The impact of hot food takeaways near schools in the UK on childhood obesity: a systematic review of the evidence

The impact of hot food takeaways near schools in the UK on childhood obesity: a systematic review... Abstract Background Obesity is the greatest health issue for this generation; schools have improved food offered within their grounds. The built environment surrounding schools and pupils’ journeys home have not received the same level of attention. This review identified papers on impacts of hot food takeaways surrounding schools in the UK. Methods Methods were informed by the PRISMA (QUORUM) guidelines for systematic reviews. Searches were completed in 12 databases. Results A total of 14 papers were included and quality assured before data extraction. Three descriptive themes were found; descriptions of hot food takeaway’s geography and impacts concerning schools, strategic food policy and pupils reported food behaviour. Conclusions Most included studies compared anthropometric measures with geographical location of hot food takeaways to find correlations between environment and childhood obesity. There was good evidence of more hot food takeaways in deprived areas and children who spend time in deprived neighbourhoods tend to eat more fast food and have higher BMIs. Few studies were able to quantify the correlation between school’s environment and obesity amongst pupils. This lack of evidence is likely a factor of the studies’ ability to identify the correlation rather than lack of a correlation between the two variables. fast food, food environment, obesity, systematic review Introduction Obesity is the greatest health issue facing the current generation; type two diabetes and other lifestyle related illnesses continue to rise within the population.1 Since ‘Jamie’s School Dinners’ was broadcast on UK television in 2005, drawing attention to the way food was managed in schools, many schools have worked hard to improve the food offer within their grounds and to influence food behaviour positively amongst their pupils. The built environment surrounding schools have not received the same attention. The term obesogenic was first identified by Boyd Swinburn,2 who defined it as the ‘sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations’. Recent guidance from the National Institute for Clinical Excellence (NICE) and Public Health England (PHE) recommend the ‘use of local planning policy to restrict development of hot food takeaways around schools, leisure centres and other areas where children accumulate’.3,4 Planning and PH professionals have demanded evidence of what makes a healthy neighbourhood.5–7 A focus has been the restriction of hot food takeaways around schools. Hot food takeaways are defined under planning guidance as providing hot food to the public without making seating available to customers to eat their meals inside the premises. They can serve any form of hot food but have been shown to serve foods which are high in salt, sugar and saturated fat;8 increased consumption of which is associated with higher risk of obesity and co-morbidities of CVD, diabetes and osteoarthritis.6 Lake has categorized hot food takeaways as ‘Convenience and instant food outlets’ providing ‘food ordered at till, food predominantly pre-prepared and held at temperature but can be prepared on ordering. Food for takeaway or immediate consumption only’.9 As the link between high fat, salt, sugar foods and obesity is more strongly evidenced, calls for controls on these foods have increased.1,3,4 Local authorities have begun to introduce policies restricting hot food takeaways, which focus most commonly on the ‘school food environment’ to enable change in individuals and their environment.10 One counterargument is hot food takeaways ‘could’ serve healthy foods. Planning legislation allows any form of hot food to be served by an ‘A5 takeaway’. The balance between encouraging or discouraging premises from opening concerns planning officers. For example, The Chartered Institute of Environmental Health’s (CIEH) ‘takeaway toolkit’ encouraged local council Environmental Health Practitioners to promote hot food takeaway owners to reduce impact on their customer’s health. The aim of this review was to identify all papers published since the identification of the obesogenic environment in 1998 focused on the impact of hot food takeaways in the food environment surrounding schools in the UK on childhood obesity. Methods The methodology of this review was informed by the PRISMA (QUORUM) guidelines for systematic reviews. Eligibility criteria Exclusion and inclusion criteria listed below in Table 1 were developed by the three researchers. Table 1 Inclusion and exclusion criteria for the systematic review Inclusion criteria  Papers reporting impacts of food environment around schools on obesity Papers reporting impacts of food environment on schools Papers based on analysis and discussion of obesity in relation to leadership, education, attitudes and behaviours Papers discussing obesity views, opinions or developments in relation to the built environment’s spatial planning Policy documents relating to obesity, children, fast food and school food cultures Papers published in English and relating to the UK  Exclusion criteria  News articles Non English Letters to academic journals Editorials Commentaries Papers not reporting empirical research Papers not published in peer reviewed journals Papers not studying the UK Papers published before 1998 Papers not mentioning fast food  Inclusion criteria  Papers reporting impacts of food environment around schools on obesity Papers reporting impacts of food environment on schools Papers based on analysis and discussion of obesity in relation to leadership, education, attitudes and behaviours Papers discussing obesity views, opinions or developments in relation to the built environment’s spatial planning Policy documents