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3
The Food and Nutrition Environment
Key Points Noted in Presentations
• The food environment is complex, and food consumption is in-
fluenced by many factors at different levels. Research examines
mainly the community environment (types, locations, market-
ing, and accessibility of food outlets) and the consumer environ-
ment (foods found within stores, restaurants, and other outlets,
as well as marketing and information about the foods, such as
price).
• Although a primary focus has been on individual consumption,
many ongoing efforts to collect data, as well as newer research
designs and data collection tools, have expanded knowledge of
food environments and policies.
• Any environment in which food is marketed, offered, or sold can
be assessed in terms of dietary quality.
• Areas suggested for additional progress include
tracking change over time;
■
developing standardized definitions of key variables and other
■
ways of facilitating the sharing and integration of data from
different sources; and
matching measures and methods to questions of interest to
■
allow for meaningful analysis and comparison at all levels of
the food stream.
21
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22 MEASURING PROGRESS IN OBESITY PREVENTION
Measures of the food and nutrition environment have much in com-
mon with those used to measure physical activity, and many parallel issues
arise in both contexts. Karen Glanz, George A. Weiss University Professor,
professor of epidemiology in the Perelman School of Medicine, and profes-
sor of nursing in the School of Nursing at the University of Pennsylvania,
provided an overview of the ways in which food environments—and the
effects of policies that influence them—are measured, and reviewed some
limitations of the measurement tools currently available. Susan M. Krebs-
Smith, chief of the Risk Factor Monitoring and Methods Branch in the
Division of Cancer Control and Population Sciences at the National Cancer
Institute, focused on surveillance in this area and the potential for expand-
ing the focus of dietary surveillance from individual-level behaviors to the
community- or national-level food environment.
UNDERSTANDING FOOD ENVIRONMENTS AND POLICIES
Presenter: Karen Glanz
As with physical activity, food choices are influenced by many factors.
Glanz presented an ecological model (Figure 3-1) to illustrate these factors,
similar to the physical activity model presented by Sallis. In the food choice
model, the large boxes connecting to the concentric circles list the specific
influences by category; the smaller boxes list the primary means by which
these influences affect behavior.
The picture is highly complex, Glanz acknowledged. A second illus-
tration (Figure 3-2) models similar ideas but highlights the environmental
variables that she believes can be measured but have not been adequately
studied, such as the locations of food outlets and the availability of healthy
options at a given outlet.
In Glanz’s view, it is important when considering food issues to distin-
guish between the community environment (encompassing the types and
locations of restaurants and supermarkets and their accessibility within
a particular community) and the consumer environment (what consum-
ers encounter when they go out to eat or to purchase food, whether in a
restaurant, at school, or elsewhere) (Glanz et al., 2005). The consumer
environment is the category that encompasses such factors as the availabil-
ity of healthful or less healthful food choices within food establishments,
the availability of nutrition information, pricing, and product placement.
“Food is a commodity, and food products are a big business,” Glanz added.
While many industries and government sectors have an interest in physical
activity, it is a behavior, not a commodity, and industry is “very invested
in food in a different way” she said. Food is also highly regulated through
safety and hygiene rules, taxation, and policies regarding both foods and
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• Home • Societal and cultural norms
• Access • Practices
• Worksites and values
• Availability • Legislative,
• School, • Food and beverage industry
regulatory, or
• Barriers
Afterschool Macro-level policy actions • Food marketing and media
• Opportunities
Environments
• Child-care • Food and agriculture policies
(sectors)
• Neighborhoods and • Economic systems
Communities
• Food production and distribution
Physical
• Restaurants and fast systems
Environments
food outlets
• Government and political
(settings)
• Supermarkets structures and policies
• Convenience and Social • Food assistance programs
corner stores Environments • Health care systems
(networks) • Land use and transportation
Individual
• Cognitions (e.g., attitudes,
Factors
preferences, knowledge,
(personal)
values)
• Skills and behaviors
• Lifestyle • Outcome expectations
• Biological (e.g., genes, • Motivations • Role modeling • Family
gender, age) • Self-efficacy • Social support • Friends
• Demographics (e.g., • Behavioral capability • Social norms • Peers
income, race/ethnicity)
FIGURE 3-1 An ecological framework depicting the multiple influences on food choices.
