;118;141)

Here, in sections 1.3 and 1.3.4 Here, in section 1.3.3

(129;166)

Here, in sections 1.3.3 and 1.3.4

* Ranked according to how often they are mentioned in the 39 papers.

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1.3.3.1 Growth of transnational food companies (TFCs) Twenty papers identified the growth of transnational food companies (TFCs) as a critical determinant of changing dietary patterns (116;118127;130;135;136;138;144;147;150;152;167). The basic rationale was that they increases the availability of processed foods through growth of fast food outlets, supermarkets and food advertising/promotion. Chopra et al. (122;125) and Lang (135;136) propose that this stems from the fact that TFCs now increasingly organize food production, distribution and marketing on a global scale. The availability of transnational brands of fast foods, snacks foods and soft drinks were identified as particular concerns: numerous papers referred to the spread of fast food companies around the world (118;122;124;130;136;144). Kennedy et al. (118) noted, for example, that in Latin America the number of McDonalds outlets increased from 100 to 1581 between 1985 and 2002, and Kinabo (134) reported that even in countries like Tanzania where numbers remain quite small, their presence and popularity is rising fast, propelled by advertising and promotion. Hawkes (130) details the market expansion of fast food and soft drinks companies around the world and their efforts to promote consumption, not just through advertising, but through strategies on packaging, price, and place. Chopra and DarntonHill (123) propose that TFCs deliberately try to increase consumption of these foods through several key mechanisms: advertising and promotion; large serving sizes; price inducements; aggressive entry into markets in developing countries; and by what they term substitution (the progressive reduction of agricultural products to simple industrial inputs that allows replacements by increasing non-agricultural components e.g., margarine replacing butter). TNCs are also identified as important agents of cultural change (see below). The only paper to actually measure dietary intake of modern fast foods, snacks and soft drinks in developing countries Adair and Popkin (120) found that these foods actually contribute relatively few calories to diets in developing countries (a summary of Adair and Popkin (120) is included in section 1.3.5). 1.3.3.2 International food trade Seventeen papers highlighted the implications of the increasing amount of international food trade for diets (114;119;121;122;125;128;129;133135;139;142;146;148;149;151;168). Their basic rationale is that imports change food availability and/or food price, with both negative and positive dietary implications. Chopra (122;125) notes that a progressive lowering of tariffs combined with increasing speed and lower cost of transportation has led to an explosion of cross border food trade, and argues that the supply of imported goods is shaping peoples food preferences, while also encouraging the formation of large TFCs. With reference to India, Pingali and Khwaja (119) consider that trade liberalisation greatly facilitates the widespread

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establishment of global supermarket chains and fast food outlets and thus speeds up the homogenous foods sand of a global diet in the Indian market (p.16). Pedro et al. (142) exemplifies the situation in the Philippines, where imports (as of 1999) contribute to over 50% of the total supply of milk and milk products. Fajorado (129) reports from Colombia that the proportion of calories from imported foods has been rising over time: available energy from several key imported foods had increased to 40% in 2000 and imports of vegetable oils as a percentage of total availability increased from 8.52% to 57.31% between 1990 and 2001. Kinabo (134), Mann (151) and Regmi et al. (169) emphasise the potential advantage of increased food trade: providing increased food variety and choice (151). Regmi et al. (170) argue that trade liberalisation has facilitated the availability of foods associated with the Mediterranean diet around the world, while Kinabo (134) notes that increased trade (and associated improvements of transportation) has improved the availability of fresh fruits and vegetables in Tanzania. Tullao (148) stresses both the dietary opportunities and threats arising from trade liberalisation. He notes that trade liberalisation has the effect of lowering food prices and production costs, but also growing the market for energy-dense, nutrient-poor processed foods. Vepa (149) says that higher imports into India have likely had little impact on diets: since the country began to open up its economy to external trade and investment in 1991, imports of edible oils and pulses have increased significantly, but she argues, it is unlikely that these have altered consumption since these products are price inelastic. Four papers also analyse the role of trade in changing diets in the Pacific Islands (128;133;139;146), three of which are summarised in the next section. 1.3.3.3 Global food advertising and promotion Twelve papers identified global food advertising and promotion as a critical determinant of dietary change (118;119;122-125;130;134;135;144;150;171). Their underlying rationale was that advertising and promotion, especially to children, shapes food preferences by affecting food desirability. The papers present the case that the use of aggressive marketing techniques by TFCs are shaping food preferences and stimulating the rapid adoption of new foods, especially energy-dense, nutrient poor foods (118;122;130;146). From Brazil, Sawaya et al. (144) reports that close to 60% of all food advertisements in 2002 were for foods high in fats and sweeteners. Hawkes (130) reports that fast food and soft drinks companies use a wide range of techniques to deliberately encourage children and youth to adopt regular and frequent consumption of these products in developing countries. Several papers support their argument by providing data on food advertising expenditures: according to Chopra (123;124), the food industry in the United States spend over $30 billion on direct advertising and promotions (more than any other industry) and expenditure is rising in developing countries as well. In South Africa, Coca-Cola spent $25 million on advertising in 2002, making it one of the
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top ten advertisers in the country. Though this literature lacks studies examining the actual impact of advertising and promotion on global dietary change, there is a body of the literature that examines the impacts of food advertising and promotion on the diets (and dietary precursors) of children, mainly in the United States and Europe. This literature is reviewed in section 1.5. 1.3.3.4 Growth of transnational supermarkets Eleven papers identified the rapid growth of transnational supermarkets as playing a potentially important role in dietary change, (114;118;119;125;127;129;134;136;144;145;172). Their basic rationale is that the growth of transnational supermarkets is changing food availability, accessibility and price. More specifically, the papers perceive that supermarkets play two important roles: shifting demand for home-produced foods or foods purchased in open (wet) markets to increased dependence on store-bought foods supplied by TFCs; and expanding available food choices, especially varieties of processed foods. The increased number of supermarkets in developing countries was widely reported, as was their comparative advantage in providing foods with a long shelf-life (i.e., packaged and processed foods) (144). Pingali and Khwaja (119) argue that supermarkets are playing an active role in accelerating and broadening the scope for diet diversification (p.17). This is considered by Hawkes (173) to be directly linked to globalization since their growth can be linked with policies implemented to facilitate foreign direct investment, as further exemplified in the next section. Kennedy et al. (118), Popkin (114) and Schmidhuber and Shetty (145) report on earlier work by Reardon and colleagues and analyse the potentially positive and negative dietary implications. They note that the general pattern of market entry of supermarkets into developing countries is marked initially by their specialization in the sale of processed foods; after establishment, supermarkets then diversify into products like frozen meat and fruits and vegetables. Supermarkets, they argue, have positive dietary implications such as making ultra-heat treated milk more widely available but also negative implications by providing unhealthy processed foods at lower prices. Many of the identified papers considered the rise of transnational supermarkets on dietary change a pressing research issue. Two papers were identified by the database search on food retailing on the types of foods consumers tend to buy in supermarkets vis a vis traditional stores in Argentina and China (174;175). As summarised in section 1.4.2, these papers that people tend to purchase more processed foods in supermarkets and more fresh produce in traditional markets. But as noted by Popkin (114) there is no research to date that can provide any analysis of the consequences of these food distribution shifts on dietary intake patterns (p.8). There is, however, a body of literature from high-income countries on the dietary implications of the lack of supermarkets and other retailers in

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impoverished neighbourhoods. These papers are subject to a full systematic review in section 1.4. 1.3.3.5 Cultural influences Nine papers highlight the role of cultural influences in introducing new foods, and desire for those foods, into the diet, thereby affecting food availability and food desirability (125;127;135-137;140;148;152;153). TNCs, tourism, and migration, were identified as the key cultural influences. Lang critiques (135;136) the influence of TNCs on the basis they have encouraged negative transfers of tastes and preferences from high- to developing countries. Cwiertka (127) notes that in urban India, TNCs are penetrating the cultural traditions of middle class households leading to changes in patterns of eating and local traditions (127). Watson (153) presents an anthropological analysis of the role of McDonalds in changing food cultures in East Asia. He argues that McDonalds has successfully adapted to but also nurtured and encouraged changes in family values in the region during the 1980/90s and in so doing, encouraged children to adopt fast food as a social norm, habits they will then pass onto future generations. Leatherman and Goodman (137) highlight the role of tourism in Mexico, as expanded upon below. Lang (136), McKay (152) and Mennell (140) also note the importance of migration in spreading ethnic foods from middle- or low-income countries to high-income countries (e.g., from Asia to Europe) or with regions (e.g., from China to Malaysia), processes that, they note, have been ongoing for hundreds of years. 1.3.3.6 Global food governance Five papers explicitly criticize the development new forms of global food governance mechanisms from a dietary perspective (125;128;135;136;138). Institutions such as the World Trade Organization (WTO), the authors argue, prioritize commodities over public health, and undermine local food production. A particular concern is that TNCs have increasing influence in global food governance, which will further encourage the development of unhealthy dietary patterns. The authors also argue that these new governance mechanisms affect the ability of countries to implement policies to address the negative aspects of globalization and dietary change. 1.3.3.7 Foreign direct investment (FDI) Four papers consider the role of foreign direct investment (FDI) in dietary change on the basis that this changes the type of foods available and their price. Hawkes (132) presents evidence to support the hypothesis that the more liberal investment environment associated with globalization has made it easier for food manufacturers to produce and sell more highly processed foods at lower prices. The study notes that governments have

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been liberalizing rules on cross border investments and increasing investment incentives since the early 1980s and that this can be directly associated with the growth of FDI into food processing in developing countries. As FDI has risen, the allocation to highlyprocessed foods has risen. This is exemplified in a second paper, which is summarised in the next section (176). Vepa (149) briefly considers the role of FDI in dietary changes in India. She notes that while the consumer food industry remains relatively small, it has been growing since 1990, notably in packaged bread and biscuits. Consumption of these products has increased. Yet she also notes that a relatively small proportion of this growth came from foreign relative to domestic investment: of the United States$156 billion of investment in the Indian processed foods industry between 1991 and 2002, just $US2 billion was from FDI. In an earlier paper, Connor (126) singles out FDI from TFCs in the United States into Europe during the 1980s as a critical driver in the convergence in the food patterns between the two regions. 1.3.3.8 Technology and transportation Four papers highlight the importance of the availability and access to modern technologies in dietary change on the basis that this affects the transportation, storage and processing of foods, and therefore their availability, accessibility and price (114;115;118;141). Important technological factors identified were transportation networks (to transport and trade food), car ownership (encouraging different shopping patterns), access to electricity and electric devices (such as refrigeration used by TNCs and in households). Echoing earlier work presented in Drewnowski and Popkin (115), Popkin (114) exemplifies the importance of technology in increasing the global availability of vegetable oils. He notes that prior to 1945, the majority of fats available for human consumption were animal fats, milk, butter, and meat. Subsequently, a technological revolution in the production and processing of oilseed-based fats occurred, which greatly reduced the cost of baking and frying fats, margarine, butter-like spreads, salad oils, and cooking oils in relation to animal-based products. Along with a number of major economic and political initiatives in oilseed production and trade, he attributes this to an almost fourfold increase in vegetable oil production in the United States (in contrast to an increase in animal fat production increased by 11%) between 1945 and 1965, and a tripling in the global availability of the vegetable oils between 1961 and 1990. 1.3.3.9 Domestic agricultural liberalisation Two papers referred to domestic agricultural liberalisation as a process of globalization with dietary implications on the basis that it changes food availability and price (129;177). Hawkes (178) argues that more market-oriented domestic agricultural policy has provided the facilitating context for greater international food trade and investment,

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and presents the example of the domestic liberalisation of vegetable oils (summarised in the next section). In Colombia, Fajardo (129) suggests that the liberalisation and modernization of the poultry and pork industry during the 1990s, combined with lower trade barriers on animal feed, had the result of increasing the total availability of poultry and pork in the country. The 39 papers reviewed here identified nine globalization processes as important agents of dietary change. But few of these papers made a concerted effort to provide evidence of a specific and traceable link between one of these processes in a particular context and the dietary indicators of concern in this review. For example, several papers (e.g., (129;142)), identified increasing food imports as a critical process of globalization, but failed to show if or how this may be affecting total food availability. Thus despite much discussion and debate, they do not actually provide empirical information on if these processes have actually affected dietary indicators, let along measurable dietary outcomes. Four papers did, however, attempt to make a link between specific dietary indicators and a particular change in a globalization process or policy. These four papers are reviewed in the next section. 1.3.4 Linking globalization policies and processes to specific dietary indicators

The four papers attempt to trace links between globalization and dietary indicators, but still remain in the realm of hypothesis generation rather than testing since they do not provide empirical information on if these processes have actually affected dietary outcomes. Three papers examine the role played by international trade specifically food imports in the rising availability and consumption of fats (and associated levels of obesity) in the diets of Pacific Islanders. Evans (128), Hughes and Lawrence (133) and Schultz (146) note that before 1945 each Pacific Island was essentially food self-sufficient, with nutritionally adequate diets comprising locally produced staples, fish and fruits. After 1945, the Europeans colonized the islands and foods began to be imported. This marked a specific change in the foods available on the islands: people began to consume increasing amounts of imported foods, so changing their source of calories. The papers argue that changes in food availability contributed to the changes in dietary patterns observed on the islands over the past 60 years: the transition from healthy, locally-sourced foods (preimports) to unhealthy, fatty foods (post-imports). This, they contend, can help explain the rapid increases of obesity and associated diet-related diseases on the islands. In Fiji, Schultz (146) reports that the total energy supply derived from imported foods rose from 43% to 60% between 1985 in 1996. In 1996, 100% of pulses, 95% of vegetable fats, 82% of cereals, 50% of animal fats, eggs and vegetables, and 57% of meat were

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imported. In Tonga, Evans et al. (128) reports that meat imports rose from 3389 to 5559 tonnes between 1989 and 1999, mainly of high-fat chicken parts. During the same period, consumption increased by 60%. A recurring theme is that neighbouring Australia and New Zealand use the islands to dump their high fat meat cuts, such as mutton flaps and turkey tails. Hughes and Lawrence (133) present national food availability data for fats for seven different Pacific Islands. Between 1963 and 2000, the total fat supply increased by between 5% and 80%, the largest increases in the most economically advanced islands (80% in French Polynesia and 65% in Fiji). The paper suggests that this increase occurred because imported fats and oils have added to existing sources of fats, such as coconut oil. The paper also presents, second-hand, the results of a 1998 chronic disease survey on the island of Vanautu. The survey showed that the proportion of energy as fat consumed from imported foods was 44.8% for urban populations compared with 8.4% from rural and semi-rural populations. People who consumed fats from imported foods rather than traditional fats were 2.2 times more likely to be obese and 2.4 times likely to be diabetic. Individual imported foods providing fat were identified as vegetable oils, margarine, butter, meat and chickens, canned meat and canned fish. The three papers come to the conclusion that increased fat imports has been a major determinant of increased fat availability, and, consequently, consumption throughout the Pacific Islands, which in turn has led to high levels of obesity and diet-related chronic diseases. Quality issues: The results of these studies should be interpreted with caution. Although it is clear that fats are imported, and that imports provide an increasing source of calories, it is not possible, on the basis of the evidence provided, to conclude that increased imports is the primary driver of increased fat consumption. For rather than imports driving demand, other determinants, such as income and urbanisation, may in fact be stimulating greater demand for fats, which in turn is met by imports. The papers also do not actually present data on direct and indirect substitution between imports and local foods and how this has affected the overall nutrient balance of the diet. One of the papers, by Schultz (146) even shows that while the percentage of energy supply from imported foods increased between 1985 and 1996, the amount of energy from imported foods has actually declined since 1993. Second, many of the major changes predate the onset of economic globalization of the 1980s; food imports were already very high by the 1970s and the papers do not identify whether changes of imported foods is stimulated directly by any particular policies implemented to advance globalization (such as a free trade agreement). The studies also present data on changes in imports from quite random dates which do not date back to the original changes of the globalization process (opening up

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the imports post-1945). Third, the results cannot be generalized to other settings since the Pacific Islands are small island states with very unique and distinct histories. The fourth paper attempts to link globalization policies that have affected domestic agricultural liberalisation, international trade, FDI and advertising and promotion to increased availability and/or desirability and/or lower prices of vegetable oils and processed foods. Hawkes (179) presents the results of three case studies, the first concerned with vegetable oil availability and consumption and globalization policies in Brazil, China and India. The study starts by noting that in the 1990s, in line with the globalization agenda, the Brazilian government opened up its soybean market by reducing restrictions on FDI, restructuring farm income taxes, lowering import tariffs on fertilisers and eliminating the soybean export tax. The result was a 67% increase in Brazilian soybean oil production between 1990 and 2001, a more than doubling of exports, and one of the lowest soybean oil prices worldwide. During this time period, however, per capita calorie consumption from soybean oil remained stable in Brazil even declining. The study therefore hypothesises that the increased availability of soybean oil had dietary implications elsewhere, notably China and India, where markets were also opening up in line with the globalization agenda. The paper reports that during the 1990s, China implemented new tax and import regulations to encourage soybean oil imports. Subsequently, Brazil became a major source of soybeans and the amount of soybean oil available for consumption in China soared. Household survey data now suggest that vegetable oil consumption has increased significantly throughout China in the past 15 years. The same applies to India: in 1994/95, trade reforms in India led to significantly higher imports of vegetable oil from Brazil. This had the affect of increasing availability and lowering prices. Consumption of imported oils subsequently increased, so changing the type of vegetable oils being consumed: by the end of the 1990s, soybean oil accounted for 21% of consumption in contrast to the complete dominance of domestically produced peanut, rapeseed and cottonseed oil in India the 1970s. The case study suggests that while this may appear to increase homogeneity, competition in the vegetable oils market is also leading to the development of new vegetable oils with positive health profiles. These oils will be targeted at high income consumers, while the cheap vegetable oils will be targeted at the mass market. The second case study asks whether trends in processed food availability in Mexico can be linked with the North American Free Trade Agreement (NAFTA), signed by Mexico, the United States and Canada in 1994. The study starts by noting that NAFTA contained key provisions designed to facilitate foreign investment. A significant consequence of these more liberal investment rules was a rapid acceleration of FDI from the United States into Mexican food processing: in 1993, US FDI into the Mexican food processing

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industry was US$210 million, which, in the anticipation of NAFTA, had increased to US$2.3 billion by 1993. Five years after NAFTA, the United States invested US$5.3 billion into the Mexican food industry, nearly three-quarters of which was into the production of processed foods. The study hypothesises that FDI stimulated the growth of the processed foods market in Mexico during this period. Although very little data is available on processed food consumption, between 1995 and 2003, sales of processed foods (e.g., soft drinks, snacks, baked goods and dairy products) expanded rapidly relative to other food groups, at a rate of 5-10% per year. The study then goes on to examine the role of transnational supermarkets in this trend. It shows that NAFTA stimulated the growth of transnational retailers (the number of chain supermarkets, discounters, and convenience stores grew from less than 700 to 3,850 in 1997, and 5729 in 2004) to account for 55% of all food retail in Mexico. However, the fact that many soft drinks and snacks are sold by the remaining 45% of food retailers thousands of traditional, family-owned, general merchandise stores or street vendors and open markets suggests that supermarkets cannot be directly implicated more than any other retailers in the growth of processed foods consumption during this period. But the paper argues that supermarkets are likely to be critical in the long-term future growth of the processed foods market given that their size, capital base, economies of scale in storage and distribution and technological advancements in supply logistics, means they are able to make available a far wider range of processed foods than small stores, to take the risks inherent in introducing new foods, and to sell them at lower prices. It also means they are more able to stock and promote healthy processed foods targeted at high-income consumers, alongside cheap, low quality processed foods targeted at lower income groups. The third case study asks whether the increase in the desirability of snacks, and associated increases in consumption among children in Thailand can be linked with the globalization of TFCs and the advertising and communications industry. The study starts by noting that the advertising and promotions industry in Thailand is among the most developed, dynamic in Asia: from 1987 to 1996, advertising expenditures grew nearly 800%, and advertising revenues have grown at double digit figures in recent years. The paper hypothesises that two sets of policies have contributed to this dynamism, both related to the countrys tradition of openness to trade and investment. First, foreign ownership of advertising/marketing agencies is not restricted, and while advertising is regulated to some degree, campaigns are not subject to restrictions like maximum foreign content requirements. Second, free trade agreements have encouraged the influx of foreign food brands, so creating the incentive to promote differentiation between brands and products within and between domestic and multinational companies. This relatively open market, the paper argues, has encouraged TFCs to enter Thailand and to use the

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network of global marketing and communications agencies to develop highly sophisticated marketing campaigns using wide variety of promotional techniques. The study provides the example of the American company Frito-Lay. When Frito-Lay first consolidated their presence in the country in 1999/2000, per capita snack consumption was still relatively low (1kg per person per year in 1999 compared with 3kg in Mexico and 10kg in the United States), so the company developed an aggressive strategy to increase consumption, and more than doubled their promotional spending between 1999 and 2003. Frito-Lays share of the total snack market subsequently grew from the low single digits in the mid 1990s to 30% by 2003. More importantly from a dietary perspective, the entry of Frito-Lay into the market also had the affect of stimulating growing total snack sales. Snacks sales grew particularly rapidly during 1999-2004, the period of most intensive marketing, and sales volumes of the most heavily promoted products (chips and extruded snacks) increased by the largest amount. From these three case studies, the author concludes that although the dietary changes may be the result of increase demand, a series of globalization policy reforms in these countries shaped the availability, price and desirability of vegetable oils and processed foods, with implications for longer-term dietary development. Quality Issues. The conclusions of this paper should be interpreted with caution since the case studies were not designed to measure or model the dietary impact of globalization. The most important limitation of the narrative is that the supply-side factors discussed may simply be responses to changing demand. This means, for example, that imports may merely be substituting what otherwise would be domestically produced, and FDI substituting domestic investment. The impact of globalization on indicators of vegetable oil and processed food consumption therefore remains purely speculative. 1.3.5 Globalization policies and processes and dietary outcomes

Two of the dietary impacts of globalization emphasised by the earlier papers were dietary convergence and increased consumption of fast foods, snacks and soft drinks. Three papers measured these dietary patterns in the context of a globalization. But, as already noted, they do not actually measure an association between a globalization policy or process and dietary outcomes, so should be interpreted in that light. Taking a global perspective, Bruinsma (121) takes on the hypothesis advanced in the conceptual papers that globalization is leading to dietary convergence. He does so by modelling the degree of convergence in consumption of primary commodities between countries with food economies at differing stages of globalization. Consumption is measured using the food availability statistics in the food balance sheets of the Food and Agricultural Organization of the United Nations [FAO]). Convergence is measured using

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a consumption similarity index (CSI) which compares how many calories consumed in different countries originate from the same primary products. Degree of globalization is not measured per se; rather, some countries are assumed to have greater degree of openness than others (e.g., through increased trade, technology adoption, market liberalisation, communication infrastructures, economies of scale in market, retailing and promotion etc). The study uses the index to estimate the similarity in the consumption of 29 primary product groups in 150 countries relative to the United States over a period of 70 years (1961 to 2030). It finds that countries perceived as fully integrated into the global food economy broadly equating to the traditional OECD countries have diets similar to the United States. Around 75% of calories available (i.e., CSI=75%) in these countries come from the same primary commodities as the United States. In contrast, the CSI in Asia and Africa is 30% and 40% respectively, and there is far greater variation between the countries relative to the relatively tight OECD cluster. The study also finds that since 1960, diets have converged everywhere. Bruinsma asserts that diets have converged faster in the countries that have undergone the globalization process more rapidly. For example, the CSI for Japan rose from 40% to 70% between 1960 and 2000 and for South Korea from 20% to 65%, whereas the CSIs in Indonesia and Thailand increased from 30% to 45%. Bruinsma concludes that the forces of globalization have resulted in a growing convergence of consumption patterns openness to trade and investments, geographic location, income levels and growth and TNC activity are almost always associated with a rapid convergence in food consumption patterns (p.288). Quality Issues. This study has some major limitations. First, it does not measure the degree to which the countries have globalized their food economies. It simply assumes that the OECD countries have more open food economies and that countries such as South Korea and Japan have globalized faster. This limitation considerably compromises the conclusion that globalization enhances convergence. Secondly, the CSI is based on food availability statistics, which are not measures of actual consumption. Thirdly, and related, the CSI only captures the similarities in the structures of the diet in terms of primary products as defined in this study, not the degree of similarities in food products actually consumed (which, as suggested by the conceptual models outlined above, may show divergent patterns). Moving down to the national scale, Adair and Popkin (120) describe the changes in consumption of modern processed foods in four countries in the context of growth if TFCs (the study is not designed to measure the association between the rise of TFCs and dietary outcomes). The study examined changes in consumption of fast foods, snacks and soft drinks among youth using household survey data from in China, Russia and the Philippines (Cebu in Metropolitan Manila) and the United States. Data for the United

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States and Russia came from two rounds of nationally representative surveys, for China from rounds of a national survey, and for the Philippines, a sample of around 2000 people. The study found that in the United States, calorie consumption from modern snack increased among youth from 3.5% to 7.6% between 1977/78 and 1994/98. Percent calories from fast food rose from 3.5% to 7.6% in the same time period, and from soft drinks from 4.8%-8.5%. The contribution of these foods to caloric intake in the other countries was much smaller. In Chinese youth, modern snacks, fast foods and soft drinks made up less than 0.1% of caloric intake in both 1991 and 2000. In Russian youth, percent calories from modern snacks rose from 0.9-1.4% between 1994-2003, fast food remained the same at 0.2% and soft drinks rose from 0.2-0.5%. In Cebu youth, percent calories from modern snacks declined from 2.6% to 0.6% between 1994 and 2002, fast food remained the same at 0.7%, and soft drinks rose from 1.6% to 3%. The authors thus concluded that relative to the United States, the presence of fast foods, snacks and soft drinks in the diets of youth remains relatively small, although these products are beginning to affect diets of youth in these countries. Quality Issues. As already noted, the results of this study should not be interpreted as an impact analysis of the rise of TFCs, since no measurement was made of whether foods consumed were obtained from TFCs. Nor did it measure changes in the number of transnational fast food outlets selling snacks, fast foods or soft drinks, the retail availability of these foods manufactured by TFCs, nor the trade or FDI into these products during the time period of the household surveys. At a more local level, Leatherman and Goodman (137) examine the impact of global tourism, as a measure of cultural influence, on dietary patterns in the Yucatan region of Mexico in the context of what they term coca-colonization. They compare dietary intake in two coastal villages dominated by tourism, a third village inland characterised by a strong tourist trade, and a fourth village little affected by tourism (although some inhabitants migrated to work in tourism). They measured dietary intake in 30 households in each of the four villages (1996-1998), visited local stores to identify the range of foods on sale, and interviewed store owners about food purchasing patterns. The study found that the populations in the coastal villages (i.e., those most affected by tourism) had greater dietary diversity, but this diversity was characterised by a replacement of the traditional tortillas by soft drinks, snack foods and meat, along with greater fruit intake. In terms of nutrients, coastal communities consumed more fats, high quality protein, and micronutrients. In all villages, soft drinks, snacks and sugar accounted for the third largest proportion of calories consumed relative to other food groups, and transnational soft drink and snack food brands were widely available in local stores. The authors

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conclude that these types of dietary changes can be expected to continue as the villages become more affected by globalization. Quality Issues. This was a very poorly designed study (which explains why the numerical results are not included here). The lack of a sampling frame, small sample size and the use of unstructured qualitative analysis means that the results can only be used as the basis of hypothesis generation, and not to test an association or generalized to other contexts. 1.3.6 Summary, discussion and conclusions

This section has presented a survey of the literature on the relationship between globalization and the human diet. It has attempted to answer the question: Is globalization a determinant of diet, and if so, how does it affect diet? In conducting this review, it became clear that the literature on globalization and diet raises more questions than it answers. First, the literature was full of papers providing arguments and opinions on globalization, or providing data on dietary changes, without actually linking them together. This applies almost as equally to dietary indicators as dietary outcomes. Second, even where studies did attempt to make the link, the studies were not designed to measure or model a clear association or cause and effect. Third, the dietary changes measured tend not to provide information on the globalized foods under discussion, such as processed foods. The evidence base is thus quite weak. While the nature of the evidence base limit the conclusions that can be drawn, the process of reviewing the literature did enable lessons to be learned from this body of work from a policy making perspective. These lessons are as follows: First, it is widely accepted that globalization is playing an important role in the development of dietary patterns linked with the growth of diet-related chronic diseases, such as diet-related cancers, in the developing world. Second, the conceptual understanding of globalization as a dietary determinant is growing. It is now more evident that there is no contradiction between globalization as a homogenising and a diversifying dietary force, since the nature of globalization facilitates both processes. The diversifying nature of globalization processes has positive implications, but also raises the policy concern that globalization may encourage the uneven development of new dietary habits between rich and poor. As high-income groups in developing countries accrue the benefits of a more dynamic marketplace, lower-income groups may experience convergence towards poor quality obseogenic diets, as has been observed in western countries. People of low socio-economic status (albeit not the poorest of the poor) are more likely to be influenced over the long-term by the converging trends of the global marketplace, while the more affluent and educated move onto the more expensive, healthy market niches.

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Thus much of the influence of globalization on diet will depends on the context in which its policies and processes are operating. Third, the review confirmed that several specific globalization policies and processes require particular attention from a policy making perspective. It also identified the dietary indicators which these processes are likely to affect links which can inform future research in this area. These are: the growth of transnational food companies and food availability; the liberalisation of international food trade and food availability and price; global food advertising and promotion and food desirability; the development of supermarkets and food availability, accessibility and price; cultural influences and food availability and desirability; the development of new forms of global food governance and food availability and price; the liberalisation of foreign direct investment and food availability and price; technological developments and food availability, accessibility and price; and domestic agricultural liberalisation and food availability and price. The papers present the case that these globalization processes are driving changes in these dietary indicators, which in turn is leading to the development of dietary patterns high in energy, fats and sweeteners, so giving rise to obesity and diet-related chronic diseases. In identifying the globalization policies and processes of most significance, and their links with dietary indicators, the review refines the context for how to proceed in research and policy making to address the role of globalization in global dietary change, and the opportunities and challenges therein. Fourth, in specific national contexts, case studies suggest that processes such as food imports, market liberalisation, foreign direct investment, and the growth of TFCs, supermarkets, and advertising can shape peoples dietary choices. These policies and processes identified are all supply-side processes in that they drive changes in consumer behaviour by altering the food supply and, therefore, the availability, accessibility, quality, price and desirability of foods. But demand-side aspects of globalization could be equally important. In fact, the papers reviewed were all based firmly in the context of three key demand-side drivers: urbanisation, income growth and changes in employment. These processes were identified as critical since they provide the cash and incentives for people to choose different foods, especially foods which are more convenient. Indeed, it has been argued that income growth and urbanisation are the key drivers of dietary change around the world (180) and thus that supply-side changes may simply be responses to demand side drivers arising from such changes. This fundamental tension is not dealt well with in the literature, in large part because of the lack of high quality studies conducted by either epidemiologist or economists that allow the relative role of these different factors to be identified. It also indicates that the findings of this review should be interpreted in the light of findings on income, urban living, and employment status made in Chapter 2 of this report. Hypothetically, it is likely that the dietary changes observed are a balance of both supply- and demand-side processes, but without studies designed to examine cause and effect, it is difficult to conclude where and how it is appropriate to intervene in these

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supply-side processes. Still, the evidence on changing dietary patterns, and the fact that supply-side processes are facilitating negative choices, should not be ignored by policymakers. From a research perspective, work is urgently needed to link known information about dietary change to globalization policies and processes. Researchers are beginning to try to understand the dietary outcomes of globalization but their efforts are limited by the lack of data availability or poorly designed studies. The rhetoric and fierce debate around the merits and problems of globalization renders it critically important that research is well-designed and focused on the key questions from a policy-making perspective.

1.4 Results: Food retailing

1.4.1 Searching, characterising and classifying the literature 1.4.1.1 Characterisation of the literature Most of the 1221 articles retrieved by the databases were clearly irrelevant, dealing, for example, with food retail development, or presenting the results of interventions conducted within a supermarket setting (the latter papers are covered in the interventions review in Chapter 3). These papers were excluded on the basis of the initial title and abstract scan. The remaining papers were scanned to see if they presented results on the association between food retailing and the availability, accessibility, quality, price and desirability of food. 132 papers were identified that broadly fit these criteria. On reading these papers, it became clear that there were two clear gaps in the literature. First, very few relevant papers were concerned with how food retailers affect the desirability of food through promotional strategies. To confirm this gap, a further search was conducted using terms concerning food promotion at point of sale, but no useful papers were identified that fit the inclusion criteria (the lack of literature in this area was also noted by Hastings et al. ((180;181)) and McGinnis et al. (182) in section 1.5.3). Second, there were no studies designed to examine the dietary impact of the rapid rise of the number of supermarkets in developing countries. The papers reviewed in the earlier section on globalization hypothesised that the growth of supermarkets in developing countries has made processed foods more available and accessible(section 1.3.3.4). Just two papers were identified, from Argentina and Taiwan, China, which examined this question and in a very limited way. Even though these papers do not report dietary outcomes, they are summarised here since they describe the foods available according to the type of food retailer. The rest of the available literature was from high-income countries, where the spatial absence of supermarkets is viewed as the core issue from a dietary perspective, and their role in providing fresh fruits and vegetables and other healthy foods considered more relevant than their role in providing processed foods. These papers were notable in three
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respects: they were mainly set in the context of retail food access in low-income neighbourhoods in Australia, the United Kingdom and the United States; they all focused on supermarkets, and relatively few of them included dietary outcomes. Even when diet was measured, the studies were not designed in a way to allow conclusions on cause and effect to be drawn. Clear inclusion and exclusion criteria were set for these studies, as listed on Table 1.13. Many of the 132 studies were excluded on the basis of poor study design, or because they did not actually measure any aspect of the food retail environment. Based on the inclusion/exclusion criteria, twenty papers from high-income countries were selected for inclusion in the review. These papers either examined the relationship between the food retail environment and dietary indicators (food availability, accessibility and price), or with dietary outcomes (household food expenditure, dietary intake, diet-related health). The former papers do not warrant a full review since they do not actually measure dietary outcomes, so are summarised en masse with no particular reference to quality. The latter papers are subject to a full systematic review. 1.4.1.2 Classification of the literature To summarise, 132 of the original 1221 articles were requested in their full paper form for a second level of selection and 127 were obtained for potential inclusion in the review. These papers were examined in more detail for relevancy and adherence to inclusion and exclusion criteria. Four articles that were not retrieved during the systematic database search process, but which were identified by the authors through personal knowledge or reference lists were also included, as were five additional papers from the search update conducted in June 2005. 22 of these articles met the inclusion/exclusion criteria. These statistics are summarised in Table 1.14 below.

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Table 1.13. Inclusion and exclusions criteria for review of food retailing Study characteristic Focus Inclusion criteria - Study on association between food retail environment and the dietary indicators of food availability, access and/or price - Study on association between food retail environment and dietary precursors - Study on association between food retail environment and dietary outcomes - Study from developing countries that examine the types of foods people buy at different food retail outlets Exclusion criteria - Study qualitatively assesses of barriers to healthy eating or preference for different food retailers with no measure of food retail environment - Study describes socio-economic, demographic and cultural determinants of food purchasing habits with no measure of food retail environment - Study describes food retail access for a particular population group without comparing groups - Study describes differences in food availability and/or price between different areas but without systematically reporting the role of food retail outlets in influencing these differences - Conceptual papers or commentary articles

Study type

Foods

Quality

- Study presenting the results of a research study - Comprehensive reviews of the research literature - At least one of the food or nutrients related to cancer as described in the introduction - Measured testable differences in the food retail environment - Included significance tests - Sample size large enough for significance tests to be valid

- Ecological studies with no controls (meaning that any other area-level effect could explain the difference) - No significance testing - Self-selected samples - Sample sizes too small to be able to draw conclusions - Inadequate multivariate analysis - No control for confounders,

Table 1.14. Food retailing: Summary of the literature selection process Papers identified through initial database search Papers requested in full paper form for second-level review Papers obtained from updated searches (June 7 2006) Papers obtained from own knowledge Papers obtained for potential inclusion in review Papers included that met inclusion/exclusion criteria and are included in the review 1,221 132 5 4 136 22

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1.4.2

Food purchasing patterns in food retailers in developing countries

Two papers were identified which examined, in a very limited way, differences between food purchasing patterns between different types of retailers (a third was also identified but rejected due to small sample size and other design flaws). In Argentina, Rodriguez et al. (175) explored differentiation of supermarket buying habits among categories of food products. Data came from the national household expenditure survey of 1996/97 which includes information on where different foods were purchased (supermarkets and hypermarkets relative to small stores). Probit models were used to examine if consumers were more or less likely to purchase particular product categories in supermarkets. The estimates show that for all levels of income, there is always a higher probability that a household will buy meat, vegetables fruit and bread in smaller stores rather than a supermarket. The results are not fully reported, so it was not clear if there were any significant differences in other food categories examined (e.g., bakery products, pasta, milk products). Li and Houston (174) assess the differences between purchasing patterns for fresh foods and processed foods between supermarkets, traditional vegetable markets, hypermarkets, consumer cooperatives, CVS and grocery stores in Taiwan, China. They surveyed 1,200 randomly selected food consumers conducted between January and February 1999 (randomly stratified sampling). The survey asked consumers if they had purchased 188 types of processed foods or 130 kinds of fresh foods at any of 18 predefined types of food retail outlet in the past year, as well as questions on socio-demographic characteristics. Stepwise regression was used to identify the significant variables explaining the choice of food retail outlet for fresh foods and processed foods (with a distinction made between whether outlets were used for planned versus occasional purchases of processed foods). Since the aim of the study was to examine the characteristics of shoppers at different outlets, the results of the analysis of the different types of foods purchased from each type of retail outlet are rather limited. The study found that 83.3% of the surveyed consumers shopped at traditional vegetable markets over the past year, and 80% had shopped at supermarkets. 47.1% of all surveyed consumers most frequently purchased fresh foods at traditional vegetable markets relative to 23.6% at a supermarket; 17.7% of all surveyed consumers most frequently made planned purchases of processed foods at supermarkets relative to 7.5% at vegetable markets, and 29% for occasional purchases relative to 8.2% at vegetable markets. 1.4.3 Food retail environment as a dietary indicator

Ten studies examine the food retail environment and the dietary indicators of food access, availability and price. Four studies measured access (183-186) (i.e., the distance between households and food retailers, or the density of food retailers in the neighbourhood of the

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household), one paper measured access and food availability (187), four papers measured food availability and price (188-191), and one paper presented the results of a literature review (192). These studies were assessed for coherence to the inclusion/exclusion criteria to ensure only high quality studies were included. Yet since none of these studies can actually determine whether the food retail environment is associated with dietary precursors or outcomes (only indicators), they are summarised below and in Appendix 1.3 rather than presented in full. Quality concerns with the papers are also summarised in Appendix 1.3. 1.4.3.1 Food retail access and food availability at food retail outlets The four studies measuring access and the one measuring access and availability were based on the precept that access to food retailers selling healthy foods is a dietary determinant. The context for this research is the food deserts hypothesis that food retailers avoid deprived neighbourhoods, leaving a desert where residents have nowhere to purchase healthy foods. Studies have also examined the presence in these deprived neighbourhoods of fast food outlets selling unhealthy foods. All five included studies were from the United States. Block et al. (183) found that populations in predominantly black areas in New Orleans were exposed to six times more fast food restaurants than predominantly white neighbourhoods. Moore and Roux (184) report from Maryland, New York State and North Carolina that there are significantly fewer supermarkets, and significantly more smaller grocery stores, in predominantly black or racially-mixed neighbourhoods, and in poorer neighbourhoods, relative to predominantly white and higher income neighbourhoods. Morland et al. (193) identified a similar pattern in a study in Mississippi, Maryland, North Carolina and Minnesota: there were significantly fewer supermarkets in predominantly black and lower income neighbourhoods, but significantly more grocery and convenience stores. The study also found that there were significantly fewer fast food restaurants and takeaways in black neighbourhoods, and no significant differences between neighbourhoods with different income levels. Zenk et al. (194) found in metropolitan Detroit that populations in black and poor neighbourhoods had to travel a longer distance to supermarkets relative to neighbourhoods with fewer blacks and lower poverty. Within black neighbourhoods, there was a significantly longer distance in the poor neighbourhoods compared with middle or high income blacks, whereas this relationship was no found for white neighbourhoods with differing poverty levels. Baker et al. (195) found that neighbourhoods characterised dominance of African-Americans (regardless of income), or mixed race or white (high poverty) were less likely to have access to supermarkets or fast food outlets selling foods adhering to dietary guidelines in metropolitan St Louis, Missouri.

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Of note, one study from Australia and three from the United Kingdom presented the results of ecological studies on the relationship between area-measures of deprivation and the density of fast food outlets. These studies were excluded on the basis they were ecological studies with no controls, meaning that any other area-level effect could explain the difference. Nevertheless, their results are much cited. In Australia, Reidpath et al. (196) found that people living in areas of Melborne with the lowest median income category had 2.5 times the exposure to fast food outlets than people living in areas in the wealthiest category. Cummins et al. (197) found that as degree of neighbourhood deprivation increases in England and Scotland, the number of McDonalds restaurants increases. The same group of researchers (Macintyre et al. (198)) found, however, that in Glasgow, no significant differences between density of out-of-home eating outlets, including fast food outlets, and neighbourhoods with different levels of deprivation. In conclusion, the evidence from the highest quality studies suggests that people living in black and poor neighbourhoods in the United States have less access to supermarkets relative to smaller grocery stores. No clear conclusion can be drawn on fast food outlets. Evidence from Australia or the United Kingdom comes from studies that are of too low a quality to be included in this review and thus no conclusions can be drawn. 1.4.3.2 Food availability and food prices at food retail outlets Four studies, all authored by economists, examined food availability and food prices between different types of retailers in different locations, all in the United States. The studies are limited by the fact that they are not explicitly concerned with the degree of healthiness of the foods. Chung and Myers (188) found that in metropolitan areas in Minnesota, the average price of a market basket were significantly lower in chain (supermarkets and large grocery stores) than convenience/small grocery stores ($16.62 price gap). Controlling for poverty, availability and percentage of all stores in zip code, chains had the effect of lowering the market basket price by $11.81. Availability of foods in the market basket was higher in chain versus nonchain stores, especially for fresh fruits and vegetables and meat (differences were less pronounced for other dried and canned goods and breads and grains). Availability had a direct impact on price: the direct impact of food availability was to lower market basket prices by $23.16 (i.e., the more food is available, the cheaper it is). The authors concluded that store type is an important determinant of price differentials, and is more important than neighbourhood location. Kaufman et al. (189) reviewed the literature on (among other determinants) the relationship between type of food retailer and food prices. Thirteen out of the 14 papers reviewed found that food prices are lower in supermarkets. The review made a tentative

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estimate of an average 10% difference between small stores and supermarkets. Again, store type was considered more important in prices that neighbourhood location: after controlling for store type and location, the review identified no significant relationship between neighbourhood income and food prices. Leibtag (190;191) assessed the price differences between traditional supermarkets and non-traditional large retail formats (e.g., super centres and wholesale clubs). He found that the price of eggs, low fat milk, fruits, vegetables, beef, poultry, coffee and sweet biscuits was significantly lower at non-traditional retailers relative to traditional supermarkets. A larger study on dairy showed that (controlling for similar-sized packages), dairy prices are 5-25% lower at non-traditional large stores than traditional supermarkets; skim and low-fat milk prices consistently 5-12% lower at non-traditional large stores. A representative basket of dairy products purchased at traditional supermarkets was 9.1% above non-traditional large stores. These price differences are significant, especially when compared with standard measures of food price inflation over time. The author concludes that that the growth of non-traditional retailers is an important determinant of food prices and will continue to drive variation and declines in retail food prices. Of note, nine studies examined the relationship between food retail characteristics and food availability and price but were excluded owing to poor sample design or weak analysis. These studies reported that: healthy foods are less available at smaller (e.g., convenience stores) relative to larger stores (e.g., supermarkets); stores in poor areas are less likely to stock foods that contribute to a healthy diet (199); and prices of foods recommended for consumption are more expensive than those which are not (200). Two of these studies found that food prices are less expensive in poorer areas (200;201). An additional study showed that availability of fruits and vegetables did not vary between neighbourhoods with different income levels, but that quality was significantly poorer in poor neighbourhoods (this study was rejected because it did not fully evaluate the role of food retail characteristics) (202). No conclusions can be drawn from the studies which are explicitly concerned with healthy foods, but from the three paper on the association between store type and food price, one of which was an extensive review of earlier studies, it can be concluded that, in the United States, the larger the food retailer, the lower the average food prices. 1.4.4 Food retail environment and dietary precursor or outcomes

Ten papers were included which measured the association between the food retail environment and a dietary precursor or outcome. These papers, which are described in full below, measured the association between the food retail environment, a dietary

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precursor, dietary intake, diet-related health (obesity, chronic diseases risks), or between changes in the food retail environment and dietary intake. The studies measured the association between these dietary measures and food retail access (measured either through density or distance or both) or the availability or price of healthy foods. These studies are also summarised in Appendix 1.3. 1.4.4.1 Association between food retail access and dietary intake Three papers measured the association between access and some measure of dietary intake, one of which measured density (203), one distance (204), and one both (205). All the papers were from the United States. Laraia et al. (205) used data from a prospective large study in the United States (which examined determinants of pre-term birth) to analyse the association between diet quality among pregnant women and distance and density of food retailers. The study, which used a cross-sectional design, focused on supermarkets. The study sample comprised 918 pregnant women living in Wake County, in the state of North Carolina (62% with incomes less than 185% of the poverty line; 47.8% African American, 34.7% white and 17.5% other race). Diet quality data had been collected using self-administered food frequency questionnaire (FFQ), followed by a telephone interview to obtain information on socio-demographic characteristics. The diet quality index was generated based on the information in the FFQ based on eight dietary characteristics: grains, vegetables, fruits, vegetables, and percentage recommended daily allowance of folate and iron, AI of calcium, percentage of calories from fat and a meal pattern scores. Womens diet quality scores were divided into tertiles. To enable measurement of density of food retailers and distance to households, a list of food retailers was obtained for Wake Country (n=561) and classified into six discrete categories based on the Standard Industrial Code (SIC) categories for the United States: supermarket, grocery store, convenience store, ethnic grocer, convenience store was gas station, and other. Of the original 561, 96 were omitted because they had been misclassified in the original data, were no longer in use, or had inadequate street addresses. The stores were geocoded into a GIS (Arcview), as were the residential addresses of the study sample. The data was analysed using multivariate analysis, controlling for socio-demographic characteristics (age, race, income, education, marital status), as well as distance to grocery stores and convenience stores. The study found that living more than four miles from a supermarket was significantly associated with a lower diet quality index. For a woman living over four miles from a supermarket, after controlling for socio-demographic characteristics and distance to other food retailers, the odds of falling into the lowest diet quality tertile were more than double compared with the highest tertile (adjusted odds ratio = 2.16; 95% CI = 1.2, 4.0). For convenience stores, each one mile change in distance to the closest convenience store

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was associated with increased odds of falling unto the lowest relative to the highest diet quality tertile (e.g., 38% of women living four miles from the nearest convenience store had low diet quality scores compared with 26% of women with high diet quality scores). No association was found with grocery stores, or between density of all food outlets (within 0.5 miles of the womens home) and diet quality. The authors conclude from this that proximity to food retail outlets influences the diet quality of pregnant women. Quality Issues. The study used a strong analytical approach but had several limitations. First, gaps in the data did not allow the study to control for potentially important confounders. No information was available on where households actually purchased food, the type of transportation used to access food stores, or the availability and cost of foods in the stores. So there is no validation that people actually purchased food at the stores closest to them and what food was available to them in those stores. Transportation maybe an important determinant of shopping patterns and was not controlled for. Second, as a cross-sectional design, the study could not identify cause and effect: it is possible that proximity to supermarkets did not influence diet quality but rather, prevailing dietary choices influenced where supermarkets decide where to locate: in a process that can be referred to reverse causality or endogeneity of supermarket placement, the association may stem from the fact that supermarkets may chose to locate in places where there is optimal demand for their products. The study does not rule out other factors in explaining the relationship. Third, and related, there were time differences in the data collection: the diet quality data was collected between 1995 and 2000, where as the food retailers were geocoded using data from 2000, and changes could have occurred in the food retail environment during that time periods. Finally, geocoding can be inaccurate and could have introduced error into the study that was not accounted for in the results. Morland et al. (206) used data from the third assessment of a prospective study (the atherosclerosis risk in communities study) to examine the association between density of food retailers and reported compliance with recommended dietary intakes for foods and nutrients in the United States. The study, which had a cross-sectional design, focused on supermarkets. The study sample comprised 10623 participants (2392 Black Americans and 8231 White Americans) in census tracts in the states of Maryland, North Carolina, Mississippi and Minnesota. Food stores and food service outlets (1999 data) were geocoded to census tracts and classified according to the North America Industry Classification System (NAICS) into supermarkets, grocery stores, full service restaurants and fast food restaurants. Participants addresses were also geocoded through exact address matching. Multivariate analysis (risk ratios) was used to examine associations in the data stratified by race (Black Americans and White Americans), controlling for

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education and income (not age because shown not to be associated), and, in some cases for the presence of other types of food outlet. The study found that (after controlling for education and income and the presence of other types of food outlets) fruit and vegetable intake among Black Americans increased by 41% for each additional supermarket in the census tract (linear relative risk ratio = 1.41%; 95%CI = 1.13, 1.76). The proportion of residents consuming recommended levels of total fat increased by 22% in census tracts with at least one supermarket (relative risk ratio = 1.22; 95%CI = 1.03, 1.44), and intake of recommended levels of saturated fat increased by 30% (relative risk ratio = 1.30; 95%CI = 1.07, 1.56). For full service restaurants, there was an association for saturated fat only: Black Americans living in a census tract with a full service restaurant reported a 21% (relative risk ratio = 1.21; 95% CI = 1.01, 1.46) increase in meeting recommended levels of saturated fat intake, compared to Black Americans living in census tracts with no full service restaurant. There were no associations with small grocery stores or fast food outlets. Among White Americans, associations were generally in the same direction but were far weaker. The presence of at least one supermarket was associated with an 8% (relative risk ratio = 1.08; 95%CI = 0.89, 1.30) increase in meeting dietary requirements for fruits and vegetables, and a 9% (relative risk ratio = 1.09; 95%CI = 0.99, 1.20) increase for meeting requirements for saturated fat. In a finding that contrasted with the findings for Black Americans, the presence of fast food restaurants was associated with a 12% increase in meeting fruit and vegetable requirements (relative risk ratio 1.12; 95%CI = 0.91, 1.37). The paper concludes that there is an association between the local food environment and the likelihood that Black Americans are meeting dietary recommendations. The fact that there is a weaker association for White Americans maybe because they had three times greater access to private transport, so had a larger geographic area in which to shop for food. Quality Issues. As for the study by Laraia et al. (205), the study used a strong analytical approach but faced exactly the same quality issues, as detailed in the above paragraph. In this instance, the time difference in the collection of diet and food retail data was even longer: the FFQ was administered between 1993 and 1995, whereas the data on food outlets was from 1999, and changes could have occurred in the food retail environment between 1993/95 and 1999. The fact that it is based on density rather than distance also introduces a border issue: people living close to the border of a tract may have had a greater or lower density of surrounding food stores over the border from the tract. An additional issue is that the study failed to control for gender, which is potential important giving the differences in shopping patterns and asset allocation between men and women. It is also not clear if the study examined meeting food and nutrient requirements for other things that they do not report (such as fibre, calcium, iron, etc.).

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Rose and Richards (207) conducted a cross-sectional study using secondary data from the 1996-97 National Food Stamp Program Survey in the United States. The goal was to examine the association between distance (composite access variable) to supermarkets and fruit and vegetable use among participants in the food stamp programme (a welfare programme for low income Americans). The survey employed a one-week food inventory method, including two at-home interviews to determine household food use (use is defined as all foods used from the home food supply, whether consumed, or wasted, inside or outside the home; it does not include foods purchased and eaten outside the home). The food retail environment was measured through self-reported store access variables, including information on the store in which the food was purchased (whether or not this store was a supermarket), the distance to the store, the round-trip travel time to the store, and an indicator of whether the household owned a car. The study derived a trichotomous supermarket access variable that took into account the fact that car ownership maybe a less important influence on access for urban residents than rural residents, given the former may be able to access a supermarket relatively quickly using public transportation. The trichotomous variable thus combined supermarket shopping, travel time and car ownership. Households were then divided into one of three access groups. Multivariate analysis (linear regression models) was used to analyse the relationship between the access variable and fruit and vegetable use. Independent variables included distance to store, travel time to store, ownership of a car and difficulty of supermarket access. All models controlled for a full set of socio-demographic variables (degree of urbanisation, race/ethnicity, education, household income and size, employment and marital status). The analysis found that 93% of households bought most of their food from supermarkets (Table 2). For 38% of households, the store where they bought most of their food was within a mile of their house, while 27% travelled over 5 miles. Round-trip travel time to the store and back was less than 30 min for over two-thirds of households, and a little under half of households owned a car. The composite variable divided households into three according to this data: households with easy access to supermarkets who bought most of their food there, and either owned a car or had a roundtrip travel time of less than 30 min to their supermarket; households with moderate access who reported buying most of their food from supermarkets, but did not own a car and spent 30 min or longer in round-trip travel to their store; and households with little access to supermarkets, who reported buying most of their food from other types of store. In the study sample, 76% had easy access. After controlling for confounding variables, easy access to supermarket shopping was associated with increased household use of fruits (84 grams per adult equivalent per day; 95%CI = 5, 162). This is largely explained by closer distance: those living within a mile of their nearest supermarket consumed 65g ae-1day-1

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more fruit compared with those living more than five miles away (p<0.023). Adults with shorter round trip travel times consumed 25g ae-1day-1 more fruit, but the difference was not significant, and car ownership was actually associated with lower consumption of fruits. The latter relationships possibly resulted from greater consumption of fruits among the elderly, and yet lower rates of car ownership in this group. Similar patterns were seen with vegetable use, though associations were not statistically significant. Of note, the study found that households consumed less fruit and vegetables when household respondent worked over 20 hours a week (data not shown). The authors conclude that food store access is importantly related to dietary choices among low income Americans. Quality Issues. This study had quite a different design to the previous two studies and therefore faced different as well as similar quality issues. The study had the significant benefit of taking transportation into account. At the same time, since the study relied on self-reported data on store access based on where households bought most of their food, this may well not have been their closest supermarket. Not shopping in a supermarket may therefore be a factor of choice rather than access (although the authors cite data from another study on national food stamp programme recipients in which 90% of nonsupermarket shoppers indicated that lack of access to a reasonably priced supermarket was the main reason). The main quality issue in common with the previous two studies is that the cross-sectional design makes it impossible to determine cause and effect: supermarkets may have chosen to locate in places where they know demand for fruits and vegetables is high, rather than the other way around (particularly important for fruits and vegetables since they are perishable). In conclusion, three studies with robust designs all conclude that access to a supermarket is associated with some measure of improved diet intake among vulnerable subpopulations in the United States. 1.4.4.2 Association between food retail access and diet-related health Three studies measured the association between retail access and diet-related health outcomes. Two studies (208;209) examined obesity and one examined cardiovascular outcomes (210). All three studies examined density as the access variable, and all included food service outlets (eating places): two of the studies examined both food retail and food service outlets (211;212), while one study only examined food service outlets (fast food) (210). Alter and Eny (210) present the results of a cross-sectional ecological study from Ontario, Canada. The goal of the study was to assess whether inter-regional differences in fast food concentration (density) can explain some of the regional differences in mortality and

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acute coronary syndromes. The study used a two-stage sampling procedure of first, selecting nine leading fast food chains, and second, selecting 380 regions (Forward Sortation Areas) within Ontario (all with >-1000 people) with 1,630 fast food outlets. Fast food chains were aggregated and divided by population size for each geographic area and analysed against the region-specific per capita (pc) mortality and acute coronary syndrome hospitalization rate. Head trauma was included as a reference health outcome (it was not expected to be related to fast food concentration). Multivariate analysis was used in the analysis, controlling for community-level income, age, gender. The study also tested the interaction between socio-economic status and fast food concentration. The study found that there is an association between concentration of fast-food outlets and mortality and admissions for acute coronary (AC) syndromes: each increase of one fast food outlet per 1000,000 people corresponded to one additional death. No interaction between socio-economic status and fast food concentration and mortality and AC syndromes was identified. Quality Issues. Overall, this is a well-designed ecological study. As an ecological study, another limitation is that the association studied is at level of communities, not individuals. Also, the study only included the top nine fast food chains, whereas there may well have been many other fast food outlets not falling under this categorization. As for the other studies already reviewed, it is unable, by the nature of its design, to draw conclusions about cause and effect. It also does not measure the mechanisms through which fast food may affect cardiovascular outcomes, though the authors hypothesise that it is through the availability of poor quality food. Morland et al. (213) used data from the prospective study (the atherosclerosis risk in communities study) already described (214) to examine the association between density of food stores and food service outlets and risk factors for cardiovascular disease, including obesity. Using a cross-sectional design, the study sample comprised 10,763 participants. Risk factors for cardiovascular disease collected in the prospective study were overweight and obesity, diabetes, hypertension and hypercholesterolemia. Food stores and food service outlets (1999 data) were geocoded to census tracts and classified according to the North America Industry Classification System (NAICS) into supermarkets, grocery stores, full service restaurants and fast food restaurants. Participants addresses were also geocoded through exact address matching. Multivariate analysis (risk ratios) was conducted to examine associations in the data, controlling for the socio-demographic factors of race, education, income, age, gender, physical activity and, in some cases, for the presence of other types of food outlet. The study found different associations with different types of food outlets. The presence of supermarkets was associated with a lower prevalence of overweight, obesity, and
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hypertension. In census tracts with at least one supermarket, the prevalence of overweight individuals was 6% lower than census tracts with no supermarkets (prevalence ratio = 0.94). Prevalence of obesity was 24% lower (prevalence ratio = 17%) and hypertension 8% lower (prevalence ratio = 0.83). The associations were stronger when sociodemographic factors were not controlled for (9%, 24% and 7% respectively). On the other hand, convenience stores were associated with higher overweight, obesity and tension. In census tracts with at least one convenience store, the prevalence of overweight individuals was 6% higher than census tracts with no convenience stores (prevalence ratio = 1.06). Prevalence of obesity 16% higher (prevalence ratio = 1.16), and hypertension 8% higher (prevalence ratio 1.08). These associations were only slightly stronger when socio-demographic factors and presence of other food outlets were controlled for (7%, 19% and 12% respectively). For grocery stores, there were no significant associations when socio-demographic factors were controlled for (in the unadjusted model, there were significant and positive associations with overweight and obesity). The study also found that any combination of food stores was associated with a significantly higher prevalence of overweight and obesity relative to the presence of only supermarkets in a census tract: in census tracts with supermarkets, grocery stores and convenience stores had a 28% higher prevalence of obesity and a 9% higher prevalence of overweight relative to census tracts with only supermarkets. Associations with diabetes, cholesterol, and hypertension were not consistent. Unlike their previous study focusing on diet, this study found no significant differences with race. No independent differences were found for fast food outlets. The authors conclude that the availability of supermarkets is associated with a decreased prevalence of overweight and obesity, while the presence of convenience stores is associated with increased prevalence of overweight and obesity and thus that the local food retail environment may play role in the prevalence and therefore prevention of overweight and obesity. Quality Issues. Though the study used a strong analytical approach, the study faced the same limitations discussed in the earlier study by Morland et al. (215) (also see Laraia et al.(205)), though gender was controlled for in this study. This study faced additional limitations since it dealt with cardiovascular risk factors but did not measure diet as an intermediary variable. The study could but does not model association between place of purchase and outcomes though differences in food and nutrient intakes. Cardiovascular risk factors are more distal indicator than dietary measures, and may reflect non-dietary factors over space (e.g., presence of parks, tracks) and the food retail environment individuals have been exposed to throughout the life course, rather than just their current environment.

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Sturm and Datar (216) used data from a nationally representative longitudinal study (the Early Childhood Longitudinal Study) in the United States to examine the association between food outlet density and changes over time in body mass index (BMI) among kindergarten school children. (The second major goal was actually to example the association with metropolitan area food prices; the results of this are reported in section 1.6.4.1). The study followed 3,489 boys and 3427 girls from kindergarten to third grade (three year difference). The study merged individual-level data to per capita number of grocery stores, convenience stores, full-service restaurants, fast food restaurants) in the childs home and school zip code (i.e., food outlet density). The association between changes in BMI over one and three years and density of food outlets and food prices were estimated using multivariate analysis (mean changes using least-squares regression; median changes and 85th percentile changes with quantile regression) controlling for baseline BMI, age, real family income and socio-demographic household characteristics. The study found that BMI increased overtime in both girls and boys between kindergarten and the third grade. But it identified no association was identified between change in BMI and food outlet density, either as a composite variable of for different types of food outlet (model adjusted for controls and also food prices, which were found to be significantly associated with BMI). The authors noted that the density of retail outlets in poorer areas is higher (probably as a result of a greater number of smaller stores). The authors conclude that there appear to be no effect of food outlet density on BMI at the neighbourhood level, possibility because availability of food retail outlets is not a limiting factor in metropolitan areas. Quality Issues: If an association had been found, this study would have faced most of the quality problems outlined from the two studies above. The lack of association could also be explained by some methodological issues: the data did not allow separation into supermarkets, and it is well known that supermarkets are the major source of food for most Americans; there was unlikely to have been much variability in food outlet density at the scale of metropolitan areas (as opposed to no effect of outlet density in general) and the widespread availability of food retail outlets suggests this may be because it was not a limiting factor; measuring the relationship with a more distal outcome BMI as opposed to diet may have excluded some important dynamics in terms of food consumption patterns; the study included no measure of food consumption. In conclusion, there is insufficient data available to draw a clear conclusion about the association between supermarkets, fast food outlets and overweight/obesity.

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1.4.4.3 Association between food availability at food retail outlets and diet Three papers measured the association between food availability and diets, all from the United States (217-219). Cheadle et al. (217;220) present the results of two studies in two states in the United States (California and Hawaii). The goal of the studies was actually to identify simple indicators (in food retail outlets) that may be predictors of diets and could be used for that purpose. The first study, published in 1991 used a cross-sectional approach; the second follow up study published in 1993 tested whether same indicators could be used to track changes in dietary patterns. Though not the precise goal of the study, the study design and results allow for an examination of the association between individual dietary practices and availability of low-fat, high fibre foods available in retail outlets. The first study used a cross-sectional design at a community level (n=12) and zip code within community (n=34). The total study sample size comprised 5654 people in 12 communities (counties, cities, census tracts; 11 in CA, 1 in Hawaii), with a total of 141 full-service food retail outlets. The study measured the shelf-space of low fat, high fibre foods in stores (low fat milk, bread, meat) and conducted a telephone survey to collect self-reporting information on usual-diet from individuals (percentage calories from fat, intakes of saturated fat and fibre). The association between store availability and diet data was examined using multivariate analysis by zip code (zero order correlation; ordinary least squares analysis) adjusted for stratified sampling and nonresponse bias. The second study used the same methods but multivariate analysis done at community level not zip code. T-tests were used to estimate changes over time and restricted maximum likelihood techniques The first cross-sectional study found significant correlations between store healthfulness scale and consumption of low fat milk (r=0.69), eating whole wheat bread (r=0.58). The association between calories from fat and store healthfulness scale was -0.52, but not statistically significant. The second study, however, found no statistical significance between changes in availability of healthful products in stores and healthfulness of individual diets. The authors suggest that this lack of association is due to small actual changes in the communities over the two year interval between surveys and the crude nature of the grocery store indicators. Quality Issues. For the purposes of studying the association (rather than the primary goal of identifying indicators), the studies had an important limitation in common with many of the papers already discussed. The study could not identify cause and effect: it is possible that some of the grocery stores sold more low-fat milk and high-fibre bread because there was more demand for those products rather than the other way around. And also like other studies, there was no direct link between individuals and grocery stores surveyed, so there was no evidence that the household actually shopped at those stores
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it only used a measure of geographic proximity. The sample sizes were also small for a study done as the community or zip-code level, and only correlation coefficients were used to examine the association with no controls. Finally, diet data was reported using a self-reported measure. Fisher and Strogatz (221) likewise conducted a study with the main goal of developing indicators to monitor dietary patterns in this case in the United States. And again, the study can also be used to examine the associations between individual dietary practices and availability of foods available in retail outlets. This cross-sectional study was conducted in seven countries in New York State, comprising 53 zip codes and 503 food retail outlets (all outlets, not just full-service). The study specifically examined the association between low fat milk in stores and presence of low fat milk in households using a telephone survey. Fifteen stores from each zip code were randomly sampled and the average percentage of low fat milk (defined as skim milk and 1% milk) on store shelves relative to all milk. Household milk consumption was measured by reporting on presence or usual presence in the refrigerator, and multivariate analysis to test determinants of percentage low-fat milk in stores The study found that there was a strongly significant positive relationship between proportion of low fat milk and presence in households (R2=0.82) (a lot higher than Cheadle at el (217), which the authors notes could be because of methodological differences such as including all food retail outlets rather than just full-service grocery stores). The study also found that the main determinants of percentage low fat milk in the food retail outlets were the characteristics of the zip code were: median income level of the zip code (higher = more low fat milk), being in an urban setting, and, to a lesser extent, being non-Hispanic white. The authors conclude that there is a relationship between low-fat milk consumption in households and availability in food retail outlets, along with income and urban level. Quality Issues. The two major quality issues faced by the previous study that of the potential of reverse causality and the lack of information on whether telephone respondent actually visited the stores nearest to them are likewise methodological problems here. The study also did not estimate the relationship between low fat milk consumption and availability in outlets after controlling for income and urban level, even those these were identified as being important. The relationship between availability and consumption could thus be largely an income effect. Finally, the study, also only measured presence or absence in fridge, rather than reported consumption by individuals (though this can be a good proxy).

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In conclusion, there is insufficient evidence on the association between the availability of food and the purchase of that food. The usefulness of this evidence is also limited because a difference in availability is the most likely dietary indicator to reflect differences in demand. 1.4.4.4 Quasi-experimental studies of food retail access and dietary outcomes One study included here did aim to overcome the limitations of cross-sectional studies. One other study also attempted this but did not satisfy the inclusion/exclusion criteria, though this study is included in Chapter Three (222). Cummins et al. (223) present the results of a prospective, quasi-experimental study involving a pre-post including a intervention and control groups in the United Kingdom (natural experiment). The study sample was 412 men and women in an area of Glasgow known to have poor food retail provision. The goal was to assess the impact of the opening of a new supermarket in a low-income community on intake of fruits and vegetables, and self-reported and psychological health A total of 3975 postal questionnaires were administered early October 2001 to obtain self-reported data from the main household shopper on fruit and vegetable intake (How many portions of fruits and vegetables do you usually eat per day?), socio-demographic variables, and self-reported and psychological health. Questionnaires were mailed to two groups: the intervention group where the supermarket was about to open, and the control group about five kilometres away. Respondents were followed up after a 12-month interval, giving a period of 10 months after the opening of the supermarket in November 2001. Multivariate analysis was conducted to examine the association controlling for age, sex, economic activity, education. Interactions between the variables were also tested. An important component of the analysis was of the switchers: whether the opening of the new supermarket caused people to switch their main food purchase from other stores to the supermarket regardless of where they lived. Of the 3,975 questionnaires originally sent out, there were 412 respondents at the baseline who also followed up after one year. 191 were in the intervention group and 221 in the control group. Area differences in variables between the intervention and control groups were not significant. The study found that self-reported fruit and vegetable intake significantly increased among both the intervention and control groups during the 10month period after the opening of the supermarket. In the intervention group, consumption increased by 0.29 portions from 3.92 to 4.21 (p=0.07), and in the control group, by 0.44 portions from 4.16 to 4.60 portions (p=0.003). After controlling for sociodemographic variables, comparing the intervention and control groups showed a very weak impact of the intervention on fruit and vegetable consumption (-0.10; 95%CI=0.59-0.40). The most important component of the analysis was on whether people switched to the supermarket as their main place to shop, and in turn whether this has any

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impact on fruit and vegetable consumption. The study found that a minority of the sample (n=61) switched to the supermarket. Since 95.1% resided in the intervention area, this represents almost one third of the intervention sample (n=191) but is nevertheless small. These switchers did not consume statistically significantly more fruits and vegetables after the opening of the supermarket. The authors conclude that the intervention had no net effect on fruit and vegetable consumption. Quality Issues. Though this study has the considerable strength of a quasi-experimental design with a control group, it also had considerable methodological limitations. First, the study design was not randomized and there was a low response rate to the survey, suggesting that some self-selection had taken place. Second, the most important results of this study concerned whether the people who switched to the supermarket as their main place of shopping. But the sample size was small so the analysis lacked statistical power. The small number of switchers suggests, in fact, that consumers were adequately served by their food retail environment before the entry of the new supermarket. Moreover, no information was provided about why the switchers moved to the supermarket: these switchers were essentially self-selected and could have changed their main shopping outlet to the supermarket, but still buy fruits and vegetables from other outlets. Therefore it would not be expected that the supermarket would affect this group. Following from this, a major gap in this study is the lack of qualitative information. At the baseline, no information was collected on whether residents actually found access to shops problematic: this was simply assumed through general observation of poor retail provision. Finally, while 10 months is a decent time period, dietary responses to environmental changes can be a long-term process and so it may not have been long enough to detect an effect. The authors note that a non-randomized control study cannot produce conclusive evidence about the impacts of supermarkets on diet. No information either is provided on fruit and vegetable provision in the neighbourhood. It maybe that people do not like to buy fruits and vegetables in supermarkets for cultural reasons, or because they find them expensive. There was also no information provided about competition with other supermarkets which may have lowered the prices of their fruits and vegetables in order to compete. Thus the supermarket entry may have had an effect, but it would have been through the indirect effect of creating competition rather than a direct effect. 1.4.5 Summary, discussion, and conclusions

This section has presented a systematic literature review on the relationship between the food retail environment and the human diet. It has attempted to answer the question: Is the food retail environment a determinant of diet, and if so, how does it affect diet? The literature in this area is considerably more advanced than available for environment,

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agriculture or globalization, but does face three major limitations. First, there are no substantive studies from developing countries, despite the dramatic changes that are taking place in the food retail environment in these countries, and the widespread calls for more research into this issue. A second limitation is that the highest quality studies that is, those included in this systematic review are heavily skewed towards the United States, so where clear conclusions can be drawn, they concern just the United States not other developed countries. The third limitation is that all but one study had crosssectional or ecological designs, which precluded conclusions being drawn about cause and effect. In other words, whether the food retail environment determines diets, or whether the diets people choose to consume determines the accessibility of these food retailers, the foods they have available, and the prices they charge. This question cannot be answered using cross-section or ecological studies. More recent research is beginning to address this gap but does not reach the level of quality required to come to convincing or probable conclusions. Still, the following conclusions can be drawn for the United States that help address the question of whether the food retail environment a determinant of diet, and if so, how it affects diet: People living in poor and black neighbourhoods have less access to supermarkets relative to smaller grocery stores The larger the food retailer, the lower the average food prices (e.g., mega discounters relative to supermarkets, and supermarkets relative to grocery stores) Easier access to a supermarket is associated with improved diet intake among vulnerable sub-populations

Taken together, the probable conclusion can be drawn that socio-economically disadvantaged groups in the United States have less access to supermarkets relative to more advantaged groups; in turn, less access to supermarkets is associated with lower quality diets. More evidence is needed from experimental studies to determine whether these conclusions are a result of cause or effect. Better designed studies could help overcome the limitations of endogeneity of where people actually live (a person who prioritises eating healthy diets may chose to in a location with good access to supermarkets) and endogeneity of placement of retail stores (a retail store may locate where people are more concerned about eating healthy diets). In addition, such studies could clarify whether the association is in fact the results of potential confounders (since these studies tend to lack information on place of purchase). There are reasons to believe that the findings United States may not necessarily apply to other parts of the world. This is the result of socio-economic differences, and differences in the food retail environment. For example, in some European countries, healthy food may be more widely available in small grocery stores; in developing countries,

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supermarkets maybe more expensive than small stores. In is notable that in their comprehensive (not systematic) review of this literature, Cummins and Macintyre (192) concluded that the evidence did show different trends between North America and the United Kingdom. The picture from North America was reasonably consistent: as shown here, places inhabited by poorer people and black people had poorer access to healthier foods. But in the United Kingdom, there is far less evidence for an association (this evidence was mainly considered of too poor quality to be included in this review). There is insufficient data available to draw clear conclusions about the association between supermarkets and overweight/obesity and other measures of diet-related health. Likewise, insufficient evidence is available on fast food outlets. Research is continuing in this area and will likely allow more decisive conclusions to be drawn in the relatively near future. It is noteworthy that four of the included studies were published between the time of the original database search and the re-run in June 2006, and that two further studies on this topic were published in July 2006. The issue of retail access is now on the agenda of health policymakers in the United Kingdom and the United States. Care is needed when translating the evidence into policy recommendations. Though the nature of the evidence suggests that more supermarkets in deprived neighbourhoods would increase the consumption of nutritious foods (222;224), early work suggests that retail interventions need to involve more than simply opening a supermarket. There is also no reason to believe that other forms of retail intervention such as through small stores that do stock healthy foods, or improved transportation networks could not achieve the same result. This is a complex policy question requiring a thoughtful approach that takes into account the available evidence, but also the geographic, socio-economic and cultural context.

1.5 Results: Food Advertising and Promotion

1.5.1 Searching and classifying the literature 1.5.1.1 Characterisation of the literature Three systematic reviews were identified on the effects of food advertising and promotion on diets. The first was conducted in 2003 for the Food Standards Agency, the government agency concerned with food in the United Kingdom (Hastings et al. (180)). The second was an update of this report, conducted in 2006 for the World Health Organization (Hastings et al. (181)). The third was published as a report Food Marketing to Children and Youth: Threat or Opportunity? by the Institute of Medicine of the National Academies of Sciences in the United States in 2006 (McGinnis et al. (182)). All three reviews dealt exclusively with the impact of food advertising and promotion on children and adolescents. They used standard systematic review methodologies, with

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clear inclusion and exclusion criteria and ratings for quality. Hastings et al. (180;181) searched 11 databases; McGinnis et al. (182) searched 15 databases as well as industry and marketing sources (more detail on the systematic review methodologies used can be found in the individual reports). The reviews reviewed the literature on the effects of food promotion on three outcome variables: dietary intake, precursors to dietary intake (e.g., nutritional knowledge, food preferences and choices) and diet-related health (e.g., obesity, cholesterol). After accounting for the inclusion/exclusion criteria, the Hastings et al. review published in 2003 (180) included 55 papers describing 51 studies on the effects of food promotion. The 2006 update by Hastings et al. (181) included a further 19 studies on the effects published between 2003 and 2006. With similarly stringent inclusion and exclusion criteria, McGinnis et al. (182) included a larger number of studies on the effects of food promotion on dietary outcomes a total of 123 studies. 1.5.2 Impact of food advertising promotion on childrens diets

The three reviews came to similar conclusions. It should be noted at the outset that all three reports also found that the vast majority of food advertising to children was for high calorie and nutrient poor foods. Their conclusions thus should be interpreted in that context. Hastings et al. (180) 2003 report reviewed the literature on the effects of food promotion on childrens food knowledge, preferences and behaviour, coming to the following conclusions: Does food promotion influence childrens nutritional knowledge? The weight of evidence suggests that food promotion is unlikely to influence general perceptions of what constitutes a healthy diet, but it can, in certain contexts, have a modest effect on certain types of nutritional knowledge. Does food promotion influence childrens food preferences? There is reasonably robust evidence that food promotion influences food preferences for both brand and category effects. Does food promotion influence childrens food purchasing and purchase-related behaviour? The weight of evidence suggests a strong influence of food promotion on childrens food purchase and purchase-related behaviour Does food promotion influence childrens food consumption behaviour? There is modest evidence of an effect of food promotion on consumption behaviour. Food promotion can, in some contexts, influence childrens food consumption behaviour Does food promotion influence childrens diet and health-related variables? Overall, there is evidence of small but significant associations between television viewing and diet and television viewing and obesity.

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If food promotion is shown to have an effect on childrens food knowledge, preferences and behaviour, what is the extent of this influence relative to other factors? There is evidence that food promotion has a significant influence on childrens food behaviour and diet that is independent of other factors. However, there is little evidence to show whether the influence relative is greater or weaker than other factors. In the studies which demonstrate an effect of food promotion on childrens food knowledge, preferences and behaviour, does this affect total category sales, brand switching or both? There is evidence that food promotion causes both brand switching and category effects. In other words, the effects of food promotion are not limited to brand switching.

The 2006 update of the 2003 report by Hastings et al. (181), came to exactly the same conclusions: The 19 additional studies neither provided sufficiently more evidence to strengthen any of the more tentative conclusions, nor sufficiently different evidence to change any of the conclusions. The 2006 review did make an additional effort to identify and highlight research from developing countries. Despite extensive searching, the review did not identify any studies establishing causality between food promotion and dietary outcomes in developing countries, so the review was restricted to weaker papers that examined how children respond to food promotion. Fifteen studies were identified from developing countries, which showed the same results of developed countries: that (i) there is a great deal of food promotion to children, particularly in the form of television advertising; (ii) this is typically for highly processed, energy dense, unhealthy products with evocative branding; and (iii) that children recall, enjoy and engage with this advertising. Hastings et al. also make the case that children in the developing world may be more vulnerable to food promotion because: They are likely to be less sophisticated about modern marketing and branding because it is such a new phenomenon in many developing countries. In China, for example, the economy has only just opened up to western influence. Western firms see children as a bridgehead for entering developing economies, because they are more flexible and responsive than their parents. They also represent a very real direct and indirect market: even in relatively poor countries they have disposable income from an early age and are known to have a big influence on family consumption behaviour.

Back to the developed country context, the systematic review by McGinnis et al. in 2006 (182) came to similar conclusions. One difference in approach from Hastings (180;181) was the distinction made by McGinnis et al. (182) between the evidence related to children aged between 2 and 11 years, and between youth aged 12 to 18 years. Overall, the study concluded that:

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With respect to dietary precursors, food and beverage advertising on television has some influence on the preferences and purchase requests of children and youth as follows: ! There is strong evidence that television advertising influences the food and beverage preferences of children ages 211 years. There is insufficient evidence about its influence on the preferences of teenagers aged 1218 years. ! There is strong evidence that television advertising influences the food and beverage purchase requests of children ages 211 years. There is insufficient evidence about its influence on the purchase requests of teenagers aged 1218 years. ! There is moderate evidence that television advertising influences the food and beverage beliefs of children ages 211 years. There is insufficient evidence about its influence on the beliefs of teenagers aged 1218 years.

Therefore, given the findings from the systematic evidence review of the influence of marketing on the precursors of diet, and given the evidence from content analyses that the preponderance of television food and beverage advertising relevant to children and youth promotes high-calorie and low-nutrient products, it can be concluded that television advertising influences children to prefer and request high-calorie and lownutrient foods and beverages. With respect to diets, food and beverage advertising on television has some influence on the dietary intake of children and youth: ! There is strong evidence that television advertising influences the shortterm consumption of children ages 211 years. There is insufficient evidence about its influence on the short-term consumption of teenagers aged 1218 years. ! There is moderate evidence that television advertising influences the United Statesual dietary intake of younger children ages 25 years and weak evidence that it influences the United Statesual dietary intake of older children ages 611 years. There is also weak evidence that it does not influence the United Statesual dietary intake of teenagers aged 1218 years. With respect to diet-related health, food and beverage advertising on television is associated with the adiposity (body fatness) of children and youth: ! Statistically, there is strong evidence that exposure to television advertising is associated with adiposity in children ages 211 years and teenagers aged 1218 years. ! The association between adiposity and exposure to television advertising remains after taking alternative explanations into account, but the research does not convincingly rule out other possible explanations for the association; therefore, the current evidence is not sufficient to arrive at any finding about a causal relationship from television adverting to adiposity.

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1.5.3

Summary, discussion and conclusions

The three reviews came to the following overall conclusions: Food promotion can have and is having an effect on children, particularly in the areas of food preferences, purchase behaviour and consumption. These effects are significant, independent of other influences and operate at both brand and category level (Hastings et al. 2003 (180); Hastings et al. (181)) Among many factors, food and beverage marketing influences the preferences and purchase requests of children, influences consumption at least in the short term, is a likely contributor to less healthful diets and may contribute to negative diet-related health outcomes and risks among children and youth (p.ES-6) (McGinnis et al., 2006 (182))

Food promotion can thus be said to play a role in determining childrens diets. Since most promoted foods are high in calories and low in nutrients, food promotion is likely to increase the amount of these foods in the diet. However, the effect of food promotion relative to other factors influencing the consumption of these foods is not known. The quality issues concerning individual papers can be found in the text of three systematic reviews. The main reported concern is that studies are prone to measurement error. The reviews also identified some gaps in the literature which prevented them from making firmer conclusions. These can be summarised as follows: Most of the literature available deals with television advertising; there is a great paucity of published literature on the many other forms of marketing strategies used to reach children and youth. The cumulative effect of modern brand-building integrated marketing communications is largely ignored. The evidence on relative effects (food promotion relative to other dietary determinants) is weak.

1.6 Results: Food Price

1.6.1 Characterising and classifying the literature 1.6.1.1 Characterisation of the literature The database searches revealed hundreds of potentially relevant papers on food price. Most of these were from peer-reviewed publications, but also included many papers from the non-peer reviewed literature (mainly conference proceedings or economics working papers). Papers identified of relevance to this review fell into three categories: papers concerned with the impact of food price on food consumption measured as a dietary precursor or outcome, on nutrient consumption measured as a dietary precursor or outcome, or on diet-related health. Most of the studies used data collected from North America and Europe. There were relatively few studies identified from Africa, Asia and Latin America concerned with the role of price of foods of relevance to the review. This
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includes papers published in non-English languages (only one relevant paper in a nonEnglish language was identified from a developing country and translated). There were also very few studies using cross-country data, though one study conducted by the International Comparison Project (ICP) used data from 114 countries (38 low-income, 44 middle income, and 32 high income) worldwide. The inclusion criteria were thus set as follows (Table 1.15). Firstly, no distinction was made between peer-reviewed and non peer-reviewed papers, as long as the study satisfied the other inclusion criteria. For the sake of information, a remark is given on the non peer-reviewed papers in the last column of Appendix 1.4). Secondly, papers were included if they had the following scope: an examination of the impact of price on foods associated with cancer (as set out in the introduction to this report) or on nutrients in these foods (macronutrients and micronutrients), of if they measured or modelled an association between food prices and diet-related health (e.g., obesity). Third, papers were included if they linked price with dietary precursors in (e.g., household food expenditure, per capita food availability) or dietary outcomes (dietary intake, diet-related health outcomes). Most measured dietary precursors (the meaning of dietary precursors and outcomes is described in section 1.1.1 and Table 1.1). Third, papers were generally included if they used nationally representative data. This ensured that the results were representative of national populations. However, to increase the geographical coverage of the review, some studies from Africa, Asia, and Latin America were included if they used data from national surveys which were not nationally representative, or were representative of only urban or rural areas.
Table 1.15. Inclusion criteria for food price review

Study characteristic Scope Type Foods Diet measures Scale

Methodology

Inclusion criteria Impact of food price on food consumption, nutrient consumption and diet related health Peer-reviewed and non-peer reviewed At least one of the food items related to cancer as described in the introduction to this report Dietary precursors, dietary outcomes Nationally representative data (though some exceptions were made in the case of studies conducted in developing countries and in some topics such as the impact of price on obesity/health) Standard methodology

The vast majority of the papers adhering to these criteria measured the impact of price on food or nutrient consumption via the estimation of own- and/or cross-price elasticities (the exception being the literature on food price and diet-related health). The next criteria thus concerned the methodology used to estimate price elasticities (the meaning of the term price elasticity and the methods used to derive them are set out in Table 1.16).

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The estimation of reliable price elasticities requires the estimation of a demand system with high quality data and a robust methodology. Papers were thus only included if they used a standard, well-accepted methodology for the estimation of price elasticities and applied it using high quality data. The methodological framework for most of the studies was based on the Almost Ideal Demand System (AIDS) model developed by Deaton and Muellbauer in 1980 (225) and most equations were estimated using Seemingly Unrelated Regression (SUR) method. It is important to note, however, that even after this criterion had been applied, significant variations were observed in methodologies used to estimate the demand systems, which can be summarised as follows: Some studies adjusted the original AIDS model to allow for non-monotonic behaviour between the budget share of an item and total expenditure. Studies used different methods in approximating the price index and in using dynamic or static AIDS model. Studies varied in addressing the issue of zero expenditure and missing cases. Due to the variation in the degree of separability, different studies used different numbers of stages in their analyses: some used single stage while others up to three-stages of analyses. Studies used different types of food expenditure data: time series, cross sectional or panel, with differing recall periods or length of time considered (24 hrs, weekly, two-weeks, monthly, yearly). Studies also aggregated food groups in different ways and the source of food often varied significantly (purchase, own production, gift, etc.). The studies also varied significantly in the way that they measured price data. Type of price data used includes community level prices, simple unit values, quality adjusted unit values, price indices, etc. Most cross-sectional studies used unit values as a proxy for price. However, differences were observed in the adjustment made for quality differences, treatment of missing cases etc.