relating to obesity, children, fast food and school food cultures Papers published in English and relating to the UK  Exclusion criteria  News articles Non English Letters to academic journals Editorials Commentaries Papers not reporting empirical research Papers not published in peer reviewed journals Papers not studying the UK Papers published before 1998 Papers not mentioning fast food  Table 1 Inclusion and exclusion criteria for the systematic review Inclusion criteria  Papers reporting impacts of food environment around schools on obesity Papers reporting impacts of food environment on schools Papers based on analysis and discussion of obesity in relation to leadership, education, attitudes and behaviours Papers discussing obesity views, opinions or developments in relation to the built environment’s spatial planning Policy documents relating to obesity, children, fast food and school food cultures Papers published in English and relating to the UK  Exclusion criteria  News articles Non English Letters to academic journals Editorials Commentaries Papers not reporting empirical research Papers not published in peer reviewed journals Papers not studying the UK Papers published before 1998 Papers not mentioning fast food  Inclusion criteria  Papers reporting impacts of food environment around schools on obesity Papers reporting impacts of food environment on schools Papers based on analysis and discussion of obesity in relation to leadership, education, attitudes and behaviours Papers discussing obesity views, opinions or developments in relation to the built environment’s spatial planning Policy documents relating to obesity, children, fast food and school food cultures Papers published in English and relating to the UK  Exclusion criteria  News articles Non English Letters to academic journals Editorials Commentaries Papers not reporting empirical research Papers not published in peer reviewed journals Papers not studying the UK Papers published before 1998 Papers not mentioning fast food  Search strategies Systematic searches were carried out using the following search terms (Table 2). Table 2 Search terms Search term string  1  Obes* OR BMI OR ‘Body Mass Index’ OR ‘obesity cause*’ OR ‘obesity attitude*’ OR fat* OR adiposity OR overweight OR over-weight OR ‘over weight’  2  School* OR child* OR adolesen* OR teenag* OR ‘ school* children’ OR youth OR young* OR primary OR secondary  3  ‘hot food takeaway*’ OR HFSS OR ‘High Fat Salt Sugar’ OR A5 OR ‘Food environment’ OR ‘food culture’ OR environment OR ‘fast food’ OR takeaway  Search term string  1  Obes* OR BMI OR ‘Body Mass Index’ OR ‘obesity cause*’ OR ‘obesity attitude*’ OR fat* OR adiposity OR overweight OR over-weight OR ‘over weight’  2  School* OR child* OR adolesen* OR teenag* OR ‘ school* children’ OR youth OR young* OR primary OR secondary  3  ‘hot food takeaway*’ OR HFSS OR ‘High Fat Salt Sugar’ OR A5 OR ‘Food environment’ OR ‘food culture’ OR environment OR ‘fast food’ OR takeaway  Table 2 Search terms Search term string  1  Obes* OR BMI OR ‘Body Mass Index’ OR ‘obesity cause*’ OR ‘obesity attitude*’ OR fat* OR adiposity OR overweight OR over-weight OR ‘over weight’  2  School* OR child* OR adolesen* OR teenag* OR ‘ school* children’ OR youth OR young* OR primary OR secondary  3  ‘hot food takeaway*’ OR HFSS OR ‘High Fat Salt Sugar’ OR A5 OR ‘Food environment’ OR ‘food culture’ OR environment OR ‘fast food’ OR takeaway  Search term string  1  Obes* OR BMI OR ‘Body Mass Index’ OR ‘obesity cause*’ OR ‘obesity attitude*’ OR fat* OR adiposity OR overweight OR over-weight OR ‘over weight’  2  School* OR child* OR adolesen* OR teenag* OR ‘ school* children’ OR youth OR young* OR primary OR secondary  3  ‘hot food takeaway*’ OR HFSS OR ‘High Fat Salt Sugar’ OR A5 OR ‘Food environment’ OR ‘food culture’ OR environment OR ‘fast food’ OR takeaway  The interdisciplinary nature of the subject matter required a wide range of databases to be searched: Cochrane Library; NICE guidance, Medline; pubmed; Web of Science; AMED; CINAHL; Embase; psycinfo; SOCINDEX; TRIP (Turning Research into Practice) BMJ. These databases cover medical, educational and social science databases and were likely to find the most relevant papers from each field of study. Searches were completed in June 2016 using all three search strings simultaneously except on TRIP which prevented combined search strings. Individual search strings were used with hand searching of returned papers. Study identification Search results study titles were screened, irrelevant titles removed, remaining titles were collected and organized using ENDNOTE X4. Duplicates were removed and abstracts were downloaded for investigation. Abstracts not meeting inclusion criteria were removed. Full text copies of 18 papers were downloaded and reviewed by one researcher (C.T.); papers not meeting inclusion criteria were excluded at this stage. Overall, 15 papers were screened independently by two researchers (J.R. and C.P.) to confirm inclusion and one paper was excluded using exclusion/inclusion criteria. Quality assurance of included papers was carried out before data extraction. See Fig. 1 for selection process and results. Fig. 1 View largeDownload slide Systematic review flowchart. Fig. 1 View largeDownload slide Systematic review flowchart. Results Included studies Quality assessment and data extraction Three quality assessment processes were used as included studies applied a range of methods. Observational studies were quality assessed using criteria adapted from the CRD handbook.11 Qualitative papers were assessed using criteria adapted from Spencer’s framework for Quality in Qualitative Evaluation.12 Systematic reviews were quality assessed using criteria adapted from Greenhalgh’s ‘Improving the quality of reports of meta-analyses of randomized controlled trials: the QUORUM statement’.13 Results are listed below in Table 3. Table 3 Quality assessment of