SOURCE: Story et al., 2008. Annual Review of Public Health Copyright 2007 by ANNUAL REVIEWS, INC. Reproduced with
23
permission of ANNUAL REVIEWS, INC. in the format Other book via Copyright Clearance Center.
3-1.eps
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24
Policy Variables Environmental Variables Individual Variables Behavior
Organizational
Community Nutrition Nutrition Environments
Environments
Socio-demographics
• Type and location of food
Home School
outlets (stores, restaurants)
• Accessibility—hours of
operation, drive-thru) Work Other
Government
Psychosocial Eating
and Factors Patterns
Industry Policy Consumer Nutrition Environment
• Available healthy options
• Price, promotion, placement Perceived
• Nutrition Information Nutrition
Environments
Information
Environment
(Media, Advertising)
FIGURE 3-2 Model of community nutrition environments.
SOURCE: Glanz et al., 2005. Annual Review of Public Health Copyright 2005 by ANNUAL REVIEWS, INC. Reproduced with
permission of ANNUAL REVIEWS, INC. in the format Other book via Copyright Clearance Center.
3-2.eps
landscape
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25
THE FOOD AND NUTRITION ENVIRONMENT
nutrients, for example, which adds considerable complexity to the business
of food.
Policy can influence food availability and food choices in a variety of
ways, Glanz added. Federal and state policies regarding the nutritional
value of foods served in public schools, price supports for agricultural
products, and food assistance policies may all have significant influence,
and Glanz noted that changes in such policies during the last decade are
beginning to yield benefits. “We’d like to think,” she observed, “that most
food-related government policies are designed to improve health,” but not
all are, and other efforts to promote health may be defeated politically. The
food environment also can evolve in the absence of policies, she added,
because commercial enterprises do not necessarily look to government’s
goals as they make marketing decisions.
Measures
Given this complex picture of influences on food choices, Glanz
explained, there are five reasons for the measurement of food and nutri-
tion environments:
• Observation, or simply observing what is available and what peo-
ple eat and why they eat the way they do in the different environ-
ments to which they are exposed
• Explanation of the reasons for people’s choices
• Evaluation of the results of programs and strategies
• Support for advocacy or other actions
• Surveillance, or ongoing monitoring to identify trends and problems
A variety of data sources support these goals. Glanz noted, much the same
as those used to measure physical activity: self-report surveys; observations
and audits; databases that may exist for other purposes but contain food-
related information; and GIS-based measures, which track the locations of
food outlets, for example.
Glanz described a few examples of current efforts to measure food
environments and policies in schools, worksites, food stores, restaurants,
and local/state communities. There is a long history of measuring health
policies affecting public schools, she noted, and this is an area in which
the Centers for Disease Control and Prevention (CDC) has taken the lead.
The School Health Policies and Programs Study, for example, has assessed
such issues as vending machines’ offerings of junk foods (Kubik et al.,
2010) and offerings of fruits, vegetables, french fries, and high-fat baked
goods in elementary, middle, and high schools in all states since 1994. The
School Nutrition Environment State Policy Classification System compares
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26 MEASURING PROGRESS IN OBESITY PREVENTION
state policies in 11 policy areas related to food (Mâsse et al., 2007). A
third study that explores the school context is the Food and Beverage
Environmental Analysis and Monitoring System (FoodBEAMS), in which
competitive foods and beverages offered in schools are assessed and linked
to nutritional databases so that adherence to nutritional guidelines can be
monitored (Bullock et al., 2010). Glanz observed that studies tend to focus
on the availability of healthy foods but, she believes, should also examine
the availability of unhealthy, competing choices.
A modest amount of research has explored the food environments in
worksites. One example is the Working Well Trial (WWT) (Patterson et al.,
1998), in which researchers examined access to healthy food and nutrition
information in more than 100 worksites as part of a cancer prevention
trial. The researchers collected self-report data and found an association
between interventions designed to alter food choices and changes in work-
ers’ choices. An Australian study of a number of aspects of the workplace
included a nutrition component, collecting data on such features as avail-
ability of nutrition information, cafeteria options, and food in vending
machines (Oldenburg et al., 2002). The researchers used a measure devel-
oped by Australia’s National Heart Foundation to track workers’ food
choices.