As a result of these differences, it is difficult to compare elasticities even for a single country wit nationally representative data. The results of each study should therefore be interpreted within the context of the framework of the study. Indeed, the presence of these differences prevented the use of meta analysis and other similar literature review techniques. Therefore, in writing the results of this review, emphasis was placed on the direction and relative values rather than on absolute magnitudes of parameters, and the different studies viewed as complementary investigations rather than direct comparisons. But to facilitate comparability in understanding the figures presented in most cases uncompensated (Marshallian) price elasticities are presented (most of the studies did not estimate both the uncompensated and compensated (Hicksian) price elasticities of demand) (see Table 1.16). And in as far as is possible, the report is organized according to differences in goals and methodologies of the papers.

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Table 1.16. Price elasticities of demand and their estimation: definitions The price elasticity of demand is a measure of changes in demand of a good in response to the change in price of that good, or of other goods. For food, it estimates how changes in food prices affect food consumption. There are two main types of price elasticities: own-price elasticity and cross-price elasticity. Own-price elasticity measures the percentage change in quantity demanded of food item X that occurs in response to a percentage change the price of the same food item X. Mathematically, this is measured by: Own-price elasticity=(percentage change in quantity demand of X) / (percentage change in the price of X) So, for example, if, in response to a 1 % increase in the price of X, the quantity demanded decreases by 1.3 %, the price elasticity of demand would be 1.3 %/( 1 %) = 1.3. If the absolute value of own-price elasticity of demand is <1 it is called inelastic and if it is >1 it is called elastic. A food price elasticity greater than 1 usually indicates that consumers are very responsive to the change in price. Unitary elasticity implies own-price elasticity of demand =-1. Cross-price elasticity of demand measures the percentage change in quantity demanded of food item X that occurs in response to a percentage change the price of another food item, item Y. Mathematically, this is measured by: Cross-price elasticity=(percentage change in quantity demand of X) / (percentage change in the price of Y) Own-price and cross-price elasticities are derived from some measure of food consumption (e.g., expenditure, food availability, dietary intake) and some measure of price, such as a national consumer price index, actual retail prices (community level prices), or, most commonly, unit prices (expenditure divided by quantity of food purchased). Own-and cross-price elasticity of demand can be computed from two main forms of demand functions: Marshallian or Hicksian. Elasticities computed from the Marshallian demand functions are called uncompensated while elasticities computed from the Hicksian demand functions are called compensated. Uncompensated (Marshallian) demand functions refers to the effect of a change in prices on demand, assuming that real income will also change as a result from having to pay more or less for a good. It thus includes both the price and the income effects of a change in price. Compensated (Hicksian) demand functions refers to the effect of a change in prices on demand, holding real income constant, and thus measures the pure price effect. For food items that account for a large share of the budget, there can be large difference between these two elasticities. Food price elasticities can be estimated through the construction of a complete food demand system or specific food demand analyses. A complete food demand system implies that all food items are included in the model. As the name implies, specific food demand analysis refers to analysis of demand for specific food items such as meat, oil, fruits and vegetables. The basic difference between the two analyses is the assumption of separability. In the complete food demand system case, households are assumed to make their decisions to consume or buy any food item simultaneously and the price of one food item will affect the demand for the other food item (not only through income effect but also through price effects). Elasticities estimated from complete and specific food group can vary significantly especially if specific food demand studies did not use two-or three stages of analysis. Both complete demand and specific demand systems can involve up to three stages of analysis. The first stage is estimating the demand for food relative to other goods (e.g., clothing, medical care); the second stage is the sub-division of the food group into food groups (e.g., meat, cereals, fruits and vegetables, sugar); and the third stage is sub-division of those groups into smaller groups (e.g., the meat group into beef, pork and chicken). If three groups are used, this is a three-stage analysis.

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The method of organizing this review is depicted in Figure 1.1. It is primarily organized by the three objectives identified in the literature: Impact of food prices on dietary precursors or dietary intake measured by foods Impact of food prices on dietary precursors or dietary intake measured by nutrients Impact of food prices on diet-related health (obesity and/or chronic diseases)

Each of the three main categories was further subdivided into two parts based on the type of data used for analysis: cross-sectional/cross-country or time series/panel data. Whenever appropriate, the studies were further sub-divided into two parts based on the level of analysis as complete food demand system or specific food demand analyses (for explanation see Table 1.16).
Figure 1.1. Process of classifying the papers for the food price review Impact of food price on:

Dietary precursors/intake (foods)

Cross-sectional data (one country/cross-country)
Complete food demand

Panel/ time series data (one country/cross-country)

Complete food demand

Some specific food items

Some specific food items

Dietary precursors/intake (nutrients)

Cross-sectional data (one country/cross-country) Panel/ time series data (one country/cross-country)

Diet-related health (e.g., obesity)

Cross-sectional data (one country/cross-country) Panel/ time series data (one country/cross-country)

Following this categorization, the results of each study are described in the following sections. Appendix 1.4 also presents a summary table of describing each study, including its objective, the data type, the sample size/country, the foods/nutrients studied, the type of price data, the methodology (price elasticity estimation strategy), the major findings,

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and comments. Quality issues are also included, and are summarised in the discussion at the end. 1.6.1.2 Classification of the literature To summarise, a total of 699 papers were identified through the database searches. After screening for title and/or abstract relevance, 260 references were selected for full paper review. Out of these references, 255 were obtained and subjected to a final level of selection based on the inclusion and exclusion criteria listed in Table 1.15. Sixty-eight papers were selected for inclusion in the review, all but two of which came from the economics literature (the remaining two came from public health and nutrition journals). These statistics are summarised in Table 1.17.
Table 1.17. Summary of the Literature Selection Process

Papers identified through initial database search from the three search engines Papers requested in full paper form for second-level review Paper received for second-level review Papers that met the final inclusion criteria and included in the final review

699 260 255 68

1.6.2

Impact of food price on dietary precursors/intake (foods)

1.6.2.1 Cross-sectional/cross-country data based studies Twenty four studies assessed the impact of food prices on food consumption using crosssectional/cross-country data. Eighteen of these studies estimated a complete food demand system (226-243) and the remaining six estimated the demand for fish (244), fats and oils (245), disaggregated beef (246), carbonated soft drinks (247); beef (248), and disaggregated fish (249). The report first describes the complete food demand studies and then the specific food group studies. Complete food demand studies Sahn (242) analysed the impact of price and income changes on food demand and energy intake in Sri Lanka. Cross-sectional data collected in 1980/81 were used. Fourteen food groups, viz., rice, coconuts, sugar, condiments, vegetables, fish, bread, pulses, oil, wheat flour, milk, root crops, meat, and other grains were considered and a log-log quadratic model was used. Hickmans two stage procedure was used to take into account zero levels of consumption. The results of the study revealed that the price elasticity of demand for rice, coconuts, sugar, condiments, vegetables, bread, and oil were inelastic (| | <1) while the demand for fish, pulses, wheat flour, milk, meat, and root crops were price elastic (| | >1) for almost all income groups. The disaggregation of the elasticity

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coefficients by income group revealed that the poor were more responsive to price and income changes. The actual elasticities were not shown clearly in the paper so could not be reported here. Deaton (226) measured own-and cross-price elasticities of demand from special variations in prices using household survey data (1981) from Indonesia. More than 14,400 households from 3,200 clusters in rural Java were considered. Eleven food items (rice, wheat, maize, cassava, roots, vegetables, legumes, fruit, meat, fresh fish, and dried fish) were considered and cluster level unit values adjusted for quality differences were used. The results of the study showed that demand was responsive to own- price ( < 0) changes. The own-price elasticities of demand for rice ( = -0.424), wheat ( = -0.692), maize ( = -0.822), cassava ( = -0.325), fresh fish ( = -0.762), and dried fish ( = 0.239) were inelastic. The own-price elasticity of demand for vegetables ( = -1.113), meat ( = -1.091) fruits ( = -0.953), legumes ( = -0.954), and roots ( = -0.963) was relatively elastic. The study also showed strong substitution effect between fresh and dried fish. The study concluded that own-and cross-price elasticities could be estimated using spatial variation in unit values. Tzoneva et al. (227) examined the impact of economic transition on the patterns of food consumption in Bulgaria using a double-log specification of the Engel function. Data from the National Statistical Institute official publication between 1990 and 1994 was used. Five broad groups (food, non-food, housing, services, and others) and ten food subgroups (bread and bread products, potatoes, vegetables, fruits, meat and meat products, milk and milk products, eggs, sugar, oil and fats, others items) were used and fifty observations were derived for ten income groups over five years span. The estimated price elasticities (uncompensated) showed that most of the food items were price inelastic (| | < 1.00) and demand for potatoes ( = -0.49), vegetables ( = -0.42), fruits ( = 0.43), and meat ( = -0.36) was more price elastic than other food items. The cross-price elasticity of demand showed that most of the food items were complementary though the magnitude of the coefficients was close to zero. The study also showed that income effect was stronger than price effect due to high share of food from the total consumption and high level of inflation in the country. Han and Wahl (228) estimated price and income elasticity of demand (with special emphasis on the fruits and vegetables) for rural households in China using national rural household survey (1993) of China. 10% of the 66,960 sampled rural households were taken for this study and a two-stage LA/AIDS model was used. In the first stage the demand for food, clothing, housing, durable goods, and other items was estimated. In the

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second stage the demand for grain, wheat, rice, meat, other, leafy vegetable, root vegetable, other fresh vegetable, dried vegetable, apples, grapes, and other fruit was estimated. Unit values were used as a proxy for price. The first stage results revealed than demand for food was relatively price elastic ( = -0.844) than the demand for other items. The second stage results revealed that, except for other fruits ( = -1.011) and grapes ( = -1.042), the conditional own-price elasticities of demand were inelastic though negative and statistically significant. The overall results revealed that fruits were more responsive (elastic) to own-price changes than vegetables. The results also showed that the poor were more sensitive to price changes than the rich. Abdulai et al. (243) estimated price and expenditure elasticities of demand for rural and urban households in India using LA/AIDS model. Cross-sectional data collected from 1100 households in 1995/1996 was used. By assuming weak separability, six commodity groups (milk and milk products; cereal and pulses; edible oils; meat, fish and eggs; vegetables and fruits; other food products) were included in the analysis and price was approximated by unit values. Both compensated and uncompensated price elasticities were estimated. The results revealed that all food groups except milk and milk products ( = -1.04) in the rural areas, were price inelastic. Meat, fish, and eggs group were the least responsive to own-price changes both in urban and rural areas ( = -0.57 and = 0.49, respectively). The estimated cross-price elasticities (from compensated and uncompensated models) were generally negative but weak, indicating that most of the food groups were complements. The study also showed that compensated elasticities were lower than uncompensated elasticities and the former gave reasonable cross-price elasticities. Elsner (229) used the Russian Longitudinal Monitoring Survey round VII of 1996 (n = 2874 households) to estimate the expenditure and price elasticities of food demand for different household groups in Russia. The two-stage LA/AIDS model (where the price index was approximated by the linear Stone price index) was used and several food groups were included in the analysis: bread, rice and grain, flour and pasta, potatoes, vegetables, fruits, beef and veal, pork, poultry, processed meat, fish, fresh milk, milk products, cheese, eggs, sugar and sweets. Unit values adjusted for quality effects were used as a proxy for prices and the two-stage Heckman procedure was applied to take into account zero expenditure. Compensated (Hicksian) and uncompensated (Marshiallian) own-price elasticities were estimated. The uncompensated price elasticity figures showed that the demand for flour and pasta, potatoes, vegetables, fruits, and sugar were highly sensitive to price changes (absolute value of price elasticity of demand >1) and the

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demand for bread was the least responsive ( = -0.69). The study also showed that demand was more responsive to price than to income changes. Huang and Lin (231) estimated demand elasticities for different income households using the United States National Food Consumption Survey of 1987/88 (n = 4495 households). One-stage AIDS model (where the price index was approximated by the log of the Stone price index) was used and food groups beef, pork, poultry, other meat, fish, dairy products, cereal, bread, fats and oils, eggs, vegetables, fruits, and juice were included in the analysis. Prices were approximated by unit values and unit values were adjusted for quality differences. However, no adjustment was made for zero expenditure. Uncompensated own-and cross-price elasticities were computed for each food category for different income groups. The results showed that the demand for dairy ( = 0.795) ,
vegetables ( = -0.724), and fruits ( = -0.719) were relatively more price elastic than other food groups. The results also indicated that the estimated price elasticities did not vary systematically across different income groups in the United States. Huang and Bouis (230) examined the impact of structural shifts in food demand patterns in Taiwan, China, using the Taiwan household expenditure surveys of 1981 and 1991 (n = 11886 in 1981 and n =12734 in 1991). Items such as meat (pork, chicken, and beef), rice, wheat, fish, fruit, other foods, and non-food were included and AIDS model was used. County (in the case of rice, wheat flour, chicken, eggs, and fruit) and regional (for other foods) level prices obtained from secondary sources were used and expenditure and price elasticities were estimated for village, town and city residents separately. For all food groups except rice and meat, the uncompensated own-price elasticities were elastic (| | >1). Fish was the most elastic food item ( =-1.638) followed by wheat ( =-1.514) and fruit ( =-1.412). The unusual low price elasticity for meat could be the use of regional/county level prices instead of household-level prices. The study indicated that there was significant change in the diets of Taiwanese consumers between 1981 and 199. It also pointed out that, structural changes such as urbanisation, occupation, and family size explained most of the changes in the consumption of rice, wheat, and fruit whereas price and income changes explained the changes in meat and fish consumption. The study also showed that income and price individually affected consumption Turk and Erjavec (232) analysed the demand for basic food items in Slovenia during the pre-transitional (1988) and transitional (1993) periods using two annual household budget surveys (n = 3027 households in 1988 and n = 3112 in 1993). A one-stage AIDS model (where the price index was approximated by the log of the Stone price index) was used. Seven food categories, namely bread and cereals, meat, fruits, vegetables, milk, oils,

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other food, were included in the analysis. Unit values were used to approximate prices but not clear if they were adjusted for quality differences and adjustments were made for zero expenditure. In order to make comparison between the two periods, income and prices in 1993 were deflated to the 1988 level and both own- and cross-price elasticities were estimated for different food commodity groups. The uncompensated own-price elasticities computed for 1993 showed that other foods ( = -1.273), fruits ( = -0.877), meats ( = -0.750), milk ( = -0.677) and vegetables ( = -0.461) were more price elastic than breads and cereals ( = -0.331) and oils and fats ( = -0.404). The comparison of the two period price elasticities revealed that as the result of the market liberalisation, consumers became more sensitive to prices of meat ( = -0.412 in 1988), oils ( = -0.072 in 1988) and cereal ( = -0.331 in 1998). These results indicated that the market liberalisation in Slovenia influenced the consumption of fruits, and vegetables positively and the consumption of meats, bread and cereals, and oils and fats negatively. Most of the estimated cross-price elasticities were close to zero indicating the absence of major substitution across different commodity groups. Raper et al. (241) estimated price and income elasticities for different income groups using the 1992 consumer expenditure survey and the United States Bureau of Labor Statistics data set of 3577 households and 7154 observations. Linear expenditure system that incorporates demographic variables were used to estimate a complete food demand system for nine broadly aggregate d food commodity groups (non-alcoholic beverages, food away from home, meat, other food at home, cereals and bakery products, dairy, fruits and vegetables, sweets and sugars, and fats and oils). The Heckmans two step procedure was used to take into account zero observations and compensated and uncompensated elasticities were reported. The results showed that both poor and nonpoor groups had similar uncompensated and compensated elasticities for most of the food groups mainly due to the food stump programme. The own-uncompensated price elasticity of demand for meat, cereals & bakery products, dairy, fruits and vegetables, sweets and sugars, and fats and oils were -1.0 for the poor and -0.98 for the non-poor households. However, poor households were more sensitive to price of food away form home (compensated price elasticity for the poor was -0.71 compared to -0.57 for the nonpoor households). The study also showed that including demographic variables in subsistence quantity may provide more information for policy makers. zer (234) estimated compensated and uncompensated own-and cross-price and expenditure elasticities of demand for Turkey using linear expenditure system. Six food groups, viz. bread and cereals; meat, fish, and poultry; milk, dairy products, fats, oils, and eggs; vegetables and fruits; various processed food; tobacco products, liquors, and beverages were considered and consumer price indices were used as a proxy for price.
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Cross-sectional data collected from 26256 households in 1994 were used. All the estimated own-price elasticity coefficients were negative and significant indicating the sensitivity of households to price changes. Except for bread and cereal groups, the estimated own-price elasticities were elastic. The demand for tobacco, liquors, and beverages was highly elastic ( = -1.510 uncompensated and = -1.401 compensated) followed by the demand for meat, fish, & poultry ( = -1.207 uncompensated and = 1.300 compensated); fruits and vegetables ( = -1.097 uncompensated and = -0.889 compensated); and processed foods ( = -1.092 uncompensated and = -0.964 compensated). Generally, compensated price elasticities of demand were less than uncompensated ones indicating consumers were more responsive to own-price changes than to cross-price changes. Agbola et al. (233) examined the effect of bottom-up and top-down estimation procedures on food consumption parameters and they estimated compensated and uncompensated own and cross-price elasticities of demand for South African households. They used the 1993 South Africa integrated household survey (n = 6960 households) and the flexible two-stage LA/AIDS model. Unit values (unadjusted for quality differences) were used as price variables and no adjustment was made for zero expenditure. Missing price variables were replaced by cluster level mean prices. The estimated uncompensated price elasticities based on the top-down approach (an approach that was suggested for South Africa data) showed that South African consumers were highly sensitive to prices, especially to meat and fish ( = - 1. 309), grains ( = - 1. 258), vegetables ( =-1.123), fruits ( = - 1.061) and dairy products ( =-0.958). However, the cross-price elasticities were generally insignificant and close to zero, indicating that demand for a certain food item was more sensitive to changes in its own-prices than to changes in other food prices. Seale et al. (235) examined the responsiveness of consumers to food prices and income changes throughout the world. Thirty-eight low-income (<15 % of U.S. income level), 44 middle income (15-44 % of U.S. income level), and 32 high income (> = 45 % of U.S. income level) countries were included in the study. It was one of the most comprehensive studies in the area of cross-country analysis of demand. The data was collected by the International Comparison Project in 1996. The analysis was made at two stages. In the first stage, the Florida-Preference Independence model was used to estimate an aggregate demand system across nine broad consumption categories. In the second stage, the Florida-Slutsky model was used to analyse the demand for food across eight food subcategories (bread and cereals, meat, fish, dairy products, oils and fats, fruits and vegetables, beverages and tobacco, and other food products). Prices were adjusted for differences in purchasing power in different countries and were converted into US dollars

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to facilitate comparison across countries. Missing price data were generated using weighted least squares approach. Unconditional own-price elasticities of demand were estimated for the eight food categories and are summarised in Figure X. As shown in Figure 1.2, price elasticity of demand were generally inelastic (| | <1) in both developed and developing countries for all food groups. However, consumers in low income countries were more responsive to price changes of all food items than consumers in middle- and high-income countries. The results also showed that consumption of highervalue food items such as fish, dairy, meat, and fruits and vegetables was more price sensitive than cereals and oil and fats in all countries.
Figure 1.2. Unconditional Frisch own-price elasticity for food sub-categories by national income, based on Seale et al. (235)
0.9 0.8
Own-price elasticity

Fish Dairy Meat Fruits & vegs. Cereal Oils & Fats

0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 Middle income High income Low income

Khaled et al. (237) updated the price and income elasticities of demand using recent time series data for New Zealand (1981-2001). Approximately 3000 private households were included in the survey. Six consumption groups and eight food groups (fruits and vegetables; meat; poultry; fish; farm products, fats and oils; cereals and cereal products; sweet products, spreads, beverages and other foods; and meals away from home and ready-to-eat food) were considered in the study and consumer price index was used. The study used a two-stage Rotterdam model to estimate price and income elasticities. The results showed that food was the most inelastic expenditure category (=-0.0183) compared to housing (=-0.1420), household operation(=-0.1908), apparel (=-0.1184), transport(=-0.0817), and other goods & services (=-0.1112), and over the last twodecades consumption of fruits and vegetables, poultry, food eaten away from home, and sweet products increased significantly. The estimated elasticities also showed that demand for cereals (=-3.433), fish (=-1.562), poultry (=-1.205), farm products (=1-102

1.007), and meals eaten away from home (=-1.751) were more price elastic than other food groups (meat and sweets and others) and earlier estimates. Most of the food categories were not also sensitive to cross-price changes. Yen et al. (236) estimated elasticity of demand for beef, pork, poultry, fish, other meat, grain, fats and oils, egg, milk, vegetable, and fruits for urban Chinese households using the 2000 Chinas food consumption and expenditure survey. More than 3,700 households were included in the survey and unit values were used as a proxy for price. Uncompensated own-price elasticities estimated from a translog demand system showed that the demand for all food items were sensitive to each own-price. Except for milk and other meat, demand was generally price inelastic. Milk had the highest own-price elasticity of demand ( =-1.40) followed by other meat ( =-1.00), beef, ( =-0.96) grain ( =-0.90), fruits ( =-0.76), poultry ( =-0.75) and vegetables ( =-0.72). The demand for pork had the lowest own-price elasticity of demand ( =-0.21). The gross cross-price elasticity of demand showed that egg products were gross substitute for fats and oils, beef, pork and poultry. Most products were also gross complements to fish and poultry. Generally, however, the cross-price elasticity of demand was very small compared to the own-price elasticity of demand estimates. Dong et al. (238) examined the food demand structure of Mexican households using Amemiya-Tobin approach. Using the 1998 nation wide survey of Mexican household food and nonfood purchase data (2,972 households), the study examined Marshallian own-and cross-price elasticities for beef, pork, poultry, processed meat, seafood, vegetable, fruits, grain, beans, cheese, nonalcoholic beverage and milk. The results showed that all food items were price inelastic except milk ( =-1.136) and unprocessed pork was the most price inelastic ( =-0.132). The cross-price elasticities also showed that milk was the most and pork the least substitutable products. The smallest elasticity value for complement food items was between beef and pork (cross =-0.367). Kedir (239) estimated own-and cross-price elasticities for urban Ethiopia. The study placed twenty-six food items into six groups (teff, cereals, pulses, fruits and vegetables, meat, coffee). The study used a within cluster methodology (as developed by Deaton), with within cluster quality adjusted unit values and actual market prices. The results indicated that all the own-and cross-price elasticities were inelastic. Teff had the highest elasticity ( =-0.29) followed by meat ( =-0.04) and pulses ( =-0.20). The results also revealed that unit values, corrected for quality differences, could perform more than market prices collected from published sources from a theoretical perspective.

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Chung et al. (240) estimated a quality adjusted price elasticity of demand using a 1996 survey of Mexican household (6,394 urban households) food purchases. The analysis was based on urban households to reduce potential bias associated with self-produced foods in rural areas. A model that includes both expenditure and unit value equations and that took into account zero expenditures was used. Unit values adjusted for quality variation in both prices and quantities were used. Meat, beef, seafood, vegetables, grain, and nonalcoholic beverages were included in the study. The results indicated that unit values unadjusted for quality variations in both prices and quantities could yield biased demand elasticity estimates. The quality adjusted unit value (both in quality and price) elasticities showed that meat ( =-1.183), beef ( =-1.662), and seafood ( =-2.573) were price elastic and vegetables ( =-0.757), grain ( =-0.962) and non-alcoholic beverages ( =0.606) were price inelastic.

Specific food group studies

Dey (244) estimated the demand elasticities for different fish types in Bangladesh using cross-sectional household expenditure data collected by the Bangladesh Bureau of Statistics in 1988/89 (n = 5667 households). Six varieties of fish, namely ilish, live fish, carp, small fish, shrimp, and dried fish were included in the study. The grouping was made by the opinion of the respondents. Unit values were used as a proxy for price and missing prices were replaced by village level prices. Three-stage QU/AIDS model was used and an attempt was made to take into account zero consumption using Tobit model at the second stage of the analysis. Own-compensated and cross- price elasticities were estimated for the poorest and richest quartile. Carp had the highest (in absolute terms) compensated price elasticity ( = -2.87 for the poorest quartile and = -2.02 for the richest) and assorted small fish the lowest ( = -0.42 for the poorest quartile and = 0.59 for the richest quartile). Based on the estimated elasticities, the study showed that consumers in Bangladesh were highly sensitive to the prices of different fish types. Yen et al. (245) examined the demand for fat and oil (butter, margarine, shortening, cooking oil and salad dressing) in the United States using the 1987/88 nationwide food consumption survey conducted by the United States Department of Agriculture (n = 3943 households). Two-step translog censored demand system was used and own-compensated and uncompensated, and cross-price elasticities were estimated. Unit values were used as a proxy for price and missing prices were replaced by regional average values. The estimated own-price elasticities were generally high. Butter had the highest elasticity ( = -1.132) followed by margarine ( = -0.991), and salad dressing ( = -0.990). The study concluded that price could play significant roles in shaping the consumption of fats and

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oil in the United States. Most of the uncompensated cross-price elasticities were very small and insignificant indicating the absence of gross substitutability or complementarity. Lazaridis (248) investigated the demand for meat (beef, lamb, pork and poultry) in Greece using the 1987/88 and 1993/94 family budget survey conducted by the National Statistical Service of Greece (n = 6756 households). Two-stage LA/AIDS model was used and the price index was approximated by the log-liner analog of the Laspeyres price index. Unit values adjusted for quality differences were used as proxy for prices. The compensated and uncompensated own- and cross-price elasticities were estimated. The uncompensated own-price elasticities showed that beef ( = -0.804 in 1987/88 and -0.677 in 1993/94) and poultry ( = -0.619 in 1987/88 and -0.592 in 1993/94) were more elastic than lamb ( = -0.278 in 1987/88 and -0.111 in 1993/94) and pork ( = -0.133 in 1987/88 and -0.277 in 1993/94). The study concluded that the absolute values of the income elasticities of demand for all meat items were higher than the estimated own-price elasticities indicating that income policies might be more effective in directing the meat consumption patterns in Greece than price policies. Yen and Huang (246) estimated censored demand equations for four different types of beef using the 1987/88 Nationwide Food Consumption Survey in the United States. A Translog demand functions were used and estimated by full-information maximumlikelihood (FIML) and simulated maximum likelihood (SML) methods. Four disaggregated forms of beef, namely, steak, roast, ground beef, and other beef were used. The estimated unconditional price elasticities of demand showed that the demand for roast ( = -1.305), steak ( = -1.382), and other beef ( = -1.975) are price elastic while the demand for ground beef ( = -0.844), and other meat ( = -0.844) are price inelastic. The study also showed that while price and income mostly affect the demand for different bee cuts, other factors such as household composition, urbanisation, gender, food stamp participation, affect the probability that a household would consume beef products given price and income. Dhar et al. (247) investigated the impact of price and expenditure endogeneity in empirical demand analysis using the 1998 IRI-Infoscan carbonated soft drinks data from 46 major metropolitan marketing areas in the United States A total of 920 quarterly observations and nine carbonated soft drinks ( 7-up, Coke, Dr. Pepper, Mt. Dew, Pepsi, RC Cola, Sprite, Private label, All-other) were used. Modified AIDS model and retail prices were used in the estimation. Both price and expenditure variables were found endogenous in the system. The estimated price elasticities indicated that demand for carbonated soft drinks was highly sensitive to price changes for all items ( = < -1)

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especially after the endogeneity of price and expenditure variables were corrected. The study concluded that the endogeneity of price and expenditure variables could significantly affect the consistency of demand elasticities and the tests of separability. Garcia et al. (249) investigated the consumption patterns of households for disaggregated fish in the Philippines. A countrywide family income and expenditure survey conducted in 2000 was used. The survey covered 39,000 households. A three-sated QUAIDS model was used. In the first stage the demand for food (cereals, fish, meat, fruits/vegetables, beverages, and other) and in the second the demand for fish (capture, aquaculture, and processed fish) was estimated. In the last stage a QUAIDS model was estimated for fish by species. Four fresh fish (milkfish, tilapia, shrimp, shells/crabs) four marine species (roundscad, anchovies, squid, other fresh fish) and three processed fish (Dried/smoked fish, canned fish, salted fish) were included in the final analysis. Province level market prices were used and both uncompensated and compensated elasticities were estimated. The estimated results revealed that except for shrimp and shells, the uncompensated ownprice elasticities of demand for all species of fish were elastic for all income groups. The uncompensated elasticities were generally higher than the compensated elasticities indicating that if income was held constant, the responsiveness of households to fish price decreases. Rich households were more sensitive to the prices of high value fish varieties such as shrimp ( =-0.88 for the first income quintile compared to =-0.90 for the fifth quintile) and poor households to cheap fish varieties such as milkfish ( =-3.61 for the first quartile and =-1.26 for the fifth quartile) tilapia, squid, and shells/crabs. Most of the cross-price elasticities, though relatively inelastic, showed that most of the fish types were substitutes each other. The paper concluded that demand for fish highly varies according to fish type and price in the Philippines. Generally, the own-price elasticity of demand for fish was high and consumers were more likely to substitute meat for fish as the price of fish increased.

1.6.2.2 Time series/panel data based studies

Twenty nine studies examined the impact of food prices on food expenditure using panel or time series data. Out of these studies, seventeen (252-268) estimated a complete demand system and twelve estimated demand for specific food items: specifically numerous food items (269), snacks (270), fats and oils (271), fresh fruits and vegetables (272); meat (273); edible oils (274); selected healthy food items (275); swine and bovine meat (276); animal products (277); fish (278); animal products (279), and fruits and vegetables (280).

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Complete food demand studies

Ingco (252) examined the responsiveness of demand for meats (beef, pork, and fish) and grains (rice, wheat, and barley) in the Republic of Korea between 1961 and 1987. Monthly retail price were used and a modified LA/AIDS model was applied (urbanisation and habit were considered in addition to other variables). The results showed that the own-price elasticity of demand for all food items, except for pork, were price inelastic. The own-price elasticity of demand for pork was -1.0 and remained the same between 1965 and 1987. Generally, the own-price elasticity of demand for meat items was higher than that of grain items in absolute terms. From meat products the demand for beef was more sensitive than the demand for chicken and it appeared more price responsive through time (( =-0.2 in 1965 to =-0.6 in 19887). The responsiveness of chicken for its own-price, however, showed a declining trend. The demand for wheat was more responsive than the demand for rice though both elasticities have shown a declining trend (in absolute terms) through time. Ingco (253) examined the characteristics of demand for major food stuffs in the Philippines using time series data (1965-1990) and L/AIDS model. Rice, corn, wheat, meat, fish, fruits & vegetables, and other goods were included in the analysis. Data from the FAO, Philippines Bureau of Agricultural Statistics, and from the National Statistics Office were used. Except for meat, the estimated uncompensated price elasticities of demand were inelastic ( = < -1). Rice ( =-0.020), corn ( =-0.068), and fish ( = 0.042) were least responsive to their own-price changes compared to meat ( =-1.210), wheat ( = -0.453), and fruits and vegetables ( = -0.209). There was similar pattern between the uncompensated price and income elasticities of demand indicating the relatively high income effect in the price elasticity values. The cross-price elasticity figures indicated that the demand for most of the food items was responsive to changes in rice prices and wheat and meat were complementary (mainly due to high consumption of bread and hamburgers, and noodles in restaurants and fast food chains). Balisacan (254) examined the structure of food consumption in the Philippines using the Family Income and Expenditure Survey of the National Statistics Office for 1985, 1988, and 1991. A sub-sample of 13,487 households (aged between 15 and 65) were selected from the three rounds. A two-stage budgeting framework was followed and quadratic (extended) AIDS model was used. In the first stage, total expenditure is allocated between food and non-food and in the second stage among 11 food groups (rice, corn, wheat, other cereals, vegetables, fruits, pork beef, poultry, milk, eggs, and fish). Elasticities were estimated for different income quartiles by urban/rural settings. The uncompensated price elasticities showed that fruits and vegetables ( = -1.104), other

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cereals ( = -1.102) and corn ( = -1.078) were price elastic. For most of the food items (except corn), price elasticities were relatively low (in absolute terms) for rich and urban households though the variation was not as big as commonly presumed. The comparison of different elasticities estimated for the Philippines showed that less aggregated studies tend to report more elastic price elasticities compared to highly aggregated studies mainly due to limited scope of substitution. Molina (255) analysed demand for food in Spain using a time series data (1964-1989). AIDS model was used to estimate compensated and uncompensated price elasticities of demand for bread and cereals, meat, fish, milk and eggs, vegetables and fruits, and other food items. The estimated results revealed that elasticities estimated from Marshallian (uncompensated) demand functions were higher than elasticities estimated from Hicksian demand functions. All the estimated uncompensated own-and cross-price elasticities were inelastic. The own-price elasticity of demand for milk and eggs ( = -0.89) were more elastic than the other food groups followed by meat ( = -0.77) and vegetables and fruits ( = -0.68). Bread & cereals ( = -0.17) and fish ( = -0.35) had relatively inelastic own-price demand. The study also showed that Hicksian (compensated) models were more appropriate in estimating cross-substations than Marshiallian (uncompensated) models since the former measured substitution net of income effects. Most of the estimated cross-price elasticities of demand were generally weak. Soe et al. (256) estimated demand functions for some important food items using a time series data in Myanmar. Aggregate quarterly time series data for 51 observations between 1975 and 1987 were used. Double-log and LA/AIDS model were applied and open market prices were used. Three variety of rice (poor, medium, and high quality); wheat flour; groundnut oil; sesame oil; pulses; potato; onion; garlic; chilli; salt sugar; coffee; beef; pork; mutton; goat-meat; chicken; duck; fish were included in the study. The results of the study indicated that the LA/AIDS model gave more theoretically consistent results than the double-log method. The estimated elasticities showed that the demand for non-meat basic foods was generally inelastic. However, the demand for wheat flour was relatively elastic than the demand for all types of rice indicating that wheat flour was semi-luxury (festival food) in Myanmar. The own-price elasticities of demand for other non-meat basic foods items such as oil, pulses, potato, and onion were close to unity. The cross-price elasticities of demand on the other hand were generally small. The sign of the coefficients indicated that high quality rice was a substitute for low quality rice but low quality rice was a complementary to high quality rice. Sesame and groundnut oil were substitutes. For meat items beef had the lowest (in absolute terms) ( = -0.18) and chicken the highest ( = -1.70) own-price elasticity of demand. The cross-price elasticity

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among different meat items was generally low but the substitution between pork and chicken was considerably large. Laajimi et al. (257) analysed factors that determine food consumption in Spain using the Spanish Food Consumer Panel data (October 1989 September 1992). Altogether, there were 5149 households with consistent information for the three-year period. Food items were aggregated into seven groups as cereals and bread, meat products, fish products, dairy products, oils and fats, fruits and vegetables and other foodstuffs, based on their common nutritional sources. Weak separability between food and non-food items was assumed and consequently only one stage AIDS model (where the price index was approximated by the average price weighted by the average budget share) was used. Prices were approximated by unit values but no adjustment was made for quality differences and for zero expenditure. Missing prices were replaced by the average price for each year. The type of panel data estimation procedure used in the analysis was not mentioned. Compensated and uncompensated own-and cross-price elasticities were estimated. The results revealed that dairy products had the highest (in absolute terms) elasticity ( = -1.014) followed by fruits and vegetables ( = -0.836), meat ( = -0.742) and fish ( = -0.671). The paper also showed that meat and fish were good substitutes but demand was more responsive to own-price rather than to cross-price changes. Edgerton (258) tested the impact of multistage sampling (weak separability) and low variability of price indices on elasticities using annual data for aggregate private consumption from the Swedish national accounts for the period 1963-90. In the first stage, total private consumption was divided into food at home, food out-of-home, goods excluding food, and services excluding restaurants. In the second stage, food at home is divided into animals, beverages, vegetables, and miscellaneous. In the final stage, each food group is divided into three more food items. Implicit price indices (current exp/ real exp) formed using the Paasche indices were used. A dynamic version of LAIDS model was used and both within group and within food price elasticities were computed. The estimated elasticities showed that most of the food items were price inelastic. The demand for alcohol ( =-0.83), cereals ( =-0.78), soft drinks ( =-0.65), and fruits and vegetables ( =-0.59) were relatively more elastic than the demand for meat, fish, dairy fats and potatoes. The study also showed that assumptions about separability and price indices can affect the estimated price elasticities and elasticities estimated from a last stage of multiple budgeting processes can give error results which may have policy consequences.

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In one of the only two papers published in the nutrition and health literature, Guo et al. (259) examined the effects of food price changes on dietary intake of different food groups (they also examined macronutrients, for which the results are reported on below). Data from the first three rounds of the China Health and Nutrition Survey (1989, 1991, and 1993) were used (a nationwide survey, but not nationally representative). The total longitudinal sample size was 6667 individuals. Six food groups (rice, what flour, coarse grains, pork eggs, and edible oils) were identified and community level prices collected from three different sources (free market, state sore, authority price records) were used. A random effect model was used to estimate price elasticities. Fruits, vegetables, and other meat items were not included, and it was not clear why random effect model was used. At the same time, no information was given whether the model used satisfied the usual demand theory restrictions. Uncompensated own-and cross-price elasticities were estimated for poor and rich consumers separately. Poor consumers were more sensitive to price changes compared to rich consumers for almost all food items, except for coarse grains and edible oils. Poor consumers were sensitive to pork price ( = -0.96) compared to rich consumers ( = -0.33). Consumers were also sensitive to the price of edible oils ( = -0.47 for the rich and = -0.39 for the poor). The paper concluded that there was evidence that food intake is responsive to price change in China. Meenakshi and Ray (260) analysed the regional differences on Indias expenditure pattern and estimated demand parameters using five rounds national sample surveys (1972/73 -1987/88). More than 2000 households in sixteen Indian states were included in the study. Nine food items namely, cereals and cereal substitutes, pulses, milk and milk products, edible oils, meat, egg and fish, other food, closing and footwear, fuel and light, and other non food items were considered in the study. Fruits and vegetables, however, were lumped in other food category. Demographically extended two-stage QA/AIDS model and retail state level price data were used. Based on a weak separability assumption between food and non-food expenditure, uncompensated own-price elasticities were estimated for five food items disaggregated by urban and rural areas. The results showed that the demand for meat, egg and fish was highly sensitive to its ownprice in both rural ( = -2.107) and urban areas ( = -1.080) followed by the demand for edible oils. The study showed that the demand for milk and milk products ( = - 0.923) and edible oil ( = - 1.187) were more sensitive to own-price changes in urban areas than in rural areas ( = -0.383 and = -0.802, respectively) while the demand for meat, egg and fish were more sensitive to own-price changes in rural than in urban areas. The study concluded that estimated price elasticities were quite sensitive to functional forms used in the analysis and in developing countries like India, non-economic factors were as important as economic-factors in explaining food expenditure patterns.

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Balcombe et al. (261) estimated demand elasticities for Bulgarian households (2,500) using the Bulgaria household budget survey carried out by the National Statistics Institute between January 1991 and April 1996. Four food groups namely, bread, milk, cheese, meat and all other products were considered and a modified AIDS model adjusted for seasonality was used. The estimated price elasticities showed that all of the products were price elastic (| | > 1) and most cross-price elasticities were insignificant. Cheese had the highest elasticity ( = - 1.40) followed by meat ( = - 1.24), milk ( = - 1.24), and bread ( = - 1.08). Tiffin and Tiffin (262) estimated price and income elasticities for households in the United Kingdom using neo-classical demand theory consistent LAIDS model. Time series data (between 1972 and 1994) data from the United Kingdoms Office for National Statistics and from the National Food Survey Committee annual report were used. A three stage estimation technique was applied. In the first stage, consumers allocated expenditure into food and non-food items and in the second (third) stage into staple foods (milk, cheese, bread, eggs), meat (pork beef, chicken other meat lamb), vegetables (processed vegetable., green, vegetable., other fresh vegetable., potatoes),, and fruits (bananas, apples, citrus fruit, other fresh fruit, other fruit). For each food group and item, annual national average price were used and compensated and uncompensated price elasticities were estimated. The results of the study showed that the own-price elasticities of demand for meat ( = - 0.951) was higher than for staples ( = - 0.567) and vegetables ( = - 0.311). Due to its seasonal nature, lamb had the lowest (in absolute terms) ownprice elasticity ( = - 0.525) from meat group. Citrus fruits ( = - 0.462) and apples ( = 0.487) had also the lowest own-price elasticity from the fruit group indicating the staple status of these fruits. The study also indicated that the own-price elasticities for aggregated food groups (second stage) were generally lower (in absolute terms) than for individual items (last stage) indicating higher degree of substitution within groups. The very high elasticity of demand for brown bread ( = - 3.638) also revealed that price was one of the major factors for the shift of demand from white to brown bread. Lind (263) estimated a demand system for India using a time series data from FAOSTAT C-ROM 1998 (1967-1997). A dynamic AIDS model was used and the expenditure shares of vegetables, animal products, and other were considered in the model. The estimated long-run price elasticity coefficient (from the AIDS model) showed that all the food items were price inelastic. However, the demand for animal products was more price elastic ( = - 0.92) than vegetables ( = - 0.18) and households substitute vegetables for meat especially as income increases (cross = 0.04). The study concluded that Indian households were price responsive than was otherwise thought.

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Luchini et al. (264) examine the impact of market reform on the consumption patterns of Bulgarian households using a two-stage LAIDS model. Private per capita consumption data collected by the National Statistics institute of Bulgaria for the period January 1985 to December 1997 were used. For the empirical verification the data were seasonally adjusted using the ARIMA technique. In the first stage total private consumption was divided into food, alcoholic drinks and tobacco, clothing, footwear, housing, and other expenditures and in the second stage the food group was subdivided into meat and fish, fruit and vegetables, milk and eggs, bread and cereals, and miscellaneous. The study made distinction between short-term responses to price shocks and long-term behaviours. The results showed that consumers actively responded to the dramatic increase in prices between February 1991 and January 1992. However, in the long-term most items became more price inelastic (even compared to the pre-reform period) partly because of high self produced food consumption in the country. The cross-elasticities also showed that complementarity was more common than substitutability. At the time of hardship, bread was a substitute for items such as meat and milk and quantitative factors were still important than qualitative factors in influencing food demand in Bulgaria. Elasticities were shown graphically so it was difficult to identify their exact values Hossain, et al. (266) examined the demand elasticities for different food items using a panel data set in Lithuania. Information collected from a total of 1500 households observed each month between July 1992 and December 1994 was used in the analysis and a LA/AIDS model was used. Food groups including grains, fruits & vegetables., beef, pork, poultry, eggs, other meat, milk, butter & cheese, other dairy, and sugar & confectionery were used consumer price indices were used to measure price. The results revealed that Lithuanian households were responsive to price changes (all food groups had negative own-price elasticity coefficients). However, the own-price elasticity of demand for essential food items were relatively more inelastic (grains = -0.440, other dairy = -0.51, fluid milk = -0.59) than non-basic food items (pork = -1.49, other food = -1.35, butter and cheese = -1.49, and other meat = -1.12). The cross-price elasticities, though generally small, indicated that the consumption of grains did not respond to dairy product price changes and the consumption of meat to changes in the price of poultry. Consumption of fruits and vegetables was also insensitive to the price of meat and dairy products. The study concluded that, during the transition time in the country, households were responsive to price changes. Hossain et al. (265) estimated price elasticities of demand for food and non-food expenditure groups using pooled data from Latvian Household Budget Survey data between January 1996 and December 1997 (13,537 observations were included). AIDS model was specified and a non-linear estimation method was applied at two-stage
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budgeting process. The estimated price elasticities showed that households were responsive to the price changes especially to meat ( =-1.09), fruits and vegetables ( =1.08), and fat ( =-0.92). The own-price elasticity of demand for grains ( =-0.63), fish ( =-0.50), and dairy ( =-0.40) was relatively inelastic. Klonaris and Hallam (267) estimated unconditional and conditional demand system for Greece using the National Accounts of Greece for the period 1959-1955. A three-stage dynamic AIDS model was used. In the first stage, the demand for education, medical care, durable household goods, food, clothing, housing, transport, and other goods and services was modelled. In the second state, the food category was disaggregated into beverage and tobacco, livestock products, and various foods. In the final stage beverage and tobacco was divided into non-alcoholic, alcoholic, tobacco; livestock into meat, fish, dairy; and various foods into bread and cereals, fruits and vegetable, oils and fats, and miscellaneous. The estimated elasticities showed that all the commodities including food ( =-0.543) were price inelastic except medical and personal care ( =-1.253). The results also indicated wide differences between conditional (elasticities estimated from within a subsystem) and unconditional (elasticities estimated from a demand system that includes all goods) elasticities and indicated the need for adjustments if these elasticities were to be used for policy and welfare analyses. The second stage analysis showed that the demand for beverages and tobacco ( =-0.979) was more elastic than the demand for livestock products ( =-0.790) and various foods ( =-0.602). The final stage analysis revealed that the price elasticity of demand for all food items was price inelastic. The demand for fruits and vegetables ( =-0.765) and bread and cereals ( =-0.708) was more elastic than the demand for oils and fat in various food group and the demand for meat ( =-0.780) was more elastic than the demand for fish ( =-0.567) and dairy products in the livestock product group. Smed et al. (268) analysed the impact of food taxes and subsidies on nutrition across different socio-economic groups in Denmark. A weekly panel representative data collected by Danish food consumers from GfK ConsumerScan between January 1997 and January 2000 was used (n = 2000 households). Eggs, other meat, other dairy, fish, processed fish, grain based products, poultry, processed fruit and vegetables, fresh fruit, fresh vegetables, potatoes, biscuits and cakes, milk, margarine, beef, cheese, processed meat, rice and pasta, butter, sugar, pork and curdled milk products were considered. The data did not include beverages and food away from home. A one-stage dynamic specification of the AIDS model was used and price data was aggregated to pure time series data for 7 age groups, 3 geographical regions and 5 social classes. The estimated elasticities showed that butter, margarine, beef, pork, poultry, sugar, fruit, and vegetables

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had elastic demand (| | >1). The actual elasticities were not shown clearly in the paper so could not be reported here. Lower social classes and rural households were more responsive to price changes than upper classes and urban households.

Specific food group studies

Beatty and LaFrance (269) analysed the role of food price in the demand for food and nutrients in the United States between 1919 and 2000 (excluding 1942-1946) using aggregated food and nutrient demand data. Twenty-one food items in four food categories were included in the study: dairy products (fresh milk and cream, butter, cheese, ice cream and frozen yogurt, and canned and powdered milk); meats, poultry, and fish (beef and veal, other red meat, pork, poultry, fish and shellfish); fruits and vegetables (fresh citrus fruit, other fresh fruit, fresh vegetables excluding potatoes, potatoes, processed fruit, and processed vegetables); and miscellaneous foods (eggs, fats and oils, excluding butter, cereal grains and bakery products, sugar and caloric sweeteners, and coffee, tea, and cocoa). Annual time series price data (deflated by consumer price index for all items except food) was used and some demographic variables were included in the analysis. A new model was developed based Gormans class of exactly aggregable demand models. The new model nested exiting models, incorporated income distribution, and combined demand estimates with nutrient content of foods. The results of the study showed that all food items (except other red meat) had an inelastic own-price elasticity of demand (||<1) and had shown no significant change over the study period. The only exception was poultry which own-price elasticity of demand had shown a significant decline from near unity to near zero between 1947 and 2000. Kuchler et al. (270) examined the potential impact of excise taxes on snack foods. The ACNielsen Homescan panel data (n =7195 households) were used in the analysis. Five salty snacks namely, potato chips, pretzels, cheese puffs, microwavable popcorn, and nuts were considered. Descriptive and simulation analyses were used to examine the impact of different levels of taxes (0.4, 1.0, 10.0, and 30.0 percent) at three levels of elasticity: very inelastic (-0.2), inelastic (-0.7), and unitary elastic (-1.0). It was assumed that the entire tax would be passed to the consumer, all purchases were consumed, and other foods would not be substituted for salty snacks. The results showed that almost 99% of the sampled households purchased some snack foods and households that purchased potato chips purchased 9.8 pounds per year. The simulation results revealed that the consumption of salty snack declined as the tax rate and price elasticity of demand (in absolute terms) increased. However, imposing taxes of around 1% per pound (as suggested in the literature) or less, would unlikely to have a significant impact on the consumption level of salty snakes (only 0.19 2.32 ounces per year depending on the

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elasticity assumption). The study concluded that lower tax rates alone were less likely to reduce salty snack consumption. Complementing such measures by information programme might help to influence diet choices. Gould et al. (271) analysed the impact of prices and expenditure on fats and oils consumption in the United States Aggregated quarterly time series data between 1962 and 1987 were used. Five types of fats and oils, namely butter, margarine, shortening, salad and cooking oils, and lard were considered. Retail city average prices were used to measure prices and LA/AIDS model that incorporates demographic variables was used. The estimated uncompensated own-price elasticity coefficients revealed that demand for fats and oils was sensitive to price but inelastic (| | <1). Among the five items, butter was more price elastic ( =-0.662) followed by salad and cooking oils ( =-0.440), and shortening ( =-0.421). The cross-price elasticity of demand indicated that butter and margarine were complements and except for lard and butter, most of the cross-price elasticities indicated gross complementarity. You et al. (272) estimated the demand for fresh fruits and vegetables at the retail level in the United States using time series data covering 1960-93. At the first stage, 11 food categories and one non-food sector were considered and at the second stage the demand for 11 fresh fruits (apples, bananas, cherries, grapefruit, grapes, lemons, oranges, peaches, pears, strawberries, watermelon) and 10 fresh vegetables (asparagus, cabbage, carrots, celery, cucumbers, lettuce, onions, peppers, potatoes and tomatoes) was investigated. Two-stage composite demand system was used and own-and cross-price elasticities were estimated. The study showed that grapefruit ( = -1.022), grapes ( = -0.907), oranges ( = -1.135), and peaches ( = -0.9624) were more responses to own-price changes than bananas ( = -0.424), lemons ( = -0.302), and water melons ( = -0.600). Demand for cabbage, celery, and lettuce responded insignificantly to changes in own-prices while demand for asparagus, carrots, cucumbers, onion, peepers, potatoes and tomatoes responded significantly to own-price changes though inelastic (| | <1). The study concluded that the demand for most fresh fruits and vegetables was responsive to price changes though inelastic and the cross-price elasticities were generally small. Fang and Beghin (274) estimated a demand for edible oils and fats in urban China using a panel data set between 1992 and 1998 (20,000 observations). A LinQuad incomplete demand system was used and the Hickman two step procedure was used to take into account zero observations. Rapeseed oil, peanut oil, soy oil, and animal fat were considered. The estimated elasticities showed that staple oils such as soy oil in Northeast region ( = -0.671), rapeseed oil in Middle and West ( = -0.435), and peanut oil in

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South ( = -0.272) China were own-price elastic. In most cases, the demand for condiment-oil (except in the South region) and animal fats (except in the Northeast region) were more price responsive ( from -1.085 to -1.23). Hsu (273) examined gradual structural changes of meat and fishery products consumption in Taiwan using LAIDS model. The transition paths for each product were identified and included in the analysis. Pork, beef, poultry, and fish were considered. The estimated results revealed that elasticities with and without structural shifting factors differed significantly. With structural shifting factors, beef and fish became price elastic (changed from = -0.2801 to = -1.5089 for beef, and from = -0.238 to = -1.314) and pork poultry become more responsive to price changes. Beef and poultry also became substitute and the substitution between pork and poultry increased significantly. The study concluded that elasticities estimated with gradual switching time paths could reflect consumption patterns more accurately. Feng and Chern (275) analysed the demand for selected healthy food items in the United StatesA using a time series monthly data between 1981 and 1995. Seven health food groups (fresh fruits, fresh vegetables, processed vegetables, processed fruits, cereal and cereal products, bakery products, and poultry) and one other foods group were used in the analysis. The consumer price index for food was used as a price for the other food group and two seasonal dummy variables (for winter and summer seasons) were included in the analysis. Modified one-stage LA/AIDS model was used and compensated and uncompensated own-and cross-price elasticities were estimated. The study showed that poultry ( = -0.864), fresh fruits ( = -0.820), fresh vegetables ( = -0.614) were relatively more price elastic than bakery products ( = -0.485), processed vegetables and fruits ( = -0.267), and cereals ( = -0.090). The demand for fresh fruits and fresh vegetables was more elastic than the demand for processed fruits and processed vegetables. The cross-price elasticities of demand also showed that fresh fruits and fresh vegetables were complementary (could be purchased and consumed together) and fresh and processed fruits, fresh and processed vegetables were substitutes. However, the absolute magnitude of the cross-price elasticities of most of the commodities was very small. Mata et al. (276) examined the leading economic and technological factors affecting the behaviour of domestic swine meat supply and demand and determined the impact of price changes on supply and demand of swine meat in Mexico. A time series data between 1960 and 2002 were used and swine and bovine meat were considered. Producer prices based on Nerlove adaptive expectation and consumer prices were used to estimate the

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supply and the demand equations simultaneously. The results revealed that the average (1961-2002) short-term price elasticity of demand for swine meat was negative but inelastic ( =-0.58). The results also showed that this elasticity declined through time from -0.84 during 1961-70 to -0.29 during 1990-2002). The poor were also more sensitive to the price of swine meat than the rich. The result also revealed that bovine meat was a good substitute for swine in the short and long terms. Dhehibi and Laajimi (277) investigated the impact of economic factors on animal food choices and nutrient availability in Tunisia using a time series data (1973-1998). Five animal food products (meat products, beef, lamb, poultry, eggs, and fish) and eleven nutrients (energy, protein, total fats, calcium, iron, magnesium, zinc, thiamine, riboflavin, niacin, folate) were considered. Annual price series for each food item deflated by the consumer price index was used as proxy for price. A model developed by Huang (1999) that incorporates own, cross-price, and income elasticities into nutrient responses was used. The results of the study reveal that demand for animal products was price responsive but inelastic. The own-price elasticity of demand for beef and poultry was relatively elastic ( =-0.86 and =-0.65 respectively) and the demand for eggs was highly inelastic ( =-0.006). Most of the compensated cross-price elasticities of demand were insignificant. The significant coefficients revealed that eggs were a net substitute for most products and beef and fish, and lamb and poultry were complementary. Kumar and Dey (278) analysed the responsiveness of demand for fish to changes in price and income across different income groups and states in India. Time series data from Indian National Sample Survey for the years 1983, 87/88, 93/94, 99/2000 were used. The households then aggregated at 906 grouped observations based on state/years/ and rural/urban stinting and weighted by each group population size were used. Three-stage analyses were applied and at the last stage LAIDS model was used. In the fist stage, total expenditure was divided between food and non-food and in the second stage between vegetarian and non-vegetarian expenditures. In the last stage the non-vegetarian expenditure was subdivided into fish, goat meat, poultry, and eggs. Aggregated unit values were used as a proxy for price. The estimated fish price elasticity of demand coefficients showed significant variation among income groups and across different states. The overall fish price elasticity of demand (uncompensated) was -0.7 and was higher (in absolute terms) for the poor and for eastern, north-eastern and southern states. However, the elasticity had not shown any significant differences for the last 15 years. Ma et al. (279) estimated price elasticities of demand for animal products (pork, eggs, chicken, aquatic products, beef, dairy products and mutton) in China using LA/AIDS

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model. Annual panel data from household expenditure and income survey between 1991 and 2001 for 28 provinces were used. Food consumed away form home was also considered. Average annual prices collected through market survey (covering 100 free market in rural and 70 in urban areas) were used. Own-price elasticities of demand were estimated for urban and rural areas separately. The estimated unconditional own-price elasticity of demand showed that except for aquatic, dairy, and beef, most of the commodities were price inelastic. Between 1999 and 2001 beef has the highest (in absolute terms) price elasticity of demand ( = -1.782) in rural areas and aquatic ( = 1.403) and dairy ( = -1.191) products in urban areas. In both rural and urban areas the responsiveness of demand for chicken to its own-price increased through time and eggs had the lowest own-price elasticity of demand both in urban are rural areas between 1999 and 2001. Generally, except for aquatic products, the own-price elasticities of demand for all animal products were higher (in absolute terms) in rural areas than in urban areas. Yen et al. (280) examined the demand for different types of vegetables (fresh deep green and deep yellow, processed deep green and deep yellow, fresh potatoes, processed potatoes, fresh tomatoes, processed tomatoes, other fresh, other processed) in the United States. Data reported by ACNielsens Homescan panel (10 months in 1999) of US households (n = 7195 households) was used. A one-stage trans-log model, taking into account the problem of censoring was used. Compensated and uncompensated own-and cross-price elasticities were estimated. The study showed that low income households were more responsive to changes in vegetable prices than high-income households. Price elasticity of demand for the poor were elastic for fresh potato vegetables ( = -1.27), processed deep green and deep yellow vegetables ( = -1.24), and processed potato ( = 1.04). The elasticities for rich households were also relatively large ( = -0.98 for processed potato and | | > 0.76 for all other food items). The authors argued that the estimated elasticities were higher than the vegetable elasticities reported by other studies (both that used time series and cross-sectional data) due to the high level of disaggregation of vegetables used in the study. The paper concluded that consumers would increase their vegetable consumption as a response to lower prices but not by a lot. Therefore, price policies should be combined with other strategies such as information campaign.

1.6.3

Impact of food price on dietary precursors/intake (nutrients)

Ten studies (259;268;269;281-287) examined the impact of price on nutrient expenditures. Three used cross-sectional data while eight used time-series/panel data. Three of these papers also considered foods and thus were also included in earlier sections. These studies are similar to those on foods but calculate the macronutrient

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and/or micronutrient composition of the food groups based on known food composition data, so generating nutrient price elasticities.

1.6.3.1 Cross-sectional data based studies

Ramezani, et al. (282) investigated the role of food price on food and nutrient intake in the United States using the household component of the 1987/88 Nationwide Food Consumption Survey (n = 4273 households). Intake was measured Foods were aggregated into six food groups (dairy, meat and protein, fruit and vegetable, bread and cereals, fats and oils, sugar and others) based on the United States daily food guide. The following nutrients/food components were considered: calories, protein, fats, cholesterol, fibre, vitamin A, vitamin E, vitamin C, vitamin B6, vitamin B12, thiamine, riboflavin, niacin, folate, calcium, magnesium, iron, zinc. Unit values (collected in all seasons) were used as a proxy for prices and regional dummies were included to take into account quality effects of unit values. The estimated nutrient elasticities are summarised in Figure 1.3. They suggest that meat and protein prices have the largest average impact on nutrient intake owing to their impact on protein, fats and cholesterol expenditure. Changing the price of fruits and vegetables had the second largest average impact due to its above average affect on fibre and vitamin expenditure. Mineral intake was most sensitive to changes in meat, protein and dairy prices, while fat and cholesterol were most sensitive to the prices of meat and protein and fats and oils. The study also showed that nutrient elasticities of expenditure were nearly one indicating that income policies might be more effective in influencing nutrient intake patterns than price policies. Kinsey and Bowland (283) investigated the amount of change in the relative price of food items needed to achieve the balance of food servings eaten into the line with Food Guide Pyramid (FGP) in the United States, using already estimated price and income elasticity figures. Two basic pieces of information were collected. First, own-and cross-price elasticities and income elasticities estimated for 34 commodities by Huang (1993) were collected. Second the share of each of the 34 food items in the proportion of servings in each FGP was computed from the data base of the 1996 Continuing Survey of Food Intakes by Individuals (CSFII), 1994-96 CSFII CD Rom (linkages between reported food and the FGP groupings) and from disappearance data set (average per capita food consumption). Seven FGP group (sugar, discretionary fat, dairy, fruits, grains, meats, and vegetables) were considered and the percentage response of these food groups to a percentage change in aggregate food commodity (meats, dairy, grains, fruits, vegetables, fats, and sweets) was estimated. The results of the study showed that decreasing the price of fruit, meats and dairy products would increase the consumption of fruits and dairy products, the two FGP food groups where consumers in the United States are most

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deficient. However, lowering the price of meat could increase the consumption of all foods (except added sugar) mainly through income effect it might also lower the HEI score since it also increased the consumption of discretionary fat. The actual elasticities were not shown clearly in the paper so could not be reported here. The study concluded that increasing the purchasing power of consumers through either lowering food prices or increasing income might not improve the HEI score since it increased fat consumption more than it increased fruits and vegetables. Therefore, economic incentives should be supplemented with public education.
Figure 1.3. Nutrient intake in response to prices of food groups in the United States according to Ramezani et al. (282)*
...leads to % change in calorie and nutrient availability

0.4 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 Meat & Fruits & Bread & Fats protein veg. cereals &oils

Calories Protein Fats & cholesterol Fibre Vitamins M inerals

Dairy Sugar & misc.

A 1% decrease in the price of...

Weinberger (281) examined the impact of income, food prices, and other factors on micronutrient intake among rural households in India. Cross-sectional data collected from 5,800 rural households of India in 1993/94 were used. Prices were measured by village level prices, and six food items (cereals, pulses, milk and eggs, meat, vegetables, fruits) and ten micronutrients (calories, protein, fat, calcium, vitamin A, iron, vitamin C, vitamin B1, vitamin B2, and niacin) were considered. To take into account the potential reverse causality between per capita expenditure and nutrient intakes, both expenditure and nutrient intake equations were estimated simultaneously using a two-stage least-square estimation method. The results of the study indicated that food prices affected micronutrient intake in the rural areas of India. Particularly, vitamin A and C intakes were responsive to the price of vegetables and intake of most micronutrients particularly vitamin B1 and B2, iron, and calcium were responsive to cereal prices. However, the price of other food groups such as milk and eggs, meat, and fruits had relatively low

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effect on the intake of micronutrients. The actual elasticities were not shown clearly in the paper so could not be reported here. The study concluded that in addition to price and income factors, community-based behaviour changes might be needed to reduce micronutrient malnutrition in India.

1.6.3.2 Time series/panel data based studies

Huang (285) explored the impact of food prices on the per capita availability of food and nutrients in the United States the context of the classical demand analysis framework. Time series data between 1953 and 1990 compiled from Putnam and Allshouses Food Consumption, Prices, and Expenditures was used. Total nutrient available for consumers and food shares of nutrients were obtained by multiplying the amount of each food consumed by its unit nutritive values. Price elasticities estimated from previous studies (Huang, 1993) were also used to compute the responses of 15 nutrients to changes in 35 food prices. The study showed that most of the nutrients were responsive to price changes. For instance, a 1% increase in the price of beef would reduce per capita food energy by 0.027%, protein by 0.091%, fat by 0.025%, but vitamin A would increase by 0.064%. A 1% increase in the price of eggs might also cause cholesterol to decrease by 0.031%. At the same taken, a 1% increase in the price of carrots might cause vitamin A to decrease by 0.11% and the same percentage increase in the price of oranges would decrease vitamin C by 0.19%. Huang (286) investigated the impact of price and income on the per capita availability of nutrients from meats (beef, pork, and chicken) in the United States. Time-series data between 1990 and 1994 was compiled from the Food Consumption, Prices, and Expenditures survey of USDA. Price information was aggregated from the food disappearance series of the USDA (Economic Research Service). Descriptive analysis and elasticities estimated from previous studies (Huang, 1996a) were used. The results showed that the high price of beef relative to chicken (as well as the concern of consumers about fat) led to an increase in per capita availability of poultry meat and a decrease of red meat in the last two decades. The effects of price changes on eight nutrient intakes were also estimated, as summarised in Figure 1.4. Most of the nutrient elasticities were very small due to inelastic demand and offsetting changes in nutrient intakes between complementary and substitute foods. Overall, a decrease in the price of pork increased the intake of all nutrients except vitamin A; similar results are seen for beef and chicken, though a decrease in their prices led to lower per capita availability of vitamin A.

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Huang (287) analysed how prices and income changes affected the per capita availability of nutrients in the United States using average aggregate food consumption data between 1989 and 1993. Seven food groups, namely grains, vegetables, fruits, dairy, meats, fats, sweeteners and 11 nutrients, namely protein, fat, saturated fat, cholesterol, dietary fibre, vitamin A, vitamin C, vitamin E, folate, calcium, and iron, were considered. The 1996 USDAs nutrient database was used to compile nutrient values and food price data was taken from the United States Department of Labour. Price and income elasticities of nutrients were derived from price and income elasticities of demand. Price elasticity of nutrients (for a 1% decrease in the price of the given food group) were computed for 12 nutrients, as summarised in Figure 1.5. The results showed that a 1% decrease in the price of meat group (beef, poultry, fish, eggs, dry beans and nuts) increases the daily per capita availability of protein, and iron by 0.18% and 0.19%, respectively but increases total fat and cholesterol availability by 0.03% and 0.15%, respectively. It also reduces the per capita availability of vitamin A. Decreases in dairy prices increases the per capita availability of protein, and energy but also reduces the availability of vitamin A, fibre, and iron and increases the availability of cholesterol. A decrease in the price of fruits significantly increases the availability of vitamin C but also total fat and cholesterol. A decrease in the price of vegetables increases the availability of vitamin C but also decreases that of Vitamin A by 0.026%. The study highlighted the interdependence among the different food groups through cross-price effects and concluded that a price policy should take into account such interdependences.
Figure 1.4. Nutrient availability in response to prices of beef, pork and chicken in the United States according to according to Huang (286)
0.11 0.09

leads to % change in nutrient availability

0.07 0.05 0.03 0.01 -0.01 -0.03 -0.05 -0.07 Beef Pork Chicken

Energy Protein Fat Cholesterol Iron Vitmain A Thiamin Niacin

A 1% decrease in the price of...

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Figure 1.5. Nutrient availability in response to prices of food groups in the United States according to Huang (287)

0.5
. . % change in the availability of

0.4 0.3 0.2 0.1 0 -0.1 -0.2 -0.3

Gran Vegetables Fruit Dairy Meat Fats Sweeteners

Energy Protein Total fat Cholesterol Fiiber Iron Vitamin A Vitamin C

A 1% decrease in the price of

In a study already described above, Guo et al. (259) examined the effects of food price changes on dietary intake of different macronutrients in China. The results indicated that fat intake was quite responsive to the price of pork -0.79 % (-0.49 and 1.10 % for the poor and the rich, respectively) followed by the price of edible oils -0.32 (-0.33 and -0.25 for the poor and the rich, respectively) and eggs -0.19 % (-0.11and -0.39 % for the poor and the rich, respectively). Dhehibi and Laajimi (284) investigated the impact of economic factors on animal food choices and nutrient availability in Tunisia using a time series data (1973-1998). Five animal food products (meat products, beef, lamb, poultry, eggs, and fish) and eleven nutrients (energy, protein, total fats, calcium, iron, magnesium, zinc, thiamine, riboflavin, niacin, folate) were considered. Annual price series for each food item deflated by the consumer price index was used as proxy for price. A model developed by Huang (1999) that incorporates own, cross-price, and income elasticities into nutrient responses was used. The main results of the study are presented in the Figure 1.6. Generally, priceelasticities of nutrients were less (in absolute terms) than own-price elasticities. Energy, total fats, iron, and zinc were more sensitive to the price of beef, thiamine, zinc, fats to the price of lamb. The availability of protein, calcium, magnesium, niacin, and folate was

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more sensitive to the price of fish. The availability of most nutrients was less sensitive to the price of eggs. Niacin, protein, and magnesium were also responsive to the price of poultry.
Figure 1.6. Price elasticity of nutrients for animal products in Tunisia (1973-1998) according to Dhehibi and Laajimi (284)

0.45 0.4 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0

Own-price nutrient elasticities

Fish Eggs Poultry Lamb Beef

In a study already described above, Smed, et al. (268) analysed the impact of food taxes and subsidies on nutrition in Denmark, and included consideration of its impacts on fats (though the price elasticities were not shown clearly and so could not be reported here). The simulation results showed that a general tax on fats (7.75 DKK/kg) reduced the total energy intake as well as the share of fats and saturated fats, but increased the share of sugar for most of the consumers. This effect was slightly stronger in the lower social classes. In the study also described above, Beatty and LaFrance (269) found that nutrient responses to price changes were generally very small mainly due to the availability of a wide range of substitute foods from which comparable nutrients can be derived. The results indicated that taxing some food items might not substantially change nutrient intakes.

1.6.4

Impact of food price on diet-related health

Five studies examined the impact of food price on body weight/obesity (288-292). Two used cross-sectional data and four used time series/panel data. Unlike the studies reported

M Iro n ag ne siu m Zi n Th c ia Ri min bo fla vi n N ia ci n Fo la te

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En er gy Pr ot To ein ta lf at Ca s lc iu m

in the previous two sections, these studies do not estimate price elasticities, but use alternate modelling techniques. One study came from the public health literature.

1.6.4.1 Cross-sectional/cross-country studies

Schroeter, Lusk and Tyner (292) investigated the effect of high-calorie food tax, lowcalorie food subsidy, and income subsidy on body weight in the United States using microeconomic framework and parameters estimated from different studies. The results of the theoretical framework showed that high-calorie food tax certainly decreased body weight if high-and low-calorie foods were complements while the effect varied in the case of substitute foods. The empirical results also showed that small subsidy on diet soft drinks, fruits/vegetables, etc., were more effective in reducing weight than a tax on soft drinks and on food away from home. The study concluded that price intervention such as thin subsidy or even a fat tax would help to decrease weight. Sturm and Datar (298) examined the association between food prices and changes in the BMI among elementary school children in the United States (this study is also described in section 1.4.4.2 because it also examined association with food outlet density). The data came from a nationally representative survey conducted by ECLS-K survey on kindergarten children from over 1000 schools during the 1998/99 school year ( n =13182 children). Four food groups, namely meat, fruits and vegetables, dairy and fat foods were considered and descriptive and multivariate analyses were used. The results of the study showed that relative food prices were highly associated with the BMI and obesity rates and the association was very strong and robust in the case of fruits and vegetables: higher prices of fruits and vegetables predicted higher BMI increase. The study also showed that price differences among metropolitan areas explained nearly 0.5 BMI gain differences between kindergarten and third grade children. The study concluded that lowering the real prices of fruits and vegetables compared to other goods and services might slow excess weight gain.

1.6.4.2 Time series/panel studies

Richards, Patterson and Tegene (289) provided a test of the rational addiction hypothesis as a potential explanation for the obesity epidemic in the United StatesA. The A.C. Nielsen, Inc HomeScan panel data (1998-2001) was used (n = 73000 individual observations). Ten different snack foods namely, popcorn, corn chips, reduced fat potato chips, regular potato chips, pretzels, puffed cheese, tortilla chips, pork rinds, snack meat, cookies, crackers, apples, and carrots purchased at retail outlets were considered. A random coefficients (mixed) logit model was used and the issue of irrelevant of the independent alternative (IIA) assumption of the multinomial logit model was addressed.

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The estimated results showed that consumers could be rationally addicted (based on cost and benefits) to certain nutrients especially to carbohydrates. The study therefore, argued that carefully designed price policies could be an effective means of addressing the obesity epidemic. Boizot-Szantai and Etile (290) examined the relationship between food-at-home prices and BMI in France. Three years (200-2002) food-at-home expenditures and quantities from the French household panel Secodip were used (n =3668). Food items were classified into 16 subgroups as water, alcohol, non-alcohol beverages, fats and oils, sugars and sweets, non-cooked meats and eggs, milky deserts, sea products, dairy, ready meals and sauces, cheeses, snacks, starchy foods, vegetables, and fruits. A modified model of Lakdawalla and Philipson approach, which expresses utility as a function of consumption, weight, and other goods was adopted and a correlation analysis were used. The theoretical results of the study revealed that the impact of price on weight depended on how choices of non-food goods affected energy expenditure, substitution between different varieties of the same food groups, and between different food groups. The correlation analysis showed that there were few significant correlations between prices of various food groups and BMI of adult French women. The study concluded that fat tax or any nutritional tax policies alone might not curb the epidemic of obesity at least in the short run. However, the long-term effects of such policies were not investigated. The study also argued that the welfare loss associated such policies might outweigh their benefits. Cash, Sunding and Zilberman (291) investigated the possible effects of thin subsidies, consumption subsidies for healthier foods, on diet and health outcomes in the United States The study outlined that the effect of any risk-reducing price policy depended on the response of price to policy, the response of consumption to price, and the response of health to consumption. A sample of 18081 individuals over the age of two included in the USDAs Continuing Study of Food Intakes by Individuals (CSFII) for 1994-1996 and 1998 were considered. The relationship between CSFII coronary heart disease and ischemic stroke and aggregate intake of fruit and vegetables were considered. The cost per life saved by a fruit and vegetables subsidy was also examined. The simulation results showed that an increase in the price of fruits and vegetables was likely to increase coronary heart disease and ischemic strokes significantly. The cost-benefit analysis also showed that retail price subsidies on fruits and vegetables would be one of most cost effective ways of saving lives.

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1.6.5

Summary, discussion and conclusions

This review identified 68 studies on food price as a determinant of food and nutrient consumption and diet-related health. Before reaching any conclusions, a number of methodological issues and limitations should be noted. Some of the major methodological limitations are the following. First, studies that used time-series or panel data did not show whether the variables used in the analysis were stationary or not (regressing a non-stationary variable against a stationary variable may give spurious regression results). Second, studies that used crosssectional data considered price and expenditure as exogenous variables, but recent studies indicate that they could be endogenous (247). Failure to address the potential endogeneity of price and expenditure variables could therefore have caused bias in the demand elasticity estimates. The endogeneity of price and income variables can affect the consistency of estimated demand elasticities. Third, the estimated price elasticities of demand can be quite sensitive to the methodology, particularly the functional form used, the estimation procedure adopted, the grouping of the food items, the data type used, and the degree of separation assumed. Therefore, variations in price elasticities may reflect differences between the models used to estimate them, rather than actual differences in consumer responses to price. Two particular patterns were seen as a result of these differences: Elasticities estimated from more disaggregated food items tended to be larger (in absolute terms) than elasticities estimated from aggregated food items. This indicates a limited scope for substitution as the level of aggregation increases. The elasticities estimated from complete demand systems tended to be lower (in absolute terms) than the elasticities estimated from specific food demand analysis.

However, no consistent pattern was observed between elasticities estimated from cross sectional and time series/panel data sets.

The fourth methodological problem is related to measurement of price. Some papers used unit values that were unadjusted both for price and quantity, which may have had the effect of overstating the quality adjusted price elasticity estimates. Finally, elasticities estimated for urban households may vary from rural households because rural households can be both producers and consumers of certain food items. Unless this behaviour of rural households is modelled explicitly, the estimated elasticities could be biased. Apart from methodological issues, other limitations should be also kept in mind when interpreting the results. First, although 68 is a relatively large number of studies, there were some gaps in the literature. Importantly, the geographical distribution of the studies was skewed towards the United States and Western and Eastern Europe, although there were a fair number of studies from Asia, and a few from Africa and Latin America. The
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lack of studies from Latin America was particularly noteworthy. Second, there is lack of studies on nutrient elasticities. Though the reviewed studies indicated that nutrient elasticities could be computed, there were relatively few studies and all were conducted using similar methodologies in the United States. There were also very few studies analysing the relationship between food prices and diet-related health and the quality of most of these studies was low. A third limitation of the existing literature is the relative lack of studies by economists or epidemiologists on the relationship between food prices and dietary intake at the individual level relative to the more aggregate dietary precursors. A fourth limitation was the lack of price elasticities estimated specifically for different processed foods (e.g., of the type associated with globalization). It is therefore recommended that more research is conducted in these areas to address these gaps. In general, the complexity of food prices as a determinant of dietary precursors or dietary outcomes emerged strongly from the literature. Factors such as the differences between own-and cross-price elasticity of demand, the impact of price changes on the expenditure on non-food items, the role of other economic factors such as income, and non-economic factors such as cultural norms, render it difficult to understand how exactly consumers respond to changes in food prices. Moreover, food price as a dietary determinant is only as important as the actual price variations experienced by consumers. Despite these limitations, the number of studies using robust methodologies allows a number of conclusions to be drawn on relative differences and direction in the relationship between food prices and dietary precursors and outcomes. Table 1.18 maps the conclusions that are supported by convincing and probable evidence, as well as those which are unlikely and for which no conclusions can be drawn. Due to the variation of conclusions from one food item to another, the matrix could not be presented in a more concise form. The trends for foods can be summarised as follows: The own-price elasticity of demand for many food items is generally inelastic (| | <1). However, the demand for fish, eggs, milk, meat, and fruits and vegetables is sometimes elastic (| | >1), and there is convincing evidence that meat, eggs, milk, fish and fruits are generally more elastic than other food groups. No conclusions could be drawn for vegetables, sugar, oils and fats. In contrast, in many cases, the demand for staple or basic food items which usually account for a large budget share of households and do not have close substitutes tended to be price inelastic. Within staple foods, the demand for wheat was generally more price elastic than the demand for rice and other staple grains. In most cases, the demand for fruit was more elastic than the demand for vegetables.

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The elasticities for oils and fats and sugar varied significantly from one study to another study so that no clear pattern could be observed about the relative size of the price elasticity of demand for these food groups. Most cross-price elasticities were close to zero, statistically insignificant, or lower than the own-price elasticities (in absolute terms) indicating that demand is more responsive to own-price changes than to cross-price changes. It might also indicate the absence of major gross substitutability/complementarity across different food categories considered. For most food items, compensated/Hicksian price elasticities (pure price effects) were less than the uncompensated/Marshallian price elasticities (price plus income effects) (in absolute terms) indicating changes in prices would have considerable income effect. Most of the studies showed that low income consumers (within a country) were more responsive to price changes (probably except for cereals) than middle-or high-income consumers. Price elasticities estimated for low income countries were also relatively higher (in absolute terms) than elasticities estimated from data collected in developed countries indicating that the poor were more sensitive to price changes than the non-poor. This could be due to two reasons. First, the real income effect of price change was higher for the poor than for the rich. Second, the substitution effect of price change declined as income increased. Generally, elasticities estimated for rural areas were higher than for urban areas though there were some exceptions for some products. Rural households tend to be more responsive to processed food items, meat, fish, egg, and sugar compared to cereals, pulses, milk and vegetables. No consistent conclusion could be drawn on whether the income effect was higher than price effects though in most cases income elasticities were higher than price elasticities (in absolute terms).

The trends for nutrients can be summarised as follows: Computed nutrient elasticities were generally inelastic (in most cases less than 0.5 in absolute terms) due to the low price elasticity of demand and the offsetting changes in nutrient intakes. In most cases nutrient elasticities were less than own-price elasticities for foods (in absolute terms). Though inelastic, most of the results revealed that vitamins and minerals consumption was most sensitive to the prices of fruits and vegetables, meat, and dairy products. Also, due to the some interdependence among different food items, it was shown that a decrease in the price of one food group might increase the availability of essential nutrients such as vitamins but might also increase the availability of fats and cholesterol or might decrease the availability of other nutrients such as minerals.

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The trends for diet-related health can be summarised as follows: Most of the studies reviewed indicate that there is some relation between the prevalence of obesity/chronic diseases and prices of food items. This raises the issue of whether lowering the relative price of food items such as fruits and vegetables through carefully designed interventions can help to reduce dietrelated chronic diseases. But overall, there are an inadequate number of high quality studies to draw conclusions, and this report did not review these papers using the criteria needed to assess such interventions.
Table 1.18. Evidence matrix of impact of food price on household food expenditure
Compared to other Own-price food groups, own-price elasticity higher elasticity of demand is than cross-price relatively elastic elasticity
Convincing Probable Unlikely No conclusion Meat Convincing Probable Unlikely No conclusion Egg and milk Convincing Probable Unlikely No conclusion Fish Convincing Probable Unlikely No conclusion Fruits Convincing Probable Unlikely No conclusion Vegetables Convincing Probable Unlikely No conclusion Sugar Convincing Probable Unlikely No conclusion Oil & fat Convincing Probable Unlikely No conclusion x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x

Food group
Cereals

Low income consumers more Rural consumers responsive to price more responsive than urban changes than high income consumers

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1.7 Conclusions
Through this systematic review of the environmental, economic and political determinants of diet, the following conclusions can be drawn: The environmental, economic and political determinants reviewed were the natural environment, agriculture, globalization, food retailing, food advertising and promotion, and food price. This attempt to systematically review, in one report, such distal, upstream determinants of diets is unprecedented. The distal nature of the determinants introduced many methodological challenges into the review, not least the lack of literature measuring associations. To make the most of a complex and challenging body of literature, the review examined the impact of these determinants on dietary indicators, dietary precursors and/or dietary outcomes. Since the evidence base varied considerably between the different determinants, each produced different types of conclusions. On the natural environment, there is little evidence on if and how the environment determines diet. The review did find evidence that factors in the natural environment are determinants of the consumption of two contaminants associated with cancer: arsenic and aflatoxins. Agricultural production practices are also determinants of arsenic and aflatoxin contamination. On agriculture, the review succeeded in identifying some key agricultural issues potentially relevant to cancer prevention: a series of agricultural production practices (crop fertilisation practices, livestock feeding practices, crop breeding and diversity of cropping system), and agricultural policies that create incentives or disincentives to the production and marketing of foods associated with cancer. Agricultural production practices are potential determinants because they affect food nutrient quality (and contamination). Research in this area has focused on the nutrient quality of fruits, vegetables, meat and staple crops. Agricultural policies are potential determinants because they affect food availability and price. Evidence from different geographical regions suggests that in some contexts, agricultural policy influences dietary outcomes. But overall, evidence is either is conflicting or not available to confirm if and how these practices and policies are actually associated with dietary outcomes. Still, the evidence base is growing, and given their position at the base of the food supply chain, these agricultural practices and policies warrant closer attention from public health policymakers. On globalization, it was widely reported that globalization policies and processes are playing an important role in the development of dietary patterns linked with the increasing prevalence of chronic diseases, such as cancer, in the developing world. The growth of transnational food companies (including supermarkets), trade liberalisation and global food advertising and promotion, were the most widely implicated determinants. Recent analysis shows that it is possible to link specific globalization policies and processes to changes in food availability and price, but no studies measuring associations nor cause and effect are available to confirm these findings. More policy-oriented research on the link between globalization policies and processes and diet would help inform the
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debate around the merits and problems of globalization from a chronic disease perspective. For food retailing, the evidence reviewed allowed one probable conclusion to be drawn: socio-economically disadvantaged groups in the United States have less access to supermarkets relative to more advantaged groups, and less access to supermarkets is associated with lower quality diets. The nature of the evidence base prevents this conclusion from being applied to other parts of the world. More evidence is needed to determine if this association is the result of cause or effect. The most conclusive evidence can be drawn about food advertising and promotion. Existing systematic reviews conclude that food promotion can have and is having an effect on children, particularly in the areas of food preferences, purchase behaviour and consumption. These effects are significant, independent of other influences and operate at both brand and category level. Among many factors, therefore, food advertising and promotion influences the preferences and purchase requests of children, influences consumption at least in the short term, is a likely contributor to less healthful diets, and may contribute to negative dietrelated health outcomes and risks among children and youth. The actual effect of food promotion relative to other factors influencing the consumption of these foods remains unclear. The evidence base on price is made up almost exclusively of economic studies of price elasticities. It is difficult to draw conclusions from this literature because variations in price elasticities often reflect differences between the models used to estimate them, rather than actual differences in consumer responses to price. But the number of studies included in the review did allow some conclusions to be drawn. First, while consumers are often not very responsive to changes in food prices, there is convincing evidence that they are more sensitive to changes in the prices of meat, eggs and milk, fish and fruits relative to other food groups. In most cases, consumers are more sensitive to the price of fruit than vegetables. Second, there is convincing evidence that low income consumers are more sensitive to the price of meat, eggs and milk, fish, fruits and vegetables than higher income consumers. Also, consumers in lower income countries tend to be more price sensitive to all foods than consumers in higher income countries. Third, if the price of a particular food changes, consumers are generally more likely to respond by changing consumption of that food rather than compensating by changing consumption of another food (since cross-price elasticities are generally lower than own-price elasticities).