included papers Paper  Focus  Quality issues  Quality rating  Fraser et al.20  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  If QA of included papers was undertaken it is not described. No flowchart. Population, intervention, context and follow-up of included papers not described  Low  Harrison and Jones18  Correlation between food environment and weight  No QA of included papers carried out. No weighting of results was reported. Sensitivity of results was not reported  Medium  Fraser et al.25  Correlation of consumption of fast food and BMI  No quality issues identified  Good  Caraher et al.7  Food environment, policy, foods eaten  Consent for focus groups was not described  Medium  de Vet et al.24  Correlation between self-regulation ability and self-reported food behaviour  It was not clear why and how the included schools were selected. (Possibly a convenient sample?) Validity of questionnaire used was not described  Good  Edwards et al.14  Correlation between food behaviour and location of hot food takeaway  Home address used to categorize socio-economic status—can be inaccurate  Good  Ellaway et al.22  Description of location of hot food takeaway  No comparison group  Good  Gallo et al.23  Description of location of hot food takeaway  No issues identified  Good  Griffiths et al.19  Correlation between food environment and weight  Collapsing of food categories into one category could mask influence on BMI  Medium  Harrison et al.17  Correlation between physical environments around school, home and route from school and FMI  Definition of healthy and unhealthy food premises could mask influence on FMI  Medium  Macdiarmid et al.15  Description of school lunch time purchasing behaviour  Study focuses on identifying patterns in the data collected and describing behaviour—does not cover causes  Medium  Briggs and Lake9  Description of food behaviour  No description of how analysis was completed in report. Poor description of subject’s recruitment. Analysis is referred to but not described  Medium  Devi et al.16  Correlation between food policies in schools and food behaviour  Study subjects were not intended to be representative  Medium  Estrade et al.26  Description of location of hot food takeaway in relation to schools  Struggled to recruit vendors into the study. Results may not be generalizable. Potential bias introduced due to difficulty of recruiting subjects  Good  Paper  Focus  Quality issues  Quality rating  Fraser et al.20  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  If QA of included papers was undertaken it is not described. No flowchart. Population, intervention, context and follow-up of included papers not described  Low  Harrison and Jones18  Correlation between food environment and weight  No QA of included papers carried out. No weighting of results was reported. Sensitivity of results was not reported  Medium  Fraser et al.25  Correlation of consumption of fast food and BMI  No quality issues identified  Good  Caraher et al.7  Food environment, policy, foods eaten  Consent for focus groups was not described  Medium  de Vet et al.24  Correlation between self-regulation ability and self-reported food behaviour  It was not clear why and how the included schools were selected. (Possibly a convenient sample?) Validity of questionnaire used was not described  Good  Edwards et al.14  Correlation between food behaviour and location of hot food takeaway  Home address used to categorize socio-economic status—can be inaccurate  Good  Ellaway et al.22  Description of location of hot food takeaway  No comparison group  Good  Gallo et al.23  Description of location of hot food takeaway  No issues identified  Good  Griffiths et al.19  Correlation between food environment and weight  Collapsing of food categories into one category could mask influence on BMI  Medium  Harrison et al.17  Correlation between physical environments around school, home and route from school and FMI  Definition of healthy and unhealthy food premises could mask influence on FMI  Medium  Macdiarmid et al.15  Description of school lunch time purchasing behaviour  Study focuses on identifying patterns in the data collected and describing behaviour—does not cover causes  Medium  Briggs and Lake9  Description of food behaviour  No description of how analysis was completed in report. Poor description of subject’s recruitment. Analysis is referred to but not described  Medium  Devi et al.16  Correlation between food policies in schools and food behaviour  Study subjects were not intended to be representative  Medium  Estrade et al.26  Description of location of hot food takeaway in relation to schools  Struggled to recruit vendors into the study. Results may not be generalizable. Potential bias introduced due to difficulty of recruiting subjects  Good  Table 3 Quality assessment of included papers Paper  Focus  Quality issues  Quality rating  Fraser et al.20  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  If QA of included papers was undertaken it is not described. No flowchart. Population, intervention, context and follow-up of included papers not described  Low  Harrison and Jones18  Correlation between food environment and weight  No QA of included papers carried out. No weighting of results was reported. Sensitivity of results was not reported  Medium  Fraser et al.25  Correlation of consumption of fast food and BMI  No quality issues identified  Good  Caraher et al.7  Food environment, policy, foods eaten  Consent for focus groups was not described  Medium  de Vet et al.24  Correlation between self-regulation ability and self-reported food behaviour  It was not clear why and how the included schools were selected. (Possibly a convenient sample?) Validity of questionnaire used was not described  Good  Edwards et al.14  Correlation between food behaviour and location of hot food takeaway  Home address used to categorize socio-economic status—can be