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Overview of Issues Related to Measuring Food and Nutrition
Policies and Environments
George A. Weiss University Professor
Workshop on Measurement Strategies for Accelerating Progress in Obesity Prevention
Overview of Issues Related to Measuring Food and Nutrition
Policies and Environments
Karen Glanz, PhD, MPHGeorge A. Weiss University Professor
University of Pennsylvania
Workshop on Measurement Strategies for Accelerating Progress in Obesity Prevention
Ø Scope of food environments and policies
Ø Types of measures & examples in settings
Ø Assessing food environments & policies: evaluating population strategies
Ø Limitations of measures to accelerate progress
Ø What we need to accelerate progress
Scope of food environments and policies
Types of measures & examples in settings
Assessing food environments & policies: evaluating population strategies
Limitations of measures to accelerate progress
What we need to accelerate progress
To make significant progress in the area of eating & nutrition environments…* we need valid, reliable measures of nutrition environments and policies… that are also practical
The balance between scientific rigor and practicality is challenging
To make significant progress in the area of eating & nutrition
we need valid, reliable measures of nutrition environments and policies… that are also practical
The balance between scientific rigor and practicality is challenging
An Ecological Framework Depicting the Multiple Influences on What People Eat
Individual Factors
(personal)
Social Environment(networks)
MacroEnvironments
(sectors)
Physical Environments
(settings)
HomeWorksitesSchool, AfterschoolChild-careNeighborhoods & CommunitiesRestaurants & fast food outletsSupermarketsConvenience & corner stores
=Access=Availability=Barriers=Opportunities
Cognitions (e.g. attitudes, preferences, knowledge, values)Skills and behaviorsLifestyleBiological (e.g. genes, gender, age)Demographics (e.g. income, race/ethnicity)
=Outcome expectations=Motivations=Self-efficacy=Behavioral capability
An Ecological Framework Depicting the Multiple Influences on What People Eat
Individual Factors
(personal)
Social Environment(networks)
Macro-level Environments
(sectors)
Physical Environments
(settings)
=Societal and cultural norms and values
=Food and beverage industry=Food marketing and media=Food and agriculture policies=Economic systems=Food production & distribution
systems=Government & political
structures and policies=Food assistance programs=Health care systems=Land use and transportation
=Practices=Legislative,
regulatory, or policy actions
=Family=Friends=Peers
=Role modeling=Social support=Social norms
Story et al., ARPH, 2008
Social Environment(networks)
MacroEnvironments
(sectors)
Physical Environments
(settings)
HomeWorksitesSchool, AfterschoolChild-careNeighborhoods & CommunitiesRestaurants & fast food outletsSupermarketsConvenience & corner stores
=Access=Availability=Barriers=Opportunities
Story et al., ARPH, 2008
Social Environment(networks)
Macro-level Environments
(sectors)
Physical Environments
(settings)
=Societal and cultural norms and values
=Food and beverage industry=Food marketing and media=Food and agriculture policies=Economic systems=Food production & distribution
systems=Government & political
structures and policies=Food assistance programs=Health care systems=Land use and transportation
=Practices=Legislative,
regulatory, or policy actions
=Family=Friends=Peers
=Role modeling=Social support=Social norms
MacroEnvironments
(sectors)
Physical Environments
(settings)
HomeWorksitesSchool, AfterschoolChild-careNeighborhoods & CommunitiesRestaurants & fast food outletsSupermarketsConvenience & corner stores
=Access=Availability=Barriers=Opportunities
Story et al., ARPH, 2008
Macro-level Environments
(sectors)
Physical Environments
(settings)
=Societal and cultural norms and values
=Food and beverage industry=Food marketing and media=Food and agriculture policies=Economic systems=Food production & distribution
systems=Government & political
structures and policies=Food assistance programs=Health care systems=Land use and transportation
=Practices=Legislative,
regulatory, or policy actions
Model of Community Nutrition Environments
[Glanz, Sallis, Saelens, & Frank 2005]
Policy Variables Environmental Variables