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Appendix 1.1. Conceptual framework of impact of food price and on food expenditure, body weight and diet-related health
Factors affect food prices Technological progress in
Agricultural production Agricultural production Food processing Food processing Food transportation Food transportation Food storage/shelving life Food storage/shelving life Decreasing cooking time Magnitude of the change Cross- food price elasticity Effectiveness Impact on nonfood consumption Supply response Income

Effects depend on

Effects depend on
Own- price elasticity

Agro-climatic condition Food policy

Agricultural subsidy Export tax/subsidy Import tax/subsidy Other trade barriers Membership to WTO

Supply/ Demand
Income

Price

Nutrient content

Consumption/ body weight/ chronic diseases

Energy-density

Infrastructure

Product type (staple or not)

Globalization
Institutional changes Expansion of multinational companies Expansion of supermarkets Reduction of tariff and non-tariff barriers 1-133 Resources availability Nutr. knowledge Culture/ religion Physical activity

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Appendix 1.2: Search record

Terms Search 1. Environment and dietary indicators, precursors & outcomes PubMed - Searches done in all fields - All terms were MESH terms - Limited to human only papers - Limited to review papers only - Publication date January 1980- search date ISI Web of Science - Searches done as general searches - Publication dates January 1980- search date CAB Direct - Searches done as advanced searches for descriptor only - Limited to database subsets Agricultural economics and rural studies & Human Health - Publication date January 1980- search date Search 2. Agriculture and dietary indicators, precursors & outcomes PubMed - Searches done in all fields - All are MESH terms - Limited to human only papers - Publication date January 1980- search date ISI Web of Science - Searches done as general searches - Publication dates January 1980- search date CAB Direct - Searches done as advanced searches in descriptor - All are, or form part of, descriptor terms - Limited to database subsets Agricultural economics and rural studies & Human Health - Publication date January 1980- search date Search 3. Agriculture and environment and arsenic PubMed - Searches done in all fields - Limited to human only papers - Publication date January 1980- search date ISI Web of Science - Search done as general searches - Publication dates January 1980- search date CAB Direct - Search done as quick search in all fields - Search limited to subject subsets Agricultural economics and rural studies and Human Health - Publication date January 1980- search date Search Date*

July 10 2006 (Biodiversity OR ecosystem OR greenhouse effect OR meteorological factors OR soil OR water) AND (food habits OR diet) July 10 2006 (Ecosystem OR greenhouse effect OR meteorological factors OR soil OR water) AND (dietary pattern*) July 10 2006 Environment AND (food consumption OR diet)

April 10 2006 Agriculture AND (diet OR nutrition OR obesity) April 10 2006 Agricultur* AND (diet OR nutrition OR obesity) April 10 2006 Agricultur* AND (diet* OR food consumption OR obesity)

Arsenic AND (agricultur*) AND June 22 2006 (drinking water OR Nutrition OR Diet OR Food intake OR diet* OR food consumption*) arsenic AND agricultur* AND June 22 2006 (drinking water OR Nutrition OR Diet* OR food consumption OR Food intake) June 22 2006 (Agricultur* AND arsenic) AND (drinking water OR diet OR nutrition OR food consumption)

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Terms Search 4. Agriculture and environment and aflatoxin PubMed - Searches done in all fields - Limited to human only papers - Publication date January 1980- search date ISI Web of Science - Searches done as general searches - Publication dates January 1980- search date CAB Direct - Searches done as advanced searches in all fields - Searched all database subsets - Publication date January 1980- search date

Search Date*

(Agricultur* OR crop) AND (aflatoxin*) AND (diet OR diet* OR nutritional disorders) (Agriculture OR environment) AND (aflatoxins) AND (diet OR nutrition OR health) (agriculture OR environment) AND Aflatoxins AND (diet OR nutrition OR health)

July 14 2006

July 14 2006 July 14 2006

* Search data refers to the time of the final search; test searches and similar searches were usually carried out far in advance of that date

GLOBALIZATION
Terms
(Globalization OR Globalisation OR Coca-Colonization OR Mcdonaldization) AND (Nutrition OR Diet OR Food intake OR food habits OR food preferences OR food supply OR nutritional disorders OR body weight OR diet* OR food consumption* OR food choice* OR food expenditure* OR food access* OR food price* OR obesity OR nutrition transition* OR diet transition* OR dietary transition*) (Globalization OR Globalisation OR ISI Web of Science - Searches done as general searches Coca-Colonization OR Mcdonaldization) AND (Nutrition OR - Publication dates January 1980- search date Diet* OR food consumption OR Food intake OR food habit* OR food preference* OR food choice* OR food expenditure* OR food supply* OR food price* OR food access OR obesity OR nutrition transition* OR diet transition* OR dietary transition*) (Globalization OR Mcdonaldization) CAB Direct - Searches done as advanced searches AND (Nutrition OR Diet OR Food - Terms in bold searched as descriptors, terms not consumption OR Food prices OR in bold in all fields Food preferences OR Obesity OR - Limited to database subsets Agricultural Food expenditure* OR Food choice* economics and rural studies & Human Health OR nutrition transition OR diet - Publication date January 1980- search date transition)

PubMed - Searches done in all fields - Terms with no * are MESH terms - Limited to human only papers - Publication date January 1980- search date

October 25 2005 Rerun April 14 2006

October 27 2005 Rerun April 14 2006

October 25 2005 Rerun April 14 2006

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FOOD RETAILING
Terms (Supermarket* OR Food retail* OR food store* OR grocery store* OR food outlet* OR food shop* OR Street market*) AND (Nutrition OR Diet OR Food intake OR food habits OR food preferences OR food supply OR nutritional disorders OR body weight OR obesity OR food consumption* OR food choice* OR food expenditure* OR food access* OR food price* OR nutrition transition* OR diet transition* OR dietary transition*) (Supermarket* OR Food retail* OR food store* ISI Web of Science - Searches done as general searches OR grocery store* OR food outlet* OR farmers - Publication dates January 1980- search market* OR food shop* OR food desert* OR date street market* OR wet market*) AND (Nutrition OR Diet* OR food consumption OR Food intake OR food habit* OR food preference* OR food supply OR food choice* OR food expenditure* OR food price* OR food access OR obesity OR nutrition transition* OR diet transition* OR dietary transition*) (Retail marketing OR supermarket* OR Food CAB Direct retail* or food store* OR food outlet* OR grocery - Searched as combination of advanced store* OR street market* OR wet market* OR searches - Terms searched in all fields except fields farmers market* OR farmer's market* OR food desert* OR food shop*) AND (Nutrition OR in bold, which are descriptor only - Limited to database subsets Diet* OR Food consumption OR Food prices Agricultural economics and rural OR Food preferences OR consumer behaviour studies & Human Health OR Food supply OR Obesity OR Food - Publication date January 1980- search expenditure* OR Food choice* OR food access date OR nutrition transition OR diet transition) PubMed - Searches done in all fields - Human and animal papers - Publication date January 1980- search date
- Quick search - Limited to database subsets Agricultural economics and rural studies & Human Health - Publication date January 1980- search date

Date October 23 2005; re-run June 7 2006

October 25 2005; re-run June 20 2006

October 23 2005; re-run June 7 2006

Food desert*

October 23 2005; re-run June 7 2006

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FOOD PRICE
EconLit - Searched keywords - Publication date January 1980- search date Terms Food price+ AND (food consumption OR diet) NOT tobacco NOT cotton NOT Cigarette NOT genetically NOT alcohol Date December 10 2005

(Food and (price+ and (elasticity or elasticities))) April 15 2006 and (food and consumption) not (tobacco or cotton or Cigarette or genetically or alcohol (Price w elasticity OR price w elasticities) AND (food+ OR diet) NOT tobacco NOT cotton NOT Cigarette NOT genetically NOT alcohol (Food price*) AND (food consumption OR diet OR obesity) AND (1980 <=YEAR <= 2005) (Food price* OR food consumption) AND (elasticity OR elasticities) April 15 2006 December 10 2005 April 15 2006

CAB Direct - Searched in quick search - Limited to database subsets Agricultural economics and rural studies & Human Health - Publication date January 1980- search date AgEcon

Food price AND food consumption, food price AND nutrition Food price AND diet Food price AND obesity

All December 10 2005

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Appendix 1.3: Summary of food retailing studies reviewed

FOOD RETAIL ENVIRONMENT AND DIETARY INDICATORS
Author/year/ country Study type Sample size/ population Goal Type of analysis/methods Results Comments

a) Variations in access to food retailers (density, distance)

Block et al. 2004 (183); US/New Orleans, LA Cross-sectional 156 census tracts in City of New Orleans which had (i) >500 people; (ii) >2000 people per square mile; and (iii) <200 alcohol outlets per 1000 people to ensure comparability between tracts Association between density of fast food outlets and race of residents in shopping area (census tract plus buffer zone) Geocoding of fast food outlets and mapping in GIS; Multivariate analysis (multiple regression) between %black residents and fast food restaurant density, controlling for median household income, median home value, alcohol outlet density, presence of highway Identifying, counting and classifying different types of food retailers in census tracts Type of store categorized according to standard US SIC classification; Multivariate analysis (X2 tests; analysis of variance; Poisson regression for number of stores, Neighbourhoods with 80% black residents 2.4 fast food restaurants/mile2 ; neighbour. with 80% white residents 1.5/mile2. Av size of shopping area 6.2 miles2, so predom black neighbour. exposed to 6x more fast food rest than predom white No food stores 8-10 per 10000 people in all sites, but types varied; For race/ethnicity with 95% CI, there were significantly more grocery stores in black (x2.7) and mixed (x2.7) for mixed; but significantly fewer supermarkets (x0.5 for black; x0.7 for Only one city so not sure where generalisable to other places or nationally Causality cannot be established with this type of studies.

Moore and Roux 2006 (184); US, parts of MD, NC, NY

Cross-sectional

75 census tracts in Forsyth County, NC; 276 in Baltimore City and county; 334 census tracts in New York City; covered predominantly white or black neighbourhoods with range of household incomes and

Association between density of different types of food retailers and neighbourhood racial/ethnic/SES composition

Purely descriptive Because examined diff types of stores, found a more complex picture than other studies Location not geocoded so not possible to simulate buffer zone of spatially variable units (to take account of fact that people travel outside their local neighbourhood to shop); Did not control for socioeconomic groups because

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urban and rural area

median household income, and racial/ethic composition

Morland et al., 2002 (293); US part of MI,NC,MD,MN

Cross-sectional

216 census tracts in 4 states (all with >-10 housing units) with 2437 food stores and food service outlets

Assoc between density of supermarkets and convenience stores and racial composition of neighbourhood

Geocoding of food stores and foodservice outlets to census tracts Modified version of North America Industry Classification System (NAICS) used to classify foods stores; median home value used to measure neighbourhood wealth; multivariate analysis (Poisson regressions) controlling for geographic difference

mixed); picture more mixed for fruit and vegetable markets, but significantly fewer in black neighbourhoods in 2 or the 3 sites (x0.6 for NT; 0.7 for MD); +For income with 95% CI, there were significantly more (x4.3) grocery stores and meat and fish markets (x1.5) in low income neighbourhoods than the wealthiest but significantly less (x0.5) supermarkets. With 95% CI, significantly more supermarkets in predominantly white neighbourhoods (x4.3) compared with predominantly white neighbourhoods, but less grocery and convenience stores (x0.4); also significantly more fast food restaurants in predominantly white neighbourhoods (x1.5) and full service rests (x2.4); highest income neighbourhoods had 3.3 more

closely linked with race Concludes that for complete picture, need to assess actual food offered in stores, which may give a different picture

Purely descriptive Did not control for individual wealth (household income) Did not simulate buffer zone of spatially variable units (to take account of fact that people travel outside their local neighbourhood to shop);

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Zenk et al, 2005 (294); US (metropolitan Detroit)

Cross-sectional

869 census tracts with 160 supermarkets in met Detroit with 15 mile buffer zone (to calculate supermarket access to peripheral neighbourhoods)

Association between distance to chain supermarkets and neighbourhood racial composition and poverty

Geocoding supermarkets into GIS to street address level Euclidean distance measure in GIS for spatial accessibility; characterise census tracts by poverty (tertiles of % residents below poverty line); and race (tertiles of %non-Hispanic black, then divided into poverty tertiles), and multivariate analysis (ordinary least square regression, controlled/adjusted for presence of spatial autocorrelation; and linear spatial trend Stores and outlets surveyed for availability of foods recommended by US dietary guidelines (& method of preparation for fast food outlets) (78 fruits and veg, plus

supermarkets than poorest, and 0.6 fewer grocery stores and insig different fast food Significantly greater distance for supermarket for neighbourhoods with top tertile black and top tertile poverty relative to lowest tertiles; No significant difference between distance to supermarket by poverty tertile for low black neighbourhoods; significantly greater distance to supermarkets among highest poverty tertile for medium black (1.10 miles further) and high black (1.15 miles further)

Just one city Did not control for travel times, social barriers (e.g., crime), non spatial factors that affect accessibility 9e.g., store operating hours) Small sample size after divide neighbourhoods into tertiles No evidence of causality

b) Difference in food retail access and food availability

Baker ET al., 2006 (295); US (St Louis, MO) Cross-sectional 220 census tracts in St Louis, MO; 81 supermarkets or major-chain food retailers; 355 fast food outlets (including 26 major chains) Association between density of supermarkets and fast food outlets and the foods they have available and neighbourhoods (by poverty and race) Mixed race or white high poverty areas and all AfricanAmerican areas (regardless of income) were less likely to have access to supermarkets and fast food outlets Several limitation .- No consideration of other racially mixed communities - only done in specific area of country - assumes that people are influenced by the availability of food in their own neighbourhoods

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lean meat, low fat dairy); each study area stratified in poverty tertiles and racial tertiles; GIS clustering analysis of stores controlling for chance, income and race

which had foods available that enables individuals to chose diets adhering to dietary guidelines

whereas they may travel elsewhere - provides no evidence of causality

c) Differences in food availability and food prices between food retail outlets
Chung and Myers, 1999 (188); US (metropolitan Minneapolis and St Paul, MN) Price survey in stores Cross-sectional 526 stores in metropolitan Minneapolis and St Paul in inner city and suburbs matched to zip codes Association between type of food retailer and location (inner city/suburban and poor/nonpoor) and food availability and price Overall goal was to examine of poor pay more for food Zip code information on poverty composition Stores categorized by standard US SIC classifications (chain, small grocery, convenience); price of foods (most popular brands and package sizes) in USDA Thrifty Food Plan (providing weekly nutritional requirements for family of four) collected from a random sample of 55 stores; average market basket price calculated for each using mean value for price of missing items; market basket prices compared between poor and nonpoor, chain/nonchain and suburb/inner city; econometric model to determine determinants of price differences; ttests for significance; OLS controlling for Inner city neighbourhoods had sig less chain stores (22% of total) than suburbs (no sig test) Poor neighbourhoods has less chain stores (11% of total) than nonpoor (no sig test) Consistently lower availability of all items in inner city compared to suburbs and small grocery/convenience stores compared to chains (no sig test) Market basket prices significantly lower (at 99%CI) in chain than convenience /small grocery stores ($16.62 price gap) . Controlling for poverty, availability and % of all stores in zip code, chains lower the market basket price by $11.81 - Study not explicitly focused on healthiness of food - Used Thrifty Food basket but some do not consider this to be that healthy, - No significance testing for some of the associations

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poverty, availability and % of all stores in zip code

Availability of foods in market basket higher in chain versus nonchain especially for fresh fruits and vegetables and meat; differences were less pronounced for other food groups No significant differences in price between inner-city and suburbs or poor versus non poor Direct impact of food availability is to lower market basket prices by $23.16 (i.e., the more food is available, the cheaper it is) Concludes that main price differentials are a result of store type rather than location 13 of the 14 studies found that prices were lower in supermarkets; tentative estimate of difference between small stores and supermarkets is 10% (greatest differences were 20-30% and smallest difference 23%); after controlling for store type and location, no sig Did not account for differences in prices between healthy food basket and other foods Review also useful because it raises a number of methodological issues that need to be addressed in studies that look at whether or not poor pay more for their food than the less poor.

Kaufman et al. 1997 (189); US

Review of earlier literature on price studies

NA

Association between type of food retailer and food price (among others) Overall goal was to assess whether the poor pay more for food

14 studies reviewed published between 1966-1996 (does not appear to be systematic review)

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Leibtag, 2005 (190;191); (US national)

Examination of CPI for different products over time

15,000 randomly selected households across US

AC Nielsen Fresh Foods Homescan dataset records food expenditures by 15,000 households, including point of purchase; analysed purchases of certain foods by nontraditional (super centres, wholesale clubs, mass merchandisers and dollar stores) relative to traditional (trad supermarkets and grocery stores)

relationship between neighbourhood income and food prices Prices of fresh foods significantly lower at non-traditional retailers relative to traditional for eggs, low fat milk, fruits, vegetables, beef, poultry, coffee and sweet biscuits e.g., Larger study on dairy showed that (controlling for similar-sized packages), dairy prices are 5-25% lower at nontraditional retailers than traditional SM; skim and low-fat milk prices consistently 5-12% lower at nontraditional stores. R representative basket of dairy products purchased at traditional and nontraditional retailers, traditional store prices 9.1% above non-traditional store prices Price differences are significant, especially when compared with standard measures of

Only national study done from US Not linked to whether it affects peoples diets

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food price inflation over time Concludes that the growth of nontraditional retailers will drive declines in food prices

FOOD RETAIL ENVIRONMENT AND DIETARY INDICATORS

Author/year/ country Study type Sample size/ population Goal Type of analysis/methods Results Comments

a) Retail access (density, distance) and dietary precursors or dietary intake

Laraia et al. 2004 (205); US/NC/Wake county Prospective large study; Data for this: xsectional, observational Pregnant women (n=918) Association between proximity (distance) of food retailers and diet quality index (DQI) Residential addresses and food retailers geocoded into Arcview GIS and classified by SIC Food frequency questionnaire (FFQ) DQI=servings of grains, veg, fruit; intake of folate, iron, calcium; % cal from fat; meal pattern score Multivariate, association, controlling for income, age, race, education, marital status > 4 miles distance to a SM compared to within 2 miles: assoc. with lower DQI (OR: 2.16) (low vs high tertile of DQI) Good analytical approach in general Three main limitations: No measure of transportation, where the women actually shopped, or the availability and cost of foods in the stores, so could not be controlled for. Second, geocoding can be inaccurate. Third, diet quality data collected between 1995-200, whereas the food retailers were geocoded using data from 2000, and changes could have occurred in the food retail environment during that time periods. Cross-sectional design makes it impossible to establish cause and effect

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(did not deal with endogeneity of placement of food retailers) Morland et al. 2002 (296) US atherosclerosis risk study US Prospective Study used 3rd assessment info (x-sectional) 10623 atherosclerosis risk in communities participants (men and women) Association between density of SMs and other food stores (number in census tract) and reported compliance with RDI for foods and nutrient intakes SMs, grocery stores and full-service and fast-food restaurants=geocoded to census tracts and classified by NAICS Food frequency questionnaire Multivariate; stratified by race; controlled for education, income, and, where necessary, type of food store; age not necessary because not associated; not adjusted for calories (they explain why) Fr&veg 32% per each additional SM (RR=1.32) in Black Americans; SM also associated with greater chance of meeting RDI for total fat, sat. fat Fr&veg11T% with presence of >1 SM (RR: 1.11); much smaller assoc. with fat than for blacks Concl: local food environment=assoc. with meeting dietary requirements Good analysis but several limitations: no information was available on where hhs actually purchased food, the type of transportation used to access food stores, or the availability and cost of foods in the stores.; no account of census tract borders; FFQ administered between 1993 and 1995, whereas the data on food outlets was from 1999; no control for gender,; not clear if they looked at meeting food and nutrient requirements for other things that they do not report (e.g., fibre, calcium, iron, etc.) Cross-sectional design makes it impossible to establish cause and effect (did not deal with endogeneity of placement of food retailers) Authors controlled for several potentially confounding factors. Report several limitations; self-reported measure of SM access not true measure of access (distance not actually measured); food use did not

Rose and Richards (2004) (297) US food stamp programme

X-sectional (secondary data analysis)

N=963, nationally representative of food stamp participants

Association between SM access and hh fruit and vegetable use among food stamp participants

Multivariate analysis controlling for degree of urbanisation, race/ethnicity, education, hh income and size, employment and marital status

Overall access to SM not a big problem (90% bought from SM; were within 5 miles). Those living > 5 miles away from SM consumed 62 g/AEQ

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less of fruit/day compared to those living within 1 mile. No significant relationship with vegetables. Less fruit and veg were consumed when hh respondent worked > 20 hrs/week (data not shown)

take into account food consumed outside home, (probably true for several other studies). Cross-sectional design makes it impossible to establish cause and effect (did not deal with endogeneity of placement of SMs)

b) Food retail access (including food service outlets) and diet-related health
Alter and Eny, 2005 (210); Canada (Ontario province) Cross-sectional, ecological study 2 stagesampling. 1) selected 9 leading fast food chains; 2) selected 380 regions (Forward Sortation Areas) within Ontario (all >-1000 people) with 1,630 fast food outlets Assess whether interregional differences in fast food concentration can explain some of the regional differences in mortality and acute coronary syndromes Fast food chains aggregated and divided by population size for each geographic area; Outcomes: Regionspecific per capita (pc) mortality and acute coronary syndrome hospitalization rate Used head trauma as a reference health outcome (not expected to be related to fast food concentration). Multivariate analysis (OLS); controls for community-level income, age, gender; Shows association between concentration of fastfood outlets and mortality and admissions for acute coronary (AC) syndromes; for each increase of one fast food outlet per 1000,000 people corresponded to one additional death No interaction between SES and fast food concentration on mortality and AC syndromes No association between fast-food Did not all include all fast food outlets only nine top chains No explanation provided for link (e.g., through diet) Did not deal with endogeneity of placement of fast-food outlets Discuss hypothesised mechanisms by which fast food may affect outcomes (i.e., through poor quality food, etc.) Discuss limitations (ecological fallacy: i.e., that association studied is at level of communities, not individuals) Overall good ecological

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tested interaction between SES and fast food concentration Used other types of multivariate models Morland et al. 2006 (298) atherosclerosis risk study US (same as above) Prospective Study used 3rd assessment info (x-sectional) 10,763 participants (men and women) Association between density of SMs and other food stores risk factors for cardiovascular disease, including obesity SMs, grocery stores and full-service and fast-food restaurants=geocoded to census tracts and classified by NAICS Multivariate models adjusted for education, income, age, gender, race, physical activity

concentration and head trauma (as expected)

study, which discusses limitations and lack of ability to demonstrate causality because of nature of design Interesting description of measurement of local food environment Study could but does not model association between place of purchase and outcomes though differences in food and nutrient intakes. Previous study (above) showed racial differences in nutrient/food intakes; but this one looking at health outcomes did not find such differences

SMs associated with lower prevalence of ovwt (Prevalence ratio PR=0.94); obesity (0.83); convenience stores assoc. with higher obesity (1.16) ovwt (1.06) Association with diabetes, cholesterol, hypertension not consistent Conclude that local food retail environment may play role in the prevalence and therefore prevention of overweight/obesity No association was identified between change in BMI and food outlet density, either as a composite variable of for different types of food outlet (model adjusted for controls and also food prices, which were found to

Sturm and Datar 2004 (299) USA

Nationally representative longitudinal study; look at changes over time (1 y; and 3 y;)

Kindergarten children followed in primary school 3,489 boys 3427 girls

Association between food prices and food outlet density and changes in BMI among elementary school children (price results not reported here but in Chapter 1, section X)

Individual level data merged with area characteristics (zip code of food outlets classified into NAICS categories of grocery stores, convenience stores, full-service restaurants, fast food restaurants)

Data does not allow separation into SMs (although unclear why because NAICS data does allow this) Comment that no effect of outlet density probably suggests that there is not much variability in these metropolitan areas (as

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Multivariate analysis; controlled for baseline BMI birthweight, age, , real family income sex, mothers educational achievement, race/ethnicity, TV watching, physical education, number of Outcome is change in BMI Explanatory variable is food outlet density (per capita number of food outlets) in childs home zip code or school zip code

be significantly associated with BMI) Results the same for childs zip code and school zip code because primary school children tend to go to schools in their own zip code Note that density of retail stores in poorer areas is higher (probably as a result of more smaller stores)

opposed to no effect of outlet density in general). But also higher density is associated with more small shops. Do not examine relationship with diets; the study included no measure of food consumption.

c) Availability of foods in retail outlets and dietary precursors or intake

Cheadle et al. 1991 (217); US (CA and Hawaii) Cross-sectional; community level (n=12); and zip code within community (n=34) 5654 people in 12 communities (counties, cities, census tracts; 11 in CA, 1 in Hawaii); 141 grocery stores Association between individual dietary practices and availability of lowfat, high fibre foods available in retail outlets Note that this goal was secondary to the major study objective to identify simple indicators (in food retail outlets) that may be predictors of diets and could be Measured shelf-space of low fat, high fibre foods in stores (low fat milk, bread, meat); self-reporting of individuals regarding usual diet (% cal from fat, intakes of sat fat and fibre) (telephone survey); Multivariate analysis by zip code (zero order correlation; ordinary least squares analysis) adjusted for Significant correlations between store healthfulness scale and consumption of low fat milk (0.69), eating whole wheat bread (0.58); association between calories from fat and store healthfulness scale = -0.52, but not stat signif. Good study to achieve their overall goal to identify simple community level indicators that can be used as a tool for assessing community-level dietary behaviour. For this purpose, it does not matter what comes first (store affecting behaviour or behaviour affecting store). For the purposes of studying the association, it has several limitations: Results may be due to

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used for that purpose

stratified sampling and nonresponse bias

reverse causality, i.e.: it may be that individual dietary behaviours and purchasing patterns determine foods that grocery stores stock and nutritional info they provide. Used self-reporting for diet Did look at non respondent (only 53% response rate) No direct link between individuals and grocery stores surveyed, but used geographic proximity Analyses done at community level; or zip code level. This is appropriate given design, but SS are small (n=12 or 34). Only used correlation coefficients to examine the association with no controls No statistical sig between changes in availability of healthful products in stores and healthfulness of individual diets. Authors interpret lack of sig of association (when looking at changes) to the fact that changes were rather small and indicators (at store level) was not sensitive enough to detect the changes.

Cheadle et al. 1993 (300); US (CA and Hawaii)

Follow up study over time

5654 people in 12 communities (counties, cities, census tracts; 11 in CA, 1 in Hawaii); 141 grocery stores

Association between changes in healthy foods in stores and consumption of low fat high fibre foods Again, main goal was to determine whether same indicators could be used to track changes in dietary patterns over time Association between low fat milk in stores and presence of low

Follow up to previous study; use same methods but multivariate analysis done at community level not zip code; t tests used to estimate changes over time and restricted maximum likelihood techniques Random sampling of 15 stores from each zip code;

Fisher and Strogatz 1999 (301); US (NY

Cross-sectional

7 New York counties (53 zip codes); 503

Strong significant and positive relationship between

Problem of reverse causality (or endogeneity of store supply)

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counties)

stores

fat milk in hh (telephone survey) As for Cheadle et al. (217;302), the studys actual main objective is indicator development (to confirm or not utility of environmental measures to monitor health behaviours (dietary patterns in this case)

average%1%/skim milk of all milk measured for stores; hh milk consumption measured by reporting on presence or usual presence in the refrigerator); Multivariate analysis used to test determinants of % low-fat milk in stores

proportion of low fat milk and presence in hhs (R2=0.82) Main determinants of % low fat milk in stores: income, urban, non Hispanic white

No direct link between individuals and grocery stores surveyed, but used geographic proximity The study also did not estimate the relationship between low fat milk consumption and availability in outlets after controlling for income and urban level, even those these were identified as being important. The relationship between availability and consumption could thus be largely an income effect. Only took presence or absence in fridge, not reported consumption by individuals, though this can be a good proxy.

c) Quasi-experimental studies
Cummins et al. 2005 (303); Glasgow, UK Prospective, quasiexperimental study Pre-post (10 months postintervention assessment); interventioncontrol 412 men and women Assess the impact of introduction of SM in poor Scottish community (natural experiment) on fr&veg intake and psychological health Postal questionnaire to obtain information on fruit and vegetable consumption, selfreported and psychological health and sociodemographic variables. Multiv analysis; control for age, sex, economic activity, education; also tested NO impact on fr&veg intake or health. Some reduction in prevalence of poor psychological health of residents who directly engaged in intervention. Also some trend toward worsening of self-reported health and improved Interesting analysis of switchers - or people who actually did use intervention. But SS quite small, so lack of statistical power. Limitations of study regarding design: i.e., not randomized, relatively low adoption rate and low response rate (to the survey) self-selection problem due

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interactions (trt*gender; trt*work; trt* age, etc.)

psychological health in intervention communities, but not significant

to low response rate

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Appendix 1.4: Summary of food price studies reviewed

Impact of food price on food consumption Cross-sectional data based studies, complete demand system
Reference /year Sahn, 1988 Objective of the study Predicting the impact of price and income changes on food energy intake among different income groups in Sri Lanka. Data type Sample size/ & year Country CrossNationally/ sectional sectorally/ 1980/81 regionally/ representativ e/ Sri Lanka Food/nutrient items studied Food items: rice, coconuts, sugar, condiments, vegetables, fish, bread, pulses, oil, wheat flour, milk, root crops, meat, and other grains Rice, wheat, maize, cassava, roots, vegetables, legumes, fruit, meat, fresh fish, and dried fish Bread, potatoes, veg., fruits, meat, milk, eggs, sugar, oil & fats, others Price Not indicated Methodology Log-log quadratic form Major findings The demand for rice, coconuts, sugar, condiments, vegetables, bread, and oil were price inelastic while the demand for fish, pulses, wheat flour, milk, meat, and root crops were price elastic for almost all income groups. Comment - The theoretical consistency of the coefficients with demand theory was not tested - Hickmans two stage procedure was used to take care of zero observations -Unit values were assumed to vary spatially -Weak separability assumed

Deaton, 1990 Measuring own-and cross-price elasticities of demand from spatial variation in prices using household survey data Tzoneva, Mishev, Mergos, Ivanova, 1997 Investigating the impact of the dynamic changes in Bulgarian economy on food consumption patterns

Crosssectional, 1981

14,487 households/ Rural Indonesia

Cluster level unit values

Modified AIDS model where unit values were separately modelled A double-log specification of the Engel function

Own-price elasticity of demand for all food groups was negative and inelastic except for vegetables and meat. The own-price elasticity of demand for fruits, legumes, and roots was nearly unitary. Strong substitution between fresh and dried fish was observed Demand was price inelastic for all food items. Demand for potatoes, veg,, fruits, and meat was more price elastic than other food items. The estimated cross-price elasticities showed that most of the food items were complementary though they were close to zero Due to relatively high share of food from the total expenditure and high inflation income was more important than price in determining consumption patterns.

Crosssectional (19901994)

50 observations for 10 income groups over 5 years span/ Bulgaria

Price indices

- The level of analysis not shown - Price elasticities were derived from income elasticities - Small no of obs.

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Reference /year Han, Wahl, 1998

Objective of the Data type Sample size/ study & year Country Estimating the Cross6,696 rural demand elasticities section, households/ for rural households 1993 rural China in China with special emphasis on fruit sand vegetables

Food/nutrient items studied In the first stage: food, clothing, housing, durable goods, and other items. In the second stage: grain, wheat, rice, meat, other, leafy veg., root veg., other fresh veg., dried veg., apples, grapes, other fruit Bread, rice & grain, flour & pasta, potatoes, veg., fruits, beef & veal, pork, poultry, processed meat, fish, fresh milk, milk products, cheese, eggs, sugar, sweets Milk & milk products; cereal & pulses; edible oils; meat, fish, & eggs; vegetables & fruits; other food products

Price Unit values

Methodology LA/AIDS -

Two-stage Unit LA/AIDS values (adjusted for quality) -

Elsner, 1999

Estimating exp and Cross2874 HHs/ price elasticities of sectional19 Russia food DD for different 96 household groups

Major findings The first stage regression result showed that the own-price elasticity of demand for food was -0.844 and was more elastic than other expenditure groups At the second stage all own-price elasticities of demand were negative and statistically significant Other fruits and grapes were price elastic while all other food items were price inelastic. Fruits were more price elastic than vegetables Demand for most of the food items was less sensitive to price changes in higher income groups than in lower income groups. Uncompensated price elasticities: Flour & pasta (-1.80), potatoes (-1.61), veg. (-1.19), fruit (-1.05), sugar (-1.10), bread (-0.69) (the lowest ) DD is generally more responsive to price changes than to changes in total exp Comp. elast. < uncomp. elast. suggesting that a change in price would have considerable exp. effects The uncompensated own-price elasticities of demand were negative and mostly inelastic except in the case of milk and milk products in rural areas. Meat, fish, and eggs group were the least responsive to own-price changes both in urban and rural areas. Cross-price elasticities were generally negative but weak, indicating that most of the food groups were complements. Compensated elasticities gave more accurate cross-substitutions than uncompensated elasticities. Most of the compensated price elasticities were lower in absolute terms than uncompensated elasticities.

Comment -Hickmans two-step procedure was used to take into account zero consumption - Unit values were not adjusted for quality differences

- Internally per reviewed - Hickman two-step procedure is used to deal with zero expenditure

Abdulai, Providing estimates Cross1100 Jain, Sharma, of price and households/ section, 1999 expenditure 1995/ 1996 India elasticities of demand for rural and urban areas of India using recent survey data

Unit values

LA/AIDS

- Weak separability was assumed -Unit values were not adjusted for quality differences -Both compensated and uncompensated elasticities were estimated

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Reference /year Huang, Lin, 2000

Objective of the study Estimating demand elasticities for households segmented with different income levels

Data type Sample size/ Food/nutrient & year Country items studied Cross4495 HHs/ Beef, pork, sectional USA poultry, other 1987/88 meat, fish, dairy products, cereal, bread, fats & oils, eggs, veg., fruits, & juice

Price Methodology AIDS - Unit values (adjusted for quality) -

Major findings Own-price elasticities for dairy (-0.795), fruits (-0.719), and vegetables (-0.724) were relatively more elastic Own-price elast. for meat categories were 0.35 for beef, -0.69 for pork, -0.64 for poultry, & -0.39 for fish The own-price elast. >> those obtained from time-series data Own-price elast. among different income groups did not vary systematically across income groups

Comment - No adjustment for zero consumption - The analysis was limited to urban areas to avoid potential bias associated with self-produced foods in rural areas

Huang, Bouis, 2000

To examine the impact of structural shifts in food demand patterns Analyzing the demand for basic food commodities during the first stage of the economic and political transformation

Two-point 11886 & cross12734 / section Taiwan 1981 and 1991 Two 3,027 & annual HH 3,112 HHs / budget Slovenia surveys, 1988 & 1993

Rice, wheat, meat, Country fish, fruit other and food & non-foods regional level price data Bread & cereals, Unit meat, fruits, vegs., values milk, oils, other food

AIDS

Turk, Erjavec, 2001

LA-AIDS

Own-price elasticities: rice -.609, wheat 1.514, meat -.243, fish -1.638, fruit -1.412 - Real chicken prices fell substantially between 1981 &91 more than pork & beef prices fell, & chicken cons. increased more than consumption of pork and beef. - A growing economic crisis between 1988 and 93 has changed the elasticities 1988 1993 Bread & cer. -.331 -.409 Meat -.412 -.750 Fruits -.877 -.708 Vegts. -.629 -.461 Milk -.630 -.677 Oils & fats -.072 -.404 Other foods -1.273 -1.244 - Market liberalisation increased the price responsiveness of consumers - Consumers responded strongly to price changes in meat, oils & fats, and cereal, - In the entire period bread remained a basic food item - Most cross-price elasticities are inelastic and close to zero

- Prices were collected from different levels (for rice, wheat, chicken, eggs, & fruit at country and for others at regional levels) - The overall price index is approximated by the Stones geometric price index - No information if unit values were adjusted for quality

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Reference /year Raper, Wanzala, Nayga, 2002

Objective of the study Measuring the impact of demographic variables on subsistence quantities and price and income elasticities

Data type Sample size/ Food/nutrient & year Country items studied Cross11713 Non-alcoholic sectional observations/ beverages, food 1992 U.S.A away from home, meat, other food at home, cereals & bakery products, dairy, fruits and vegetables, sweets and sugars, and fats and oils Crosssection, 1994 26256 Bread & cereals; households/T meat, fish, and urkey poultry; milk, dairy products, fats, oils, and eggs; veg. & fruits; various processed food; tobacco products, liquors, and beverages

Price Methodology Consumer Linear price expenditure indices for system each aggregate food category

Major findings Both poor and non-poor groups had similar compensated elasticities mainly due to the food stump programme. However, poor households were more sensitive to price of food away form home.

Comment -Heckmans two step procedure was used to take into account zero obs. - Compensated and uncompensated elasticities reported

zer, 2003

Estimating demand elasticities for a disaggregated and complete set of food items in Turkey

Consumer LES price index collected from secondary source

All the uncompensated own-price elasticities of demand were negative Except for bread and cereals groups, uncompensated own-price elasticities were elastic The absolute value of uncompensated ownprice elasticities were highly correlated to expenditure elasticities indicating that the former included considerable income effects. Compensated elasticities were lower in absolute terms than uncompensated ones. The absolute value of cross-price elasticities were lower than the own-price elasticity estimates indicating that consumers were more responsive to changes in own-prices Unconditional Frisch own-price elast. were calculated for 114 countries for 8 food groups Low income countries were more responsive to price changes compared to higher-income countries Staple food consumption changed the least, while consumption of higher-value food items such as dairy and meat changed the most

- Weak separability was assumed -Unit values were not adjusted for quality differences -Both compensated and uncompensated elasticities were estimated

Seale, Regmi, Bernstein, 2003

Analyzing DD across Crosscountries country crosssectional19 96

22 Africa, 25 America, 34 Asian & Oceania, 36 European

Country Beverages & tobacco, breads& level cereals, meat, fish, prices dairy, fats & oils, fruits & veg., other

Two-stage aggregate Florida-PI model

-Sample size in each country not shown - One of the most comprehensive studies in the area

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Reference /year Agbola, Maitra, McLaren, 2003

Objective of the Data type Sample size/ study & year Country Examining the effect Cross6960 HHs/ of estimation sectional19 South Africa procedures on South 93 African HH food consumption parameters

Food/nutrient items studied Meat & fish, grains, dairy, fruits, vegs., other foods

Price Unit values

Methodology Major findings Flexible two- - Uncompensated price elasticities stage AIDS Meat & fish -1.309 Fruits -1.061 Grains -1.258 Vegs. -1.123 Dairy products -0.958 Consumers were sensitive to price changes The cross-price elasticities < own-price elasticities and are generally non-significant implying that SA HHs are more sensitive to changes in own-prices (no gross substitution) All own-price elasticities were negative and significant The uncompensated own-price elasticity of demand results revealed that most of the food groups were price inelastic. Milk had the highest uncompensated ownprice elasticity of demand followed by other meat, grain, fruits, and veg. The highest milk elasticity coefficient indicated that government price-support programme could help to promote calcium intake At the other extreme, the demand for pork was the least sensitive to its own-price of all food groups. The gross cross-price elasticity of demand showed that egg products were gross substitute for fats and oils, beef, pork and poultry. Most products were also gross complements to fish and poultry. Compared to own-price elasticities, crossprice elasticities were generally small

Comment - Not peer reviewed - Missing prices were replaced by cluster prices - Prices were not adjusted for quality - Compensated & uncompensated elasticities shown

Yen, Fang, Su, 2004

Quantifying the determinants of demand by urban households in China

Crosssectional, 2000

3,715 urban households/ China

Beef, pork, Unit poultry, fish, other values meat, grain, fats and oils, egg, milk, veg. ,and fruits

Translog demand system

_Weak separability assumption b/n food and non-food - Unit values not adjusted for quality - Care was taken for zero consumption

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Reference Objective of the /year study Dong, Gould, Examining the food Kaiser, 2004 demand structure of households in Mexico

Data type Sample size/ Food/nutrient & year Country items studied Price Cross2972 Beef, pork, Unit sectional households/ poultry, processed values 1998 Mexico meat, fish/shellfish, veg., fruits, grains, beans, cheese, nonalcho. bev., fluid milk Crosssectional 1994 Twenty six food 1,500 households/U items grouped into rban Ethiopia six food groups: teff, cereals, pulses, fruits & veg., meat, coffee 6,394 urban households/ Mexico Meat, beef, seafood, vegetables, grain, nonalcoholic beverage Within cluster quality adjusted unit values and actual market prices Unit values adjusted for quality and quantity

Methodology AIDS -

Major findings All food items were price inelastic except that of milk and unprocessed pork had the lowest (in absolute terms) elasticity. Milk had also the highest and pork the lowest substitutability of any of the commodities Beef and pork were the least complement food items

Kedir, 2005

Estimating own-and cross-price elasticities using spatial variation in prices for six food groups in Ethiopia Estimating qualityadjusted price elasticities of demand form crosssectional data

Modified AIDS model where unit values were separately modelled A model that includes both expenditure and unit value equations and that took into account for zero expenditures

Comment -Amemiya-Tobin approach was used to take into account zero purchase - Unit values not adjusted for quality differences - Uncompensated, unconditional own-& cross-price elasticities estimated Most of the price coefficients were price -Unit values were inelastic and two-third of them were assumed to vary spatially -Weak separability statistically insignificant Unit values, corrected for quality differences, assumed can perform more than market prices collected from published sources from a theoretical perspective - The analysis was limited to urban areas to avoid potential bias associated with self-produced foods in rural areas - Cross-price elasticities were not estimated

Chung, Dong, Schmit, Kaiser, Gould, 2005

Crosssectional 1996

Ignoring quality adjustments in either prices or quantities could yield biased demand elasticity estimates. The quality adjusted elasticities showed that beef and seafood were price elastic while vegetables, grains and nonalcoholic beverages were inelastic

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Impact of food price on food consumption, cross-sectional data based studies, specific food items Data Sample size/ Food/nutrient Reference Objective of the type & year Country /year study items studied Price Methodology Dey, 2000 Estimating Cross5,667 HHs / Fish: Ilish, live Unit Three-stage demand section, Bangladesh fish, carp, small value QUAIDS elasticities by 1988/89 fish, shrimp, fish type dried fish

Major findings Own-price elasticities varied significantly across fish types The own-price elasticity of DD for fish was high and carp had the highest ownprice elasticity (-2.87) - Uncompensated own-elas. > compensated elas. for small fish reflecting its large share in the fish budget - Most of the compensated and uncompensated own & cross-price elasticities varied with expenditure

Yen, Kan, Su, Examining U.S. 2002 fat and oil demand

Crosssection, 1987/88

3943 HHs / Butter, USA margarine, Shortening, cooking oil, salad dressing 4,273 HHs/ U.S.A

Unit value

Two-step translog censored demand system Translog demand system estimated using FIML and SML methods

Yen & Huang, 2002

Estimating the a Crosssection, system of 1987/88 censored demand equations for disaggregated beef products using FIML and SML estimation methods

Unit Four values disaggregated forms of Beef: steak, roast, ground beef, and other beef

Comment - Fish groping was made by the respondents - Predicted values were used for food and fish expenditure - Missing price replaced by village price - Tobit model was used at the second stage to take into account zero fish consumption - Uncomp. own-price elasticities for butter -Both compensated & uncompensated (-1.132), margarine (-0.991), and salad elasticities were dressing (-0.990) were significant and presented negative. - Missing prices - Uncomp. elast > comp. elast. were replaced by - Prices played important roles in regional average determining fat and oil consumption - Unit values not - The demand for roast & other beef are adjusted for quality price elastic - In addition to price, other factors such as - Demand elasticities are household composition, urbanisation, decomposed into gender, food stamp participation, probability & influence demand - Price affects the level of consumption in conditional elasticities different beef cuts while demographic factors affect the consumption probabilities - Additional insight can be gained by studying beef demand at a disaggregated level

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Reference Objective of the /year study Dhar, Chavas, Estimating Gould, 2003 demand for carbonated soft drink using AIDS model taking into account the issue of price and expenditure endogeneity

Methodology Major findings AIDS model - Both price and expenditure endogeneity significantly affects the consistency of demand parameter estimates - Elasticities estimated form demand analysis who did not control for price and expenditure endogeneity could give inconsistent results - The estimated price elasticities indicated that demand for carbonated soft drinks was highly sensitive especially after controlling endogeneity problems. Lazaridis, Investigating the Cross6489 and Beef, lamb, Unit Two-stage - The uncompensated own-price elasticities 2003 meat section 6756 HHs / pork, poultry value LA-AIDS are all negative, and <1 (in absolute consumption 1987/88 Greece terms) in both periods. patters in Greece &1993/94 - Beef (-0.6) & poultry (-0.7) were more elastic & lamb (-0.1) & pork (-0.3) were less price-elastic - The compensated cross-elas. showed that lamb & pork were complements. - Income policies might be more effective in influencing cons. patterns than were price policies. - Except for shrimp and shell/crabs fish Province Three-stage Fresh fish: 39,000 Garcia, Dey, Establishing the CrossQUAIDS type demand for fish was highly elastic households/ milkfish, tilapia, level section, Navarez, 2005 fish - The compensated elasticities were lower market model Philippines shrimp, 2000 consumption than the uncompensated ones indicating price shells/crabs, pattern and that if income was held constant, the roundscad, estimating price responsiveness of households to fish anchovies, and income price decreases squid, other elasticities of - Rich households were more sensitive to fresh fish demand for fish the prices of high value fish varieties Processed fish: in the such as shrimp and poor households to Dried/smoked Philippines cheap fish varieties such as milkfish, fish, canned fish, tilapia, squid, and shells/crabs salted fish Most of the cross-price elasticities though relatively inelastic showed that most of the fish types were substitutes each other

Data type & year Crosssection, 1998 [Major metropoli tan marketing areas]

Sample size/ Country 920 quarterly observation s (46 cities with 20 quarters) by nine brands

Food/nutrient items studied Price Nine carbonated Retail soft drinks: 7-up, price Coke, Dr. Pepper, Mt. Dew, Pepsi, RC Cola, Sprite, Private label, All-other

Comment - Elasticities are estimated controlling for both price and expenditure endogeneity - Separability assumption is tested

- Prices adjusted for quality - Both compensated & uncompensated elas. were presented

-Heckmans two step procedure was used to take into account zero obs. Both compensated and uncompensated elasticities were estimated

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Impact of food price on food consumption, time series/panel data based studies, complete demand system Data type & year Annual time series from 1961-87 Sample size/ Food/nutrient Country items studied 27 years/ Beef, pork, Republic of chicken, fish, Korea rice, wheat, and barley

Reference /year Ingco, 1990

Objective of the study Estimating the responsiveness of demand for meats and food grains in the Republic of Korea

Price Retail price index

Ingco, 1991

Analyze the characteristics of demand for major food stuffs in the Philippines

Time series, 19651990

26 years/ Philippines

Rice, corn, wheat, meat, fish, fruits & veg, and other goods

Methodology Major findings Modified - Except for pork the estimated own-price LA/AIDS elasticities of demand were inelastic - Overtime, the demand for meat became more price sensitive and the demand for chicken appeared to be relatively less price-responsive. - The own-price elasticity of demand for pork remained stable and the demand for rice was very price-inelastic and appeared to become even less elastic through time. - Demand for wheat was more responsive to its own-price than other grains though it declined through time like other grains. - All estimated uncompensated price elasticities Consum LA/AIDS er price were less than unity - Rice, corn, and fish were the least responsive index - Meat, wheat, & fruits and veg. were more responsive - The absolute value of the own- price elasticity values had similar trend to income elasticity figures showing the high income effect in the price elasticity figures - The cross-price elasticity figure showed that most of the food items (especially wheat) were responsive the changes in rice prices but not vice versa mainly due to the high budget share of rice - Complementarities between wheat and meat observed (hamburgers, bread and noodles)

Comment - No information on stationarity and structural break tests - Some of the compensated price elasticities were positive - Degree of separability was not shown -Compensated and uncompensated elasticities computed - No information on stationarity and structural break tests

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Reference /year Molina, 1994

Objective of the study Analysing food demand in Spain between 1964 and 1989 using AIDS model

Data type & year Time series, 19641989

Sample size/ Country 26 years/ Spain

Food/nutrient items studied Price Bread and Annual cereals, meat, price fish, milk and eggs, vegetables and fruits, other food

Balisacan, 1994

Examining the structure of food consumption in the Philippines.

13,487 Time households/ series Philippines 1985, 1988, 1991, Philippine s Aggregate quarterly time series, 1975-187 51 observation s from 1975(quarte r 1) to 1987(quarte r 3)/ Myanmar

Last stage: rice, Price indices corn, wheat, other cereals, veg., fruits, pork beef, poultry, milk, eggs, fish Rice (poor quality, medium, and high); wheat flour, groundnut oil,; sesame oil; pulses; potato; onion; garlic; chilli; salt sugar; coffee; beef; pork; mutton; goat-meat; chicken; duck; fish Open (black) market prices

Estimating Soe, demand Batterham, Drynan, 1994 functions for important food items for Myanmar.

Methodology Major findings AIDS - Generally, the Marshallian own-price elasticities were higher than (in absolute terms) than the Hicksian own-price elasticities. - All uncompensated price elasticise of demand were inelastic. - Milk and eggs had the highest (in absolute terms) own-price elasticity and bread, cereals and fish the lowest. - Cross-price elasticities estimated from Hicksian values measured cross-substitution accurately since it they measured substitution net of income effects. - Most of the estimated cross-price elasticity coefficients were generally weak - All own-price elasticities were close to unity Extended - Except for corn price elasticities did not vary (quadratic) significantly across income quartiles and AIDS between urban and rural areas - The lower the level of disaggregation, the inelastic is the estimated demand price elasticity indicating limited scope for substitution. LA/AIDS/ - The AIDS model gave more theoretical double-log consistent results than the double-log method - The demand for all types of rice was price inelastic - The demand for wheat flour tended to be more price elastic than other non-meat basic food items - The cross-price elasticities were generally small and high quality rice was a substitute for low quality rice. - For meat items beef had the lowest and chicken the highest own-price elasticity of demand - The cross-price elasticity among different meat items was low but the substitution between pork and chicken was considerably large

Comment - Weak separability assumed - No information on stationarity and structural break tests Marshallian and Hicksian own-price elasticities were estimated

-Endogeneity of expenditure was considered

-Not clear if adjustment was made for zero observations - No information on stationarity and structural break tests

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Reference /year Laajimi, Gracia, Albisu, 1997

Objective of the study Analyzing factors determining food consumption in Spain

Sample Data size/ type & Country year Panel, 2500 HHs / October Spain 1989Septembe r 92

Food/nutrient items studied Price Cereals & bread, Unit meat, fish, dairy, value oils & fats, fruits & vegs., other foodstuffs

Methodology Major findings AIDS - The own-price elas. (Marshallian & Hicksian) showed that all food groups except dairy products were price inelastic: - Marshallian elas.: oils -.262, cereals -.657, fish -.671, meat -.742, fruits & vegs. -.836, others .916,dairy -1.014 - Meat & fish were good substitutes but in general food DD was more responsive to ownprices rather than to cross-prices

Edgerton, 1997

Testing the impact of weak separability and low variability of price indices on elasticities using Swedish food data

Pooled Not data from indicated/ 1963 to Sweden 90

Final stage: Meat, fish, dairy, soft drinks, coffee/tea, alcohol, cereals, fruits/veg., potatoes, fats, sugar, confect.

Implicit Three-stage - Estimating price elasticities from the last stage dynamic price of a multistage budgeting process can give indices LAIDS model error results (current - Comparing results from different exp/ real exp) using the Paasche indices

Comment - No adjustment for zero exp and quality effects of unit values - Missing prices were replaced by the average price for each year - Not clear which type of panel data analysis used -Within group and within food elasticities are estimated separately - No information if stationarity and structural break tests were done - Stationarity test was done - No adjustment of unit values for quality

Balcombe, Davidova, Morrison, 1999

Estimating demand elasticities in Bulgaria

2,500 Time households/ series monthly Bulgaria data from January 1991- to April 1996, Bulgaria

Monthly AIDS adjusted - Most of the cross-price elasticity coefficients Bread, milk, for seasonality cheese, meat and unit were insignificant. values all other - The own-price elasticities of demand show products that demand is elastic

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Reference /year Tiffin, Tiffin, 1999

Objective of the study Estimating price and income elasticities consistent with the neo-classical demand theory

Sample Data size/ type & Country year Not shown/ Annual household UK demand data from 1972 to 1994, UK.

Food/nutrient items studied Price Second and third Annual stage: staple national foods (milk, averages cheese, bread, eggs), meat (pork beef, chicken other meat lamb), vegetables (processed veg., green, veg., other fresh veg., potatoes), and fruit (bananas, apples, citrus fruit, other fresh fruit, other fruit)

Methodology Major findings Three-stage - The own-price elasticities for fruits and meat budgeting were higher than for staples and vegetables. LAIDS - Lamb had the lowest own-price elasticity from the meat category mainly due to its seasonal nature - Citrus fruit and apples were also price inelastic, of the fruit group indicating their status as a staple-fruit. - Price Elasticities for aggregated food groups (second stage) were generally lower (in absolute terms) than for individual items (last stage) indicating higher degree of substitution within groups. - Own-price elasticity for brown bread was -3.638 indicating that price was the main factor that determined the growth of demand for this item compared to white bread - Overall, there was evidence of substantial responses to price in food consumption - Overall price elas. were computed (rice -.38, wheat flour -.36, coarse grains -.04, pork -.48, egg -.14 & edible oils -.25) - Poor consumers were more responsive to price changes than the rich, except for coarse grains and edible oils (e.g., rice: -.54 vs. -.25, pork .96 vs. -.33) - Price changes could have different effects on the rich and the poor

Comment -Compensated and uncompensated elasticities computed - No information if stationarity and structural break tests were done

Guo, Popkin, Mroz, Zhal, 1999

Examining how Panel, 1989, 91, food price & 93 changes could affect dietary intake

Six food groups 6667 individuals/ (rice, what flour, coarse grains, China pork eggs, edible oils) & 3 macronutrients (calories, protein, fat)

Time Two-stage series log-log commun method ity level

- Not clear why random effect model was chosen - Not shown if some theoretical restrictions were satisfied - The movement from the 1st to the 2nd stage was not shown

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Reference /year Meenakshi, Ray, 1999

Objective of the study Examining regional disparities on Indias expenditure pattern and estimated demand parameters

Sample Data size/ type & Country year Longitudi 2071 HHs/ India nal, 1972/73, 73/74, 77/78, 83, 87/88

Food/nutrient items studied Price Cereals & cereal Retail substitutes, price pulses, milk & milk products, edible oils, meat, egg & fish, other food

Methodology Major findings Demographica - Elas. quite sensitive to functional forms lly extended - The own-price elasticities revealed large two-stage differences in responses to price changes QAIDS - The DD for milk and edible oils were more sensitive to own-price changes in the urban than in rural areas while the reverse held for cereals, pulses, and meat, egg and fish - Own-price elasticities Rural Urban Cereals & substitutes -0.781 -0.783 Pulses -0.263 -0.320 Milk & milk prod. -0.383 -0.923 Edible oils -0.802 -1.187 Meat, egg & fish -2.107 -1.080 - In the context of large developing countries, cultural and non-economic factors were as important as the economic factors in explaining food exp patterns Autoregressiv - All estimated long-run price elasticities of e distributed demand were inelastic - Vegetabilia were much less sensitive to ownlag AIDS price changed compared to animalia model - The cross-price elasticities showed that animalia and vegetabilia were substitute in food demand - Indian households were more price responsive than was otherwise thought

Comment - Fruits & vegs. were not considered - The unconditional ownprice elas. for cereals and pulses in urban areas were >0

Lind, 2000

Estimating a demand system for India using a theoretically consistent demand model

FAO Time series, 19671997, India

31 years/ India

Vegetabilia , animalia, and other goods

Aggrega ted prices using Tornquis t index

- Co-integration test conducted - Food items and prices were highly aggregated

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Reference /year Hossain, Jensen, 2000

Objective of the study Estimating demand elasticities for food using a complete demand system and panel data

Data type & year Househol d budget survey between July 1992 and December 1994

Sample size/ Country 1500 households observed each month/ Lithuania

Food/nutrient items studied Price Methodology Major findings Grains, fruits & Consum LA/AIDS - Households were responsive to price changes veg., beef, pork, er price though most of the uncompensated own-price poultry, eggs, indices elasticities of demand were inelastic other meat, milk, - These elasticities were relatively low for butter &cheese, essential foods compared to for non-essential other dairy, and food items. sugar & - The demand for pork, butter and cheese, and confectionery other meat were price elastic. - The Dairy products, fish and grains are less price sensitive - Meat, fruits, and vegetables are more price responsive (close to unity) Price Final stage: index Meat & fish, fruit and vegetables, milk & eggs, bred & cereals, miscellaneous LAIDS - Consumers actively reacted to short term price shocks (February 1991-January 1992), - In the long run, however, most items became more price inelastic than before mainly due to high self-produced food consumption - Complementarity is more common than substitutability - During times of hardship, bread was a substitute for items such as meat and milk - Quantitative factors were more important than quality factors in influencing food demand in Bulgaria - Households are responsive to price changes - Dairy products, fish and grains are less price sensitive - Meat, fruits, and vegetables are more price responsive (close to unity)

Comment - Weak separability between food and non-food expenditure

Luchini, Procidano, Mason, 2000

Examining the impact of market reform process in Bulgaria on food consumption patterns of Bulgarian population

Monthly data between Jan. 1985 to Dec. 1997 (156 monthly data)

156 monthly data/ Bulgaria

-Two stage budgeting model used - The data were seasonally adjusted using ARIMA technique

Estimating Hossain, Helen, Snuka, demand elasticities for 2001 food and nonfood expenditure group using a complete demand system

13,537 Pooled data from observation January s/ Latvia 1996-Dec. 1997

Consum AIDS Meat & meat, dairy, fish, eggs, er price bread & cereal, indices potatoes, fruits & vegetables, sugar, and veg. fats

-Both compensated & uncompensated elasticities were presented - Weak separability between food and non-food expenditure

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Reference Objective of the /year study Klonaris, Estimating a Hallam, 2003 three stage conditional and unconditional demand elasticities for food and nonfood items in Greece. Khaled, McWha, Lattimore, 2004 Update the price and income elasticities of demand using recent time series data for New Zealand

Sample Data size/ type & Country year Annual Not time indicated/ series data Greece from 19591995

Food/nutrient items studied Price Final stage: Price Beverage & index tobacco; Livestock (meat, fish, dairy); various food (bread &cereals, fruits and veg., oils.)

Methodology Major findings Three-stage - Except for medical and persona care, all dynamic commodities appeared price inelastic AIDS model - Significant deviations were observed between conditional and unconditional price elasticities of demand.

Comment - Conditional/ unconditional and within/total elasticities estimated - No information if stationarity and structural break tests were done - No information if stationarity and structural break tests were done

Weekly time series expenditu re data between 1981 and 2001

3000 households/ New Zealand

Food: fruits Consum Two-stage &veg., meat, er price Rotterdam poultry, fish, fats index model & oil, cereals, sweets, meals away from home

Smed, Jensen, Analyzing the Denver, 2005 nutritional effects of using economic policy tools such as taxes or subsidies on different socioeconomic groups

2000 HHs/ Weekly HH panel, Denmark Jan 1997 to Jan 2000

Eggs, other meat, other dairy, fish, proc. fish, grain based products, poultry, proc. fruit & vegs., fresh fruit, fresh vegs., potatoes, biscuits & cakes, milk, margarine, beef, cheese, rice & pasta, butter, sugar, pork, curdled milk products

Time series regional level data disaggre gated by income

Dynamic specification of AIDS model

- Of all broad expenditure categories, food was the most inelastic category - Over the last two-decades, consumption of fruits & vegetables, poultry, food eaten away, and sweet products, drinks and other foods - The demand for fish, poultry, meat, farm products, cereals, and meals eaten away from home were more price elastic - Most of the food categories were not sensitive to cross-price changes. - A tax on fats reduced the total energy intake as well as fats share of total energy, but increased sugars energy share for most consumers - A tax on sugar reduced the share of sugar but increased the share of different fats - The effects of a subsidy on fibres, on fats and sugars energy shares were small or negligible so a relatively high rate of support was needed - General tax or subsidy instruments couldnt solve the problems with regard to nutrition and obesity for all groups. But these economic instruments (tax+ subsidy) could be used in combination with other instruments/regulations such as information campaign, rule-based regulation

- Not peer reviewed - Food cons. was assumed to be weakly separable from the cons. of other goods - The impact of taxes and subsidies on the supply side was not considered

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Impact of food price on food consumption, time series/panel data based studies, specific food items Data Sample type & size/ Food/nutrient Reference Objective of the year Country /year study items studied Price Methodology Gould, Analyzing the Aggregat Quarterly Five types of Retail LA/AIDS Cox, Perali, impact of prices e data fats and oils city 1991 and expenditure on quarterly between (butter, average fats and oils time 1962 and margarine, prices consumption series, 1987 / shortening, salad 1962U.S.A. and cooking oils, 1987 lard) You, Epperson, Huang, 1996 Time Estimating the series, U.S. demand for fresh fruits & vegs. 1960-93 at retail level 34 years/ USA Retail At first stage prices meats, eggs, dairy, fats, sweeten, flour fresh fruit, fresh veg, processed fruit, processed. veg, other food, nonfoods, and at the second stage 11 fresh fruits and 10 fresh vegs. Two-stage composite demand system -

Major findings All estimated uncompensated own-price elasticities of demand were negative but inelastic. Butter was relatively price elastic than other fat and oil products. The cross-price elasticity of demand indicated that butter and margarine were complements Except for lard and butter, most of the cross-price elasticities indicated gross complementarity. The own-price elas. for grapefruit, grapes, oranges, and peaches was relatively high (around -1) The own-price elas. for bananas (-.42) lemons (-.30), sberries (-.27), & w. melon (.60) were inelastic. DD for cabbage, celery, and lettuce responded insignificantly to changes in their own-prices. For asparagus, carrots, cucumbers, onions, peppers, potatoes & tomatoes, DD responses to changes in own-prices appeared to be inelastic though significant. Most fresh fruits and vegs. were found to respond significantly to changes in their own-prices All own-price elasticities obtained (except for grapefruit and oranges) were <1.

Comment - No information if stationarity and structural break tests were done

- The stationarity of the variables used in the analysis were not tested - The possibility of structural change in commodity demands was considered

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Reference Objective of the /year study Hsu, 2000 Examining the structural changes of meat consumption in Taiwan

Data type & year Time series from 19971996

Sample size/ Country 18 years, Taiwan

Food/nutrient items studied Price Pork, beef, Annual poultry, and fish average retail prices

Methodology LA/AIDS

Major findings - Elasticities estimated with structural shifting factors were more price responsive - With gradual switching time paths, estimated elasticities showed that pork, beef, and fishery products were price elastic. - Beef and poultry were substitute and the substitution between poultry and pork had increased significantly - All staple oils were own-price inelastic - The demand for flavouring vegetable oils and animal fats were more own-price responsive than staple oils - Cross-price elasticities showed heterogeneous substitution among different oils.

Comment -Time transition paths for each product were identified & used - One stage analysis - No test for stationarity of variables - Hickmans two step procedure was used to correct for 0 obs. -Not clear what type of panel data model was used - One stage analysis Not published in a peer reviewed journal - Not per reviewed - Elasticities were compensated

Fang & Beghin, 2000

Estimating urban demand for edible oils and fats in China

Panel data 19921998,

20,000 Rapeseed oil, urban peanut oil, soy observation oil, animal fat s (3,600 per year) China

- LinQuad incomplete demand system

Feng, Chern, 2000

Analyzing the demand for selected healthy food items

Time series monthly data, 1981 1995

180 months/ Fresh fruits, USA fresh vegs. processed . fruits, processed. vegs., cereals, bakery products, poultry, other foods

Monthly price index of each food item

Modified - Poultry was most price elastic(-.864) and cereals were least price elastic (-0.076) LA/AIDS model - Fresh fruits and vegs. were more price using a elastic (-.796 &-.586) than processed ones Laspeyres index (-.247 & -.547)

1-169

Reference /year Mata, Villaln, Salazar, Flores Snchez, 2004

Objective of the study Determining the leading economic and technological factors affecting the behaviour of domestic swine meat supply and demand and to examine the impact of price on supply and demand

Data type & year Time series data 19602002

Sample size/ Country 43 years

Food/nutrient items studied Swine meat, bovine meat

Price Methodology Annual Two-stages producer mean square prices (based on Nerlove adaptive expectati on), wholesale prices, and consumer price Annual price series deflated by the consumer price index Nutrient response model developed by Huang

Major findings - The average short-term price elasticity of demand for swine meat was negative but inelastic - Own-price elasticity of demand for wine meat declined (in absolute terms) through time. - The poor was more sensitive to price than the rich. - Bovine meat was a good substitute for swine in the short and long terms.

Comment - Both supply and demand were estimated simultaneously - No information if stationarity and structural break tests were done - All monetary values deflated by the appropriate price index _ Lag prices used - No information if stationarity and structural break tests were done

Dhehibi, Laajimi, 2004

Investigating and measuring the impact of economic factors on animal food choices and consequently on nutrient availability in Tunisia

Time series, 19731998

27 years/ Tunisia

Animal food products: meat products, beef, lamb, poultry, eggs, and fish Nutrients: energy, protein, total fats, calcium, iron, magnesium, zinc, thiamine, riboflavin, niacin, folate,

- All estimated own-price elasticity of demand were price inelastic - The demand for beef and poultry was more elastic than the demand for the other animal products - Most of the compensated cross-price elasticity of demand were statistically insignificant - Eggs were a net substitute for most products and beef and fish, and lamb and poultry were complementary - Nutrient elasticities were generally lower than (in absolute terms) own-price elasticities

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Reference Objective of the /year study Kumar, Analyze the Dey, 2004 responsiveness of demand for fish to changes in price and income in India

Data type & year Time series for the years 1983, 87/88, 93/94, 99/2000,

Ma, Rae, Huang, Rozelle, 2004

Estimating more refined demand for animal products in China

Panel annual/ province data (19912001)

Sample size/ Country 906 grouped obs. based state, years and rural/urban Only nonvegetarian households were considered, India 11 years and 28 provinces/C hina

Food/nutrient items studied Second and third stage: vegetarian (cereal, veg., pulse) and nonvegetarian (fish, goat meat poultry, eggs)

Price Unit values aggregate d at state, years and rural/urba n level

Methodology First stage linear, second stage linear and third stage LAIDS

Major findings - The uncompensated fish price elasticity of demand was -0.7 for most of the population and the poor were more sensitive to fish price than the non-poor. - The fish price elasticity had not shown any significant change in the last 15 years in India though there were significant variations across different regions (high in eastern, north-eastern and southern states). - All conditional own-price elasticities were negative and except for aquatic and dairy products all elasticities were inelastic both in urban and rural areas. - The own-price elasticity for ruminant meats and beef was higher in rural areas than in urban areas. - Between 1999 and 2001, egg was the most price inelastic animal product both in urban and rural areas.

Comment - Compensated and uncompensated elasticities estimated - Sample population under each 906 group was used as a weight -Cross-price elasticities were not presented Own-price elasticities were estimated for urban and rural areas separately - Weak separability was assumed

Animal commodities: pork, eggs, chicken, aquatic products, beef, dairy products and mutton

LA/AIDS Annual price series collected from free markets

Yen, Lin, Harris, & Ballenger, 2004

Analyzing the demand for vegetables

Panel, 10 7,195 HHs / Fresh deep green USA & deep yellow, months, processed deep 1999 green & deep yellow, fresh potatoes, proc. potatoes, fresh tomatoes, proc. tomatoes, other fresh, other proc.

Not clear whether retail price or unit values were used

Trans-log taking - Low income HHs were more responsive to changes in vegetable prices than highinto account the income HHs problem of - These elas. were larger than those obtained censoring from both time series & cross-section data because veg. is disaggregated into 8 - The elas. indicated that consumers would increase their veg. consumption as a response to lower prices, but not by a lot - Price policies should be combined with other strategies such as info campaign to enhance cons.

It was one stage analysis

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Impact of food price on nutrient consumption, cross-sectional

Reference /year
Sahn, 1988

Objective of the study

Data type & year

Sample size/ Country

Nationally/ sectorally/ regionally/ representativ e/ Sri Lanka

Food/nutrient items studied

Food items: rice, coconuts, sugar, condiments, vegetables, fish, bread, pulses, oil, wheat flour, milk, root crops, meat, and other grains Nutrient: calorie

Price

Methodology
-

Major findings
The price elasticities of demand for calories were much lower than the own-price elasticities. Except for meat, the price elasticities of demand for calories were negative. A change in the price of rice has the highest impact on calorie intake followed by coconuts.

Comment
- The theoretical consistency of the coefficients with demand theory was not tested - Hickmans two stage procedure was used to take care of zero observations

Predicting the impact Crossof price and income sectional changes on food 1980/81 energy intake among different income groups in Sri Lanka.

Not Log-log quadratic indicate form d

Ramezani, Investigating Rose, & factors that affect Murphy, 1995 food consumption and nutrient intake

Crosssection, 1987/88

4273 HHs/ USA

Calories, protein, fats, cholesterol, fibre, vit. A, vit. E, Vit. C, vit. B6, vit. B12, Thiamin, Riboflavin, Niacin, Folate, calcium, Magnesium, Iron, zinc

Unit values

Almost IdealTranslog model

- All nutrient elasticities with respect to food prices were negative, indicating that food price increases led to lower intake of most nutrients. - Overall, a change in the price of protein foods had the largest impact on the consumption of most nutrients. - Changes in the prices of fruits & vegetables had the greatest impact on intake of fibre, vitamin A, & vitamin C. - Calcium intake was most sensitive to changes in dairy prices. - Overall, the model indicated that income policies might be more effective in influencing consumption patterns than price policies

- Foods are aggregated based on the USDAs Daily Food Guide - No adjustment for quality differences by assuming that variation in prices are due to seasonality

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Reference /year Kinsey, Bowland, 1999

Objective of the study Analyzing the impact of changing the prices of aggregate food groups on the number of servings that would be eaten on the healthy eating index (HEI)

Sample Data size/ type & Country year Paramete Not rs applicable/ estimated USA from other studies

Food/nutrient items studied Price Sugar, Not discretionary fat, applica dairy, fruits, ble grains, meats, & vegs.

Methodology Descriptive analysis based on elasticities estimated from other sources

Major findings Comment - Lowering the price of fruit, meats and - Existing income & dairy products would increase the price elasticities were servings consumed of fruits and dairy, used - Lowering the price of meat increased consumption of all foods (through income effect). However, this also increased the cons. of discretionary fat - Increasing the spending power alone trended to decrease HEI scores because it increased Fat consumption more than it increased of fruits & vegs. or grains - Small economic incentives alone were less likely to have a large impact on the mix of foods consumed habits than mix of foods consumed - Education made a significant difference in choice of diet; - Vitamin A and C intakes were more responsive to the price of vegetables. - Intake of most of micronutrients particularly vitamin B1 and B2, iron, and calcium were responsive to cereal prices. - The price of other food groups such as milk and eggs, meat, and fruits had relatively low effect on the intake of micronutrients. - No test on the consistency of the estimated model with demand theory - Each nutrient equation is estimated separately

Weinberger, 2001

Examining the impact of income, food prices and other factors on micronutrient demand among poor rural households in India

Crosssection (1993/ 1994)

5,800 rural Food items: households, cereals, pulses, milk & eggs, India meat, vegetables, fruits Micronutrients: Calories, protein, fat, calcium, vitamin A, iron, vitamin C, vitamin B1, vitamin B2, and Niacin

Prices at village levels

Per capita expenditure and nutrients were simultaneously estimated using two-stage leastsquares.

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Impact of food price on nutrient consumption, time-series/panel Data Sample type & size/ Food/nutrient Reference Objective of the year Country items studied Price /year study Huang 1996a Linking food Time Not shown/ 35 food Retail choices with series, USA categories and prices nutritional status in 195315 nutrient the context of the 1990 elasticities classical demand framework

Methodology AIDS

Huang, 1996b

Investigating the impact of price and income on nutrients consumed from meats

Time series, 1970-94

25 years/ USA

Beef, pork, chicken

Not indicat ed

Descriptive based on the results from other studies

Major findings - Most own-price elas. of major food categories as meat , f. fruits, f. veg., proc. fruits, and veg. had statistically significant estimates with negative sign - Nutrient elas. to changes in 35 food prices were computed (e.g., a 1% increase in the price of beef would reduce per capita food energy by .027%, protein by .091%, fat by .025%, but vit. A would increase by .064%; a 1% increase in the price of eggs might cause cholesterol to decrease by .031%, the same price change for carrots might cause Vit. A to decrease by .11%, while for oranges vit. C would decline by .19%.) - The cross-price elas. of beef in response to the price changes of pork and chicken were 0.11 and 0.018, indicating substitution. - The American diet in the last two decades had shown a trend toward consumption of more poultry meat and less red meat - This change was partly related to the relatively higher beef price. Between 1970-74 & 1990-94 the price chicken relative to beef dropped by 14 %. - This could also be due to consumers diet concerns regarding fat in the diet

Comment - The stationarity of the variables used in the time series analysis were not tested

The paper was based on the results from Huang 1996

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Reference Objective of the /year study Huang , 1998 Analyzing how a price or income changes affected the availability of nutrients

Data type & year Time series 19891993

Sample size/ Food/nutrient Country items studied Price Not shown/ Calories, Not USA protein, fat, indicat saturated fat, ed cholesterol, dietary fibre, vit. A, vit. C, vit. E, folate, calcium, and iron

Methodology AIDS

Guo, Popkin, Examining how Mroz, Zhal, food price changes affected dietary 1999 intake

6667 Panel individuals/ data, 1989, 91, China & 93

Six food Comm groups (rice, unity what flour, level coarse grains, pork eggs, edible oils), calories, & 2 macronutrient s (protein, fat)

Two-stage loglog method

Major findings - 12 nutrient elas. were estimated for 7 food groups - The results highlighted high interdependence among the different food groups through cross-price effects. - The effect of a price change on overall dietary quality was complex. . Ex. A price decrease for F&V, while encouraging their cons., would also increase availability of total fat and a price decrease for veg would trigger an unanticipated reduction in overall availability of vit. A - The price elasticity of nutrients was computed - As a high energy dense food, pork had large price elasticities for nutrients (-0.8 for daily fat intake, -0.18 for protein & 0.2 for total energy) - Fat intake appeared quite responsive to changes in the cost of pork (-1.10 for the poor and -.49 for the rich) - Price elas. of eggs and edible oils for fat intake were -0.1 and -0.3 among the poor, and -0.4 and -0.3 among the rich, respectively - Price changes for animal protein foods had a large effect on reducing fat intake (0.79) but also decreased the protein intake of the poor (-0.26) whereas oil price increases would not adversely affect protein intake while decreasing fat intake (-0.32) - Price policy could decrease fat intake

Comment - Weak separability is assumed - Estimates are based on food group

- Not clear why random effect model was chosen - The theoretical consistency of the model was not examined - The movement from the 1st to the 2nd stage is not shown - Only uncompensated Elasticities were reported

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Reference /year Kuchler, Tegene, Harris, 2004

Objective of the study Examining the potential impact of excise taxes on snack foods

Sample Data size/ type & Country year Homesca 7195 HHs/ n panel USA for at least 10 months in 1999

Food/nutrient items studied Price Salty snacks: Unit chips (potato, values corn, tortilla), pretzels, cheese puffs, microwave popcorn, nuts)

Methodology Descriptive

Major findings - Almost everyone (99%) purchased some snack foods - Imposing taxes on the order of 1 cent per pound (as suggested in the literature-was unlikely to have much influence on consumer diet quality or health - Lower tax rates yield virtually no diet impacts - Adding an information programme might increase diet impacts, but that conclusion if far from certain - All food items (except other red meat) had an inelastic own-price elasticity of demand over the study period. - Poultrys own-price elasticity of demand had shown a significant decline from near unity to near zero between 1947 and 2000. - Own-price elasticity of demand for other foods remained the same over the period under study. - Nutrient responses to price changes were generally very small due to the availability of a wide range of substitute foods from which comparable nutrients can be derived. - The results indicated that taxing some food items might not substantially change nutrient intakes.

Comment - The entire tax is assumed to be passed to consumers - The simulation was based -0.2, 0.7 & -1.0 elasticity of demand

Beatty, LaFrance, 2005

Analyzing the demand for food and nutrients using new method

Aggregat 77 years, U.S. e time series (19192000 excludin g 19421946)

Deflate Extended Twenty-one food items in d prices Gormans class four general of aggregable categories: demand models dairy to incomplete products; systems (it meats; fruits nested exiting and veg.; models, miscellaneous incorporated foods and five income nutrients distribution, and (energy, combined protein, demand carbohydrates, estimates with fat, and nutrient content cholesterol) of foods)

-No information if the stationarity of variables was tested

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Impact of food price on diet-related health, cross-sectional/cross-country

Reference /year Schroeter, Lusk, Tyner, 2005

Objective of the study Investigating the effect of price and income changes on weight in an effort to determine how different policies affect body weight

Data Sample type & size/ Food/nutrient year Country items studied Paramete Not High and low rs applicable/ calorie foods estimated USA from other studies

Price Methodology Major findings Not Micro-economics - High-calorie food tax certainly decreased body applica framework weight if high-and low-calorie foods were ble complements while the effect varied in the case of substitute foods. - A market intervention such as a fat tax, or a thin subsidy would be able to decrease weight and increase the welfare of the society - Low-calorie food subsidy is progressive because low-income HHs would obtain the highest benefits on a proportional basis - Relative food prices are associated with changes in the BMI and obesity rates, and the relationship was significant and robust for fruit & vegs. prices: higher fruit & vegs. prices predicted greater BMI increase - Price differences across metropolitan areas in the study accounted for a gain of almost 0.5 BMI units between kindergarten and third grade - Lower real prices for fruits & vegetables relative to other goods & services (including other foods, housing) might slow excess weight gain

Comment -Based on parameters estimated from different studies which may not be comparable - Submitted for publication

Sturm, Examining the Datar, 2005 association between food prices and food outlet density and changes in the BMI among elementary school children

Two waves (autumn & spring) between 1998/99

Metrop Descriptive and Meat, fruits & 13,282 vegs., dairy, fats olitan multivariate children level analyses from 1000 food schools between kindergarte n & third grade/ USA

-Prices were at the metropolitan level and no measures for neighbour hood differences

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Impact of food price on diet-related health, time series/panel Data type & year Panel 19982001 from HH scanner data Sample size/ Country 73,000 individual observation s/ USA

Reference /year Richards, Patterson, Tegene, 2004

Objective of the study Testing addiction to food nutrients as a potential explanation for the obesity epidemic

Food/nutrient items studied Price Different snack Unit foods: popcorn, value corn chips, reduced fat potato chips, regular potato chips, pretzels, puffed cheese, tortilla chips, pork rinds, snack meat, cookies, crackers, apples, carrots purchased at retail outlets Nutrients: protein, fat, carbohydrate and sodium Water, alcohol, Unit values non-alcohol bev., fats & oils, sugars, noncooked meats & eggs, milky deserts, sea products, dairy, ready meals, cheeses, snacks, starchy foods, vegs., fruits,

Methodology Random coefficients (mixed) logit model

BoizotExamining the Szantai, relationship Etile, 2005 between food-athome prices & BMI

Three years data, 2002-02

3668/ France

Major findings - Pork rinds (-5.061) and snack meat (-5.011) were far more elastic than other foods and apples (-0.766) and carrots (-0.752) were the only two snacks that were inelastic implying that price policy applied to snack meats or pork rinds would be likely effective in reducing consumption while would be less effective in increasing fruit & vegs. snacking - Regular potato chips were less elastic in demand (-1.779 ) than reduced-fat alternatives (-2.971) so any sin tax that targets potato chips in an indiscriminate way was likely to alter consumption toward high fat option - The results supported the rational addiction hypothesis (comparing current and future costs and benefits) and the addiction to carbohydrate was far stronger than to other nutrients - Price based policies designed to address the obesity epidemic were likely to be more effective than once thought to be the case - The theoretical analysis showed that the impact A modified of price on weight was an empirical question model of - The impact of price on weight heavily depended Lakdawalla & on: how choices of non-food goods affected Philipson energy expenditure & on the substitution b/n approach: utility different varieties of a same food product & b/n was a function different food products of consumption, weight, & other - Few significant correlations between prices of various food groups and BMI goods - Fat tax or any nutritional tax might not curb the epidemic of obesity in the short-term Correlation Actions on energy expenditure as well on specific analysis nutritional knowledge might be more attractive

Comment -73,000 observations were derived from only 30 HHs (through four years) - The dependt. vars. were measured as a dichotomous making comparison difficult - The IIA problem of multinomial logit model is addressed indirectly - Not peer viewed - BMI were self reported and no adjustment was made - Price in 2001was assumed to affect BMI in 2002

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Reference /year Cash, Sunding, Zilberman 2005

Objective of the study Investigating the possible health effects of thin subsidies on fruits and vegs.

Sample Data size/ Food/nutrient type & Country items studied year Eight 9925 cases/ Fruits & veg. years USA follow up for men & 14 years for women

Price Unit values

Methodology Empirical simulations

Major findings - The simulation result showed that a 1% increase in the price of all fruits and vegs., would increase the cases of coronary heart disease by 6,903 and ischemic strokes for by 3,022 in the US - But these numbers did not reflect a complete accounting of all negative health outcomes

Comment - Not peer viewed - Elas. were taken from other studies - Linear doseresponse curve was assumed

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Chapter 2 Socio-economic and Cultural Determinants of Diet

Jef L. Leroy and Marika C. Smith National Institute of Public Health Cuernavaca, Mexico

2.1 Scope and Methodology

2.1.1 Scope
This aim of this chapter is to present a systematic review of the literature on the socioeconomic and cultural determinants of the consumption of foods and contaminants, and the diet-related health risks, associated with cancer. It identifies the following (similar to Giskes et al.(1)): the socio-economic and cultural determinants of food consumption examined in existing research; of these determinants, those for which the existing evidence suggests an influence on food consumption and dietary intakes, and the nature of that influence; the limitations of existing research that hinders examining the association between environmental factors and dietary intakes.

Owing to existing scientific knowledge about the relationship between diet and cancer, and existing systematic reviews on the determinants of diet, the scope of this review was confined to (a) known convincing and probable associations between diet and cancer, as set out in the introduction; and (b) areas that have not been covered by previous systematic reviews. A directly relevant systematic review was carried out by Brug and van Lenthe(2) in 2005. The review covered environmental determinants and interventions for nutrition, smoking, and physical activity. The review thoroughly covered fruit and vegetable consumption for adults and children.(1, 3), but was limited to countries with an established market economy as defined by the World Bank (no source given). (The definition of established market economy or a list of countries that do (not) fall in this category could not easily be found. It is assumed that countries without an established market economy largely overlap with developing countries.) A second recent relevant systematic review was also identified on the socio-economic determinants of obesity by Monteiro et al.(4) Given the known convincing and probable associations between diet and cancer and the recent literature review on determinants of nutrition by Brug and van Lenthe(2), this review is limited to the following foods: meat (specifically red, preserved, and processed meat), salt preserved foods, pickled food, green and cruciferous vegetables, tomatoes,

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allium vegetables, foods contaminated with aflatoxins, and hot drinks. Fruit and vegetables more generally are reviewed only for developing countries (i.e., those countries without an established market economy). On obesity, it includes a summary of Monteiro et al.(4) and additional existing systematic reviews of the socio-economic and cultural determinants of obesity. 2.1.2 Methodology

The review was undertaken in two stages. Stage one involved identifying studies through database searches. Stage two involved a detailed review of the identified studies.

2.1.2.1 Identification of relevant studies Data sources and search strategies

Electronic databases were searched using a wide range of terms intended to maximize the number of potentially relevant articles identified. The following databases were included: PubMed, The Cochrane Library, ISI Web of Science, Sociological Abstracts, ERIC, and Econlit. In addition, papers were added on the subject known to the authors but not identified through the database search process. The search strategy combined a group of exposure terms, which represented the determinants of food consumption, with outcome terms, which represented dietary and food choices (see Table 2.1). The exposure terms included two subsets: socio-economic terms, related to education, income, family and neighbourhood characteristics, demographics and culture; and intervention terms, included to identify intervention studies. Diet terms were selected to limit the number of identified studies to manageable proportions. Additional search terms were used to limit the scope of the general fruit and vegetable searches to developing countries. To create the final search syntax, exposure terms were combined with the outcome terms and the diet terms by the Boolean operator AND (i.e., exposure terms AND outcome terms AND diet terms). Search terms within the exposure, outcome, and diet term groups were connected by the Boolean operator OR. The final search strings used within each database are listed in Appendix 2.1. As indicated, where spellings differ between British and American English, both were searched. The terms mentioned above were used within each of the databases to identify relevant indexing terms to be included in the database specific search phrase. ERIC, Sociological Abstracts, and EconLit were searched using OCLC. Thesauruses were used to identify database specific descriptors that were then included in the search phrases. PubMed was searched using NCBI. Relevant MeSH (medical subject heading) terms were identified

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and included in the PubMed search phrases. ISI Web of Science was searched using topic areas. Identical terms as those for PubMed were used.

Domain Exposure

Outcome

Table 2.1. Overview of search terms Description Search terms Socio-economic terms socio-economic, education, occupational status, employment, poverty, income, household, neighborhood/neighbourhood, transportation, urbanisation, urban population, urban, rural population, rural, social environment, marital status, social class, family, families, parenting, culture, ethnic group, taboo religion and food insecurity Intervention terms intervention, public policy, nutrition policy, education, government programmes, guideline, health promotion, nutrition program/programme, mass media, food labeling/labelling, and nutrition labeling/labelling Food terms all countries red meat, pork, veal, beef, lamb, mutton, goat, preserved meat, processed meat, salted meat, meat products, pickled food, salting, green vegetable, green leafy vegetable, cruciferous vegetable, tomato, allium, hot drink, aflatoxin Diet terms food consumption, intake, nutrition, food choice, eating and diet Food terms developing fruit, vegetable countries Terms added to food developing countries, third world countries, low income terms developing countries, middle income countries countries

For the socio-economic and cultural determinants of obesity, a search was conducted for existing systematic reviews (not individual studies) using the search terms obesity (the outcome), determinants (the exposure) and review connected by the Boolean operator AND.

Inclusion/exclusion criteria
The exclusion criteria are listed in Table 2.2 and comprise set criteria for study scope, type and quality. In terms of inclusion, the review includes both observational studies and studies evaluating the impact of interventions. Intervention studies were included because they can provide stronger evidence for a causal association between determinants and diet relative to descriptive studies (if included, they were not evaluated for their efficacy or effectiveness per se). For instance, a well conducted intervention relating income and vegetable consumption provides stronger evidence for a causal pathway than a descriptive study. The inclusion criterion for the dietary measures is as follows: studies were included if they measured the dietary precursors (termed here indirect measures of dietary intake)

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such as individual or household food expenditure, food purchases, or household food consumption, or if they measured the dietary outcome of direct dietary intake (i.e., studies using dietary intake of individuals as the dependent variable). (A description of the rationale of the dietary measures used Chapters One and Two can be found in Chapter One, Table 1.1 and section 1.1.1) Based on the inclusion and exclusion criteria, the selection of articles for full review was conducted in three phases, with increasing specificity. Titles were first scanned to exclude papers out of the scope of the review. The remaining abstracts were then scanned to exclude papers clearly failing to meet the criteria for scope, type, and quality. The remaining papers were obtained, read in their entirety and excluded if they did not meet the three set of criteria. These papers dealt with the socio-economic and cultural determinants listed in Table 1.1 in Chapter One.
Table 2.2. Overview of exclusion criteria Exclusion criterion Study scope Study excluded if (a) The studys focus, or main focus, was NOT consumption of specific foods, food groups, or specific dietary patterns convincingly or probably associated with cancer risk/prevention; (b) The study was NOT about the barriers to, facilitators of, or specific and generic determination of, consumption of foods associated with cancer (socio-economic, lifestyle, culture, risk factors, attitudes); (c) Did NOT either 1) identify how, or the extent to which, various aspects of peoples lives at the individual, community and society level are associated with, or predict their consumption of, specific foods or food groups OR 2) evaluate an intervention aimed at diet change through the modification of these aspects. (a) editorials, commentaries or book reviews; (b) policy documents; (c) surveys solely reporting the prevalence or incidence of, consumption of specific foods or, specific dietary patterns; (d) non-systematic reviews; (e) non-evaluated interventions; (f) theoretical or methodological studies only; (g) single-case studies; (h) studies that evaluated the process of interventions only. (a) outcome measure assessed for less than one day (i.e., study assessing intake at a singe meal); (b) studies not including a measure of individual or household level intake of the foods of interest as the dependent variable; (c) quantitative and qualitative studies that did not provide sufficient details about the procedures followed for data analysis; (d) quantitative studies that did not report statistical tests on the studied associations; (e) quantitative studies that only used univariate methods for data analysis (i.e., do not control for confounding); (f) Coefficients and level of significance not reported numerically or graphically.