inaccurate  Good  Ellaway et al.22  Description of location of hot food takeaway  No comparison group  Good  Gallo et al.23  Description of location of hot food takeaway  No issues identified  Good  Griffiths et al.19  Correlation between food environment and weight  Collapsing of food categories into one category could mask influence on BMI  Medium  Harrison et al.17  Correlation between physical environments around school, home and route from school and FMI  Definition of healthy and unhealthy food premises could mask influence on FMI  Medium  Macdiarmid et al.15  Description of school lunch time purchasing behaviour  Study focuses on identifying patterns in the data collected and describing behaviour—does not cover causes  Medium  Briggs and Lake9  Description of food behaviour  No description of how analysis was completed in report. Poor description of subject’s recruitment. Analysis is referred to but not described  Medium  Devi et al.16  Correlation between food policies in schools and food behaviour  Study subjects were not intended to be representative  Medium  Estrade et al.26  Description of location of hot food takeaway in relation to schools  Struggled to recruit vendors into the study. Results may not be generalizable. Potential bias introduced due to difficulty of recruiting subjects  Good  Paper  Focus  Quality issues  Quality rating  Fraser et al.20  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  If QA of included papers was undertaken it is not described. No flowchart. Population, intervention, context and follow-up of included papers not described  Low  Harrison and Jones18  Correlation between food environment and weight  No QA of included papers carried out. No weighting of results was reported. Sensitivity of results was not reported  Medium  Fraser et al.25  Correlation of consumption of fast food and BMI  No quality issues identified  Good  Caraher et al.7  Food environment, policy, foods eaten  Consent for focus groups was not described  Medium  de Vet et al.24  Correlation between self-regulation ability and self-reported food behaviour  It was not clear why and how the included schools were selected. (Possibly a convenient sample?) Validity of questionnaire used was not described  Good  Edwards et al.14  Correlation between food behaviour and location of hot food takeaway  Home address used to categorize socio-economic status—can be inaccurate  Good  Ellaway et al.22  Description of location of hot food takeaway  No comparison group  Good  Gallo et al.23  Description of location of hot food takeaway  No issues identified  Good  Griffiths et al.19  Correlation between food environment and weight  Collapsing of food categories into one category could mask influence on BMI  Medium  Harrison et al.17  Correlation between physical environments around school, home and route from school and FMI  Definition of healthy and unhealthy food premises could mask influence on FMI  Medium  Macdiarmid et al.15  Description of school lunch time purchasing behaviour  Study focuses on identifying patterns in the data collected and describing behaviour—does not cover causes  Medium  Briggs and Lake9  Description of food behaviour  No description of how analysis was completed in report. Poor description of subject’s recruitment. Analysis is referred to but not described  Medium  Devi et al.16  Correlation between food policies in schools and food behaviour  Study subjects were not intended to be representative  Medium  Estrade et al.26  Description of location of hot food takeaway in relation to schools  Struggled to recruit vendors into the study. Results may not be generalizable. Potential bias introduced due to difficulty of recruiting subjects  Good  Study focus Fourteen papers met the inclusion criteria. Four descriptive categories were expected within the papers,1 describing fast food impacts in the environment around schools2 describing policies in food environments surrounding schools,3 describing food related behaviour by pupils in fast food restaurants in the food environment surrounding schools and4 evaluation of interventions into the food environment designed to influence one of the three categories above (environment, behaviour and policy). The papers found were categorized into themes as described (Table 4), no papers reporting theme four were found and only three categories were used in the table below. Problems, effects or impacts of hot food takeaways in the food environment surrounding schools on BMI/weight/obesity. Strategic policy for food environments surrounding schools. Food related behaviour by pupils or adults in the environment surrounding schools. Table 4 Included papers organized by theme, showing focus, hot food takeaway definition and variables measured Title  Theme  Focus  Definition of hot food takeaway used  Variables measured  Fraser et al.25  1  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  Various: n = 26 used national or international franchises only, n = 1 macdonald’s only, n = 5 included small independent outlets plus franchises. N = 2 no definition  None  Semi-systematic review  Harrison et al.18 Observational  1  Correlation between food environment and weight  Food outlets (all) - healthy = supermarkets, green grocers and unhealthy = convenience stores and takeaways  BMI, FMI, height, socio-economic  Fraser et al.25  1  Consumption of fast food vs BMI  List of foods bought by children: chips, burgers, pizza, sandwich, pies or pasties, chocolate, crisps, fruit and other food  BMI  Survey  de Vet et al.24  1  Self-regulation ability influence on food behaviour  Unhealthy eating = sweet and salty snacks, sugar-sweetened beverages  Weight  Survey  Ellaway et al.22 Observational  1  Location of hot food takeaway  Food premises register—categories cafes, takeaways, food stores, multi-national fast food chains, fixed stance vans  None  Gallo et al.23 Observational  1  Location of hot food takeaway  