Health Education Research Advance Access originally published online on July 21, 2006
Health Education Research 2007 22(2):203-226; doi:10.1093/her/cyl069
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A systematic review of environmental correlates of obesity-related dietary behaviors in youth
1 Department of Public Health, Erasmus MC, University Medical Center, PO Box 1738, 3000 DR Rotterdam, The Netherlands
2 Center for Prevention and Health Services Research, National Institute for Public Health and Environment, Bilthoven, The Netherlands
* Correspondence to: K. van der Horst. E-mail: k.vanderhorst{at}erasmusmc.nl
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Abstract |
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There is increasing interest in the role the environment plays in shaping the dietary behavior of youth, particularly in the context of obesity prevention. An overview of environmental factors associated with obesity-related dietary behaviors among youth is needed to inform the development of interventions. A systematic review of observational studies on environmental correlates of energy, fat, fruit/vegetable, snack/fast food and soft drink intakes in children (4–12 years) and adolescents (13–18 years) was conducted. The results were summarized using the analysis grid for environments linked to obesity. The 58 papers reviewed mostly focused on sociocultural and economical–environmental factors at the household level. The most consistent associations were found between parental intake and children's fat, fruit/vegetable intakes, parent and sibling intake with adolescent's energy and fat intakes and parental education with adolescent's fruit/vegetable intake. A less consistent but positive association was found for availability and accessibility on children's fruit/vegetable intake. Environmental factors are predominantly studied at the household level and focus on sociocultural and economic aspects. Most consistent associations were found for parental influences (parental intake and education). More studies examining environmental factors using longitudinal study designs and validated measures are needed for solid evidence to inform interventions.
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Introduction |
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The promotion of healthful eating in children and adolescents has become an increasingly important public health and research priority as the prevalence of overweight and obesity among children and adolescents continues to rise [1, 2]. Preventing the onset of obesity-inducing dietary behaviors or modifying these behaviors at an early age is likely to contribute to the prevention of overweight and obesity. A detailed understanding of factors that determine these behaviors is essential, to be able to effectively prevent or modify obesity-inducing eating patterns. The research of determinants of dietary intake in children and adolescents has predominantly focused on individual level determinants of these behaviors, such as attitudes, taste preferences, social influences and perceived behavioral control. However, more recently a shift in attention to environmental determinants of behavior has occurred as it has been acknowledged that a major driving force for the increasing obesity prevalence may be the environment that encourages eating and discourages physical activity [3, 4]. These environmental factors are highlighted in so-called ecological models, and are conceptualized as being interrelated with factors at the individual level [5]. As stated by Rothschild [6], the likelihood that an individual will engage in a healthy behavior is largest when someone is motivated to act healthily, has the abilities to engage in the healthy behavior and the environment offers the right opportunities to engage in the healthy behavior. Motivation and abilities can be regarded as individual determinants of health behavior, whereas opportunities depend on environmental factors.
Child and adolescent dietary behavior is likely to be strongly influenced by environmental factors, since children may have less autonomy in food choice. From the age of 
3 years, children's eating behavior is influenced by their responsiveness to environmental cues, and a variety of family and social factors start to influence children's eating behaviors [7]. The role of parents is considered to be of particular importance, since parents directly determine the child's physical and social environment, and indirectly influence behavior and habits through socialization processes and modeling [8]. When children grow older and move into adolescence they become more autonomous, and lifestyle, developmental, social and environmental changes take place. During this transition to adolescence, dietary intake patterns change and decline in quality compared with childhood. Intakes of fruit, vegetables, milk and fruit juice decrease, whereas intake of soft drink increases during this time [9].
The expected importance of the environment for obesity-related behaviors in children and adolescents is well documented in position papers and narrative reviews [3, 7–11]. The number of studies examining the influence of environmental factors on behavior is expanding, but there is no systematic overview of which environmental factors have been studied extensively, and what aspects of the environment are more influential than others. Such an overview is needed to identify a research agenda for further investigation and to inform interventions that take environmental factors into account.