Study type*

Study quality

Adjusted from Shepherd(5).

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Obesity reviews were included if they identified current research according to an explicit

search strategy, selected studies for review according to defined inclusion and exclusion criteria and evaluated the studies against consistent methodological standards. Even though the review by Sobal and Stunkard (46) did not meet those criteria, it was included in our review for two reasons; first, it was the only review identified on the association between socio-economic determinants and obesity in developed countries and, second, it is often referred to in the literature.

2.1.2.2 Detailed review Extraction of study data

The studies that met the inclusion criteria were reviewed in depth, their characteristics were described and their results synthesized. Data extraction tables were used to facilitate the greatest possible synthesis. Different data extraction tables were used for the different types of studies. For the descriptive quantitative studies, data were summarised into the following categories: focus (country, exposure and outcome), methods (study design, collection of dietary data), sample characteristics (sample size, age, gender, study population), data analysis (univariate or multivariate, confounders controlled for), whether the coefficients were reported, concerns about the study, and finally the study findings. Separate tables were used for the studies which measured dietary precursors (i.e., indirect measures of dietary intake) (see Appendix 2.3) and direct measurements of dietary intake (see Appendix 2.2). The data extraction table for the obesity reviews (Appendix 2.4) summarised the reviews by focus (country, population), methods (design, data sources, . . .), findings and conclusions, and limitations. None of the qualitative or intervention studies met the inclusion criteria outlined in Table 2.2.

Assessment of study quality

Standard criteria were used to determine the quality of methodology used in both quantitative and qualitative studies. For quantitative studies, the following characteristics were used: the type of study (cohort, case control, . . .), number of participants, the age range, socio-economic and/or ethnic background, original sample size and analyzed sample, the characteristics of the individuals lost, control for confounding variables, and the adequacy of the analytical and statistical procedures. As none of the qualitative studies met the inclusion criteria outlined in Table 2.2, no criteria for study quality are presented.

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2.1.2.3 Summary of the study selection process

Around 6000 citations were identified by the databases and imported into EndNote reference software (see Table 2.3). (Just over 6000 were identified but the actual number was less than 6000 because some studies were identified twice, yet failed to be identified as duplicates in Endnote because of small differences in the Endnote records). Following the title and abstract scan, 301 articles were requested in their full paper form for a second level of selection. Two hundred eighty-six were obtained in time for potential inclusion in the review; 42 of these articles met the inclusion criteria and were selected for inclusion in the main body of this review. These statistics are summarised in Table 2.3 below.
Table 2.3. Summary of the study selection process Number of descriptive quantitative papers < 6,000
301 286 40 0 1 1

Description Papers identified through initial database search

Papers requested in full paper form for second-level review Papers obtained in time for potential inclusion in review Papers from second-level review that met inclusion/exclusion criteria and are included in the review Papers obtained through other means and included in the review Total papers included that met inclusion/exclusion criteria and are included in the review

Number of obesity reviews

40

2.1.2.4 Structure of this report

Based on the range of studies identified and retrieved through this search, the results of this review are written up in the following subsections: Summary of the findings of the existing systematic review by Brug and van Lenthe(2) (section 2.2); Detailed descriptions of the included studies (section 2.3.1), divided into descriptive quantitative studies using direct measures of dietary intake (section 2.3.1.1), descriptive quantitative studies using indirect measures of dietary intake (section 2.3.1.2), and obesity reviews (section 2.3.1.3); Summary of these studies organized by key determinants of dietary intake (section 2.3.2), which are identified as income (section 2.3.2.1), socio-economic status, poverty and food insecurity (section 2.3.2.2), employment and occupational status (section 2.3.2.3), education (section 2.3.2.4), race and ethnicity (section 2.3.2.5), urban/rural residence (section 2.3.2.6), household size and composition (section 2.3.2.7), marital status (section 2.3.2.8), religion

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(section 2.3.2.9), neighbourhood (section 2.3.2.10), and family (section 2.3.2.11). Each of these sections includes a conclusion about the nature and degree of importance about the dietary determinant discussed. Summary of previous literature reviews on determinants on obesity (section 2.3.3); Conclusions of this chapter (section 2.4).

2.2 Summary of results from the Brug and van Lenthe review
The findings as reported by van der Horst et al.(3) (chapter 6) and by Giskes et al.(1) (chapter 8) are summarised below.

2.2.1

Determinants of fruit and vegetable intake in children

Parental intake of fruits and vegetables was a significant determinant of intake in children. One study found that this held only when fruits and vegetables were readily available. No associations were found between parental encouragement and fruit and vegetable intake. Verbal praise was associated with a higher vegetable intake, but not associated with fruit intake. No associations were found for controlling and restrictive parenting practices. One study found a positive association between having family dinners and childrens fruit and vegetable intake, whereas another study found an inverse association with girls vegetable intake and no association with girls fruit intake and boys fruit and vegetable intake. Household economic deprivation was examined in four study populations. In two samples no association with fruit and vegetable consumption was reported and in one sample an inverse association was found; an inverse association with fruit intake was found in the last one. Higher parental education was associated with higher fruit and vegetable consumption in two studies. Hours per week worked by the mother was not found to be associated with fruit and vegetable intake.(3)

2.2.2

Determinants of fruit and vegetable intake in adolescents

Family breakfast did not determine fruit and vegetable intake for boys or girls according to one study. Another study found that family dinner was associated with a higher fruit intake among girls, but not associated with vegetable intake, or with boys fruit intake. Authoritative and indulgent parenting styles, family connectedness, and positive relationships with parents were positively associated with fruit and vegetable intake. Family income was not a significant predictor of fruits and vegetable intake in three studies but parental education was in five studies.(3)

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2.2.3

Determinants of fruit and vegetable intake in adults

Marital status was positively associated with fruit intake in one study but not associated in another study. The effect of having children on fruit intake ranged from negative (one study), non-significant (two studies), to positive (one study) associations. Marital status was positively associated with vegetable intake, but having children showed mixed associations. Household income showed a large positive association with fruit consumption in two studies but the opposite relationship was found in another study. Household income showed a consistent positive association with vegetable consumption. Living in a poor neighbourhood was associated with lower fruit and vegetable consumption.(1).

2.3 Results of the current review

2.3.1 Description of the studies included
This section comprises individual descriptions of the studies included in the review. Given the objective of the review, the descriptions focus on the outcomes and determinants of interest (many of the included studies actually evaluated a larger set of determinants and outcomes than described here). The descriptions start with a discussion of the quantitative studies that measure dietary intake at the individual level (assumed to be the highest quality). Next described are studies that measure dietary precursors (i.e., indirect measures of dietary intake such as food expenditure, or consumption at the household level). The section ends with a description of the two included obesity reviews.

2.3.1.1 Descriptive quantitative studies using direct measures of dietary intake

Bartholomew et al.(6) studied the socio-economic determinants of dietary intake in a group of low income, elderly Mexican Americans and non-Hispanic whites in the United States. In 1984 the authors interviewed 252 respondents from an area probability sample drawn in 1976 in four low income census tracts in San Antonio, Texas. The original sample was part of a longitudinal study on institutionalization of elderly. The high attrition rate (50%) was attributable to the fact that 25% of the original cohort had died and the remaining 25% were too ill or refused to participate, had moved, or could not be located. The study population was, on average, 75 years old and consisted of both men and women. Dietary data were collected by means of the 57 item food frequency questionnaire used in the Hispanic Health and Nutrition Examination Survey. The dietary outcomes of interest for this review were the intake of beef, organ meats, lunch meat, bacon, and orange and green vegetables. A stepwise regression procedure was followed to estimate the importance of the following determinants: income, ethnicity

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(born in Mexico), marital status, and education. Gender and age were controlled for (to the extent that the stepwise procedure selected these variables into the model). Income was found to be positively associated with the intake of organ meat and bacon. Mexican Americans (as compare to white non-Hispanics) consumed less organ meat and less orange or green vegetables. Higher education was found to be associated with more beef consumption. Higher age and being male were significant predictors of higher lunch meat consumption.

Quality issues: Due to the high attrition rate, the representativeness of the original sample was probably lost and the authors did not evaluate or discuss how the loss of subjects may have affected their findings. It is conceivable that the 25% subjects who died predominantly belonged to a subgroup consuming unhealthy diets. This way, the dependent variable may have been truncated and selection bias may have affected the results. A second concern was the use of stepwise regression. Rather than building the model ex ante using researchers understanding of determinants, the statistical package builds the model that maximizes the amount of variability explained. Using stepwise regression, it is unclear what the coefficients are of the variables not selected into the model.
The determinants of the decision to consume pork and the decision regarding the amount of pork intake (conditional on consuming pork) were studied by Capps and Park.(7) The data for this study were obtained from the Continuing Survey of Food Intake of Individuals (CFSII, 1994-1996) and the Diet and Health Knowledge Survey (DHKS). The CFSII was designed to measure food intake and nutrient consumption by Americans. The DHKS measured their attitudes about diet and their knowledge about the relationship between diet and health. Only DHKS observations with two days of intake data in CFSII were included in the analysis. Of the 5,649 observations meeting this criterion, only 4,691 had no missing values for any of the variables of interest. Subjects were over 20 years of age. The amount of pork consumed was collected for two non-consecutive days. A double-hurdle model was used to estimate the role of branded and generic advertising, income, region, household size, race, education, employment and participation in a government programme (food stamps, WIC) in two different outcomes: the decision to consume pork, and for those people who consume pork, the amount of pork consumed. The model further controlled for age, gender, season, health, and nutrition (exercise, smoking, vegetarian), attitudinal, and lifestyle factors. Statistical significance was set at p < 0.01. The authors found that pork advertising had a positive effect on both decision to consume and the amount consumed. Income, being black, and living in a nonmetropolitan statistical area were positively associated with the decision to eat pork. Higher education levels were negatively associated with that decision. For the other
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variables in the model, the following was found: age, smoking, BMI, and eating red meat were positively associated with the decision to consume pork; being on a low fat diet, always trimming fat from meat and knowing that diet can make a difference with respect to disease were negative predictors of that decision; the amount of pork consumed was associated with being male.

Quality issues: This was one of the few studies estimating the double-hurdle model (decision to consume, decision on the amount to be consumed) using dietary intake data (instead of using household level consumption data). It was not clear from the article what the original DHKS/CSFII sample size was and how many observations were excluded from the analysis because of missing data; the authors did not provide any details on how that may have affected the results. Further more, it was unclear how the diet was assessed and energy intake was not taken into account as a confounding variable.
Demory-Luce et al. studied the change of intake of pork and beef from childhood to young adulthood.(8) Data were collected from 1989 to 1991 on a group of young adults who participated as 10 year olds in one of three surveys conducted from 1973 to 1979. The cohort was part of the Bogalusa Heart Study. A total of 246 men and women participated in the study. Thirty-one percent of the sample was African American; 69% was European American. Dietary data were collected by means of a 24-hour dietary recall. A regression model was used to estimate the impact of ethnicity on the change (from baseline to follow-up) in intake of pork and beef. The model controlled for age, sex, and energy intake at baseline and follow-up, and cohort effects. Ethnicity was not significantly associated with the change in intake over time.

Quality issues: The longitudinal design of the study was an important strength. It was also one of the few studies that controlled for energy intake in the analysis. However, the authors did not provide details on the original cohort (the Bogalusa Heart Study) or on the subsample they used in the analysis, making it difficult to evaluate the internal and external validity of the results. (More information on the original study sample was available from reference 26 and 27 in the Demory-Luce et al. study. Those references could not be obtained in time to be used in this review.) The use of a single 24-hour recall per person is not adequate to capture an individuals usual eating pattern. Moreover, all dietary data were collected on weekdays. The level of statistical significance (and not the coefficients) was reported for selected covariates in a rather confusing table.
The intake of processed and red meats was studied in Scotland by Forsyth et al.(9) The data used by the authors were collected as part of a longitudinal study on the impact of
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social patterning on health. In 1987/88 women and men in three age cohorts (15, 35, and 55 years old) were enrolled. A component of the study involved residents from two socially contrasting neighbourhoods in Glasgow City. The 1992 follow-up data of the two oldest groups (then 40 and 60) were analysed. For the analysis, each of the two original neighbourhoods was further divided into two more socially homogenous areas. Dietary data were collected by means of a self-administered food frequency questionnaire. Data for a total of 691 subjects were analysed. In a first regression model the authors used neighbourhood and social class as the independent variables, controlling for age and sex. In a second model, income, housing tenure, and car ownership were added as covariates. Neighbourhood explained 10.1% of the variance in processed meat consumption, but was not a significant determinant of bacon and ham or red meat intake. The most socially advantaged neighbourhood consumed less processed meat than the most socially disadvantaged neighbourhood. No statistically significant association was found between social class and intake of any of the foods of interest. Age was found to be associated with bacon and ham and red meat consumption (direction not reported). Sex determined processed meat and red meat intake (direction not reported). The additional covariates added to the second model were not associated with meat intake.

Quality issues. The authors were not clear about sample size. A total of 778 respondents were interviewed in 1992 (representing 81% of the original sample), but results were only presented for 691 subjects. There was no discussion of internal or external validity. No regression coefficients were reported, only percentage of the variance explained by each covariate. The authors report in the discussion that the most advantaged neighbourhood consumed less processed meat than the most disadvantaged neighbourhood. It was unclear whether these differences were statistically significant, and what the intake was in the other two neighbourhoods.
Fraser et al.(10) estimated the impact of marital status and education on the intake of red and processed meats in England. The subjects were recruited from general practices and formed part of the larger East Anglia cohort of the European Prospective Investigation of Cancer (EPIC) Study. Data on 1968 men and women between 45 and 74 years of age were analysed. Dietary data were collected by means of a repeated diet diary, a 24-hour recall, and a food frequency questionnaire. Three regression models were estimated: intake as a function of gender and age, intake as a function of marital status, gender, and age and, finally, intake as a function of education, gender, and age. Age was found to be positively associated with the frequency of red meat consumption in the age, sex model (sex not reported). When adjusting for age and sex, married subjects were found to consume red meat more often.
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Higher education levels were associated with a lower frequency of red meat and processed meat consumption.

Quality issues. The authors did not provide enough details on how the sample was constructed. As a consequence, external and internal validity could not be evaluated. An additional limitation that the authors failed to discuss was how the selection of subjects from general practices may affect the validity of the findings. In an unadjusted analysis the authors show that men consume beef and processed meats more frequently than women. Whether sex remained a significant predictor when controlling for covariates was not clear. Interpreting the marital status variable was not straightforward, especially since the authors did not control for other socio-economic variables such as income.
Fu et al. studied pastoral living, ethnicity and education as determinants of daily intake of vegetables in China.(11) Men and women were recruited when visiting physicians in Huhlot, the capital of the Mongolian Autonomous Region in China. The subjects mean age was between 35 and 46 years. A food frequency questionnaire was used to evaluate the diet of the 592 study participants. A logistic model was used to predict daily vegetable intake. Apart from pastoral living, ethnicity, and education, the models controlled for age and sex. Pastoral living and being male were associated with lower odds of daily vegetable consumption. Being an ethnic Mongolian, level of education and age were not associated with the outcome.

Quality issues. The authors reported that in order to enrol as many pastoralists as possible, all pastoralists were invited to participate as opposed to one out of 10 of the non-pastoralists. The algorithm to select 10% of the non-pastoralists was not reported. The potential bias introduced by recruiting subjects in hospitals was not discussed. The authors did not explain why they present a logistic model for the daily consumption of vegetables, but not for fruits, even though fruits form a food group discussed in this article. Finally, the variability in the level of education and the mean education by pastoral living were not reported, making the interpretation of the non-significant education coefficient difficult.
Gillman et al. report the results of a study on the intake of red meat by children of participants in the Nurses Health Study.(12) From the total cohort of 160,000 nurses, 40,000 were identified as having at least one child between 9 and 14 in 1996. Twentyfive thousand mothers consented to their childrens participation, and a total 16,202 boys and girls returned the questionnaire. Dietary data were collected through a selfadministered, mailed, semi-quantitative food frequency questionnaire.

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Regression analysis was used to estimate the impact of family dinner frequency and income on red meat intake. The models controlled for age and sex. Family dinner frequency was found to be statistically significant, but the magnitude of the coefficient was not biologically significant. Adjusting for a number of other covariates (BMI, physical activity, hours of television watched, smoking intention, the presence of smoking in the home, two parent home versus another arrangement, household income, and the frequency of the child making his or her own dinner) did not alter this result.

Quality Issues. The authors were very clear on how the sample was selected and how many subjects were excluded for specific reasons; there was no discussion, however, on how the loss of subjects may have affected the results. Nevertheless, the large sample of children included children from all the 50 U.S. states. It was not clear from the article whether the authors controlled for the other covariates (BMI, physical activity, . . .) simultaneously or one at a time. The coefficients of these covariates were not reported.
The intake of beef in the U.S. population was studied by Gossard and York.(13) The authors used data from the U.S. Continuing Survey of Food Intakes by Individuals (CSFII), collected in 1996. Dietary data were collected by means of two non-consecutive 24-hour dietary recalls. From the 15,029 observations with complete dietary information, 8,876 respondents had the necessary data for all variables included in the analysis. The sample consisted of women and men between 18 and 90 years of age. A first regression model was estimated with intake of beef as the dependent variable and income, education, occupation, race (white, black, Asian, Native American, or other), ethnicity, living in an urban area and region as the independent variables of interest. The model further controlled for age, sex, and body weight. The second model additionally included two interaction terms: gender X ethnicity and gender X race. In the main effects model, education, living in urban areas, and being Asian or other (versus white) were negatively associated with beef intake. Higher income, being Hispanic, black, or Native American (versus white) were associated with higher beef intake. Individuals in labour occupations ate more beef than individuals in professional occupations, service occupations, and people not working. Other significant covariates were age and being female (associated with lower consumption) and body weight (negatively associated). The significant interactions showed that the difference in intake between male and female subjects depends on race: in whites, blacks, and Asians, the intake in men was significantly higher than in women. In Native Americans, however, the opposite was found.

Quality Issues: This was one of the few papers investigating the association between ethnicity and consumption that controlled for socio-economic factors. Another strength of the paper was that the authors evaluated the observations excluded from the analysis
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and concluded that the data were missing at random. The analysis did not control for energy intake, but the authors included body weight and age. Guenther et al.s paper presented the results of a study on the intake of red meat in the United States.(14) Data were obtained from the National Continuing Survey of Food Intakes by Individuals (CSFII) and the Diet and Health Knowledge Survey (DHKS), both conducted from 1994-1996. The DHKS collected data on dietary and health knowledge from all individuals 20 years or older with at least one day of dietary intake data. The authors only included observations with two complete days of intake data (5649 women and men). Two non-consecutive 24-hour food recalls were used to collect dietary data. Two models were estimated: a probit model was used for the decision to consume beef, pork, or processed pork and a regression model was used for the amount consumed. Region (Northeast, Midwest, South, West), urban/rural, education, household size (1, 2-3, and 4), race/ethnicity (white non-Hispanic, black non-Hispanic, Mexican American, other Hispanic, other) were used as independent variables in the probit model. The model further controlled for sex, assessment of ones own diet (fat, saturated fat, cholesterol: too high, too low, about right), diet beliefs, nutrition knowledge, pork nutrition knowledge, and making low-fat choices when buying meat. The model also controlled for sex, assessment of ones own diet, and factors important when buying food. The authors found lower probabilities of consuming pork or processed pork with higher education, and lower absolute intakes of processed pork. Beef intake was not associated with education. Individuals with higher income consumed more processed pork; there was no effect on the intake of beef or pork. The absolute intake of beef and pork was higher for people living in (non-central and central city) metropolitan areas than for people outside of metropolitan areas. Mexican Americans were more likely to consume beef. Being black non-Hispanic was positively associated with the probability of consuming pork and beef and with the absolute amount of pork consumed. No ethnicity/race effect was found for processed pork intake. Processed pork consumption did not depend on urban or rural living. Household size increased the probability of consuming beef but lowered the likelihood of consuming pork. The intake of pork was highest for individuals in two- to three-person households. Region was a significant predictor of both the probability of eating beef, pork and processed pork, and the absolute intake.

Quality issues: Since the authors did not provide information on how many subjects were excluded from the analysis (or on their characteristics), it was not clear whether the results were representative of the U.S. population. The percentage of people consuming beef, pork, and processed pork was reported for the entire CSFII sample, but not for the subsample of observations with information from the DHKS (i.e., the observations used

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for the regression models). The variables used in both regression models were different; income, for instance, was only a covariate in the second model. The authors did not discuss how they chose variables for use in each model (based on theory, maximizing statistical fit, . . .). Gulliford et al. estimated the impact of food security and ethnicity on the intake of fruits and green vegetables in Trinidad and Tobago.(15) A sample of 300 households was randomly selected from a constituency in north central Trinidad that was believed to provide a good representation of the ethnic and socio-economic characteristics of the entire population of Trinidad and Tobago. Of the 631 women and men 25 years and older, data were obtained for 548, of which 531 were analysed. Dietary data were collected by means of an interviewer administered food frequency questionnaire with 10 food groups. A short form of the Household Food Security Scale (HFFS) was used to measure food insecurity. Logistic regression was used to estimate how food security and ethnicity were associated with eating fruits and green vegetables and salad. The models controlled for age and sex. Food-insecure households were found to be significantly less likely to consume fruits or green vegetables and salads. The results for ethnicity were not reported.

Quality issues: The study provides detailed information on the original size of the sample and how many observations were excluded for missing data. The response rate was lower in more affluent areas, which may have biased the prevalence estimate of food insecurity upwards.
Pork consumption was studied by Guo et al. in China.(16) The authors used the China Health and Nutrition Survey, which provided longitudinal data on women and men between 20 and 45 years of age collected in 1989, 1991, and 1993. Households were randomly selected from a sampling frame of urban and rural areas. Only observations with multiple days of dietary data (collected through a 24-hour recall combined with weighing and measurement) were included in the analysis. A total of 6,667 observations were used in the longitudinal analysis. Pork consumption was modelled as a two-step process: the decision to consume pork and (for the consumers) the quantity consumed. Prices, income, household size, urban/rural, and region (South Hinterland, Central Core, and North) were used as independent variables. Age and gender were controlled for. The authors reported the price elasticities. The price of pork, rice, eggs, and oils were found to be negatively associated with the decision to consume pork, whereas the price of wheat flour and coarse grains were positively associated with the decision. With respect to the amount of pork consumed, significant negative price elasticities were found for pork, eggs, and oil, whereas the price
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elasticity of coarse grains was positive. The authors reported larger price elasticities for the poor, but did not provide statistical significance tests.

Quality issues: The authors did not provide information on whether the China Health and Nutrition Survey was designed to be representative of the Chinese population and the number of observations lost due to missing dietary data was not reported. No statistical significance tests were reported for the finding that the price elasticities for pork consumption were larger for the poor than for the rich.
Harris et al. investigated the association between ethnicity and dietary intake in New Zealand.(17) From January 2000 to February 2002, 1,617 men were recruited into the Wellington Regional Community Prostate Study. The study participants were enrolled by two separate means to ensure an adequate representation of Maori and Pacific Island men. First, men 40 to 69 years old were identified in census units with over 5% Maori and 5% Pacific Islanders and invited to participate in the study. A total of 698 were enrolled. Second, 919 men were recruited from the individuals who had been screened as part of the Wellington hepatitis and diabetes-screening programme for Maori and Pacific Islands populations. Men were excluded on the basis of suspected prostrate cancer. Of the 1,405 eligible subjects, 1,031 provided food frequency data. A self-administered food frequency questionnaire was used. The mean daily intake of tomatoes, green vegetables, lamb, and pork were regressed on ethnicity (European, Maori, or Pacific Islander), controlling for age. Raw and cooked tomatoes, tomato juice, tomato soup, and table tomato sauce were consumed more often by Pacific Islanders than by Maori or Europeans. The same was found for green vegetables. For tomato sauce, however, the opposite was found. Pacific Islanders had the highest mean daily lamb and pork intake. Lamb intake was similar for Maori and Europeans; Maori consumed more pork than Europeans.

Quality issues: The subject recruitment process, and the substantial loss of subjects due to missing data, inhibited the generalisibility of the findings. The authors stated, however, that the dietary patterns were consistent with those found in other New Zealand studies. Two tables were presented: one with means by ethnic group (adjusted for age) and another with p-values. It was not clear whether p-values were age adjusted as well. The authors did not define the difference between tomato sauce and table tomato sauce, making it difficult to explain why the findings for tomato sauce were different from all other tomato products. The models did not control for energy intake, which may explain (part of) the difference between the ethnic groups. Finally, because the analyses were not adjusted for socio-economic factors (income, for instance), it was unclear whether the identified dietary differences were culturally determined or simply a consequence of budget constraints.
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Food intakes of adult Melbourne Chinese were studied by Hsu-Hage et al.(18) A set of Chinese surnames was compiled from Chinese community organisation membership lists. Using a telephone directory, a sampling list was compiled by identifying Chinese surnames. The 545 women and men included in the study were at least 25 years of age. A 220-item food frequency questionnaire was used to collect dietary data. The first model estimated the mean daily intake (per mega joule) as a function of education and length of stay in Australia (controlling for age). In the second model, birth place was added as a covariate. The models were estimated separately for men and women. In men, higher levels of education and being born in Australia were associated with lower leafy green vegetable intake. Being born in Australia was associated with higher red meat intake. In women, higher education was found to be associated with higher red meat consumption.

Quality issues: According to the authors, the study population was representative of the Melbourne Chinese population at the time of the study. An added strength of the study was that the mean daily intakes were expressed per MJ. It was not clear whether the reported p-values were the result of testing for differences in means or for a linear trend (the findings for education were interpreted assuming that the authors tested for a linear trend). Finally, the food groups reported were different for the different exposures and for men and women. The authors did not explain how the groups were selected for each analysis and/or what they chose to report. Finally, the authors did not control for income or any other measure of socio-economic status.
Efforts to reduce red meat intake were studied by McIntosh et al.(19) Free living elderly (58 years and older) Anglos in the metropolitan Houston area were recruited through random digit dialling and by random sampling of the membership lists from the American Association of Retired Persons and churches. The response rate was 61% (424 out of 695). The study sample consisted of men and women. Respondents were asked about their efforts to reduce red meat intake. If they answered affirmatively, they were asked about the source of influence/information to reduce intake. A generalized logit model was used to estimate the association between the dependent variable (no red meat consumption versus reduction due to (a) friends/ relatives, (b) mass media, (c) doctor, or (d) self) and education and companionship. The model additionally controlled for food attitudes, abdominal girth, sex, and two interaction terms: sex X companionship and sex X attitudes. With better education, it was less likely to having reduced intake as a consequence of friends or relatives or because of self-influence. Larger abdominal girth was associated with a lower probability of reducing intake, independent of the source. Believing in health foods increased the probability of having made changes because of mass media or physician influences. Males were significantly
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more likely to having made changes as a consequence of mass-media or physician influence than women. Finally, as the number of female elderlys companions increased, it was more likely that they would make changes because of friends and relatives. The opposite was found for males. The effect of strongly believing in health foods was different for women and men; in women, it increased the likelihood that reductions in red meat intake were a consequence of physician or mass media influence, whereas in men, it decreased those probabilities.

Quality issues: This was one of the few studies reporting (limited) information on the subjects not included in the analysis. The authors conducted interviews with 71% of the refusals and found that the study participants were healthier and more interested in nutrition.
Metcalf et al. investigated the dietary intakes of middle-aged New Zealanders.(20) Data were obtained from 5,677 men and women between 40 and 64 years who participated in a health screening survey of a local workforce between 1988 and 1990. A 142-item food frequency questionnaire was completed by 5,523 individuals. The study sample consisted of Maori, Pacific Islanders and European New Zealanders. The mean number of red meat servings per month was regressed on ethnicity, controlling for age, and total energy intake. ,Models were run separately for men and women. Among the men, Pacific Islanders consumed more servings of red meat than Maori, and Maori consumed more than European New Zealanders. In women, Pacific Islanders and Maori were found to consume more than European New Zealanders.

Quality issues: The results were adjusted for energy intake. The authors did not discuss whether the study sample was comparable to the 40-64 year olds in the general New Zealand population. Nevertheless, they claimed their results have important consequences for health policy in New Zealand. Since the analyses were not adjusted for socio-economic factors (e.g., income), it was unclear whether the identified dietary differences were culturally determined or a consequence of other factors.
Green vegetable consumption was studied by Morgan et al. in the United Kingdom.(21) A subsample from the Medical Research Council Cognitive Function and Ageing Study (MRC-CFAS) was used. This longitudinal study was carried out in six centres in England and Wales, in which random samples sufficiently large to yield 2,500 interviews with individuals aged 65 and over were collected. The samples included elderly people in residential care. For this study, sample subsets from two centres were used: rural Cambridgeshire and urban Nottingham. Respondents were eligible if they achieved an AGECAT organicity level < 03, an MMSE score of > = 18, a score of > = 8 on the Clackmannan activities of daily living scale, they had not been selected to participate in
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other MRC-CFAS follow-up assessments and they did not have severe communication problems. Dietary data were collected by means of a food frequency questionnaire. Regression analysis was used to evaluate whether the frequency of green vegetable intake was associated with living in an urban or rural area, living with others, occupation before retirement (or husbands main occupation) or education. An age X urban interaction term was added to test the hypothesis that the urban/rural difference was different by age. The model additionally adjusted for sex. Living in a rural area and living with others were significant predictors of higher green vegetable intake. The significant interaction term showed that the rural effect was stronger for subjects 75 years and older. Female subjects were more likely to consume green vegetables.

Quality issues: The study clearly describes the sampling approach and the reasons why subjects could not be enrolled.
Park et al. studied the effect of place of birth on diet in U.S. and Korea-born Korean Americans.(22) The Multiethnic Cohort Study in Hawaii and Los Angeles targeted five ethnic groups (African Americans, Latinos, Japanese Americans, Native Hawaiians, and whites) and enrolled subjects based on ethnic specific name. The small group of Korean participants (570 out of 215,000) who were unintentionally selected was used for this study. Data were collected between 1993 and 1996 in adults aged 45 to 75 years of age. A self-administered quantitative food frequency questionnaire was used as the dietary assessment tool. Because of the small proportion of men, only women were included in the analysis; the authors further excluded 29 women who were not born in Korea or the United States. The number of servings of red meat, organ meat, process meat, dark green vegetables, and tomatoes was regressed on place of birth and education. The analysis further adjusted for age, BMI, smoking status, and physical activity. The authors only reported the adjusted means for place of birth and found that being born in the United States was positively associated with higher intakes of red meat.

Quality issues: The authors clearly described how the sample was constructed and acknowledged that the women in the study were not representative of the Korean American population. It was not clear why less than 9% of the original sample were men. The food frequency questionnaire was not developed for Koreans, which may have caused some underreporting (which may be higher in the Korean born group if consuming more traditional Korean food). The analysis was not adjusted for energy intake (BMI is not a good proxy for energy intake; body weight would be better) or for socio-economic status.

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Popkin et al. analysed the determinants of beef, pork. and processed meat consumption in the United States.(23) Data from two nationally representative surveys were used: the Nationwide Food Consumption Survey (NFCS; 1977) and Continuing Survey of Food Intake by Individuals (CSFII; 1985). Since information on adults in the last survey was limited to women from 19 to 50 years old, the analyses were limited to this group in the NFCS as well. Removing women with missing data yielded a final sample size of 5,406 from NFCS (out of ?) and 1,069 (out of 1,459) from CSFII. The dietary data used from the 1977 survey came from a one-day 24-hour recall and a two-day food record and in 1985 from three days of 24-hour recall. The authors estimated two models: the first analysing the decision to consume (yes or no) and the second analysing the amount of food consumed (for the consumers). (The authors only reported the elasticities in the published paper but kindly provided us with copies of the regression models.) The first model was estimated using a probit model; the second by means of a truncated regression model. The food groups of interest for this review were red meat (lower fat, medium fat, and high fat), lunch meats (low and high fat), and green and yellow vegetables and cruciferous vegetables. Ethnicity (Spanish origin, black, other race), central city or suburb residence, household size and structure, income, employment and education of the female head, receipt of food stamps, and region were included as independent variables in both models. The models were adjusted for survey year (1977 or 1985), body weight, special diet status (e.g., for medical reasons), and an interaction term between each independent variable and year. Education of the female head of household was found to be negatively associated with both the probability of consuming high fat lunch meat and the amount eaten. It was also a positive determinant of the decision to consume green and yellow vegetables and cruciferous vegetables. Having more children under 18 years of age was associated with a higher consumption of lower fat red meat and with a lower probability of consuming cruciferous vegetables. Women in larger households consumed smaller amounts of all types of red meat. Being childless was associated with higher intakes of lower-fat red meat, a lower probability of consuming high fat lunch meat, and higher intakes of green and yellow vegetables and cruciferous vegetables. Not being black or of Spanish origin was associated with a higher probability of medium-fat meat consumption and a larger absolute intake of high-fat red meat, low fat lunch meat, and cruciferous vegetables. Being of Spanish origin was associated with a higher probability and higher absolute amounts of consuming high-fat red meat, a higher probability of eating low fat lunch meat, a higher absolute intake of high fat lunch meat, and a lower probability of green, yellow and cruciferous vegetable intake. Blacks consumed less high-fat red meat and low-fat lunch meat, but had a higher probability and higher absolute intake of high-fat lunch meat. Both the likelihood and absolute amounts of green, yellow, and cruciferous

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vegetable intake were significantly higher in blacks. The intake of lower-fat red meat and the probability of consuming high-fat red meat, low fat lunch meat, and high fat lunch meat were higher in households with a male head present. Receiving food stamps was associated with a lower probability of consuming medium-fat red meat, higher absolute intakes of high-fat red meat, and lower probabilities of green, yellow, and cruciferous vegetable intake. City residents had lower intakes of lower-fat red meat, but higher intakes of high-fat read meat and cruciferous vegetables. Suburban residence was associated with a higher intake of medium-fat red meat, a higher probability of eating high-fat red meat and high fat lunch meat, a higher probability of eating green and yellow vegetables, and a higher intake of cruciferous vegetables. Higher income was associated with a higher intake of high-fat red meat, but a lower probability and intake of high-fat lunch meat. Green/yellow and cruciferous vegetable intake did not vary with income. Finally, employment was associated with a higher intake of low fat lunch meat.

Quality issues: Strengths of the study were that weight (a proxy for energy intake) and socio-economic status were controlled for in the analysis. The size of the original 1977 sample was not reported. The extent to which the exclusion of observations with missing values in both surveys affected the representativeness of the sample was not discussed.
Swanson et al. modelled the frequency of red and processed meat intake in 30-80 year old men and women in the United States.(24) The data were obtained from a sample of adults who participated as controls in case control multiple myeloma study. The controls were randomly selected individuals from three geographic areas in the United States. Of the 3,055 identified controls, 2,153 were interviewed, and 1,976 were included in the analysis. Dietary data were collected by means of a food frequency questionnaire. The frequency of red and processed meat intake were modelled as a function of education and race. Age, gender, study centre, smoking, and alcohol consumption were controlled for in the analysis. Only the coefficients for race (white or black) were reported in the article. Race was not associated with the frequency of red meat consumption but processed meat was more frequently consumed by blacks.

Quality issues: The authors clearly described how the sample was drawn and discussed potential biases due to the study design and due to observations excluded from the analysis. The authors only reported the coefficients for race.
Tepper et al. studied the intake of beef and cured meats in adult U.S. men.(25) One hundred and thirty-seven U.S. Army National reservists in New Jersey between 19 and 56 years old were included in the study. Reservists lived in the local community and participated in military training one weekend per month. A 62-item food frequency questionnaire was used to assess the intake of beef and cured meats.
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A logistic regression model was used to model whether or not the subjects consumed beef or cured meat. Household size, living in an urban or rural area, income, and education were used as the independent variables. The model further controlled for age, nutrition knowledge, level of dietary restraint, beliefs. Higher income was found to increase the probability of eating beef, while dietary restraint was associated with a lower probability.

Quality issues: The authors did not provide information on the size of the pool of eligible subjects the sample was drawn from. Even though the authors acknowledged that the subjects might have been more likely to adhere to strict standards of fitness and physique (due to the military training) than the general population, it was not clear how self-selection into the research sample might have affected the results. Moreover, the table of descriptive statistics suggested that only 100 subjects were included in the regression model. Only 10 of the subjects lived in rural areas, which may explain the lack of a significant effect.
Torun et al. studied the intake of red meat, fruits, and vegetables in Guatemala.(26) The authors tried to locate 762 adults who participated as children in the INCAP longitudinal study on growth and development from 1969 to 1977 and invited them to participate in the study. A total of 473 women and men between 19 and 29 years of age were studied. A food frequency questionnaire was used to measure dietary intake. Regression analysis was used to compare the frequency of read meat, fruit, and vegetable intake between rural non-migrants, commuters, and urban migrants. Age and village of birth were controlled for in the regression model. Compared to rural people, urban residents ate more red meat and vegetables. Intakes of commuters tended to be between rural and urban intakes, but the number of commuters was too small to show a clear intermediary position.

Quality issues: The authors provided clear reasons for loss to follow up and found that there was no concern for selection bias after comparing socio-economic indicators from the study in the 1970s and the 1988 follow up. The coefficients for age and village of birth were not reported. The authors did not control for socio-economic status, so it was not clear to what extent it affected urban, rural differences.
Fresh meat consumption was studied by Verbeke et al. in Belgium.(27) Disproportionate quota sampling (with age and gender as quota control variables) was used. The sample was almost equally spread over age categories and included respondents from different household sizes, locations, and education levels. As a consequence, the sample did not mirror the Belgian population. After excluding observations with missing values, data on 291 subjects were used in the analysis. Non-meat consumers and vegetarians were not included in the analysis. The respondents (female and male) were 20 to 89 years of age.
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Dietary data were collected by means of an in-home survey with questions about past changes and intention to change fresh meat intake. Even though fresh meat was studied, it primarily referred to red meat (95% of the time, red meat was the fresh meat subject to change). A probit model was used to model changed fresh meat consumption since the BSE crisis as the dependent variable. The independent variables were education, having children under 12 and attention to television coverage of meat issues. Age and the frequency of fresh meat consumption were controlled for. An age X attention to television coverage interaction term was included in the model as well. The same model was repeated using the intention to decrease fresh meat consumption in the future as the dependent variable. Having children less than 12 years old and high levels of attention to TV coverage were found to be associated with reduced intake. Likewise, higher age and less frequent meat consumption were associated with reduced intake. The significant interaction term showed that the impact of television decreased with age. Less frequent consumption of fresh meat and high levels of attention to television coverage were associated with reductions in future consumption.

Quality issues: A high proportion of observations were used in the analysis. The authors were very clear on how the sample was drawn and about its representativeness. A limitation of the study was that the authors did not report what instrument was used to measure changes in meat consumption and whether the respondents knew the objective of the study.
West et al. studied the frequency of veal intake in Canada.(28) Shoppers in grocery stores in Quebec City and Montreal were interviewed. Data on 1,027 individuals were analysed. An ordered probit model was used to estimate the association between the frequency of eating veal and income, education, ethnicity, or having children younger than 18. Having eaten veal with parents, sex, age, and veal beliefs were also added to the model. People with ethnic roots outside of Canada ate veal more frequently. Having eaten veal with parents, eating veal at restaurants and buying veal to diversify ones diet were positively associated with intake frequency. Additionally, in Montreal (but not in Quebec), age and the belief that veal is better were positive predictors of frequency.

Quality issues: The possible selection bias due to drawing a sample in a supermarket was not discussed by the authors.
Winkleby et al. studied the frequency of red and cured meat consumption in the United States.(29) The data analysed were from four cross-sectional surveys of people age 12 to

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74 in randomly selected households from two treatment and two control communities from a cardiovascular risk reduction project. The study sample consisted of 886 Hispanic and white female and male adults with less than a high school education and the 170 female and male youth from the above households. Regression models were used to estimate the association between the intake frequency of red and cured meats and ethnicity and city of residence (Salinas, Monterey, Modesto, and San Luis Obispo). The models controlled for age, sex, time of survey and two interaction terms: age x ethnicity and sex x ethnicity. Only the ethnicity coefficients were reported. In adults, being white was associated with a higher frequency of red and cured meat consumption. In youth, no ethnicity effect was found. The four cross-sectional surveys were conducted in the same communities, but it was not clear whether the same subject may have been selected more than once. If the same subject were included several times, the standard errors would be underestimated. The authors did not report what the risk reduction project entailed, and whether it could have affected the reported associations. Finally, the model did not control for income or any other measure of socio-economic status. Whether the ethnicity effect was a consequence of cultural preferences or of resource constraints thus remained unclear.

Quality issues: The authors were not clear on what proportion of eligible study subjects were surveyed and what proportion were analysed and how this affected the validity of the results. 2.3.1.2 Descriptive quantitative studies using indirect measures of dietary intake
Brumfield et al. studied household consumption of Jersey Fresh and other fresh tomatoes in New Jersey, U.S.A.(30) Data were collected in supermarkets targeting high income consumers. Face-to-face interviews were conducted with 757 customers. Regression models were used to study the association between the quantity purchased and per capita income. A separate model was estimated for Jersey Fresh tomatoes and other tomatoes. The models controlled for prices and taste and preference variables (i.e., product origin and overall quality). Per capita income, the price of substitutes, the origin, and overall quality were found to be positive predictors of Jersey Fresh tomato purchases. For other tomatoes, income was positively associated with purchase, whereas the price of Jersey Fresh tomatoes was negatively associated with purchase.

Quality issues: The authors did not report how the respondents were selected and how many people refused to participate. The possibility of selection bias due to a sample drawn in a supermarket was not discussed. The only information provided about the study respondents was that they were likely to be high-income consumers. No details were given on age or sex distributions.

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Deaton(31) estimated expenditure elasticities for household beef consumption in Cte dIvoire using data from a national sample of households. The analyses were only conducted on the rural households. Sixty rural clusters (containing 12 households) were surveyed four times each over the course of one year. Clusters in different quarters were considered different clusters yielding a total of 240 cluster-quarters. Forty-nine clusters in which no household purchased a specific good in the market were excluded since no unit value could be calculated. The budget share for beef was regressed on expenditure, household composition, and household size. The author only reported the total expenditure and price elasticities. Total expenditure elasticity for beef was 1.56 and the price elasticity was -1.91.

Quality issues: Even though the author was clear on the number of included clusters, he did not report the total number of households included in the analyses. Also, it was unclear whether or not households were visited more than once. Only the expenditure and price elasticities were reported, but without information on their statistical significance.
Dong et al. investigated the household purchase of beef in the United States using data from the 1987/88 Nationwide Food Consumption Survey (NCFS).(32) Data on 4,004 households were analysed. Beef expenditure was modelled as a function of income, being a food stamp recipient, house ownership, and household composition. The model further controlled for unit value and season. Beef expenditure was positively associated with household income and with the number of household members 19 years and older. Households with more members between 1 and 12 of age purchased less beef.

Quality issues: The authors did not report how many households were originally surveyed in the NCFS and what proportion they included in the analysis. The possible consequences on the estimates and the validity of the results were not discussed.
Pork consumption in Mexico was investigated by Dong and Gould.(33) The authors used the 1994 National Household Income and Expenditure Survey (ENIGH). A weekly diary of household expenditures was used to collect food consumption data. Data on more than 11,800 households were used in the analysis. The authors used two statistical models. The first model estimated the market participation as a function of household income, owning a fridge, education and occupation of the head of household, household size and age composition, and further controlled for region. The second model estimated pork expenditure as a function of household income, owning a fridge, household size and age composition, and occupation.

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The decision to purchase pork was found to be positively associated with household size and negatively associated with income. The amount spent on pork increased with higher income, household size, owning a fridge, and working in service jobs. A higher percentage of household members younger than 15 reduced the probability of purchasing pork.

Quality issues: It was stated that data on more than 11,800 households were used in the analysis, but the authors did not report how many households were dropped from the analysis due to missing data, nor did they discuss the consequences on the validity of the results. The authors did not explain why the independent variables used in both models were different (education was included in the market participation but not in the expenditure equation).
Goodwin and Koudele modelled the purchase of variety meats in the United States.(34) Variety meats were defined as beef and pork liver, heart, tongue, kidney, thymus glands, stomach, brains, pigs feet. Shoppers at eight Kansas retail supermarkets were interviewed. Of the 3,340 interviewed shoppers, 2,998 were included in the analysis. The probability of purchasing variety meats was modelled as a function of household income, household size, ethnicity, and education. Age, sex, and location were also added to the model. Household size, the perception that ones ethnic origin is important for taste and preference of variety meats, and age were found to increase the probability of consuming variety meats. Income was a negative predictor of the likelihood to consume variety meats.

Quality issues: The authors discussed their concern about possible bias due to conducting the survey in Midwestern cities. However, they did not discuss selection bias due to drawing the sample in supermarkets or due to refusal to participate.
Gracia and Albisu conducted a study on the demand for beef and veal, fresh pork, lamb and goat, and processed pork in Spain.(35) Data were obtained from the 1990-91 Spanish National Expenditure Survey, which collected data on 21,155 households. Only households in rural (towns of < 10,000 inhabitants) and urban areas (towns of > 100,000 inhabitants) were included in the analyses. The budget shares of specific meats were used as the dependent variables. Total per capita expenditure, the number of household members in different age groups, the percentage of males in the household, the percentage of income earners, and the education level of the head of household were used as the independent variables. The models were estimated separately for urban and rural households. Households with higher per capita expenditure spent a higher proportion of their budget on all studied

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meats in both urban and rural areas. The percentage of males in the household increased the proportion of the budget spent on pork, lamb and goat, and processed pork in rural areas and the share spent on beef and veal, pork, and processed pork in urban areas. The effect of education was more complicated; it was positive for beef and veal, but negative for pork, in both areas. A larger percentage of income earners led to a larger budget share for beef and veal and processed pork and a smaller budget share for lamb and goat in rural areas. In urban areas, a larger percentage of income earners had a positive effect on budget share for processed pork and a negative effect for beef and veal, pork, and lamb and goat. Finally, significant, but highly variable, effects were found for the number of household members in different age groups (see Appendix 2.3 for results).

Quality issues: The authors reported how many households were surveyed but did not mention how many could be analysed after excluding households in towns with 10,000 to 100,000 inhabitants and households with missing values. The possible consequences on the validity of the results were not discussed. Finally, the authors did not discuss how to interpret the percentage income earners variable.
Heiman et al. used data collected in the four largest Israeli cities and several rural villages to study the consumption of beef and processed meat.(36) Of the 435 individuals contacted, 405 were interviewed. The consumption share of meat was regressed on household income and religious observance. The model controlled for household preference, the joy of cooking, leisure time, and feedback to the cook. Family preference was found to be positively associated with consumption share of beef and processed meat. Religious observance was a predictor of the consumption share of processed meat.

Quality issues: The dependent variable consumption share was not defined. It was not clear whether the authors used budget share, share in quantity purchased or consumed, or share in frequency of consumption. In addition, it was unclear why family preference was added to the model. It appeared that the family preference variable was nothing more than an alternate measure of the dependent variable, which would explain its high significance (and the lack of significance of other variables). Finally, the external validity of the results was not discussed.
Huang and Raunikar studied household beef expenditures in the United States.(37) A consumer panel consisting of 120 families from Griffin, Georgia, was interviewed about household purchases of fresh beef, ground beef, beef roasts, and beef steak. A spline function was estimated with household income and household size as the independent variables. Higher income was associated with higher expenditure on fresh

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beef, beef roasts, and beef steaks. The association between ground beef expenditure and income followed an inverse U. A decreasing rate of increase in ground beef expenditure was found with increasing household size.

Quality issues: This study was one of the few testing for non-linear effects in income and household size. A limitation was that no information was reported on the number of households that refused to participate and the number dropped because of missing data. The extent to which this might have affected the results was not discussed.
Jones and Yen modelled household beef consumption in the United States.(38) Data from the 1987-88 Nationwide Food Consumption Survey were used. Of the 4,495 observations in the original sample, 4,150 were used in the analysis. A double hurdle model was used to estimate the probability of consuming beef and the quantity consumed. Household income, the households age composition, urban residency, home ownership, race, and ethnicity were used as the independent variables. The prices of beef and other meats were controlled for in the models. The probability of consuming beef was higher in larger households and amongst Hispanics. ,The price of beef lowered the probability of consumption. The quantity of beef consumed was higher in larger households. Being white, owning a home, and prices of other meats were negatively associated with beef consumption.

Quality issues: The authors were very clear about how many observations were dropped due to missing variables. Another strength of the study was that this was one of the few studies testing for non-linear income effects.
Manrique and Jensen conducted a study on the household expenditure on convenience meat products in Spain.(39) The authors used data from the 1990-91 Spanish National Expenditure Survey, which collected data in 19,535 households. The analyses were limited to dual headed and single female-headed households. The authors used a double hurdle model to estimate the decision to consume convenience meats (defined as commercially frozen or pre-cooked steaks, roasts, ground beef, veal, and pork) and the amount spent. Both dependent variables were modelled as a function of the number of income earners, the households age distribution, womens income, other income, employment of the head of household, home ownership, urban residency, womens education, and whether the household was a single female-headed household. The authors further controlled for womens age and region. Womens income and other household income, urban residency, and household size were all positively associated with the probability of consuming beef. Womens age, being a female-headed household, and living in the Northwest lowered the probability of beef consumption. The amount

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spent on beef increased with both forms of income, household size, and womens age. Households with an employed head spent more on beef as well. Womens education was negatively associated with household beef expenditure. Beef expenditure was lower in female-headed households, households owning their home, and households residing in urban areas or living in the South.

Quality issues: The number of households excluded from the analyses because they did not fall in the dual or single female-headed household categories were not reported. The authors do not provide information on how many households were dropped because of missing data and what the consequences were in terms of the validity of the results.
Household red and processed meat consumption in Bulgaria was modelled by Moon et al.(40) Using nationwide food consumption survey data, out of 2,500 households, 2,133 were included in the analysis. A double hurdle model was used to estimate the association between market participation and the frequency of consumption of beef, pork, lamb, and processed meats on the one hand and household income, employment status, household size, and region on the other hand. A higher income was associated with a higher probability of consuming beef, ham, and sausage and a higher frequency of consuming beef, pork, ham, sausage, and Kremvirshi (Bulgarian frankfurter). Household size was positively associated with the probability of consuming beef, lamb, and sausage and to a higher frequency of consuming beef, pork, lamb, sausage, and Kremvirshi. Being unemployed or a pensioner lowered both the probability and frequency of consumption of almost all meats under study. Region was found to be significant for all meats except for beef and pork.

Quality issues: The article used very clear methodology. However, the authors did not provide a discussion of the possible bias introduced by dropping households due to missing data.
The Canada 1986 Food Expenditure Survey was used by Salvanes and DeVoretz to study household budget shares of red and processed meat.(41) The survey collected two-week food expenditure data in 10,591 households. The household budget share of red and processed meat was modelled as a function of household expenditure, household size, urban residency, nationality of the head of household, education and employment status of the head of household, and whether the spouse lived at home. Price, region, season, and age and sex of the head of household were controlled for. Expenditure elasticities were above one and statistically significant for both red and processed meat. Age of the head of household and residing in an urban area increased the proportion of the budget spent on red meat. Households with a better

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educated or employed head spent a lower proportion of their budget on red meat. The budget share spent on processed meat was larger in larger households. Urban residency, higher levels of education of the head of household, and being employed or having a female head of household were all associated with lower processed meat budget shares. Finally, red and processed meat consumption differed significantly by region.

Quality issues: It was not clear from the article how many households were dropped from the analysis due to missing values and the consequences this may have had on the generalisibility of the results.
Su and Yen studied household pork consumption in the United States.(42) The 1987-88 Nationwide Food Consumption Survey was used. The response rate of the survey was very low, with only 37% of the selected households participating. Of the 4,495 households available in the sample, 4,198 were included in the analysis. A double hurdle model was used to estimate both the decision of households to consume pork and the absolute amount consumed. The independent variables in the first model were household age composition, education of the head of household, urban residence, and being white. The gender of the meal planner and region were included as covariates. In the second model, the following variables were used: receiving food stamps, being a home owner, being Hispanic, household income, and the prices of pork and other meats. The probability of consuming pork was found to be greater in larger households and in households with a female meal planner or living in a rural area. Being a white household lowered the probability of consuming pork. The quantity of pork consumed increased with household size. Higher levels of education, being a white household, and the price of pork lowered the quantity consumed. Region was associated with both the probability and the quantity consumed.

Quality issues: The authors provided details on the low response rate for the 1987-88 Nationwide Food Consumption Survey that were not discussed in the other studies using this data set. The consequences on the validity of the presented estimates, however, were not discussed.
Yen et al. studied food consumption in China.(43) The Urban Households Survey collected data in 30 randomly selected cities from 29 Chinese provinces. Of the 3,800 households in the sample, 3,715 were used in the analysis. The budget share of beef and lamb, pork, vegetables, and fruits were modelled as a function of household size and age and education of the head. The models controlled for prices and region. The expenditure elasticity was higher than one (1.41) for beef and lamb and smaller than one for pork (0.94), vegetables (0.83), and fruits (0.6). All

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expenditure elasticities were statistically significant. Age of the head of household was negatively associated with the share of the budget spent on pork and vegetables. The age elasticity for fruits was negative as well. The effect of household size differed for the different food groups: the proportion of the budget spent on beef and lamb was lower in larger households but the share spent on vegetables was positively associated with household size. The household size elasticity for fruits was negative as well. ,Having a high school degree was associated with a higher proportion of the budget spent on vegetables. No significant effect was found for having a college degree. Region was a significant predictor in the beef, pork, and vegetable equations.

Quality issues: The authors clearly described the sample. Weaknesses were that the equation for fruits was not reported (only the elasticities were) and the discussion of the results in the text did not correspond to the table with regression results.
The demand for beef products in the United States was studied by Yen and Huang.(44) Data from the 1987-88 U.S. Nationwide Food Consumption Survey were used. Of the 4,237 available observations, 4,050 were included in the analysis. The proportions of the budget spent on four different beef products (steak, roast, ground beef, and other beef) were modelled as a function of total meat expenditure, household age composition, the education of the head of household, urban residence, home ownership, race, ethnicity, and receiving food stamps. Region, prices, and the gender of the meal planner were controlled for. Higher total meat expenditure was found to increase the probability of consuming steak, roast, and other types of beef, but lowered the probability of ground beef. Total meat expenditure was positively associated with higher expenditures on all types of beef. Household size increased the budget share spent on steak. The number of members younger than 20 increased the proportion of the meat budget spent on roast, but lowered the ground beef budget share. More household members older than 65 decreased the budget share for roast; more members between 20 and 64 years old decreased the budget share for ground beef. Households in urban areas spent a smaller proportion of their meat budget on steak. Being white lowered the proportion of the budget spent on ground beef. Hispanics spent a lower proportion of the meat budget on steak, but a larger proportion on roast and other beef. Receiving food stamps increased the proportion of the meat budget spent on steak and lowered the proportion spent on ground beef.

Quality issues: The authors did not discuss the consequences that the very low response rate (38%) might have had on the estimates.
Yen et al. investigated the determinants of the proportion of the budget spent on beef and pork in households receiving food stamps in the United States.(45) The National Food
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Stamp Program Survey provided data on 1,109 households. A total of 817 households were included in the analyses. Household size and total food expenditure were used as the independent variables in a model estimating beef and pork budget shares. Prices were included in the model as well. The expenditure elasticity for beef was found to be between 0.92 and 0.95 and for pork between 1.16 and 1.27. Both elasticities were statistically significant.

Quality issues: Parameterisation and subscripts were not well explained by the authors. As a consequence, it was not clear what the parameter estimate was for household size. The authors did not provide a discussion of possible bias due to dropping households with missing values. 2.3.1.3 Obesity reviews
Sobal and Stunkard reviewed 144 published studies on the relationship between socioeconomic status (SES) and obesity in women, men, and children.(46) Studies were included if they provided information on SES and obesity. Socio-economic status was broadly defined: most of studies used income and education; some studies used occupation or other measures. Some studies used a number of indicators or composite indicators of socio-economic status. Papers from both developed and developing countries were reviewed. Of the 30 studies in U.S. women, 28 reported a negative association between SES and obesity and 2 found no association. The results for women in other developed countries were similar: 18 out of 24 studies found a negative association, 5 found no association, and 1 found a positive association. The results in men, however, were inconsistent. In U.S. men, 12 studies found a positive association, 12 found a negative association, and 3 found no effect. The association between SES and obesity in men in other developed countries was negative in 22 of 39 reviewed studies, positive in 8, and insignificant in 8. One study conducted in Israel found a U-shaped association. The association for children was not consistent: in girls, 13 found a negative association, 8 found a positive association, and 11 no association. Of the 34 studies in boys, higher SES led to less obesity in 11 studies, more obesity in 9 studies, and 14 found no association. In developing countries, a positive association between SES and obesity was found in women (10 out of 11 studies), men (12 out of 14 studies), girls (14 out of 16 studies), and boys (13 out of 15 studies). None of the developing country studies found a negative association. The authors concluded that there was a clear negative association between SES and obesity in women in developed societies. For men and children in developed countries

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the relationship was inconsistent. In developing countries, a strong positive association was found between SES and obesity in women, men, and children.

Quality issues: The authors did not report which database(s) were searched to identify the studies. No information was available on which measure of SES was used in each reviewed study. It was thus unclear to what extent the income-obesity relationship was the same as the education-obesity relationship. Even though the authors mentioned that some studies used more than one measure of SES, they failed to explain how studies were classified (positive, negative, or no association) in cases where different results were found for the different measures of SES within the same study.
Monteiro et al. reviewed studies on socio-economic status and obesity in adults in developing countries.(4) Medline was searched for articles published between 1989 (when Sobal and Stunkards review was published) and June 2004. A number of studies known to the authors (but not identified through the search) were added to the pool of papers as well. Sixteen studies (14 single-country and 2 multi-country studies) met the inclusion criteria and were reviewed. Ten out of 14 studies found an inverse association between SES and obesity. The remaining four studies found no effect (two) or a positive effect (two). In men, seven studies found a positive association and seven studies found no association. The first multi-country study analysed 38 surveys of non-pregnant women from 32 developing countries. Education was used as the SES measure. In 24 surveys, a lower risk of obesity was found among the low SES groups, no statistically significant association was found in 11 studies, and in 3 surveys more obesity was found in lower SES groups. The relative protection against obesity among women of low SES was attenuated with rising national income. The second multi-country study analysed data on non-pregnant women from 37 data sets, 18 of which had been included in the first multi-country study. Country-specific education quartiles were used as the SES measure. A lower risk of obesity was found in the low SES group in 26 countries, no association in 3 countries, and an inverse association in 8 countries. The authors further found that the countrys level of economic development was a significant modifier of the relation between SES and obesity: in low income countries, the highest prevalence of obesity was found in the high SES groups, whereas in the upper-middle income countries, an inverse association was found. The authors concluded that obesity was increasingly prevalent in the lower SES groups. As the level of economic development improved, the burden of obesity shifted to the groups of lower SES.

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Quality issues: The authors were very clear about how the literature search was conducted and which measure of socio-economic status was used in each reviewed study. Even though the authors used the term socio-economic status throughout the article, 8 of the 14 single country studies and the 2 multi-country studies used education as the measure of socio-economic status. The difference between the impact of higher education, higher income or a higher composite SES score on obesity was not discussed. 2.3.2 Determinants of dietary intake Studies using direct measures of dietary intake
Three studies of the general U.S. population used data from the CSFII 1995 survey. The first study found that people with a higher income had a higher probability of consuming pork, but the amount consumed was not different.(7) In the second study, income was positively associated with daily beef intake(13) and the third study found that individuals with higher income consumed more processed pork and found no effect on the intake of beef or pork.(14) Using two other large U.S. surveys, Popkin et al. found income to be associated with higher intake of high-fat red meat and a higher probability of consumption and absolute intake of high-fat lunch meat in adult women. The authors did not find income differences in the probability and amount of low or medium-fat red meat or low fat lunch meat.(23) The frequency of organ meat and bacon intake was positively associated with income in low income elderly in the United States. Income was not associated with beef or lunch meat intake.(6) Male U.S. Army National Guard Reservists in New Jersey were more likely to consume red and cured meats if there income was higher.(25) In Scotland, the frequency of eating processed and red meats in 40 to 60 year olds was not associated with income.(9) The frequency of veal intake by shoppers in grocery stores in Quebec City and Montreal did not depend on income.(28)

2.3.2.1 Income

Studies using indirect measures of dietary intake

Many of the studies on household consumption used total or food expenditure as a proxy for household income. Four of the reviewed studies used data from the 1987-88 U.S. Nationwide Food Consumption Survey (NCFS). Dong et al. found that income was positively associated with household beef expenditure.(32) In Jones et al.s study, income was not associated with the probability of consuming beef or the quantity consumed.(38) Su and Yen likewise reported no association for pork.(42) Yen and Huang found higher total meat expenditure increased the probability of consuming steak, roast, and other types of beef, but lowered the probability of consuming ground beef.

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Total meat expenditure was positively associated with higher expenditures on all types of beef.(44) The likelihood of consuming variety meats (beef and pork liver, heart, tongue, kidney, thymus glands, stomach, brains, pigs feet) was lower amongst shoppers with higher incomes in supermarkets in Kansas.(34) Among a small consumer panel in Georgia, higher income led to higher expenditures on fresh beef, beef roast, and beef steaks. An inverse U association was found between income and ground beef expenditure.(37) In a survey of food stamp recipients in the United States, total expenditures elasticities for beef (below one) and pork (above one) were statistically significant from zero.(45) Higher per capita income was associated with purchasing larger quantities of tomatoes among high income supermarket shoppers in New Jersey.(30) In Canada, expenditure elasticities were above one and statistically significant for both red and processed meat.(41) In urban and rural areas in Spain, higher total per capita expenditure was associated with higher budget shares for beef and veal, pork, lamb and goat, and processed pork.(35) A study on dual headed and single female-headed households, using the same data set, found that womens income and other household income were positively associated with both the probability of consuming beef and the amount spent on beef.(39) In Bulgaria, a higher income was associated with a higher probability of consuming beef, ham, and sausage and a higher frequency of consuming beef, pork, ham, sausage, and Kremvirshi (Bulgarian frankfurter).(40) No significant income effect on beef and processed meat consumption was found in Israel, but this may have been due to including the family preference variable in the model (see above).(36) Income was negatively associated with the probability of consuming pork in Mexico, but positively associated with the amount spent on pork.(33) In urban China expenditure elasticities for beef and lamb (1.41), pork (0.94), vegetables (0.83), and fruits (0.6) were significantly different from zero.(43) Deaton reported a total expenditure elasticity of 1.56 for beef in rural households in Cte dIvoire but it was not clear from the study whether this elasticity was statistically significant.(31)

Conclusions
Studies using direct measures of dietary intake in the general U.S. population found either no effect or a positive effect of income on red and processed meat intake. The U.S. study in women found no effect of income on vegetable intake. The four other studies in the United States, Scotland, and Canada found mixed, positive, and insignificant results. The household-level studies consistently reported that with increasing income (or any proxy such as expenditure) households spent more on red and processed meat and one

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study reported a larger proportion of the budget spent on red and processed meat. It must be noted, however, that those results may have been a consequence of an increase in the quantity purchased or a preference for higher quality (and thus more costly) goods with increasing income. The results were less consistent when studying the likelihood of buying or the quantity purchased: two studies in the general U.S. population found no income effect on the likelihood of consuming beef or pork or on the quantity consumed; a third study found higher meat expenditure increased the probability of consuming steak, roast, and other beef and lowered the likelihood of buying ground beef. In Bulgaria, the likelihood and the frequency of consuming red and processed meats increased with income. In Mexico, the likelihood of buying pork decreased with income (but the amount spent increased). One study in shoppers found a lower probability of consuming variety meats with increasing income; another found that the likelihood of purchasing tomatoes increased. Overall, the findings suggested that individual intake of red and processed meat increased along with income in high income countries. U.S. households spent more on red and processed meats as income increased, but this was likely due to preferences for higher quality products. The lower income levels in Bulgaria may explain the positive incomequantity relationship. The evidence from developing countries for both meat and vegetable consumption was too limited to draw conclusions.

2.3.2.2 Socio-economic status, poverty and food insecurity Studies using direct measures of dietary intake
In the U.S. general population, receiving food stamps or being a recipient of the WIC (Women, Infants, and Children) programme was not associated with likelihood to eat pork or the amount consumed. The models controlled for income.(7) None of the socioeconomic status variables (social class, home or car ownership) explained a significant proportion of the variability in the frequency of processed and red meat intake in 40 to 60 year olds in Scotland. Controlling for income did not alter that finding.(9) In Trinidad, food insecurity was associated with less frequent intake of fruits and vegetables. The analysis did not control for any other measure of socio-economic status.(15)

Studies using indirect measures of dietary intake

The four household-level studies including a measure of socio-economic status or poverty in the analyses also controlled for household income or expenditure. Receiving food stamps in the United States was not associated with beef expenditure(32) or pork consumption.(42) The likelihood of consuming beef in the United States was not related to homeownership, but the amount consumed was lower in homeowners.(38) In the same

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data set, receiving food stamps increased the proportion of the meat budget spent on steak and lowered the proportion spent on ground beef. Homeownership did not have a significant impact.(44) Similar results were found in Spain: homeownership did not affect the decision to purchase pork, but lowered the amount spent on pork. The number of income earners was not found to be significant.(39)

Conclusion
In developed countries, none of the indicators of socio-economic status, except for homeownership (in two out of three studies), were found to predict dietary intake or household-level consumption. All of these studies controlled for income. The one developing country study found food insecurity to be associated with less frequent fruit and vegetable consumption.

2.3.2.3 Employment and occupational status Studies using direct measures of dietary intake
Three U.S. studies included employment or occupational status in the model and controlled for income. Being employed was not associated with pork intake in the general U.S. population.(7) Using the same data, individuals in labour occupations ate more beef than individuals in professional occupations, service occupations, and people not working,(13) although this finding might have been due to higher energy requirements of labourers. In U.S. women, employment was associated with a higher intake of low fat lunch meat, but not with the intake of low, medium, or high fat red meat, high fat lunch meat, or vegetables.(23) In U.K. elderly, the main occupation before retirement in a sample of elderly individuals was not associated with green vegetable intake.(21)

Studies using indirect measures of dietary intake

All of the household studies investigating employment controlled for income or expenditure in the analysis. In Canada, households with employed heads spent a lower proportion of their budget on red meat or processed meat.(41) Employment of the head of household in Spain did not effect the likelihood of purchasing beef, but increased the amount spent on beef.(39) In Bulgaria, being unemployed or a pensioner lowered the probability and frequency of consumption of almost all the red and processed types of meat studied.(40) In Mexico, working in personal services did not increase the probability of purchasing pork but increased the amount spent on beef.(33)

Conclusion
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There was little evidence that employment and occupational status are significant determinants of individual dietary intake once income was been taken into account. The household-level studies (all of which controlled for household income) yielded inconsistent results: one study found a negative effect of employment on the proportion of the budget spent on red or processed meat, whereas three other studies (one of which was conducted in a developing country) found an increase in the amount spent or the frequency of household consumption.

2.3.2.4 Education Studies using direct measures of dietary intake

The following studies on education controlled for income or socio-economic status in the analyses. Low income U.S. elderly with higher levels of education consumed more beef, while the intake of organ meat, bacon, or lunch meat did not depend on education.(6) The probability of consuming pork, however, was lower with a higher level of education in the general U.S. population. The amount of pork consumed was not affected by education.(7) Two other studies using the same data set reported negative associations as well; higher education was associated with a lower probability of daily beef intake,(13) a lower probability of consuming (processed) pork, and lower absolute intake of processed pork. Beef intake was not associated with education in Guenther et al.s study.(14) In two other large U.S. surveys, women with higher education were less likely to eat high fat lunch meat and ate it in smaller amounts. Their likelihood of consuming more green, yellow, and cruciferous vegetables was higher.(23) The education of shoppers in grocery stores in Quebec City and Montreal did not determine veal consumption.(28) The level of education of U.S. Army National Guard reservists in New Jersey was not associated with the probability of eating red or cured meats.(25) Five of the studies on education did not control for income or socio-economic status. In free living elderly Anglos in the United States, better education was associated with a lower probability of reducing beef intake as a consequence of friends, relatives, or selfinfluence.(19) In the United Kingdom, higher education of 45 to 74 year olds was associated with less frequent consumption of red meat, processed meat, and meat pies(10) and a study among the elderly found no effect of education on green vegetable intake.(21) Chinese Australian men with higher education consumed less leafy greens, whereas women with higher education ate more red meat(18) (see limitations in Table 2.5). In the Mongolian Autonomous Region in China, no effect of education was found. It was not clear from the paper whether the lack of variability in education could explain this.(11)

Studies using indirect measures of dietary intake

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All studies on education controlled for income. In the United States, education of the head of household was not associated with the decision to consume pork but lowered the absolute amount of pork consumed.(42) In the same survey data, education was not a significant predictor of the proportions of the meat budget spent on different types of beef.(44) The purchase of variety meats in Kansas supermarkets was not associated with education.(34) Households in Canada with a better educated head spent lower proportion of their budget on red meat.(41) In Spain, the effect of education of the head of household on the proportion of the household budget spent on beef and veal was positive. It was negative for pork in both urban and rural areas.(35) In the same data set, womens education was found to be negatively associated with household beef expenditure.(39) In Mexico, education was not associated with the decision to consume pork or the amount of pork consumed.(33) The only significant education effect found in urban China was that in households with high school educated heads, a larger proportion of their budget was spent on vegetables. No significant effect was found for having a college degree or for any of the other foods studied (beef and lamb, pork, vegetables and fruit).(43)

Conclusion
Education tended to have either no effect or a negative effect on the individual dietary intake of red and processed meats. Exceptions were found in specific subpopulations (low income elderly in the United States and Chinese Australian women). The evidence for effect on vegetable intake and from developing countries was too limited to draw meaningful conclusions. The household-level evidence seemed to point to a negative education effect on red and processed meat. Two studies in the general U.S. and Canadian population found negative education effects on meat consumption. Two studies using the same national data from Spain found somewhat conflicting results: the first study found education of the head of household to be negatively associated with the beef budget share, but positively associated with pork budget share; the second study found womens education to be negatively associated with household beef expenditure. The two developing country studies found no education effect.

2.3.2.5 Race and ethnicity Studies using direct measures of dietary intake
Five studies investigated ethnicity and controlled for socio-economic status. Low income elderly Mexican Americans in the United States consumed less organ meat and less orange or green vegetables than whites. Beef, bacon, and lunch meat intake were not
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associated with ethnicity.(6) In the 1995 U.S. Continuing Survey of Food Intakes by Individuals, Hispanics had a higher probability of daily beef intake. Asians and people falling in the other races category (i.e., not Asian, white, black, or Native American) had a lower probability of eating beef daily than whites. Blacks and Native Americans were more likely then whites to consume beef daily. Interestingly, the authors found that ethnicity also modified the gender effect on beef intake: daily beef intake was more likely in men than women in white, black, Asian, and other races. In Native Americans, however, women had a higher probability of daily consumption.(13) Analyses using the same data set showed that Mexican Americans were more likely to consume beef. Being black non-Hispanic was positively associated with the probability of consuming pork and beef and with the absolute amount of pork consumed. No ethnicity/race effect was found for processed pork intake.(14) In U.S. women, not being black or of Spanish origin was associated with a higher probability of medium-fat meat consumption and a larger absolute intake of high-fat red meat, low fat lunch meat, and cruciferous vegetables. Being of Spanish origin was associated with a higher probability and higher absolute amounts of consuming high-fat red meat, a higher probability of eating low fat lunch meat, and a higher absolute intake of high fat lunch meat, and a lower probability of green, yellow, and cruciferous vegetable intake. Black women consumed less high-fat red meat and low-fat lunch meat, but had a higher probability and higher absolute intake of high-fat lunch meat. Both the likelihood and absolute amounts of green, yellow, and cruciferous vegetable intake were significantly higher in black women.(23) Individuals with ethnic roots outside of Canada ate veal more frequently in a group of grocery store shoppers in Quebec City and Montreal.(28) The eight remaining studies did not control for socio-economic variables. In a group of African and European Americans, ethnicity was not associated with changes in pork or beef intake from childhood to young adulthood.(8) Race was not associated with the frequency of red meat consumption but processed meat was more frequently consumed by blacks in U.S. adults.(24) In the Mongolian Autonomous Region in China, no effect of ethnicity was found.(11) In comparison with the Maori and Europeans, Pacific Islanders in New Zealand consumed lamb, pork, raw and cooked tomatoes, tomato juice, tomato soup, table tomato sauce, and green vegetables more often. The frequency of tomato sauce intake, however, was higher in the Maori and Europeans. The only significant difference between Maori and Europeans was that Maori ate pork more frequently.(17) In the same country, Pacific Island men ate more red meat than Maori men, who in turn ate more than European men. Red meat intake by Pacific Islanders was the same as by Maori but higher than in Europeans.(20) Chinese Australian men born in Australia had a higher intake of red meat and lower intake of leafy greens. There was no birthplace effect in women.(18) Being born in the United States was a significant

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positive predictor of red meat intake in Korean American women in the United States.(22) In a sample of U.S. whites and Hispanics enrolled in a cardiovascular risk reduction project, adult whites ate red and cured meat more often than Hispanics. No significant difference was found in children.(29)

Studies using indirect measures of dietary intake

In the United States, Hispanics were more likely to consume beef than non-Hispanics. Whites were found to consume smaller quantities of beef than other races.(38) Using the same U.S. data, white households were found to be less likely to consume pork and also consumed smaller amounts of pork. No significant effects were found for being a Hispanic household.(42) The third national U.S. study found that being white lowered the proportion of the budget spent on ground beef. Hispanics spent a lower proportion of the meat budget on steak, but a larger proportion on roast and other beef.(44) Perceiving ones ethnic origin to influence tastes and preferences for variety meats was positively associated with variety meat consumption in a sample of retail shoppers in the United States.(34) In Canada, country of origin was not associated with the proportion of the budget spent on red or processed meat.(41)

Conclusion
The different classification systems make comparisons across studies difficult. For instance, Gossard et al. used both ethnicity (Hispanic) and race (white, black, Asian, Native American, other) variables, whereas Guenther et al. used a single race/ethnicity variable (white non-Hispanic, black non-Hispanic, Mexican American, other Hispanic). The dietary intake studies controlling for socio-economic status suggested that in the United States, blacks and Hispanics consume red meat more frequently or in larger quantities and have lower vegetable intakes. The findings from the studies not controlling for socio-economic status were difficult to interpret, as they might have been (partly) driven by differences in socio-economic status. Two studies in New Zealand suggested that Pacific Islanders consume more tomatoes, tomato products, and red meat than Maori and European New Zealanders. Being born in the United States (for Korean Americans) or in Australia (for Australian Chinese) was associated with higher red meat intake. The U.S. household-level studies found that white households consumed less beef and less pork.

2.3.2.6 Urban/rural residence Studies using direct measures of dietary intake

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Four U.S. studies controlled for income. In the general U.S. population, living in urban areas was associated with a lower intake of beef.(13) People living in non-central city metropolitan areas (not central city metropolitan areas) were more likely to consume pork than people living in non-metropolitan areas. The absolute intake of beef and pork was higher for people living in (non-central and central city) metropolitan areas than for people outside of metropolitan areas. Processed pork consumption did not depend on urban or rural living.(14) In the United States, women living in cities had lower intakes of lower-fat red meat, but higher intakes of high-fat red meat and higher intakes of cruciferous vegetables. Suburban residence was associated with a higher intake of medium-fat red meat, a higher probability of eating high-fat red meat and high fat lunch meat, a higher probability of eating green and yellow vegetables, and, finally, a higher intake of cruciferous vegetables.(23) Living in urban areas was not associated with beef or cured meat intake in male U.S. Army National Guard Reservists in New Jersey.(25) U.K. elderly living in rural areas were more likely to consume green vegetables; the analyses did not control for income.(21) Guatemalan adults selected from records of the INCAP longitudinal study ate more red meat and vegetables when living in urban areas. Intakes of commuters tended to be between those for urban and rural areas.(26) In the Mongolian Autonomous Region in China, the non-pastoral urban residence group had a higher probability of consuming vegetables daily.(11)

Studies using indirect measures of dietary intake

Beef consumption in the United States was not different in urban or rural areas.(38) The likelihood of consuming pork (but not the quantity consumed) was higher in rural areas.(42) U.S. households in urban areas spent a smaller proportion of their meat budget on steak; budget shares spent on other beef products were not different.(44) Residing in an urban area in Canada increased the proportion of the budget spent on red meat, but lowered the proportion spent on processed meat.(41) In Spain, urban residence increased the probability of consuming beef but lowered the amount spent on beef.(39)

Conclusion
The findings of the studies using direct measures of dietary intake do not show a consistent picture. Urban living in developed countries has been found to be associated with both higher and lower intakes of red meat and vegetable intake. The two studies from developing countries showed that urban living was associated with higher intake of vegetables and red meat (one study). It should be noted that an important factor that may

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drive the differences in diet between urban/rural areas is the difference in prices; a factor that was not controlled for in any of the studies with direct measures of dietary intake. The only significant differences found between rural and urban areas were in the household-level studies related to expenditure and budget shares, not to absolute quantities consumed.

2.3.2.7 Household size and composition Studies using indirect measures of dietary intake
Household size was not associated with intake of pork in U.S. adults.(7) However, it increased the probability of consuming beef and lowered the likelihood of consuming pork. The intake of pork was highest for individuals in two and three person households. Processed pork intake was not associated with household size. Having children younger than 5 was not associated with beef or (processed) pork intake.(14) In a representative study of U.S. women, having more children below 18 years of age was associated with a higher consumption of lower fat red meat and with a lower probability of consuming cruciferous vegetables. Women in larger households consumed smaller amounts of all types of red meat. Being childless was associated with higher intakes of lower-fat red meat, a lower probability of consuming high fat lunch meat and higher intakes of green and yellow vegetables and cruciferous vegetables. The intake of lower-fat red meat, the probability of consuming high-fat red meat, low fat lunch meat, and high fat lunch meat were higher in households with a male head present.(23) Household size was not associated with the probability of eating red or cured meats in male New Jersey National Guard reservists.(25) The frequency of eating veal was not associated with the number of children under 18 in supermarket shoppers in two Quebec cities.(28) In Belgium, having children under 12 years old was found to be associated with reduced intake of red meat.(27)

Studies using indirect measures of dietary intake

Household beef expenditure in the United States increased with the number of household members older than 19 and was lower when more children between 1 and 12 years of age were present.(32) In the same data set, both the likelihood to consume beef and the quantity consumed increased with household size.(38) The same was found for pork.(42) The fourth study on the general U.S. population found that household size increased the meat budget share spent on steak. The number of members younger than 20 increased the proportion of the meat budget spent on roast, but lowered ground beef budget share. More household members older than 65 decreased the budget share for roast; more members between 20 and 64 years old decreased the proportion spent on ground beef.(44)
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Kansas shoppers from larger households were more likely to purchase variety meats.(34) Household size was not associated with fresh beef, beef roast, or beef steak expenditure in the small Georgia consumer panel. Ground beef expenditure increased with household size but at a decreasing rate.(37) The budget share spent on processed meat was larger in larger households in Canada. No significant impact of household size on red meat was found.(41) The percentage of males in Spanish households increased the proportion of the budget spent on pork, lamb and goat, and processed pork in rural areas and the budget share spent on beef and veal, pork, and processed pork in urban areas. Significant but highly variable effects were found for the number of household members in different age groups.(35) Another study using the same data found the probability of purchasing beef and the amount spent on beef increased with household size.(39) The Bulgaria study reported that household size was positively associated with the probability of consuming beef, lamb, and sausage and to a higher frequency of consuming beef, pork, lamb, sausage, and Kremvirshi.(40) In Mexico, the probability of buying pork and the amount spent on pork were higher in larger households. The proportion of household members younger than 16 years of age lowered pork expenditure.(33) The effect of size in urban households in China differed for the different food groups: the proportion of the budget spent on beef and lamb was lower in larger households while the share spent on vegetables was positively associated with household size. The household size elasticity for fruits was negative as well.(43) Four studies included other household characteristics in the analysis. In Spain, single female-headed households were less likely to consume beef and spent smaller amounts on beef.(39) The presence of a spouse at home did not effect red or processed meat consumption in Canada.(41) U.S. households with a female meal planner were more likely to consume pork but the quantity of pork consumed was not different.(42) Having a female meal planner did not alter the proportion of the meat budget spent on different types of beef.(43)

Conclusion
The findings from the studies on dietary intake were contradictory: larger household size was found to be both positively and negatively associated with red meat intake. The finding of the one study on vegetable intake suggested that vegetable intake in women was higher if women had no children. As would be expected, the household-level studies (one of which was conducted in Mexico) generally found that size was positively associated with red meat expenditure and the quantity of red meat consumed. The positive association between the likelihood

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of consuming red meat and household size could be (partially) due to the higher absolute consumption in larger households: as absolute household consumption increases, the probability of having purchased red meat during the survey recall period increases. Larger households were further found to spend a larger proportion of their budget on processed meats (one study), and to consume red and processed meat more frequently (one study). In one study, households with more males spent a larger budget share on red and processed meat; another study found single-headed female households spent less on beef. In China, the proportion of the budget spent on beef and lamb decreased, while the proportion spent on vegetables increased, in larger households. Overall, the householdlevel studies did not allow us to draw conclusions on the association between household size and the per capita quantity consumed.

2.3.2.8 Marital status Studies using direct measures of dietary intake

Only two studies investigated the effect of marital status on dietary intake. Marital status was not associated with the intake frequency of beef, organ meats, lunch meat, bacon, or orange and green vegetables in low income elderly Mexican Americans and nonHispanic whites.(6) In the United Kingdom, being married was associated with more frequent consumption of red meat, but had no effect on the intake frequency of processed meat or meat pies.(10)

Studies using indirect measures of dietary intake

None of the household level papers studied marital status.

Conclusion
The evidence was too limited to draw meaningful conclusions.

2.3.2.9 Religion Studies using direct measures of dietary intake

No studies with direct measures of dietary intake estimated the effect of religion.

Studies using indirect measures of dietary intake

The only study with indirect measures of dietary intake was conducted in Israel. Religious observance was associated with higher consumption of processed meat but was not a significant predictor of beef consumption.(36)

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Conclusion
The evidence was too limited to draw meaningful conclusions.

2.3.2.10 Neighbourhood Studies using direct measures of dietary intake

The only study on neighbourhood was conducted in Scotland, comparing diets of residents from socially contrasting neighbourhoods controlling for socio-economic status. Neighbourhood explained 10.1% of the variance in processed meat consumption, but was not a significant determinant of bacon and ham or red meat intake. The most socially advantaged neighbourhood consumed less processed meat than the most socially disadvantaged neighbourhood.(9)

Studies using indirect measures of dietary intake

None of the identified papers studied neighbourhood.

Conclusion
The evidence was too limited to draw meaningful conclusions.

2.3.2.11 Family Studies using direct measures of dietary intake

Family dinner frequency was a statistically significant predictor of red and processed meat intake in children of the participants in the Nurses Health Study, but the coefficient was too small to be biologically significant.(12)

Studies using indirect measures of dietary intake

None of the identified papers studied family characteristics.

Conclusion
The evidence was too limited to draw meaningful conclusions.

2.3.3

Determinants of obesity

Sobal and Stunkard concluded that, based on the literature up to 1989, in developed countries, there was a clear negative association between SES and obesity in women; however, for men and children the relationship was inconsistent. In developing countries,

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a strong positive association was found between SES and obesity in women, men, and children.(46) According to Monteiro et al.s more recent review, the situation in developing countries had changed significantly. The authors concluded that obesity was increasingly prevalent in the lower SES groups and that the burden of obesity shifted to the groups of lower SES.(4)

Conclusion
Obesity is associated with lower SES in developed countries. In the poorest developing countries an inverse association is found. As the level of development increases, the burden of obesity shifts to the lowest SES groups. It is important to note that both reviews made a meaningful interpretation of socio-economic status difficult. Neither Sobal and Stunkard nor Monteiro et al. separated studies based on the measure of SES used, but pooled the findings from studies using income, education, and other SES measures. In addition, one could not evaluate to what extent the studies included in Sobal and Stunkards review represented the state of knowledge in 1989, as the authors did not report the study selection process.