Five categories—sit down eatery, convenience and instant food outlets, traditional shops, convenience shops, other food outlets  None  Griffiths et al.19 Observational  1  Correlation between food environment and weight  Food premises list—supermarkets, takeaways and retail (including petrol stations)  BMI  Estrade et al.26 Observational  1  Location of hot food takeaway in relation to schools  Independent establishments selling foods prepared on site for takeaway consumption during the school lunch period  None  Caraher et al.7 Triangulation of observations  2  Food environment, policy, foods eaten  Food premises register—category takeaway  Food premises visited by school children during lunch times  Edwards et al.14 Survey and Observational  3  Food behaviour and location of hot food takeaway  None given  BMI  Harrison and Jones18  3  School’s physical environments and behaviour  No definition given  None  Systematic review  Macdiarmid et al.15 Observational  3  School lunch time purchasing behaviour  No definition given  BMI  Briggs and Lake9  3  School food behaviour  None given  None  Descriptive  Devi et al.16 Observational  3  Food behaviour  None given  None  Title  Theme  Focus  Definition of hot food takeaway used  Variables measured  Fraser et al.25  1  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  Various: n = 26 used national or international franchises only, n = 1 macdonald’s only, n = 5 included small independent outlets plus franchises. N = 2 no definition  None  Semi-systematic review  Harrison et al.18 Observational  1  Correlation between food environment and weight  Food outlets (all) - healthy = supermarkets, green grocers and unhealthy = convenience stores and takeaways  BMI, FMI, height, socio-economic  Fraser et al.25  1  Consumption of fast food vs BMI  List of foods bought by children: chips, burgers, pizza, sandwich, pies or pasties, chocolate, crisps, fruit and other food  BMI  Survey  de Vet et al.24  1  Self-regulation ability influence on food behaviour  Unhealthy eating = sweet and salty snacks, sugar-sweetened beverages  Weight  Survey  Ellaway et al.22 Observational  1  Location of hot food takeaway  Food premises register—categories cafes, takeaways, food stores, multi-national fast food chains, fixed stance vans  None  Gallo et al.23 Observational  1  Location of hot food takeaway  Five categories—sit down eatery, convenience and instant food outlets, traditional shops, convenience shops, other food outlets  None  Griffiths et al.19 Observational  1  Correlation between food environment and weight  Food premises list—supermarkets, takeaways and retail (including petrol stations)  BMI  Estrade et al.26 Observational  1  Location of hot food takeaway in relation to schools  Independent establishments selling foods prepared on site for takeaway consumption during the school lunch period  None  Caraher et al.7 Triangulation of observations  2  Food environment, policy, foods eaten  Food premises register—category takeaway  Food premises visited by school children during lunch times  Edwards et al.14 Survey and Observational  3  Food behaviour and location of hot food takeaway  None given  BMI  Harrison and Jones18  3  School’s physical environments and behaviour  No definition given  None  Systematic review  Macdiarmid et al.15 Observational  3  School lunch time purchasing behaviour  No definition given  BMI  Briggs and Lake9  3  School food behaviour  None given  None  Descriptive  Devi et al.16 Observational  3  Food behaviour  None given  None  Table 4 Included papers organized by theme, showing focus, hot food takeaway definition and variables measured Title  Theme  Focus  Definition of hot food takeaway used  Variables measured  Fraser et al.25  1  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  Various: n = 26 used national or international franchises only, n = 1 macdonald’s only, n = 5 included small independent outlets plus franchises. N = 2 no definition  None  Semi-systematic review  Harrison et al.18 Observational  1  Correlation between food environment and weight  Food outlets (all) - healthy = supermarkets, green grocers and unhealthy = convenience stores and takeaways  BMI, FMI, height, socio-economic  Fraser et al.25  1  Consumption of fast food vs BMI  List of foods bought by children: chips, burgers, pizza, sandwich, pies or pasties, chocolate, crisps, fruit and other food  BMI  Survey  de Vet et al.24  1  Self-regulation ability influence on food behaviour  Unhealthy eating = sweet and salty snacks, sugar-sweetened beverages  Weight  Survey  Ellaway et al.22 Observational  1  Location of hot food takeaway  Food premises register—categories cafes, takeaways, food stores, multi-national fast food chains, fixed stance vans  None  Gallo et al.23 Observational  1  Location of hot food takeaway  Five categories—sit down eatery, convenience and instant food outlets, traditional shops, convenience shops, other food outlets  None  Griffiths et al.19 Observational  1  Correlation between food environment and weight  Food premises list—supermarkets, takeaways and retail (including petrol stations)  BMI  Estrade et al.26 Observational  1  Location of hot food takeaway in relation to schools  Independent establishments selling foods prepared on site for takeaway consumption during the school lunch period  None  Caraher et al.7 Triangulation of observations  2  Food environment, policy, foods eaten  Food premises register—category takeaway  Food premises visited by school children during lunch times  Edwards et al.14 Survey and Observational  3  Food behaviour and location of hot food takeaway  None given  BMI  Harrison and Jones18  3  School’s physical environments and behaviour  No definition given  None  Systematic review  Macdiarmid et al.15 Observational  3  School lunch time purchasing behaviour  No definition given  BMI  Briggs and Lake9  3  School food behaviour  None given  None  Descriptive  