GovernmentGovernmentandand
Industry PolicyIndustry Policy
Community Nutrition Community Nutrition EnvironmentsEnvironments
•Type & Location of FoodOutlets (stores, restaurants)
•Accessibility – hours of Operation, drive-thru)
Organizational Organizational Nutrition EnvironmentsNutrition Environments
Home
Work
Consumer Nutrition EnvironmentConsumer Nutrition Environment•Available healthy options
•Price, promotion, placement
•Nutrition Information
Information Information EnvironmentEnvironment
(Media, Advertising)(Media, Advertising)
Model of Community Nutrition Environments
[Glanz, Sallis, Saelens, & Frank 2005]
Individual Variables Behavior
Organizational Organizational Nutrition EnvironmentsNutrition Environments
School
Other
Consumer Nutrition EnvironmentConsumer Nutrition Environment
Price, promotion, placement
SocioSocio--demographicsdemographics
PsychosocialPsychosocialFactorsFactors
Perceived Perceived NutritionNutrition
EnvironmentsEnvironments
EatingEatingPatternsPatterns
Community & ConsumerEnvironments
Community nutrition environments•Type & location of food outlets•Accessibility (e.g., hours, drive
Consumer nutrition environments = •Availability of healthful food choices•Pricing, promotion, placement•Information availability
Glanz, Sallis, Saelens & Frank, Am J Health
Consumer Nutrition Environments
nutrition environments = Type & location of food outletsAccessibility (e.g., hours, drive-thru)
nutrition environments = Availability of healthful food choicesPricing, promotion, placement
Am J Health Promot 2005
Nutrition/Food vs PA Environments
Food is a commodityFood products are big businessFood is highly regulated
(safety, taxation, hygiene)Complex (nutrients, foods)Organizational environments
play a large roleMore recent development
than PA environment measures
Nutrition/Food vs PA Environments
Food products are big businessFood is highly regulated
(safety, taxation, hygiene)Complex (nutrients, foods)Organizational environments
More recent development than PA environment
Food Environments & Policies: How do they go together?
Policies can shape environments school food policies, catering policies,price supports, food assistance policiesBUTEnvironments often evolve in the absence of specific policiesANDPolicies can be health-promoting or not
Food Environments & Policies: How do they go together?
Policies can shape environments àschool food policies, catering policies,price supports, food assistance policies
Environments often evolve in the absence of
promoting or not
Reasons for Measuring Food Reasons for Measuring Food & Nutrition Environments & Nutrition Environments
ObservationExplanationEvaluationAdvocacy/ActionSurveillance
Reasons for Measuring Food Reasons for Measuring Food & Nutrition Environments & Nutrition Environments
Related to ObesityRelated to Obesity
Advocacy/Action
Types of Measures & Data Sources
Self-report (surveys)
Observation/Audit
Archival, Existing DatabasesOften developed for purposes other than health research
GIS-based Measures/SpatialMost-used indicators: density, proximity
Combinations
Types of Measures & Data Sources
Archival, Existing DatabasesOften developed for purposes other than health research
based Measures/Spatialused indicators: density, proximity
Ideally, measurement involves…
Data source (s)ØExisting data ORØNew data collection
Definition of boundaries &/or samplingSound psychometric propertiesMetrics and plans for analysis“Packaging,” disseminationAdaptability
, measurement involves…
New data collection OR bothDefinition of boundaries &/or samplingSound psychometric propertiesMetrics and plans for analysis“Packaging,” dissemination
Ø Schools
Ø Worksites
Ø Food stores
Ø Restaurants
Ø Communities (local, state)
Examples of Food Environments & Policy Measures in Settings
Communities (local, state)
Examples of Food Environments & Policy Measures in Settings
Organizational Nutrition Environments
Home
Work
Organizational Nutrition Environments
School
Other
School Food Environments & PoliciesSchool Health Policies & Programs Study (SHPPS) [CDC]ØSince 1994; all statesØElementary/middle/senior high schoolsØEnvironment issues assessed: vending machines; offerings of fruit,
vegetables, french fries, high-fat baked goods