2.4 Conclusions
This review identified 24 studies on the socio-economic and cultural determinants of individuals dietary intake, 16 studies with indirect measures of dietary intake such as individual or household food purchases, and 2 literature reviews on obesity. Before drawing any general conclusions on the determinants of diet, it is important to briefly discuss a number of limitations. First, the majority of studies identified were conducted in developed countries. Second, the evidence regarding fruit and vegetable consumption was very limited. Third, a limitation of many of the direct studies, and most of the indirect studies, was that the study samples were not clearly described: the process of drawing the sample, and the number of observations lost due to refusal to participate or incomplete data were seldom explicitly discussed. For instance, only one of the four studies using the 1987-88 U.S. Nationwide Food Consumption Survey mentioned the very low (38%) response rate. Virtually no study discussed how the loss of observations may have affected the validity of the study findings. A final limitation is that a number of studies did not adequately control for confounding variables. Despite the limitations outlined above, a lot can be learned from the studies reviewed. First of all, it is possible to draw a probable conclusion from the studies of red and processed meat consumption in developed countries. The studies on individual dietary intake in developed countries consistently show either a positive association, or no association, between red and processed meat intake and income. On balance, it is

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concluded that this reflects a moderate positive association: increasing income leads to higher intake of red and processed meats. Considered together, the household-level studies conducted in developed countries provide a slightly different picture: as income increases, households spend more on red and processed meats, but this is most likely a consequence of selecting for higher quality, and thus more expensive products, rather than of buying larger quantities (indicating that increases in income lead to increases in the quality of meat intake, not meat quantity). The difference between the individual and household-level studies does not necessarily indicate a contradiction, since it can be explained by differences or changes in intrahousehold allocation that were not addressed by any of the studies. In other words, red meat intake among some household members may increase, but not among others. More evidence is needed with respect to the overall income-diet relationship in developing countries. The same holds for the relationship between income and fruit and vegetable consumption in both developed and developing countries. A second clear finding that emerged from the reviewed studies was that education tended to have either no effect or a negative effect on individual dietary intake of red and processed meats. It is therefore concluded that higher education thus protects individuals from consuming red and processed meats. This conclusion was actually confirmed by the results of the household-level studies, which showed that increased educational status of households led to lower consumption of red and processed meat. This raises an interesting question for future research not resolved by the studies: how do income and education interact to determine dietary intake? i.e., as income increases, can higher levels of education protect individuals from consuming higher amounts of red and processed meat associated with higher income? As for income, the evidence for the relationship between education and fruit and vegetable intake in developing countries was very limited. Third, despite the fact that the race and ethnicity classification systems used in the different studies made comparisons across studies difficult, the dietary intake studies controlling for socio-economic status suggested that in the United States, blacks and Hispanics consume red meat more frequently or in larger quantities and have lower vegetable intakes than whites. The U.S. household-level studies similarly found that white households consumed less beef and less pork. Since all of these studies controlled for socio-economic status, the differences thus reflect differences in cultural patterns between the different race/ethnicity groups, and not simply differences in purchasing power. A fourth finding is that urban living in developed countries was associated with both higher and lower intakes of red meat and vegetables. Since the studies showed mixed results, no clear conclusions could be drawn. The limited evidence in developing

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countries, however, showed urban living to be associated with higher intake of vegetables and red meat. Despite the limitations of these studies (e.g., differences in prices, income, and availability between urban and rural areas were not controlled for), the finding that urban living changes peoples diet is important. Even though acculturation was not explicitly examined in any of the studies, the findings of a number of papers suggested it to be an important factor in determining dietary intake within the same ethnic groups. Being born in the United States for Korean Americans was associated with higher red meat intake than those not born in the United States. In Australian Chinese men, being born in Australia was associated with a higher intake of red meat and lower intake of leafy greens. In Chinese Australian women, education and red meat intake were positively associated with red meat intake. Finally, the urban/rural difference findings may to some extent - be explained by a process of adopting a different cultural and hence a different diet. Another interesting finding is that one determinant can be associated with both positive (i.e., healthy) and negative dietary behaviour. The studies conducted in New Zealand found significant differences in dietary intake between ethnic groups: Pacific Islanders consumed significantly more tomatoes and tomato products but at the same time ate more red and processed meat. Likewise, in urban living in developing countries was associated with both higher red meat and vegetable intake. Finally, obesity was found to be associated with lower socio-economic status in developed countries. In the poorest developing countries an inverse association was found, but as the level of development increased, the burden of obesity shifted to the lowest SES groups. It should be noted that evidence for socio-economic status was actually pooled evidence from studies using income, education, and other SES measures. Separating out the independent effects of SES and education and understanding how they jointly determine obesity is an important topic for future research.

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2-1

Appendix 2.1: Search record

DATABASE SEARCHED: PubMed SEARCH TYPE: PubMed Search DATE: Mar 3, 2006 LIMITS: Publication date: 1980 - 2006 Search Term Syntax Used (intervention studies OR intervention* OR public policy OR health policy OR nutrition policy OR randomized controlled trials OR health education OR nutrition education* OR education* OR government programs OR national health programs OR dietary guideline* OR guideline* OR health promotion OR nutrition programme* OR nutrition program* OR mass media OR food labelling OR food labeling OR nutrition information OR nutrition labelling OR nutrition labeling OR school health services OR school health service* OR school-based intervention*) AND (red meat* OR pork OR veal OR beef OR lamb OR mutton OR goat OR preserved meat* OR processed meat* OR meat products OR salted meat* OR pickled food* OR salting OR green vegetable* OR green leafy vegetable* OR cruciferous vegetable* OR tomato* OR allium* OR hot drink* OR aflatoxin*) AND (food OR consumption* OR intake* OR nutrition OR food choice* OR eating OR diet) (socio-economic factors OR socio-economic* OR poverty OR income OR family structure* OR family table* OR household expenditure* OR household* OR family OR families OR occupational status OR educational status OR education OR ulture rhood OR ulture rhood* OR neighbourhood OR neighbourhood* OR social environment OR residence characteristics OR marital status OR employment OR social class OR food insecurity OR parenting OR culture OR ulture* OR ethnic group OR ethnic group* OR taboo* OR taboo OR religion OR religi* OR transportation OR urbanisation OR urban population OR urban OR rural population OR rural) AND (red meat* OR pork OR veal OR beef OR lamb OR mutton OR goat OR preserved meat* OR processed meat* OR meat products OR salted meat* OR pickled food* OR salting OR green vegetable* OR green leafy vegetable* OR cruciferous vegetable* OR tomato* OR allium* OR hot drink* OR aflatoxin*) AND (food OR consumption* OR intake* OR nutrition OR food choice* OR eating OR diet)

Fields Searched All fields

# Articles 1,392

# Kept 98

Notes Intervention: Deleted many animal studies, salmonella, lysteria, trichinella

3,386

143

Socio-economic: Took out many animal studies, lab microbiological studies, salmonella, e.coli, etc. Also threw out studies that only addressed the association between food/patterns and cancer

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DATABASE SEARCHED: PubMed SEARCH TYPE: PubMed Search DATE: Mar 8, 2006 LIMITS: Publication date: 1980 Search Term Syntax Used (socio-economic factors OR socio-economic* OR poverty OR income OR family structure* OR family table* OR household expenditure* OR household* OR family OR families OR occupational status OR educational status OR education OR neighborhood OR neighborhood* OR neighbourhood OR neighbourhood* OR social environment OR residence characteristics OR marital status OR employment OR social class OR food insecurity OR parenting OR culture OR cultur* OR ethnic group OR ethnic group* OR taboo* OR taboo OR religion OR religi* OR transportation OR urbanisation OR urban population OR urban OR rural population OR rural) AND (food OR consumption* OR intake* OR nutrition OR food choice* OR eating OR diet) AND (fruit* OR vegetable*) AND (developing countries OR third world countries OR low income countr* OR middle income countr*) DATABASE SEARCHED: PubMed SEARCH TYPE: PubMed Search DATE: Mar 9, 2006 LIMITS: Publication date: 1980 Search Term Syntax Used (intervention studies OR intervention* OR public policy OR health policy OR nutrition policy OR randomized controlled trials OR health education OR nutrition education* OR education* OR government programs OR national health programs OR dietary guideline* OR guideline* OR health promotion OR nutrition programme* OR nutrition program* OR mass media OR food labelling OR food Fields Searched All # Articles 232 # Kept 8 Notes Intervention fruits and veggies: Fields Searched All # Articles 259 # Kept 16 Notes Socio-economic fruits and veggies: Removed studies on breast feeding and weaning practices, also studies about environmental contaminants, and bacteria

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labeling OR nutrition information OR nutrition labelling OR nutrition labeling OR school health services OR school health service* OR school-based intervention*) AND (fruit* OR vegetable*) AND (developing countries OR third world countries OR low income countr* OR middle income countr*) DATABASE SEARCHED: ISI Web of Science SEARCH TYPE: DATE: Mar 9, 2006 LIMITS: Search Term Syntax Used (socio-economic factors OR socio-economic* OR educational status OR education OR occupational status OR employment OR poverty OR income OR household expenditure* OR household OR neighborhood OR neighbourhood OR neighborhood* OR neighbourhood* OR residence characteristics OR transportation OR urbanisation OR urban population OR urban OR rural population OR rural OR social environment OR marital status OR social class OR family structure* OR family OR families OR family table* OR parenting OR culture OR culture* OR ethnic group OR ethnic group* OR taboo OR taboo* OR religion OR religi* OR food insecurity) AND (red meat* OR pork OR veal OR beef OR lamb OR mutton OR goat OR preserved meat* OR processed meat* OR meat products OR salted meat* OR pickled food* OR salting OR green vegetable* OR green leafy vegetable* OR cruciferous vegetable* OR tomato* OR allium* OR hot drink* OR aflatoxin*) AND (food OR consumption* OR intake* OR nutrition OR food choice* OR eating OR diet) Fields Searched All # Articles 1,699 # Kept 107 Notes Socio-economic: Got rid of many related to E. coli, other bacteria, ELISA tests, metabolism, determinants of cancer, plant studies, animal studies and animal nutrition,

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DATABASE SEARCHED: ISI Web of Science SEARCH TYPE: DATE: Mar 10, 2006 LIMITS: 1987-2006 (default) Search Term Syntax Used ((government programs OR national health programs OR dietary guideline* OR guideline* OR health promotion OR nutrition programme* OR nutrition program* OR mass media OR food labelling OR food labeling OR nutrition information OR nutrition labelling OR nutrition labeling OR school health services OR school health service* OR school-based intervention*) AND (red meat* OR pork OR veal OR beef OR lamb OR mutton OR goat OR preserved meat* OR processed meat* OR meat products OR salted meat* OR pickled food* OR salting OR green vegetable* OR green leafy vegetable* OR cruciferous vegetable* OR tomato* OR allium* OR hot drink* OR aflatoxin*) AND (food OR consumption* OR intake* OR nutrition OR food choice* OR eating OR diet)) OR ((intervention studies OR intervention* OR public policy OR health policy OR nutrition policy OR randomized controlled trials OR health education OR nutrition education* OR education*) AND (red meat* OR pork OR veal OR beef OR lamb OR mutton OR goat OR preserved meat* OR processed meat* OR meat products OR salted meat* OR pickled food* OR salting OR green vegetable* OR green leafy vegetable* OR cruciferous vegetable* OR tomato* OR allium* OR hot drink* OR aflatoxin*) AND (food OR consumption* OR intake* OR nutrition OR food choice* OR eating OR diet)) (socio-economic factors OR socio-economic* OR poverty OR income OR family structure* OR family table* OR household expenditure* OR household* OR family OR families OR occupational status OR educational status OR education OR neighborhood OR neighborhood* OR neighbourhood OR neighbourhood* OR social environment OR residence characteristics OR marital status OR employment OR social class OR food insecurity OR parenting OR culture OR cultur* OR ethnic group OR ethnic group* OR taboo* OR taboo OR religion OR religi* OR transportation OR urbanisation OR urban population OR urban OR rural population OR rural) AND (food OR consumption* Fields Searched All # Articles 667 # Kept 73 Notes Intervention: Got rid of many related to E. coli, other bacteria, ELISA tests, metabolism, determinants of cancer, plant studies, animal studies and animal nutrition

All

73

10

Socio-economic fruits and veggies:

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OR intake* OR nutrition OR food choice* OR eating OR diet) AND (fruit* OR vegetable*) AND (developing countries OR third world countries OR low income countr* OR middle income countr*) DATABASE SEARCHED: ISI Web of Science SEARCH TYPE: DATE: Mar 13, 2006 LIMITS: 1987-2006 (default) Search Term Syntax Used (intervention studies OR intervention* OR public policy OR health policy OR nutrition policy OR randomized controlled trials OR health education OR nutrition education* OR education* OR government programs OR national health programs OR dietary guideline* OR guideline* OR health promotion OR nutrition programme* OR nutrition program* OR mass media OR food labelling OR food labeling OR nutrition information OR nutrition labelling OR nutrition labeling OR school health services OR school health service* OR school-based intervention*) AND (fruit* OR vegetable*) AND (developing countries OR third world countries OR low income countr* OR middle income countr*) DATABASE SEARCHED: Sociological Abstracts SEARCH TYPE: DATE: Mar 13, 2006 LIMITS: 1980-2007 Search Term Syntax Used ( social w status OR socio-economic* OR socio-economic w factors OR socio-economic w status OR socio-economic w class OR education OR education w work w relationship OR occupational w status OR employment OR poverty OR income OR household* OR neighborhood* OR neighbourhood* OR residence w characteristic* OR transportation OR urbanisation OR urban w population* OR urban OR rural w population* OR rural OR social w environment Fields Searched All # Articles 48 # Kept 7 Notes Intervention fruits and veggies:

Fields Searched

# Articles 64

# Kept 12

Notes Socio-economic:

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OR marital w status OR social w class OR family OR families OR parenting OR parenting w methods OR culture* OR ethnic w group* OR taboo* OR religion* OR religious OR food w insecurity OR food w security) AND ( red w meat* OR pork OR veal OR beef OR lamb OR mutton OR goat OR preserved w meat* OR processed w meat* OR meat w products OR salted w meat* OR pickled w food* OR salting OR green w vegetable* OR green w leafy w vegetable* OR cruciferous w vegetable* OR tomato* OR allium* OR hot w drink* OR aflatoxin*) AND ( food OR consumption* OR intake* OR nutrition OR food w choice* OR eating OR diet) ( intervention w studies OR intervention* OR public w policy OR health w policy OR nutrition w policy OR randomized w controlled w trials OR health w education OR nutrition w education* OR education* OR government w programs OR national w health w programs OR dietary w guideline* OR guideline* OR health w promotion OR nutrition w programme* OR nutrition w program* OR mass w media OR food w labeling OR food w labelling OR nutrition w information OR nutrition w labeling OR nutrition w labelling OR school w health w service* OR school-based w intervention*) AND ( red w meat* OR pork OR veal OR beef OR lamb OR mutton OR goat OR preserved w meat* OR processed w meat* OR meat w products OR salted w meat* OR pickled w food* OR salting OR green w vegetable* OR green w leafy w vegetable* OR cruciferous w vegetable* OR tomato* OR allium* OR hot w drink* OR aflatoxin*) AND ( food OR consumption* OR intake* OR nutrition OR food w choice* OR eating OR diet) ( social w status OR socio-economic* OR socio-economic w factors OR socio-economic w status OR socio-economic w class OR education OR education w work w relationship OR occupational w status OR employment OR poverty OR income OR household* OR neighborhood* OR neighbourhood* OR residence w characteristic* OR transportation OR urbanisation OR urban w population* OR urban OR rural w population* OR rural OR social w environment OR marital w status OR social w class OR family OR families OR parenting OR parenting w methods OR culture* OR ethnic w group* OR taboo* OR religion* OR religious OR food w insecurity OR food w security) AND ( fruit* OR vegetable*) AND ( food OR consumption* OR intake* OR nutrition OR food w choice* OR eating OR diet) AND ( developing w countries OR third w world w countr* or low w income w areas OR low w income w countr* OR

Intervention:

Socio-economic fruits and veggies: Article on feasibility of anthropometric studies in Bolivia and Samoa

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middle w income w countr*) ( intervention w studies OR intervention* OR public w policy OR health w policy OR nutrition w policy OR randomized w controlled w trials OR health w education OR education* OR government w programs OR national w health w programs OR guideline* OR health w promotion OR nutrition w programme* OR nutrition w program* OR mass w media OR food w labeling OR food w labelling OR nutrition w information OR nutrition w labeling OR nutrition w labelling OR school w health w service* OR school-based w intervention*) AND ( fruit* OR vegetable*) AND ( food OR consumption* OR intake* OR nutrition OR food w choice* OR eating OR diet) AND ( developing w countries OR third w world w countr* or low w income w areas OR low w income w countr* OR middle w income w countr*) Obesity and determinants and review DATABASE SEARCHED: ERIC SEARCH TYPE: DATE: Mar 24, 2006 LIMITS: 1980-2007 Journal Articles Only Search Term Syntax Used (socio-economic* OR "socio-economic background" OR "socioeconomic influences" OR "socio-economic status" OR education* OR "educational background" OR "education work relationship" OR "occupational status" OR employment OR poverty OR income OR household* OR neighborhood* OR neighbourhood* OR "community characteristics" OR transportation OR urbanisation OR urban* OR "urban population" OR rural* OR "rural population" OR "social environment" OR "marital status" OR "social class" OR "social factors" OR family OR families OR "family sociological unit" OR "family income" OR parenting OR "child rearing" OR culture* OR "ethnic group*" OR taboo* OR religion OR religious OR "food security" OR "food insecurity") AND ("red meat" OR pork OR veal OR beef OR lamb OR mutton OR goat OR "preserved meat" OR 1 0 Intervention fruits and veggies: Same as above

Obesity

Fields Searched All

# Articles 7

# Kept 1

Notes Socio-economic:

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"processed meat" OR "meat products" OR "salted meat" OR "pickled food*" OR salting OR "green vegetable*" OR "green leafy vegetable" OR "cruciferous vegetable" OR tomato* OR allium* OR "hot drink" OR aflatoxin) AND (food OR consumption* OR intake* OR nutrition OR "food choice" OR eating OR diet) (intervention* OR "public policy" OR "health policy" OR "nutrition policy" OR "randomized controlled trials" OR "health education" OR education OR "comprehensive school health education" OR "nutrition education" OR "nutrition program" OR "nutrition information" OR "government program*" OR "national health program*" OR "national program" OR "outreach program" OR "dietary guideline*" OR "health promotion" OR "educational media" OR "mass media" OR "food labeling" OR "food labelling" OR "nutrition labeling" OR "nutrition labelling") AND ("red meat" OR pork OR veal OR beef OR lamb OR mutton OR goat OR "preserved meat" OR "processed meat" OR "meat products" OR "salted meat" OR "pickled food*" OR salting OR "green vegetable*" OR "green leafy vegetable" OR "cruciferous vegetable" OR tomato* OR allium* OR "hot drink" OR aflatoxin) AND (food OR consumption* OR intake* OR nutrition OR "food choice" OR eating OR diet) (socio-economic* OR "socio-economic background" OR "socioeconomic influences" OR "socio-economic status" OR education* OR "educational background" OR "education work relationship" OR "occupational status" OR employment OR poverty OR income OR household* OR neighborhood* OR neighbourhood* OR "community characteristics" OR transportation OR urbanisation OR urban* OR "urban population" OR rural* OR "rural population" OR "social environment" OR "marital status" OR "social class" OR "social factors" OR family OR families OR "family sociological unit" OR "family income" OR parenting OR "child rearing" OR culture* OR "ethnic group*" OR taboo* OR religion OR religious OR "food security" OR "food insecurity") AND (fruit* OR vegetable*) AND (food OR consumption* OR intake* OR nutrition OR "food choice" OR eating OR diet) AND (third world countr* OR developing nations OR developing countr* OR middle income countr* OR low income countr*) (intervention* OR "public policy" OR "health policy" OR "nutrition policy" OR "randomized controlled trials" OR "health education" OR education OR "comprehensive school health education" OR "nutrition education" OR "nutrition program" OR "nutrition information" OR

Intervention:

Socio-economic fruits and veggies:

Intervention fruits and veggies:

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"government program*" OR "national health program*" OR "national program" OR "outreach program" OR "dietary guideline*" OR "health promotion" OR "educational media" OR "mass media" OR "food labeling" OR "food labelling" OR "nutrition labeling" OR "nutrition labelling") AND (fruit* OR vegetable*) AND (food OR consumption* OR intake* OR nutrition OR "food choice" OR eating OR diet) AND ("third world countr*" OR "developing nations" OR "developing countr*" OR "middle income countr*" OR "low income countr*") DATABASE SEARCHED: EconLit SEARCH TYPE: DATE: Mar 15, 2006 LIMITS: 1980-2007 Search Term Syntax Used ( social w status OR socioeconomic* OR sociodemographic OR sociocultural OR education OR education w policy OR occupation OR employment OR poverty OR income OR household* OR household w economics OR neighborhood* OR neighbourhood* OR transportation OR urbanisation OR urban w population* OR urban OR rural w population* OR rural OR social w environment OR marital OR social w class OR family OR families OR parenting OR culture* OR ethnic* OR taboo* OR religion* OR religious OR food w insecurity OR food w security) AND ( red w meat* OR pork OR veal OR beef OR lamb OR mutton OR goat OR preserved w meat* OR processed w meat* OR meat w products OR salted w meat* OR pickled w food* OR salting OR green w vegetable* OR green w leafy w vegetable* OR cruciferous w vegetable* OR tomato* OR allium* OR hot w drink* OR aflatoxin*) AND ( food OR consumption* OR intake* OR nutrition OR food w choice* OR eating OR diet) ( intervention* OR public w policy OR food w policy OR nutrition w policy OR education* OR government w program* OR government w programme* OR guideline* OR health w promotion OR nutrition w program* OR nutirition w programme* OR media OR food w labelling OR food w labeling OR nutrition OR school*) AND ( red w meat* OR pork OR veal OR beef OR lamb OR mutton OR goat OR preserved w

Fields Searched

# Articles 51

# Kept 13

Notes Socioeconomic:

1980-2007 Journals only

144

17

Intervention: Threw out many animal and livestock studies and studies on meat production/industry policy,

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meat* OR processed w meat* OR meat w products OR salted w meat* OR pickled w food* OR salting OR green w vegetable* OR green w leafy w vegetable* OR cruciferous w vegetable* OR tomato* OR allium* OR hot w drink* OR aflatoxin*) AND ( food OR consumption* OR intake* OR nutrition OR food w choice* OR eating OR diet) ( intervention* OR public w policy OR food w policy OR nutrition w policy OR education* OR government w program* OR government w programme* OR guideline* OR health w promotion OR nutrition w program* OR nutirition w programme* OR media OR food w labelling OR food w labeling OR nutrition OR school*) AND (fruit* OR vegetable*) AND ( food OR consumption* OR intake* OR nutrition OR food w choice* OR eating OR diet) AND ( developing w countr* OR third w world w countr* OR middle w income w countr* OR low w income w countr*) ( social w status OR socioeconomic* OR sociodemographic OR sociocultural OR education OR education w policy OR occupation OR employment OR poverty OR income OR household* OR household w economics OR neighborhood* OR neighbourhood* OR transportation OR urbanisation OR urban w population* OR urban OR rural w population* OR rural OR social w environment OR marital OR social w class OR family OR families OR parenting OR culture* OR ethnic* OR taboo* OR religion* OR religious OR food w insecurity OR food w security) AND (fruit* OR vegetable*) AND ( food OR consumption* OR intake* OR nutrition OR food w choice* OR eating OR diet) AND ( developing w countr* OR third w world w countr* OR middle w income w countr* OR low w income w countr*)

11

Intervention fruits and veggies:

Socioeconomic fruits and veggies:

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DATABASE SEARCHED: PubMed SEARCH TYPE: PubMed DATE: February 13, 2006 LIMITS: none Search Term Syntax Used obes* and determinant*

Fields Searched Reviews

# Articles 327

# Kept 60 (title) 40 (abst)

Notes Threw out genetic studies and postobesity consequences. Threw out studies that addressed genetic and metabolic determinants of obesity as this was considered out of the scope of the review.

DATABASE SEARCHED: ISI Web of Science SEARCH TYPE: General (all topic words) in all ISI databases: - Science Citation Index Expanded (SCI-EXPANDED)--1974-present - Social Sciences Citation Index (SSCI)--1974-present - Arts & Humanities Citation Index (A&HCI)DATE: February 14, 2006 LIMITS: -Papers between 1987 and 2006 (default) Search Term Syntax Used obes* AND determinant* AND review Fields Searched All # Articles 90 # Kept 19 (title) 14 (abst) Notes Many papers focusing on blood pressure/hypertension/diabetes. Also metabolic and genetic studies.

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DATABASE SEARCHED: Sociological Abstracts SEARCH TYPE: DATE: Mar 27, 2006 LIMITS: 1980-2007 Search Term Syntax Used obes* AND determinant*

Fields Searched All

# Articles 11

# Kept 1

Notes Obesity: Only kept review articles, threw out 9 that werent reviews and one review that focused on smoking

DATABASE SEARCHED: ERIC SEARCH TYPE: DATE: Mar 24, 2006 LIMITS: 1980-2007 Journal Articles Only Search Term Syntax Used obes* AND determinant*

Fields Searched All

# Articles 4

# Kept 1

Notes

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DATABASE SEARCHED: EconLit SEARCH TYPE: DATE: Mar 27, 2006 LIMITS: 1980-2007 Journal Articles only Search Term Syntax Used Obes* AND determinant*

Fields Searched

# Articles 2

# Kept 0

Notes obesity: No reviews

DATABASE SEARCHED: EconLit SEARCH TYPE: DATE: Mar 15, 2006 LIMITS: 1980-2007 Journal articles only Search Term Syntax Used ( social w status OR socioeconomic* OR sociodemographic OR sociocultural OR education OR education w policy OR occupation OR employment OR occupational w status OR poverty OR income OR household* OR household w economics OR neighborhood* OR neighbourhood* OR transportation OR urbanisation OR urban w population* OR urban OR rural w population* OR rural OR social w environment OR marital OR social w class OR family OR families OR parenting OR culture* OR ethnic* OR taboo* OR religion* OR religious OR food w insecurity OR food w security) AND ( red w meat* OR pork OR veal OR beef OR lamb OR mutton OR goat OR preserved w meat* OR processed w meat* OR meat w products OR salted w meat* OR pickled w food* OR salting OR green w vegetable* OR green w leafy w vegetable* OR cruciferous w vegetable* OR tomato* OR allium* OR hot w drink* OR aflatoxin*) AND ( food OR consumption* OR intake* OR nutrition OR food w choice* OR eating OR diet)

Fields Searched

# Articles 110

# Kept 31

Notes Socioeconomic: Re -searched

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( social w status OR socioeconomic* OR sociodemographic OR sociocultural OR education OR education w policy OR occupation OR occupational w status OR employment OR poverty OR income OR household* OR household w economics OR neighborhood* OR neighbourhood* OR transportation OR urbanisation OR urban w population* OR urban OR rural w population* OR rural OR social w environment OR marital OR social w class OR family OR families OR parenting OR culture* OR ethnic* OR taboo* OR religion* OR religious OR food w insecurity OR food w security) AND (fruit* OR vegetable*) AND ( food OR consumption* OR intake* OR nutrition OR food w choice* OR eating OR diet) AND ( developing w countr* OR third w world w countr* OR middle w income w countr* OR low w income w countr*)

Socioeconomic fruits and veggies:

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Appendix 2.2: Summary of descriptive quantitative studies using direct measures of dietary intake reviewed
Reference/ Year Bartholomew et al. 1990 (6) Data analysis/ Evaluation Multivariate Weekly intake frequency =f(income, ethnicity, marital status, gender, age and education) Results (p<.05) +increase -decrease Organ meat: +income Mexican American (vs. white) Beef: +education level Bacon: + income Lunch meat: +age, male Orange or green vegetables: Mexican American (vs. white) Intake (yes/no): + income, age, non-metro, black, smoking, BMI, eating red meat, pork advertising - education, low-fat diet, fall, always trim fat, knowing diet can make a diff in disease Intake (amount): +pork advertising, male, fall NOTE: sign =p<0.10

Focus Country: US Exposure: income, ethnicity, marital status, and education Outcome: weekly intake frequency of beef, organ meats, lunch meat, bacon, orange and green vegetables Country: US Exposure: income, region, HH size, race, education, employment, government programme Outcome: intake (yes/no and amount) of pork

Methods Design: crosssectional Diet data: FFQ (57 items) from the Hispanic Health and Nutrition Examination Survey (HHANES)

Capps and Park 2002 (7)

DemoryLuce et al. 2004 (8)

Multivariate Intake pork (yes/no and amount)=f(adverti sing, income, age, region, HH size, gender, race, education, employment, season, participation in gov. programme, health, nutrition, attitudinal & lifestyle factors) Country: US Design: longitudinal N=246 (out of ?) Multivariate* Exposure: ethnicity (89-91 follow up of Age: 10 (baseline), 19-28 Change in mean daily intake of = Outcome: change in three cross-sectional (follow up) f(age, sex, mean daily intake surveys conducted Gender: F & M of pork, beef from from 73-79) Population: cohort from ethnicity, energy intake at baseline childhood to young Diet data: one 24 hr Bogalusa Heart Study ( dietary recall in each 31% African Am., 69% and follow-up, adulthood survey cohort effects) European Am.)

Design: crosssectional Diet data: two days of intake data

Sample Characteristics N=252 (out of 522) Age: >=68 Gender: F & M Population: low income elderly Mexican Americans and nonHispanic whites; sample based on 1976 area probability sample of subjects in 4 census tracts in San Antonio, TX (in 1984 50 % attrition from original sample) N = 4691 (out of 5649?) Age: >20 Gender: F & M Population: general American population (1994-96 Continuing Survey of Food Intake of Individuals & Diet and Health Knowledge Survey)

Quality Issuess Limitations Representativeness due to attrition Stepwise regression Only significant coefficients reported

Strengths One of the few double hurdle models on dietary intake Limitations Not clear what the original DHKS/CSFII sample size was and how many observations were not included in the analysis because of missing data Model does not control for energy intake

Strengths Longitudinal study Controlled for energy intake Limitations Limited information on original cohort Results table confusing Only one 24 hour recall per survey

Beef: age?

2-65

Reference/ Year Forsyth et al. 1994 (9)

Focus Country: Scotland Exposure: neighborhood, social class, and income Outcome: intake frequency of processed and red meats

Methods Design: crosssectional Diet data: Self-administered FFQ

Sample Characteristics N= 691 (out of 960?) Age: 40 and 60 Gender: F & M Population: part of longitudinal study on social patterning and health in Glasgow City

Data analysis/ Evaluation Multivariate+ Intake frequency =f(neighbourhood , age, sex, social class) Intake frequency =f(idem, income, housing tenure, car ownership)

Quality Issuess Limitations Insufficient information on sample construction Coefficients not reported, only % of variance explained (hence NOTE: direction effect is not reported the direction of the effects is not clear) Results not reported (but insignificant) for HH income, housing tenure and car ownership Limitations Not sufficient information on sample construction No discussion of effect drawing sample from general practices No control for socioeconomic variables Red meat: +age, married education Processed meat: -education Meat Pies: -education

Results (p<.05) +increase -decrease Processed meat: neighbourhood, sex Bacon and ham: age Red Meat: age, gender

Fraser et al. 2000 (10)

Country: England Exposure: marital status and education Outcome: intake frequency of red & processed meats

Design: crosssectional Diet data: repeated diet diary, 24-hr recall, self administered FFQ Design: crosssectional Diet data: FFQ

Fu et al. 2000 Country: China (11) Exposure: pastoral/urban living, ethnicity, education Outcome: daily intake of vegetables

N=1968 (out of ?) Age: 45-74 Gender: M& F Population: East Anglia cohort of the EPIC study (recruited in general practices; 33% invited, participated) N = 592 (out of ?) Age: mean 35-46 Gender: F & M Population: people visiting physicians in Huhlot, the capital of the Mongolian Autonomous Region

Multivariate Intake frequency =f(gender, age) Freq=f(marital status, gender, age) Freq=f(education, gender, age) Univariate Multivariate Daily vegetable intake=f(pastoral living, ethnic Mongolian, education, age, sex)

Daily vegetable consumption: Limitations Algorithm sample selection is + non pastoral urban living and female not clear Logistic models presented for consumption of meat, fish, milk and vegetables, but not for fruits (even though fruits form a food group discussed in this article) Range values education not given

2-66

Reference/ Year Gillman et al. 2000 (12)

Focus Country: US Exposure: family dinner frequency, income Outcome: intake of red and processed meat

Methods Design: crosssectional Diet data: selfadministered mailed survey including a semi-quantitative FFQ

Gossard and York 2003 (13)

Country: US Exposure: income, education, occupation, race, ethnicity, urban, region Outcome: daily intake of beef

Design: crosssectional Diet data: twononconsecutive interviewer administered 24-hr dietary recalls

Data analysis/ Sample Characteristics Evaluation N=16202 (out of Multivariate 25000) Servings of red Age: 9-14 and processed Gender: F & M meat=f(family Population: children of dinner frequency, participants in Nurses age, sex) Health Study (all eligible Further added: children invited) BMI, physical activity, hours of TV, smoking intention, smoking in home, 2-parent home, HH income, child making own dinner N = 8876 (out of 15028) Multivariate Age: 18-90 Daily beef Gender: F & M intake=f(income, Sample Population: data education, from US Continuing occupational Survey of Food Intakes status, age, race, by Individuals ethnicity, gender, urban, region, wt, gender x ethnicity, gender x race)

Quality Issuess Strengths Details on sample construction Children from 50 US States Limitations No discussion of impact of excluding many observations Not clear whether other covariates (in italics) were controlled for simultaneously; coefficients not reported

Results (p<.05) +increase -decrease Red and processed meat: + dinner frequency NOTE: even though significant, coefficient is so small that it is not biologically significant

Strengths Controls for socioeconomic status Evaluated impact missing values Controlled for body weight

Beef: main effects model: -education, urban, age, female, Asian & other race (vs white) +income, wt, Hispanic, black & native American (vs white) Interaction: difference between male & female depends on race: man>women: white, black, Asian, other; women>men: native American

2-67

Reference/ Year Guenther et al. 2005 (14)

Focus Country: US Exposure: region, urban, income, education, HH characteristics, race/ethnicity Outcome: intake (yes/no and amount) of beef, pork and processed pork

Methods Design: crosssectional Diet data: 2 nonconsecutive 24hr food recalls

Sample Characteristics N=5,649** (out of ?) Age: >= 20 Gender: F & M Population: data from individuals in National Continuing Survey of Food Intakes by Individuals and the Diet and Health Knowledge Survey

Gulliford et al. 2003 (15)

Country: Trinidad and Tobago Exposure: food security and ethnicity Outcome: intake of fruits and green vegetables and salad at least 5-6 days/week

Design: crosssectional Diet data: Interviewer administered FFQ (10 food groups)

N = 531 (out of 631) Age: >25 Gender: F & M Population: random sample of 300 HH (considered representative of ethnic & SE characteristics of population Trinidad & Tobago)

Data analysis/ Evaluation Multivariate Intake (yes/no)= f(region, urban, sex, education, HH size, race/ethnicity, assessment of own diet, diet beliefs, nutrition knowledge, pork nutrition knowledge lowfat choices) Intake (amount)= f(region, urban, income, sex, education, HH size, race/ethnicity, children 1-5, assessment own diet, diet beliefs, nutrition knowledge, pork nutrition knowledge, factors important when buying food) Multivariate Food intake at least 5-6 days/week = f(food security, age, sex, ethnicity)

Quality Issuess Limitations Representativeness of the sample not clear Two regression models different: e.g., income only a covariate in the second model; how did the authors decide on what variables to use in each model (theory, statistitical fit, ?)

Results (p<.05) +increase -decrease Beef (yes/no): - Northeast, female, > high school, < high school, law fat diet believed important, low fat choice; + Mex American, HH size, own diet perceived too fat Beef (amount): - metro, female, low chol. diet believed important; + Midwest, Black non-Hispanic Pork (yes/no): - metro (non-central city), female, college education, HH size, own diet perceived not fat enough, low fat choice; + Midwest, black non-Hispanic, pork nut knowledge Pork (amount): - metro, female, low chol. diet believed important, low fat choices; + Midwest, Northeast, HH 2-3 people, black non-Hipanic Processed Pork (yes/no): - West, female, college education, low fat diet believed important; +low fat choice Processed Pork (amount): - West, income, female, college education, nutrition & lowfat choice import when buying food;

Fruit: Strengths Detailed information on sample -food insecure Green vegetables and salad: -food insecure Limitations Coefficients for ethnicity not reported

2-68

Reference/ Year Guo et al. 1999 (16)

Harris et al. 2004 (17)

Focus Country: China Exposure: income, HH size, urban, region Outcome: intake of pork ((cross) price elasticities) Country New Zealand Exposure: ethnicity Outcome: frequency of tomato, green vegetable, lamb, pork intake

Methods Design: Longitudinal Diet data: 24-hr dietary recall combined with weighing and measurement Design: crosssectional Diet data: self administered FFQ

Data analysis/ Sample Characteristics Evaluation N=6,667 (out of ?) Multivariate++ Pork intake (1989, 1991, 1993) (yes/no and Age: 20-45 amount)=f(prices, Gender: F & M Population: China Health income, age, HH size, gender, and Nutrition Survey urban, region) N= 1,031 (out of 1,405) Age: 40-69 Gender: M Population: identified in census units with >5% Maori/Pacific Islanders and through hepatitis & diabetes screening programme for Maori/PI (616 New Zealand Europeans (E), 230 Maori (M), 185 PI (PI)) Multivariate Intake frequency =f(ethnic group, age)

Quality Issuess Limitations Representativeness Statistical significance shown for price elasticities intake (yes/no and amount), but not for the difference in elasticities between the poor and the rich

Hsu-Hage et al. 1995 (18)

Limitations Recruitment process not clear Loss due to missing data not discussed Authors present table with means by ethnic group (adjusted for age) and table with p-values. It is not clear whether p-values are age adjusted as well. No definition of difference tomato sauce and table tomato sauce No control for energy intake No control for SES Country: Australia Design: crossN= 545 (out of ?) Multivariate Strengths Exposure: Age: >=25 Mean daily intake Representativeness discussed sectional education, length of Diet data: FFQ (220- Gender: F & M (per MJ) = Controlled for energy intake stay in Australia, item); reference Population: sampling list f(education, age, being born in portions used to using Chinese surnames length of stay in Limitations Australia calculate to calculate compiled from telephone Australia) P values for differences in Outcome: mean daily intake/day. directory (representative Mean daily intake means or trends? daily intake (per of Melbourne Chinese) (per MJ) =f(birth The food groups reported MJ) of red meat, place, age, length different for the different leafy green of stay, exposures and for men and vegetables education) women; not clear how selection Men and women was done and what the authors analyzed chose to report separately.

Results (p<.05) +increase -decrease Elasticity for intake (yes/no): - price of rice, pork, eggs, oils + price of wheat flour, coarse grains Elasticity for intake (amount): - price of pork, eggs, oil + price of coarse grains Larger elasticities for the poor (NOTE: see concerns) Raw & cooked tomatoes, tomato juice, tomato soup, table tomato sauce : PI > M &E Tomato sauce: PI < M & E Green Vegetables: PI > M & E Lamb: PI > M & E Pork: PI>M>E

Men: Leafy greens: - education, born in Australia Red meats: + born in Australia Women: Red meat: + education (?)

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Reference/ Year McIntosh et al. 1995 (19)

Data analysis/ Focus Methods Sample Characteristics Evaluation Country: USA N=424 (out of 397?) Design: crossMultivariate Exposure: Age: >58 No efforts to sectional education, Diet data: Gender: F & M reduce red meat companionship questionnaire Population: free living intake vs Outcome: No elderly Anglos (>=58) in reduction due to efforts to reduce red metropol. Houston area; (a) friends/ meat intake vs recruited through random relatives, (b) mass reduction due to (a) digit dialing (355) and media, (c) friends/ relatives, random sample of physician, (d) self (b) mass media, (c) American Association of =f(companions, doctor, (d) self Retired Persons and abdominal girth, churches food attitudes health foods, education, sex, sex X companion, sex X attitudes) Metcalf et al. Country: New Design: crossN = 5,523 (out of 5,677) Multivariate 1998 Zealand Age: 40+ Mean servings sectional (20) Exposure: ethnicity Diet data: FFQ (142- Gender: F & M per month= Outcome: servings item) Population: health f(ethnicity, age, per month of red screening survey work total energy meat force (Maori (M), Pacific intake) by gender Islanders (PI) & European New Zealanders (E)) Morgan et al. Country: UK N = 2,041 (out of 2,333) Multivariate Design: cross2000 Exposure: urban, Age: >=65 Daily intake = sectional (21) living with others, Diet data: FFQ Gender: F & M f(urban, age, occupation, Population: subset from urban x age, sex, education Medical Research living with others, Outcome: daily Council Cognitive occupation, intake of green Function and Ageing education) vegetable Study

Quality Issuess Strengths Authors report information on subjects not included in the analysis

Results (p<.05) +increase -decrease Reducing red meat intake: + small abdominal girth (indep of source); belief in efficacy health foods (because of source mass media or physician), men (because of mass media & physician); women with companionship from social network (because of friends/relatives) - education (because of friends/relatives, self)

Strenghts Control for energy intake Limitations Representativeness not discussed No control for SES

Red meat (men): PI>M>E Red Meat (women): PI & M > E

Green vegetables: Strengths Sample selection and exclusion +rural, female, living with others clearly described Interaction: rural effect stronger for >=75 year olds

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Reference/ Year Park et al. 2005 (22)

Focus Country: US Exposure: place of birth (US vs Korea), education Outcome: intake (servings/day) of red meats, organ meats, processed meats, dark green vegetables, tomatoes

Methods Design: crosssectional Diet data: Selfadministered quantitative FFQ

Sample Characteristics N = 492 (out of ?) Age: 45-75 Gender: F Population: US and Korea born Korean American (drawn from the Multiethnic Cohort Study in Hawaii & LA)

Data analysis/ Evaluation Multivariate Servings/day= f(place of birth (US vs Korea), age, education, BMI, smoking status and physical activity)

Quality Issuess Strengths Sample selection clear Acknowledge non representativeness Limitations FFQ not developed for Koreans Only coefficients for US vs Korea born reported No control for energy intake No control for SES

Results (p<.05) +increase -decrease Red meat: +US born

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Reference/ Year Popkin et al. 1989 (23)

Data analysis/ Focus Methods Sample Characteristics Evaluation Country: US Design: crossN= 5,406 (1977) and Multivariate*** Exposure: ethnicity, sectional Intake (yes/no 1,068 (1985) residence, HH size Diet data: for these and amount)= Age: 19-50 and structure, f(year (77 or 85), analyses: 1977: 1day Gender: F income, weight, ethnicity, 24h recall +2day Population: compared employment, suburb or central food record data from two nat. education, region city residence, 1985: 3 days of 24h representative surveys: Outcome: intake special diet status, recall Nationwide Food (yes/no and HH size and Consumption Survey amount) of beef, structure, income, (1977) and Continuing pork & mixed Survey of Food Intake by employment, dishes; lunch meats education, region, Individuals (1985) & sausage; dark season, X year green or yellow interaction with vegetables each primary indep var)

Swanson et al. 1993 (24)

Country: US Exposure: education, race Outcome: frequency red and processed meat intake

Design: crosssectional Diet data: FFQ

Results (p<.05) +increase -decrease Quality Issuess Lower fat red meat (yes):NS Strength Lower fat red meat (amount): Control for body weight + Children <18, childless, male HHH Control for SES present; - HH size, city Medium fat red meat (yes): Limitations Sample selection 1977 data not + Other race; - food stamps Medium fat red meat (amount): discussed - HH size, suburban, Representativeness not High fat red meat (yes): discussed + Spanish, male HHH present, suburban High fat red meat (amount): + Spanish, other race, food stamps, city, income; - black, HH size Low fat lunch meat (yes): + Spanish, male HHH present Low fat lunch meat (amount): + employed, other race; - black High fat lunch meat (yes): + black, male HHH present; - education, childless, income High fat lunch meat (amount): + Spanish, black, suburban; - education, income Green/yellow vegetables (yes): + education, black, suburban; - Spanish, food stamps Green/yellow vegetables (amount): + childless, black Cruciferous vegetables (yes): + education, black; - children <18, Spanish, food stamps Cruciferous vegetables (amount): + childless, black, other race, urban, suburban N= 1,976 (out of 3,055) Multivariate Red meat: Strength Age: 30-80 Frequency=f(educ Discuss potential biases due to NS Gender: F & M ation, race, age, study design Processed meat: Population: randomly gender, study + black selected individuals from center, smoking, Limitations 3 US areas to be controls alcohol) Only race coefficients reported in case control multiple myeloma study

2-72

Reference/ Year Tepper et al. 1997 (25)

Focus Country: US Exposure: HH size, urban, income, education Outcome: intake (yes/no) of beef and cured meats

Methods Design: crosssectional Diet data: FFQ (62item)

Torun et al. 2002 (26)

Country: Guatemala Exposure: residence in rural or urban area or commuting from rural to urban area, and village of birth Outcome: intake of red meat, fruits, vegetables Verbeke et al. Country: Belgium 2000 Exposure: children (27) under 12, attention to TV coverage of meat issues Outcome: having reduced fresh meat consumption (and future intentions)

Design: crosssectional Diet data: FFQ

Data analysis/ Sample Characteristics Evaluation N = 137 (out of ?) Multivariate Consumption of Age: 19-56 beef and cured Gender: M meats Population: US Army National Guard reservists (yes/no)=f(age, BMI, HH size, nut knowledge, dietary restraint, urban, income, education, beliefs) N = 473 (out of 762) Multivariate Age: 19-29 Food intake= Gender: F & M f(rural/urban Population: selected from residence or records of the INCAP commuting from longitudinal study rural to urban area, age and village of birth)

Quality Issuess

Results (p<.05) +increase -decrease Beef and cured meats: + income, - dietary restraint

Only residence in rural or urban Red meat: +urban area or commuting from rural to urban area reported Vegetables: +urban (intakes of commuters tended to be between rural and urban)

Design: crosssectional Diet data: in home survey with questions about the individuals past changes and intention to change

N = 291 Age: 20-89 Gender: F & M Population: disproportionate quota sampling (so not statistically representative of pop) w/ age and gender as quota control variables

Multivariate Changed fresh meat consumption since BSE-crisis =f(age, education, children under 12, frequency fresh meat consumption, attention to TV coverage of meat issues, age X attention to TV) Intent to decrease fresh meat consumption in next year=f(idem)

Uses the term fresh meat but states that in the context of the article it is primarily referring to red meat because 95% of the time red meat was the fresh meat subject to decrease.

Reduced fresh meat: + age, children, less frequent consumption, high levels of attention to TV coverage Impact TV decreases with age (interaction term) Reduce future consumption: + less frequent consumers, high levels of attention to TV coverage

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Reference/ Year West et al. 2001 (28)

Winkleby et al. 1994 (29)

Data analysis/ Focus Methods Sample Characteristics Evaluation Country: Canada Design: crossN = 1,027 (out of ?) Multivariate Exposure: income, sectional Age: Frequency of education, Diet data: Gender: intake = f (ate ethnicity, children < interviewer Population: shoppers in veal with parents, 18, veal beliefs administered grocery stores in Quebec income, Outcome: intake questionnaire City and Montreal education, frequency veal ethnicity, sex, age, children < 18, veal beliefs) Country: US Design: crossN= 170 (youth sample) Multivariate Exposure: ethnicity, sectional (4 biennial N= 886 (adult sample) Intake frequency city surveys in the 80s) Age: 12-19 and 20-64 = f(ethnicity, age, Outcome: intake Diet data: FFQ and Gender: F & M sex, city, time of frequency of red & 24-hr dietary recalls Population: adult survey, age x cured meats (for approx 40% Hispanic & whites with < ethnicity, sex x only) high school; youth: from ethnicity) by age above HHs; sample group taken from crosssectional survey of people age 12-74 in randomly selected HH from 2 treatment & 2 control communities from a CVD risk reduction project

Quality Issuess Strengths: Limitations: Selection bias due to supermarket interviews not discussed

Results (p<.05) +increase -decrease Veal: + ethnic roots outside Canada, ate veal with parents, eat veal at restaurants, buy veal to diversify, (believe veal better, age)* * only significant in Montreal, not in Quebec

4 cross-sectional surveys conducted in same communities; not clear whether same subject may have been selected more than once (and thus affect SEs) Only ethnicity is reported Not clear what risk reduction project entailed, and whether it could have affected the reported associations

Red Meat (adults): +white Cured Meat: + white Red meat (youth): NS

NOTES: abbreviations used: BMI = body mass index; F = female; FFQ = food frequency questionnaire; HH = household; HHH = head of household; M = male; N - sample size; NS = not significant; NA = not applicable; SES = socio-economic status.
*

Coefficients not shown, only statistical significance. Significance of the unique variance explained by each covariate is given; coefficients are not. ** Article uses 14,262 individuals from the CSFII to describe general consumption patterns and a subset (5,649) from the DHKS for the multivariate analysis. ++ Model coefficients are not reported, but elasticities are. *** The authors only reported the elasticities in the published paper but kindly provided us with copies of the regression models.
+

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Appendix 2.3: Summary of descriptive quantitative studies using indirect measures of dietary intake reviewed
Reference/ Year Brumfield et al. 1993 (30) Focus Country: US Exposure: income Outcome: quantity of tomato purchased Methods Design: crosssectional Diet data: face-toface interviews Sample Characteristics N =757 (out of ? ) Age: ? Gender: F & M ? Population: high income groups interviewed in New Jersey supermarkets N= ? (out of 2,292*) Age: Gender: Population: random national sample of HHs; only rural HHs used Data analysis/ Evaluation Multivariate Quantity purchased=f(per capita income, price, price of substitutes, product origin, overall quality) Concerns: Strengths: Limitations: Not clear how people were selected and who may have refused to participate Possible selection bias due to supermarket interview Sample characteristics not discussed Strengths: Limitations: Not clear whether same HHs visited more than once Only price and expenditure elasticities are reported Not clear whether HHs were excluded for missing values No statistical significance reported Strengths: Limitations: Not clear how many HHs were dropped and what the consequences were on the estimates No details on analytic sample inclusion and exclusion criteria Not clear why the independent variables in both models were different Results (p<.05) +increase -decrease Quantity purchased Jersey fresh tomato: + income, price of substitutes, origin, overall quality Quantity purchased other fresh tomato: +income - price Jersey tomatoes Beef: Total expenditure elasticity: 1.56 Price elasticity: -1.91 NOTE: no statistical significance reported

Deaton 1988 (31)

Country: Ivory Coast Exposure: expenditure Outcome: HH expenditure beef (expenditure and price elasticities for beef, meat) Country: US Exposure: HH composition, income, foodstamp, house ownership Outcome: HH purchase of beef Country: Mexico Exposure: HH size, income, education and occupation HHH Outcome: HH expenditure (yes/no and amount) on pork (income and HH size elasticities)

Design: crosssectional (same clusters visited 4 times during year, different HHs?) Diet data: survey

Multivariate Budget share=f(per capita food expenditure, HH composition, HH size)

Dong et al. 1998 (32)

Design: crosssectional Diet data: food consumption survey

N = 4,004 (out of ?) Age: Gender: Population: 1987-88 US Nationwide Food Consumption Survey (NCFS) N > 11,800 (out of ?) Age: Gender: Population: National Household Income and Expenditure Survey (ENIGH, 1994)

Multivariate. HH purchase=f(income, unit value, foodstamp, house ownership, season, HH composition)

Beef+: + income, # of HH members 19-64, # HH members > 65 - # of HH members 1-12

Dong and Gould 2000 (33)

Design: crosssectional Diet data: weekly diary of HH food expenditures

Multivariate: Market participation =f(HH income, fridge, education and occupation HHH, HH size & age composition, region) Expenditure=f(HH income, fridge, HH size & age composition, occupation)

Pork expenditure (yes/no) + HH size - income Pork expenditure (amount) + income, HH size, owns fridge, occupation=personal services, unit value - % HH members <5, % HH members 6-15

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Reference/ Year Goodwin and Koudele 1990 (34)

Focus Country: US Exposure: income, HH size, ethnicity, education Outcome: purchase (yes/no) of variety (red) meats**

Methods Design: crosssectional Diet data: survey

Sample Characteristics N=2,998 (out of 3,340) Age: <25 - >64 Gender: F &M Population: shoppers at 8 Kansas retail supermarkets

Data analysis/ Evaluation Multivariate Purchase (yes/no) =f(age, sex, HH income, HH size, ethnicity, education, location)

Gracia and Albisu 1998 (35)

Country: Spain Exposure: HH age distribution, total per capita expenditure, % income earners, education HHH Outcome: HH purchase of beef and veal, fresh pork, lamb and goat, processed pork (expenditure elasticities of quantity and quality) Country: Israel Exposure: religious observance, HH income Outcome: HH consumption of beef and processed meat

Design: Crosssectional Diet data: HH survey of expenditures and quantity purchased

N=? (out of 21,155) Age: Gender: Population: 1990-91 Spanish National Expenditure Survey; only rural (towns <10,000 inhabitants) and urban (>100,000) HHs included

Multivariate Budget share of specific red meat=f(total per capita food expenditure, # HH members <=5, 625, 26-45, 45-65, >65, % males, % income earners, education level HHH) by urban and rural

Concerns: Possible selection bias due to supermarkets or refusal to participate not discussed (authors only discussed concern about bias due to Midwestern cities) Ethnicity measured as consumers perception on whether his ethnic background influence taste & preference variety meats Sample size not specified Number of observations dropped due to missing values not specified

Results (p<.05) +increase -decrease Variety meat: +age, HH size, perceiving ethnic origin to be influence tastes & preferences for variety meats - income

Rural: Beef & veal: + total pc exp., education, % income earners, 26-45, >65 Pork: + total pc exp., % males, 6-25, 26-45, 4565; - education Lamb & goat: + total pc exp., % males, 45-65, >65; - % income earners, 6-25 Processed pork: + total pc exp., % male, % income earners, 6-25, 26-45; - >65 Urban: Beef & veal: + total pc exp., education, % males, 26-45, 45-65, >65; - % income earners, <=5 Pork: + total pc exp., % males, 6-25, 26-45, 4565; - education, % income earners, >65 Lamb & goat: + total pc exp., 45-65, >65; - education, % income earners, 6-25 Processed pork: + total pc exp., % male, % income earners, 6-25, 26-45; - 45-65, >65 Beef: + family preference Processed meat: + family preference, religious observance

Heiman et al. 2001 (36)

Design: crosssectional Diet data: number of times/month family consumes various meats

N=405 (out of 435) Age: Gender: Population: 4 largest Israeli cities and several rural villages

Multivariate Consumption share= f(HH preference, religious observance, HH income, joy of cooking, leisure time, feedback to cook)

Strengths: High response rate (93%) Limitations: Survey representative? Definition of consumption share not clear What does the family preference variable really mean? (whether every family member likes the specific meat product)

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Reference/ Year Huang and Raunikar 1981 (37) Jones and Yen 2000 (38)

Focus Country: US Exposure: HH income and size Outcome: HH beef expenditures Country: US Exposure: income, HH composition, urbanisation, home ownership, race & ethnicity Outcome: HH beef consumption (yes/no and quantity) (income and (cross) price elasticity) Country: Spain Exposure: number of income earners in HH, HH age distribution, womens & HH income, womens age, HH head employed, homeowner, region, education, HH in a singleheaded women family. Outcome: HH expenditure (yes/no & amount) on convenience meat products++ (includes red and processed meat)

Methods Design: crosssectional Diet data: consumer panel to determine HH food purchase info Design; crosssectional Diet data: survey of HH food use over 7days

Sample Characteristics N=120 (out of ?) Age: Gender: Population: consumer panel in Griffin, Georgia N=4,150 (out of 4,495) Age: Gender: Population: 1987-88 US Nationwide Food Consumption Survey

Data analysis/ Evaluation Multivariate Fresh beef, ground beef, beef roasts, beef steak expenditure=f(HH income, HH size) Multivariate HH beef consumption (yes/no and quantity) =f(income, price of beef, price of other meat, HH age compostion, urbanisation, home ownership, race & ethnicity)

Concerns: Strenghts: Study non-linear HH size and income effects by means of splines Limitations: Study representative? Strengths: Explicit about sample size Tested non-linear income effects Limitations:

Results (p<.05) +increase -decrease Fresh beef: + income Ground beef: inverse U income, decreasing rate of increase as HH size increases Beef roasts: + income Beef steaks: + income Beef consumption (yes/no): + Hispanic, HH size - price of beef Beef consumption (quantity): + HH size - White, homeowner, price of other meat

Manrique and Jensen 1997 (39)

Design: crosssectional Diet data: HH expenditure surveys (Encuestas de presupuestos familiares)

N=? (out of 19,535) Age: Gender: Population: dual headed and single female headed HHs from the 1990-91 Spanish National Expenditure Survey

Multivariate HH expenditure (yes/no & amount)=f(number of income earners, HH age distribution, womens income, other HH income, womens age, HHH employed, homeowner, region, urban residency, womens education, single female headed HH)

Limitations: Analytic sample size not reported

Beef expenditure (yes/no): + womens income, other HH income, urban, HH size - womens age, female headed HH, Northwest Beef expenditure (amount): + womens income, other HH income, womens age, HH size, HHH employed - womens education, female headed, homeowner, urban, South

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Reference/ Year Moon et al. 2001 (40)

Focus Country: Bulgaria Exposure: HH socio-economic and demographic factors Outcome: HH consumption (yes/no and frequency) of red & processed meat

Methods Design: crosssectional Diet data: monthly HH consumption of 102 foods

Sample Characteristics N=2,133 (out of 2,500) Age: Gender: Population: nationwide food consumption survey

Data analysis/ Evaluation Multivariate Consumption (yes/no & frequency) of beef, pork, lamb, processed meats=f(HH income, employment status, HH size, region)

Concerns: Strenghts: Very clear methodologically Limitations: No discussion of possible bias due to missing values

Salvanes and DeVoretz 1997 (41)

Country: Canada Exposure: region, urbanisation, HH size, nationality & education HHH, employment HHH, spouse at home, expenditure Outcome: HH budget share of red & processed meat (expenditure and (cross) price elasticities)

Design: crosssectional Diet data: two week food expenditure data

N=? (out of 10,591) Age: Gender: Population: Canada 1986 Food Expenditure Survey

Multivariate Budget share red meat=f(region, urbanisation, season, HH size, nationality, education, age, sex and employment of the HHH, spouse at home, price, expenditure)

Strengths: Limitations: Not clear how many HHs were dropped from the analysis due to missing values

Results (p<.05) +increase -decrease Beef: yes/no: + income, HH size; - unemployed, pensioner Beef: freq: + income; - pensioner Pork: yes/no: - pensioner Pork: freq: + income, HH size; - unemployed, pensioner Lamb: yes/no: + HH size, Southern, Coastal; pensioner Lamb: freq: +medium income, HH size, employed Ham: yes/no: + income; - unemployed, pensioner, Southern, Northern Ham: freq: +income; -pensioner, Northern Hamburger: yes/no: - pensioner, Coastal, Northern Hamburger: freq: - pensioner, Southern, Coastal, Northern Sausage: yes/no: + medium income, HH size; unemployed, pensioner, Southern, Northern Sausage: freq: + income, HH size; - unemployed, pensioner, Southern, Northern Kremvirshi***: yes/no: NS Kremvirshi: freq: + income, HH size; pensioner, Northern Red meat: + expenditure elasticity > 1 model I+++: + age HHH, Quebec; - education, employed, female HHH, Atlantic Provinces, British Colombia model II: + age HHH, urban, Quebec; - education, employed, Atlantic Provinces, Manitoba & Saskatchewan model III: + age HHH, urban, Quebec; - education, employed, Atlantic Provinces, Manitoba & Saskatchewan, British Colombia Processed meat: + expenditure elasticity > 1 model II: + HH size, Manitoba & Saskatchewan; - urban, education, employed, female HHH model III: + HH size; - urban, education, employed, female HHH, Quebec, British Columbia

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Reference/ Year Su and Yen 1996 (42)

Yen et al. 2004 (43)

Focus Country: US Exposure: HH income, HH age composition, education HHH, region, ethnicity, gender meal planner, foodstamps, urban, home ownership and race Outcome: HH pork consumption (yes/no & quantity) (Elasticities calculated for age distribution, education of HH head, price of pork and price of other meat) Country: China Exposure: HH size, age and education of HHH Outcome: HH budget share beef & lamb, pork, vegetables, fruit (expenditure and price elasticities)

Methods Design: crosssectional Diet data: Food consumption survey on each food item used by HH over 7 days

Sample Characteristics N = 4,198 (out of 13,118) Age: Gender: Population: 1987-88 US Nationwide Food Consumption Survey

Data analysis/ Evaluation Multivariate**** HH consumption of pork (yes/no) =f(price, HH age composition, education HHH, region, gender meal planner, urban, white) HH consumption of pork (quantity)++++ =f(idem, foodstamp, home owner, Hispanic, income, price pork, price other meat)

Concerns: Strengths: Details on response rate and observations dropped for data reasons Limitations: Consequences of the very low response rate (38%) on estimates not discussed

Results (p<.05) +increase -decrease Pork: yes/no: + HH size, female meal planner, rural, Midwest, South; - white Pork: quantity: + HH size, Northeast, Midwest, South - education, white, price of pork

Design: Crosssectional Diet data: quantities and expenditures of purchases

N=3,715 (out of 3,800) Age: Gender: Population: Urban Households Survey (30 randomly selected cities from 29 provinces)

Multivariate Budget share =f(HH size, age and education HHH, region, prices)

Strengths: Sample clearly described Limitations: Equation for fruits not reported, only elasticities Discussion of results in text does not correspond to table with regression results

Beef (& lamb): + expenditure elasticity (1.41), Northeast, North, East, South, West; - HH size Pork: + expenditure elasticity (0.94); - age, Northeast, North, East, South, West Vegetables: + expenditure elasticity (0.83), HH size, high school, North, East, South; - age, Northeast Fruits: + expenditure elasticity (0.6); - age elasticity (-0.18), HH size elasticity (-0.27)

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Reference/ Year Yen and Huang 2002 (44)

Focus Methods Concerns: Country: US Design: CrossStrengths: Exposure: meat sectional expenditure, HH Diet data: Food Limitations: age composition, consumption survey Consequences of the very low education HHH, on each food item response rate (38%) on urban residence, used by HH over 7 estimates not discussed home ownership, days race, ethnicity, gender meal planner, foodstamp Outcome: expenditure steak, roast, ground and other beef Yen et al. Country: US Design: CrossN=817 (out of 1,109) Strengths: Beef: Multivariate 2003 Exposure: HH Age: Budget share=f(HH Total expenditure elasticity: 0.92-0.95 sectional (45) size, total Diet data.: 7 day food Gender: size, prices, total food Limitations: expenditure use Population: National expenditure) Parameterisation and subscripts Pork: Outcome: HH Food Stamp Program not well explained (not clear Total expenditure elasticity: 1.16-1.27 budget share beef Survey what the HH size coefficient & pork was) (price and No discussion of possible bias expenditure due to missing values elasticities) * Twelve households were surveyed in each cluster and each cluster was surveyed twice. One hundred ninety-one cluster-quarters were included in the analysis, giving a total of 191 12 = 2,292 households. + Authors reported a bivariate and the Cox and Wohlgenant procedure, but conclude, based on the high correlation between the unit value and expenditure equation that the latter procedure is not appropriate. Findings are only reported from the bivariate procedure. ** Beef and pork liver, heart, tongue, kidney, thymus glands, stomach, brains, pigs feet. ++ Defined as commercially frozen or pre-cooked steaks, roasts, ground beef, veal, and pork. *** Bulgarian frankfurter. +++ The authors estimated three models to test separability (fish and meat) by using separate aggregation levels. **** The author estimated the HIS double-hurdle and the HIS infrequency-of-purchase model; since the former provided a better characterisation of the data-generating process, only these findings are reported ++++ Variables different in both models because insignificant variables in a preliminary probit model were removed from the probit equation of the final double-hurdle model.

Sample Characteristics N=4,050 (out of 4,237) Age: Gender: Population: 1987-88 US Nationwide Food Consumption Survey

Data analysis/ Evaluation Multivariate Budget share=f(meat expenditure, prices, HH age composition, education HHH, urban residence, home ownership, race, ethnicity, gender meal planner, foodstamp, region)

Results (p<.05) +increase -decrease Steak (yes/no): + expenditure elasticity Steak (budget share):+ expenditure, HH size, Northeast, Midwest, South, foodstamp; - urban, Hispanic Roast (yes/no): + expenditure elasticity Roast (quantity): + expenditure, # <20, Hispanic; - # >65, Northeast Ground beef (yes/no): - expenditure elasticity Ground beef (quantity): + expenditure, Northeast; - # <20, # 20-64, White Other beef (yes/no): + expenditure elasticity Other beef (quantity): + expenditure, Hispanic, Midwest, South

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Appendix 2.4: Summary of reviews on socio-economic and cultural determinants of obesity reviewed
Reference/ Year Monteiro et al. 2004 (4) Focus Country: developing countries (defined by world bank as having annual GNP per capita equivalent < US $9075 Population: adults Methods Design: Systematic Review Data Sources: MEDLINE (via pubmed.com) Keywords: yes Dates: 1989-2004 # of publications included: 15 Explicit inclusion/exclusion criteria: yes Explicit procedure for evaluating methodological quality: no Design: Review Data Sources: ? Keywords: ? Dates: ? # of publications included: 144 Explicit inclusion/exclusion criteria: no Explicit procedure for evaluating methodological quality: no Findings/Conclusions Women: - SES Men: +SES Burden of obesity shifts to lower SES groups as countrys GNP increases Limitations Education used as an SES SES indicators included education and composite scores

Sobal and Stunkard 1989 (46)

Country: developing and developed countries Population: adults and children

Developed countries: Women: - SES Men and children: inconsistent Developing countries: women, men and children: + SES

Not clear which database(s) were searched No information on measure of socio-economic status used in each study Some studies used more than one measure of SES. The authors do not explain how studies were classified (positive, negative or no association) in case different results were found for the different measures

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2-82

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12. Gillman MW, Rifas-Shiman SL, Frazier AL, Rockett HRH, Camargo CA, Field AE, et al. Family dinner and diet quality among older children and adolescents. Arch Fam Med. 2000;9(3):235. 13. Gossard MH, York R. Social structure influences on meat consumption. Hum Ecol Rev. 2003;10(1):1-9. 14. Guenther PM, Jensen HH, Batres-Marquez SP, Chen CF. Sociodemographic, knowledge, and attitudinal factors related to meat consumption in the United States. J Am Diet Assoc. 2005;105(8):1266-74. 15. Gulliford MC, Mahabir D, Rocke B. Food insecurity, food choices, and body mass index in adults: nutrition transition in Trinidad and Tobago. Int J Epidemiol. 2003;32(4):508. 16. Guo XG, Popkin BM, Mroz TA, Zhai FY. Food price policy can favorably alter macronutrient intake in China. J Nutr. 1999;129(5):994. 17. Harris A, Gray MA, Slaney DP, Turley ML, Fowles JR, Weinstein P. Ethnic differences in diet and associations with clinical markers of prostate disease in New Zealand men. Anticancer Res. 2004;24(4):2551-6. 18. Hsu-Hage BH, Ibiebele T, Wahlqvist ML. Food intakes of adult Melbourne Chinese. Aust J Public Health. 1995;19(6):623-8. 19. McIntosh WA, Fletcher RD, Kubena KS, Landmann WA. Factors associated with sources of influence/information in reducing red meat by elderly subjects. Appetite. 1995;24(3):219-30. 20. Metcalf PA, Scragg RK, Tukuitonga CF, Dryson EW. Dietary intakes of middle-aged European, Maori and Pacific Islands people living in New Zealand. N Z Med J. 1998;111(1072):310-3. 21. Morgan K, Armstrong GK, Huppert FA, Brayne C, Solomou W. Healthy ageing in urban and rural Britain: a comparison of exercise and diet. Age Ageing. 2000;29(4):341. 22. Park SY, Murphy SP, Sharma S, Kolonel LN. Dietary intakes and health-related behaviours of Korean American women born in the USA and Korea: the Multiethnic Cohort Study. Public Health Nutr. 2005;8(7):904-11. 23. Popkin BM, Haines PS, Reidy KC. Food consumption trends of US women: patterns and determinants between 1977 and 1985. Am J Clin Nutr. 1989;49(6):1307-19. 24. Swanson CA, Gridley G, Greenberg RS, Schoenberg JB, Swanson GM, Brown LM, et al. A comparison of diets of blacks and whites in three areas of the United States. Nutr Cancer. 1993;20(2):153-65.

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25. Tepper BJ, Choi YS, Nayga RM. Understanding food choice in adult men: influence of nutrition knowledge, food beliefs and dietary restraint. Food Qual Prefer. 1997;8(4):307. 26. Torun B, Stein AD, Schroeder D, Grajeda R, Conlisk A, Rodriguez M, et al. Rural-tourban migration and cardiovascular disease risk factors in young Guatemalan adults. Int J Epidemiol. 2002;31(1):218. 27. Verbeke W, Ward RW, Viaene J. Probit analysis of fresh meat consumption in Belgium: exploring BSE and television communication impact. Agribusiness. 2000;16(2):215-34. 28. West GE, Larue B, Touil C, Scott SL. The perceived importance of veal meat attributes in consumer choice decisions. Agribusiness. 2001;17(3):365-82. 29. Winkleby MA, Albright CL, Howardpitney B, Lin J, Fortmann SP. Hispanic White differences in dietary-fat intake among low educated adults and children. Prev Med. 1994;23(4):465. 30. Brumfield RG, Adelaja AO, Lininger K. Consumer tastes, preferences, and behavior in purchasing fresh tomatoes. J Am Soc Hortic Sci. 1993;118(3):433. 31. Deaton A. Quality, quantity, and spatial variation of price. Am Econ Rev. 1988;78(3):418-30. 32. Dong D, Shonkwiler JS, Capps O, Jr. Estimation of demand functions using crosssectional household data: the problem revisited. Am J Agr Econ. 1998;80(3):466-73. 33. Dong D, Gould BW. Quality versus quantity in Mexican household poultry and pork purchases. Agribusiness. 2000;16(3):333-55. 34. Goodwin BK, Koudele JW. An analysis of consumer characteristics associated with the purchase of beef and pork variety meats. Southern J Agr Econ. 1990;22(1):87-94. 35. Gracia A, Albisu LM. The demand for meat and fish in Spain: Urban and rural areas. Agr Econ. 1998;19(3):359-66. 36. Heiman A, Just DR, McWilliams B, Zilberman D. Incorporating family interactions and socio-economic variables into family production functions: the case of demand for meats. Agribusiness. 2001;17(4):455-68. 37. Huang C-L, Raunikar R. Spline functions: an alternative to estimating incomeexpenditure relationships for beef. Southern J Agr Econ. 1981;13(1):105-10. 38. Jones AM, Yen ST. A Box-Cox Double-Hurdle Model. Manch Sch. 2000;68(2):20321.

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PART B: Dietary Interventions

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Chapter 3 Effectiveness of Interventions for Dietary Prevention of Cancer in Australasia, Europe, and North America
This review, by Simera et al., has already been submitted to WCRF. Although WCRF requested IFPRI to incorporate this document into the main review, Simera et al. failed to make a Word version available to IFPRI to enable IFPRI to incorporate it into the full review. Chapter 3 is thus represented by the separate document: Simera et al. Population and community programs for dietary prevention of cancer: systematic review of effectiveness. Note that this review was covered by the summary at the beginning of this report.

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Chapter 4 Effectiveness of Interventions for Dietary Prevention of Cancer in the Rest of the World
Cara Eckhardt International Food Policy Research Institute

4.1 Scope and Methodology

4.1.1 Scope
The aim of this chapter is to present a systematic review of the literature on the impact of interventions that address dietary patterns related to cancer risk, and obesity, in developing countries and the high-income countries not covered in Chapter 3. Thus, interventions that took place in any country other than the United States, Canada, Australia, New Zealand, or the nations of Western Europe were considered. As outlined in the introduction to this report, foods covered are those known, to have a link with cancer.

4.1.2 Methodology Databases. Intervention studies published from 1980 to October of 2005 were identified thorough a structured electronic search of the PubMed, ISI Web of Science, and CAB Direct databases. Searches were conducted in all languages. In addition to the databases, significant efforts were made to identify other studies. The grey literature was searched using Google and through accessing relevant websites. Around 40 experts in developing countries were contacted through e-mail or in person to ask if they were aware of any diet or obesity interventions in their region. Experts were approached at relevant conferences to ask if they were aware of any evaluated interventions. The author of a systematic review of obesity interventions was contacted to identify further papers. This process did not, however, yield any additional studies that fit the inclusion/exclusion criteria, though some are included in Appendix 4.5 (see below). Search terms. WCRFs 1997 report on diet and cancer (1) was used as a reference to establish a preliminary list of terms relating to foods, food groups and dietary constituents with links to cancer. These food terms, accompanied by terms for obesity, were matched with a series of terms for interventions, policies and programmes. Some search strings were intended to identify interventions aimed specifically at reducing or increasing intakes of specific foods, food groups, or dietary constituents that may be associated with either increased or decreased risk, respectively, of various forms of cancer. These terms were then used within each of the three databases to find related MeSH terms, keywords, and topic headings for additional inclusion in the search strategy. Search terms were also used to limit the scope of interventions identified to the regions of the world of interest
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and to the theme of diet and cancer, and to limit the search to interventions tested in humans. The final search strings used within each database are listed in Appendix 4.1.

Inclusion/exclusion criteria. The inclusion/exclusion criteria differed slightly depending on the type of intervention in question. To facilitate the comparison between these criteria, they are listed alongside each other, by intervention type (corresponding with the subsections of this review), in Appendix 4.2. In all cases, studies had to have an experimental or quasi-experimental design to be included. Only studies published in peerreviewed journals were considered. The intervention had to be clearly described, have a study population of at least 40 subjects in each group studies, and include tests of statistical significance in the impact analysis. Searches. Using the search strings listed in Appendix 4.1, 4,328 were articles were retrieved by the databases and were subjected to a title and abstract scan for relevancy; 115 of those articles were requested in their full paper form for a second level of selection, and 86 were obtained in time for potential inclusion in the review. These papers were examined in more detail for relevancy and for adherence to inclusion and exclusion criteria. Twelve of these papers were foreign-language (non-English) papers that were not considered for this review (their abstracts indicated they would not satisfy the inclusion/exclusion criteria). Nine of these papers were evaluations of relevant interventions that met the inclusion/exclusion criteria and were selected for inclusion in the main body of this review. An additional 10 relevant papers meeting the inclusion/exclusion criteria that were not retrieved during the systematic database search process, but which were identified by the authors through personal knowledge or through email contact with key informants, were also included among the interventions reviewed. These 19 total papers included in the review cover only 17 interventions, because in two cases, there are two papers about one intervention and both papers for each of those interventions were included in this review. These statistics are summarised in Table 4.1.
Table 4.1. Summary of the literature selection process
Papers identified through initial search of the three databases Papers from the database search that were requested in full paper form for second-level review Papers from the database search that were obtained in time for potential inclusion in review Papers from the second-level review of papers from the database searches that reported on relevant evaluations of interventions, met inclusion/exclusion criteria, and are included in the body of this review Papers obtained through other means and included in the body of this review of evaluations Total papers included in the body of this review Additional papers resulting from the search of the three databases that did not meet the inclusion/exclusion criteria summarised in Appendix 4.4 4,328 115 86 9 10

19
18

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Eighteen studies on interventions were identified through the search that did not adhere to the inclusion/exclusion criteria. Given the general lack of information available on the interventions that have taken place in developing countries regardless of their quality, these interventions are described in Appendix 4.4. The reasons for their exclusion are also described. Though their study design meant they are not of sufficient quality to be included here, these studies provide a broader picture of the types of interventions being carried out in developing countries. To provide an even broader overview of the interventions being carried out in this area, information on unpublished, unevaluated, and up-and-coming interventions that were identified during the course of this review are also described, in Appendix 4.5. This appendix is not a comprehensive list of all such interventions, but a compilation of examples identified during the course of this review.

Report structure. Based on the range of studies identified through this search, this review includes four categories of interventions, covered in the following subsections: Community-level interventions with the primary purpose of targeting specific foods, food groups, or dietary constituents that have established links with cancer (section 4.2);
Individual-level and community-level interventions explicitly targeting the prevention or reduction of overweight and obesity (section 4.3); Individual-level, community-level, and population-based interventions with the goal of chronic disease prevention (section 4.4); Community-level interventions addressing contamination of foods with aflatoxin (section 4.5. As made clear by the search terms used (see Appendix 4.1), the search strategy used consistently involved identifying individual-level, community-level, and population-level interventions. Community-level interventions were identified for all five topic categories shown above. Individual-level interventions were found both with regards to the prevention or reduction of overweight and obesity (subsection 4.3) and with regards to chronic disease prevention (subsection 4.4). The only population-level interventions identified meeting the inclusion/exclusion criteria were two national programmes geared towards chronic disease prevention (subsection 4.4). In addition to being discussed at length in the text and conclusions of this review, all of the interventions included in the subsections listed above are also summarised in Appendix 4.3. Although this report does not provide a complete literature review of relevant interventions in the context of nutrition during early childhood and its link to cancer, it does additionally provide a brief overview of this topic area.

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4.2 Results: Community-level interventions with the primary purpose of targeting specific foods, food groups or dietary constituents that have established links with cancer
4.2.1 Characterisation of the literature
Some of the associations between specific foods, food groups and dietary constituents and cancer risk noted by WCRF are unlikely to be targeted for intervention in developing countries due to competing health and nutrition issues. Specifically, the WCRF notes a link between red meat consumption and cancer.(1) In the literature search for interventions targeting these foods, the only relevant interventions that were identified aimed to increase the consumption of red meat through animal husbandry to improve intakes of vitamin A, iron, and/or protein in populations where food insecurity is high and diet quality is poor. This literature has recently been reviewed.(2) Because the low levels of animal-source food consumption in low-income populations contribute to micronutrient deficiencies and are unlikely to affect cancer risk at levels in which they are usually consumed; it would therefore not be advisable to encourage reduced consumption of these foods among such populations. However, there may be risks in populations undergoing rapid economic growth and urbanisation; no interventions to address this link were identified. In fact, the search of the literature revealed only two studies, both community-level interventions, meeting our inclusion/exclusion criteria that had the overt goal of reducing chronic disease risk through targeting specific foods. These studies are reviewed below in a section focusing on interventions in the context of chronic disease prevention. The literature search did reveal a substantial literature on interventions, all communitylevel programmes, designed to prevent and reverse micronutrient deficiencies through strategies to increase the access to and consumption of fruits and vegetables, an important food group in the fight against cancer. However, these interventions were designed for populations in which the consumption of micronutrient-rich foods is very low, and in which the increases in fruit and vegetable intake associated with the interventions did not tend to raise intakes even close to the range of 400-800 grams/day recommended by the WCRF for cancer prevention.(1) In addition, these interventions focused almost entirely on promoting home gardens in rural areas. Nonetheless, these interventions provide some of the most cohesive evidence of well-designed successful diet interventions relevant to the fight against cancer. Thus, these interventions are reviewed below in a separate section on interventions in the context of micronutrient deficiencies.

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4.2.2

Interventions in the context of chronic disease prevention

Two studies, both community-level interventions, meeting the inclusion/exclusion criteria and targeting specific food groups in the context of chronic disease prevention, were identified and are summarised below.(3-5) A paper by Aziz et al.(3) describes a community-level intervention designed by the National Institute of Cardiovascular Diseases in Karachi, Pakistan, in cooperation with the National Heart, Lung and Blood Institute in the United States with the goal of developing a model for a community-based intervention. The specific goals of the intervention were to reduce household use of cooking fats and oils by one-third, to reduce salt consumption by one-fourth, and to substitute vegetable oil for ghee (clarified butter that is high in saturated fat and trans fatty acids). The intervention took place in Metroville, a lower middle-class suburban community of Karachi, with a high prevalence of CVD risk factors and strong community leadership. Of the 4,296 households in the community, 450 responded to letters of invitation and 403 agreed to participate. Participating households were randomly assigned in clusters, assigned by location on a map of Metroville, to control (n = 201) and intervention (n = 199) groups. Due to exclusions from missing data and outmigration, data from 351 households at baseline and 238 households at follow-up, two years later, were used in the analyses. Self-reported food consumption data were collected as well as some information regarding knowledge and attitudes relating to CVD. Control households were invited to health fairs where men were given general health lessons and women learned about perinatal care, personal hygiene, and immunizations. The intervention group was invited to separate health fairs including demonstrations and lectures about CVD and prevention. Men and women attended separate discussions: men learned about smoking and CVD and were advised to stop smoking, while women received instructions to promote adoption of healthy cooking habits. The intervention group additionally had six visits with social workers regarding cooking methods to reduce salt, fats, and ghee in the diet. These visits were followed by eight maintenance visits. The visits occurred approximately every two months. The attendance at the health fairs was reported elsewhere by Aziz et al.(5) to have been about 53% in the intervention group and about 39% in the control group. Knowledge and attitudes about CVD and CVD risk factors were similar among men and women in control and intervention groups both at baseline and at the follow-up. Consumption data were based on self-report and were validated in the intervention group by measurement. Consumption of ghee, vegetable oil, total cooking fat, and salt were all reduced in the intervention group and the changes were significantly different than the changes seen in the control group. The validation exercise indicated correlation of 0.60 (p = 0.0001), 0.35 (p = 0.0013), and 0.57 (p = 0.0001) for ghee, vegetable oil, and salt, respectively.
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The intervention group met or exceeded the goals of reducing use of cooking fats and oils by one-third, and reducing salt consumption by one-fourth, but did not eliminate ghee from cooking. When changes in body mass index, systolic and diastolic blood pressure, and total cholesterol were analyzed using matched pairs of adults at baseline and followup (n = 326), no significant differences in change between baseline and follow-up were seen. Measured consumption at serial time points in the intervention group indicated that for ghee and salt, compliance with the intervention goals increased with continued contact with the visiting social workers.

Quality issues: This intervention was randomised and thus the evaluation is drawn from the randomised (treatment and control) groups, which allows for stronger assumptions of causality to be drawn. However, no physiological effects were seen, although some effects were noted regarding food consumption. The paper states that household cooks were surveyed about consumption of fats and salt, thus some of these differences could be due to responder bias, with respondents in the treatment group providing more desirable responses than those in the control group. Without more objective measures of consumption, and with no differences seen with regard to physiological measures, it is impossible to know whether this intervention resulted in real changes in behaviour that may, in the future, be transferred into physiological improvements.
Takashashi et al.(4) published an evaluation of a 1-year community-level intervention aimed at reducing salt intake and increasing intakes of vitamin C and carotene in two rural Japanese villages with high incidences of stomach cancer and stroke, low carotene intake, and high salt intake. Participants between 40-69 years of age were recruited through advertisements in magazines and posters; 274 and 276 subjects were randomised at the individual-level into intervention and control groups, respectively. Data were collected both at baseline and after one year and included data from a validated selfadministered diet history questionnaire and fasting blood levels of ascorbic acid and carotenoids, and urinary sodium excretion. The intervention consisted of two dietary counselling sessions, one group lecture and two newsletters. Individualised education schemes were created based on the results of the baseline dietary survey and health check-up. Increasing fruit and vegetable intake, particularly dark-green leafy vegetables and carrots, was emphasised. To decrease sodium intake, subjects were advised to decrease their intakes of miso, salted vegetable pickles, salted fish, and seasonings with high salt contents. In addition, subjects were encouraged to set goals and had access to leaflets with cooking and nutrition information and to individually tailored leaflets. The control group received the same intervention at the end of the first year.

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The dietary and serum data were analyzed for 470 subjects with complete data and the analysis of dietary and urine data was based only on 191 subjects (out of over 500 subjects with blood measures and over 200 with urine measures). The authors state that subjects were excluded from the serum data if they did not have blood samples at both baseline and follow-up, or their estimated energy intake was less than 50% of energy for a sedentary lifestyle or was greater than 150% of energy necessary for a vigorous lifestyle. For urine data, subjects were excluded if they had a creatinine(mg):body weight(kg) ratio of < 14.4 or > 33.6 in men, or < 10.8 or > 25.2 in women; or if their urine volume difference between baseline or follow-up were in the highest or lowest quintile. There were no significant differences at baseline between the groups with regards to demographic, diet, and health-related characteristics, nor were their differences between the groups for those with complete data. During the first year, there were large and significantly different changes in the intervention group compared to the control group, when adjusting for baseline values, in terms of sodium intake (-384 and +255 mg/day, p < 0.001, respectively), urinary sodium excretion (-1,003 and -84 mg/day, p < 0.001, respectively). With regard to carotene and vitamin C, the changes in reported dietary intake, the changes were also significantly different although the changes in serum levels were not. For carotene, the dietary changes were +418 and +220 ug/day (p < 0.05) and the serum levels showed differences of (+13 and -25 mg/L (p = 0.09) for the intervention v. the control group, respectively. For vitamin C, the dietary changes were +13 and +2 mg/day (p < 0.05) and the ascorbic acid serum levels showed differences of (+0.1 and -0.5 mg/L (p = 0.09) for the intervention v. the control group, respectively. Differences between the groups in serum level changes for ascorbic acid were in the expected direction, but did not reach statistical significance. It should be noted that, while serum carotene reflects intakes over several weeks, urinary sodium and serum ascorbic acid measures reflect only a history of a few days. Thus, some overall changes in vitamin C intake in individuals may not have been noted if intakes varied across days and the last few days were not reflective of mean intake. At baseline there were no statistical differences in the consumption of salted foods, fruits, and vegetables between the control and intervention groups. Intakes of a variety of salted foods decreased significantly in the intervention group compared to the control group, and intakes of green and yellow vegetables and fruits increased.