Devi et al.16 Observational  3  Food behaviour  None given  None  Title  Theme  Focus  Definition of hot food takeaway used  Variables measured  Fraser et al.25  1  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  Various: n = 26 used national or international franchises only, n = 1 macdonald’s only, n = 5 included small independent outlets plus franchises. N = 2 no definition  None  Semi-systematic review  Harrison et al.18 Observational  1  Correlation between food environment and weight  Food outlets (all) - healthy = supermarkets, green grocers and unhealthy = convenience stores and takeaways  BMI, FMI, height, socio-economic  Fraser et al.25  1  Consumption of fast food vs BMI  List of foods bought by children: chips, burgers, pizza, sandwich, pies or pasties, chocolate, crisps, fruit and other food  BMI  Survey  de Vet et al.24  1  Self-regulation ability influence on food behaviour  Unhealthy eating = sweet and salty snacks, sugar-sweetened beverages  Weight  Survey  Ellaway et al.22 Observational  1  Location of hot food takeaway  Food premises register—categories cafes, takeaways, food stores, multi-national fast food chains, fixed stance vans  None  Gallo et al.23 Observational  1  Location of hot food takeaway  Five categories—sit down eatery, convenience and instant food outlets, traditional shops, convenience shops, other food outlets  None  Griffiths et al.19 Observational  1  Correlation between food environment and weight  Food premises list—supermarkets, takeaways and retail (including petrol stations)  BMI  Estrade et al.26 Observational  1  Location of hot food takeaway in relation to schools  Independent establishments selling foods prepared on site for takeaway consumption during the school lunch period  None  Caraher et al.7 Triangulation of observations  2  Food environment, policy, foods eaten  Food premises register—category takeaway  Food premises visited by school children during lunch times  Edwards et al.14 Survey and Observational  3  Food behaviour and location of hot food takeaway  None given  BMI  Harrison and Jones18  3  School’s physical environments and behaviour  No definition given  None  Systematic review  Macdiarmid et al.15 Observational  3  School lunch time purchasing behaviour  No definition given  BMI  Briggs and Lake9  3  School food behaviour  None given  None  Descriptive  Devi et al.16 Observational  3  Food behaviour  None given  None  Main findings from the evidence in the included papers Theme 1: Problems, effects or impacts of hot food takeaways in the food environment surrounding schools The definition of hot food takeaway used in all papers was heterogeneous. Edwards, Macdiarmid, Briggs, Lake, Devi and Harrison did not define hot food takeaways although they referred to them within their paper’s text.9,14–17 Harrison, Jones and Griffiths categorized hot food takeaways and corner shops as unhealthy and supermarkets and green grocers as healthy.18,19 Fraser et al.20 found children accessing supermarkets to purchase crisps, chocolate and fizzy drinks therefore the categorization of a supermarket as healthy may mask health impact. The Food Standards Agency standardized coding category allows any hot food to be sold; healthy or unhealthy in a hot food takeaway.21 Caraher, Madelin, Ellaway, Griffiths, Harrison, Jones and Gallo all used food premises registration data held by the local authority to describe the food environment surrounding schools.7,17–19,22,23 Harrison used the yellow pages to confirm the location of hot food takeaways.17 Harrison and Gallo carried out a foot survey recording the location and type of all food businesses within the survey area.17,23 Using anthropometric measures Harrison, de Vet, Fraser, Edwards, Griffiths and Macdiarmid categorized children’s obesity/overweight status.14,15,18–20,24 Harrison et al.17 used both BMI and FMI to categorize their study participants. FMI is a non-standardized way of categorizing obesity, it is calculated by dividing fat mass by the height of a person, this is different to BMI where weight is divided by height to categorize. Fat mass is measured by the use of bioelectrical impedance assessment (BIA). Edwards, Fraser, Griffiths and Macdiarmid used BMI to categorize children in their studies.14,15,19,25 De Vet et al.24 used weight. BMIs were calculated using secondary data from programmes such as the National Child Measurement Programme (NCMP) or its local antecedent. Theme 2: Strategic policy for food environments surrounding schools Fraser and Edwards found children in schools were exposed to more hot food takeaways than expected and suggested this had implications for obesity control policies.25 Ellaway supported this finding; in Glasgow there are on average 35 food outlets within a 10 min walk of each secondary school.22 Harrison found some associations between obesity and the design of home and school environments, with the strongest associations observed amongst the girls in her study.17 Griffiths et al.19 paper's found ‘while consumption of fast food may be associated with obesity…the evidence from their study was not strong enough to say exposure to fast food and other food outlets in the home, school and commuting neighbourhoods increases the risk of obesity in children’. Gallo described the school fringe environment in the UK and found the provision of ‘traditional sit down eateries’ more common in affluent neighbourhoods, and there were more ‘Convenience and Instant food outlets’ in deprived areas.23 Harrison and Jones’s18 second paper included in this review suggested the physical environment of schools has an impact on children’s diet and physical activity; however, the hot food takeaway element of this study was very small. Caraher identified the need for a comprehensive public health strategy which linked across formal public health services and local authority planning services in order to impact on the foods eaten by