Data are available regarding the types and locations of food stores and
restaurants, but less measured are variables affecting access to these outlets,
such as hours of operation and drive-through options, Glanz explained.
States, counties, and cities all maintain lists of food establishments for
licensing purposes, she noted, and commercial enterprises such as Dun &
Bradstreet and InfoUSA also collect such data. Wang and colleagues (2006)
found, however, that these data generally are not complete, up to date, or
altogether accurate. They noted, for example, large discrepancies in the
counts produced by state boards and by business directories. Using any
single list is not likely to be adequate, Glanz observed. Counting food estab-
lishments is “a messy business,” she suggested, because, for example, some
may be located within other buildings and not fully accessible to the public.
The consumer nutrition environment also has attracted considerable
research attention. Observational measures have been used to assess the
environments within food stores. An early example is the Food Availability
Survey, conducted in 1986 (Sallis et al., 1986), which audited the presence
of 71 different heart-healthy foods in food stores. Cheadle and colleagues
(1990, 1991, 1993) built on this work by reporting on a smaller number
of items but comparing results with those from community surveys. Glanz
also described the Nutrition Environment Measures Survey (NEMS), which
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27
THE FOOD AND NUTRITION ENVIRONMENT
has examined foods in retail stores, as well as restaurant offerings.1 The
restaurant component of NEMS addresses such issues as price, promotion,
and children’s menus, along with choices available in stores and vend-
ing machines. Measures used in stores cover the availability of healthful
choices, prices of healthy and less-healthy foods and how they vary by store
type and neighborhood, and the quality of fresh produce.
NEMS was originally developed for research purposes, but the informa-
tion collected has also been used for community assessments, for advocacy,
and in the design of interventions. The measurement tools developed for
NEMS proved useful for these other purposes, Glanz explained. Funding
from foundations and state health departments has allowed for expanded
dissemination of results as well as tools and training for those who wish to
use the data. The measures are widely available in different technological
formats, and individuals from 40 states have now been trained.
Glanz also described a CDC project, the Common Community Mea-
sures for Obesity Prevention (which has a physical activity component as
well). This project, she explained, was designed to provide communities
and local governments with measures they could use to plan and monitor
environmental and policy changes related to obesity prevention. The food-
related measures included whether communities had a plan for applying the
Dietary Guidelines for Americans2 in their government facilities and largest
school district, the numbers of full-service grocery stores (per 10,000 peo-
ple) in their three largest underserved census tracts, and the availability of
government incentives to retailers for offering healthy food and beverages.
In answer to a question, Glanz noted that some surveys focus on con-
sumer behavior and attitudes, but those topics have been relatively difficult
to study. One approach used has been to look at receipts or intercept cus-
tomers as they exit food stores to do a quick survey of their purchases as a
way of assessing responses to calorie labeling. It is not always easy to obtain
sales data, however, which, according to Glanz, would be “much stronger
and more comprehensive.” The issue of attitudes and other influences on
individuals’ choices is important, a workshop participant noted, because
time pressure has meant that a shrinking proportion of food consumed is
actually prepared at home from unprocessed ingredients. Glanz agreed,
and said that prepared, take-out food is the fastest-growing segment of the
supermarket business and that foods obtained away from home generally
have more fat and calories than those prepared at home. Furthermore,
1 For more information about NEMS, see http://www.med.upenn.edu/nems/ (accessed July
2011).
2 For more information about the Dietary Guidelines for Americans, a source of research-
based nutrition recommendations, see http://www.health.gov/dietaryguidelines/ (accessed July
2011).
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28 MEASURING PROGRESS IN OBESITY PREVENTION
studies of behaviors and attitudes could better assess, for example, whether
declines in cooking skills are now playing a role in people’s food choices.
Research
Glanz noted that many measures now available did not exist even 4 or
5 years ago, so “tremendous progress” has been made.3 Published studies
have used a variety of research designs: cross-sectional or correlational,
comparative, longitudinal or prospective, experimental (looking at pre-
and post-intervention, for example), and quasi-experimental. Randomized
controlled trials are sometimes conducted, but in Glanz’s view they are not
essential; they are expensive, and in many circumstances they are either
inappropriate or infeasible.