We conducted a systematic review of environmental factors that may potentially influence obesity-related dietary behaviors of children and adolescents. We focused our review on energy, fat (total and percent energy), fruit/vegetable, snack/fast food and soft drink intake. These behaviors have been identified as factors most strongly associated with obesity in adults [4], and are considered to be important obesity-inducing behaviors in children and adolescents as well [12, 13]. The environment was defined as ‘anything outside the individual’. Many classifications have been proposed to order the complexity of potential environmental factors. We chose to use the analysis grid for environments linked to obesity (ANGELO) framework [14] as a tool to classify the various environmental determinants. The ANGELO framework dissects the environment by two dimensions: the size (micro and macro) and the type of environment. Microenvironments are environmental settings where groups of people meet and gather (e.g. homes, schools, restaurants and neighborhoods). Macroenvironments include the broader infrastructure that may support or hinder health behaviors (e.g. town planning, transport infrastructure, the health system and the media). The ‘types’ of environments distinguished in the ANGELO framework are the physical, sociocultural, economic and political environment. The physical environment refers to the availability of opportunities for healthy and unhealthy choices, for instance the availability and accessibility of healthy and unhealthy foods. The sociocultural environment refers to the social and cultural subjective and descriptive norms and other social influences such as parental influences and peer pressure. The economic environment refers to the costs related to healthy and unhealthy behaviors, for instance costs of fruit and vegetables and household income. The political environment refers to the rules and regulations that may influence food choice or availability, for example, bans on snack vending machines in schools.
The review aimed to address the following specific research questions:
- (i) Which environmental correlates have been studied in relation to child and adolescent energy, fat (total and energy percent), fruit, vegetable, snack, fast food and soft drink intake? and
- (ii) Which environmental factors are consistently associated with these obesity-related dietary behaviors?
- (ii) Which environmental factors are consistently associated with these obesity-related dietary behaviors?
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Methods |
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Data sources and search strategy
Studies eligible for inclusion in the review were located from the Medline (PubMed), PsychInfo, Web of Science and Human Nutrition databases, from January 1980 to December 2004. Our search strategy involved using a combination of the broad indexing terms of each database and searching for terms in article titles and abstracts. We used the combination of dietary intake keywords with environmental factor keywords to locate suitable articles. For dietary intake the following keywords were used: energy intake, caloric intake, fat intake, fat consumption, soft drink, soft drink consumption, soft drink intake, sweetened beverage, fruit, fruit consumption, fruit intake, vegetable, vegetable consumption, vegetable intake, eating, diet, nutrition, food habits and food preferences. For environmental factors the following keywords were used: physical environment, social environment, cultural environment, sociocultural environment, socio-economic environment, social influences, neighborhood, political environment, built environment, urban environment, rural environment, local environment, school environment, home environment, availability, accessibility, residence characteristics, environment design, parental influence and parenting. Key terms were matched to database-specific indexing terms. The sensitivity of the search strategy was verified by checking whether key articles from our personal databases that should be selected through the search strategy were actually retrieved. In addition to database searches, reference lists of review studies and articles included in the review were screened for titles that included key terms.
Inclusion/exclusion criteria
A study had to meet the following criteria to be eligible for inclusion: healthy young people in the age range of 3–18 years (or mean age within this range) as subjects of study; a measure of energy and/or fat intake (total or percent energy), fruit, vegetable, snack, fast food or soft drink consumptions as the dependent variables and an outcome measure that was assessed for at least one complete day (for example, studies assessing fruit intakes at just one meal were not eligible). The study samples had to be drawn from countries with established market economies as defined by the World Bank, and the paper had to be published in international peer-reviewed journals in English. Intervention studies and studies that included only overweight/obese children were excluded.
Identification of relevant studies
Potentially relevant papers were selected by screening the titles (first step), abstracts (second step) and the entire article (third step) retrieved through the database searches. Two researchers (K.V.D.H. and I.F.) independently conducted this screening. Disagreement about eligibility between the reviewers was solved through discussion with a third co-author (J.B.).
Data extraction
Two authors (K.V.D.H. and A.O.) extracted the data from the included studies. Each study's findings and methodological details, such as study design, sample size, dietary outcomes, environmental determinants assessed, assessment methodology (child and/or parent-report, objectively measured) and statistical analysis methods were listed in tables.
Summarizing study findings
Associations between environmental factors and dietary outcomes were coded as ‘+’ for a positive association, ‘–’ for an inverse association and ‘0’ for no association. Associations were regarded significant when the P value reported in the study was <0.05. In studies that reported results from univariate and multivariate analysis, only the multivariate results were included. To reduce the number of specific environmental correlates studied, conceptually similar environmental factors were combined (e.g. intakes from father and mother to parental intake). An independent sample was used as the unit of analysis and was defined as the smallest independent subsample for which relevant data were reported (e.g. boys/girls) [15].