School Nutrition-EnvironmentState Policy Classification SystemØSystem to compare state policiesØOrdinal scoring system, 11 policy areasØModerate to high inter-rater agreement
Food BEAMS (Samuels & Associates)ØSystem to assess competitive foodsØLinks food item ID to nutrient databaseØHigh inter-rater reliability
School Food Environments & PoliciesSchool Health Policies & Programs Study (SHPPS) [CDC]
Elementary/middle/senior high schoolsvending machines; offerings of fruit,fat baked goods
State Policy Classification System
rater agreement
Links food item ID to nutrient database
Worksite Food Environments & Policies
Mainly used in intervention studies
Example: Working Well Trial (Biener, Glanz et al. 1998)ØMulticomponent assessmentØAccess to healthy food, nutrition informationØFound to be associated with intervention + self
Example: Section of CHEW (Australia)(Oldenburg, Sallis, et al. 2002; dev 1995)ØAudit tool, included nutrition information,
canteen (cafeteria), vending machinesØUsed NHF ‘tick’ to indicate healthful choicesØHigh reliability (0.8-1.0)
Worksite Food Environments & Policies
Mainly used in intervention studies
Working Well Trial (Biener, Glanz et al. 1998)
Access to healthy food, nutrition informationFound to be associated with intervention + self-report
Section of CHEW (Australia)(Oldenburg, Sallis, et al. 2002; dev 1995)Audit tool, included nutrition information,canteen (cafeteria), vending machinesUsed NHF ‘tick’ to indicate healthful choices
Community Nutrition Environments
•Type & Location of FoodOutlets (stores, restaurants)
•Accessibility Operation, drive
Community Nutrition Environments
Type & Location of FoodOutlets (stores, restaurants)
Accessibility – hours of Operation, drive-thru)
Community Food Environments: Objective Data Sources
Or, ‘where are places to get food’?
Public SourcesGovernment: Food licenses (retail & food service)Other: Yellow Pages, Online directories, etc.
Commercial SourcesDun & Bradstreet, InfoUSA, others
Issues: Completeness? Up-to-Wang et al. [IJBNPA, 2007] –• compared sources of historical data on food stores• State Board vs business directories: 127 vs 351 food stores• State Board had 36 added stores, directories showed 260 more
Community Food Environments: Objective Data Sources
Or, ‘where are places to get food’?
Food licenses (retail & food service)Yellow Pages, Online directories, etc.
Dun & Bradstreet, InfoUSA, others
-date? Accuracy? High turnover
compared sources of historical data on food storesState Board vs business directories: 127 vs 351 food storesState Board had 36 added stores, directories showed 260 more
Consumer Nutrition Environments
•Available healthy options•Price, promotion, placement
•Nutrition Information
Consumer Nutrition Environments
Available healthy optionsPrice, promotion, placement
Nutrition Information
Early Observational Measures of Food Store Environments
Sallis, Nader et al (1986, Pub Health Reports•San Diego Food Availability Survey•Supermarkets, groceries, convenience stores•Inventory of 71 ‘heart-healthy’ foods•78-99% interobserver agreement•Documented more HH foods in supermarkets (m=56.7)than neighborhood groceries (m=25.7) and conveniencestores (m = 12.2)
Cheadle et al. (1989, 1990, 1991, 1993)•Evaluation of Kaiser Family Fdn healthy communities•Focused on small # of items (e.g. skim milk); comparedhealthy to less healthy
•Examined shelf space
Measures of Food Store Environments
Pub Health Reports)
Supermarkets, groceries, convenience storeshealthy’ foods
Documented more HH foods in supermarkets (m=56.7)than neighborhood groceries (m=25.7) and convenience
Cheadle et al. (1989, 1990, 1991, 1993)Evaluation of Kaiser Family Fdn healthy communitiesFocused on small # of items (e.g. skim milk); compared
•Availability (of healthful choices)•Prices (compare healthy vs. less healthy; fastfood vs. sit-down)
•Promotion, Information•Facilitators & Barriers•Kids’ Menus
NEMS-R: Measures of Nutrition Environments in Restaurants
Availability (of healthful choices)Prices (compare healthy vs. less healthy; fast-
R: Measures of Nutrition Environments in Restaurants
Nutrition Environment Nutrition Environment Measures Survey:
A Case Study in Dissemination of
Measures
NEMS tools are research tested, valid and reliable instruments:• NEMS-S: Stores, NEMS• NEMS-R: Restaurants• NEMS-V: Vending machines
NEMS…* was originally developed for research* can be (and has been) used for community
