Western University Scholarship@Western Electronic Thesis and Dissertation Repository 9-23-2015 12:00 AM The Association Between the Neighbourhood Food Environment and Prevalence of Three Chronic Diseases in Urban Canada: A Cross-Sectional Analysis Jagraj Singh Pandher The University of Western Ontario Supervisor Dr. Sisira Sarma The University of Western Ontario Graduate Program in Epidemiology and Biostatistics A thesis submitted in partial fulfillment of the equirr ements for the degree in Master of Science © Jagraj Singh Pandher 2015 Follow this and additional works at: https://ir.lib.uwo.ca/etd Part of the Community Health and Preventive Medicine Commons, Environmental Public Health Commons, and the Epidemiology Commons Recommended Citation Pandher, Jagraj Singh, "The Association Between the Neighbourhood Food Environment and Prevalence of Three Chronic Diseases in Urban Canada: A Cross-Sectional Analysis" (2015). Electronic Thesis and Dissertation Repository. 3268. https://ir.lib.uwo.ca/etd/3268 This Dissertation/Thesis is brought to you for free and open access by Scholarship@Western. It has been accepted for inclusion in Electronic Thesis and Dissertation Repository by an authorized administrator of Scholarship@Western. For more information, please contact [email protected]. THE ASSOCIATION BETWEEN THE NEIGHBOURHOOD FOOD ENVIRONMENT AND PREVALENCE OF THREE CHRONIC DISEASES IN URBAN CANADA: A CROSS-SECTIONAL ANALYSIS Thesis format: Monograph by Jagraj Singh Pandher Graduate Program in Epidemiology & Biostatistics A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science The School of Graduate and Postdoctoral Studies The University of Western Ontario London, Ontario, Canada © Jagraj Singh Pandher 2015 Abstract Research on the association between the neighbourhood food environment and prevalence of chronic diseases is very limited in Canada. The objective of this thesis was to investigate: (i) the associations between the neighbourhood food environment and prevalence of type II diabetes, cardiovascular disease and hypertension among Canadian adults living in urban areas; and (ii) whether or not dietary patterns, obesity and physical activity mediate such associations. Self-reported diagnosis of three chronic diseases, and individual-level socio-demographic and lifestyle variables were taken from the 2009- 2010 Canadian Community Health Survey; neighbourhood-level socio-economic data were taken from the 2011 National Household Survey; and the locations of all restaurants and grocery stores in Canada were taken from the 2011 CFM Leads Business Dataset. The associations between prevalence of three chronic diseases and the density of various restaurant and food outlets (density is defined as the number of outlets per 10,000 people and per square kilometer in the respondent’s Forward Sortation Area) were analyzed using a modified Poisson regression. The mediation analyses were conducted using the Baron & Kenny method. I found that fast-food restaurant density is positively associated with the prevalence of type II diabetes but statistically non-significant for cardiovascular disease and hypertension. I also find that non-chain restaurants density is negatively associated with the prevalence of type II diabetes. Obesity, fruits & vegetables consumption, and physical activity were found to be partial mediators of these associations. The main implication of this study is that fast-food restaurant density is an important factor for the prevalence of type II diabetes in urban Canada. ii Keywords Food Environment; Chronic Disease; Modified Poisson; Diabetes; Cardiovascular Disease; Hypertension; Baron and Kenny; Mediation iii Acknowledgments I would first like to thank Dr. Sisira Sarma for all the help and guidance he has provided me with during my time at the University of Western Ontario. From the beginning right to the completion of the final draft of my thesis, you offered me advice and remained committed to my development as a researcher. Without your unwavering dedication and expertise the completion of this thesis would have not been possible. I would like to recognize and thank my committee members, Dr. M. Karen Campbell, Dr. John Koval, and Dr. Jason Gilliland, who all provided valuable insight and feedback that helped shaped my research and thesis. I would also like to recognize the advice and input received from my thesis examiners, Dr. Neil Klar, Dr. Bridget L. Ryan, and Dr. Shauna Burke, for which I am grateful for. In addition, I would like to thank Dr. Bradley Corbett for his cooperation and assistance while working in the Statistics Canada Research Data Center at the University of Western Ontario. I would also like to recognize the financial support from the Western Graduate Research Scholarship and monthly stipend through the “Econometric analyses of adult obesity in Canada: Modifiable risk factors and policy implications” project funded by the Canadian Institutes of Health Services Research and the “Research to prevent adult obesity” project funded through the Estate of Margaret May Dodge. Finally I would like to thank all my friends and family, who all offered me their support throughout my Masters study. To my Mom, Dad, Brother, and Sister, thank you all for standing by me not only during my thesis, but throughout my entire life. Your unwavering belief in me and my abilities as not only an academic, but as a person, has helped me in ways words can never truly describe. I hope I can continue to make you proud. iv Table of Contents Abstract ............................................................................................................................... ii Keywords ........................................................................................................................... iii Acknowledgments.............................................................................................................. iv Table of Contents ................................................................................................................ v List of Tables ..................................................................................................................... ix List of Figures .................................................................................................................... xi List of Appendices ............................................................................................................ xii List of Acronyms ............................................................................................................. xiii Chapter 1 ............................................................................................................................. 1 1 Introduction .................................................................................................................... 1 1.1 Research Objective ............................................................................................... 4 Chapter 2 ............................................................................................................................. 5 2 Literature Review ........................................................................................................... 5 2.1 Literature Search Strategy .................................................................................... 5 2.2 Summary of the Measures of the Food Environment ........................................... 6 2.2.1 Definition of Neighbourhood ...................................................................... 6 2.2.2 Databases .................................................................................................... 8 2.2.3 Classification of the Food Environment ..................................................... 9 2.2.4 Types of Measures .................................................................................... 10 2.3 Review of the Food Environment and Chronic Disease .................................... 13 2.3.1 Type II Diabetes ........................................................................................ 14 2.3.2 High Blood Pressure and Hypertension .................................................... 19 2.3.3 High Cholesterol ....................................................................................... 22 2.3.4 Cardiovascular Disease ............................................................................. 23 v 2.4 Potential Mediators ............................................................................................. 26 2.4.1 Dietary Patterns ......................................................................................... 27 2.4.2 Body Mass Index and Obesity .................................................................. 30 2.4.3 Physical Activity ....................................................................................... 32 2.5 Gaps in the Literature ......................................................................................... 33 Chapter 3 ........................................................................................................................... 37 3 Conceptual Framework ................................................................................................ 37 3.1.1 Taste .......................................................................................................... 38 3.1.2 Nutrition and Health ................................................................................. 39 3.1.3 Price .........................................................................................................