Glanz also stressed that available measures may be quite accurate for
a single point in time but less useful for tracking change over time. Studies
by Cheadle and colleagues (1991, 1993, 1995) illustrate this point. The
early studies identified a clear association between the characteristics of a
grocery store environment and community members’ reports of their eating
patterns. The correlations were less strong, however, as the researchers fol-
lowed the community over time, and when they were able to compare three
points in time, the results were inconsistent and contradictory.
Thus, for Glanz, examining the capacity of measurement tools is an
important component of the needed research on food and nutrition, but
many unanswered questions remain. It is not clear, she observed, what
degree of environmental change will be needed to bring about meaningful
changes in food intake and, ultimately, in obesity, or how long meaningful
change might take. Relatively little is known about which people respond
to interventions that have been tried.
Limitations of Measures
Efforts to measure the food environment are hampered by several fac-
tors, Glanz noted. The food environment is complex, variable, and far from
static. For example, the variation in portion sizes at restaurants makes it
difficult to assess nutritional value. Field-based measures have practical
limitations because of this complexity. Researchers also lack common met-
rics for many of the features they want to measure, and not all measures
3 Glanz suggested several resources for further information: a web compilation of measures
and articles, at https://riskfactor.cancer.gov/mfe/; the Healthy Eating Research website, at
www.healthyeatingresearch.org; Your Food Environment Atlas, at http://www.ers.usda.gov/
foodatlas/; and the NCCOR Catalogue of Surveillance Systems, at http://tools.nccor.org/css/
(accessed July 27, 2011).
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29
THE FOOD AND NUTRITION ENVIRONMENT
are of equal psychometric rigor. Limited archival measures4 are available,
and researchers do not know how sensitive measures are to change. Glanz’s
hope is that the field will eventually have a set of measures, based on shared
definitions, that have been tested and proven valid and are feasible to use,
adaptable to changing circumstances, and able to yield results that are easy
to disseminate for wide use. In her view, it is also “increasingly important
to tie those measures to calories, or to the foods that contribute the most
calories to the diet.” With those tools, she concluded, well-designed studies
that permit reasonable inferences about the impact of interventions should
help accelerate progress in reducing obesity.
SURVEILLANCE OF FOOD ENVIRONMENTS
Presenter: Susan M. Krebs-Smith
Currently, national surveys related to food and obesity focus mainly on
the behavior of individuals, Krebs-Smith noted, but she believes a national
surveillance system is needed to track nutrition-related environmental and
policy changes and their effects. She offered her thoughts about what
such a system would look like and the lessons that could be drawn from
individual-level surveys.5
Prior studies have explored these questions in limited ways, Krebs-
Smith noted. A series of reports issued by the National Nutrition Monitor-
ing and Related Research Program during the early 1990s explored and
developed a model of the relationships between food and health (Figure
3-3). The shaded boxes in this figure show the areas for which data have
traditionally been collected.
More recently, Krebs-Smith explained, researchers have focused
increased attention on the food stream and the additional levels through
which food travels from the food supply to consumption by individuals.
Figure 3-4 illustrates Krebs-Smith’s suggested expansion of the various
levels in the food stream that connect the food supply to individual con-
sumption. Foods are in different forms as they travel through the levels
from the food supply to individual consumption; the food supply contains
raw agricultural commodities, foods in markets may be raw or processed,
and foods consumed by individuals are ready to eat (and may include raw
agricultural commodities or processed or prepared foods). This is an impor-
4 That is, preexisting data that do not require new collection.
5 Krebs-Smith noted that she was using “level” to refer to the unit of analysis (e.g., individu-
als’ dietary intake) and “scope” to refer to the area to which a particular study’s results apply,
or the sampling frame.
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30
Away-from-Home Household Influential
Food Acquired Food Acquired Factors
Exports Nutrient
Imports Requirements
Storage
Nutrition and
Consumption Nutrient Nutrient Related Health
Food Supply
by Individuals Intake Utilization Measurements
Food Production
Supplement
Use
Food Knowledge,
Composition Attitudes, and
Behavior
FIGURE 3-3 Diagram of the relationships between food and health.
3-3.eps
NOTE: Shaded boxes indicate that data have traditionally been collected for these factors.