assessment, advocacy, and intervention
NEMS tools are research tested, valid and reliable instruments:
S: Stores, NEMS-CS: Corner StoresR: RestaurantsV: Vending machines
* was originally developed for research* can be (and has been) used for community
assessment, advocacy, and intervention
Measures of the Nutrition Environment in Stores: NEMS
NEMS-S Measures:
• Availabilityo Of healthful choices
• Priceo Healthy vs. less healthy o By store type/neighborhood
• Qualityo For fresh produce
Measures of the Nutrition Environment in Stores: NEMS-S
S Measures:
AvailabilityOf healthful choices
PriceHealthy vs. less healthy By store type/neighborhood
QualityFor fresh produce
Measures of the Nutrition Environmentin Stores
Core Categories of FoodsMilk Ground BeefFruits Hot DogsVegetables Frozen DinnersSoda Fruit Juice
Measures of the Nutrition Environmentin Stores
Core Categories of FoodsGround Beef Baked Goods
BreadFrozen Dinners Chips
Cereal
Dissemination of NEMS: Tools & Methods
• Demand started during development• Initial funding support from RWJF• 2-3 day trainings & train-the• CD-Rom and online tools post• Assumed from the start that tools should be
customizable• Partnerships to stretch funds
departments, universities, CDC, etc• CDC State nutritionist group & webinars
Dissemination of NEMS: Tools & Methods
Demand started during developmentInitial funding support from RWJF
the-trainerRom and online tools post-training
Assumed from the start that tools should be
Partnerships to stretch funds - state health departments, universities, CDC, etcCDC State nutritionist group & webinars
Customization• The NEMS-S tool was designed to be easily
customizable to suit a projects’ needs• All measures are available in Word or Teleform
formats• NEMS adaptations have included WIC stores,
Latino versions, Texas adaptation, Brazil, ….• Other innovations: NEMS
for PDA and Tablet-PC
CustomizationS tool was designed to be easily
customizable to suit a projects’ needsAll measures are available in Word or Teleform
NEMS adaptations have included WIC stores, Latino versions, Texas adaptation, Brazil, ….
: NEMS-V, NEMS-CS, NEMS
Dissemination of NEMS: In Person Trainings
40 states in the U.S. with over 200 people trained, 3 from Canada, 3 from Singapore, and participants from Netherlands, Japan, and China
Dissemination of NEMS: In Person Trainings
40 states in the U.S. with over 200 people trained, 3 from Canada, 3 from Singapore, and participants from Netherlands, Japan, and China
NEMS Online Training
• NEMS-S and NEMS-R modules included• Initially launched in January 2010• Free to use• Won a 2010 bronze award from the United
States Distance Learning Association (USDLA) Best Practices in Distance Learning Programming
NEMS Online Training
R modules includedInitially launched in January 2010
Won a 2010 bronze award from the United States Distance Learning Association (USDLA) Best Practices in Distance Learning Programming
* As of July 2010
Dissemination of NEMS: Online Training
As of March 2011: 410 registrants, 131 completed the course; 31 outside the USA
Dissemination of NEMS: Online Training
: 410 registrants, 131 completed the course; 31 outside the USA
Assessing Food Environmentsand Policies in Large and Population-Based Programs
Assessing Food Environmentsand Policies in Large and
Based Programs
CDC's Common Community Measures for Obesity Prevention Project
Strategies and associated measures that local governments can use to plan & monitor environmentaland policy-level changes for obesity preventi
Examples--food related measuresüPolicy to apply DGA in government
facilities & large school districtü# of full service groceries
per 10,000 in 3 largest underservedcensus tracts in jurisdiction
üGovernment offers incentives to retailers to offer healthy food/beverages
CDC's Common Community Measures for Obesity Prevention Project (Khan et al., MMWR, 2009)
Strategies and associated measures that communities &can use to plan & monitor environmental
level changes for obesity prevention
food related measuresPolicy to apply DGA in governmentfacilities & large school district
per 10,000 in 3 largest underserved
Government offers incentives to retailers to offer healthy food/beverages
Logic Model Approach(Cheadle, Samuels et al., AJPH 2010)
üDescribe steps to change environs & individual health impacts