Categorization of variables
Study findings were tabulated by categorizing the distinct dietary outcomes in a grid dissecting different environmental settings, i.e. home/household, educational institutions, neighborhoods, city/municipality and the various types of environmental factors: physical, sociocultural, economic and political, following the ANGELO framework [14] (Tables II and III).
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Results |
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Search and selection of studies
The databases search located 6616 titles (Pubmed 1975; PsychInfo 317; Web of Science 2932; Human Nutrition 1392), resulting in 6121 unique titles of potentially relevant articles. Reference sections of earlier reviews and primary studies added 44 titles. Screening the titles and abstracts resulted in a selection of 81 articles, for full-text review. Twenty-three of these articles did not meet the inclusion criteria, resulting in a final inclusion of 58 articles with 77 samples.
Characteristics of included studies
Most of the studies were cross-sectional (n = 55) (Table I). Twenty-nine studies (37 samples) had children as the study population [16–44], and 27 (40 samples) included adolescents [45–71]. One study included a child and adolescent sample [72]. In one paper the age of the population was unclear, and this study was reviewed under an adolescent sample [73]. Environmental determinants of fruit/vegetable intake were examined in 34 studies, determinants of fat intake in 23 studies, determinants of fast food/snack intake in 21 studies, determinants of energy intake in 17 studies and determinants of soft drink intake in 10 studies. Only five studies reported the validity and seven studies reported the reliability of the dietary intake measurements used.
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Potential environmental correlates of children's dietary behaviors
The findings from the studies are summarized in Tables II and III. Table IV provides a summary of the number of studies and the consistent associations in each cell of the ANGELO framework. In the following sections, a summarized description of the results is provided for the various behaviors. The factors examined on each environmental level and the environmental factors that showed consistent associations with dietary behaviors in at least two replicated studies are described.
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Environmental correlates of energy intake
At the household environmental level, physical factors (one study/sample), sociocultural factors (five studies, six samples) and economic factors (five studies/samples) were examined in relation to energy intake (Table II). One study examined factors in the school environment, no studies examined factors in the neighborhood environment and two studies examined factors at the city/municipality level. At the household sociocultural level, an inverse association with energy intake was found for encouragement, offering assistance and giving prompts to increase food intake during meals in two out of three samples [35, 36, 40].
Environmental correlates of fat intake
At the household environmental level, physical factors (one study/sample), sociocultural factors (four studies, five samples) and economic factors (seven studies/samples) were examined in relation to fat intake. One study examined factors in the school environment, no studies examined factors in the neighborhood environment and two studies examined factors at the city/municipality level. At the household sociocultural level, a positive association was found for parental fat intake (three out of three samples) [27, 43], and parental control over food intake (two out of two samples) [27, 36]. Parental education was inversely associated with fat intake in two out of two samples [23, 39].
Environmental correlates of fruit and vegetable intake
At the household environmental level, physical factors (6 studies, 11 samples), sociocultural factors (12 studies, 14 samples) and economic factors (six studies/samples) were examined in relation to fruit/vegetable intake. One study examined factors in the school environment, one study (two samples) examined factors in the neighborhood environment and no studies examined factors at the city/municipality level. At the household physical level, availability of fruit/vegetables was associated with higher fruit/vegetable intake in four out of seven samples [25, 28, 30, 34]. Accessibility of fruit/vegetables was positively associated with fruit/vegetable intake in four out of six samples [21, 25, 28]. At the household sociocultural level, positive associations were found for modeling (two out of two samples/studies) [21, 28] and parental intake of fruit/vegetables (six out of six samples) [16, 18, 21, 26, 30, 37].
Environmental correlates of snack/fast food intake
At the household environmental level, physical factors (one study/sample), sociocultural factors (five studies, six samples) and economic factors (five studies/samples) were examined in relation to snack/fast food intake. No studies examined factors in the school environment, one study (two samples) examined factors in the neighborhood and one study examined factors at the city/municipality level. None of the factors examined showed consistent associations with snack/fast food intake.
Environmental correlates of soft drink intake
At the household environmental level, physical factors (two studies/samples), household sociocultural factors (five studies, six samples) and household economic factors (three studies/samples) were examined in relation to soft drink intake. One study examined factors in the school environment and no studies examined factors in the neighborhood or city/municipality environment. At the household sociocultural level, parental soft drink intake was positively associated with children's soft drink intake in two out of two samples [16, 17].
Potential environmental correlates of adolescent's dietary behaviors
Environmental correlates of energy intake
At the household environmental level, sociocultural factors (six studies, nine samples) and economic factors (two studies/samples) were examined as potential correlates of energy intake (Table III). No studies examined factors in the school, neighborhood or city/municipality environment. At the household sociocultural level, parental energy intake was positively associated with adolescent's energy intake (six out of six samples) [46, 54, 56, 73]. A positive association was also found for sibling intake (four out of four samples) [54, 73].
