Research articleSocial Inequalities in Food Exposure Around Schools in an Urban Area
Introduction
Overweight and obesity are increasing at unprecedented rates among children and adolescents,1, 2, 3 particularly among socially disadvantaged populations.4 In response, researchers are seeking to unravel the role of environmental factors in the pathways leading to obesity.5, 6, 7 Studies on children and youth have demonstrated positive associations among caloric consumption, overweight, and obesity.8 Rising caloric intake among youth9 is underpinned by growing consumption of out-of-home prepared10 energy-dense processed food,11, 12 fast food,13 and soft drinks,14 and fast-food consumption is related to adverse metabolic outcomes among youth.15, 16, 17, 18 Children and adolescents spend a substantial amount of time at schools, and the role of the food environment around schools particularly as it varies with SES may be relevant to understanding the obesity epidemic for this age group.9 Schools have some control over their interior food environments,19 but food opportunities around schools and along home–school routes may contribute to obesity as well as social gradients in obesity among youth.
It is established that SES gradients exist in access to fast-food outlets. Such associations have been widely observed20 in the U.S.,21, 22, 23 England and Scotland,24, 25 Australia,26 and New Zealand.27 Studies28, 29, 30 evaluating SES gradients in food store accessibility are less clear. School-level analyses of SES and food accessibility are limited and indeterminate. A study31 of 31,622 U.S. middle and high schools found a positive association between school-area material deprivation and restaurant presence within 400 m. A longitudinal U.S. study32 found no relationship between BMI change and density of food stores around children's schools.
A New Zealand national study33 found no clear relationship between school-area deprivation and distance from schools to fast-food outlets27; however, an analysis of a subsample of 406 schools showed a strong SES gradient. A Quebec Province study34 indicated an SES gradient in access to fast-food chains but not to convenience stores for urban or rural areas. A study on 188 schools in Canada35 found no overall SES gradient in food accessibility within 1 km of schools, but it did observe such a gradient for full-service restaurants. In this study,36 most associations observed within 5 km disappeared once population density was considered. Density was a confounding variable in other cases.31 In Los Angeles, an inverse association between income and fast-food outlets within 400 m of a school was apparent for high–commercial density areas only.37
Few studies have evaluated school-level environmental factors in relation to consumption and overweight among youth. One study38 indicated that school-level exposure to fast-food outlets was associated with a lower consumption of fruits and vegetables, more soda, and overweight (OR=1.06) or obesity (OR=1.07). A longitudinal study32 over 3 years in the U.S. found no association between school-area food store density and change in BMI among kindergarten children. Other data39 from Canada indicate no association between exposure to various types of food retailers in school neighborhoods and overweight among school-aged youth.
Most studies on SES gradients in food accessibility around schools have considered fast-food outlets only, with some studies suggesting confounding by population or commercial density. This study aimed to determine the associations between area income and accessibility to three types of food sources around primary and secondary schools, specifically fast-food outlets (FFO) offering high-calorie foods considered unhealthful; full-service restaurants (RST) offering mixed-choice food sets; and fruit and vegetable stores (FVS) offering mainly healthful choices. Commercial density was tested as a potential confounding factor of the income–exposure relationships.
Section snippets
Methods
The study region was the Montreal Urban Community (MUC; 3.4 million inhabitants; 2001 Canada Census). Data were obtained using a GIS developed for population health research and surveillance in Montreal, Quebec.40
A listing of all primary and secondary schools was obtained from the Ministry of Education41 and geocoded at the address level. For the MUC, a total of 828 primary and 340 secondary schools were available for analysis (1168 schools overall). A road-network buffer of 750 m was
Results
Descriptive statistics are provided in Table 1. The proportion of the 1168 schools with one or more stores within 750 m in each category was 50.4% for FFOs, 72.9% for RST, 57.4% for FVS, and 50.4% for HRD. ANOVA analyses revealed significant differences (p<0.05) in average distance, presence of, and average number of food stores and HRD within 750 m, except for the number of restaurants, for which no difference by income quartiles was detected within high-density areas. Comparing schools in the
Discussion
This school-based study showed high accessibility to FFO, RST, FVS, and HRD and revealed striking density and income differentials. Schools of the lowest income quartile had ten times more stores within 750 m than schools in the highest income quartile. Consequently, 1 of 2 schools was located near an FFO, but this proportion was 81% in the most deprived areas and 12% in the most affluent areas. Accessibility gradients by income and commercial density were similar for RST, FVS, and HRD. These
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