ü Indicators for each step, assessing those most directly exposed
üAttribute outcomes to interventions if they are:v preceded by meaningful
change in short-term and intermediate outcomes
v in a plausible temporal sequence
Logic Model Approach(Cheadle, Samuels et al., AJPH 2010)
Describe steps to change environs & individual health impacts
Indicators for each step, assessing those most directly exposed
Attribute outcomes to interventions if they are:
in a plausible temporal sequence
Philadelphia CPPW Enhanced Evaluation
Healthy Corner Stores (n=200)Pre-post assessmentsLow vs high intensity
EnvironmentNEMS-CS mobile
IndividualsIntercept interviewsCalories purchased
Philadelphia CPPW Enhanced Evaluation
School Wellness PoliciesPre-post assessmentsn=100 K-8 schools
EnvironmentCompetitive food environsDocumentation/validation
IndividualsBMI measures (standard)
Phila DPH, Food TrustU Penn, Temple U School District Phila
McKinnon, Reedy, Handy & Rodgers Eds. Website compilation of measures and articleshttps://riskfactor.cancer.gov/mfe/
Healthy Eating Research website: www.healthyeatingresearch.org
RESOURCES
McKinnon, Reedy, Handy & Rodgers Eds. – 2009 AJPM Supplement Website compilation of measures and articles
Healthy Eating Research website: www.healthyeatingresearch.org
RESOURCES
Research Design
Study designs:§ cross-sectional, correlational§ comparative§ longitudinal/prospective§ experimental/pre-post§ quasi-experimental
Research Design
correlational
longitudinal/prospectivepost
To evaluate environmental strategies, the RCT is not always the “gold standard”
To evaluate environmental strategies, the RCT is not always the “gold standard”
• May not be appropriate/feasible
• Helpful but not essential
• Can have threats to internal/external validity
Planning & Evaluation CycleHow do environment measures function
throughout the cycle?Grocery store food environment vs. individual level surveys
(Cheadle et al.)
CROSS-SECTIONALSignificant associations (1991)
TRACKING CHANGECorrelations weaker over time (1993)
EVALUATION OVER 3 TIME POINTSInconsistent & contradictory results (1995)
Planning & Evaluation CycleHow do environment measures function
throughout the cycle?
Planning
Implementation
Evaluation
Grocery store food environment vs. individual level surveys (Cheadle et al.)
CROSS-SECTIONALSignificant associations (1991)
TRACKING CHANGECorrelations weaker over time (1993)
EVALUATION OVER 3 TIME POINTSInconsistent & contradictory results (1995)
Unanswered research questionsØHow much environmental change is
needed?ØHow long will it take to improve
behavior AND health?ØWho changes after
environment/policy interventions?
Unanswered research questionsenvironmental change is
will it take to improve behavior AND health?
Limitations of measuresfor accelerating progress
Ø Complex nature of food/nutrition environmentsØ Variable rigor in measures developmentØ Practical limits of fieldØ Too little dissemination of measures Ø Lack of common metrics Ø Limited real-time (archival) measuresØ Unknown sensitivity to change
Limitations of measuresfor accelerating progress
Complex nature of food/nutrition environmentsVariable rigor in measures developmentPractical limits of field-based measuresToo little dissemination of measures Lack of common metrics
time (archival) measuresUnknown sensitivity to change
Bridging the Evidence Gap in Obesity Prevention LEAD FrameworkLocate evidenceEvaluate itAssemble itInform Decisions
Bridging the Evidence Gap in Obesity Prevention (IOM, 2010)
Recommendations
ØBuild resource baseØStandards for evidence qualityØSupport generation of evidence
• Core toolkit of valid, feasible, adaptable,
• Common metrics populations
• Measures at multiple levelssettings/organizations, communities, states, regions, national
• Measures tied to calories sources of fat and calories in diets
• Designs that permit reasonable inferences about impact
What We Need to Accelerate Progress
Core toolkit of measures: well-tested, valid, feasible, adaptable, disseminableCommon metrics to compare studies and
Measures at multiple levels: settings/organizations, communities, states, regions,
Measures tied to calories and major sources of fat and calories in diets
that permit reasonable inferences about
What We Need to Accelerate Progress
The Fork in the Road…The Fork in the Road…