SOURCE: Adapted from HHS and USDA, 1993. landscape
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Grocery Stores
and Markets
Exports
Household
Imports
Food Acquired
Storage
Food Consumption
Food Supply
Manufacturers by Individuals
Food Production Away-from-Home
Food Outlets:
Food Acquired
• Fast Food and
Other Restaurants
• Daycare
• Schools
• Worksites
• Hospitals
FIGURE 3-4 Flow of foods from the food supply to individual consumption.
3-4.eps
SOURCE: Krebs-Smith, 2011.
landscape
31
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32 MEASURING PROGRESS IN OBESITY PREVENTION
tant point because characterizing foods at all levels requires databases that
reflect these various forms.
Both individual-level surveys and food supply data have evolved in the
last couple of decades, and these methodological and database improve-
ments provide lessons for how the food environment might be examined.
In the past, researchers reported such findings as, for example, that 6
percent of individuals did not eat any vegetables during a 3-day period,
noting, however, that the value reported did not include vegetables eaten as
part of food mixtures (i.e., foods containing multiple ingredients, such as
a casserole).6 Researchers did not have the tools to discriminate in detail,
and the only way they could approximate usual intakes was to take a mean
across 3 days. Similarly, a finding that all individuals consumed an average
of 88 grams of mixtures, mainly meat, poultry, and fish, was of somewhat
limited value because there were no dietary recommendations for how
many grams of such mixtures individuals should eat.
Responding to these difficulties, nutritionists devised improved ways to
capture the intake of specific foods of interest, to estimate usual intake dis-
tributions, and to relate this information to caloric density. They also iden-
tified some gaps in food-related databases, Krebs-Smith added. Traditional
food composition databases provided the amounts of various nutrients and
other dietary elements in particular foods that can be determined using
chemical analysis, typically in terms of the amount contained in 100 grams
of the food. Thus, for example, they listed energy (in kcal), carbohydrates
(g), protein (g), beta carotene (IU), calcium (mg), fiber (g), sodium (mg), and
fat (g). These data provide valuable information, Krebs-Smith explained,
but “don’t tell us everything we need to know about comparing intakes to
recommendations.” Guidance-based databases have since been developed
that link to dietary recommendations; they measure, for example, cups
of fruit, vegetables, or milk (or milk equivalents in the form of cheese or
yogurt); ounces of whole grains, total grains, and meat; and teaspoons of
added sugars.
Researchers now can measure the prevalence of usual intakes above or
below a particular level (Carriquiry, 2003), so they can report, for example,
that over the long run, 95 percent of the population consumes an amount of
empty calories that exceeds the discretionary calorie allowance in national
guidelines. This sort of finding is compelling, Krebs-Smith added. Nutrition-
ists can identify the food sources of empty calories or other elements that
6 Examples in this paragraph are paraphrased from the Third Report on Nutrition Monitor-
ing in the United States (FASEB, 1995).
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33
THE FOOD AND NUTRITION ENVIRONMENT
should be curtailed, and the newer data provided the evidence base for the
Dietary Guidelines Advisory Committee’s most recent recommendations.7
Advances also have occurred in the collection of data on the food
supply, Krebs-Smith noted. Here as well, traditional methods produced
valuable information, such as pounds of caloric sweeteners consumed per
capita in a year, but the implications were not completely clear because
there was no guideline as to how many pounds were advisable. Researchers
were interested in the issue, as consumption of regular and low-calorie soft
drinks climbed from 26 to 44 gallons per capita between 1972 and 1992
(FASEB, 1995), but the data did not translate easily to recommendations.
Moreover, measuring quantities of particular commodities in the food sup-
ply gives only an approximation of consumption because of losses from
food waste.
These measures have now been translated into waste-adjusted serv-
ings per person per day, making it easier to assess the food supply’s align-
ment with food guidance, Krebs-Smith explained. Thus, for example, “we
know that in order to meet recommendations we’d need to be producing
about twice as many fruits and vegetables and much more whole grains
and milk.” Newer forms of data also have made it possible to project the
agricultural needs that will come with population shifts; current growth
indicates an even greater need for fruits, vegetables, and whole grains
(along with a decrease in the production of caloric sweeteners) by approxi-
mately 17 billion pounds in the United States (McNamara et al., 1999). The
United States has price and incentive structures in its agricultural policies,
Krebs-Smith noted, explaining that farmers are paid not to grow fruits and
vegetables on key acreage. In this light, she said, it is interesting to note that
the amount of fruits and vegetables in the food supply would be insufficient
if everyone wanted to eat according to dietary recommendations.