Environmental correlates of fat intake
At the household environmental level, nine studies (15 samples) examined sociocultural factors and five studies (eight samples) examined economic factors as potential correlates of fat intake. One study examined factors in the school environment and no studies examined factors in the neighborhood. One study (two samples) examined factors at the city/municipality level. At the household sociocultural level, parental fat intake was found to be positively associated with adolescent's fat intake (eight out of nine samples) [51, 54, 56, 68, 73]. A positive association was also found for sibling intake (four out of four samples) [54, 73].
Environmental correlates of fruit and vegetable intake
At the household environmental level, physical factors (two studies/samples), sociocultural factors (10 studies, 11 samples) and economic factors (8 studies, 10 samples) were examined as potential correlates of fruit/vegetable intake. One study examined factors in the school environment, one study examined factors in the neighborhood environment and one study (two samples) examined factors at the city/municipality level. At the household sociocultural level, an authoritative parenting style was positively associated with fruit/vegetable intake (two out of two samples) [63, 65]. Family connectedness was positively associated with adolescent fruit/vegetable intake (two out of two samples) [53, 58]. At the household economic level, parent educational level was found to be positively associated with fruit/vegetable intake (six out of six samples) [50, 52, 65, 69, 70].
Environmental correlates of snacks/fast food intake
At the household environmental level, sociocultural factors (four studies, six samples) and economic factors (three studies, five samples) were studied in relation to snack and fast food intake. One study examined factors in the school environment, no studies examined factors in the neighborhood environment and one study (two samples) examined factors at the city/municipality level. None of the factors examined showed consistent associations with snack/fast food intake.
Environmental correlates of soft drink intake
At the household environment level, sociocultural factors (five studies, six samples) were examined as potential environmental correlates of soft drink intake. No studies examined factors in the school and neighborhood environment. One study (two samples) examined factors at the city/municipality level. None of the factors examined showed consistent associations with soft drink intake.
Summary in ANGELO framework
Sociocultural factors on the household level are the most studied environmental factors for all dietary behaviors, followed by economic factors on the household level (Table IV). Factors studied on the school environmental level (physical and sociocultural) were mostly single studies. At the city/municipality level-only physical factors were studied.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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The present systematic review of the literature on environmental correlates of energy, fat, fruit, vegetable, snack/fast food and soft drink intake in children and adolescents showed that household sociocultural factors (e.g. parental and sibling intake, parenting practices) and household economic factors (e.g. household income, parent educational level) were studied most extensively as potential environmental determinants. Few studies examined the influence of physical environmental factors, few looked at environmental factors in schools, neighborhoods and city/municipality and none looked at political factors. This review showed consistent evidence (findings replicated in multiple studies), for the relationship between parental intake and children's fat, fruit and vegetable intake, for parent and sibling intakes with adolescent's energy and fat intake and for parent educational level with adolescent's fruit and vegetable intake. A positive association was found for the relationship between availability and accessibility with children's fruit and vegetable intake, even though the samples that found a positive association only slightly outnumbered the samples that found no association. Further positive associations were found for controlling/restrictive practices (fat), parent educational level (fat), modeling (fruit/vegetable), parental intake (soft drink), parenting style (fruit/vegetable), family connectedness (fruit/vegetable) and encouragement to increase food intake (fruit/vegetable). A negative association was found for encouragement/assistance/prompts (energy). These factors were examined in only two studies, which limit the possibility to draw firm conclusions regarding consistency of associations. The direction of the association for encouragement/assistance/prompts seems unexpected. However, since these studies were cross-sectional, it could also be that a low child food intake provokes parental encouragement, assistance and prompts to increase intakes. All other associations studied between dietary behaviors and potential environmental factors were inconsistent, appeared non-existent or were not replicated.
A major limitation of the currently available published research papers is that many potential environmental determinants have been examined for a variety of dietary behaviors, but that only few studies have been conducted on the same specific environmental factor—dietary behavior combination. Replication of studies on such combinations is necessary, to generate more compelling evidence for associations between environmental factors and dietary intake. With regard to the strength of the study designs, most of the included studies were cross-sectional, making conclusions about direction and possible causality of associations impossible. Furthermore, most studies relied on self-reported data, of which the validity and reliability of the instruments used was hard to judge, since this information was not reported in the majority of the studies. We retrieved few studies that used objective observation instruments to assess factors in the physical environment or to measure the behavioral outcome. The behavioral outcome measures in the studies included may be somewhat biased because the studies mostly relied on self-reports.