children during the whole school day. Caraher et al.7 also recommended nutrition and education services be involved in any programmes designed to impact on obesity in children. Edwards and Clarke recommended solutions to the currently obesogenic environment around schools be designed specifically for each geographical area, raising issues of the generalizability of their work. They warned what was successful in one food environment may not work in another; they cautioned their work in Leeds was not generalizable unless local issues are taken into account as well.14 Devi et al.16 concluded the impact of treating pupils as ‘consumers’ of school catering services is they are able to undermine the financial viability of their school’s catering service. This acts as a lever to force canteens to produce food which is both popular and profitable; in today’s society this is likely to be highly processed and unhealthy. Devi also concluded treating pupils as consumers will ultimately undermine any health promoting ethos within the school canteen setting. Estrade and Dick offered a similar conclusion in their paper focusing on independent food shops in disadvantaged areas of Glasgow. They found business owners faced ‘significant barriers to offering healthy food choices’ including competition and pricing policies within neighbouring businesses.26 Theme 3: Food related behaviour by pupils or adults in the environment surrounding schools De Vet found easy access to unhealthy food products was associated with higher consumption of unhealthy foods. This was contradicted by the Griffiths review which found no evidence of a link between increased exposure to fast food and increased consumption of fast food.19,24 De Vet also found this effect was lower amongst children who used ‘self-regulation strategies to facilitate healthy eating’. Fraser et al.25 found teenagers who ate at hot food takeaways consumed more unhealthy foods and were more likely to have higher BMI SDS than those teenagers who did not eat frequently at hot food takeaways. In contrast, Macdiarmid et al.15 identified a need for wider public health strategies to improve the dietary intakes of young people across the whole day, not solely during school hours. They also found <10% of the secondary school pupils in their survey purchased high sugar foods, such as non-diet soft drinks and confectionery, every day at lunch time. Macdiarmid identified a need for wider public health strategies to improve the dietary intakes of young people across the whole day, not solely during school hours. This was supported by the work carried out by Briggs which concluded parents were the ‘key moderators of (children’s) food availability and accessibility’.9 Discussion Main findings This review found analysis of interventions that change the food environment around schools is missing from the literature. Most studies included in this review compared anthropometric measures with geographical location of hot food takeaways in order to search for correlations between environmental factors and obesity in children. Through following a standardized and wide search strategy this review aimed to locate papers focused on the hot food takeaways in the environment around schools in the UK. These areas have become the focus of attention since the first UK local authority used the planning legal process to prevent the development of fast food retail outlets in their borough.27 This review aimed to build on the evidence already published on this topic and provide insight into the potential focus of future studies. The design of the review was intended to provide the widest selection of relevant papers; the papers identified show much is known about the design of the environment surrounding schools, comparisons between deprived areas and less deprived areas were well represented in the papers found. The location of fast food outlets in relation to schools has been repeatedly documented and described. The literature also indicates the definition of hot food takeaways varies between studies. This makes comparing results difficult and may be obscuring the link between fast food geography and weight status. BMI was used as the obesity comparator because it is non-invasive, easy and cheap to gather. BMI however has drawbacks when used to categorize children.28 The use of BMI to describe children’s health status can be biased, as body composition changes substantially as children age and this is more important in the analysis of BMI in children. BMI takes no account of different body shapes, puberty or ethnicity which all affects the accuracy of a BMI calculation in children.29 FMI is rarely used in clinical settings so was used only in studies where primary anthropometric data was collected. According to Cole using the percentage of fat body mass to calculate obesity is the ideal weight categorization tool; however fat mass percentage is impractical to obtain within clinical settings for epidemiological use. Percentage fat mass is measured by passing a low voltage electrical current through the body, electrical resistance is equated to percentage fat.28 BMI status is a distal measurement, it does not change quickly, it has been difficult to prove a causal relationship between obesity status in children and adult disease.28,29 Small changes monitored in a short time period (e.g. 12 weeks) often do not equate to changes over a long period (e.g. 12 months). It is therefore difficult to rely on short-term changes in BMI as a measure of success of interventions. Proximal measurements such as food behaviour may be more accurate measures of an intervention, however these are difficult, time consuming and expensive to collect. This may explain why so many included studies relied on BMI. Using geographical data about fast food retail locations to identify saturation of hot food takeaways in a geographical location has limitations. This data is ‘point in