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Dynamics of the complex food environment underlying dietary intake in low-income groups: a systems map of associations extracted from a systematic umbrella literature review

  • Sawyer, Alexia D. M.1
  • van Lenthe, Frank2
  • Kamphuis, Carlijn B. M.3
  • Terragni, Laura4
  • Roos, Gun5
  • Poelman, Maartje P.6
  • Nicolaou, Mary1
  • Waterlander, Wilma1
  • Djojosoeparto, Sanne K.7
  • Scheidmeir, Marie8
  • Neumann-Podczaska, Agnieszka9
  • Stronks, Karien1
  • 1 Amsterdam University Medical Centres, University of Amsterdam, Room J2-211, Meibergdreef 15, Amsterdam, 1105 AZ, The Netherlands , Amsterdam (Netherlands)
  • 2 Erasmus Medical Centre, Rotterdam, 3000 CA, The Netherlands , Rotterdam (Netherlands)
  • 3 Utrecht University, Utrecht, 3584 CH, The Netherlands , Utrecht (Netherlands)
  • 4 Oslo Metropolitan University, Oslo, Norway , Oslo (Norway)
  • 5 Consumer Research Institute, Oslo Metropolitan University, Oslo, 0170, Norway , Oslo (Norway)
  • 6 Wageningen University, Wageningen, 6706 KN, The Netherlands , Wageningen (Netherlands)
  • 7 Utrecht University, Utrecht, 3584 CB, The Netherlands , Utrecht (Netherlands)
  • 8 Psychology Institute, Johannes Gutenberg University Mainz, Mainz, D-55122, Germany , Mainz (Germany)
  • 9 Poznan University of Medical Sciences, Poznań, Poland , Poznań (Poland)
Published Article
International Journal of Behavioral Nutrition and Physical Activity
BioMed Central
Publication Date
Jul 13, 2021
DOI: 10.1186/s12966-021-01164-1
Springer Nature
  • Review


BackgroundInequalities in obesity pertain in part to differences in dietary intake in different socioeconomic groups. Examining the economic, social, physical and political food environment of low-income groups as a complex adaptive system – i.e. a system of multiple, interconnected factors exerting non-linear influence on an outcome, can enhance the development and assessment of effective policies and interventions by honouring the complexity of lived reality. We aimed to develop and apply novel causal loop diagramming methods in order to construct an evidence-based map of the underlying system of environmental factors that drives dietary intake in low-income groups.MethodsA systematic umbrella review was conducted on literature examining determinants of dietary intake and food environments in low-income youths and adults in high/upper-middle income countries. Information on the determinants and associations between determinants was extracted from reviews of quantitative and qualitative studies. Determinants were organised using the Determinants of Nutrition and Eating (DONE) framework. Associations were synthesised into causal loop diagrams that were subsequently used to interpret the dynamics underlying the food environment and dietary intake. The map was reviewed by an expert panel and systems-based analysis identified the system paradigm, structure, feedback loops and goals.ResultsFindings from forty-three reviews and expert consensus were synthesised in an evidence-based map of the complex adaptive system underlying the food environment influencing dietary intake in low-income groups. The system was interpreted as operating within a supply-and-demand, economic paradigm. Five sub-systems (‘geographical accessibility’, ‘household finances’, ‘household resources’, ‘individual influences’, ‘social and cultural influences’) were presented as causal loop diagrams comprising 60 variables, conveying goals which undermine healthy dietary intake.ConclusionsOur findings reveal how poor dietary intake in low-income groups can be presented as an emergent property of a complex adaptive system that sustains a food environment that increases the accessibility, availability, affordability and acceptability of unhealthy foods. In order to reshape system dynamics driving unhealthy food environments, simultaneous, diverse and innovative strategies are needed to facilitate longer-term management of household finances and socially-oriented practices around healthy food production, supply and intake. Ultimately, such strategies must be supported by a system paradigm which prioritises health.

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