Measuring associations between the food environment and dietary habits: comparing the proportion and density of food outlets

BACKGROUND: The food environment plays a crucial role in shaping our dietary choices and overall health. Spatial measures provide distinct perspectives on the physical food environment and its impact on diet. While proportion measures are theoretically considered to provide a more accurate representation of the overall physical food environment than density measures, it is important to recognize that the association between food environments and diet can vary depending on the context. Therefore, relying solely on one measure may not be appropriate.

METHODS: We systematically assessed the density and proportion of multiple food outlet types (fast-food outlets, convenience stores, supermarkets, and restaurants) around individuals homes using a large cross-sectional Danish study (N = 71,840). Densities were modeled in separate multilevel linear regression models, incorporating random intercepts from linear splines for each of the four food outlet types. Proportions were modeled without splines. Through the association with a dietary quality score (DQS), we examined the impact of quantifying the foodscape from density versus proportion measures. Associations were compared using parameter estimates, p-values, Akaike Information Criterion (AIC) values, and Akaike weights.

RESULTS: AIC values and Akaike weights were in favor of models including density measures. Across all outlet types, density measures were consistently negatively associated with the DQS until reaching densities of 3-5 (count/km2), at which point the direction of association became positive, indicating a shift towards a healthier DQS. After correcting for multiple comparisons, the most significant effect was observed for the sole significant proportion measure. A 10% increase in the proportion of fast-food outlets among "eating out options" was associated with a 7% decrease in the DQS, towards poorer dietary quality.

CONCLUSIONS: The associations highlight that choosing food outlet density versus proportions to quantify the foodscape impact findings of substantial importance when considering the significance level and direction of association. Findings suggests a threshold effect when using density measures indicating abundance of many food outlets, at which the association with dietary quality alters significantly towards healthier diet quality.