There are some issues and limitations that have to be taken into account in interpreting the results of the review. In order to summarize the findings of the studies, we collapsed conceptually similar environmental determinants into one category, although potential determinants in the same category were often dissimilar or measured in different ways. Our search strategy only included studies that were published in English in peer-reviewed journals and referenced in electronic databases; therefore, our findings may be influenced by a publication bias. However, the high number of non-associations reported in the included studies may indicate that a bias toward publication of significant results only was not very strong. The studies included were heterogeneous in the conceptualization, measurement of the environmental determinant and/or dietary intakes, samples and analyses used, and therefore it was not possible to assess the overall strength of associations. Finally, we included multiple environmental factors examined in one study in the review, and it must be kept in mind that these associations are not independent.
Previously published reviews on the associations of environmental factors regarding eating behaviors in children and adolescents were narrative as opposed to systematic reviews [7–9, 11, 74, 75]. The main conclusions from those reviews were that the role of parents is particularly important, that parents should create supportive food environments for their children [7–9, 74] and that school food environments may have a large impact on food choices [9, 11, 74]. In the present review, we indeed found that parental intake and to a lesser extent availability and accessibility were associated with intakes in adolescents and children. Furthermore, some evidence (examined in two studies) was found for a positive association between an authoritative parenting style and adolescent's fruit and vegetable intake and for specific parenting practices and children's energy and fat intakes. Only very few studies on peer influences were retrieved in this systematic review. The importance of the school food environment can also not be substantiated with the evidence from the studies included in the present review.
We identified several gaps in the currently available evidence of relationships between environmental factors and child and adolescent dietary intakes. First, we were able to identify very few studies examining associations between microenvironmental factors in school and neighborhood settings, and on macroenvironmental factors in city/municipality settings: the broader, more anonymous infrastructure that may support or hinder health behaviors. It must, however, be noted that there are studies available that examine the effects of advertising and marketing on eating behaviors of youngsters [10, 76], but since these studies are mostly intervention studies, these were not included in the review. Second, the studies mainly depended on perceived and self-reported environmental information, as opposed to more objective observations of environments. Objectively assessing characteristics of the environment (observations or Geographic Information System) is a topic of recent interest [77, 78]. Furthermore, we retrieved only a limited number of studies assessing environmental determinants of snack and soft drink intakes, while these two behaviors may be of specific importance in obesity prevention [4, 12]. An important reason for some of the gaps may be that attention to the role of the physical environment is of recent interest, and many studies that examine possible influences of the physical environment may be underway.
The current evidence of associations between environmental determinants and dietary intakes among children and adolescents suggests that parental intakes, sibling intakes and educational level of parents are environmental determinants most consistently associated with intakes. A less consistent repeated but positive association was found for availability and accessibility on child fruit and vegetable intake. The finding that parental behavior is associated with child and adolescent intakes implies that interventions should take the behavior of parents into account, or desensitize adolescents for the (unfavorable) behavior of their parents. Parents should be more strongly encouraged to give the right example, especially where fat and energy intakes are concerned. Fruit and vegetable promotion should focus especially on adolescents from parents with lower levels of education. To get a broad understanding of the influence of environmental factors associated with obesity-inducing behaviors in children and adolescents at the various levels distinguished in the ANGELO framework, studies are needed that target the environmental levels and factors that have found to be (nearly) empty in the ANGELO (Table IV), such as physical, sociocultural, economic and political factors in the school (e.g. school food policy and food prices), neighborhood (e.g. availability and accessibility of foods in shops) and city/municipality environment (e.g. food policy, food prices, marketing). Furthermore, factors such as availability and accessibility at home, school and neighborhood should be studied in relation to energy, fat, soft drink, snacks and fast food intake. For all environmental factors, including the factors that have already been studied, there is a need for longitudinal studies in which valid or objective measurement instruments are used.
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Conflict of interest statement |
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None declared.
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Acknowledgements |
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The authors wish to thank Carlijn Kamphuis and Gert Jan de Bruijn for their assistance in the review process. This study was financially supported by a grant from ZonMw, The Netherlands Organization for Health Research and Development. K.G. is supported by an Australian National Health and Medical Research Council Sidney Sax Fellowship (grant ID no. 290540).
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Received on February 1, 2006; accepted on June 14, 2006
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