Quality issues: This intervention was randomised at the outset, again allowing for comparison between control and treatment groups and for some interpretations about causality. Unfortunately, dietary data and measures of biomarkers were only analyzed among a small subset of the original study population, apparently due to exclusions described above. No information is given regarding whether those excluded from the

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serum/urine analyses were different (other than the reasons for exclusion) from those included, so it is unknown whether the serum/urine results can be generalised.

4.2.3

Interventions in the context of micronutrient deficiencies

The literature search for papers targeting diet changes in the context of micronutrient deficiencies identified a comprehensive review published by Ruel(6) that focused on food-based strategies to control vitamin A and iron deficiencies, and which included 14 new interventions based in developing countries and published between 1995 and 1999 and which updated previous reviews of the same subject.(7-10) Because the review by Ruel was quite comprehensive, its results are summarised below, followed by reviews of the four newer community-level interventions identified in a review of the literature published since the beginning of 2000 that met the inclusion/exclusion criteria. The interventions reviewed by Ruel(6) were primarily community-level programmes aimed at reducing vitamin A deficiency by increasing intakes of the pro-vitamin A carotenoids found in dark green leafy vegetables and yellow and orange noncitrus fruits. Some of the interventions included in the review additionally targeted iron and other micronutrient deficiencies through the promotion of animal husbandry and fish farming. The 14 studies reviewed by Ruel included eight interventions focusing on vitamin A, which combined nutrition education and fruit and vegetable production, one intervention that promoted fruit and vegetable production without nutrition education, and one intervention that provided nutrition education about fruit and vegetables without a production component. The review also included two interventions combining education and production components, two intervention with nutrition education and no production focus, and one intervention with only a production component to combat multiple micronutrient deficiencies via strategies to increase fruit and vegetable consumption and/or animal husbandry or fish farming. Of the food-based interventions completed prior to the mid-1990s, most did not include a nutrition education component and did not show significant impact.(7-10) However, among the more recent studies reviewed by Ruel, most combined education, social marketing, and mass media campaigns with home-gardening initiatives and did show effects: the evidence from the newer studies suggests that food-based approaches were consistently associated with a variety of positive outcomes including increased household production and consumption of fruits and vegetables, and improved knowledge, attitudes and behaviours related to fruit and vegetables. The newer generation of studies also exhibited improvements in design and implementation, combining effective behaviour change strategies with production interventions.

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Quality issues: Ruel(6) identified a variety of weaknesses with regard to the impact evaluation of these interventions. In particular, many of the studies were evaluated by comparing a single geographic area that did receive the intervention with another area that did not, and data collected from the two areas before and after the implementation of the intervention are evaluated. Interventions were also usually not randomised. This approach fails to control for changes that may have occurred over the same period in either or both of the areas independent of the intervention, and thus makes it impossible to attribute the changes in the outcomes of interest entirely to intervention effects. Including replicates of the intervention and control areas in the study design would help to control for this potential source of bias. In addition, few studies provided clear information on how the control groups were chosen and how comparable they were to the intervention groups, again making it difficult to conclude whether differences between the groups were a result of the intervention. This is especially problematic because participation and/or adoption of intervention strategies such as tending home gardens is often self-selected and may be associated with important sociodemographic, economic, or landownership differences. More careful selection of similar control and intervention groups and the collection of sufficient sociodemographic data to control for differences is needed to control for these differences. Finally, studies often did not appropriately control for confounding factors such as levels of parasitic infection, which can bias findings, especially in cases such as home-gardening interventions, where true randomisation into control and intervention groups is rarely possible. These design flaws hamper the ability to draw strong conclusions, especially with regards to impact on nutritional status. Additional studies with more rigorous evaluation methodologies are needed.
In the first paper reviewed from the period following the coverage offered by Ruels work, Bushamuka et al.(11) present an evaluation of a community-level intervention titled NGO Gardening and Nutrition Education Surveillance Projected initiated in 1993 by Helen Keller International (HKI), in partnership with local nongovernmental organisations, in Bangladesh. This intervention encouraged poor households to use home gardens to produce vitamin-A rich vegetable crops year-round and included technical and material assistance from Helen Keller International (with no further details given). The original programme covered more than 860,000 households in 210 of Bangladeshs 460 subdistricts. A cross-sectional evaluation of the project, relying on structured interviews regarding home production and other topics, was conducted in 2002, in which three groups of households, randomly selected, were evaluated: active-participant households, receiving assistance for less than three years (n = 720); former-participant households, which completed the programme at least three years prior (n = 720); and control households, of similar socio-economic status from areas where the programme had not

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yet been implemented (n = 720). Questionnaires and structured interviews were used to collect data on home food production and consumption. Significantly more former- and active-participants had gardens compared to controls (96% and 100% v. 85.6%, respectively) and year-round production was higher among former- and active-participants than among controls (50.4% and 77.8% v. 15.4%, respectively), with all differences statistically significant. Production of vegetables over a three-month period was significantly higher among former- and active-participants compared to controls (120 kg and 135 kg v. 46 kg, respectively) as was consumption over the same period (70 kg and 85 kg v. 38 kg, respectively). Data for fruit were also presented and showed similar patterns although in much lower amounts. Additional data on effects on womens status were also reported.

Quality issues: This intervention was not a randomised intervention, and no baseline data is available. The evaluation relied on cross-sectional data from three groups: activeparticipants, former-participants, and nonparticipants. While the inclusion of the formerparticipant group helped to demonstrate the sustainability of this intervention, and the nonparticipant group provided a control but without baseline data, it is difficult to know whether differences between the groups were due to the intervention or were preexisting. Some information (seemingly self-reported retrospective information, although it is not clear) suggests that the three groups were similar with regard to income before the initiation of the project, but there are no other baseline data available. The intervention showed differences in production among the groups, although this information was gained from self-report and may have been influenced by respondent bias, with active- and former-participants reporting higher production of the target foods in order to provide desirable answers. There was no collection of serum retinol values, so it is unknown whether these reported changes in production were translated into effects on nutritional status.
Jones et al.(12) present an evaluation of the Market Access for Rural Development (MARD) intervention project, initiated in 1997 in Nepal. The primary objective of this community-level intervention was to increase household income through production of high-value crops, with a secondary objective, added later, of increasing the intake of vitamin A-rich foods through the promotion of kitchen gardens. The kitchen garden portion of the project included demonstration gardens, seed distribution, and education at the community level. The original project was intended to reach about 37,000 households. This secondary intervention was implemented in two of the six districts participating in the MARD project. The intervention included a nutrition education component, development of model kitchen gardens in chosen demonstration households (four per district), additional crop demonstration sites, education materials, training

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sessions, recipe demonstrations, and seed distribution. Two years after project implementation, a cross-sectional survey was undertaken to evaluate the impact of the kitchen garden component, comparing all the households in the intervention districts (n = 430) with controls (n = 389) randomly selected from districts not participating in the MARD project. The groups were similar with regard to household composition and socio-economic status. Data collected included self-reported intake on vitamin A and other nutrition knowledge and on production and consumption of vitamin A-rich foods. Impact was evaluated by comparing vitamin A and other nutrition and hygiene knowledge, as well as self-reported production and consumption of vitamin-A rich foods. Although knowledge about vitamin A deficiency was low in both groups, knowledge scores were higher in the intervention group. Significantly more households in the intervention group reported producing and consuming a wide variety of vitamin-A rich vegetables than control households. For example, over 90% of intervention households reported consuming spinach, compared to fewer than 50% of control households.

Quality issues: This intervention was not randomised at the outset. The evaluation used a random selection of people who received the intervention and compared them with a random selection of controls with similar sociodemographic profiles from nonparticipating districts. This evaluation design was intended to provide a comparison group for those in the treatment group, but it is unknown whether there are differences between the groups that existed at baseline or which are broader than sociodemographic differencessuch as differences that exist at the district level, like differences in infrastructure and access to health care and advice. Without baseline data, it is difficult to know again whether differences seen in the evaluation were due to pre-existing differences or were evidence of intervention effect. Because the production and consumption data in this paper were self-reported, it is possible that respondents adjusted their answers to provide desirable responses. And again, since serum retinol values were not collected, it is difficult to know whether the intervention impacted nutritional status.
Kidala et al.(13) evaluated the impact of a food-based community-level intervention to address vitamin A deficiency that took place from 1992-1993 in five villages in rural Tanzania, with five villages from another district serving as controls. Each village had approximately 200-300 households. During the intervention, village leaders and villagers, and female village representatives attended a mix of several seminars covering home gardens, nutrition education, vitamin-A deficiency, preparation and storage of vitamin Arich vegetables and other relevant topics. In addition, 7,000 guava and pawpaw seedlings were distributed to households and primary schools, and booklets and posters were distributed. During the intervention period, 1,800 households (76%) established home gardens and all primary schools either established or strengthened their school gardens.

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In 1998, 125 households from the intervention district and 125 households from a nearby control district were randomly selected to participate in an evaluation. Interview data were available from 121 intervention households and 115 control households, anthropometric data and stool samples were available from 115 and 110 sample children 12-71 months of age randomly selected from the households, and serum retinol data from subjects without low C-reactive protein values (indicating low levels of systemic inflammation, which can indicate the presence of infection that affects retinol status), were available from 75 intervention and 71 control children. At the follow-up, significantly more intervention households (67%) were observed to have home gardens than control households (32%), and more grew paw-paw trees in them. Mothers knowledge and practice scores were also higher in the intervention households. Based on self-report by mothers, significantly more children in the intervention area (65%) consumed vitamin-A rich foods more than seven times a week than children in the control area (37%). Although children in the control area had a significantly higher mean serum retinol level (19.49!g dl-1) than children in the intervention area (148!g dl-1), despite no differences in reported vitamin A capsule distribution in the areas, this difference dissipated and was no longer significant when adjustment was made for helminth infection, which was much higher among children in the intervention areas.

Quality issues: This intervention was not randomised. Rather, the intervention was provided to villages in one district and those villages were compared with controls in another district during the evaluation. So, it is unknown whether differences between the group were pre-existing or were a result of the intervention. A great strength of the evaluation of this intervention is that it did include serum retinol data and did control for infection (via excluding children with abnormal C-reactive protein levels) and controlling for helminth infestation, two major potential confounders of serum retinol data. . There were no baseline values available from the groups compared, so it is not possible to determine what differences were present before the intervention, and perhaps even if the intervention improved serum retinol levels in the intervention group.
Faber et al. published two papers(14,15) with impact data from a community-level intervention to promote the household production of yellow fruits and vegetables and dark green leafy vegetables in rural South Africa. One paper reported on the dietary intake results(14), while the other paper looked primarily at mothers knowledge scores and childrens serum retinol levels.(15) The intervention, which included nutrition education, education on the preparation and storage of the foods, and demonstration gardens, was integrated into an already-established growth monitoring programme. A total of 154 children aged 2-5 years from both the experimental and an adjacent control

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community were included in a baseline survey and 100 children aged 2-5 years (50 each from households with and without project gardens) were sampled at 12 months and at 20 months following implementation of the intervention. It is not clear whether selection was random. Data collected included food intake data from 24-hour recalls and data on knowledge from questionnaires. With regard to intake data, the median vitamin A intake at baseline, calculated from 24hour recall data, was 150 !g RE. At both the 12-month and the 20-month evaluations, the median intake values were significantly higher among children in the intervention compared to the control group (1,133 !g RE v. 640 !g RE, respectively, at 12 months; 493 !g RE v. 129 !g RE, respectively, at 20 months). The higher values at 12 months versus 20 months likely reflected the coincidence of harvest season with the 12 month but not the 20 month follow-up.(14) Mothers from the experimental area had significantly higher knowledge scores than the control group at baseline and had increased their scores as measured at the 20-month follow-up. While the control group scores remained unchanged, the scores went up from baseline to 20 months in both groups. At baseline, the serum retinol concentrations were 0.730.22!mol/L (n = 107) in the intervention group and 0.800.20!mol/L (n = 58) in the control group, and at the 20-month follow-up, the concentrations were 0.810.22!mol/L (n = 110) in the intervention group and 0.730.19!mol/L (n = 111) in the control group. The changes in both groups over time were significant, as was the difference at follow-up.(15)

Quality issues: Although the treatment and control groups were not randomised, the intervention model did include baseline measurements for both groups, which made it possible to determine whether differences seen in the evaluation, post-intervention, were pre-existing or whether they may have resulted from the intervention. Unfortunately, although serum retinol data were collected, helminth infestation and C-reactive protein levels (a marker of infection and inflammation) were not taken into account. Because parasite load and infection levels can have great effect on serum retinol data, these measures should have been included. However, since the intervention group had lower serum-retinol measures than the control group at baseline and higher measures at followup, it does seem that the real effect (due to the intervention) may have been evident. 4.2.4 Summary and conclusions

With regard to the two studies designed in the context of chronic disease prevention, both studies included nutrition education and cooking instructions to help participants to learn how to reduce consumption of certain commonly-consumed nutrients and foods. Both interventions led to some positive outcomes in terms of consumption of cooking fats and

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oils, salted foods, green and yellow vegetables and fruits. Although both studies relied on self-reported diet and consumption data, they also made attempts to validate self-reported diet data, either through biomarkers or other physiological measures. With only two studies identified in this context, however, it can be concluded that more research is needed to establish consistently successful methodologies. Building on what was learned in the earlier studies reviewed by Ruel(6), almost all the more recent studies in the context of micronutrient deficiencies included an education component. Three out of the five intervention studied provided seeds, vines, or seedlings to the study participants, indicating that seed provision might be necessary in many circumstances, which one can conclude will add to the cost of these types of interventions. None of the studies were randomised at the initiation of the intervention, making evaluation later less objective. With regards to evaluation methods, three out of the five studies reviewed only carried out cross-sectional evaluations of the interventions. The lack of baseline data makes it difficult to ascertain the true effects of the intervention because the analyses cannot control for differences among intervention and control groups at baseline, and makes it difficult to attribute causality when effects are found. Thus, it can be concluded that more studies need to plan their evaluation strategies during the design stages of the intervention so that baseline data are included. Although all of the interventions reviewed showed some positive effects, only two included measures of serum retinol(13,15), and were thus able to examine the effects on nutritional status. Of these two studies, only one, by Kidala et al.(13), included appropriate additional measures of helminth infestation and C-reactive protein, a proxy for infection that may interfere with vitamin A status. This study did not show an intervention effect, perhaps due to helminth infection in the intervention group. Thus, it can be concluded that proper evaluation of these types of studies must include the collection of serum retinol and other nutritional status measures, in the attempt to verify impact on actual nutritional status, and the measurement and adjust for other potential confounders such as helminth infestation and infection rates. Because the interventions in the context of micronutrient deficiencies were developed primarily for poor rural populations at high risk for vitamin-A deficiency in very foodinsecure areasto increase both income among poor producers and to increase intake in the food-insecurefurther research is needed to see whether similar tactics might be used to promote fruit and vegetable consumption in populations at high risk for cancer. Such populations may, for example, be urban, have more access to fruits and vegetables, and be less able or less inclined to garden. While access to fruits and vegetables may be a limiting factor in rural poor communities, lifestyle factors and knowledge may be the

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primary limiting factors in other populations, requiring different strategies to increase fruit and vegetable consumption. All of the studies in this section were community-level trials that are both resource and time intensive, rather than population-level, so it is unclear whether such interventions can be scaled up to cover large populations. What can be concluded is that, knowing that fruits and vegetables are of primary importance for cancer prevention, these types of studies should be expanded and tested in populations at risk for cancer. In addition, as shown in Appendix 4.5, there are other un-evaluated strategies to increase intakes of fruits and vegetables and relevant micronutrients, such as national five-a-day programmes and biofortification projects, which should also be followed-up and evaluated in the future.

4.3 Results: Individual-level and community-level interventions explicitly targeting the prevention or reduction of overweight and obesity
4.3.1 Characterisation of the literature
Overweight and obesity are now considered global public health problems and are also recognised as contributors to a wide range of diet-related chronic diseases, including various forms of cancer.(16) Because the proportion of the population that is either overweight or obese is growing rapidly, the cost of offering treatment on an individual basis to people already suffering from overweight/obesity is increasingly high(16) and the long-term effects of weight-loss programmes are often small.(17) Thus, the prevention of weight gain and a focus on diet and lifestyle choices that promote maintenance of a healthy weight offer the only potentially successful options for tackling the overweight/obesity epidemic on a large-scale.(16) However, very few countries have developed programmes to further these goals. It has been suggested that a primary reason for this is a dearth of controlled intervention trials with adequate sample sizes and rigorous methodologies and thus a lack of consistent findings and recommendations to direct the development of large-scale preventive programmes.(16) This review of such interventions yielded only four studies(18-21) that met our inclusion/exclusion criteria to contribute to this gap in the literature. They are summarised below and are grouped as interventions targeting children and adolescents (three studies), and interventions targeting adults (one study).

4.3.2

Interventions targeting children and adolescents

The first paper in this section is an evaluation of a school-based community-level intervention(18), and the second two papers are evaluations of individual-level interventions targeted specifically at individuals identified as being overweight or obese.(19, 20)

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A study in Chile by Kain et al.(18) targeted primary school children in three different cities via a community-level intervention in Chile in 1997. The intervention was evaluated among 3,577 students in five schools, with three schools assigned to the intervention and two designated as controls. Assignment was not random and favoured higher rates of obesity in the intervention schools. The intervention programme lasted six months and included nutrition education for parents and children, meetings with private owners of school lunch kiosks to encourage the sale of healthier foods, 90 minutes of additional physical activity/week, and encouragement of physical activity during recesses. The nutrition education component for children was one developed by the FAO and the Institucion Nacional de Tecnologa Agropecuaria with the objective of introducing nutrition education directly into the school curricula. Outcome measures, including measures of anthropometry, physical fitness (measured by a flexibility test and a 20m shuttle run endurance test to measure aerobic capacity), dietary assessment, and attitudes and behaviour related to healthy eating and physical activity were measured at the beginning of the school-year (baseline) and at the end of the school year, eight months later. Of the original subjects, 3,086, or 86.3% (2,141 from intervention schools and 945 from control schools), were included in the follow-up. The proportion of obese children was significantly higher in the intervention group at baseline, and differences in BMI Z-score, BMI percentile, and waist circumference were also noted. Physical activity scores were also lower in the intervention group at baseline. Among boys, statistically significant intervention effects were observed with regard to adiposity measures such as BMI, BMI Z-score, and waist circumference, although triceps skinfold was unaffected. For example, mean BMI Z-score in the intervention group was 0.63 (0.97 s.d.) at baseline and was 0.51 (0.94 s.d.) at follow-up (for a reduction of 0.12 units). In the control group, BMI Z-score was 0.48 (0.93 s.d.) at baseline and was 0.46 (0.81 s.d.) at follow-up. These scores were significantly different at baseline, reflecting the non-random assignment to the intervention group, and the difference in change of the Z-scores from baseline to follow-up was also significant, as was an interaction (group*time) controlling for baseline value. Adiposity measures were not affected in girls. Physical fitness parameters improved significantly in the intervention group among both boys and girls. Baseline differences were accounted for. Results regarding the dietary assessment or knowledge and behaviour data were not presented.

Quality issues: Some bias may have been introduced because the assignment to intervention v. control group at the school level was not random and favoured schools with higher rates of obesity in the intervention group. Thus, for example, parents and

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children in the intervention group may have been motivated through other means to lose weight due to awareness of their high incidence of obesity. Chen et al.(19) report on the effectiveness of an individual-level health promotion and counselling intervention for overweight junior college nursing students, initiated in 1997 in Taiwan. At the beginning of a new semester, all students underwent a required physical examination. As a result, 166 of 980 students (17%) were identified as overweight based on a weight-length index > 1.2 (body weight/body height and a constant); 58 of these students were randomly selected to participated in the programme and 55 agreed to do so. The mean age of the 49 subjects who completed the study was 15.5 years. The intervention was based on self-management therapy that emphasizes the importance of subject-motivation. Trained personnel conducted small group counselling sessions for a total of eight hours of education allocated as follows: nutrition, with a focus on eating from the five food groups and reducing portion size (two hours); exercise behaviour modification, including instruction on types of exercises (two hours); education about the risk factors associated with overweight (two hours); life appreciation and interpersonal support (two hours). A companion booklet was also distributed. There was also an additional 12 hours of small group health promotion counselling, with three-to-five subjects per group for one hour/month. Although it is not entirely clear when the postintervention data was drawn, it appears to be after counselling, which lasted one year. Data were collected at baseline and at 12 months after the initiation of the intervention and included measures of anthropometry, blood pressure, cholesterol levels, and selfreported data on health promotion knowledge and practice. Differences between pre- and post-intervention measurements among the participants were compared using paired t-tests. The mean body weight was significantly lower after the intervention (67.15 kg v. 69.65 kg) with weight losses ranging from 2 to 10 kg. The weight-for-length index also decreased significantly from 1.46 to 1.40. Significant improvements were also seen in other health parameters, such as systolic blood pressure, HDL cholesterol levels, and total cholesterol.

Quality issues: This intervention randomly selected some subjects, based on overweight identified at the individual level, to participate in the intervention, but did not randomise other subjects into a control group, thus there as no control group for comparison purposes, making it difficult to know whether changes seen were due to the intervention or to other ambient causes. Also, the sample size for this intervention was quite small.
Ray et al.(20) report on the Programme on Prevention and Management of Obesity in preschool children, implemented by the government in Singapore. This community-level
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programme was implemented in 1991 and aimed to reduce the prevalence of obesity among preschool children ages 3-6 years old from 10.9% to 7% by 1995. The programme included a distribution of pamphlets on healthy eating and exercise, parental education on how to monitor growth using growth charts, educational antenatal talks on childhood nutrition, talks and demonstrations on the preparation of healthy meals for preschool children and screening of video tapes on healthy diet. This programme was carried out in 17 Government Primary Health Clinics. Within this framework, an additional individual-level intervention was included for obese children. Based on WHO criteria, 1,128 children who visited the Primary Health Clinics between November 1991 and October 1992 were identified as obese. The severely obese children were referred to a dietician for management and were discharged back to the clinic once weight status was < 160% of the reference weight-for-height. Mildly and moderately obese children underwent counselling on diet (topics such as nutritional guidelines and energy balance) and exercise with their families. Food intake and exercise patterns were recorded and goals were set and checked at follow-up visits. Counselling sessions were conducted at 1-3 month intervals until the children reached normal weight. This evaluation looked solely at the impact of the programme on the subset of the 1,128 obese children who qualified for the additional intervention components. Impact of the individual-level programme geared specifically to obese children was evaluated after one year. Pre- and post-intervention data were compared. Among the group as a whole, 40.5% improved their weight status (significant at p < 0.05) and 20.2% returned to normal weight status. There were some significant differences among ethnic groups.

Quality issues: The limitations of this study include the lack of control group and the fact that the population that attended the government-run health clinics was of lower and middle class and was not representative of all the ethnic and sociodemographic groups found in Singapore. 4.3.3 Interventions targeting adults

A community-level intervention evaluated by Kisioglu et al.(21) in Turkey targeted both the reduction of obesity and control of hypertension among middle-aged Turkish women of low socio-economic status. The intervention was carried out in the Yenice region, a developing area, of Turkey. Of 1,017 women aged 20-50 years of age, 430 were randomly selected and invited to participate in the study and 400 participated, 200 each in the intervention and control groups. It is not clear why only 430 were invited to participate, but the paper does state that the number took into account the 20% prevalence of hypertension overall among women of this age group in Turkey when choosing this

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number. Women were contacted by physicians and nurses and asked to report to a local health centre to obtain anthropometric and blood pressure measurements and to collect baseline data on sociodemographic characteristics, health behaviours, exercise, and disease history. Information on specific dietary habits (such as number of meals per day containing salt, oil consumption per day, etc.) was obtained through self-report. Women in the intervention group received training support from an expert, and a leaflet explaining the impacts of the issues raised. The intervention training consisted of the women being educated in small groups about the negative impacts of hypertension. The greatest emphasis was on the links with obesity and the importance of physical activity. With regard to diet, the importance of choosing boiling over frying when cooking foods, retaining vegetables in the diet, reducing fat and oil in the diet, replacing margarine and butter with olive and vegetable oils, and reducing salt intake was emphasized. Reducing smoking and alcohol consumption was not emphasized since these practices were not common among the participants. The women were also encouraged to participate in an ongoing education programme, but the participation and duration of these optional education sessions was not recorded. There were no significant differences between the groups among sociodemographic features, blood pressure, anthropometry, or dietary habit at baseline. Follow-up data were collected at six months after the initiation of the programme. At follow-up, the intervention group reported a significant reduction in use of salt, oils, and fat in their cooking and a preference for using boiling and baking over frying when cooking, but these results were obtained through self-report and women may have been influenced by their knowledge of the programme goals when providing their responses. However, the anthropometric results provide supporting evidence that diets were improved in the intervention group. At baseline, the prevalence of obesity was 29.0% in the control group and 34.5% in the intervention group, whereas the prevalence was 34.5% and 24.5%, respectively, at follow-up. The differences between the groups were not statistically significant at baseline but were at follow-up, and it is notable that the prevalence of obesity in the intervention group declined while the prevalence in the control group increased. There were neither significant differences in blood pressure between the groups at baseline (with about 30% of the population having high blood pressure), nor at follow-up (with no substantial changes), but self-reported awareness about hypertension increased significantly in the intervention group.

Quality issues: Although, unfortunately, all eligible women were not invited to participate, this intervention was randomised into treatment and control groups at the outset, allowing for comparisons to be made. Also, many of the results in terms of changes in cooking methods were self-reported and were not validated, although the changes in obesity prevalence provide some support for the findings.

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4.3.4

Summary and conclusions

Among the four interventions addressing overweight and obesity included in this review, several weaknesses were identified. Not all of the study designs incorporated randomisation and use of control groupsmethods that can help reduce confounding and infer causality. Two more broad limitations with regards to the obesity interventions targeting children were also noted. First, none of the studies of children and adolescents collected data on or controlled for maturation level. Adiposity in children varies with timing of maturation. Adiposity tends to increase during early infancy and then steadily declines in young children to a low point somewhere between about 3 and 7 years of age before increasing again, during a period called the adiposity rebound.(22) The age at which BMI is at its nadir, preceding the adiposity rebound, can vary widely, as can the level of adiposity at various ages following the rebound. These differences in adiposity in children may be influenced by a variety of factors, such as overweight status of the mother, maternal smoking, socio-economic status, and other influences.(23) If age at adiposity rebound and the factors influencing it differ between intervention and control groups, then differences and changes in adiposity between the groups may be due, at least in part, to differences in the underlying growth trajectories and maturation levels of the groups rather than to intervention effects. When possible, impact evaluations of interventions addressing obesity in children and adolescents should attempt to measure and control for pubertal timing and age at adiposity rebound. Second, two out of the three interventions geared towards children were individual-level interventions, that is, interventions that targeted subjects identified on an individual basis to be overweight or obese. While these interventions may help overweight and obese children lose weight, the problem of obesity is growing so rapidly and is so widespread that interventions to prevent obesity, rather than reverse it, should be the primary public health focus. All of the studies raise questions about sustainability. Most were small intense programmes that lasted short finite periods of time, when overweight and obesity are long-term issues that likely require long-term changes. Intervention studies attempting to prevent or mitigate overweight and obesity need multiple evaluations across long periods of follow-up. For example, it is vital to know whether interventions aimed at improving diet and other lifestyle behaviours in childhood have lasting effects on weight status into adulthood, or whether the effects are more circumscribed to a specific period following the intervention. In conclusion, the paucity of well-designed interventions aimed at reducing or preventing overweight and obesity, particularly in developing countries, makes it impossible to

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identify any one clearly successful approach, rigorously tested and validated through repetition. The most consistent link among the studies reviewed was that nutrition education was provided in all contexts, although delivered through various means including counselling sessions, leaflets, and integration into school programmes, and that all had significant effects on adiposity and/or body weight. It can be concluded that more interventions, with well designed impact analyses, including randomised intervention and control groups, measures of maturity, and long periods of follow-up, and focusing on prevention, are needed to determine which specific strategies will have significant, consistent, and lasting effects.

4.4 Individual-level, community-level, and population-based interventions with the goal of chronic disease prevention
4.4.1 Characterisation of the literature
In addition to interventions targeting specific foods relevant to cancer, and interventions focusing on specific biological risk factors such as obesity, the literature also revealed a variety of studies with multiple strategies, including nutrition components, and with broader goals of reducing a variety of chronic disease risk factors. Because the context of these interventions is chronic disease (although not always cancer), and because there are similarities among many of the risk factors for various chronic diseases, these interventions are included in this report. These studies have been categorised into individual-leveltargeting individuals based on individually identified risk factors, community-based interventionstargeting particular communities or groups, and population-based interventionsinitiated at the national level. Traditionally few developing countries have attempted to launch large programmes addressing chronic disease risk through their health agendas or through broad health initiatives, largely due to limited resources and competing health problems such as undernutrition, HIV/AIDS, and other communicable diseases. However, wealthier countries such as Singapore and Mauritius have recently instituted national health promotion programmes in the context of rising rates of chronic disease. These and other population-based programmes in developed countries, such as the promotion of national dietary guidelines, has prompted a rapidly growing interest and commitment to population-level health programmes relevant to diet and chronic disease in countries of all income levels. Although the search of the literature revealed only two evaluations of such programmes, a broader search of the grey literature and of information online revealed a wide variety of emerging population-based projects that have not yet been evaluated. Descriptions of these findings are included in Appendix 4.5. Because the database search revealed such a significant number and variety of emerging population-

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based interventions, they are also discussed briefly at the end of this section and in the conclusions section at the end of this review (subsection 4.7).

4.4.2

Individual-level interventions

Muto and Yamauchi(24) evaluated an individual-level randomised controlled study of a workplace health promotion programme in Japan aimed at improving CVD risk factors. Among male employees working for a building maintenance company in Japan, 152 were randomly assigned to an intervention group and 150 were assigned to a control group. All participants were recruited due to abnormal findings for at least one CVD related measure, including body mass index, blood pressure, cholesterol measures, triglycerides, or fasting blood glucose. It is not clear whether all those recruited agreed to participate or whether some declined. The intervention consisted of a main programme conducted for four days at a hot springs resort and consisted of education sessions, lectures, group discussions, and other activities emphasizing the importance of good nutrition and physical activity. With regards to diet, decreasing dietary fats and salt was particularly emphasized. Participants were then required to set individualized health goals. Progress towards goals was evaluated every three months for one year after the main programme. The control group did not receive the main programme or the follow-ups but did have annual health examinations in compliance with established laws. Data were collected in both groups 6 months prior to the initiation of the intervention, and again at 6 and at 18 months after the main programme. There were statistically significant decreases in body weight, BMI, systolic and diastolic blood pressure, and total cholesterol in the intervention group compared to the control group both by 6 and by 18 months after the main intervention programme. For example, the change in body weight by 6 months was -1.6 2.7 kg in the intervention group compared to 0.1 1.9 kg in the control group. In addition there was a significant decrease in fasting blood glucose by 6 months after the main programme and a significant decrease in triglycerides by 18 months after the main programme in the intervention group.

Quality issues: The main limitations of this study was its prohibitive expense, with a cost of approximately $1,000 USD per person paid for by the workplace, making it unlikely to be replicated in lower income countries or among less well-endowed or motivated work sites.

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4.4.3

Community-level interventions

Two community-based interventions meeting the inclusion/exclusion criteria were identified and are summarised below.(25-27) Three papers are included below because two of the papers offer different evaluations (at different follow-up points, using different evaluations methods) of the same intervention.(25, 26) Two papers, by Abramson et al.(25) and by Gofin et al.(26), evaluate the impact of a community-level intervention for the control of cardiovascular risk factors (the CHAD programme) begun in 1971 in Jerusalem, Israel. The CHAD programme was instituted within a family practice in Western Jerusalem serving four housing projects (and about 2500 people) and operated by the Department of Social Medicine of Hebrew University in response to high rates of CVD risk factors and diabetes in the neighbourhood. The programme was directed at all adults (> 25 years of age) and was integrated into the primary health-care setting and delivered by physicians and nurses. The goals of the intervention were to reduce the prevalence of hypertension hypercholesterolemia and overweight through changes in diet, smoking, and exercise behaviours. The intervention consisted primarily of individualized counselling and health-care regimens provided in the context of clinic visits. Hypertensives were prescribed diuretics and additional medications if necessary, and were provided with nutrition counselling urging salt restriction and sometimes calorie reduction, in the presence of overweight. A cholesterol-lowering diet was recommended to all. Smoking cessation was stressed and all participants were counselled on weight control and encouraged to exercise. Participation reached roughly 75% of the eligible population and the costs were covered by prepaid medical insurance. The paper by Abramson et al.(25) used baseline data from 1970 and follow-up data collected in 1975 to compare outcomes of interest in the intervention area to those in an adjacent neighbourhood used as a control. Both the intervention and control areas had free access to primary health care and high levels of coverage by medical insurance. The study population consisted of people who were examined in 1970, were 35 years old or more at that time, and were still alive and living in the study area at the time of the 1975 follow-up. In 1970, 684 people were examined in the study area and 1,995 were examined in the control area. In 1975, 574 of the original study area subjects and 1,796 in the control area were re-examined. There were statistically significant net reductions in the intervention area in the prevalence of hypertension (20% reduction), overweight (13% reduction), and smoking among men (11% reduction). There were also statistically significant net reductions in systolic and diastolic blood pressure and body weight. A larger proportion of people in the study area reported taking care with their diet and

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making other healthy lifestyle changes. Similar results were found when controlling for potential confounding by differences in age and education between the populations.

Quality issues: This intervention was not designed as a randomised intervention, and the control subjects came from an adjacent neighbourhood. Because much of the intervention was provided at the level of the individual (counselling, drugs, visits to doctors), it would not have been possible for the controls, even though they lived in close proximity, to benefit equally from the intervention. It is possible, however, that the intervention engendered raised awareness regarding chronic disease risk in both areas. With regards to the evaluation, it is possible that study participants reported desirable results rather than true changes when reporting on things like diet change and lifestyle change. Because the follow-up took place long after the initiation of the intervention, it is also possible that deaths among the study population affected the results, with people for whom the intervention was less successful dying at higher rates than people for whom the intervention did work. This type of bias could make the intervention seem more successful than it may have actually been among all participants.
Gofin et al.(26) evaluated the same intervention discusses above using more recent follow-up data from 1981 but did not use a control group for comparison. Baseline data and data from 1981 were compared among people in the intervention group who were 25 years and older at the beginning of the CHAD programme (1971) and who were still living in the neighbourhood in 1981 (n = 505). Within this eligible group, data from both years on weight were available for 423 people and data on smoking and blood pressure were available for 424 and 441 people, respectively. There were no changes in mean body weight or in the prevalence of overweight in the cohort over the 10-year period, although mean weight tended to rise in younger age groups and decrease in older age groups. The prevalences of hypertension and of heavy cigarette smoking significantly decreased.

Quality issues: Because no control group was used for comparison in this study, it is less possible to quantify the extent to which these reductions might be attributed to the CHAD programme. Again, and as the authors note, in the case of smoking and hypertension, there might also have been some survivor effect, with people who did reduce their risk factors surviving and being included in the follow-up and people with high risk factors not surviving, thus making it seem that reductions in risk factors occurred on average, which may have enhanced the level of reduction of risk factors observed over time.
Shi-Chang et al.(27) report on an evaluation of a community-level health-promoting schools (HPS) initiative in China. This evaluation covers an intervention that occurred in only six schools, but was a pilot project for a national initiative overseen by the

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Chinese Ministries of Health and Education with the assistance of the WHO. Three primary and three secondary schools from Zhejiang Province, from both urban and rural areas, were chosen to participate in the intervention, while six additional schools (three primary and three secondary) were selected as controls. The participants in the intervention schools included approximately 7,500 students and their families as well as 800 school staff. In May of 2000, baseline data were collected from 2,575 primary school children and 4,277 secondary school children from selected grades and classes. In addition, 661 school personnel (resulting from a random sample of half of the staff) and 991 parents/guardians (from two of the classes of participating students) were surveyed. It is not clear whether the 2,575 primary school students and the 4,277 secondary school students were randomly chosen. Measures of nutrition knowledge among students and parents, and self-reported information about some nutrition behaviours were collected. The intervention programme began in May of 2000 and ran through November of 2001. Follow-up data were collected in a similar sampling scheme from the same group of students, resulting in similar sample sizes, in December of 2001. The intervention included many activities such as school-based working groups on nutrition comprised of teachers, parents, headmasters, and other leaders; nutrition training for school staff; distribution of materials on school nutrition; biweekly health education classes on nutrition for students; student competitions including a drawing and a knowledge contest with nutrition themes; improvements to the school infrastructure and policies with nutrition in mind, and outreach to families and communities via leaflets, menus, recipes, lectures, and workshops. Control schools received routine health education activities. The impact evaluation focused on knowledge only. Among primary students, there were statistically significant increases in self-reported nutrition knowledge in both the intervention and control groups, although more improvements were seen in the intervention group, with greatest knowledge gains in the area of the Chinese Dietary Guidelines (from 49.2% to 78.%) and adequate dietary principles (42.9% to 68.0%). Secondary school children in the intervention group made many significant nutrition knowledge gains over the study period, while those in the control group had none and reported some decreases in knowledge. Secondary school children also showed significant improvements in the percentage who reported liking the school lunch (from 17.9% to 45.2%), while the percentage in the control schools declined. The largest gains in nutrition knowledge occurred among parents in both groups, but the increase was twofold higher in intervention than among control parents.

Quality issues: Because this study did not collect diet or anthropometric data, it is unknown whether the observed changes in knowledge were translated into healthy diet and nutritional status changes. It is also possible that, because the data collected were self-reported, at least some of the answers in the intervention group were given because

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they were known to be desirable answers rather than because they reflected actual behaviour changes. Thus, further study is needed to know whether this type of programme results in functional changes in health and lifestyle.

4.4.4

Population-level interventions

Both of the evaluations of population-based interventions that were identified met the inclusion/exclusion criteria and are summarised below.(28-30) The population-level national programme in Singapore is described in two papers. Although the first paper, by Emmanuel et al.(28), provides some information on outcomes and evaluation, it did not include details on statistical significance. Thus, this paper was officially excluded from this literature review and as such, is summarised in Appendix 4.4. However, because the paper does provide some helpful information on approaches taken when the programme was initiated in the 1980s, it is also briefly summarised here. The second paper, by Cutter et al.(29), describes the impact of the revised programme implemented in the early 1990s. The paper by Emmanuel et al. does not provide impact evaluation of the earlier programme with significance testing, although it does provide some background for the subsequent study. In response to sharp increases in the prevalence of chronic diseases, Singapore launched the Singapore Healthy Living Programme through the Ministry of Health in the early 1980s. The programme included sustained health education programmes through various media, direct patient counselling, large-scale campaigns to promote healthy eating habits, exercising a smoke-free lifestyle, and early detection of disease through an increase in screening among high-risk groups. Although statistical significance was not provided, Emmanuel et al. reported an improvement in the prevalence of hypertension (15.3% to 13.6%), a decrease in mean total cholesterol levels (5.8 to 5.3 mmol/L), and an increase in HDL cholesterol levels (0.9 to 1.3 mmol/L) between 1984 and 1992.(28) At the beginning of the 1990s, the Healthy Living Programme was reviewed, and plans were made to further integrate healthy living into daily life via broad programmes and campaigns. A National Healthy Lifestyle Committee was created, with participation from government ministries, private organisations, and others. The revised National Healthy Lifestyle Programme was implemented in April of 1992 as a 10-year programme designed to focus on a different theme each year. Programme components included community interventions, interventions in schools, workplaces, unions, and other venues. With respect to diet, several changes were implemented in schools, including the provision of healthier offerings in school cafeterias, the encouragement of healthy eating habits, and the installation water coolers in an attempt to promote drinking water over soda and other sweetened drinks. A Food and Nutrition Department was also created by

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the Ministry of Health in 1990 to bring attention to the detrimental effects of diets high in fat, cholesterol, salt, and sugar. In addition, Guidelines for a Healthy Diet were established to provide targets for healthy diets and to promote breastfeeding. Further efforts were given to establish nutrition labelling and responsible advertising of foods.(28) An evaluation of the newer National Healthy Lifestyle Programme was carried out in 1998 by comparing two rounds of the Singapore National Healthy Survey, from 1992 and 1998. These surveys were nationally representative with sample sizes of over 3,000 in both 1992 and 1998. Data were drawn from adults aged 18-69 years of age. The differences in the prevalence of hypertension and high total blood cholesterol level were significant, with, contrary to what one might expect, higher prevalences found in 1998 than in 1992. For example, the prevalence of hypertension increased in the population aged 30-69 years from 22.5% to 26.6%. The prevalence of smoking significantly decreased among men and the prevalence of regular exercise increased significantly among women between 1992 and 1998. No differences were found with respect to the prevalence of diabetes, impaired glucose tolerance, or obesity.

Quality issues: Because national-level interventions target the entire population, there is no opportunity for comparison with a control group. Without this, it is difficult to know whether the lack of change in these parameters is indicative of poor impact of the programme on these outcomes, or whether larger increases in the prevalence of these poor health outcomes were prevented by the programme, thus indicative of a positive programmatic effect.
Dowse et al.(30) review a similar population-level national health promotion programme in Mauritius. After a baseline survey in 1987 revealed high prevalences of hypertension, type II diabetes, and heart disease, a noncommunicable disease unit was created within the Ministry of Health and launched a broad national programme in 1988 to modify noncommunicable disease risk factors such as glucose intolerance, hypertension, hyperlipidaemia, obesity, smoking, alcohol misuse, and physical inactivity. The programme has employed mass media, fiscal and legislative measures, and health education components in many contexts including schools and workplaces. In 1992 a follow-up study was conducted to evaluate the impact of the programme on a variety of outcome measures. The baseline survey from 1987 was conducted among adults aged 25-74 in randomly selected clusters plus one additional cluster to provide information on the Chinese minority. The same sampling scheme was used in 1992, and both surveys covered more than 5,000 subjects. The prevalence of diabetes did not change among either men or women, and the prevalence of impaired glucose tolerance declined significantly in women. However, the

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prevalence of hypertension increased by 19.3% in men and by 12.1% in women. The prevalence of obesity and both mean waist:hip ratio and body mass index increased significantly in both men and women. Smoking prevalence decreased significantly in both men and women and frequent alcohol consumption decreased among men. The prevalence of hypercholesterolaemia and hypertriglyceridaemia also decreased dramatically in both men and women.

Quality issues: Again, without a control group, it is difficult to know whether the observed increases in hypertension and obesity reflect lack of impact, reflect increased survival of people with risk factors, or, in the case of obesity, perhaps even the effects of smoking cessation. It could also be that the intervention prevented greater increases in obesity and hypertension than were observed. 4.4.5 Summary and conclusions

All the interventions described above were interventions with multiple components. The individual-level intervention(24) and one of the community-level interventions(25, 26) reviewed required a large degree of infrastructure and financial support. In the individual-level workplace intervention in Japan(24), the programme was estimated to cost approximately $1,000 per person and was paid for by the workplace itself, clearly requiring a workplace setting with high revenues and a great degree of value placed on preventive health by the employers. In the case of the CHAD programme in Jerusalem, the intervention was dependent on the strong primary health-care system already in place and the high degree of coverage (over 80%) of the population by medical insurance.(25, 26) None of the individual-level or community-level studies were set up to evaluate the independent effects of the different aspects of the interventions but all provide some evidence that multi-component interventions with messages and health goals tailored to the level of the individual level may be successful. In several cases, the evaluations of these interventions operated only in the short-term, so it remains unknown whether these examples had or will have sustained effects. There are several similarities between the two evaluated population-level programmes included in this section. First, both were initiated by the government via the Ministry of Health. This indicates a national interest and awareness in chronic disease prevention and the importance of diet and other lifestyle determinants. Both programmes also included education components. However, because both interventions had many components and were instituted nationwide, it is difficult to evaluate which components of the programmes had the most impact. It is also impossible to tell whether any positive effects seen were entirely due to the impact of the intervention or whether they might have partially been due, for example, to the impacts of health awareness in the globalised world, unrelated to the intervention per se. Alternatively, even when improvements in

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risk factors were not observed, it is difficult to tell, in the absence of a control group, if the lack of improvement was due to poor impact of the intervention, or whether the intervention was effective in preventing a worsening of risk factors. For these reasons, the publication of the results of pilot studies, and comparisons of results from national studies to secular trends in similar contexts are encouraged to help provide some insight into what changes in health parameters might have been expected in the absence of the intervention programmes. As mentioned previously, a very large number of unevaluated population-based intervention plans were also identified (described in Appendix 4.5) and merit inclusion in this discussion. These intervention plans are varied in their approach. Following the examples of Mauritius and Singapore, a number of countries, including Pakistan, Chile, China, and India, appear to have broad national disease prevention programmes under development. On a more economic/political front, many countries have passed laws requiring mandatory labelling laws for foods. Additionally, many other countries have other school-lunch programmes in place that focus on improving the quality of foods provided at school. Again, following the leads of more developed countries, many countries have also now released National Dietary Guidelines aimed at healthy living and reflecting local diets and food availability. The implementation of these broad interventions at the national level, with no control groups and no targeting at individuals per se, makes it difficult to evaluate them and quantify their impact. That being said, these population-level programmes represent some of the most ambitious and targeted efforts to improve diets and prevent the development of diet-related chronic diseases, such as cancer, in low- and middle-income countries.

4.5 Community-level interventions addressing the contamination of foods with aflatoxin

4.5.1 Characterisation of the literature
Aflatoxin was only identified about 40 years ago(20), so the development of good techniques for preventing aflatoxin contamination and exposure in developing countries is not advanced, although work is underway to identify practical ways of reducing aflatoxin contamination at various stagesduring production, storage, and processing. During the production stage, potential interventions could include inoculation of fields with competing nonaflotoxigenic strains of fungi, insuring proper irrigation, use of insecticides (because insect infestation increases the moisture content of crops via insect respiration), and bioengineering of crops resistant to aflatoxin contamination.(31, 32) During the storage stage, when much of aflatoxin contamination occurs, adequate drying

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and elimination of insect infestation is essential and is a challenge in the context of poor farmers in developing countries. Some techniques that help support these conditions include not allowing harvested crops to be left in the field and to store foods on platforms with adequate ventilation, rather than on the ground.(31, 32) With regard to processing, manual sorting to remove obviously damaged kernels or pods can also reduce aflatoxin exposure.(31, 33) Treatment with some substances, such as alkaline substances as in the processing of corn with caustic soda as is done in Mexico and other countries in Central America also reduced aflatoxin content, but it is not clear yet whether these chemical changes are sustained.(31)

4.5.2

Interventions

Only one evaluated intervention to reduce aflatoxin contamination was identified. It met the inclusion/exclusion criteria and is summarised below. Turner et al.(33) evaluated a community-level intervention to reduce exposure to aflaxtoxins via groundnut contamination through postharvest measures among subsistence farmers in Guinea. A panel of postharvest measures was introduced to 10 villages in lower Guinea, with similar climate and farming practices and results were compared to 10 similar villages. In each village, 15 families who grew groundnuts at the subsistence level were randomly recruited to participate. In each family, the head of the household and his spouse, or another woman older than 16 years if no wife was present, were included at the individual level for monitoring of blood aflatoxin-albumin concentrations. Local government agricultural advisors, employed to provide assistance to subsistence farmer, explained and demonstrated the intervention techniques, which included: Hand-sorting to discard groundnuts with mouldy or damaged shells; Sun drying on natural fibre mats (provided) rather than on the ground; Assessing completeness of drying by shaking nuts and listening for free movement; Storing dried nuts in natural fibre bags (provided) rather than plastic or other synthetic bags, which can promote humidity; Storing bags in facilities on wooden pallets (provided) rather than on the ground in order to reduce humidity; Provision of 10kg of locally available insecticide to use on the floor and under pallets in storage facility to prevent infestation by insects, which produce humidity. Data were collected during three main surveys: at harvesttime, at 3-months postharvest, and at 5-months postharvest. Data included blood levels of aflatoxin-albumin, information on socio-demographics, and details regarding the harvest. A simple dietary questionnaire was also administered to obtain information about consumption of

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groundnuts and other staples potentially contaminated with aflatoxin. Additional surveys in the intermediate time between the main surveys were administered to assess compliance and obtain additional information about diet and farming. Data were obtained from 535 individuals in survey 1, from 529 individuals in survey 2, and from 514 individuals in survey 3. Findings for aflatoxin-albumin serum concentrations did not differ between men and women, but there was substantial variation among the villages in both groups. The mean concentration was lowest in both groups at harvesttime, but was higher at this initial survey in the intervention group than it was in the control group with mean levels of 7.2 pg/mg (95% CI: 6.2-8.4), versus 5.5 pg/mg (95% CI: 4.7-6.1), respectively. In control villages, the mean concentration of aflatoxin-albumin increased during the five postharvest months to 18.7 pg/mg (95% CI: 17.0-20.6), while the mean level in the intervention villages remained virtually the same overall. At the end of the follow-up period, the concentration level in intervention villages was less than 50% of the mean level in the control villages, after controlling for potential confounders.

Quality issues: The villages were not randomised into treatment or control groups. Groups were determined by district boundaries. Thus, it is possible that some differences inherent to the different districts were not taken into account. This intervention introduced many strategies to reduce aflatoxin contamination, but because they were introduced in a bundle, it is impossible to determine which strategies elicited the greatest effects. 4.5.3 Summary and conclusions

Clearly, the most important conclusion from this section is that more interventions to reduce aflatoxin exposure need to be tested and evaluated. Future studies should examine methods of controlling aflatoxin exposure at all stages of crop production, harvest, and storage. Long-term follow-up could also show whether sustained intervention strategies affect the incidence of hepatocellular carcinoma. Lastly, future research could also test individual strategies to isolate those most effective, particularly since some of the interventions carry costs, as in the case above, requiring specific types of storage bags and pallets.

4.6 Nutrition during early childhood and cancer risk

4.6.1 Overview
Two aspects of nutrition in early childhood, breastfeeding and stunting (short stature as a result of early nutritional deficits), may have links to cancer risk.

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While the link between breastfeeding and reduced risk for breast cancer risk in the breastfeeding mother has been established(34), it has also been suggested that breastfeeding might reduce the risk for some cancers, such as certain forms of leukaemia, in the breastfed child. Evidence is mixed. One systematic review with a meta-analysis of 26 studies found very small associations but noted that non-causal explanations were plausible and that the associations were too small to make a large impact on the incidence the cancers studied (acute leukaemia or lymphoma).(35) Another review, which identified four papers with high quality evidence, found conflicting results, with half of the studies suggesting a reduction in childhood leukaemia with breastfeeding and with increased duration of breastfeeding and the other studies failing to find an association.(36) Another meta-analysis of studies looking specifically at the link between breastfeeding and risk for acute lymphoblastic leukaemia (ALL) or acute myeloblastic leukaemia (AML) found a significant negative association between long-term breastfeeding (> 6 months) and both ALL and AML. Stunting (height-for-age Z-score < -2), or the process of linear growth retardation leading to short stature, occurs primarily during the first two years of life, the period of fastest growth velocity, as a result of dietary deficits and infections, particularly with regard to key micronutrients. Recovery from stunting is limited after infancy, and improved growth after infancy can even lead to shorter stature due to earlier maturation.(37) Recent evidence has shown that stunting in early childhood may be associated with an increased risk for obesity(38-40), a risk factor for cancer, and with a variety of other chronic diseases such as cardiovascular disease, diabetes, and hypertension.(41-44) These associations are thought to be due to the body making physiological adaptations in response to nutrition constraints in early childhood that may increase susceptibility to obesity and related chronic diseases in the context of subsequently improved access to energy and adequate diet.(45, 46) The literature on both interventions to increase the prevalence and duration of breastfeeding, and to reduce the incidence of stunting is vast. A search was conducted for reviews of breastfeeding interventions in lower-income countries that could be summarised, but no systematic reviews evaluating breastfeeding interventions in that context were identified. With regard to stunting, because it is a gross indicator of poor nutrition in childhood and is also affected by maternal nutrition and childhood infections, there are many various types of interventions that have been evaluated in developing countries, but no comprehensive reviews covering their breadth. Thus, a review of the literature pertaining to interventions to increase the prevalence and duration of breastfeeding and interventions to reduce the prevalence of stunting were beyond the scope and time limitations of this review and are not included here. There is a series

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currently under preparation for publication in the Lancet that will review the evidence regarding interventions to reduce malnutrition in early childhood.

4.7 Conclusions
The interventions reviewed in detail in the body of the report above are summarised in a more concise manner in Appendix 4.3, which gives details concerning study location, intervention type, methods of evaluation, and findings. The review included 17 different interventions (covered by 19 papers, with two interventions each having two papers associated with them), covering four different types of interventions: Community-level interventions with the primary purpose of targeting specific foods, food groups, or dietary constituents that have established links with cancer (7 interventions); Individual-level and community-level interventions explicitly targeting the prevention or reduction of overweight and obesity (4 interventions); Individual-level, community-level, and population-based interventions with the goal of chronic disease prevention (5 interventions); Community-level interventions addressing contamination of foods with aflatoxin (1 intervention). Of the 17 interventions reviewed, 6 took place in countries that are not low- or middleincome (e.g., Singapore, Japan, Taiwan (China) and Israel) (according to the World Banks classification). Of the 11 remaining interventions, 5 (including the review paper on Ruel(6)) focused specifically on promoting home garden interventions to increase fruit and vegetable production and consumption in very poor communities to reduce micronutrient deficiencies. Thus, 6 out of the 17 interventions included in this report were interventions clearly targeting diet as it relates to chronic disease risk in developing countries: one intervention to reduce aflatoxin contamination in Guinea, one intervention to reduce intakes of fat and salt in Pakistan, one to reduce obesity in Chile and another in Turkey, one to increase nutritional knowledge in China, and one to reduce chronic disease risk factors in Mauritius. This assessment clearly reveals the paucity of welldesigned and evaluated interventions geared toward improving diet with the overt goal of preventing chronic disease, let alone cancer, in developing countries. Thus, it is not possible to form any strong conclusions regarding interventions to address diet in the context of cancer in developing countries that have been proven to be reliably and consistently effective. That being said, a lot can still be learned from this review. Interventions carried out in China, Chile, Israel, Japan, Mauritius, Pakistan, Turkey and Singapore all showed a degree of success in promoting improved diets, nutritional knowledge, or reducing obesity. There is also a body of evidence showing some success in fruit and vegetable

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promotion in developing countries. This review draws four lessons from these interventions, their outcomes, and their limitations. First, virtually all of the interventions, in all five categories, incorporated education components to successful effect. The ways in which the education was provided varied and included individual or group counselling(4, 19, 25, 26), cooking demonstrations(3, 12), demonstration gardens(12, 14, 15), and other strategies. Overall, the education component appeared essential for maximising the effect a conclusion that has been proven in the case of home production of fruits and vegetables.(6) In the latter case, education was effective as a complement to home production. Based on findings showing the importance of education and its consistent inclusion in the interventions reviewed, it seems that education should be considered an important part of any intervention to alter diet in the context of cancer prevention, whether the interventions are delivered at the individual-, community- or population-level. While a positive finding, the focus on education also reflects a lack of evaluated interventions with more environmentally-based strategies. Second, the review can conclude that efforts to increase production and consumption of fruits and vegetables through home gardens and nutrition education have been quite successful among poor communities with high rates of micronutrient deficiency.(6, 1115, 57) Since fruits and vegetables are arguably an important food group in the fight against cancer, increasing their production and consumption in low-income (as well as middle- and high-income) countries should be a priority area. These types of successful programmes should be redesigned and expanded to reach the less poor, the urban, and other populations at higher risk for cancers and should be evaluated to see whether fruit and vegetable intake levels can be increased through such programmes beyond the point of eliminating severe micronutrient deficiencies to the point of the minimum of 400-800 grams/day recommended by the WCRF for cancer prevention.(1) With the past success of these programmes in the context of micronutrient malnutrition and with some alterations to address populations at risk for cancer, these interventions may represent the option with the highest potential for reducing cancer risk through diet in developing countries. Third, this review identified some positive trends with regard to ongoing and future interventions. Although many of the interventions reviewed were implemented at the individual level, many were actually community-based. Of the 17 interventions evaluated and reviewed, 3 were individual-level interventions (interventions targeted at subjects identified at the individual level as being at-risk), 12 were community-level (targeted at a group of people but not an entire population), and 2 were population-level (targeting an entire population). All of the interventions targeting specific foods of food groups were community-level interventions. The interventions targeting obesity included

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both individual-level and community-level interventions, and the interventions targeting chronic disease included interventions at all three levels. The section on interventions targeting aflatoxin contamination only included one intervention, designed at the community-level. These three categories (individual-, community- and population-level interventions) are defined by the population that was recruited for participation. That being said, the intervention methods delivered once the subjects were recruited were delivered at a variety of levels. For example, many community levels provided individual-level counselling and seed provision to individuals, and even the populationlevel interventions stated that they encouraged the development of programmes and approaches at the community level, such as through schools. Two of the evaluated interventions were national population-level interventions, and many up-and-coming and unevaluated interventions are currently underway at the national level, showing a growing trend towards national attention to diet-related chronic diseases and a growing motivation to institute broad policies to counter rising levels of risk. For example, as shown in Appendix 4.5, a variety of countries have new national plans to address chronic disease and nutrition.(47-52) Many countries, including at least 3 countries in Africa, at least 10 countries in Asia and the Pacific, and at least 13 countries in Latin America and the Caribbean, have developed National Dietary Guidelines to guide their citizens toward healthier diets.(53) Several countries have passed food labelling laws requiring producers to include some nutrition information on their products(54, 55), and several countries have school lunch, or other school-based programmes(56) or have laws providing regulation on food sales in schools.(54) Thus, governments and other organisations are clearly making efforts to develop large multicomponent, multi-goal programmes to combat the rapidly rising rates of chronic disease in many less developed nations. While many of these interventions are difficult to evaluate when initiated at the national level and while many have not been evaluated, the range and scope of these interventions clearly shows the rising motivation of many governments to be involved. Researchers should become involved in the design and evaluation of such programmes so that the best practices can be identified. Fourth, interventions to be tested in the future can be improved by learning from some of the limitations identified among the papers reviewed in this report. These limitations are summarised in Table 4.2. With regard to intervention design, few interventions in any of the categories were randomised and control groups were often not included in the design. Randomised controlled trials provide the best standard for evaluating causality and should be employed whenever possible. Many studies also did not include baseline measures, another important component for measuring impact. With regard to interventions targeting specific foods, food groups, or dietary constituents, several studies did not include measures of biomarkers at baseline (or during evaluation

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stages), such as serum retinol in the case of studies geared towards increasing vitamin A intakes.(3, 6, 11, 12, 14, 15, 57) Thus, while effects on self-reported dietary intakes are often reported, it is unclear whether they are reported accurately and whether they translate into change at the physiological level. Even when biomarkers were measured, data on potential confounders, such as C-reactive protein levels and helminth infestation in the case of vitamin A, were not always collected(14, 15) at baseline (or during the evaluation stage), making it difficult quantify impact correctly. Lastly, as discussed previously, these types of interventions, particularly home garden initiatives, have been primarily tested with the goal of reducing micronutrient deficiencies among very poor rural populations with very low intakes of fruits and vegetables. It remains unknown whether these types of interventions could be effective among populations at high risk for cancersuch as among urban and less poor sectorsand if they can raise fruit and vegetable intakes beyond levels needed to reduce deficiencies and up to levels (400-800 grams/day) recommended for cancer prevention. Among the interventions targeting the prevention or reduction of overweight and obesity, several were designed to target subjects at the individual-level who were already overweight or obese and thus do not provide solutions that can be used in obesity prevention or which can be expanded to the population level. These types of studies are also typically designed to focus on narrow age ranges or specific settings, which may be appropriate and effective, but which make it difficult to draw any conclusions about approaches that may be effective and generalisable to the larger population. Additionally, the design and evaluation of these intervention studies often do not include measures of confounders, such as maturational timing among children, and often do not include longterm follow-up to see whether any effects are maintained. The communitylevel interventions with the goal of chronic disease prevention that were reviewed were often designed to take advantage of strong infrastructure with regard to the health-care system and/or on high levels of funding.(24-26) Thus, these types of interventions may not be reproducible or effective in low-income countries with limited infrastructure and resources. Additionally, these interventions were often designed to incorporate multiple approaches to address multiple disease risk factors, making it difficult to quantify the independent effects of the various intervention strategies. The two evaluated population-based interventions addressing chronic disease(29,30) also tended to have multiple approaches and multiple goals. In addition, because these interventions were designed and launched on a national basis to the entire population, there was no ability to compare outcomes between treatment and control groups. Instead, the evaluation of these national studies relied on cross-sectional data from different time points for evaluation, making it difficult to obtain true quantification and understanding of the intervention effects. As discussed previously, even an increase in the prevalence of

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chronic disease risk factors over time in these cases cannot rule out the possibility of positive intervention effects since it is possible that the magnitude of observed increases would have been greater in the absence of the intervention. In conclusion, while this review did not identify very many evaluations of interventions directly targeting cancer through improved diets, it did identify a variety of related studies from which much can be learned. Future interventions should incorporate education, improve upon the limitations of past interventions, and focus more specifically on diet and cancer in low-income countries as the prevalence of cancer in that context continues to rise. Interventions aimed at increasing home production and consumption of fruits and vegetables show great promise and need to be reworked to address populations at high risk for cancer, such as urban dwellers and the less poor sectors of the population. Despite the fact that few population-level interventions to counter the rapidly rising rates of chronic disease in low-income countries have been evaluated, many are under development and there is a palpable interest and motivation to address chronic diseases, such as cancer, on the parts of many low-income countries. This context of raised awareness and motivation should provide researchers with the opportunity to design and evaluated a broad range of interventions in the near future so that more concrete conclusions can be drawn about what approaches are the most effective among developing country populations.

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Table 4.2. Summary of limitations among the interventions included in this review of the literature Intervention type Community-level interventions with the primary purpose of targeting specific foods, food groups or dietary constituents that have established links with cancer Limitations Several studies do not include measures of biomarkers, such as serum retinol, making it difficult to quantify the impact of the interventions on nutritional status. Many studies do not include measures of important potential confounders, such as C-reactive protein and helminth infestation, when measuring impact on vitamin A status. Some evaluations do not include baseline data and instead just rely on cross-sectional measures, making it difficult to control for differences between groups prior to the initiation of the intervention. Home garden projects should be expanded and tested in communities at high risk for cancer, such as urban areas and among the less poor sectors of the population. Some studies do not use random assignment to form their treatment and control groups, making it difficult to assess whether differences in outcome were due to the intervention or due to inherent differences between the groups. Studies often focus on narrow age ranges or specific settings so it is difficult to generalise the applicability of the findings. Studies often do not control for potential confounders, such as maturational timing. Studies, whenever possible, should include long-term follow-up measures of subjects since weight control is a life-long issue and results may not be sustained. Several intervention designs relied on strong infrastructure and/or high levels of funding and thus may not be feasible in some settings. Because many of the interventions incorporated multiple approaches, it is difficult to quantify the effects of specific intervention strategies. With regard to population-level interventions launched nationally, there are no treatment and control groups to compare. Even if prevalences of chronic disease increase postintervention, it is not know, for example, if the intervention prevented worse increases. Thus, there is a need, whenever possible, to publish pilot study results and to place intervention results in the context of national trends from similar countries to try and gain a sense of effect. Only one evaluated intervention was identified, so there is a need for more research and testing of potential interventions. Because there are so many potential intervention strategies, and because some are costlier than others, evaluations should try to isolate the independent effects of the various approaches in order to identify those that are most effective.

Individual-level and communitylevel interventions explicitly targeting the prevention or reduction of overweight and obesity

Individual-level, communitylevel and population-based interventions with the goal of chronic disease prevention

Community-level interventions addressing contamination of foods with aflatoxin

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Appendix 4.1: Search record

4.1.1 PubMed Search Record All searches done in all fields with publication dates limited to January 1980-October 2005
Broad Nutrition Terms: developing countries AND (dietary guideline* OR school?based intervention* OR food price* OR program* OR intervention* OR promotion* OR price* OR food label* OR policy* OR nutrition education* OR prevention* OR education* OR behavio?r* OR marketing* OR mass?media* OR school* OR communication OR intervention studies OR public policy OR randomized controlled trials OR health education OR government programs OR national health programs OR health promotion OR nutrition policy OR prevention and control OR guidelines OR food labeling OR policy) AND (food consumption* OR consumption pattern* OR diet* OR nutrition* OR diet OR nutrition OR food habits) AND (cancer* OR cardiovascular disease* OR diabete* OR nutrition transition* OR diet transition* OR cardiovascular diseases OR diabetes mellitus, type 2 OR health transition) Dietary Constituents: developing countries AND (dietary guideline* OR school?based intervention* OR food price* OR program* OR intervention* OR promotion* OR price* OR food label* OR policy* OR nutrition education* OR prevention* OR education* OR behavior?r* OR marketing* OR mass?media* OR school* OR communication OR intervention studies OR public policy OR randomized controlled trials OR health education OR government programs OR national health programs OR health promotion OR nutrition policy OR prevention and control OR guidelines OR food labeling OR policy) AND ((sugar* OR added sugar* OR dietary sucrose) OR (total fat* OR saturated fat* OR animal fat* OR trans fat* OR cholesterol OR dietary fats OR cholesterol, dietary OR hydrogenation OR trans fatty acids) OR (fiber OR fibre OR dietary fibre* OR dietary fiber) OR (retinol OR vitamin c OR ascorbate OR beta carotene OR vitamin a OR ascorbic acid OR vitamin e OR alpha-tocopherol) OR (selenium OR iodine)) Food Groups: developing countries AND (dietary guideline* OR school?based intervention* OR food price* OR program* OR intervention* OR promotion* OR price* OR food label* OR policy* OR nutrition education* OR prevention* OR education* OR behavior?r* OR marketing* OR mass?media* OR school* OR communication OR intervention studies OR public policy OR randomized controlled trials OR health education OR government programs OR national health programs OR health promotion OR nutrition policy OR prevention and control OR guidelines OR food labeling OR policy ) AND ((cereals OR cereal* OR whole grain* OR grain*) OR (fruit OR vegetables OR leafy green vegetable* OR cruciferous vegetable* OR fruits and vegetables OR garden* OR home garden*) OR (red meat* OR pork* OR beef* OR meat) OR (egg* OR egg) OR ((milk* OR milk OR dairy products) NOT breastfeeding) OR (fish* OR fish oils) OR (oil* OR vegetable oil* OR animal oil* OR lard*)) home garden* was also searched alone

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Food Processing and Contaminants: developing countries AND (dietary guideline* OR school?based intervention* OR food price* OR program* OR intervention* OR promotion* OR price* OR food label* OR policy* OR nutrition education* OR prevention* OR education* OR behavior?r* OR marketing* OR mass?media* OR school* OR communication OR intervention studies OR public policy OR randomized controlled trials OR health education OR government programs OR national health programs OR health promotion OR nutrition policy OR prevention and control OR guidelines OR food labeling OR policy ) AND ((aflatoxin* OR aflatoxins) OR (salted fish* OR table salt* OR salt* OR refrigeration OR sodium chloride, dietary) OR (cured meat* OR cured food* OR smoked food* OR smoked meat*) OR (grill* OR grilled food* OR grilling food* OR barbecue* OR fried food* OR fry*) OR Energy Balance: developing countries AND (dietary guideline* OR school?based intervention* OR food price* OR program* OR intervention* OR promotion* OR price* OR food label* OR policy* OR nutrition education* OR prevention* OR education* OR behavior?r* OR marketing* OR mass?media* OR school* OR communication OR intervention studies OR public policy OR randomized controlled trials OR health education OR government programs OR national health programs OR health promotion OR nutrition policy OR prevention and control OR guidelines OR food labeling OR policy ) AND (energy balance* OR energy density* OR caloric intake* OR energy intake) Overweight and Obesity: developing countries AND (dietary guideline* OR school?based intervention* OR food price* OR program* OR intervention* OR promotion* OR price* OR food label* OR policy* OR nutrition education* OR prevention* OR education* OR behavior?r* OR marketing* OR mass?media* OR school* OR communication OR intervention studies OR public policy OR randomized controlled trials OR health education OR government programs OR national health programs OR health promotion OR nutrition policy OR prevention and control OR guidelines OR food labeling OR policy ) AND (obesity OR overnutrition OR overweight)

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4.1.2 Web of Science Search record All searches done in all fields with publication dates limited to January 1980-October 2005
Broad Nutrition Terms: TS=(developing countries AND (dietary guideline* OR school based intervention* OR food price* OR program* OR intervention* OR promotion* OR price* OR food label* OR policy* OR nutrition education* OR prevention* OR education* OR behavior* OR behaviour OR marketing* OR mass media* OR school* OR communication OR intervention studies OR public policy OR randomized controlled trials OR health education OR government program* OR national health program* OR health promotion OR nutrition policy OR prevention and control OR guidelines OR food labeling OR policy OR promotion* ) AND (food consumption* OR consumption pattern* OR diet* OR nutrition* OR price* OR food price*) AND (cancer* OR cardiovascular disease* OR diabete* OR nutrition transition* OR diet transition* OR type 2 diabetes OR type II diabetes OR health transition*)) Dietary Constituents: TS=(developing countries AND (dietary guideline* OR school based intervention* OR food price* OR program* OR intervention* OR promotion* OR price* OR food label* OR policy* OR nutrition education* OR prevention* OR education* OR behavior* OR behaviour OR marketing* OR mass media* OR school* OR communication OR intervention studies OR public policy OR randomized controlled trials OR health education OR government program* OR national health program* OR health promotion OR nutrition policy OR prevention and control OR guidelines OR food labeling OR policy OR promotion* ) AND (food consumption* OR consumption pattern* OR diet* OR nutrition* OR price* OR food price*) AND ((sugar* OR added sugar*) OR (total fat* OR saturated fat* OR animal fat* OR trans fat* OR cholesterol OR dietary fat* OR hydrogenation OR trans fatty acids OR fat) OR (fiber OR fibre OR dietary fibre OR dietary fiber) OR (retinol OR vitamin c OR ascorbate OR beta carotene OR vitamin a OR ascorbic acid OR vitamin e OR alpha-tocopherol) OR (selenium OR iodine))) Food Groups: TS=(developing countries AND (dietary guideline* OR school based intervention* OR food price* OR program* OR intervention* OR promotion* OR price* OR food label* OR policy* OR nutrition education* OR prevention* OR education* OR behavior* OR behaviour OR marketing* OR mass media* OR school* OR communication OR intervention studies OR public policy OR randomized controlled trials OR health education OR government program* OR national health program* OR health promotion OR nutrition policy OR prevention and control OR guidelines OR food labelling OR policy OR promotion* ) AND (food consumption* OR consumption pattern* OR diet* OR nutrition* OR price* OR food price*) AND ((cereals OR cereal* OR whole grain* OR grain*) OR (fruit OR vegetable* OR leafy green vegetable* OR cruciferous vegetable* OR fruits and vegetables OR garden* OR home garden*) OR (red meat* OR pork* OR beef* OR meat) OR (egg* OR egg) OR (milk* OR milk OR dairy products) OR (fish* OR fish oils) OR (oil* OR vegetable oil* OR animal oil* OR lard*)))

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Food Processing and Contaminants: TS=(developing countries AND (dietary guideline* OR school based intervention* OR food price* OR program* OR intervention* OR promotion* OR price* OR food label* OR policy* OR nutrition education* OR prevention* OR education* OR behavior* OR behaviour OR marketing* OR mass media* OR school* OR communication OR intervention studies OR public policy OR randomized controlled trials OR health education OR government program* OR national health program* OR health promotion OR nutrition policy OR prevention and control OR guidelines OR food labeling OR policy OR promotion* ) AND (food consumption* OR consumption pattern* OR diet* OR nutrition* OR price* OR food price*) AND ((aflatoxin* OR aflatoxins) OR (salted fish* OR table salt* OR salt* OR refrigeration) OR (cured meat* OR cured food* OR smoked food* OR smoked meat*) OR (grill* OR grilled food* OR grilling food* OR barbecue* OR fried food* OR fry*))) Energy Balance: TS=(developing countries AND (dietary guideline* OR school based intervention* OR food price* OR program* OR intervention* OR promotion* OR price* OR food label* OR policy* OR nutrition education* OR prevention* OR education* OR behavior* OR behaviour OR marketing* OR mass media* OR school* OR communication OR intervention studies OR public policy OR randomized controlled trials OR health education OR government program* OR national health program* OR health promotion OR nutrition policy OR prevention and control OR guidelines OR food labeling OR policy OR promotion* ) AND (food consumption* OR consumption pattern* OR diet* OR nutrition* OR price* OR food price*) AND (energy balance* OR energy density* OR caloric intake* OR energy intake)) Overweight and Obesity: TS=(developing countries AND (dietary guideline* OR school based intervention* OR food price* OR program* OR intervention* OR promotion* OR price* OR food label* OR policy* OR nutrition education* OR prevention* OR education* OR behavior* OR behaviour OR marketing* OR mass media* OR school* OR communication OR intervention studies OR public policy OR randomized controlled trials OR health education OR government program* OR national health program* OR health promotion OR nutrition policy OR prevention and control OR guidelines OR food labeling OR policy OR promotion* ) AND (food consumption* OR consumption pattern* OR diet* OR nutrition* OR price* OR food price*) AND (obesity OR overnutrition OR overweight)

4.1.3 CAB Direct Search record All searches done in all fields with publication dates limited to January 1980-October 2005
One broad search: developing countries AND (intervention* OR nutrition education OR nutrition programmes OR nutrition policy OR nutrition information OR mass?media) AND (fruit* OR vegetable* OR fiber OR fibre OR whole grain* OR snacks OR garden* OR salt OR soft drinks OR obesity)

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Appendix 4.2: Inclusion/exclusion criteria

4.2.1 Community-level interventions with the primary purpose of targeting specific foods, food groups or dietary constituents that have established links with cancer Inclusion Criteria Exclusion Criteria
Intervention was evaluated for impact using an experimental or quasi-experimental design such as the comparison of baseline data and post-intervention effects in intervention v. control groups, or pre- and post-intervention data collection and analysis on a target population. The evaluation was published in a peerreviewed journal. The intervention was clearly described. Analysis of impact included statistical tests of significance. Intervention had a study population of at least 40 subjects in each group studied. The intervention targeted specific foods, food groups or dietary constituents identified as having convincing, probable or possible links with cancer by the WCRF (1). Outcome measures included measures of dietary intake, and/or biomarkers for intake of specific nutrients, and or measures of blood lipids or cholesterol in cases where cholesterol and fat intake were targeted, and/or measures of nutrition knowledge.

Participation in the intervention was sought out by subjects due to their health concerns, thus introducing bias by catering to the most motivated subjects. Intervention relied on a controlled diet. The methods or design were seriously flawed. The intervention was designed to address micronutrient deficiencies via fortification or supplementation strategies.

4.2.2 Individual-level and community-level interventions explicitly targeting the prevention or reduction of overweight and obesity Inclusion Criteria Exclusion Criteria
Intervention was evaluated for impact using an experimental or quasi-experimental design such as the comparison of baseline data and post-intervention effects in intervention v. control groups, or pre- and post-intervention data collection and analysis on a target population. The evaluation was published in a peerreviewed journal. The intervention was clearly described Analysis of impact included statistical tests of significance. Intervention had a study population of at least 40 subjects in each group studied. Outcome measures included measures of adiposity, diet, or nutrition knowledge/behaviour.

Participation in the intervention was sought out by subjects due to their health concerns, thus introducing bias by catering to the most motivated subjects. Intervention relied on a controlled diet The methods or design were seriously flawed. Intervention included drug or surgical treatments for weight reduction. The intervention was part of a treatment programme for obesity among people purposely seeking medical care at obesity treatment clinics or other medical facilities.

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4.2.3 Individual-level, community-level and population-based interventions with the goal of chronic disease prevention Inclusion Criteria Exclusion Criteria
Intervention was evaluated for impact using an experimental or quasi-experimental design such as the comparison of baseline data and effects in intervention v. control groups, or pre- and post-intervention data collection and analysis on a target population. The evaluation was published in a peerreviewed journal. The intervention was clearly described. Analysis of impact included statistical tests of significance. Intervention had a study population of at least 40 subjects in each group studied. The intervention included a component on nutrition.

Participation in the intervention was sought out by subjects due to their health concerns, thus introducing bias by catering to the most motivated subjects. The intervention relied on a controlled diet. The methods or design were seriously flawed.

4.2.4 Community-level interventions addressing contamination of foods with aflatoxin Inclusion Criteria Exclusion Criteria
Intervention was evaluated for impact using an experimental or quasi-experimental design such as the comparison of baseline data and effects in intervention v. control groups, or pre- and post-intervention data collection and analysis on a target population. The evaluation was published in a peerreviewed journal. The intervention was clearly described. Analysis of impact included statistical tests of significance. Intervention had a study population of at least 40 subjects in each group studied.

Access to the intervention was given based on a voluntary rather than a randomised basis, thus introducing bias by catering to the most motivated subjects. The methods or design were seriously flawed.

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Appendix 4.3. Summary of intervention and evaluations designs of studies reviewed

Intervention type Targeting specific foods/food groups Reference Aziz et al. 2003 (3) Country Pakistan Intervention Description of intervention level Community- Goals: Reduce use of fats and oils by level 1/3, reduce salt consumption by 1/4, substitute vegetable oil for ghee. Tools: Health fairs, discussion groups, cooking demonstrations, visits with social workers to follow-up. Target population and sample size: Households, including adults and children (n=403 households). 450 households among the 4,296 in Metroville, Pakistan responded to invitations to participate and 403 households agreed to participate. N=201 households were assigned to the control group and n=199 households were assigned to the intervention group (2 dropped out at randomisation). Randomisation was by clusters. Targeting specific foods/food groups Takshashi et Japan al. 2003 (4) Community- Goals: Reduce salt intake, increase level vitamin C and carotene intake. Tools: Dietary counselling, group lecture, newsletters and leaflets with cooking tips. Target population and sample size: Adults 40-69 years of age living in two rural Japanese villages with high incidences of stomach cancer and stroke. N=550 volunteered to participate, and these participants were randomly assigned to the intervention group (n=274) or the control group (n=276). Evaluation Design: Treatment/control, before/after. Findings and limitations Findings: Reduced consumption of ghee, vegetable oil, cooking fat and Methods: Self-reported household salt in intervention group compared consumption data and information regarding to control group. Intervention group knowledge and attitudes pertaining to CVD. met or exceeded intervention goals, except for goal of eliminating ghee. Analysis sample size: No differences seen in terms of Data from 351 total households at baseline change in body mass index, blood and 238 households at follow-up used. pressure or cholesterol. Limitations: Not enough information on how consumption was measured.

Design: Treatment/control, before/after. Methods: Self-administered dietary history, serum levels of ascorbic acid and carotenoids, urinary sodium excretion. Analysis samples size: Data from n=470 subjects who completed study analyzed (only n=191 for dietary and urine data).

Findings: Large changes in desired direction of sodium intake and sodium excretion in intervention compared to control group. Changes reported via dietary data for carotene and vitamin C intake in intervention versus control group, but serum changes were not significantly different. Limitations: data on biomarkers and dietary data only available for small proportion of total sample due to exclusions. Not known whether this subsample is representative and whether these results can be generalised. (continued)

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Intervention type Targeting specific foods/food groups

Reference Ruel 2001 (6)

Country Review paper with various countries included

Intervention level Description of intervention Most were Goals: Increase intake of carotenoids. communitylevel Tools: Various tools including home gardens, nutrition education, agricultural training, and provision of seeds. Target population: Mostly households.

Evaluation Design: Various designs including treatment/control and before/after measurements on study participants. Methods: Review of studies published from 1995-1999.

Findings and limitations Findings: Nutrition education is the key intervention strategy, producing results on its own and greatly enhancing the success of home garden projects. Limitations: Interventions often not randomised. Little available information on how control groups were chosen. Insufficient control for potential confounders. Findings: More former and active participants had home gardens than controls. Year-round production was higher among former and active participants than among controls. Production and consumption of vegetables was higher among former and active participants than among controls

Targeting specific foods/food groups

Bushamuka et al. 2005 (11)

Bangladesh

Commnuity- Goals: Encouraged poor households to Design: Former participants/active level produce vitamin A rich vegetables year- participants/controls compared 9 years after round in home gardens. initiation of intervention. Tools: Technical and material assistance from Helen Keller International; not many details given. Target population and sample size: The original programme covered more than 860,000 households in 210 of Bangladeshs 460 subdistricts. Methods: Questionnaires and structured interviews to collect data on home food production and consumption.

Analysis samples size: N= 720 active participants; n=720 former participants; n=720 subjects from areas in which no Limitations: No baseline data or programme implemented. The former serum retinol values available. participant and active participant households were randomly selected from the subdistricts where the project was implemented. Control households were selected in other districts from households with similar socioeconomic conditions to beneficiaries. Design: Cross-sectional comparison between intervention and control households.

Targeting specific foods/food groups

Jones et al. 2005 (12)

Nepal

Community- Goals: Increase household income through production of high-value crops level with a secondary objective of increasing intake of Vitamin A rich foods through kitchen garden promotion.

Findings: More households in intervention group reported producing and consuming a wide variety of vitamin A rich vegetables. Limitations: Self-reported production and consumption data, so possible reporting bias. Also no serum retinol measures collected. (continued)

Methods: Self-reported data on vitamin A and other nutrition knowledge, production Tools: Nutrition education, development and consumption of vitamin A rich foods of model kitchen gardens, additional crop demonstration sites, education Analysis samples size: N= 430 households materials, training sessions, recipe in intervention districts including the demonstrations, and seed distribution. kitchen garden component, n=389

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Intervention type

Reference

Country

Intervention level Description of intervention Target population and sample size: Targeted households with regards to production. Primary caregivers answered questions regarding nutrition knowledge. The original project aimed to affect 37,000 households in six districts. The kitchen garden component was added to a smaller proportion (two out of six districts).

Evaluation Findings and limitations households in non-intervention districts. The intervention households evaluated were all participating households from two districts selected due to high risk for malnutrition. Controls were from wards that received no direct assistance and were randomly selected within each ward.

Targeting specific foods/food groups

Kidala et al. Tanzania 2000 (13)

Community- Goals: Reduce vitamin A deficiency level through food-based intervention. Tools: Educational seminars, distribution of guava and pawpaw seedlings, mass media in the form of booklets and posters. Target population and sample size: Targeted at households in 10 villages (each with about 200-300 households) in two districts of Tanzania with high rates of vitamin A deficiency. 5 villages were assigned to the intervention group (all from one geographic district) and 5 villages were assigned to the control group (from the other district).

Design: Cross-sectional comparison between intervention and control groups. Methods: Data regarding home production from structured interviews, anthropometric data, stool samples, serum retinol data analyzed for subjects without low Creactive protein levels.

Analysis sample size: N=125 randomly selected households from 5 villages in the intervention district and n=125 randomly selected households from 5 villages in the control district. Serum retinol data was collected from one preschool-aged child (randomly chosen if more than one child) Limitations: No baseline values. per household. N=75 children from intervention group (children with serum retinol measures and low CRP) and n=71 from control areas (children with serum retinol data and low CRP) missing for some measures so sample sizes as small as n=110 (continued) in a group for some measures.

Findings: More intervention households had gardens than control households and more grew paw-paw trees in them. Knowledge and practice scores were higher in intervention group. More children in intervention group reported to consume vitamin A rich foods often. However, there were no differences in serum retinol between the groups were observed when helminth infection was adjusted for (much higher levels of helminth infection in the intervention group).

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Intervention type Targeting specific foods/food groups

Intervention Reference Country level Faber et al., South Africa Community2001 and level 2002 (14, 15)

Description of intervention Goals: Promote the household production of yellow fruits and vegetables and dark green leafy vegetables. Tools: Nutrition education, demonstration gardens, education on food preparation and storage. Target population and sample size: Targeted at households (with outcome data measured among women and children 2-5 years of age) in a rural community, no original participating sample size given.

Evaluation Design: Treatment/control, before/after 12 and 20 months of intervention. Methods: 24-hour diet recalls, questionnaires regarding knowledge and practices, serum retinol measures. Analysis sample size: N=154 total children aged 2-5 yrs were included in baseline survey (all children who attended growth monitoring centres, through which the programme was run). N=100 of these children, 50 from families with project gardens and 50 from families without, were chosen to participate in the follow-ups. It is not clear whether they were randomly selected. Design: Treatment/control schools, before/after. Methods: Measures of anthropometry, physical fitness, dietary assessment, attitudes and behaviours related to healthy eating and physical activity. Analysis sample size: Evaluation was carried out among the 3577 students enrolled in the five school at baseline anthropometry information was available both at baseline and follow-up for 3086 (86%) at follow-up, 8 months later.

Findings and limitations Findings: At both 12 month and 20 month follow-ups, median intake values of Vitamin A were significantly higher among children in intervention group than in the control group; there were no differences at baseline. Mothers in the intervention group increased their knowledge scores more than the control group. Serum retinol levels increased in the intervention group over time and decreased in the control group. Limitations: Parasite load and presence of infection were not controlled for. Findings: Proportion of obese children was significantly higher in intervention schools at baseline intervention was targeted. Among boys, statistically significant improvements in BMI, BMI Zscore, waist circumference in intervention group; adiposity in girls was not affected. Physical fitness measures improved significantly in boys and girls in intervention schools. Results regarding diet and knowledge and behaviour not presented. Limitations: Non-random assignment to intervention and control groups. Results from some of the data (such as dietary assessment) not presented. (continued)

Targeting obesity

Kain et al. 2004 (18)

Chile

Community- Goals: Reduce overweight and obesity level among primary school children. Tools: Nutrition education, meetings with school lunch kiosks, 90 min. additional physical activity/week, encouragement of physical activity during recess. Target population and sample size: Targeted primary school children in 5 different schools (n=3 intervention schools, n=2 control schools). Randomisation to intervention or control group was not random. Schools with higher rates of obesity were assigned to the intervention groups. There were a total n=2375 children in the intervention schools and n=1202 children in the control schools.