Researchers also have been able to look across decades to track changes
in the quality of the U.S. food supply from 1970 to 2007 (Krebs-Smith et al.,
2010). Despite the existence of dietary guidelines, Krebs-Smith explained,
little improvement has been seen in the consumption of fruits, vegetables,
and grains, and some aspects of the U.S. diet have worsened from a nutri-
tional perspective. Researchers can use tools such as the Healthy Eating
Index (a measure developed by U.S. Department of Agriculture’s Center
for Nutrition Policy and Promotion to monitor the quality of diets in the
United States) to assess the nutritional quality of specific menu items at fast-
food restaurants and determine relative diet quality, for example.8
7 For more information on the dietary guidelines and the committee that developed them,
see http://www.cnpp.usda.gov/dietaryguidelines.htm.
8 For more on the Health Eating Index, see http://www.cnpp.usda.gov/healthyeatingindex.
htm.
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34 MEASURING PROGRESS IN OBESITY PREVENTION
There is a lack of data with which to describe the full array of foods—
raw, semiprepared (such as a cake mix or boxed macaroni meal), and
ready-to-eat—offered in a grocery store. If more information linked to
particular foods were available from the outlets that sell such products,
Krebs-Smith explained, researchers could apply an index of diet quality
to assess the nature and mix of foods available within a particular area.
With more complete data, researchers could also look at, for example, the
food consumed by a family over 1 week and assess its quality and nutri-
tion density. More complete food-linked data also would allow for a more
detailed assessment of the progress of such initiatives as the Healthy Weight
Commitment Foundation, an effort in which food manufacturers and other
food-related businesses have pledged to support consumers in reducing obe-
sity by changing their products, packaging, and labeling and reducing the
calories in the food supply by 1.5 trillion by the end of 2015.9 It would be
valuable, Krebs-Smith explained, to look at whether the calorie reduction
goal was achieved through limits on empty calories, as opposed to the more
valuable calories supplied by fruits, vegetables, and whole grains.
Workshop participants pointed out that each sort of measure entails
complications, observing that individuals make errors when responding to
surveys in recalling and recording what they have eaten, while imprecise
estimates regarding food waste may introduce error in food supply data.
Krebs-Smith noted that some accounting of the waste is included in data
analysis and emphasized that each data source is important, although more
could be done to reconcile discrepancies.
Krebs-Smith closed by showing an altered version of the model depict-
ing the flow of foods from the food supply to the individual (Figure 3-5).
Each element is shown in a box to signal the ideal situation, in which mea-
sures of each would be available. As the figure shows, however, databases
still are needed to provide data for some elements in the model.
If the data were complete, Krebs-Smith observed, it would be possible
to describe any environment in which food is marketed, offered, or sold in
terms of dietary quality. Interventions designed to reduce obesity or target
other health objectives could be evaluated for their effect on dietary qual-
ity, and the relationships between diet quality and other factors, within and
across levels, could be examined. “We’ve learned a lot by matching our
measures and methods to questions of interest, and there is a potential for
gaining a lot of new knowledge by doing this at multiple levels,” Krebs-
Smith concluded.
9 Formore on the Healthy Weight Commitment Foundation, see http://www.healthyweight
commit.org/.
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Agricultural Some unprepared foods:
commodities: databases needed
databases available Grocery Stores
and Markets
Exports
Household
Imports
Food Acquired
Storage
Food Consumption
Food Supply Manufacturers by Individuals
Away-from-Home
Food Production Food Outlets:
Food Acquired
• Fast Food and
Other Restaurants
• Daycare
• Schools
• Worksites
• Hospitals Ready-to-eat foods:
databases available
FIGURE 3-5 Diagram showing what an ideal national surveillance system for tracking nutrition-related environmental and policy
3-5.eps
changes might examine.
landscape
NOTE: Shaded boxes indicate what would ideally be measured.
35
SOURCE: Krebs-Smith, 2011.
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36 MEASURING PROGRESS IN OBESITY PREVENTION
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