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Intervention type Targeting obesity

Reference Chen et al. 2001 (19)

Country Taiwan

Intervention level Description of intervention Evaluation IndividualGoals: Reduce prevalence of overweight Design: Participants, before/after. level among overweight junior college nursing students. Methods: Measures of anthropometry, blood pressure, cholesterol levels, and selfTools: Small group counselling sessions reported data on health promotion focusing on nutrition education, exercise knowledge and practice. behaviour modification, risk factors associated with overweight, and life Analysis sample size: n=49 completed the appreciation; booklets distributed; study. additional counselling also provided. Target population and sample size: Targeted overweight junior college nursing students (mean age 15.5 years). After all students underwent a physical screening, 166/980 (17%) were identified as overweight and 58 were randomly chosen to participate in the programme. N=55 agreed to do so.

Findings and limitations Findings: Mean body weight and weight-for-length index reduced. Improvements in systolic blood pressure, HDL cholesterol and total cholesterol. Improvements in some components of the health promotion questionnaire. Limitations: Small sample size, no control group.

Targeting obesity

Ray et al. 1994 (20)

Singapore

Individuallevel

Goals: Reduce the prevalence of obesity Design: Obese participants, before/after 1 among preschool children aged 3-6 year of intervention. years from 10.9% in 1991 to 7% in 1995. Methods: Anthropometric measures Analysis sample size: All 1,128 who Tools: Parents given pamphlets, education on growth monitoring and qualified were evaluated. nutrition, cooking demonstrations, lectures, and screening of education video tapes; additionally, obese children were referred to dieticians for management and additional counselling. Target population and sample size: Targeted 1,128 obese preschool children ages 3-6 years identified through visits to Primary Health Clinic over a 1-year period.

Findings: 40.5% improved their weight status and 20.2% returned to normal weight status. Limitations: No control group. Might not be generalisable because clinic populations not representativetend to be low/middle class and do not represent all ethnic groups.

(continued)

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Intervention type Targeting obesity

Reference Kisioglu et al. 2004 (21)

Country Turkey

Intervention level Description of intervention Community- Goals: Reduction of obesity and level hypertension among middle-aged Turkish women of low socio-economic status. Tools: Leaflet and education about diet, obesity and hypertension in small groups; encouraged to participate in ongoing education programme. Target population and sample size: Targeted low socio-economic status women ages 20-50 years of age in a developing region of turkey. 430 of 1,017 eligible women randomly selected and invited to participate. 400 women agreed and 200 each were randomly assigned to intervention and control groups.

Findings and limitations Findings: Intervention group reported reductions in use of salt, Methods: Measures of anthropometry, blood oils and fat in cooking, and pressure and self-reported dietary and preference for boiling and baking cooking habits. over frying. Prevalence of obesity rose in control group and decreased Analysis sample size: Analysis carried out in the intervention group. No effects on the n=200 in intervention group, and the on blood pressure. n=200 in the control group that participated. Limitations: Not all eligible women invited to participate. Many of results in terms of changes in cooking methods were self-reported and were not validated.

Evaluation Design: Treatment/control, before/after.

Interventions for chronic disease prevention

Muto and Yamauchi 2001 (24)

Japan

Individuallevel

Goals: Improvement of a variety of cardiovascular disease risk factors among adults with abnormal findings for at least one risk factor.

Findings: Decreases in body weight, systolic and diastolic blood Methods: Measures of anthropometry, blood pressure, total cholesterol, fasting pressure and total cholesterol, fasting glucose, and triglycerides. glucose, triglycerides. Tools: Work-place based intervention Limitations: Intervention was very including a 4-day getaway at a hot Analysis sample size: All participants expensive and thus not widely springs with educational sessions and (n=152 in intervention group and n=150 in generalisable. activities, setting of individualize health control group) were analyzed. goals, and regular evaluation of progress toward goals. Target population and sample size: Adult male employees at a maintenance company with an identified chronic disease risk factors. N=152 randomly assigned to intervention group and n=150 assigned to control group. (continued)

Design: Treatment/control, before/after.

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Intervention type Interventions for chronic disease prevention

Reference Abramson et al. 1981 (25)

Country Israel

Intervention level Description of intervention Community- Goals: Reduce the prevalence of level hypertension, hypercholesterolemia and overweight among adults in a neighbourhood with high prevalences of all conditions. Tools: Individualized counselling and health care regimens, hypertensives provided when needed, nutrition counselling, smoking cessation stressed, exercise and weight control urged. Provided through community family practices.

Evaluation Design: Treatment/control before and 5 years after intervention initiation. Programme was initiated in one chosen area and controls were chosen at the time of the evaluation from a nearby area. Methods: Measures of hypertension, anthropometry, smoking, blood pressure, body weight. Analysis sample size: Analysis carried out on the n=685 intervention subjects who were examined in 1970, were 35 years old or more at that time and were still living in the area at the 1975 follow-up. N=1995 subjects from a control area.

Findings and limitations Findings: Reduction in intervention area in hypertension and overweight in men and women. Reduction in smoking among men. Limitations: Deaths in the study population may have biased findings due to a survivor effect, with people for whom the intervention was not effective dying and those for whom effects were seen, living.

Interventions for chronic disease prevention

Gofin et al. 1986 (26)

Israel

Target population and sample size: Targeted at all adults living in four housing projects in a Jerusalem neighbourhood served by a family practice providing care for about 2,500 people. Assignment to treatment was not random: programme was just made available to all clientele of the participating clinic. Community- SAME INTERVENTION AS ABOVE Design: Participants before/after 10 years after intervention initiation level Methods: Measures of anthropometry, hypertension, and smoking.

Findings: No changes in body weight. Reduction in the prevalence of hypertension and of smoking.

Limitations: Deaths in the study population may have biased Analysis sample size: Analysis carried out findings due to a survivor effect, on the n=505 subjects who were 25 or older with people for whom the at the inception of the programme and who intervention was not effective dying were still living in the neighborhood at and those for whom effects were follow-up (1981) although complete data seen, living. was not available for all subjects.

(continued)

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Intervention type Interventions for chronic disease prevention

Reference Shi-Chang et al. 2004 (27)

Country China

Intervention level Description of intervention Community- Goals: In context of nutrition transition, level to improve diet and health among primary and secondary school children.

Findings and limitations Findings: Among primary students, improvements in both groups, although more in the intervention Methods: Measures of nutrition knowledge group with regard to nutrition Tools: School-based working groups among students and parents, self-reported knowledge, for example, knowledge comprised of staff, parents and others, information about some nutrition about the Chinese Dietary nutrition training for school staff, health behaviours . Guidelines. Among secondary education classes, student competitions school students, gains in knowledge with health and nutrition themes, Analysis sample size: N=2,575 primary were made only in the intervention school children, n=4,277 secondary school group. Largest gains in knowledge outreach to families. children, n=661 staff, and n=991 parents. were seen in parents of both groups The paper does not state whether the Target population and sample size: although magnitude larger in the Primary and secondary school students, students were randomly selected. The paper intervention group. school staff, and parents of students in 6 does state that half of the staff at all schools schools (3 primary and 3 secondary were randomly sampled and that the Limitations: Impact evaluation focused on knowledge only and schools) Original participants included parents/guardians of two classes in one responses may have been biased by 7,500 students and their families and grade in each school were included. respondents knowing the 800 school staff. It is not clear whether desirable answers. these or the control schools were randomly selected. Findings: Increases in hypertension and total cholesterol. Decrease in smoking among men. Increase in exercise among women. No differences in prevalence of diabetes, impaired glucose tolerance or obesity. Limitations: Without a comparison group, it is difficult to know whether changes in prevalences, or lack thereof, are due to the programme or not.

Evaluation Design: Treatment/control schools, before/after.

Interventions for chronic disease prevention

Cutter et al. 2001 (29)

Singapore

Populationlevel

Goals: To counter the sharp increases in Design: Comparison of two rounds of data the prevalence of chronic diseases in from adults included in the Singapore Singapore. National Healthy Survey, one beginning of the second stage of the intervention, and one Tools: Two stages of the intervention 6 years later. occurred, one in the early 1980s (various media; direct patient counselling; large- Methods: Measures of hypertension, scale campaigns on nutrition, smoking cholesterol, smoking, diabetes, obesity, selfcessation and exercise; increase in reported exercise. screening among high-risk groups) and one beginning in 1992 (different themes Analysis sample size: Comparison of two of focus each year for a 10 year period, rounds of nationally representative data with interventions in communities, schools, sample sizes of over 3000 in both rounds. workplaces and unions, establishment of dietary guidelines, attention to labelling and advertising laws). Target population and sample size: All adults living in Singapore.

(continued)

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Intervention type Interventions for chronic disease prevention

Reference Dowse et al., 1995 (30)

Country Mauritius

Intervention level Description of intervention Population- Goal: To decrease various nonlevel communicable disease risk-factors.

Evaluation Design: Cross sectional surveys from before the programme and 5 years after initiation compared.

Tools: Mass media, fiscal and legislative measures, school and workplace Methods: Measures of diabetes, impaired components. glucose tolerance, hypertension, adiposity, cholesterol, smoking, alcohol consumption. Target population and sample size: All adults living in Mauritius. Analysis sample size: Samples from two rounds of data collected among adults 2574, in randomly selected clusters plus one additional cluster to represent the Chinese minority. Each survey covered more than 5000 subjects.

Findings and limitations Findings: No changes in prevalence of diabetes. Prevalence of impaired glucose tolerance decreased in women. Prevalence of hypertension increased in both men and women. Prevalence of obesity increased in both men and women. Smoking, hypercholesterolemia, and hyper tryiglyceridaemia decreased in men and women. Alcohol consumption decreased among men. Limitations: Without a comparison group, it is difficult to know whether changes in prevalences, or lack thereof, are due to the programme or not.

Interventions Turner et al. Guinea addressing 2005 (33) aflatoxin contamination

Community- Goal: To reduce exposure to aflatoxins via groundnut contamination through level post-harvest measures among subsistence farmer families.

Design: Treatment/control villages, before/3 Findings: In control villages, the months postharvest/5 months postharvest. blood levels of aflatoxin-albumin increased over the 5 post-harvest Methods: Measures of aflatoxin-albumin moths, while it remained virtually blood levels and other data regarding the same in intervention villages. Tools: Hand-sorting of groundnuts, sun harvest and postharvest conditions and diet. drying on provided natural fibre mats, Limitations: No information on proper assessment of completeness of Analysis sample size: Data from n=535 cancer incidence, and also many drying, storage in provided natural fibre subjects in survey at baseline, 529 subjects intervention methods were tested bags, storage on provided wooden at 3 months post-harvest, and from 514 together, so independent effects are subjects at 5 months postharvest, from both not known. pallets, provision of insecticide. the 10 intervention and the 10 control Target population and sample size: 10 villages were collected. villages in Guinea were exposed to the intervention (compared to 10 control villages). These villages were not randomly assignedthe 10 intervention villages were to the north and the 10 control villages were to the southeast, to avoid intervention strategies being shared between intervention and control villages. Within each village, 15 families who grew groundnuts were (continued) randomly recruited to participate. From

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Intervention type

Reference

Country

Intervention level Description of intervention each family, the head of household and one adult woman was included at the individual level for blood monitoring.

Evaluation

Findings and limitations

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Appendix 4.4: Summary of interventions identified through database search that did not meet the inclusion/exclusion criteria
4.4.1 Interventions specifically targeting specific foods, food groups or dietary constituents
Reference A variety of papers by Singh et al. published in the 1990s (59-62) Country India Intervention level Individuallevel Description of intervention Goals: Improve cardiovascular risk factors through diet. Tools: 3-week observation period, followed by 16-week period of advised diet and exercise. Both groups advised to take American Heart Association Step I Diet. Both groups advised to use soy beans, cottage cheese and ground nuts to replace meat, eggs, and hydrogenated oils, cheese, butter etc. The intervention group was additionally instructed to include at least 400 grams/day of a variety of fruits and vegetables and to include complex carbohydrates into the diet. Intervention included keeping dietary diaries and attending meetings. Mentions some drug therapy also given, when medically needed. Target population and sample size: There is inconsistency among the papers in regards to sample size, with numbers varying from 621 to 1000, randomised into intervention and control groups. Subjects were patients with hypertension, diabetes, hypercholesterolemia, obesity, heart attack or related symptoms. Evalution Design: Treatment/control, before/after. Methods: 24 hour dietary recalls, serum and urine samples, blood pressure, and other measures. Analysis sample size: There is inconsistency in reported sample sizes. Findings Some significant changes in reported intakes of various dietary constituents in the intervention group. Significant decrease in total cholesterol, LDL, and triglyceride in intervention group. Reason for exclusion There is inconsistency with regard to the published sample sizes among the papers, and the integrity of the data has been publicly called into question (6365).

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4.4.1 Interventions specifically targeting specific foods, food groups or dietary constituents
Reference Singh et al, 1997 (66) Country India Intervention level Individuallevel Description of intervention Goals: To reduce coronary risk factors through a diet high in vitamin C (supplied via guavas). Tools: All asked to decrease salt, take no drugs, maintain usual lifestyle and keep a food record. Group A was instructed to stick to a diet that included 0.5-1.0 kg/day of guava preferably before meals to displace other more unhealthy foods. Adherence was checked throughout the study. The diet followed a 4 week observation period and lasted for 24 weeks, followed by a 12 week period of guava restriction. All given an aluminum hydroxide uniform placebo pill. Target population and sample size: 153 subjects were recruited from patients already involved in a drug trial (nifedipine) to decrease hypertension. After exclusions, 101 subjects were randomised into treatment and control groups. Hagenimana et al., 2001 (57) Kenya Communitylevel Evalution Design: Treatment/control, before/after. Methods: Nutrient intakes calculated every 24 hours (no details given), blood pressure recorded every two weeks. Body weight measured at every visit. Laboratory data collected at 4, 12 and 24 weeks. Analysis sample size: n=52 with data in the intervention group, and n=48 with data in the control group. Findings After the 24-week diet period, the guava diet was associated with a significant increase in plasma ascorbic acid, an increase in high-density lipoprotein cholesterol (HDL), and reductions in serum total cholesterol, triglycerides, systolic blood pressure, diastolic blood pressure. 12 weeks after cessation of the guava diet, there was an increase in blood lipids and blood pressure, compared to the measures directly following the guava diet. Reason for exclusion This was basically a controlled diet study. Additionally, the first authors integrity has been called into question elsewhere (63-65).

Goals: Promote the home production and consumption of vitamin-A rich orangefleshed sweet potatoes (OFSP). Tools: Provision of OFSP cultivars, and visits from agricultural extension agents to both intervention and

Design: Treatment/control, before/after. Methods: Helen Keller International Food Frequency Questionnaires. Analysis sample size:

Days in the previous week that children consumed plant or animal foods rich in vitamin A increased in the intervention group and decreased in the control group. Frequent feeding of the OFSP occurred in 22% of the

Small sample size. Although the participating women had 154 children < 6 yrs of age among them, only one child from each women was selected to participate leaving n=35 in the intervention group and n=41 in the control group.

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4.4.1 Interventions specifically targeting specific foods, food groups or dietary constituents
Reference Country Intervention level Description of intervention Evalution Only one child from each women was selected to participate leaving n=35 in the intervention group and n=41 in the control group. Findings intervention households but only 6% of the control households. Reason for exclusion

control groups; additional nutrition education and promotion activities in intervention group. Target population and sample size: To affect diets of children
<6 years of age via mothers (n=10 womens groups with a total of 154 children < 6 years of age). Goals: To reduce vitamin A deficiency and improve micronutrient status in the community, particularly among mothers and children. Tools: Multiple strategies included supplementation, primary health care, and foodbased approaches (including nutrition education, demonstration cultivation of community garden and distribution of seedlings to community members). Target population and sample size: The target population was the approximately 2 million beneficiaries of the World Vision Ethiopia Micronutrient Programme.

Balcha 2001 (67)

Ethiopia

Populationlevel

Design: Baseline and midterm assessment data from participating households compared. Methods: Assessment of presence of community and household gardens, and assessment of presence of Bitots spots in children. Analysis population: The impact assessment was carried out in 3,161 participating households. Outcomes at the community and household level were reported. Some individuallevel data for children was also reported.

2 years after implementation, 112 community demonstration gardens, 296 school vegetable gardens, and 22,630 household gardens had been established. In addition, 380,000 fruit seedlings had been distributed. Statistically significant improvements in clinical indicators of vitamin A deficiency were seen, including a decrease in Bitots spots in preschool children from 6.4% at baseline to 0.88% at follow-up.

Because vitamin A supplements were also given, it is impossible to attribute the observed changes in vitamin A status to the effects of the home gardening initiative.

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4.4.1 Interventions specifically targeting specific foods, food groups or dietary constituents
Reference Schipani et al, 2002 (68) Country Thailand Intervention level Communitylevel Description of intervention Goals: To bolster home food security. Tools: The Thai monarchy and government are broadly promoting the establishment of home gardens that produce fish, small animals and vegetables, particularly in the rural northeastern region. Target population and sample size: There is no specific intervention targeting a specific population. The information given above is the most detailed information given. Evalution Design: Cross-sectional comparison between children of mixed-gardening households and children of nongardening households. Methods: Anthropometry, 24-hour diet recall data, and biomarker data (haemoglobin, serum ferritin and serum retinol) data were collected. Analysis sample size: Thai children (one child randomly selected from each family) between 1 and 7 years of age from households in the northeastern region practicing mixed-gardening (n=30) v. matched children from households not practicing gardening. Design: Cross-sectional surveys during the year 2000. Methods: Data collection included 7-day records of household food consumption, anthropometric measures and focus group sessions. Analysis sample size: Two out of five participating urban communities within a large city were selected for review. 152 out of 1097 Findings No statistically significant differences were observed. Reason for exclusion Small sample size. Also, mixed-gardening and nongardening households very similarall had some gardening, presence of fish pond was main distinguisher. Although groups were matched, there was still some self-selection and endogenietyfamilies that had gardens might be motivated in other ways to address nutrition at household level.

Miura et al, 2003 (69)

Philippines

Communitylevel

Goals: Decrease micronutrient deficiencies, particularly iron and vitamin A deficiency. Tools: The Community Medical Union Welfare Center (CMU) an NGO, and the Barangay Health Workers (BHW) were both involved in campaigns to consume cheap nutrient-rich foods such as beans and fish, and to plant vegetables and fruit trees in backyards. The intervention was initiated in 1993.

Those who reported having received nutrition information from either the CMU or the BHW had significantly more varieties of fruits and vegetables and more dark green leafy vegetables planted than those who received their nutrition education from other sources such as TV and

Selection into the evaluations does not appear to be random. No control group for comparison. Intervention not well described.

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4.4.1 Interventions specifically targeting specific foods, food groups or dietary constituents
Reference Country Intervention level Description of intervention Target population and sample size: The project targeted 5 poor communities within Davao city (population 1.15 million) in Mindanao, Philippines. Goals: Reduce micronutrient deficiencies and malnutrition. Tools: Urban women participated in six-week sessions that included nutrition counseling, discussions and demonstrations of cooking and recipes formulated to use green leafy vegetables. The programme among the rural women included the same components but was done on one day. The focus for all was on how to include greens into cooking and participants were given a related booklet. Target population and sample size: 32 women from urban area of Mysore city and 100 women from a rural area volunteered to participate. Evalution mothers in those communities were invited to participate in the evaluation. No details why this sample was chosen. Design: Data was collected at baseline, at 3 months and at 5 months after initiation among urban participants. Among rural women, data was collected at baseline and at 1 month after the intervention was completed. Methods: Among urban participants, 24-hour recalls were collected. Knowledge was also assessed at multiple points. Among rural participants, knowledge and feedback was assessed. Findings other media. Additional results were also presented. A variety of results were discussed. Among urban participants, the self-reported intakes showed increases in calcium (130%), iron (38%), and carotene (230%) at the second followup. Greens consumption overall increased. Among rural women, knowledge scores increased by substantial amounts. Reason for exclusion

Hemalatha and Prakash, 2002 (70)

India

Communitylevel

No statistical testing.

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4.4.2 Interventions specifically targeting the prevention or reduction of overweight or obesity

Reference and year Country Englberger et al, Tonga 1999 (71) Intervention level Communitylevel Description of intervention Goals: To motivate individuals to lose weight. Tools: 3 national weight loss competitions were widely advertised on the main island of Tonga and participants were given educational leaflets on diet and exercise. Target population and sample size: The intervention targeted adults on the main island of Tonga. The population of the Kingdom of Tonga is around 100,000, with about two thirds living on the main island. Goals: To promote weight loss among overweight/obese school children aged 6-12 years. Tools: Very little information given. Just states that children underwent diet control and exercise in a weight control programme. Target population and sample size: Recruited children (goal of at least 1000) from 6 out of 12 primary schools in one municipality. Does not say whether sampling was random or not. 1,156 primary school children were enrolled in 1991. Evaluation Design: Before/after measurements and comparisons among participants. Methods: Individuals wanting to participate weighed in at beginning and were deemed eligible if overweight or obese on Tongan weight-for-height charts then weighed again at end of contest period . Analysis sample size: Adults on main island (n=1617 with complete data). Design: Baseline and postintervention data compared between children who were obese and those who were not at the initiation of the intervention. Methods: Anthropometric measurements taken annually. Analysis sample size: Data compared between years 1991 and 1993. 50 out of the original 1156 children were lost to follow-up. The obese group was comprised of 141 obese children based on 1991 measurements. Obesity rate actually Very little information about what increased form the intervention waswhether diet 12.2% to 13.5%. was controlled or not, for example was given. Also, the authors state that only 18 out of 141 obese children included in the study actually chose to attend the obesity clinic offered as part of the intervention. Findings Reason for exclusion Some evidence of No significance testing of outcomes. decreases in average Only 47% of original participants BMI in younger men completed the competitions. and older women over time

Mo-suwan et al, 1993 (72)

Thailand

Communitylevel

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4.4.2 Interventions specifically targeting the prevention or reduction of overweight or obesity

Reference and year Country Qadri et al, 2002 Jordan (73) Intervention level Individuallevel Description of intervention Goals: To induce weight loss and improve BMI. Tools: All got educational leaflets on nutrition, and treatment group got individual dietary counselling on nutrition. Target population and samples size: Volunteer overweight and obese females (aged 16-22 years) were recruited (not clear from where) and divided into two equal groups (n=21 in treatment group and n=21 in control group). Not clear if the subjects were randomly divided or not. Goals: To reduce weight and improve BMI. Tools: Dietary counselling and individual visits to nutritionist, paediatrician and psychologist Target population and sample size: Obese children and adolescents who sought help and who were treated at an obesity outpatient clinic. The size of the population of patients is not clear. Evaluation Design: Treatment/control, before/after (over a period of 12 weeks) . Methods: anthropometric measurements and calculation of BMI. Analysis sample size: Apparently no loss to followup. Analysis on original treatment and control groups. Findings No differences in body weight at follow-up. Reason for exclusion Very small sample size.

Valverde et al, 1998 (74)

Brazil

Individuallevel

Design: Comparison of anthropometric data from patients first visits (sometime between January 1992 and December 1993) and last visit before the 30th of June 1994. Methods: Anthropometric measures taken. Information on pubertal stage collected and on family history of obesity. Dual Photon X-ray Absorptiometry (DEXA) scans collected on subsample. Analysis sample size: After exclusions for dropouts and people with genetic syndromes or endocrine disturbances, the study sample included 108 girls and 90 boys with average age of 9.25 years.

Significant weight reduction overall from first to last visit.

Population is a specific group of obese individuals that sought treatment for obesity at a wellfunded obesity clinic.

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4.4.3 Interventions with the goal of chronic disease prevention

Reference and year Nishtar et al, 2004 (75) Country Pakistan Intervention level Intervention design PopulationGoals: To improve knowledge level about CVD risk factors. Findings 93% remembered seeing the articles, 87% said the articles Tools: A non-governmental Methods: Survey conducted by significantly organisation called Heartfile telephone. increased their posted weekly articles for 130 knowledge about consecutive weeks on the only Analysis sample size: Every diet, and 5% said the coloured page in the newspaper third residential number on articles were sole on a variety of topics, including each column of the Islamabad source of nutrition, aimed at CVD telephone directory was called. information about prevention. Those that did not wish to diet. 40% reported proceed, did not read The having made related Target population and sample News, and readers of The News dietary changes. size: Readers of The News, that read it less than once a Impacts on smoking Pakistans largest English week or only on weekends also assessed. language newspaper, with a were excluded. This process circulation of over 450,000 and resulted in a sample of 500 an estimated 6 readers per copy. regular readers of The News. Design: Participants were Goals: To reduce risk of Self-reported diabetes. evaluated over a period of 2 or adherence to more years, prospectively. recommended Tools: Dietary modification behaviours worse (avoidance of excess energy, Methods: Questionnaires with among diabetics and simple sugars, minimize fat questions regarding dietary conversion to intake), regular exercise and adherence, exercise, diabetes associated follow-up was advised. Diet knowledge of preventive with non-adherence. advised: 60% carbohydrates, measures, and measures of 20% protein, 20% fat. physical and mental stress. The questionnaires were Target population and sample administered by trained size: Adults with a known medical sociologists. family history of diabetes registered for a diabetes Analysis sample size: n=187, prevention programme. Those the same subjects who began the programme. without diabetes at entry were enrolled in the prevention programme (n=187) and those with diabetes were followed as well (n=100 without diabetes, n=87 with diabetes) . Evaluation Design: Cross-sectional postintervention evaluation. Reason for exclusion There was no baseline data collection and no control group to provide comparison data, and all results were based on self-report.

Ramachandran et al, 1999 (76)

India

Individuallevel

No relevant outcomes (nutritional status, knowledge, behaviours etc. about diet) reported. Subjects were seeking prevention of diabetes due to family history.

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4.4.3 Interventions with the goal of chronic disease prevention

Reference and year Goldhaber-Fiebert et al, 2002 (77) Intervention Country level Intervention design Costa Rica IndividualGoals: To improve glycemia level and CVD risk factors among patients with type II diabetes. Tools: All received a diabetes education lecture. The intervention group was invited to 11 weekly nutrition classes (90 min. each) and was encouraged to bring family members. Topics included portion control, healthy foods, basic food groups, carbohydrate types, hidden calories, and other topics. Participants set weekly goals. Those medically able to participate were encouraged to participate in 60-min. walking sessions led 3 times a week in community. Target population and sample size: Conducted among volunteers with type II diabetes from 3 small communities. Subjects with diagnosed type II diabetes were recruited. No potential volunteers were excluded. The 75 diabetics recruited were randomly assigned to an intervention or control group. (n=40 in the intervention group and n=35 in the control group). Evaluation Design: Treatment/control, before/after. The follow-up data was collected 3 months after the initiation of the intervention. Methods: Measures of weight, height, blood pressure, glycosylated haemoglobin, fasting plasma glucose, cholesterol, triglycerides were collected. Analysis sample size: N=33 from the intervention group and n=28 from the control group had complete data. Findings Reason for exclusion There were no Small sample size. differences in clinical or demographic characteristics between the groups. Over the three month period, there were significant differences in the changes between the two groups for a variety of variables: mean BMI in the intervention group decreased (-0.40.9 kg/m2) and increased in the control group (0.21.0 kg/m2), weight decreased in the intervention group and decreased in the control group, glycosylated haemoglobin decreased in both groups but significantly more so in the intervention group, triglycerides increased in the control group and increased in the control group, and diastolic blood pressure decreased in both groups but significantly more so in the intervention group. There were no differences in the

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4.4.3 Interventions with the goal of chronic disease prevention

Reference and year Country Intervention level Intervention design Evaluation Findings changes of a variety of other measures such as fasting plasma glucose total cholesterol, HDL and LDL cholesterol and systolic blood pressure. Reason for exclusion

Emmanuel et al, (28)

Singapore

Populationlevel

Goal: To control rising prevalences of chronic disease.

Tools: The Singapore Healthy Living Programme, originally launched in the early 1980s, promoted a smoke-free lifestyle, healthy Analysis sample size: Not given. eating habits and regular exercise. The programme was revised and expanded in the 1990s and included new themes every year, including fitness, strategic plans to incorporate many community-level interventions to target different population groups, workplace and school-based initiatives and more. Target population and sample size: the entire population of Singapore: 4.13 million.

Design: Cross-sectional data Between 1984 and This evaluation did not include from 1984 was compared with 1992, the significance testing and did not data from 1992. provide information on sample size prevalence of and methods. hypertension Methods: Nationally decreased from representative prevalence data 15.3% to 13.6%, covering a variety of risk and total factors was used

cholesterol levels decreased from 5.8 to 5.3 mmol/L, while HDL cholesterol levels increased from 0.9 to 1.3 mmol/L.

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Appendix 4.5: Examples of unpublished, unevaluated and up-and-coming interventions

4.5.1 Interventions specifically targeting specific foods, food groups or dietary constituents Title
Food consumption patterns in Brazil: trends, determinants and proposal of food security promotion actions (78).

Country
Brazil

Description
Intervention included nutrition education and improvements in local supply of cheap fresh and good quality fruits and vegetables. Objective to enhance knowledge about nutrition transition and propose policy options. Preliminary evaluation showed increases in fruits and vegetables when education combined with access compared with stable intakes when access improved without education component. Further evaluation not complete. The project will evaluate the impact of the 5 a Day campaign to promote the consumption of fruits and vegetables in adults, ages 17-60, users of the public health care centres and supermarkets located in low-middle income neighbourhoods in Santiago, Chile. A framework providing guiding principles for national programmes to promote fruits and vegetables and outlining roles for the WHO and FAO was endorsed unanimously by the participants of a WHO/FAO workshop on fruit and vegetables for health, held in Kobe, Japan in 2004. Programmes underway in a variety of countries including Argentina (79) Mexico (80) Uruguay (81) Peru (82) Brazil (83) Japan (84) HarvestPlus is a project coordinated by the International Center for Tropical Agriculture (CIAT) and the International Food Policy Research Institute (IFPRI) and was implemented on a full-time basis in January of 2004. The objective of HarvestPlus is to reduce the effects of micronutrient malnutrition by developing and breeding staple food crops rich in micronutrients, a process known as biofortification. In Phase I of the HarvestPlus Programme, six crops (beans, cassava, maize, rice, sweet potatoes, and wheat) and three micronutrients (iron, zinc and vitamin A) are targeted. Evaluations of some of HarvestPlus activities are planned and underway.

Impact Evaluation of a 5 a Day Educational Campaign to Increase the Consumption of Fruits and Vegetables (48).

Chile

Framework for Promoting Fruit and Vegetables at the National Level (58).

International

5 a Day campaigns

Various

HarvestPlus (85)

International

(continued)

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4.5.1 Interventions specifically targeting specific foods, food groups or dietary constituents Title Country Description
Laws providing regulation on food product sales in schools (86) Variety of Countries Examples taken from a WHO monograph on Marketing Food to Children include: Brazil: Sale and distribution of soft drinks and confectionary prohibited in schools in certain municipalities Brunei Darussalam: Canteens in all schools prohibited from selling soft drinks, confectionary, snacks, ice cream and instant noodles Japan: Only food allowed in schools is that provided under school lunch programmes Malaysia: Prohibits sale of junk foods in school canteens Saudi Arabia and other members of GCC (Kuwait, Oman, Qatar, United Arab Emirates) except Bahrain: Sale of carbonated soft drinks in all schools totally or partially prohibited Singapore: Monitoring of food and drinks sold in school canteens

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4.5.2 Interventions specifically targeting the prevention or reduction of overweight or obesity Title Country Description
Laws providing regulation on food product sales in schools (86) Variety of Countries Examples taken from a WHO monograph on Marketing Food to Children include: Brazil: Sale and distribution of soft drinks and confectionary prohibited in schools in certain municipalities Brunei Darussalam: Canteens in all schools prohibited from selling soft drinks, confectionary, snacks, ice cream and instant noodles Japan: Only food allowed in schools is that provided under school lunch programmes Malaysia: Prohibits sale of junk foods in school canteens Saudi Arabia and other members of GCC (Kuwait, Oman, Qatar, United Arab Emirates) except Bahrain: Sale of carbonated soft drinks in all schools totally or partially prohibited Singapore: Monitoring of food and drinks sold in school canteens This project will evaluate the effectiveness of an improved version of an existing schoolbased obesity prevention programme, sponsored by the Ministry of Education, in elementary schools in Mexico City. This project will develop and evaluate a two-year school-based intervention to promote healthy eating and active lifestyles in adolescents attending high school and colleges in the State of Santa Catarina. The project builds on previous findings of a pilot study, conducted in 2004, that revealed that 1/3 of the adolescent students are insufficiently active and have a high prevalence of unhealthy behaviours. The Ministry of Health is conducting an ad campaign asking adults to measure their waistlines and suggests that men with measurements >90cm and women with measurements>80 cm lose weight. Also helps Mexicans detect signs of diet-related chronic diseases via a website run by the National Center for Epidemiology and Disease Control. Ad campaigns also developed to promote healthier eating and lifestyle. The Ministries of Health and Education are implementing a programme requiring children to have 30 minutes of physical activity at school per day. The Ministry of Health is also promoting courses for health professionals to become more adept at dealing with obesity and related health issues. The programme additionally supports the activities of the Mexico, United States, Canada Health Fraud Workgroup (MUCH) which takes legal action against companies promoting fraudulent weight loss schemes. This project, run through the WHO Collaborating Centre for Obesity Prevention and Related Research and Training at Deakin University in Australia, aims to conduct comprehensive community-based obesity prevention programmes in young populations in the Pacific region to help generate evidence about whether this approach might be the most effective for obesity prevention. The last updates posted at the Deakin University website were posted in 2004. At this point, the projects in Fiji and Tonga (the countries of interest for this review) were still in the early planning stages.

Promoting Physical Activity and a Healthful Diet in the Mexican School System for the Prevention of Obesity in Children (48) Promoting Physical Activity and Healthy Eating Among Adolescents: A Cross-cultural Randomised School-Based Intervention Study (48) Mexico Takes Measure programme (87)

Mexico Brazil

Mexico

Pacific Obesity Prevention in Communities (OPIC) Project (88-91)

Fiji and Tonga

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4.5.3 Interventions with the goal of chronic disease prevention Title Country
National action plan on NCD prevention, control and health (47) Pakistan

Description
Pakistan has developed a public-private partnership among the Ministry of Health, a nongovernmental organisation called Hearfile, and the World Health Organisation to develop a national integrated plan for health promotion and the prevention of noncommunicable diseases. The implementation of this National Action Plan on NCD Prevention, Control and Health was planned for January of 2006. The project will evaluate the impact of training health professionals at primary care centres that are part of Chiles Cardiovascular Health Programme (a national programme of the Ministry of Health) and the outcomes related to physical activity, consumption of a healthy diet, and weight reduction in overweight and obese cardiovascular high-risk patients. The Chinese National Centre for Chronic and Non-communicable Disease Control and Prevention (NCNCD) was established in 2002 under the direction of the Chinese Centre for Disease Prevention and Control and the Ministry of Health. With the support of the WHO, the Ministry of Health has been developing a long-term plan for disease control that is currently being implemented. Currently under development by the Ministry of Health. This plan was issued in 1997 with broad goals of ensuring adequate food supply and reducing hunger and micronutrient deficiencies, as well preventing non-communicable disease through improvement of dietary patterns and lifestyles. The plan includes agricultural targets to increase fruit and vegetable production. This campaign, begun in 1997, had Healthy Eating as one of its themes and included an Eat More Vegetables campaign. Education materials guiding people to ASKFOR more vegetables, less fat, less salt, and less sugar as well as other activities, such as analyzing the nutrient content of certain foods, and monitoring food stalls for food safety. A variety of countries have nutrition labelling laws in place requiring producers to include some nutrition information on their products. Countries with mandatory labelling laws in place include Brazil, Thailand, and Israel (NOT a comprehensive list), while Singapore, for example, has voluntary labelling laws in place (continued)

Assessing and improving the Cardiovascular Health Programme in Chile: Training of Primary Care Staff to Reduce Physical Inactivity, Unhealthy Diet and Obesity in High-risk Cardiovascular Patients (48) National cancer prevention and control Plan (49)

Chile

China

Integrated national programme for the prevention and control of cardiovascular diseases and diabetes (50) National Plan of Action for Nutrition (51)

India China

Healthy Lifestyle Campaign (52) Healthier Me Choices Programme (52)

Malaysia Singapore

Food Labeling Laws (54, 55)

Variety of Countries

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4.5.3 Interventions with the goal of chronic disease prevention Title Country
Various strategies (56, 92) South Korea

Description
Movements to retain the traditional diet (high in vegetables) have been widespread and include mass media campaigns, promotion of concept that people should eat foods produced where they were born or are living, widespread provision of monthly training sessions on cooking traditional Korean foods, development of dishes using local products, and campaigns publicising local diet as advantageous in fight against obesity. Also a National Health Promotion Act in 1995 calling for diet and activity interventions to address diet-related chronic diseases Requires that 70% of foods be basic or minimally processed foods. Includes a focus on obesity and nutrition-related chronic disease prevention. Programme begun in 2001 in primary and secondary schools focuses on physical activity and healthy diet. In May of 2000, the World Health Assembly adopted a resolution adopting a WHO Global Strategy for the prevention of non-communicable diseases and requested Member States to develop national policy frameworks to promote community-based initiatives (93). Several regional initiatives have emerged including: Conjunto de Acciones para Reduccion Multifactorial de Enfermedades Non Transmisible (CARMEN), developed by the Pan-American Health Organisation in 1995 Network of African Noncommunicable Diseases Interventions (NANDI), established in 2001 South-East Asia Network for NCD Prevention and Control (SEANET-NCD) established in 2004 Eastern Mediterranean Approach to Non-Communicable Diseases (EMAN)

National school meal programme (56) Healthy schools initiative (56) School-based programme (56) Regional programmes on communicable disease prevention developed with support of WHO Integrated Chronic Disease Prevention and Control Programme (93)

Brazil South Africa Thailand Various Countries

(continued)

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4.5.3 Interventions with the goal of chronic disease prevention Title Country
National dietary guidelines (53) Variety of Countries

Description
Dietary guidelines that offer nutrition guidelines for healthy living in a variety of areas, although levels of implementation differ. The regions and countries with national dietary guidelines, as compiled by the FAO include: Africa o Namibia o Nigeria o South Africa Asia and the Pacific o Bangladesh o China o Indonesia o India o Japan o Malaysia o Nepal o New Zealand o Philippines o Singapore o Thailand Latin America and the Caribbean o Argentina o Bolivia o Brazil o Chile o Colombia o Cuba o Dominican Republic o Ecuador o Guatemala o Mexico o Panama o Uruguay o Venezuela The Isfahan Healthy Heart Programme is a comprehensive integrated community-based intervention programme currently underway in Iran. The intervention is aimed at preventing and controlling non-communicable disease risk factors and has been implemented in two intervention counties near Isfahan, with data also being collected in a neighbouring county serving as a control. The interventionemphasizing tobacco control, healthy diet, physical activity and stress managementbegan in 1999 and will continue until sometime in 2006.

Isfahan Healthy Heart Programme (94, 95)

Iran

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4.5.4 Interventions addressing nutrition during early childhood and cancer risk Title Country Description The Baby-Friendly Hospital Initiative (96) International The Baby-Friendly Hospital Initiative was launched by UNICEF and the WHO in 1991 to help ensure that all maternity wards become centers of breastfeeding support. A maternity facility can earn the designation of baby-friendly when it does not accept free or low-cost breastmilk substitutes, feeding bottles or teats and has implemented 10 specific steps to support successful breastfeeding. Implementation guides have been developed by UNICEF and WHO and more than 15,000 facilities in 134 countries have been awarded baby-friendly status. The UNICEF website reports that in many areas where baby-friendly hospitals exist, more mothers are breastfeeding their infants and child health has improved.

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61. Singh, RB, Sircar, AR, Singh, RG, Mani, UV, Seth, J, Devi, L. Dietary modulators of lipid metabolism in the Indian Diet Heart Study (I.D.H.S.). Int J Vitam Nutr Res. 1992;62(1):73-82. 62. Singh, RB, Dubnov, G, Niaz, MA, Saraswasti, G, Reema, S, Rastogi, SS, Manor, O, Pella, D, Berry, EM. Effect of an Indo-Mediterranean diet on progression of coronary artery disease in high risk patients (Indo-Mediterranean Diet Heart Study): a randomised single-blind trial. Lancet (British edition). 2002;360:1455-61. 63. Smith, J, Godlee, F. Investigating allegations of scientific misconduct. Brit Med J. 2005;331:245-46. 64. White, C. Suspected research fraud: difficulties of getting at the truth. Brit Med J. 2005;331:281-88. 65. Anonymous. Expression of concern. Brit Med J. 2005;331:266. 66. Singh, RB, Rastogi, SS, Reema, S, Niaz, MA, Singh, NK, Madhu, SV. Effects on plasma ascorbic acid and coronary risk factors of adding guava fruit to the usual diet in hypertensives with mild to moderate hypercholesterolaemia. J Nutr Environ Med. 1997;7(1):5-14. 67. Balcha, HM. Experience of World Vision Ethiopia Micronutrient Program in promoting the production of vitamin A-rich foods. Food Nutr Bull. 2001;22(4):366-69. 68. Schipani, S, van der, HF, Sinawat, S, Maleevong, K. Dietary intake and nutritional status of young children in families practicing mixed home gardening in northeast Thailand. Food Nutr Bull. 2002;23(2):175-80. 69. Miura, S, Kunii, O, Wakai, S. Home gardening in urban poor communities of the Philippines. Int J Food Sci Nutr 2003;54(1):77-88. 70. Hemalatha, MS, Jamuna, P. An awareness creation programme for women on nutrition through green leafy vegetables. Indian J Nutr Diet. 2002;39(1):17-25. 71. Englberger, L, Halavatau, V, Yasuda, Y, Yamazaki, R. The Tonga Healthy Weight Loss Program 1995-97. Asia Pac J Clin Nutr. 1999;8(2):142-48. 72. Mo-suwan, L, Junjana, C, Puetpaiboon, A. Increasing obesity in school children in a transitional society and the effect of the weight control program. Southeast Asian J Trop Med Pub Hlth. 1993;24(3):590-94. 73. Qadri, MG, Takruri, HR, Tukan, SK. Effect of nutrition education on weight reduction of obese girls in Jordan. Arab Gulf J Sci Res. 2002;20:236-40.

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74. Valverde, MA, Patin, RV, Oliveira, FLC, Lopez, FA, Vitolo, MR. Outcomes of obese children and adolescents enrolled in a multidisciplinary health program. Int J Obesity. 1998;22(6):513-19. 75. Nishtar, S, Mirza, YA, Jehan, S, Hadi, Y, Badar, A, Yusuf, S, Shahab, S. Newspaper articles as a tool for cardiovascular prevention programs in a developing country. J. Health Commun. 2004;9(4):355-69. 76. Ramachandran, A, Snehalatha, C, Shobana, R, Vidyavathi, P, Vijay, V. Influence of life style factors in development of diabetes in Indiansscope for primary prevention. J. Assoc. Physicians India. 1999;47(8):764-66. 77. Goldhaber-Fiebert, JD, Goldhaber-Fiebert, SN, Tristan, ML, Nathan, DM. Randomized controlled community-based nutrition and exercise intervention improves glycemia and cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica. Diabetes Care. 2003;26(1): 24-29. 78. Carlos Monteiro, S. f. P. H. U. o. S. P. B. "Flavia" sent on behalf of Carlos . 2005. Internet Communication 79. "5 a Day" Program in Argentina [website]; 2006 [cited 2006 Feb 8]. 80. "5 a Day" program in Mexico [website]; 2006 [cited 2006 Feb 8]. 81. "5 a Day" program in Uruguay [website]; 2006 [cited 2006 Feb 8]. 82. "5 a Day" program in Peru [website]; 2006 [cited 2006 Feb 8]. 83. "5 a Day" program in Brazil [website]; 2006 [cited 2006 Feb 8]. 84. "5 a Day" program in Japan [website]; 2006 [cited 2006 Feb 8]. 85. HarvestPlus [website]; 2006 [cited 2006 May 2]. 86. Hawkes, C. Marketing food to children: the global regulatory environment. World Health Organization, Geneva, Switzerland; 2004. 87. Anonymous. Mexican information campaign tackles obesity. Obesity Policy Report. 2005;3:6. 88. World Health Organization Collaborating Centre for Obesity Prevention and Related Research and Training at Deakin University [website]; 2006 [cited 2006 Feb 10]. 89. Pacific Obesity Prevention in Communities (OPIC) Project [website]; 2006 [cited 2006 Feb 10]. 90. OPIC ProjectFiji, Progress Report 2004 [website]; 2006 [cited 2006 Feb 10]. 91. OPIC ProjectMa'alahi, Progress Report 2004 [website]; 2006 [cited 2006 Feb 10].

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92. Kim, S, Moon, S, Popkin, BM. The nutrition transition in South Korea. Am J Clin Nutr. 2000;71(1):44-53. 93. World Health Organization Integrated Chronic Disease Prevention and Control Programme [website]; 2006 [cited 2006 Feb 9]. 94. Nooshin Mohammadi Fard. Isfahan Healthy Heart Programme. Cara L. Eckhardt. 2005. Internet Communication. 95. Sarraf-Zadegan, N, Sadri, G, Malek Afzali, H, Baghaei, M, Mohammadi Fard, N, Shahrokhi, S, Tolooie, H, Poormoghaddas, M, Sadeghi M, et al. Isfahan Healthy Heart Programme: a comprehensive integrated community-based programme for cardiovascular disease prevention and control. Acta Cardiol. 2003;58(4):309-20. 96. UNICEF The Baby-Friendly Hospital Initiative [website]; 2006 [cited 2006 Feb 17].

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PART C: Physical Activity

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Chapter 5 Physical Activity: Correlates and Interventions

Adrian Bauman School of Public Health, University of Sydney, Australia Fiona Bull School of Sport and Exercise Sciences, Loughborough University, United Kingdom

5.1 Scope of the Report

This document summarises the evidence on physical activity and is divided into two sections covering firstly the literature identifying the correlates of physical activity behaviour and secondly the evidence on effectiveness of interventions aimed at increasing physical activity. For both sections the available evidence for both children and adults is covered and where possible the literature specifically addressing populations in developing countries is highlighted.

5.1.1

What is physical activity?

The first concern is to define what is meant by physical activity, and to clarify how it differs from physical fitness. Figures 5.1 and 5.2 present definitions first expressed following an international consensus conference in 1985, and subsequently widely accepted and used (Casperson 1985).
Figure 5.1. Definition and attributes of physical activity

Definition: any body movement of skeletal musculature resulting in substantial increase over Basal Metabolic Rate (BMR) Types of Physical Activity
Leisure / recreation (discretionary time) Exercise- repeated movements over extended period of time with specific external objectives Sport Occupational Work Domestic Activities

Attributes of Physical Activity

Mode Intensity Frequency Duration

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The key element in the definition of physical activity is that it implies any large muscle (body) movement, irrespective of the intensity, duration or frequency of the activity. These attributes can be used to characterise physical activity. This is shown in Figure 5.1. Other attributes, such as the setting for physical activity can describe the context in which the activity occurs. There are a diverse range of settings in which physical activities might occur for different purposes, and as part of everyday living. This includes the household setting that comprises household and domestic activities, including vigorous housework and gardening, which may confer some health benefits. Other settings include transport domain where the interest is in active commuting or walking and cycling for transport, and the sport/recreation or discretionally domain comprising a large range of sports and leisure-time physical activities that are usually undertaken volitionally. One sub-type of physical activity with the specific purpose of increasing cardiorespiratory fitness levels or demonstrate some physiological training effect is exercise. This is defined as planned and repetitive structured movement with the objective of increasing of maintaining fitness levels. As shown in Figure 5.2, some descriptions of fitness are related to morphological attributes, or muscular power, but mostly this refers to cardio-respiratory fitness1. The early recommendations linked exercise with health benefits and the initial American College of Sports Medicine recommendations for health suggested that performing exercise 3-5 times per week, for around 20-30 minutes each
Figure 5.2. Definition and attributes of physical fitness

Physical Fitness - A set of attributes that people have or achieve that relates to the ability to perform physical activity Components of Health Related Fitness
Cardio-respiratory fitness (aerobic) Muscular endurance, Muscular strength,

Components of Performance-Related Fitness

Muscular power, Speed, Agility, Balance, Reaction time

Cardiorespiratory fitness (CRF) is the ability or efficiency of the body to metabolize oxygen. It is measured by maximal, or more usually submaximal estimates of exercise capacity. It is partly genetically determined, but is responsive to exercise training more performance of exercise leads to improvements in CRF.

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time, and at 65-80% of the maximal heart rate, was useful for health (ACSM 1978, 1982). This amount of exercise was known as aerobic exercise, based on the intensity and duration, and physiologically resulted in a training effect. Increases in exercise volume or duration at this level of intensity would result in improvements in fitness. The problems with the aerobic exercise recommendation were two fold. First, very small proportions of the adult population were active at this level, no more than 10-15% of adults in the 1980s were active at this level (Bauman 1987). Second, it was difficult for inactive or sedentary populations to increase their activity levels to this threshold, and for those that did, it was difficult to maintain this level of activity. In addition, high levels and high intensity of physical activity were not easily achievable by sedentary people starting to exercise, and if they tried it, they often discontinued. During the 1980s and 1990s, epidemiological research studies demonstrated that more moderate-intensity physical activity may confer a health benefit, and this new evidence was described in the landmark 1996 U.S. Surgeon Generals report on physical activity (USSG 1996). This new recommendation stated that every adult should accumulate at least 30 minutes of at-least moderate-intensity activity on most days of the week for health benefits. However, it was also noted that participation in vigorous-intensity or more sustained activity, which could result in more cardio-respiratory training, confers additional health benefits, especially around weight control and cancer prevention (USSG 1996). Two final concepts are useful for interpreting the literature on physical activity correlates and interventions; the first is the concept of structured exercise. This is defined as predetermined supervised programmes consisting of continuous aerobic exercise (Boul 2003). This is contrasted with lifestyle activity, a much broader concept which encompasses the idea of total daily energy expenditure and includes activities of everyday living, including modes associated with work, leisure and sport, and includes the subset of structured exercise programmes.

5.1.2

Prevalence and trends in physical activity levels

Routine surveillance and monitoring systems exist in many countries for assessing the prevalence of the population that engage in health enhancing physical activity, that is, physical activity sufficient for most health benefits. A central problem with surveillance tools are that they are not comparable, and prevalence rates of sufficiently active may vary from 20-60% of populations, and is mostly related to the type of questions asked, and whether leisure time physical activity prevalence is the measure of interest, or whether a broader definition, across different dimensions of physical activity is assessed. Trends over time were generally flat during the 1990s, with the exception of Canada and

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Finland. The data in Figure 5.3, derived from a comparative analysis carried out in Canada, illustrates these differences in prevalence, as well as lack of increases in several countries between 1980 and 1998 (Craig et al. 2004).
Figure 5.3. Trends in physical activity between countries and over time

70%

Finland
60

Australia
50

15+, 2+/wk
40

18+, 150m/wk, 5 sessions

Canada Scotland Australia USA

86 88 90 92 94 96 98

30

18+, 3+ kkd
20

18+, 3/wk 18+, 1625+ kwk

10

18+, vigorous

0 80 82 84

Craig CL, Cameron, Russell, Bauman Canad J Public Health 2004

5.1.3

Health benefits of physical activity

Physical inactivity is been identified as one of the leading causes of many chronic conditions, including obesity, cardiovascular disease, type 2 diabetes mellitus, and certain types of cancer (Surgeon General, 1996; Kesaniemi et al., 2001, WHO, 2005, Bauman 2004). It contributes substantially to the global burden of disease, disability and premature death, with heavy resulting economic costs (WHR 2002, WHO, 2005). Other benefits of physical activity include positive influences on weight, blood pressure and serum lipid fractions. With respect to cancer prevention and control, physical activity has a primary preventive role in some cancers, especially colon cancer and breast cancer, and also a tertiary preventive role in exercise programmes for people with already diagnosed cancers. The epidemiological evidence suggests that slightly more physical activity is recommended for cancer prevention, compared to the half-hour daily of moderate activity recommended to prevent vascular disease; this leads to a greater at risk proportion of the population from a cancer prevention perspective (Cerin et al. 2005). Recent efforts to promote and increase physical activity at the whole population level have not been successful globally, and rates of overall sedentary time have increased. This has contributed to increasing Non-Communicable diseases, and partially contributed
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to obesity and hypertension rates. A central purpose of this review is to understand why some people are active and others are not, and to identify promising interventions to positively influence the small proportions of the general population that are sufficiently physically active.

5.2 Correlates of Physical Activity

5.2.1 Introduction
The purpose of this section is to review factors associated with being physically active. An understanding of these factors should inform the development of more effective interventions, as they would aim to target known modifiable correlates of activity. A synthesis of recent systematic and other reviews of the determinants and correlates of physical activity is presented. Strictly speaking, the focus here is on the correlates, as in measures of associations that are consistently reported within the data, rather than results on antecedent causal variables [or determinants]. This field of research has a history of using both terms and often (incorrectly) interchangeably; it is only more recently that the strict use of the terms has been evident in published papers. In our review we incorporate all evidence that is, in the epidemiological sense conceptualised as correlates of physical activity to identify those factors consistently and statistically associated with physical activity behaviour. These data most often come from cross sectional studies rather than cohort or intervention research designs. Our results will present a summary of the major correlates of physical activity identified in the literature on adults and children from a review of the published literature. Given the hundreds of papers in this area, the evidence presented is derived from recent reviews, and in one sub area, environmental correlates, a review of reviews. The evidence is considered at three levels: personal; social and cultural and environmental, political and economic. Although the published literature may not use these same terms, after presenting a brief summary of the findings for each review paper, the results are synthesised across all studies to provide an overview of what we know using this three level framework. It is necessary to point out that this document interchangeably uses the concepts of physical activity (PA) and exercise, even though the former is a broader term (see Section 5.1.1). This mixed use of terms is true for some reviews and noted by several authors as an issue in the choice of primary studies included in their work.

5.2.2

Methods

An electronic search was undertaken using Medline Cinhal, DARE, EBM, ERIC, Psychlit and Sportsdiscus databases. The focus was to identify papers reporting on factors
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associated with physical activity in children and adult populations; these are referred to as correlates or determinants studies. As mentioned above, these terms have been used interchangeably in much of the literature thus both terms were used in the search strategy. Much has been published on this area as the importance of understanding physical activity behaviour has received increased attention. Many papers focus on the intra- and inter-individual and social factors and are found in the psycho-social literature. More recently, with greater focus from a public health perspective, this literature is now found throughout the medical, public health, preventive medicine and now environmental, transportation and urban planning literature. These latter discipline areas reflect a notable shift in focus in the field of physical activity and the increased attention now given to the environmental correlates (determinants) of the behaviour. Indeed, this focus has developed so rapidly that in the past 6 or so years over a dozen review papers have been published in the scientific and grey literature (though not all are systematic, and some are more opinion pieces). There has also been a recent meta-review of environmental correlates review literature. Given this diverse and large body of evidence, and in order to undertake a review in the timeframe provided, review-level evidence was sought, with a preference for systematic methodologies. Thus, this search strategy focused on identifying (quantitative and qualitative) review papers with a focus on physical activity correlates (or determinants). Search terms used were physical activity or exercise and correlates or determinants and in Medline review (see Table 5.1). Studies were excluded if their focus was not on physical activity but rather studies of correlates of solely strength training or clinical exercise; if the paper reported results of a single study; or if there was no clear evidence of a review or summary process. In addition, papers were excluded if the focus was on a single disease or specific clinical setting as this report aimed to assess the correlates of physical activity that might be of potential population or public health usefulness (see Table 5.2).
Table 5.1. Search terms for review on correlates of physical activity

Category Physical activity Review paper selection

Search terms used Physical activity or exercise [title] Defined as a review paper [Medline] or with key word or title/abstract words [any of] review /systematic /research synthesis /summary Correlate$ or determinant$ in title, or keyword or in abstract

Correlates or determinants

Overall, 66 review papers were identified in Medline, and because review paper was not a listed search term in other data bases, 320 papers were initially identified across the five other databases.

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Table 5.2. Inclusion and exclusion criteria for review papers on correlates Criteria Study focus Study excluded if: a) The focus was not physical activity related; it related to studies of correlates of strength training, or clinical exercise regimes; b) There was no clear evidence of a review or summary process; single studies of the associations between physical activity and specific factors; c) Excluded if the correlates focused on a single disease or specific clinical setting; this report assessed physical activity correlates that might be of potential population or public health usefulness. Study included if: Reviews, especially systematic reviews of correlates; Qualitative reviews of correlates included, where the authors; Summarised a field of correlate / determinant research, but this was made clear in the discussion; Meta analyses, and Cochrane reviews , and reviews of reviews as a subset of [a]. Study included if: (g) Used clear, validated self report physical activity measures, or objective measures of activity or related phenomena (h) Reviews of quantitative studies (i) Published in English (j) Published within the period 2001 2006 [to limit the number of reviews considered]

Study design

Other aspects of research quality

Of these 386 papers, 34 were considered to meet the inclusion criteria (see Table 5.3) and were obtained and read. Papers excluded were those covering the health benefits of physical activity or exercise such as paper on psychological health outcomes such as reviews of correlates of self-efficacy, rather than physical activity. Of the 34 papers, 9 were accepted at this stage. Of the 25 paper excluded at this stage, many were papers reporting studies in specific minority populations already covered, especially Hispanics and African-Americans. These papers were not included, as these groups were included in papers that were discussed. Another 9 review papers were obtained through searches of personal files, personal contacts, and through the grey literature.
Table 5.3. Summary of methods for identifying reviews papers on correlates of physical activity Stage
1 2 3 4 6 Physical activity correlates review papers identified through initial database search in Medline and in other data bases* Review Papers for consideration Review Papers obtained and time read [full paper] at second level review Papers obtained through other means and included in the review Papers included in the review

Medline or any of five other * databases

386 34 9 9 18

* other databases : Cinhal, Dare, EBM, ERIC, Pyschlit, Sportsdiscus # note that review papers not available from other databases directly search term included review, systematic, research synthesis, summary

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5.2.3

Results

Appendix 5.1 presents the review papers included in this review on correlates of physical activity reporting the primary population targeted and features of the review process. For each paper, we also noted the search strategy, data bases, and the number of primary studies included, where these data were provided. The level of correlates(determinants) addressed in each review is also summarised using the schema of three level framework of personal (individual), social and environmental and policy. In summary, three reviews assessed correlates of physical activity in children and adolescents and three papers examined these factors in older adult populations. Nine papers focused on the general adult population, with five specifically targeting identified sub-populations of adults (Hispanics, women, college-aged) for their reviews. Two papers were used to summarise the new emerging area of environmental correlates of physical activity and one paper explored physical activity policy.

5.2.4

Analysis

Below is a summary of the key findings for each of the 18 reviews included. For adults, the results of nine reviews are presented using the review by Trost et al. first as this was identified as the most systematic and comprehensive paper. It is also the only review that attempts to systematically summarise the direction and strength of association for each correlate across all papers included in their review. It is presented first to provide a backdrop for the remaining review papers. Two other reviews in adults also used a systematic approach and provided details of the search strategy, search terms and databases. However in these papers the results are synthesised qualitatively. Seven of the reviews on adults provided only a broad outline of their methods or no detail at all on their methods and discussed their findings at a more general level with a qualitative summary. Because different approaches have been used across this set of review papers, it is difficult to provide a quantitative summary measure of the overall findings. Instead, the paper by Trost et al. will be used as a basis for the conclusions with due consideration of any differences, and particularly any conflicting results presented in other reviews on correlates in the adult population. Appendix 5.2 summarised the coverage of correlates within each of the review papers focussed on adult populations. The same approach has been used for reviewing the 3 reviews on correlates of physical activity in children and adolescents. In this case the review by Sallis et al. forms the basis of the evidence as it was the most comprehensive review and provided a semiquantitative summary of evidence. Only two other review-level papers were found and these set out to update to the evidence presented by Sallis et al. using the same structure and similar methods.

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Three reviews focused on the correlates of physical activity in older adults, and one focused specifically on older women only. Mostly these papers identified correlates for physical activity at the individual level. Finally, a separate section describes the evidence on correlates at the environmental and policy level. In part because this literature tends to focus on the whole population and secondly this field of research has developed only in the last 5-6 years and has tended to explore the environmental correlates exclusively. The evidence presented is from one review of reviews for the adult population but for environmental correlates of children, where no systematic reviews are published, we draw on evidence from recent published correlate studies.

5.2.4.1 Correlates of physical activity in adult populations Trost et al. (2002) A systematic review of primary studies aimed at identifying the factors associated with physical activity in adults and presented as a replication and update of earlier work conducted by Dishman (1990), Dishman, Sallis and Orenstein (1985), Dishman and Sallis (1994) and, most recently Sallis and Owen (1999). In the latter publication the authors identified 45 new studies published between 1992 and 1997 to add to the approximately 250 studies and summarised all the findings to date in a comprehensive table. In 1999, Sallis and Owen concluded that adult participation in physical activity was influenced by a diverse range of personal, social, environmental factors. Grouping the factors into 6 categories they concluded that it was the category of individual-level variables, such as socioeconomic status and perceived self efficacy that demonstrated the strongest and most consistent associations with physical activity behaviour. In contrast, the literature provided few consistent positive or negative associations for behavioural attributes and skills, sociocultural influences or physical environmental factors. However, the Sallis and Owen noted that far fewer variables had been examined within these latter categories.
In 2002, Trost et al. reviewed standard databases and using the same search terms identified 38 new studies published since 1998. Seven of these used a longitudinal design, none used objective measures of physical activity and all relied on self-report or attendance records. Most instruments provided a global assessment of activity with the majority focusing on measures of leisure time activity only. Only 3 studies specifically focused on adherence to a structured exercise programme and these were retained in the pool of studies. Overall the variance in physical activity explained by measured correlates ranged from 3-50% with an average 21.2 15%.

Demographic and Biological Factors. Age and gender were identified as the most consistent demographic correlates consistent with earlier reviews in adult populations. Participation was consistently higher in men than women and inversely associated with age. Indicators of socioeconomic status (e.g., educational attainment, occupational status

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and measures of SES) were also consistently associated with higher levels of activity however one Australian study reported that this association was eliminated when physical activity conducted around the home and at work was included (Salmon et al., 2000). Results of studies assessing the influence of marital status and the transition (singlemarriage) were mixed. Overweight or obesity was found to be consistently negatively correlated with physical activity. One of the 6 studies reporting these results was a large multi-country study in Europe. (Martinez-Gonzalez et al., 1999)

Psychological, Cognitive, and Emotional Factors. Twenty four of the 38 new studies examined by Trost et al. assessed intrapersonal variables such as attitudes, barriers, enjoyment, expected benefits, value of outcomes, intentions, normative beliefs, self efficacy, self motivation and stage of change. Self efficacy (which is confidence that one can be physically active is specific situations) regularly emerged as a consistent positive correlate. Barriers emerged as strong negative correlates (these included lack of time, too weak (reported in elderly populations), fear of falling, bad weather, no facilities, lack of exercise partner, lack of energy and self consciousness. Attitudes, knowledge and normative beliefs were not found to be associated with physical activity and this was consistent with the earlier conclusions of Sallis and Owen (1999). Behavioural attributes and skills. Only 4 behavioural attributes were identified across the 38 studies (dietary habits, past exercise behaviour, smoking status and decisional balance). Of these, past activity was a consistent predictor of current activity level. Only 3 studies investigated dietary habits and these showed a positive association with PA. Six of 7 studies assessed the relationship between smoking and levels of activity and found a negative association those who smoked more were likely to report less physical activity. Social and Cultural factors. Social support was consistently found to be positively associated with levels of physical activity (in 9 of 9 studies). Social support was assessed differently across studies, but these studies did indicate that it was consistently associated with PA. Physical Environmental Factors. More studies since 1998 have included environmental factors although Trost et al. concluded that the strength and direction of results varied. Factors that emerged as potentially showing an association were exercise equipment in the home and access to and satisfaction with facilities; neighbourhood safety, a hilly terrain, frequent observation of others being active (modelling) and enjoyable scenery. Urban/rural location was explored in 6 studies and all found physical activity to be significantly lower among adults living in rural areas compared with urban. Most of these studies assessed leisure time activity and did not include work/occupational activity.
In summary, Trost et al., identified 38 new studies published between 1998-2000 and reviewed these within the context of updating the earlier review undertaken by Sallis and

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Owen (2000). The majority of these new studies reported associations that were already well established in early reviews. However, nearly all of these more recent studies focused on investigating the correlates of physical activity in previously under-studied populations (such as ethnic minorities, middle-older adults, disabled) and thus the results of Trost et al. establish that similar variables are correlated with participation in these sub populations. Overall, the findings reported by Trost et al. indicate a consistent pattern in both the type of correlates and the direction and magnitude of their association with physical activity in the adult population. A small number of revisions to the grading of evidence were proposed in the light of new studies, these included: a change in the strength of evidence on martial status (to weak negative correlate), weight status and smoking were identified as consistently negative correlated (rather than no-association); and the barrier lack of time as well as past exercise were identified as consistently negatively associated (not weak/mixed evidence). History of childhood activity and sport was seen as having weak/mixed evidence. This body of evidence continued to show no support for any association between physical activity and attitudes. Greater attention towards investigating the role of environmental factors was evident and the list of potential correlates was expanded by 10 new variables. Although this indicates a broader ecological perspective is being adopted in the study of physical activity, overall the evidence reported on the environmental correlates by Trost et al. remained somewhat limited. Most of the evidence on correlates of physical activity in adult populations continues to come from cross sectional study designs. Only 7 prospective studies were found among the 38 new studies on adults and, in almost all cases, the reported results were consistent with findings seen from cross sectional studies. Nonetheless given it is not possible to infer a causal relationship, additional evidence from longitudinal and from intervention studies is required. Moreover there is a lack of evidence on the correlates of different types of physical activity with a dominant focus on correlates of leisure time physical activity but little attention given to the factors associated with transport-related activity and incidental or lifestyle-related physical activity.

Sherwood and Jeffery (2000). This paper is a narrative review assessing the determinants (correlates) of exercise behaviour and the implications for individual and public health recommendations and intervention strategies for promoting physical activity. Determinants are presented in two broad categories: individual characteristics (including motivations, self efficacy, exercise history, skills) and environmental characteristics (such as access, cost, time and social and cultural). Motivation is noted as important but its form can vary by gender (women more likely to report social factors and

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stress reduction as major motivating benefits, in contrast men are more likely to state fitness and health benefits). There is also some evidence that participation in individual sports is associated with participation by those interested in physical appearance benefits while fitness activities are associated with participation for physical appearance benefits. Relatively little is known about which motivations are associated with each phase of exercise (adoption, relapse, and then initiation following relapses). Nor is it known which motivations are associated with particular types of activity. Self efficacy (situation-specific confidence) is identified as the strongest and most consistent predictor of exercise behaviour, and thought to be particularly important in the early stages of exercise adoption. Stage of change, an integrative model for understanding behaviours including physical activity, has shown less clear predictive utility. The definition of exercise history appears to influence whether an association between past behaviour and activity levels is evident. This is the same as past exercise behaviour or habit, identified in the Trost review (2002). Recent exercise history is generally predictive of future exercise history however childhood history is inconsistently related to activity in adulthood. Interestingly, it is noted that perception of childhood activity may be as important as the amount of childhood activity, as recollections of being forced or encouraged to be active were both associated with lower levels of adult activity. Across a number of health risk behaviours smoking and diet were identified as the strongest correlates of activity. Although not all studies agree, non smokers are more likely to be active. Body weight is consistently shown to be a strong (negative) correlate in cross sectional studies although the extent to which body weight is a barrier, a consequence or a motivating factor is not fully understood. Cross sectional studies show stress levels to be associated with lower levels of activity. Within the social environmental category of factors, lack of social support was identified as a robust (negative) correlate of activity and time constraints were a frequent barrier and associated with lower levels of activity. For the physical environment, access, either distance to facilities or equipment at home, and perception of safety in the neighbourhood, have been shown to be associated with participation in several studies. Finally it is noted that characteristics of the exercise itself (intensity, duration, preference/choice, variety) are likely to be additional predictors of activity and adherence but it is not known exactly how these factors might influence in different populations. This was also noted in the US Surgeon Generals report on physical activity (1996), where lower intensity physical activity was a concern of more sustained participation. It is suggested that these require further investigation.

Speck et al. (2003) A narrative review of the determinants of regular exercise (adherence) in women assessing psychological, social environmental, physiologic, demographic and

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health status variables as well as characteristics of physical activity itself. The paper has a focus on the theoretical basis for concepts and how they are used in research studies. Self efficacy, outcome expectancy, value expectancy are defined and differentiated and it is noted that self efficacy is the most frequently studied. Perceived benefits are noted as sometimes being equated with outcome expectancies in an incorrect manner. Selected studies with women are reported to demonstrate the use of these variables with different sub population groups (African American, Caucasian, college students). Social support, perceived barriers and environmental barriers were found to be associated with activity either as barriers or predictors. Consistent with other findings, social support is stated as a strong, positive correlate of behaviour and barriers such lack of time and multiple obligations were identified as negative correlates. Safety, climate, terrain and availability of facilities are identified as recent additions in the environmental correlates literature and the early findings indicate potential for these variables to be important for female populations. Given this is an area in its early stage of development no firm conclusions on environmental correlates were presented. A set of physiological benefits known to be outcomes of participation in regular physical activity (decreased blood pressure, heart rate and BMI, improved oxygen uptake, HDL cholesterol) are postulated to act as potential motivators for participation although no evidence that supports this role is presented. Age is noted as a negative correlate for adherence in exercise by women and one study is reported because it provides evidence of different subsets of demographic variables being associated with different types of physical activity (occupational, sports, active living, household/care giving) in women. For example, higher levels of household / care-giving physical activity was associated with Hispanic, older, married, young children and not being employed; in contrast higher levels of sports was associated with white Caucasian, higher education, younger, without children and lower BMI. Other studies suggest that the influence of marriage may vary by ethnic group. Health status was reported as being (positively) associated with activity. The influence of different characteristics of the activity itself (e.g., structured, intensity, duration) was explored with evidence from selected intervention studies but no overall conclusions on the relationships were evident. In summary this review identified that there is no generally accepted, well tested theory to predict maintenance in regular physical activity in women, that known predictors explain typically small to moderate amount of variance seen in behaviour and that research has focussed primarily on individual behavioural and social variables. Further study of the myriad of complex factors would benefit from epidemiological studies requiring large samples.

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White et al. (2005) This is a systematic review of papers assessing the determinants of exercise adherence in women. Thirty five papers were found although the definition and time period of adherence varied widely between studies (from 6 weeks to 2 years). Characteristics of the type of activity were explored as potential determinants. The results showed inconsistent evidence for mode of activity, some evidence that duration of activity sessions may be important with shorter durations more favourable and some supporting evidence that home based programmes or equipment and workplace programmes may be associated with better adherence. The authors argue that the convenience of these settings may explain the positive relationship although it is noted that few studies have explored exercise adherence in worksite programmes since the early 1990s. The relationship between the intensity of activity and adherence is unclear and it is suggested that there is likely to be an interaction between mode, duration, setting and intensity of activity but too few studies have explored this aspect in detail. Moreover these are dynamic characteristics that may interact and influence physical activity in different ways over the duration of a study or programme.
Enjoyment of activity and choice were associated with participation and these too may interact and vary with type and setting of the activity. Overall while there is some evidence of possible associations between type, intensity, duration, setting, choice and enjoyment, the exact relationships are far from clearly understood for this population. Social support was also identified as potentially important but it too has not been systematically studied in relation to adherence in women. It may be that social support has different level of importance depending on whether one looks at starting, or adherence to a programme. Self efficacy was identified as the most important correlate of exercise adherence. Higher self efficacy was associated with higher adherence in most but not all studies included in this review. Two other potential determinants were raised but not explored through the literature in this review: tailoring of programmes to individuals and the role of life events.

Keating et al. (2005) This is a meta-analysis of the literature on physical activity and college aged adults. The authors note the importance of this age group for primary prevention of chronic disease, the potential of higher education setting to have a positive influence and yet the dearth of research focussed on this age group. Although the paper has a broader agenda, the first category of literature reviewed was studies assessing the patterns of participation in college age students and the determinants. A limitation of the literature and this review is the focus on undergraduate population, a second limitation common to much of this literature is the multiple methods used to assess and define physical activity. Reviewing patterns of participation it is noted that college adults students in the U.S.A are not higher than the general population, students tended to be

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active on weekdays in contrast to weekend days (as seen in some adult literature) and do not prefer walking as a mode of activity (frequently cited as the most preferred activity in general adult populations). These observations might direct the development of specific interventions tailored to the college age population. Determinants of activity are presented as personal, social, cognitive and environmental and the use of social cognitive theory is prominent in the few studies undertaken in this area. Age, gender, ethnicity, year of study, health status, past history were assessed. Students less than 30 years of age were more likely to be active in vigorous exercise and the decrease in vigorous activity resulted in the decrease seen in total physical activity. Conflicting results were seen for gender in this population group. Studies on differences in patterns of activity by ethnicity are few in this age group, the results are inconsistent and thus the authors conclude our understanding is incomplete. Similarly the impact of physical disabilities, year of study and role of previous participation in sports and physical activity are poorly studied. Social support was identified as a significant (positive) factor for both men and women, although support from family may be more important for women than men while support from friends or peers was more strongly associated with participation in men. Self efficacy was reported as a strong positive correlate consistent with research in the general adult population. Fun and enjoyment was identified as one of the primary reasons for participation although it is not known how to increase enjoyment and how enjoyment might be related to adherence. There is limited evidence on the role of self motivation although the benefits of improved physical appearance appear to be important for both genders (muscle gain for men and weight loss or maintenance for women). Being healthy was rarely cited as a motivating factor. Environmental factors include access to facilities, public transport, climate and campus safety, however research on these is sparse in this population. In summary, age, gender, ethnicity, perceived enjoyment, self efficacy and history of participation were identified as correlates of physical activity in this population group. However, more research is warranted to further understanding the relationships in college-aged populations. Almost no data were obtained outside North America, so international correlates are also lacking for this group..

Thorburn and Proietto (2000) This paper is a review of the potential biological determinants of spontaneous physical activity (defined as activity associated with daily life). Using a combination of animal and human subject studies the authors explore the evidence that there are biological control mechanisms that dictates the level of spontaneous physical activity independent of an individuals volitional control. They propose that there are biological underpinnings of physical activity behaviour, independent of cognitive intrapersonal, inter-personal and environmental influences; this

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is important, as a putative biological mechanism would interact with the other levels of influence to induce and maintain physical activity. In this summary, we have not focused on biological mechanisms in this review, as these papers are still speculative and few in number, but the point is worth considering in an overall approach to understanding physical activity.

5.2.4.2 Correlates of physical activity in adult Hispanic / Latino populations

Three review level papers were identified that specifically aimed to assess the correlates of physical activity in minority ethnic groups. Two of the three focussed on Latino / Hispanic population groups. Overall it is evident that there is limited evidence on the factors that influence participation in non Caucasian populations. Moreover, there are some specific limitations to the current research methodologies which are discussed in more detail later in this chapter.

Amesty (2003) This paper is a qualitative review of the barriers to physical activity in Hispanic communities. A search was conducted to identify relevant literature (search terms and number of studies found not stated). Data on the prevalence rates of participation in Hispanic populations indicates consistently lower levels of activity compared with non-Hispanic populations in the USA, this is true for adults and young people and particularly marked differences in participation in the female population. Social support is reported as a particularly important correlate in determining health status and other health behaviours. Evidence that this is true also for physical activity is presented. The importance of understanding social support within the context of other issues such as literacy and acculturation is discussed in detail. A strong message from this paper is the need for greater understanding of these influences in this population. Perceptions of crime and fear of safety are identified as important barriers to participation with several studies providing both qualitative and quantitative evidence. Social class and poverty are also presented as important determinants (correlates) of activity level and although no mechanism or pathway for this is postulated. Structural and environmental factors are identified as needing closer investigation and the need to employ a socioecological perspective to understand how the identified individual and social factors act in relation to the broader context. The authors argue for the need to incorporate and understand the role of displacement, segregation, mobility and absence of social cohesion which are conditions experienced by many in Hispanic communities. Marquez et al. (2004) This is a systematic review of the literature for papers published until January 2003 assessing the correlates of physical activity in Latino populations. Search terms included Latino, Mexican-American and Hispanic and the review aimed to

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compare the findings on psycho-social correlates with those found for the general population. Twenty studies were identified that assessed current and future levels of physical activity. Self efficacy was most commonly studied and appears most important for men and women, young and old. Studies testing interventions showed self efficacy to be modifiable. Social support, from friends or family, was identified as important although the authors note that it is included in only a limited number of studies and yet, it is a potentially very important factor because the Latino subculture is noted as being very collectivist (Triandis et al., 1988). Perceived barriers, such as care giving were frequently studied and inversely associated with participation. Depression, anxiety, stress and normative beliefs have been included in many studies with the general population but in few studies with Latino population and the results are mixed. Overall there appears to be limited research evidence exploring the importance of environmental factors. In summary, it is evident that the majority of studies focussing on the Latino population examine similar constructs as those explored with the general population. Moreover consistent results are seen with self efficacy, social support and perceived barriers showing significant association with activity. Limitations in the evidence base are similar to those for the general population, as most studies are cross sectional in design. However, in addition, it is noted that results from studies including multiple ethnic groups are often presented for all groups combined, and this prevents a thorough understanding of the specific relationships that might exist for each specific ethnic group. Acculturation is an important concept to include in the understanding of determinants of activity but there is very little research evidence in this area.

Seefeldt et al. (2002) This paper is a narrative review of the literature and the emerging findings on the determinants of physical activity in the adult population with a particular focus on the role of ethnicity. No search terms or data bases are cited in the methods. A strong rationale for a focus on culture and role of ethnicity and race is presented along with an extended discussion on the association between childhood physical activity levels and sports participation with adult levels of activity, health status and sports participation. Using individual studies to illustrate, the evidence for the important role of past participation in exercise and sports is described. It is not possible to draw firm or consistent direction for the potential relationships. The importance of considering life transitions is presented (e.g., school to work, single to married, child birth) and the idea that the roles and values associated with these transitions may vary according to the generation (e.g., retirement is viewed differently now compared with 20-30 years ago). These factors are presented as potentially important determinants of physical activity participation that should be, but rarely are considered in the current literature.

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5.2.4.3 Correlates of physical activity in older adult populations

Four review-level papers were found that aimed to identify the correlates of physical activity in older adult populations (see Appendix 5.3). Three were reviews of correlates including personal, social / cultural and environmental and one review focussed specifically on the environmental level factors (Cunningham and Michael). This review is summarised under the section specifically on Environmental correlates (see below).

Chogahara et al. (1998) This review paper focuses on the social influences on physical activity in older adults. The authors set out to consolidate the evidence and identify the major positive and negative social influences that are associated with activity in this age group. A specific distinction is made between positive social influences (defined as supportive behaviours and helpful actions of others that encourage activity) and negative social influences (defined as unsupportive, inhibitive, resistive behaviours of others that discourage involvement in physical activity). It is noted that in much of the literature negative support is merely defined by default as the absence of positive support. Citing from 29 included studies, 85 social support variables were identified and 42 of these were found to be significantly associated with physical activity. The remaining 43 variables were not significantly associated with activity levels.. The sources of support were primarily spouse, children, other family members, peers, exercise instructors and physicians. In a sub set of studies identified as those studies with samples of over 65 years (n=7) 11 of 15 social support variables assessed were found to be significantly associated with increased activity. The authors suggest this evidence is inconclusive of any definite conclusion that social support is more important with older (greater 65 years) adults. However there is some support that physical activity in older women (greater 50 years) may be more strongly associated with peer support compared with younger women (less than 50 years). Much of the literature on social influence is focussed on the source of support not the functional role. Research in other disciplines has produced some agreement that there are 4 major dimensions of positive influence, namely; instrumental, emotional, informational, and esteem support. The authors of this review do not review their set of studies systematically against these dimensions and it is most likely that for physical activity there is insufficient primary research with consistent operational definitions from which to draw any conclusions. Evidence on the role of negative social influences was sought but very little was found indicating an absence of this focus in the physical activity literature. Personal barriers have been included in many studies (such as; physical, cognitive and knowledge-based constructs). The most frequently cited perceived barrier was I am too old. Research in other health areas has explored negative social influences and found important associations and that these influences can be longer lasting than positive social factors. This remains an area in need of further development by researchers.
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Plonczynski (2003) This is a review of the determinants of physical activity in older women. The review presents a conceptual pathway by which various categories of factors might influence. In brief, background determinants (which includes demographic, environmental, social, and health variables) may influence intrapersonal determinants (which includes motivation, cognitive appraisal and affective health) which in turn interact to influence levels of activity and subsequently health status and related risk factors. The purpose of this review was to identify the background determinants related to physical activity in women aged over 65 years using the earlier published work of Dishman (1994) as a reference point. Papers published between 1994-2001 were sought and 16 studies met the inclusion criteria.
Age, gender, SES were identified as the strongest correlates of activity while the relationship between physical activity and marital status and race was unclear. Three studies assessed race and two used a definition based on exercise not physical activity and it is postulated that this may have underestimated the participants activity level and confounded the results. One study found weather to be a key barrier. Environmental determinants were sought and lack of or poor quality sidewalks, general fear of safety in the neighbourhood and crime were negatively associated with participation in physical activity. Population density was explored in two studies and results showed women in urban areas aged over 70 years were more active than rural counterparts. Another study reported no difference suggesting that it is too early for any conclusive findings particularly given the small number of studies. Social influences were assessed and found to be positively associated with activity in older women. Better health condition, and other positive health behaviours (healthy diet, stress management and non smoking) were also positively associated with increased activity. Conversely, more frequent illness was associated with lower levels of activity. Self efficacy was found to be a strong correlate of behaviour and health was the single most important motivator. Affective health or mental wellbeing was found to be associated with greater participation as was fewer perceived barriers. In summary, age, decreased income and lower education were the demographic factors correlated with lower levels of activity, and rurality, limited access to facilities, fear of crime, safety, lack of sidewalks and weather were identified as the negative environmental correlates. Positive social support, good health and self efficacy were positively associated with increased levels of activity in older women.

Schutzer et al. (2005) This paper reviews the evidence on barriers and motivators to exercise in older adults. The predictors found for exercise adherence in younger adults are not consistent for elderly populations and the authors suggest a one-size-fits-all approach is not appropriate with the adult population. Particular challenges stated for

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working with older adults are twofold; many older adults perceive exercise as time consuming; and they may view activity as a recreational pursuit not necessarily as an aspect of medical therapy. Results in this review are presented as a qualitative assessment of the evidence around barriers (health, environment, physician advice, knowledge and childhood exercise) and motivators (self efficacy, prompts, music and demographics). The basis for the selection of factors is unclear and no theoretical framework is provided. The findings indicate that poor health is negatively associated with participation, as was injury. Environmental barriers discussed included fear of crime, access, convenience and proximity. Selected studies provided evidence of some potential associations with activity levels in this population group. Physicians are identified as a particularly important source of information for older adults and experimental evidence supports that older adults receiving advice are more likely to perform moderate-heavy levels of activity. Although knowledge might appear important limited evidence exists to support any positive association. A weak negative association was presented for the association between levels of activity in later life and childhood exercise. Self efficacy was identified as an important motivator, and in general the majority of research indicates that self efficacy is critical for initial adoption, pleasure and satisfaction may be important for sustaining behaviour. Selected aspects of the experimental evidence base exploring the effectiveness of different methods to prompt older adults are briefly reported. Telephone support is seen as potentially associated with longer term adherence and the role of programmes including music is outlined with no clear conclusions. Important demographic factors are lower BMI, female, fewer chronic diseases and pain, non smokers and higher self efficacy. In summary this paper provides a rationale for a more concerted effort in the research field to better understand the correlates for physical activity and presents a set of important personal, social and environmental level factors that are likely to have a significant influence on levels of physical activity in the older adult population.

5.2.4.4 Correlates of physical activity in children and adolescents

Below is a summary of the key findings of three reviews that report on the correlates of physical activity in young people. First, the review by Sallis et al., is described, as it sets out a systematic and semi-quantitative methodology, and provides a comprehensive summary of the evidence up to 2000. Two additional review-level papers were identified and these present subsequent updates to the evidence using similar methods to Sallis et al., (Biddle et al. 2004; Biddle et al. 2005). Appendix 5.4 presents a summary of the major correlates that have been explored within the literature with young children and adolescents.

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Sallis et al. (2000) This is one of the first comprehensive, systematic reviews of the correlates of physical activity literature focusing on primary and secondary school aged children (3-18 years) and adolescents (aged 13-18 years). The studies included school and community samples, used a variety of physical activity measures reflecting a range of intensities of activity and included both cross sectional and prospective designs. Sallis et al. developed a semi-quantitative method to describe the body of evidence where at least 3 studies had assessed the variable: no association (less than 33% of studies reporting positive association); indeterminate / inconsistent association (34-59% of studies showing a positive result); positive association (60-100% of studies showing positive associations); and negative (60-100% of studies showing negative association). The results of are presented by age group and type of correlate. Children (aged 3-12 years) Fifty four studies published between 1976 and 1999 were reviewed and 76% were cross sectional in design, 30% had subjects from one ethnic group, 26% did not report ethnicity, over 80% of studies were conducted in the USA, 24% used non-validated self-report measure of physical activity and 48% used objective measures of activity behaviour. Demographic and biological variables Seven of 11 identified variables in this category were studied more that 3 times. Gender was most frequently studies and in 81% of comparisons boys were more active than girls. Bodyweight / adiposity was also frequently studied but showed less consistent results. Age was found to be inconsistently related and indicators of socioeconomic status were not found to be associated with childrens level of activity. Psychological variables Twelve of 15 variables were assessed more than 3 times. Perceived barriers were the most consistent negative correlate. Intention to be active and preference for physical activity were consistently positively associated with activity. Body image, self esteem, perceived benefits, attitudes towards sweating and after-school activity were not found to have any association. Self- efficacy, perceived competence, attitudes had an intermediate (defined as 34-59% of studies showing a positive result) relationship with activity. Behavioural variables Eighteen variables were studied and 6 appeared more than 3 times. Time spent in sedentary pursuits (e.g., television watching) was most frequently assessed but its association was indeterminate. Healthy diet and previous physical activity were consistently associated with activity but smoking, alcohol use and calorie intake were not associated with level of activity. Social variables This category comprised variables mostly associated with parental influences, 9 factors appeared more than 3 times. Parental level of physical activity was most frequently studied and 38% found a positive association, however using the coding

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schema deemed this relationship indeterminate. This was true also for parental involvement in childs physical activity. All other social variables were found to have no association.

Environmental factors Of the 11 identified variables in this category, only 6 were studies more than 3 times. Access to facilities, time spent outdoors were found to be positively and consistently associated with higher levels of activity. Results on the influence of season (weather) and urban design (urban versus rural) were found to be indeterminate. Rating of neighbourhood safety and parental provision of transport were not associated with activity levels in young children. Adolescents (aged 13-18 years) Fifty four studies published between 1976 and 1998 were reviewed and 83% were cross sectional design, 57% had subjects from one ethnicity, 9% did not report ethnicity, 68% of studies were conducted in the USA, 69% used nonvalidated self report measures of physical activity and 4% of studies used an objective measure of physical activity. Demographic and biological variables Five of a total of 9 variables were studied more that 3 times. Gender was most frequently studied and 27 out of 28 comparisons reported boys to be more active than girls. Results on the influence of bodyweight / adiposity were coded as indeterminate. Age was found to be negatively associated with physical activity. Indicators of socioeconomic status were unrelated to activity levels in adolescents. Psychological variables Half (17) of the 35 psychological variables were assessed more than 3 times. Intention to be active and preference for physical activity were found to be consistently positively associated with activity while, rather surprisingly, self esteem, external locus of control, self motivation, enjoyment of exercise, perceived stress were found to have no association. Results on the association between physical activity and perceived benefits and perceived barriers were coded was as indeterminate and unrelated, respectively. Self efficacy, body image, attitudes, knowledge, and enjoyment were also found to have an indeterminate relationship. Depression was found to have a negative association with activity levels. Behavioural variables Only 13 of a total of 30 behavioural variables were assessed more than 3 times. Sensation seeking, previous physical activity and participation in community sports were positive associated with activity levels. Participation in sedentary pursuits after school and on weekends was found to be consistently and negatively related to level of physical activity.
Smoking, healthy diet and sedentary time were found to have an indeterminate association with physical activity.

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Social variables Parental physical activity was most frequently studied but showed no association with activity level. However, parental support, direct help from parent and support from significant other were all found to be consistently related to higher levels of activity in adolescents. Results on sibling level of physical activity were inconsistent and peer modelling and perceived support from peers were found to be unrelated, as was attitudes of significant others. Surprisingly no association was found between teacher or coach support (modelling) and physical activity participation in adolescents. Environmental variables Only 7 environmental factors were assessed of which only 3 had more 3 comparisons. Opportunities to exercise was found to be consistently and positively associated. The influence of sports media and availability of equipment appeared to be unrelated to activity.
In summary Sallis et al. found variables associated with physical activity that suggested physical activity behaviour was complex and multi-factorial.. Table XY summarises the key results for children and adolescents by level of correlate. Their findings support an ecological approach to understanding behaviour and indicates that interventions must target changes in variables in all categories to be successful and achieve sustained behaviour change.

Biddle et al. (2004) This review adopts a behavioural epidemiological framework (Sallis and Owen 1999) presenting the evidence on the health benefits of physical activity in youth, a summary of current levels of physical activity in the UK, Europe and elsewhere and a review of the determinants (correlates) of physical activity in children and adolescents. The final section explores the implications of the available evidence for policy interventions. This paper is based on the review by Sallis et al. (see above) and the authors present and discusses their findings using new, qualitative and sometimes unpublished evidence where available. No systematic search for new papers was apparent and the qualitative discussion is presented using a structure of biological, psychological, behavioural, social and environmental categories. Potential correlates of sedentary behaviour are addressed.
Trans-generational factors, including social position of parents, are thought to influence adolescent physical activity (Wold and Hendry, 1998). Additional data from the UK suggest more favourable association between activity and perceptions of enjoyment, self efficacy, competence, benefits and positive attitude towards activity, although these were not found in the Sallis review. It is noted that the restriction by Sallis et al. to exclude papers with a focus on only sports participation may have overlooked the potentially stronger associations that may exist between past participation in sports and current sports participation. In discussing correlates of sedentary behaviours the inconsistent and poor definitions of sedentary behaviours is highlighted. Using data from their own
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research Biddle et al. suggest that there is a very small positive correlation between sedentary behaviours (e.g., TV viewing, video games) and PA, and that there is in fact time for youth to participate in both.

Biddle et al. (2005) This papers reports a systematic review of the evidence on correlates of physical activity in adolescent girls. This papers represents a 4 year update on the work of Sallis et al. with a focus on girls. Using electronic search strategy and key search terms 56 papers were included and data were analysed using the framework presented in Sallis et al. (see above). Gender (male) was strongly associated with increased levels of activity, and increasing age was negatively associated with participation. Self perception, body attractiveness, physical self worth, global self esteem and task orientation were also identified as positive correlates. Negative correlates included the barriers lack of time and other activities; smoking and sedentary activities. Participation in organised sport, peer support, acceptance and influence, and parental and family support were also positively associated with increased levels of activity in adolescent girls. The authors conclude that key modifiable correlates can be identified for the sub population in the categories of psychological, behavioural and social categories. The evidence on the influence of environmental variables was not sufficiently developed to draw any conclusions. 5.2.4.5 Environmental correlates of physical activity - adults
Below is a summary of the review level evidence that focuses specifically on the environmental factors. It is noted in the majority of the literature reported above that research aimed at understanding the potential influence of features of the physical environment such as crime rate, population density, access to facilities (e.g., footpaths, sports facilities, open space), convenience, safety and other community level indicators such as level of deprivation, education or employment. Environmental correlates represents a new field of research for physical activity and it has developed rapidly over the past 6 or so years with now over 100 studies investigating the association between aspects of the physical environments and participation in physical activity published. As well, several reviews have been written. However, all of these reviews only considered a small subset of the available literature (the maximum number or primary studies was 34 studies in one of nine reviews appraised). Most reviews examined research usually found in public health or from the transportation / urban planning field, but seldom both, despite the publication of studies on environmental correlates in both sets of data bases.

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One review of reviews was completed in 2005 (Gebel et al.)2 and included 9 systematic reviews. For this paper, efforts were made to identify all review papers from a variety of relevant disciplines including the public health literature and from databases covering social geography, transport and urban planning. In addition, all primary papers were obtained and individually checked (Gebel et al. 2005). Published reviews and the original papers were obtained from detailed electronic searcher and hand searching of reference lists of identified studies. Gebel et al. collected 9 review papers published between 2002 and 2005, and these reviews examined 90 original source papers. Here we document each of those reviews, and their major findings, that generally reported similar associations between aspects of the urban or built environment and physical activity. Badland & Schofield 2005, a transport-related review, showed that urban density and mixed land use were associated with increased walkability, and that perceived and objective measures of safety were associated with physical activity. The review by Cunningham & Michael (2004) described a framework for the relationship between the built environment and physical activity, and indicated that for older adults, safety and aesthetic features of the environment were related with physical activity. The review by Lee & Moudon (2004) found associations between the quality of pedestrian and bikeways, population density and mixed residential use, accessible destinations and freely available facilities were associated with physical activity participation. Ogilvie (2004) conducted a rigorous systematic review of interventions aimed at increasing walking or cycling instead of car use. Overall, the evidence from this review was equivocal several but not all studies showed walking or cycling mode shifts, but other studies did not show any effects. Sallis (2004) review explored findings from the health, urban planning and transportation literature on active transportation. Levels of walkability were found to be associated with utilitarian trips, but not walking for exercise. Land use mix, density footpaths and
This environmental review of reviews had its own search strategy, which included perusal of the following health and urban planning electronic databases, including such as Cochrane, Medline, CINHAL, DARE/EBM, Psychinfo, Pubmed, Geobase, ScienceDirect and Avery. Key search terms were 1. PA related terms: Physical activity, Walking, Bicycling, Exercise, Physical activity behaviour, Transportation, Active transport, Physical inactivity, Sedentariness, 2. Physical environment related terms: built environment or infrastructure or public facilities or urban design or urban environment built environment or infrastructure or public facilities or urban design or urban environment 3. Correlation related terms: correlate, determinant, association 4. Review related [to identify reviews] review, systematic 5. Intervention related terms: intervention, trial, programme, effectiveness The search strategy includes the following steps: A. PA terms and Physical environment terms (1&2) B. Physical environment terms and nutrition terms (2&3) C. Physical environment terms and outcome terms (2&4) D. Restrict further using review, correlation/study or intervention related terms if required The search strategy also includes searching the grey literature including internet sources, government documents and expert consultation. 2

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street lighting were associated with active transport. The results from Saelens (2003) review demonstrated that neighbourhoods with a high population density, good land use mix, high connectivity and good provision of walking and cycling facilities are more likely to encourage walking and cycling for transportation. Owen and colleagues (2004) showed that environmental attributes were reasonably consistently related to walking behaviours, but that these correlates varied by the type or setting for walking being examined, and also varied by gender. In a well cited review, Humpel et al., (2002) investigated environmental factors associated with adults participation in physical activity. They found that accessible cycle paths, local parks, density of shop facilities, awareness of and satisfaction with facilities, safe footpaths and a safe, friendly and attractive neighbourhood were positively associated with physical activity. The Trost et al., (2002) review, discussed earlier, included physical environments as correlates for the first time, and in assessing 10 studies, showed positive associations between physical activity and environmental access, aesthetics, safety and urban [versus rural] location. One recent review was carried out by Heath et al., (2006); they conducted a systematic review of the net effect of environments on physical activity. They compared data for differing physical environments (for example, high and low walkable) and found differences in the prevalence of walking in these cross-sectional comparisons. It was assumed that these differences reflected the effects of a putative intervention (that would have been caused by the differences in environments) and they estimated quantitative effect sizes. Methodological limitations of this procedure in cross sectional data are noted, but the Heath et al. (2006) review remains a valuable resource. The main recommendations are that community-scale factors (zoning regulations, street connectivity, residential and employment density) and street-scale factors (lighting, ease and safety of crossing street, footpath continuity, traffic calming measures and aesthetic enhancements) urban design and land use policies and practices are effective environmental approaches to increase physical activity. Further, they decided that there was insufficient evidence on transport policies (e.g., roadway design standards) and practices (e.g., providing bicycle paths and racks, increasing cost of parking) to increase physical activity, because of too few studies. They also identified methodological limitations in the research to date, including diverse physical activity measurements, the under-explored interaction between social and physical environments, and the diversity of correlated urban form attributes. Most studies used cross-sectional designs (showing that walking and certain environmental attributes are correlated when each are measured at the same time point) and are inherently limited such that no conclusions about cause and effect can be reached.

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Overall, the summary findings from these reviews suggest that there are reasonably consistent associations between high population density, mixed land use and street and urban form connectivity. There are consistent associations between accessibility of physical activity facilities, and lesser evidence for accessibility of recreation facilities, and physical activity participation. Two of the reviews also identified road safety or cycle and pedestrian safety as correlates of physical activity, and two mentioned the need for safe, well lit areas which are well maintained, especially amongst older adults. Two reviews mentioned aesthetic features of the environment as being important. One systematic review of cycle/pedestrian improvements and restrictions of car use, showed the evidence here to inconclusive. Further research is needed to examine these kinds of environmental changing interventions. Physical environment and aspects of urban form seem to be consistently related to physical activity, predominately from cross sectional studies but also in those few cohort studies which have examined this relationship. This provides some promising evidence that aspects of the urban form are likely to influence physical activity, and a conclusion is tenable that changes to these aspects of the urban form would be likely to be contribute to population levels of physical activity participation.

5.2.4.6 Environment correlates of physical activity - children and adolescents

The relationships between environments and physical activities are more complex for children, and differ according to the childs age (Popkin et al, 2005). No review papers were identified, but several recent studies identified at the population-level, that provide initial insights into the environmental correlates of physical activity for children. Local or immediate factors, such as parks or play space and active recreation facilities near to home appears to be associated with physical activity choices among young people (Sallis, Prochaska and Taylor, 2000; Mota et al. 2005). The more peripheral environment, such as sporting group participation, may be more dependent on parental transport, parental time pressures, family-level socioeconomic factors and spatial factors such as distance. In the area of active commuting, many developed countries have reported declines in the proportion of children who actively commute to school or other venues [by walking, cycling or catching the bus], and this has been replaced by car transport [Sirard et al., 2005; Merom et al., 2006]. There is evidence of an association between the presence of foot paths to school and rates of active commuting behaviour (Boarnet et al., 2005). Policies at the local government level, such as regulation and zoning restrictions have impacted on facilities within local parks; play equipment is subject to more local government regulation for safety reasons, and as such, is less prevalent in smaller local parks for cost reasons. Similarly, regulation regarding the use of the school environs for after-school active recreation has declined over recent decades, but efforts to redress this

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are occurring at the school level; to date, very limited evaluated evidence has been produced on the effects of liberating school space on overall physical activity levels, but it is a built environment with substantial promise (Evenson and McGinn, 2004; ; Sallis et al., 2000). The immediate environments around households show different relationships to physical activity for adults and for children. While sprawl neighbourhoods may reduce active walking among adults, the environments of protected cul-de-sacs may facilitate street play for children, more than for children living alongside busy transport corridors. The reverse, the presence of transport corridors may facilitate adult active commuting, but restrict child-focused activity (Gordon-Larsen et al., 2006). The indoor environment has also changed for children, with more sedentary recreational opportunities offered by access to electronic media and games in indoor domestic settings. (Salmon et al. 2005). A few interventions have reported changes to aspects of the school environment, usually PE curricula and delivery systems, to promote physical activity (Brug et al., 2005; Matson-Hoffman et al., 2005). Some of these showed increases in physical activity, PE classes, or exercise among intervention group students (Kelder et al., 1993; Luepker et al., 1996; Sallis et al., 2003), but some showed no effect. Overall, the picture is complex for environmental influences on physical activity among children, but only a small proportion of the variance in childrens physical activity can be explained by environmental measures as for adults. One study noted that only around 5% of the variance in childrens physical activity could be explained by physical environmental measures (Fein, Plotnikoff et al., 2004).

5.2.4.7 Policy-level correlates of physical activity Bull et al. (2004) This paper provides a summary of the literature on policy development and defines what a policy on physical activity may usefully comprise. It presents a reviews of 8 selected countries comparing and contrasting the content of existing policy or action plans on physical activity against a set of ideal characteristics developed from World Health Organisations Global Strategy on Diet, Physical Activity and Health consultation process. Considerable similarities were found in the methods and approaches to policy development across countries, with most adopting an intersectoral approach, using consultation and partnership between sectors. Action across the lifespan was recognized, as was the need for multiple strategies across a variety of settings. National policy on physical activity was led by either the health or sport sector but the involvement of many sectors as well as the non government, civil society and potentially the private sector was usually acknowledged. This is one of only a few published papers on upstream approaches to the public health agenda around physical activity. However

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it is unable to provide evidence of any associations between the policy level actions and subsequent population levels of physical activity. This remains an important area for further research in the physical activity field.

5.2.3

Conclusions: correlates

5.2.3.1 Nature of the evidence

Most of the evidence on correlates of physical activity in adult populations continues to come from cross sectional study designs. Only 7 prospective studies were found among the 38 new studies on adults and, in almost all cases, the reported results were consistent with findings seen from cross sectional studies. Nonetheless given it is not possible to infer a causal or true determinants relationship from cross sectional analyses, additional evidence from longitudinal and from intervention studies is required. Moreover there is a lack of evidence on the correlates of different types of physical activity with a dominant focus on identifying and describing the correlates of leisure time physical activity. Little attention has been given to identifying the demographic, individual , interpersonal or environmental factors associated with transport-related activity and incidental or lifestyle-related physical activity. The evidence presented in this review is from 17 reviews plus one meta-review representing in excess of 600-700 primary studies. Most of the evidence in these reviews describe correlates of physical activity from cross sectional study designs. Some of the reviews used systematic approaches to identifying studies, but most did not. Much of the evidence on correlates of physical activity has been collected at the personal (individual) and social level, and far less evidence is available on the environmental level and no empirical work has been conducted on policy level correlates. This balance has been redressed in recent years with a surge of evidence on environmental factors emerging from multiple disciplines. Nonetheless, there is most evidence surrounding factors and variables that have been most often measured. Finally, most work has been done on young people (children and adolescents) and adult populations. Less research is available on correlates of physical activity in older adults and in minority and specific sub-populations.

5.2.3.2 Summary of findings Personal level

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Among adults, there are consistent demographic factors associated with physical activity in populations. These include age and gender, with most leisure-time physical activity measures showing lower prevalence among women and older adults, compared to men and young adults. In addition, some socioeconomic individual level attributes, especially educational attainment and income are positively related to leisure-time physical activity3. The most consistent intrapersonal factor consistently associated with physical activity is self efficacy, part of social cognitive theory, and related to the persons situation-specific confidence that they can be physically active. Self-efficacy and related constructs are measured frequently, and remain positively associated with physical activity across diverse population groups and populations. Another group of measures examine motivational readiness for activity, and are classified as components of the stages of change model; these are generally, but not always associated with physical activity. Other intrapersonal variables, including attitudes and beliefs are inconsistently associated with activity. Perceived barriers to physical activity especially perceived lack of time [adults] and feeling too old or having chronic illness [older adults] were consistently and inversely related to activity. Exercise habit or a history of previous participation earlier in adult life was a correlate of current adult participation. Some other risk factors were reasonably consistently and inversely associated with physical activity; obesity and tobacco in particular. Attributes of the activity itself, such as intensity [negatively associated with long term physical activity participation], and possibly duration, are sometimes studied. The affective components of perceived fun and enjoyment are associated with activity in some studies. Among children and adolescents, consistent associations were noted for gender [males more active], and for age, with declines in physical activity through adolescence. Some intrapersonal perceptions, such as body image and self perceptions [inverse] and selfesteem [direct] are associated in some studies. Intention to be active and preferences are important in younger children, but not in adolescents. Previous physical activity and membership of community sports associations were associated with being active in adolescence. Depression and psychological distress, as well as increased sedentary pursuits are inversely related to physical activity among adolescents.

Social / cultural level

Note that other relationships may exist for other types of physical activity for example active commuting may show an inverse association with active commuting, as those of least income may not be able to afford cars and other sedentary transport modes.

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In adults, social support is associated with physical activity, particularly among older adults, women, and some minority populations. Cultural factors have some influence, but it is not consistent; for some groups, promoting dance or other active cultural expression is useful for promoting activity, but this is not universal. Among younger children, social influences are quite important. Consistently, parental and other adult role models are important, but this becomes less important among adolescents. Peer influences and teacher modelling of active behaviours is unrelated to youth physical activity.

Environmental / policy / economic level

For adults, environmental characteristics consistently associated with physical activity include urban density, mixed land use and street connectivity and destinations close by, which are elements of the walkability of a neighbourhood. In addition, aesthetic factors, safety [for older adults] and paths/ infrastructure appear important. Some of these are at the local level [street scale], whereas others are part of the larger urban environment. Children who are active report greater access to local facilities, paths and recreation opportunities than less active children. For younger children, parental transport and parental affluence are correlated with participation, especially in organised sport and recreation. Policies that promote physical activity are often linked to environmental changes. For example, policies that influence zoning ordinances, play equipment, transport policy and urban planning policies might contribute to active-friendly environments; however, these are theoretical, rather than based on much longitudinal data.

5.2.3.3 Generalisability of the review findings

The central public health importance of correlates of physical activity is concerned with the generalisability of the findings. If results are generalisable to diverse populations, then correlates studies can be used to guide public health programmes and interventions. For example, the consistent association between self-efficacy and physical activity has led to the development of numerous intervention programmes using self-efficacy and other social cognitive theory elements in the intervention design, with the potential for them to effectively support physical activity behaviour change. The same is true of environments thought to be related to activity, and work with urban planners and transportation systems is under way to utilise these correlates in intervention design. However, one limitation is that some research, even if systematic and replicated, was carried out in small and non-representative samples, and hence may not be observed as a correlate in all samples. Finally, the evidence base is limited by what is measured; for

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example, if cultural and social norms foster and support sedentary behaviours, but are not measured, then identifying social norms as a correlate will not have occurred, and this may lead to missed opportunities for intervention. Research on correlates has been carried out almost exclusively in developed countries. Our understanding of the correlates of physical activity in developing countries is very limited, and no clear patterns are available. In order to develop strategies to influence physical activity, correlates and determinants research will need to be broadened to include these settings.

5.2.3.4 Limitations of the review / evidence

Researchers have only identified some of the elements that determine physical activity behaviours in humans. For example, even if all correlates are included together in statistical models, they only explain around one fifth of the variation in physical activity. This means much of the variation remains unexplained; either correlates are insufficient, or are poorly measured and assessed. It may be that we underestimate the strength of association between proposed correlates and physical activity because of measurement error; this is a problem with self report physical activity measures, especially when various types and intensities of activity are assessed. Common methodological problems are identified, especially in studies of correlates in sub-populations. They may be based on studies with small sample sizes, lack a theoretical basis, and may use measures of physical activity that have not been validated. Other variables, such as social support may be poorly defined and measured. Responses may be unreliable, particularly among children, where measurement error may differ among children. The assessment of physical and social environments remains in early stages of development, and researchers may omit important dimensions of these environments in their studies.

5.2.3.5 Implications for future research

Despite the fact that numerous questions remain about the determinants of activity, there is clearly a plethora of information available on the multiple factors associated with physical activity, and this information base has increased markedly over the past decade. It is clear that multiple determinants, from individual level factors, through to environmental factors, are important. More focused research will identify the specific settings and types of physical activity, and explore determinants of setting-specific behaviours. Physical activity measurements are improving, with increasing use of objective measures of environments, and of the behaviour itself. New psychometric techniques is

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contributing to improved measures of beliefs, attitudes, and other intrapersonal constructs. Measures specific to culturally diverse sub-groups are being developed and tested and will further contribute to our understanding of physical activity in these groups. More emphasis on longitudinal designs will allow clearer identification of true determinants and separate them out from factors that are simply statistically associated correlates. These determinants can be better understood, and fed back into intervention designs. Optimal interventions are likely to be at multiple levels, and attempt to influence multiple domains of physical activity.

5.2.3.6 Final conclusion

Physical activity is a complex, dynamic process and over the lifespan, individuals typically move through various phases of structured exercise and lifestyle activity participation that are determined by diverse factors. Consistent patterns of intra- and inter-personal and environmental correlates of physical activity are emerging. These associations provide the basis for developing better hypotheses regarding physical activity, and implementing innovative and evidence based interventions.

5.3 Interventions on Physical Activity

5.3.1 Introduction
This review of physical activity interventions is based on a distillation of review-level evidence. Summary findings for each included review will be provided and efforts made to summarise the strength and direction of major findings in terms of programme effectiveness. There will also be a synthesis of best practice case studies from developing countries, and a framework for assessing evidence of physical activity interventions from developing countries, as a method of establishing an evidence base where detailed intervention data are not available.

5.3.1.1 Conceptual framework

There are potentially a number of conceptual frameworks for use in this review of correlates and interventions on physical activity, there is however no standard or consensus. Even amongst the papers included there is evidence of different ways of grouping, describing and classifying the independent variables. The correlates literature shows more similarity in classifying potential correlates with typical groupings being: individual level, interpersonal, social, environmental and policy level. Studies will be summarised using their classification system.

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Figure 5.5. Framework for physical activity interventions (adapted from Kahn 2002)

The literature on physical activity interventions followed different and diverse classifications methods. An example of one such classification system is shown in Figure 5. 5, where interventions are classified as information based, behavioural and social and facilities-oriented [environmental] interventions. This schematic is derived from the comprehensive system for classifying interventions developed as part of the U.S. Guide to Preventive Services and applied to physical activity (Kahn 2002, one of the reviews considered here). This framework will be referred to in the intervention section.

5.3.2

Methods

An electronic search was undertaken using Medline Cinhal, DARE, EBM, ERIC, Psychlit and Sportsdiscus databases. The focus was to identify published papers reporting on interventions aimed at physical activity; this is a field in which many hundreds of papers have been published over recent years. For example, using physical activity as a title word with interventions since 1990 produced 412 intervention trials, which increased to 2,881 if the search term physical activity or exercise is used4 (see Table 5.4). In order to undertake a review of this field in the timeframe provided, review papers were sought, with a preference for systematic reviews. The search strategy therefore focused on identifying (quantitative and qualitative) review papers with a focus on physical activity interventions. Additional search terms were tested to identify review

Unpublished bibliometric research [in progress] demonstrates the specificity falls from around 0.9 to >0.5 when exercise is added, and that physical activity as a single title term is highly sensitive (>0.8) and specific (around 0.9) for papers of relevance to public and population health and physical activity(Bauman, Kohl et al, in preparation).

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papers on interventions in specific settings5 but did this not add any new reviews to those already identified.
Table 5.4. Search terms used for interventions on physical activity

Category Physical activity Review paper selection Interventions

Search terms used Physical activity or exercise [title] Defined as a review paper [Medline] or with key word or title/abstract words [any of] review, systematic, research, synthesis, summary Intervention$ or trial or controlled or evaluation or impact or effectiveness or experiment [title]

Overall, 117 review papers were identified from Medline, and 116 were found across the five other databases. These searches are available as documents from the first author (AB)6. Of these 117 and 116 papers, 33 and 29 were considered, respectively, and 28 and 21 deemed relevant were obtained and read (see Table 5.5 and Table 5.6). Note that the differences here [5 papers from Medline and 8 from other data bases] were considered but not read 7 An additional 11 papers were obtained through a detailed search of personal files and through personal contacts. This set of papers included relevant reports and review of interventions from the grey literature.
Table 5.5. Summary of the search process for interventions on physical activity Stage 1
2 3 4 5 6

Physical activity intervention review # papers identified through initial database search in Medline (A) and in other data bases (B) Review papers for consideration Review papers obtained and time read [full paper] at second level review Papers from second-level review included in the final review Papers obtained through other means and included in the review Papers included in the review

A [Medline]
117 33 28 13 11 30

B [other data bases] *

116 29 21 18

* other databases : Cinhal, Dare, EBM, ERIC, Pyschlit, Sportsdiscus # note that review papers not available from other databases directly search term included review/systematic/research synthesis/summary

5 6
7

Search terms included: worksite/workplace/primary care/general practice/family practice/ community/ communitywide/ mass media/campaign/ school$/ health care/clinical/ environmental / policy/

Available as documents labelled PA-interventions1_medline and PA-interventions-2_other

This was a judgment, and these could be included; knowledge of most of these unread papers led to the decision; in some cases, multiple reviews already were included, and hence the paper did not add to the overview of programme effectiveness. These papers are references numbered 92, 104, 107,108 and 114 in PA-Intervenitons1, and references numbered 8,52,57,74,79,109, 32 and 44 in PA-Interventions2. Note the last two references here were Cochrane reviews that were incomplete.

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Table 5.6. Inclusion and exclusion criteria for interventions Criteria Study focus Study excluded if: (d) The focus was not on physical activity related; it related to exercise physiology, or clinical exercise research; (e) There was no clear evidence of a review process; (f) Single intervention studies; (g) Focused on a single disease, or specific clinical setting. Study included if: Reviews, especially systematic reviews of interventions Qualitative reviews where the authors summarised a field of intervention research; Meta analyses, and Cochrane reviews as a subset of [a] were included. Study included if: (k) Used clear, validated self report physical activity measures, or objective measures of activity or related phenomena (l) Reviews of quantitative studies (m) Published in English (n) Published within the period 2001 2006 [to limit the number of reviews considered]

Study design

Other aspects of research quality

The focus of this review was on general population studies, or on studies in healthy populations. Disease specific physical activity interventions were excluded, as were reviews of tertiary prevention trials of exercise. In addition, papers on physical activity and cancer, related to tertiary prevention of exercise or physical activity for patients with cancer, were identified; In total 10 papers were identified across the databases. To date, these have not been included in this report.

5.3.3

Results

Appendix 5.5 presents a summary of the review papers on physical activity interventions providing details on the year, overall topic, population groups studied, and search processes. In addition, the number of studies included in each review is indicated as well as the broad settings of the interventions. Reviews are categorised into conceptually congruent groupings, so that, for example, reviews of physical activity interventions among older adults are considered together. This table shows the subset of reviews published in the five years between 2001-2006. Most were focused on physical activity interventions that could target whole populations, but several focused on physical activity interventions in older adults (Conn 2002, Conn 2003, Cress 2005, Taylor 2004, van der Bij 2002, Fiatarone Singh 2004, Cyarto 2004), and another cluster focused on physical activity programmes aimed at youth (Epstein 2001, Timperio 2004) and those reviewing the on worksite physical activity interventions (Proper 2002, Enbers 2005, Marshall 2004). These clusters of papers are described together in the narrative synthesis.

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Below is a summary of the main findings from each review paper grouped around conceptually congruent themes. Each review is summarised in a short section, with an emphasis on the following sections [where relevant information could be extracted from the review]: 1. The main purpose or research question 2. the studies reviewed 3. research methods issues including study designs 4. length of follow up 5. estimates of intervention effects [effectiveness] 6. Population applicability or generalisability 7. Overall summary of findings.

5.3.3.1 Generic reviews of physical activity interventions Holtzman et al. examined whether there was evidence that a physical activity intervention alone (or diet, tobacco cessation) led to sustainable increases in aerobic physical activity. Secondary research questions assessed whether the interventions were theoretically based and had theoretically-based mediators [as in intervening causal variables]. A subsidiary review within this paper had a special focus on whether physical activity led to increased quality of life among cancer survivors.
This review examined 47 physical activity intervention studies and as the authors point out, pooling of results was not possible due to the diversity of outcomes and populations studied. The 47 studies excluded children/older adults, and was comprised of 71 interventions. There were 24 interventions in the health care setting, 12 were home based physical activity programmes, 17 in community settings, 20 in worksites, and 11 in centres or through government organisations. Most studies scored low-moderate on methodological quality criteria. Multiple outcomes were reported; 8 studies had 2 physical activity outcomes, 11 had three physical activity outcomes, and 4 studies had > 5 physical activity outcomes. A key feature was that most had short follow up periods of less than 12 months. The effect sizes (ESs) were calculated as standardised differences between intervention and control groups; 59% of studies had an ES>0.2 (small positive effect), and 45% of studies had at least one outcome statistically significant. Mediators were sought, and 6 of 9 studies found no intervention effect on proposed mediators. An overall summary of the findings of this general population intervention review indicated that it was possible to increase physical activity in the short term (< 3 months) with around half of the studies showing some statistically significant effect. There were successful interventions across settings and at all levels of intervention

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intensity/complexity. A key problem was durability (or sustainability) of effects but this could not be assessed due to lack of long term follow up in these intervention studies. Key recommendations were for longer follow up, standardised measures of physical activity (especially an objective measure rather than self report measures), and for researchers to obtain greater retention of participants in studies (i.e., reduce loss to follow up).

Hillsdon, Foster and Thorogood (2005) carried out a formal Cochrane systematic review of RCTs aimed at encouraging physical activity in sedentary and communitydwelling adults. Interventions included counseling, supervised and group or unsupervised home-based physical activity programmes. The review used formal Cochrane inclusion and quality scoring criteria (these include; RCT designs, blinding, intention-to-treat analyses, minimal loss (<20%) to follow up and whether outcome effects were controlled for baseline values). Outcomes measures were self report physical activity, change in fitness, and change in categorical measure such as the proportion reaching a healthenhancing threshold of physical activity.
For the 11 studies with self-reported physical activity outcomes, the standardised mean difference8 (SMD) was 0.31 [modest in size, but significant], but six of the 11 studies did not show a significant effect of the intervention condition over the control. For the 7 fitness9 outcomes, the SMD was significant at 0.4. For outcomes that assessed a threshold of physical activity for health, [n=6 interventions], the odds ratio was 1.30 for the intervention group 10 but this was not significant. No differing effects were seen for interventions of greater frequency of contact, or for different types of physical activity. Nor was there any evidence of a greater incidence of adverse effects, either injuries or cardiovascular events, between these trials. Methodological issues identified in this Cochrane review included the paucity of longer term follow up [of more than a year] and the methods used to select participants. This was identified as a threat to external validity, with mostly self-selected and motivated volunteer samples, who in turn were referred by motivated professionals or general practitioners. There was a low participation rate when considered at the population level.

Kahn et al. (2002) conducted the most comprehensive review of physical activity interventions as part of the U.S. Centres for Disease Control and Preventions framework for assessing Community Preventive Services. This framework allowed systematic
8

Used in pooled data analyses and meta analyses to summarise the relative effect of intervention over controls in a statistical way that is standardised and unitless, and therefore can be pooled across studies that used different (PA) outcome measures. 9 Studies used cardio-respiratory fitness measures as outcomes measured with either a maximal or sub-maximal test 10 30% more likely to reach the threshold for HEPA levels than controls

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reviews in a number of public health areas, one of which was around physical activity interventions (Kahn et al, 2002). This was a systematic review of a range of different interventions aimed at increasing physical activity. The framework (see Figure 5.5) categorised interventions as: information based; behavioural and/or social focus; and those aimed at the environment/policy. The methods for finding, reviewing and classifying interventions were systematic, utilised many researchers over a long period of time, and produced the most comprehensive approach to synthesising the published evidence on physical activity interventions for general populations.

Informational interventions The first group of physical activity interventions was informational approaches, these usually provided people with information that enabled them to move towards changing their behaviour, primarily through cognitive skills development. This information provision is meant to change knowledge and understanding of physical activity, and influence the ways in which people can become more active. There are four different categories of interventions reviewed here, and each is assigned a final strength of evidence statement.
The first category are point of decision prompts, for example signs placed near elevators or lifts or escalators to try and get people to use the stairs as a form of incidental and time-equivalent physical activity. The review identified six studies, usually using before-after or time-series designs, and found significant but small effects of these interventions. The review found that these studies had been conducted in diverse settings, so concluded that these are interventions are Recommended for increasing physical activity in that particular setting11. The next group of informational interventions is community wide campaigns, these are multi-sectoral and multi-strategy campaigns utilising mass media, community-based and community-wide strategies as well as individual change strategies. There were 8 studies and several of these were large scale community-wide cardiovascular disease prevention projects. This systematic review concluded that these interventions increased the proportion of people being active and participants, on average, increased their energy expenditure. Thus these were Strongly recommended as interventions. The next category was mass media campaigns as stand-alone approaches. There were only three such studies, and they were too diverse to provide clear evidence. The review concluded that there was Insufficient evidence for the effectiveness of this strategy alone. The final category of informational interventions grouped classroom-based health education programmes, and identified ten studies. These interventions showed
11

Other reviews have categorised these stair climbing interventions as environmental interventions (Sallis, Bauman and Pratt 1998), based on their location or setting, rather than as information-only approaches to physical activity: in reality they are both, because the cognitive prompt is towards making a decision shift to using the stairs, but any modifications to the setting (stairs e.g., refurbishment) would constitute an environmental change.

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inconsistent effects on outcomes measures of time spent in physical activity or self reported physical activity amongst children exposed to these interventions, hence this review concluded there was Insufficient evidence to assess the effectiveness of this kind of intervention.

Behavioural and social approaches The next category of interventions considered by Kahn et al. was behavioural and social approaches to increasing physical activity, this included applying behavioural skills and structuring the social environment to support choices to become more physically active or to maintain behaviour change. There were six categories of interventions reviewed under this approach.
The first category was school based physical education initiatives, and 13 effects from 12 studies were used in this review. These studies generally increased energy expenditure, or time spent in physical activity, or even measures of fitness or endurance testing. The conclusion was that this type of intervention was likely to be effective across diverse settings and population groups, and the evidence rating was considered Strong evidence. The next category was college-based health education and physical education programmes, which included lectures and courses for University and young adult populations. Five studies were identified, but only two met the methodological criteria for inclusion in this review. Effectiveness was not established for this area of intervention, and future work is needed to clarify whether this type of intervention in this setting is effective. The next category was classroom-based interventions to reduce television and video exposure. These usually target primary school aged children, and three papers were included. The studies seemed to have a clear impact on screen time, in terms of reducing television and video viewing, but this was inconsistently related to physical activity behaviour. For this reason effectiveness was not established due to Insufficient evidence. The next category was family-based social support interventions that usually target children with family members / parents taking a supportive role. Eleven studies were included in this review, but the results showed inconsistency in terms of physical activity and physiological outcome measures. For this reason there was insufficient evidence to assess the effectiveness of family-based social support interventions. The next category was social support interventions in community settings, which are based on strengthening community networks and using social networks to influence and reinforce individuals attempts to be physically active. These included group programmes, physical activity buddy systems and reinforcement from study staff to help maintain physical activity. Nine studies were included and showed strong evidence that social support interventions was effective in increasing physical activity, increasing
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the proportion of people who were physically active, and increasing measures of energy expenditure. These studies were conducted in different populations, adding to the generalisability of these findings and therefore this type of intervention was deemed Strongly recommended. A large group of studies comprised the category of individuallyadapted health behaviour change programmes, these were usually programmes tailored to an individuals readiness for change. These studies were based on theories of health behaviour change, and used established behaviour change and social support processes to facilitate change. Eighteen studies qualified for this review, with varied outcome measures. The results showed that most of the outcomes improved following the intervention, including time spent in physical activity, energy expenditure, measures of adherence or attendance at exercise sessions, or the proportion of people that started exercise programmes. It was noted that these studies typically included volunteer samples, which limits the generalisability of these results to whole the population. Nonetheless the evidence was considered strong that these individually adapted health behaviour change programmes were considered effective in increasing physical activity and thus Strongly recommended

Environment and policy interventions The third category if intervention was environment and policy approaches to increasing physical activity. Most of the literature in this area is correlational, showing that people who live in supportive environments tend to be more active (see above section on correlates of physical activity). However one category of 10 interventions was identified which used modification of place to create or improve access. The results showed a general increase in physical activity, aerobic capacity, or frequency of exercise sessions across studies, but all studies were conducted in selected populations in the United States. Nonetheless, the evidence was strong enough to support the recommendation that enhanced access to places for physical activity is an evidence-based intervention, but it was noted that these environmental interventions were often combined with informational and behavioural and social support strategies as well.
In summary, Table 5.7 shows the recommendations next to each of the categories of interventions. The key issues that remain relate to the lack of standardisation of measurement of physical activity, which is often the outcome measure considered, and is measured in numerous different ways across studies. Further, the maintenance of intervention effects beyond the short term has not been assessed in many studies, and remains an important area for future research. The final issue is the concept of generalisability, and whether most of these studies have volunteer samples, and although the effects are statistically and practically significant, the question remains whether these can be translated into population level interventions, in order to increase population levels of physical activity participation.

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Table 5.7. Summary of results from the CDC guide to preventive services review of physical activity Strategy Recommendation Comment

Informational approaches to increasing physical activity

Point of decision prompts [stair use encouraging signage] Community wide education Mass media campaigns alone Classroom-based health education focused on information provision School-based physical education Recommended Strongly recommended Combined environmental and information approach Usually includes media campaigns

Insufficient evidence Seldom conducted alone; usually part of community-wide interventions Insufficient evidence Inconsistent effects seen

Behavioural and social interventions to promote physical activity

Strongly recommended Strongly recommended Controlled settings efficacy studies rather than effectiveness research These interventions often had other and multiple strategies including support

Social support in community settings

Family-based social support Health education to reduce TV and video exposure College age / young adult PE and Health education Individually adapted health behaviour change

Insufficient evidence Potential to influence childrens PA but inconsistent findings to date Insufficient evidence Effects on PA less certain even if TV and screen time reduced Insufficient evidence Too few studies to draw any conclusion Strongly recommended Strongly recommended Broad set of behavioural interventions; volunteer samples Other environmental strategies now under review as well

Environment and policy interventions#

Creation and/or enhanced access to places for physical activity combined with informational outreach activities
#

NOTE: additional Environmental and Policy interventions are under review these include street-scale urban design and land use policies and practices, Community-scale urban design and land use policies and practices [both of these are now Recommended], and Transportation and Travel policies and practices [insufficient data to draw a conclusion]. These were accessed July 2006 at http://www.thecommunityguide.org/pa/pa.pdf]

Schoeppe et al., (2005) reviewed interventions aimed at increasing physical activity in developing countries and created a framework for considering evidence because few developing countries have published research data on which to form evidence-based judgments. In this situation alternative approaches to evidence generation are required (Kahn and Goodstadt 2002). The framework involved considering process evaluation indicators and using these to illustrate the features of comprehensive population-wide physical activity programmes. If the indicator was present in an intervention or approach then good or excellent practice can be presumed to be present. The strength of this approach is that stricter public health criteria can be applied to assess and describe truly

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population level programmes on physical activity. The weakness is that impact or outcome data (on population level of physical activity) are often lacking. In this review, Schoeppe and colleagues described a set of optimal attributes of a developing country comprehensive physical activity programme, which included: clear objectives and programme identity; multiple physical activity promotional components; sufficient resources; and clear dissemination strategies. In addition, population level monitoring and evaluation are required. This review reflects a practical approach to describing the evidence base on interventions in developing countries - a description of good practice rather than a review of the more objective and scientific evidence-based approach taken in other reviews. This review identified that there were very few primary studies in developing countries, and that other ways of describing useful physical activity intervention were required. This poses challenges for the scientific evidence base for physical activity interventions in developing countries, but not for the practice base, for which these approaches were developed.

5.3.3.2 Reviews of physical activity interventions for older adults

The reviews presented below assess the effectiveness of physical activity interventions aimed at older adults, published between 2001 and 2006.

Asthworth et al. (2005) carried out a formal Cochrane review of home-based versus centre-based physical activity programmes for older adults. Using standard Cochrane criteria and methods they identified six trials for inclusion. Weighted and standardised mean differences were used to describe post-intervention effects [compared with controls]. Overall the results suggested that both home- and centre-based physical activity interventions were useful for improving older adults quality of life and functional status, however home-based programmes showed better adherence than centre-based physical activity programmes suggesting that there may be greater benefits from home-based or unstructured programmes on physical activity. These findings were limited to a review of only six studies and their conclusions differ with the conclusions in other reviews. The focus of this review was on health outcomes [improved health status] for older adults with chronic illness, and on maintenance of participation in exercise regimens, rather than on m ore usual measures of physical activity or fitness. Taylor et al., (2004) provided an overview of the health benefits of physical activity in the elderly with a narrative review of interventions aimed at this population illustrating principles of good practice. They refer to the work of their co-author van der Bij [v.i] who has conducted a systematic review. The major new ideas are the assertion that participation in home-based and group-based interventions are similar, that tailoring of

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interventions to meet individual needs is important, and that social and behavioural reinforcement strategies are not shown to influence adoption and maintenance of physical activity among older adults. Low-moderate intensity physical activity that is safe and achievable by older adults is recommend. They refer to exercise referral schemes and other modes of integrating physical activity programmes into health service delivery as important from policy actions. Finally, they demonstrate some research that shows cost effectiveness of physical activity, especially around falls prevention among older adults.

Fiatarone & Singh (2004) reviewed exercise and ageing and made the case for physical activity/exercise in terms of health benefits (psychological, physiologic, functional status, as part of chronic disease management). This review examined the epidemiological and scientific evidence for health benefits in the elderly, indicating different forms of physical activity for different purposes. This review did not provide a summary of intervention effects. Van der Bij et al., (2002) reviewed 57 physical activity interventions from 38 studies in older adults published between 1985-2000 and using RCT study designs. The authors noted that more than half of the interventions in this 15 year period had been published in the last five years 1995-2000. The focus was on older adults, but the minimum age was 40 years and mean age around 50 years making this a review of the younger end of the older-age spectrum. These studies excluded those with chronic disease. Outcomes were categorised in two ways 1) participation (programme adherence/ compliance, or the percentage of sessions attended) or 2) changes in physical activity (short and long term); the latter were usually based on walking programmes, or strength training or aerobic classes, in that order of frequency. Participants were usually community-based volunteers and of high educational status and income. There were three types of intervention assessed; home-based (n=9 interventions); group based (n=38) and education/information (n= 10 interventions). The group-based programmes were organised and structured exercise programmes in small groups, often located in a centre or facility. The educational programmes included primary care advice, counselling and motivational interviewing. The results indicate that the evidence was least clear for home-based programmes combined with behavioural reinforcement interventions; fewer than half complied with recommended physical activity [adherence] and effects on physical activity were equivocal. Group and centre-based interventions were seen as effective in the short term using physical activity outcomes and showed good programme adherence (around 80%). However adherence and physical activity effects dropped in the few studies conducted over the longer term. Educational and primary care advice and counselling interventions showed the lowest participation rates but appeared effective in the short term in influencing physical activity.
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This review concluded that in the short term, high participation rates were achievable for older adults, but participation declines in most long term follow up. A minority of studies assessed physical activity changes and in general, group-based interventions and educational interventions increased physical activity in the short term. There was no evidence of longer term maintenance effects for educational interventions and insufficient data for any conclusions for group-based interventions. Group-based programmes showed better long term participation than home based programmes, but this may have been due to greater selection effects in the type of people recruited to group programmes. Participation tended to be better for those aged >60 years than younger age groups. This review did not support the notion that behavioural reinforcement strategies improved participation or physical activity outcomes. Limitations of the studies reviewed were in the large rate of non-response (i.e., selection bias in recruitment to the studies), in the paucity of studies that assessed physical activity change compared to controls, the lack of long term follow up, and that research designs and physical activity measurements were not comparable among studies. The authors suggested that intervention failure was often due to non-compliance with recommended physical activity and lack of long term maintenance. Further, they identify the need for more evidence on home-based programmes, as these had greater potential for promoting incidental and lifestyle physical activity and a broader population reach than group or centre-based structured programmes. Physician counselling and educational advice as part of more intensive multi-strategy interventions is recommended and comprehensive programmes seem to these authors to provide the best potential for longer term maintenance of physical activity.

Conn (2002) conducted a meta-analysis of physical activity interventions in the elderly, and examined whether intervention effects were influenced by participant attributes or the type of intervention offered. The review included studies with very small sample sizes. The focus was mainly on interventions aimed at increasing endurance exercise. Most were individual or group programmes, with cognitive behavioural strategies used to increase the chances of behaviour change. The meta-analysis pooled data from interventions, using an estimation of the standardised mean difference [delta, " ] between intervention and control groups. From 43 studies, the overall effect size (ES) weighted by sample size was " = 0.26, a small but significant effect size. Delta was larger for studies with short term follow up compared to longer term follow-up. Effect sizes were similar for walking interventions compared to other physical activity modalities. ESs were larger if the interventions were not health educational in focus, if they used more intensive contact, and emphasised behavioural self-monitoring. There were no differences in effect size for randomised trials compared to quasi-experiments, and no difference for objective or self-report physical activity measures. This review found that

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group or centre-based programmes showed greater ESs than home-based programmes12. This meta-analysis also showed larger ESs for physical activity-only programmes compared with interventions that attempted to influence multiple risk factors. In summary, there appeared to be small effects of physical activity interventions in older adults; this was a positive finding. However, this should be balanced against the non-representative samples in which these results were obtained, as well as the high intervention complexity (and potential costs) required to produce them.

Conn (2003) extended the work reported above with a systematic review of 17 RCTs of aerobic/endurance types of physical activity. This excluded studies where moderate intensity physical activity was recommended and studies of resistance training. Most of the trials here were in clinical settings [mostly patients with chronic illnesses thought to benefits from physical activity; nine of the 17 studies were recruited as patients with health problems visiting their physician. One outcome was exercise adoption (at short term and <6 months), four of 6 interventions showed intervention group effects over controls. In terms of longer term maintenance (over 6 months), 5 of 7 showed intervention effects. For physical activity outcomes, 10 of 17 trials showed a significant intervention effect over controls; note that 7 of 17 did not show any significant effect. Interventions were more effective if they used individually tailored physical activity interventions. This systematic review concluded that some interventions were effective among older adults, but that there was potential for other types of intervention, especially walking programmes where evidence was lacking. There were no identifiable programme components or elements that were specifically efficacious in older adults. The review identified that included studies involved younger and more mobile volunteers, and not representative of all elderly adults in the population. Cyarto, Moorehead and Brown (2004) updated the evidence on physical activity interventions and strength training programmes for the elderly examining interventions published between 1999-2003. There were 8 studies, seven of which were RCT designs, but mostly of small sample size and with volunteer populations. Most studies focused on moderate-intensity physical activity, and all but two of them found increases in physical activity levels. The other studies were trials of progressive resistance training (n=17 studies, 14 interventions). These were structured progressive resistance training programmes, usually three sessions weekly, and found significant increases in strength, as well as other benefits such as improved glycaemic control and better functional status (such as balance or gait). This update shows that interventions to promote moderate-

12

This was opposite to the earlier 1996 meta-analytic review of PA interventions (Dishman and Buckworth) for general populations that had observed greater effects for home based interventions

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intensity physical activity are generally effective although no effect sizes were calculated and that other modes of physical activity may have substantial benefits13.

Cress et al., (2005) provide a descriptive review of best practices in physical activity promotion and counselling for the elderly. They describe the need for multiple types of physical activity, including lifestyle activity, strength training, balance and flexibility training, as well as endurance-related exercise, and the different benefits of these components on functional status, quality of life and health gain among older populations. Apart from these general recommendations, they do not provide further scientific evidence based assertions, as this paper is more a review for practitioners. 5.3.3.3 Reviews of physical activity interventions for children and youth
The reviews below assessed the effectiveness of physical activity interventions for young people, including evidence for interventions effects for pre-schoolers through to schoolage students, and finally, young adults and college students.

Epstein (2001) assessed interventions targeting sedentary behaviours. This was more of a description of behavioural choice theory to explain how children made choices to be active. It was a conceptual model for interventions, and provided illustrative examples of single studies, and was not a systematic review with evidence of effectiveness. Gunner et al., (2002) described physical activity interventions and approaches with the very youngest age groups; infants, toddlers and pre-school age children. This paper focused on recommendations and guidelines for physical activity promotion approaches in these age groups. The guidelines were developed by NASPE14 and encourage large motor skills and increased playtime with infants and toddlers and recommend at least an hour or more of structured time each day with preschoolers as well as unstructured play. This set of guidelines is not based on empirical research from any specific interventions, but is a set of recommendations for an under-researched group. Given the increases in childhood obesity among primary school age children, it is asserted that physical activity interventions and research should target children before they reach school age. Timperio et al., (2004) updated the evidence published between 1999-2003 for physical activity interventions targeting children, adolescents and young adults. They identified 38 studies from 31 papers. Twelve papers assessed interventions to promote childrens
13

In addition to the benefits Fiatarone Singh [2004] describes reductions in depression for older adults following strength training intervention trials. 14 National Association for Sport and Physical Education

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physical activity in schools [reported from 9 studies]. These results suggested that integrated approaches were more effective than curriculum-based programmes alone. Most projects were short term, but the CATCH programme showed longer term maintenance of effects (intervention compared with controls). A second group of studies tested interventions targeting children in out-of-school settings, these included family support interventions, community settings, internet-delivered programmes, after-school programmes and active-commuting interventions. There were 10 papers mostly focusing on obesity prevention. Results were characterised by poor attendance and low levels of programme exposure. Of the active-commuting to school interventions, mixed results were seen, and most lacked control groups. Only 4 of the ten studies in the out-ofschool category showed a significant increase in physical activity. Studies in out of school settings aimed at adolescents were sought and five were located. Again, these focused on obesity prevention. Two of the five studies showed significantly increases in physical activity. Programmes were more effective if they included family members for support and physical activity behavioural modelling. Few programmes aimed at young adults were located, although this is an important group, because physical activity participation rates decline during young adulthood. Four interventions were found that used various educational and behavioural approaches. Results were mixed, but all used only a short term follow-up. No conclusions were possible for this age group. Overall, the reviewed concluded that interventions aimed at youth using whole-of-school interventions were more effective than curricula alone, that longer term follow up and objective measures would improve the evidence base, and that a physical activity focus on the whole populations rather than an emphasis on weight loss, is important in future research.

5.3.3.4 Reviews of physical activity interventions in communities, worksites and primary care settings
These reviews consider the effectiveness of physical activity in a number of communitybased settings, specifically; worksite, primary care, and the whole community.

Proper et al. (2002) examined the effectiveness of worksite interventions that promoted physical activity. Previous reviews had examined the impact of worksite programmes on physical activity outcomes15 but this review assessed whether worksite physical activity
15

Dishman et al., 1998 and reported that there was no conclusive evidence that worksite programme influenced physical activity levels irrespective of the type of intervention, theoretical base, dose of intervention or worksite attributes.

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programmes influenced absenteeism, job satisfaction, job stress, productivity and employee turnover. The underlying rationale was that healthier and more active workers would show cost savings and other benefits through improved productivity. The methods included careful quality assessment of studies that scored RCT designs, intention-to-treat analyses, and clear inclusion criteria to create a quality score. The findings were that there was limited evidence for an effect on absenteeism, no effect on productivity, and inconclusive evidence for job stress, satisfaction and employee turnover rates.

Engbers (2005) assessed worksite interventions that changed environments or provided facilities to support health promoting behaviour. Thirteen trials were included, but only three focused on physical activity. There were careful attention to methodological criteria in reviewing studies. The 3 physical activity studies were of relatively low methodological quality and the evidence on physical activity with environmental change in this worksite setting was deemed inconclusive. Marshall (2004) updated previous reviews of worksite interventions, including studies published 1999-2003. In this review period, Marshall identified 31 interventions, of which 18 used RCT or quasi-experimental designs. Nine of the 32 studies were in blue collar worksites, but the most frequently reported settings were universities, hospitals or government departments. Strategies employed included health checks, health education materials, motivational messages, workplace exercise programmes and incentive programmes. Participation of those initially enrolled was around 50-60%. Effects were short term, and stronger in the sample of more motivated or already active workers. These findings reinforced the earlier review and meta-analysis of Dishman et al., [1998] that suggested limited impact of physical activity programme in worksite settings. The perceived potential for workplace programmes may need to change as working conditions change, and their potential may be best as a setting for encouraging incidental physical activity, active commuting to and from work, and environmental changes in the workplace, such as around stairs and cycling facilities. Smith (2004) reviewed the effectiveness of interventions in the primary care setting, updating earlier reviews by reviewing studies published between 1999-2003. Inclusion criteria were physical activity as an outcome, RCT/Quasi-experimental design, and population-based. Studies reporting the effectiveness of physical activity advice from physicians and health workers for patients with existing chronic diseases such as diabetes or CVD, thus these studies were excluded. Population reach, adoption and implantation was considered using the RE-AIM criteria. Smith found 16 new studies to add to the previous 35 primary interventions in this area. Of these, 12 had physical activity as outcomes, and the remaining 4 were multiple risk factor interventions. Most of the 16
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studies involved brief advice in the setting of primary care, sometimes delivered by the family doctor, and at other times by ancillary staff or exercise experts. In addition to this primary review, Smith summarised 9 identified review papers in this area. Of these, six concluded that interventions conducted in this setting were effective, but only in the short term. Three review papers reported there was insufficient evidence to support the efficacy of these interventions. In terms of the results across the 16 new studies, Smith concludes that 7of 9 studies provided good evidence of an effect on physical activity, for short term follow up (<6 months). For the multiple risk factor trials, (n=4) there was insufficient data for physical activity outcomes to be conclusive. The major limitations in these studies were the lack of comparability of measurement, small samples, and lack of representativeness information. Attention to reach and adoption by doctors/professionals and their patients were not reported, and implementation poorly was often documented. Thus, although there is evidence of short term effects on physical activity, these studies are limited by the selection effects of patients and professionals who participate in them.

Morgan (2004) explored the evidence on the effectiveness of exercise referral schemes - these are programmes involving referral from a primary care provider to exercise / gym facilities or structured programmes that provide and support physical activity programmes. These are also known as exercise prescription studies. In this review, only RCT/quasi experiments were included with referral from primary care and 9 studies met the inclusion criteria. Low uptake was noted by those eligible for referral, and among those who attend initially, completion rates were moderate or low. The effects of these interventions were short term, but did suggest physical activity increased in those that participated in and completed the programmes. Exercise referral might be slightly more effective for those who are overweight but not obese, and for those who are insufficiently active but not completely sedentary at baseline. Dugdill (2005) considered whether exercise referral schemes (see above) were the panacea for public health physical activity promotion. The principles for exercise referral schemes are described and two large case studies from England are described in detail. The key aspects of such schemes are a referral from primary care to a centre-based 12-14 week exercise programme. Subsequent physical activity adherence is a key outcome. Although the term exercise referral is used, the aim is also to increase lifestyle and incidental physical activity, not just to produce a training effect or offer only structured exercise regimes. The two case studies were large schemes recruiting between 600-1000 participants per year. The key discussion issues were that most participants are referred for obesity management or chronic diseases management (diabetes and CVD in particular). Of those who are referred, many fail to present at the programme (substantially less than half of those referred) and of those that start a programme, 355-50

50% adherence to the full programme is typical. The limited evidence for exercise referral programmes has been reinforced in recent policy document assessing four categories of physical activity interventions for use in primary care (NICE, 2006); as found by Smith [2004, above] they recommended primary care brief advice regarding physical activity, but did not find enough evidence to support exercise referral programmes.

Lawlor and Hanratty (2001) assessed the provision of primary care advice for physical activity, and using systematic search criteria, located 8 trials . These used RCT or quasiexperimental designs and all had volunteer settings or participants. There was evidence of short term effects on physical activity outcomes, but limited evidence of any sustained effect. Sharpe (2003) reviewed community-based physical activity programmes, including whole community interventions, as well as smaller community based programmes. The first category of study types was person focused interventions such as those conducted in the health setting [referral from primary care, counselling with chronic disease patients] or in non-clinical settings [churches, senior citizens centres]. Twenty-nine person focused interventions were located, with average participation rates of around 75%. These studies showed short term impact on physical activity comparing intervention group with control group. Sharpe concludes that home-based programmes showed better long-term adherence than classes and structured exercise programmes. The second category of interventions was the community-wide risk factor reduction programmes, most prevalent in the 1980s and 1990s for the prevention of cardiovascular disease, Some of the largest of these integrated multi-strategy CVD prevention programmes occurred in Stanford, Minnesota, and Pawtucket in the USA. Overall they showed little impact on physical activity levels, or that intervention and control communities did not differ on physical activity levels. In the Minnesota project, there were early physical activity effects, but secular trends in control regions resulted in no difference at the end of the community-wide interventions.
Community planning for environment and policy changes can also potentially influence population physical activity. These interventions would create facilities or environments that would increase community-level physical activity opportunities. Most studies here are correlational [see correlates section], and the only few interventions are promotional stair-use studies, that show small effects. Finally, integrated approaches, that combine, within a socioecologic model, individual, social and environmental / policy changes are generally seen as promising. However, there is sparse experimental evidence to demonstrate effectiveness in this area.

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In summary, person-focused interventions were reported as effective in the short term to increase physical activity levels. Home-based and active-living interventions are considered as effective as structured group programmes. Adults may prefer unstructured physical activity and incorporating this into everyday life is potentially of population benefit. Long term maintenance of physical activity is poor, even amongst those that change their initial physical activity levels. Finally, success of large scale communitywide interventions is complex, and probably depends on the focus given to and maintained on physical activity throughout the years of the intervention.

Cavill and Foster (2004) assessed physical activity interventions at community level. They summarised seven previous reviews (two of which were published since 2001, and are in this document). Their framework was similar to that developed by Sharpe (2003) to categorise community interventions using [i] comprehensive integrated community wide approaches, [ii] community interventions using mass media, [iii] community interventions using person-level techniques such as counselling and behaviour change approaches, and [iv] environmental changes at the community level. The authors provided examples, rather than a systematic review, of interventions targeting children, older adults, women and minority groups. 5.3.3.5 Reviews of physical activity interventions in other settings Cavill and Bauman (2004) reviewed the effects of mass media campaigns to promote physical activity. These were stand-alone physical activity campaigns, or were programmes where mass media was integrated into a community-wide approach to promoting physical activity. In this mass media and communications were a central intervention component. Fifteen media campaigns were assessed, and their impact divided into proximal [on awareness and message understanding], intermediate [on physical activity related self-efficacy, intention, beliefs and attitudes] and distal [on the end point of physical activity behaviour]. Based on a theoretical review of how campaigns work, using the cascade of effects model, it can be seen that most campaigns impact upon awareness and understanding, some effect is noted for intermediate outcomes, but limited evidence is available that media campaigns can influence actual behaviour on their own. Behaviour change was more likely as part of an integrated comprehensive community-wide approach. An important methodological difference was noted in this set of studies compared with other studies testing interventions in the adult population. In 12 of 15 media campaigns, the evaluation was carried out using representative sample population surveys, thus assessing the population-level impact of campaigns; this method is notably absent in the evaluation of most other interventions

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aimed at the adult population and conducted in other settings, this is despite the fact that (often) the intervention is purported to reach the population level16.

Marshall, Owen and Bauman (2004) discussed the effects of media campaigns, and mediated interventions, that were delivered by mail, phone or websites. This was an update of earlier studies. Twenty media campaigns were found, and most used paid mass media messages in concert with other community-level strategies. The results showed significant effects on issue awareness and message recall, as well as understanding of the benefits of being active. There were 14 studies of mediated interventions, that were individual-targeted but with strong potential for high population reach. Six interventions using print media were identified, these could be tailored to an individuals readiness for change. Overall there was mixed evidence of an impact on physical activity levels, but some promise for tailored interventions. Four telephone based trials were located and these appeared effective and had high reach into communities. Four internet or website interventions were appraised and these appeared as effective as print media in increasing physical activity. Blamey and Mutrie (2004) discuss recent reviews of the evidence for individual-level physical activity interventions, especially focusing on the data from the review by Kahn et a;. [2002] based on the U.S. Community Guide for Preventive Services. The lack of data on economic efficiency is reported as a concern, as the costs of these programmes on physical activity need to be considered in the light of their potential for health sector savings. They comment on other reviews that suggest a stage of change tailored approach is often cited, but may not be evidence based (Riemsma 2002). Further, they critique the evidence on exercise referral schemes, concluding that enthusiasm for these approaches exceeds the evidence base in the UK. Several improvements in the study methods are suggested, including better attention to programme implementation, clear and standardised evaluation and measurement, and greater focus on translational research, in order to make an impact on population levels of physical activity. Palmer and Jaworski (2004) described the principles of exercise prescription for U.S. based underprivileged minorities. They discuss the need for community-based settings, focusing on culturally valued outcomes, such as physical health for African-Americans, and psychosocial health among Hispanics. No specific intervention modalities were identified, but theoretical variables, such as self-efficacy, were identified as important.

16

Note that other community-based interventions and some environment and policy interventions also used population samples in their evaluation design but these outcome methods and measures were otherwise rare across other settings for interventions on physical activity aimed at adult population.

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Bull et al., (2004) wrote about the principles of physical activity related policy, defined as formal statements that define physical activity as a priority area, develop clear targets, a plan for implementation.and defines the [involved] partnerships. A review of policy in 8 selected countries was reported but no complete case studies were provided. Using criteria on the potentially ideal components of a national policy and action plan, the presence or absence of elements in this set of countries is reported. Specific aspects of a population-wide physical activity policy intervention that were thought to constitute best practice included those with comprehensive approaches, multi-disciplinary stakeholder support, sustainable and well-resourced policy components, developed across sectors and including multiple levels of intervention with cooperation and implementation shared across multiple agencies. No country achieved all criteria. 5.3.4 Conclusions: interventions

5.3.4.1 Nature of the evidence

The rationale for public health approaches to promoting physical activity remains strong; this is especially true for non-communicable disease prevention, including cardiovascular disease and diabetes prevention. The rationale is also strong for physical activity having a role in obesity prevention, and in the primary prevention of some cancers, especially colon and breast cancer. There are other benefits of physical activity, including mental health promotion, and quality of life and functional status improvements in the elderly. However, realising these benefits requires change at the population level and this is much more difficult than at the individual, volunteer level, and hence the challenge remains to identify effective and generalisable physical activity interventions that can be translated into public health and clinical practice, and disseminated across systems and population groups.

5.3.4.2 Review findings Personal Level

Overall the evidence on interventions aimed at the individual level suggests they are effective in influencing physical activity in the short term. In particular, specialised behaviour change focused interventions are effective, including those that tailor interventions to individuals. Theoretically based, well delivered and comprehensive behaviour change can increase physical activity in the short term among adult populations.

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Older adults Interventions on physical activity using individually focussed strategies with older adult populations can produce positive and short term change in physical activity. This is true of primary care and general practice based brief advice, those emphasising social support and individually tailored interventions. Group interventions are effective, buts show short lived effects, whereas home-based programmes may not be as effective, but the effects persist for longer on physical activity adherence. Home-based programmes had the advantage of permitting incidental and lifestyle physical activity and therefore have greater potential for sustained change. There is limited evidence for walking interventions, although they may appeal to the elderly. Social Level
Interventions that emphasise social support, either through engagement of primary care providers, family or peers show positive outcomes on physical activity participation. For older adults this is likely to be linked with the provision of group based programmes (rather than home-based). Few interventions have compared different types of social support programmes, and a clearer conceptual framework would be beneficial. In particular, programmes targeting minority and disadvantaged groups need better integration of traditional and cultural modes of physical activity. This may be particularly relevant in developing countries, or countries in transition, where industrialisation and urbanisation may reduce previous physically activity practices.

Children and youth Integrated school based programmes are effective. These are programmes that are comprehensive approaches to information, environmental change, regulatory change [such as mandatory physical education] and encouraging out-of-school and family engagement in activity. This approach is more effective that physical education classes or curriculum changes alone. There are very few interventions for young adults, although declines in physical activity are marked during this period. Environment and Policy Level
There is limited evidence of the effectiveness of environmental interventions to promote physical activity, despite the volume of cross sectional association between the physical environment and physical activity levels. Some interventions areas, such as stair-use promotions, and increasing access to facilities are evidence based and effective. However, other aspects of environmental intervention seem best suited to integration into multi-

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strategy, well resourced community-wide interventions. The maintenance of facilities to be active, and usable transport systems and cycling/walking infrastructure may be useful, especially in developing countries at risk of losing this infrastructure through development.

5.3.4.3 Generalisability of findings

The interventions reviewed here are based on many studies with small, volunteer and selected samples. Realising these effects at the population level is more difficult and the translation of these review findings into practice remains the greatest public health challenge around physical activity promotion.

5.3.4.4 Limitations of the review / evidence

The quality of evidence is limited by methodological and implementation issues. Many studies were comprised of volunteer samples, that limited representativeness of the findings. Interventions that were effective usually reported results in the short term, and few sustained effects were noted. Many were randomised trials, but optimally evaluated community-wide interventions cannot always use this design (Bauman and Koepsall 2005). The quality of outcome measures varied, and observing significant outcomes was constrained by the limitations of self-report physical activity instruments. Follow-up rate within studies was an issue in some studies, where less than 80% of those enrolled at baseline provided follow-up data. Finally, there are differences between the evidence generated in efficacy trials of volunteer subjects, where design and measurement and follow up are optimised, compared to field-based effectiveness studies of larger and less differentiated people, but where the results, if significant, would be more generalisable to whole populations. This tension between internal and external validity in evidence is important in considerations of programme effects in developing countries, and in marginal or disadvantaged populations groups or settings in developed countries. For this reason, careful attention in future research should be given to the public health utility of physical activity programmes and interventions, in order to make population-level changes in physical activity participation and prevalence

5.3.4.5 Implications for research

The research priorities suggested here are to overcome the evidence gaps through better measurement, standardised outcomes, better retention rates in studies, and the use of representative samples at enrolment. In addition, comprehensive programmes need to be evaluated, using many of the strategies and settings described here, rather than one approach or setting at a time. Physical activity, especially encouraging active living

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requires multiple approaches, and rigorous evaluation of such multi-component interventions.

5.3.4.6 Final conclusion

Yach et al. (2005) presented a synthesis of lessons learnt through tobacco control, and these principles are applicable to physical activity interventions. The best approaches might include elements of all the successful physical activity interventions described above, and would address both individual level and environmental determinants of inactivity in integrated multi-sectoral programmes. Interventions need to be fully implemented, and delivered to their target audiences as intended. They should be based on strong theory, especially social cognitive theory and stages of motivational readiness. Finally, programmes should be tailored to the specific physical activity needs and preferences of their target audiences. In summary, this review paper has set out the principles for understanding why people are active, and approaches to intervening to increase activity levels for the whole population. Consistent research and evaluation will underpin future efforts in this direction, but are the essential quality control mechanism for evidence generation and translation of effective physical activity programmes.

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5-58

Appendix 5.1: Summary of included review papers on correlates of physical activity

Populations 64/3"78"57& 934"*& (4,3-7& && Review Features :"(*8.& >/?&/@& -"*;7& <(-(=(7"7& 7-,4$"7& 7-(-"4& 7-(-"4& 7-(-"4& No Yes Yes No No No No Yes Yes No Yes Yes Yes Older women Yes Yes No Yes No Yes No No Yes Yes Yes No No No No Yes Yes No Yes Yes No Yes No Yes No No No No Yes No No No No Yes Yes No Yes Yes Yes Yes No Yes No No Yes Reports Correlates on && A$/3/B$ 8(3& C5#$*/5D 5;"5-& Yes Yes Yes Yes Yes Yes No Yes Yes Yes No Yes No Yes Yes Yes Yes '/3$8E&F& C8/5/;$8& No No No No No No No No No Yes No No No No No No Yes

!"#$"%&'()"*&+(,-./*0& Adult populations Amesty et al. Keating et al. Marquez et al. Seifeldt et al. Sherwood Speck et al. Thorburn & Proietto Trost White Young people Biddle et al. Biddle et al. Sallis et al. Older adults Chogahara et al. Plonczynski Schutzer & Graves Environments ** Gebel
#

1"(*& 2003 2005 2004 2002 2000 2003 2000 2002 2005 2004 2005 2000 1998 2003 2004 2005 2006 2004

2.$34*"5&

64,3-7& Latino only College aged Hispanic only Yes Yes Women only Yes Yes Yes

'"*7/5(3& Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes No No

:/8$(3& Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes No No

Yes Yes Yes

Yes Yes Yes

Heath et at al Policy Bull et al.

# **

the 9 reviews used in the Gebel meta-review are referred to in the text and in the reference list, but not provided in this table. note environmental correlates for children and adolescents derived from the few recent primary studies, not from a review paper.

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Appendix 5.2: Summary of coverage of potential correlates of physical activity by review adult populations
Trost et Seefeldt et al. 2002 al., 2002 Demographic and Biological Factors Age Gender Indicators of socioeconomic status: educational attainment, occupational status and measures of SES) Ethnicity/race Dependent children Marital status Year of study in higher education
Overweight or obesity or body weight General health (or health status) Level of fitness Functional status Mental wellbeing

Reviews White et Sherwood & Speck et Keating et al., 2004 Jeffery 2000 al., 2003 al., 2005

Psychological, Cognitive, and Emotional Factors Attitudes Barriers Enjoyment Expected benefits Value of outcomes Outcome expectancy Intentions Normative beliefs Self efficacy Self motivation Stage of change Self efficacy Barriers Lack of time Too weak (elderly populations) Fear of falling (elderly populations) Bad weather No facilities Lack of exercise partner Lack of energy Self consciousness Fear of joint pain / MI / chest pain Injury Attitudes Knowledge

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Trost et Seefeldt et al. 2002 al., 2002 Adherence related correlates Mode (type) of physical activity Duration of activity sessions Setting (home / workplace) Choice / variety Behavioural attributes and skills Diet habits Past exercise behaviour Past sports participation Smoking status Decisional balance Stress levels Social and Cultural factors Social support Belonging to community groups Number of (social) roles Acculturation Physical Environmental Factors Individual level: Exercise equipment in the home Access to facilities (places to exercise) Satisfaction with facilities Community level: Neighbourhood safety Hilly terrain Frequent observation of others being active (modelling) Enjoyable scenery Urban location - rural /urban Presence of sidewalks Street lighting Safety (perceived / from crime) Places to walk to / destinations Access (walk / exercise facilities) Presence of unattended dogs Traffic Public transport Climate Cost

Reviews White et Sherwood & Speck et Keating et al., 2004 Jeffery 2000 al., 2003 al., 2005

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Appendix 5.3: Summary of coverage of potential correlates of physical activity by review older adult populations
Schtzer & Graves Demographic and Biological Factors Age Gender Indicators of socioeconomic status: educational attainment, occupational status and measures of SES) Ethnicity/race Dependent children Marital status Overweight or obesity or body weight General health (or health status) Level of fitness Mental wellbeing Psychological, Cognitive, and Emotional Factors Barriers Enjoyment Self efficacy Self motivation Barriers lack of time Weather Injury Behavioural attributes and skills Past exercise behaviour Past sports participation Smoking status Stress levels Social and Cultural factors Social support Positive social influences Negative social influences Physician advice Physical Environmental Factors Individual level: Access to facilities (places to exercise) Community level: Neighbourhood safety Urban location - rural /urban Presence of sidewalks Safety (perceived / from crime) Cost Reviews Chongahara et al. Plonczynski

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Appendix 5.4: Summary of correlates for children and adolescents*

Sallis et al. 2000 Children (4-12 years) Demographic and biological variables Sex (male) Age Ethnicity (Euro/American) Socio economic status indicators Bodyweight / adiposity Psychological variables In children Perceived benefits Body image Self esteem Attitudes towards sweating (negative) After school activity General barriers Intention to be active Preference for physical activity Self efficacy Perceived competence Attitudes (outcome expectancy) In Adolescents External locus of control Achievement orientated Self motivation Enjoys exercise Stress Sensation seeking Perceived physical appearance Likes PE Knowledge of exercise Depression Behavioural variables In children Time in sedentary pursuits (e.g., TV) Healthy diet Alcohol use Smoking Calorie intake Healthy Diet Previous physical activity In Adolescents Sensation seeking, Participation in community sports On school sports teams Sedentary pursuits after school and on weekends Previous community sports
Positive Inconsistent Inconsistent No association Inconsistent

Sallis et al. 2000 Adolescents (13-18 years)

Positive Negative Positive No association No association

No association No association No association No association No association Negative Positive Positive Inconsistent Inconsistent Inconsistent No association Positive

Inconsistent No association

No association

Inconsistent Inconsistent Inconsistent

No association No association No association No association Inconsistent Inconsistent Inconsistent Negative

Inconsistent Positive No association No association No association

No association Inconsistent No association Positive No association No association No association Inconsistent Positive

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Sallis et al. 2000 Children (4-12 years) Social variables In children Parental physical activity Parental involvement in childs activity Parental benefits of activity Parental barriers to activity Parental encouragement / support Parent transports child Peer Influence In adolescents Direct help / support from parent Support from significant other Sibling physical activity Peer modelling Support from peers Subjective norms, perceived Teacher / Coach modelling / support Environmental In children Access to facilities Time spent outdoors Season (Summer/Spring) Urban design (urban) Neighborhood safety Parents providing transport In adolescents Opportunities to exercise Equipment Sports media influence

Sallis et al. 2000 Adolescents (13-18 years)

Inconsistent Inconsistent No association No association No association No association No association

No association

Positive No association Positive Positive Positive Inconsistent Inconsistent Inconsistent No association

Positive Positive Inconsistent Inconsistent No association No association Positive No association No association

* Based on the review by Sallis et al. 2000 (Key correlates of interest and included in many of the primary studies have been included, results on other factors can be found in Tables presented in Sallis et al.).

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Appendix 5.5: Review papers of intervention studies to increase physical activity

Review (author) Year Content Category Populations / Groups in the review Systematic search
Cochrane review [followed Cochrane protocol]

Number of studies reviewed

Intervention settings
"home based programmes" are compared with centre-based structured exercise programmes review of behavioural and social interventions; environmental interventions; primary care; economic efficiency of trials

Ashworth Blamey & Mutrie

2005

2004

Cochrane Home based versus Centre PA review Programmes intervention Changing individuals to promote HEPA - the difficulties of producing evidence and translating it into practice Intervention

older adults >50 yrs no specific population group

Bull, Bauman, Schoeppe, Bellew Cavill and Bauman Cavill and Foster

2004

National PA Policy

Policy review

2004

Mass media PA review

Intervention

review of policies to promote PA mass media campaigns targeting populations or defined population segments whole communities; review papers mean aged 60 years or older

6 RCTs focus on overview of evidence from not stated diverse settings five countries' PA policy reviewed and compared convenient sample of countries with national PA with Australian PA policies at the Government policies; identified through PA policy level with objectives to increase PA at the community level contacts as good examples development 15 mass media campaigns

6 databases searched PubMed; keywords, 10yr period as per Conn 2003; attempted to estimate effect sizes

2004

Health enhancing PA - community interventions Interventions (meta analysis) Interventions older adults Intervention

Conn

2002

Conn

2003

integrative review of PA intervention research with aging adults

Interventions

clear inclusion criteria; aged 65 years and older, published 1960-2000; with PA or exercise searched 6 electronic outcomes databases review of best practices for PA interventions and counseling programmes for older adults not stated

Cress

2005

Best practice for PA programmes in older adults

Intervention

focus on mass media campaigns to promote PA in populations community settings comprehensive community Ix; campaigns; community-based; community environ change 7 review papers older adults in diverse settings; 43 studies results [Ess] coded by study included in meta- design, FID of PA, source of analysis subjects identified across settings; reported according to theoretical framework, supervised exercise, motivational intervention content, intervention delivery attributes and type of PA [walking special focus] 17 studies distilled 'elements' from many aim to identify barriers to interventions participation; and elements of 'best practice programmes'

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Review (author)
Cyarto, Moorehead, Brown Dughill

Year

Content

Category

Populations / Groups in the review

older adults, divided into 'young old' [50-60 yrs] through to 'old old' [over 70 years] primary care referral to exercise schemes Theoretical review of behavioural choice theory for PA in children general worksite interventions with evidence of environmental changes as well

Systematic search
update of previous reviews; PubMed and citations in other studies focus on two selected programmes

Number of studies reviewed

8 studies identified 2 studies described interventions to illustrate behav choice model

Intervention settings
focus on general PA interventions, and on progressive resistance training studies primary care eg. General practice- referral programmes environments lead to individual choices that in turn lead to choices regarding active or sedentary pursuits not PA specific - most were comprehensive or non-PA outcomes not evidence or research based; provides recommended levels of PA for these age groups [not based on epidemiological evidence] nor effectiveness of any interventions to achieve these levels community dwelling adults, RCT design; various interventions - advice, prescribed exercise, education, structured exercise programmes etc

2004 2005

Evidence on Interventions in older people Intervention Exercise referral as public health panecea critical review Reducing sedentary behaviour (children) Intervention Correlates ? Intervention

Epstein

2001

not stated

Engbers, van Poppel

2005

worksite health promotion with environmental changes

worksite interventions

systematic 1985-2004; 13 studies but assessed methodol criteria; only 3 were PA 3 databases outcomes guidelines provided with recommended activity at each preschool age not stated group 11 PA Interventions; 7 fitness enhancing Cochrane review interventions; 6 interventions to [followed Cochrane protocol] - searched 10 reach active databases 1960s to 2001 (HEPA) threshold 47 interventions met the criteria of behavioural Ix in general systematic review PubMed population; 24 1966-2003 of PA PA studies of interventions cancer patients

Gunner

2005

Health promotion strategies to encourage PA in infants, toddlers and pre-schoolers

Intervention

toddlers, infants and preschoolers adults aged 16+ years; RCTs aimed at increasing PA or encouraging sedentary to be more active general population interventions; separate sub review of PA interventions for cancer patients

Hillsdon, Foster and Thorogood

2006

Cochrane review interventions for PA Intervention Effectiveness of Behavioural Interventions to Modify Physical Activity Behaviors in General Populations and Cancer Patients and Survivors Intervention

Holtzman, Schmitz , Babes et al

2004

general population settings; cancer patient and clinical settings

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Review (author)

Year

Content

Category

Populations / Groups in the review

based on Guide to Preventive Community Services framework for Ix {CDC, USA}; target all population subgroups; Ix aimed at increasing moderate or vigorous PA or improve facilities or environments related to PA trials of advice in primary care

Systematic search

Number of studies reviewed

Interventions categorised as: [i] information change Ix, [ii] behavioural and social interventions, [iii] environment and policy Ix

Intervention settings
Informational interventions - 6 point of decision prompts, 10 community-wide campaigns, 3 mass media campaigns, 13 classroom based health education programmes; Behavioural and social interventions - 16 school based PE programmes; 5 College Ix; 3 TV restriction primary care/ family practice

Kahn, Ramsey, Brownson et al 2002 Lawlor and Hanratty 2001

Effectiveness of interventions to increase physical activity PA advice in primary care

Intervention Intervention

Marshall

2004

Workplace PA interventions

Intervention

Marshall

2004

Mediated Interventions

Intervention

Morgan

2004

Exercise referral schemes

Murphy M

2004

lifestyle activity for health

Intervention review of lifestyle interventions

9 studies from 8 trials 32 papers identified, of updated review 1999-2003 which 18 worksite health of worksite interventions, intervention trials (11 RCTs) promotion programmes 2 databases reviewed 34 Interventions mass media 20 mass media; 6 interventions; print print Ix; 4 interventions; telephone telephone delivered programmes; delivered Ix; 4 website or internet internet interventions interventions 2 databases searched referral programmes to exercise facilities; with Expt/quasi-expt designs and based in primary systematic, 3 databases 9 studies met care setting 1960s-2002 inclusion criteria various; includes children, adults lifestyle activity; search not specified conceptual review of potential strategies for intervention with minorities

systematic review, 4 data bases. Measured PA outcomes [especially objectively assessed measurements] systematic review; 4 databases; careful methodological criteria

mostly white collar workplaces; more than blue-collar worksites

settings were media-delivered, whether mass media or more individualised media delivery of PA programme

primary care settings to defined community or private facilities

Palmer and Jaworski

2004

Exer prescription [interventions] for minorities

Intervention

interventions for disadvantaged / minority groups [US focushispanics, AfricanAmericans] not stated

identified determinants and barriers to intervention, and then described principles of effective Ix [increased efficacy, adherence] - descriptive, not evidence based review

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Review (author)

Year

Content

Category

Populations / Groups in the review

Systematic search

Number of studies reviewed

Intervention settings
cf. earlier findings from Dishman [1998] worksite interventions review for PA outcomes ; this review on work outcomes [absenteeism; productivity; job stress; job satisfaction]; interventions at least aerobic fitness training programmes

Proper, Staal, Hildenbradt et al

2002

Worksite trials review

interventions

Schoeppe

2005

(WHO Report PA Interventions in developing countries review

physical activity Ix at workplace; focus on work related outcomes review based on contact with PA programmes in developing countries; systematic only in Western Pacific Region of WHO At level of community [community-based and community-wide interventions]

careful study quality appraisal and inclusion criteria; work outcomes

12 papers, 10 studies and 8 were at least controlled trials

through direct enquiry of countries

34 country level PA programmes presented

focus on community-wide or population level integrated or comprehensive PA programme various community settings health care, non health care [churches, service centres]; other multi-strategy community interventions Practice based recommendations, disease focus

Sharpe Fiatarone Singh

2003 2004

Commun based PA interventions Exercise and aging

Intervention (clinical review)

Smith

2004

PA in primary care; review of primary care settings

Intervention

Taylor Timperio, Salmon and Ball

2004

Pa in older adults reviews

Intervention

several were non systematic; illustrative other reviews; but examples x setting some specific described studies used Not a systematic Clinical settings Review for practitioners review 16 studies - 12 2 databases; selected PA only outcome, RCTs or quasi-expt 4 with multiple designs; updated , review risk factor Ix patients attending Ix 1999-2003 primary care settings including PA focused on reviews; supplemented reviewed earlier reviews [van der Bij 2002; King case studies 1998] ; mentioned general review; no specific published since search strategy reviews economic costs of Ix children and adolescents; young adults 4 databases ; update of interventions; this review 28 studies from of Ix published 1999-2003 31 papers

primary care physicians, general practice settings

2004

PA strategies among children adolescents

Intervention

interventions to increase PA in the elderly 12 interventions for children in the school setting; 10 for children out of school setting; 5 adolescents out of school; 3 young adults

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Review (author)

Year

Content

Category

Populations / Groups in the review

older adults >40 yrs, published 1985-2000; mostly primary prevention [healthy older adults]

Systematic search

Number of studies reviewed

Intervention settings

Van der Bij

2002

Effectiveness of Intervention for older adults

Intervention

systematic; used 7 electronic databases

focus on elderly; main outcomes were PA or programme participation; interventions categorised as 'home based' or 38 studies reviewed [with 57 group programmes or Primary Ix] care settings

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