time’; the local authority holds data on category of food premises at its last inspection but this data could be up to two years old. The accuracy of the geographical information therefore varied between studies. NCMP data was used by several of the papers as a measure of obesity. There is no guarantee the children measured in the NCMP have been exposed to the geographical area in which they are measured due to children moving house/schools. What is already known on this topic? The design and building of the environment within our cities is iterative. Planning policy is difficult to change; years may pass between the first inclination to change a policy and the change. Several more years may then pass before the built environment is significantly impacted by the policy. This makes the study of this impact difficult to analyse and time consuming. This is reminiscent of the study of exposure to cigarette smoke and its impact on health. Tobacco smoking was identified as harmful to health in the 1940s and 1950s. The prevention of exposure to tobacco smoke in the working environment was a hard won change to the built environment and was legally enshrined in the Health Act 2005.30 Similarly the correlation between fast food retail location, fast food consumption and obesity is still disputed. This lack of evidence may however indicate the inability of many papers to measure the impact of hot food takeaway exposure accurately. Cohort studies such as the Fenland Study, Cambridgeshire31 and the ALSPC32 are beginning to identify more substantial evidence for this link. Despite the lack of good evidence on hot food takeaways and health, planning policies around the UK are being changed to reduce exposure to fast food, a review by Medway Council in 2013 found 21 local authorities in England with a hot food takeaway related policy in place.10 It is therefore timely to investigate the impact of interventions that change the food environment outside the school grounds. What this study adds In future studies the location of hot food takeaways should be confirmed and the ‘healthiness’ of foods available should be rated. The assumption all hot food takeaways sell solely unhealthy foods could mask the correlation between unhealthy hot food takeaways and obesity. Future research should investigate the impact of spatial planning around schools on food behaviour. A standardized definition of fast food such as Lake’s should be used in future studies. This would allow comparisons between data sets. Analysis of the impact of changes to the food environment around schools should be undertaken. Some data are available from existing cohort studies where food behaviour has been collected over several years along with anthropometric measures. There is good evidence of higher numbers of hot food takeaways in more deprived neighbourhoods. The literature showed children who live, work and socialize in deprived neighbourhoods tend to eat more fast food and have higher BMIs. Few studies found were able to adequately quantify a correlation between the food environment surrounding schools and obesity amongst pupils attending those schools. The lack of reliable evidence found in this review is more a factor of the ability of the studies found to identify the correlation than the actual lack of a correlation between the two variables. Limitations of this study This review was not able to carry out a meta-analysis due to the heterogeneous nature of the papers found. Fast food around schools is a live topic and new research which is relevant may have been published since the database search was completed. Key points The literature provides good evidence there are higher numbers of hot food takeaways in more deprived neighbourhoods. Few studies found were able to adequately quantify a correlation between the food environment surrounding schools and obesity amongst pupils attending those schools. The lack of reliable evidence found in this systematic review regarding the impact of hot food takeaways in the food environment around schools on obesity in children attending those schools is more a factor of the ability of the studies found to identify the correlation than the actual lack of a correlation between the two variables. Future research should investigate the impact of spatial planning around schools on food behaviour amongst the population and a standardized definition of fast food such as Lake’s should be used in future studies to aid with meta-analysis. Acknowledgements Chartered Institute of Environmental Health for funding this review. Conflicts of interest None declared. References 1 Public Health England. Government H (ed). Healthy Lives, Healthy People: A Call to Action on Obesity in England . London: HM Government, 2011. 2 Swinburn BaE G, Swinburn B, Egger G. Preventive strategies against weight gain and obesity. Obes Rev  2002; 3( 4): 289– 301. doi:10.1046/j.1467-789×.2002.00082.x. Google Scholar CrossRef Search ADS PubMed  3 Public Health England, Chartered Institute of Environmental Health, Local Government Association. Obesity and the environment: regulating the growth of fast food outlets. Public Health England; 2014. 4 NICE. Guidance 42: Obesity: Working With Local Communities . London: NICE, 2012. 5 Audrey S, Batista-Ferrer H. Healthy urban environments for children and young people: a systematic review of intervention studies. Health Place  2015; 36: 97– 117. Google Scholar CrossRef Search ADS PubMed  6 Butland B, Jebb S, Kopelman K et al.  . Foresight: Tackling Obesities: Future Choices—Project Report , In: Science Gof, editor. 2nd edn. London: Foresight Programme, 2007: 164. 7 Caraher M, Lloyd S, Madelin T. The ‘School Foodshed’: schools and fast-food outlets in a London borough. Br Food J  2014; 116( 3): 472– 93. Google Scholar CrossRef Search ADS   8 Stender S, Astrup A, Dyerberg J. Fast food: unfriendly and unhealthy. Int J Obes  2007; 31: 887– 90. Google Scholar CrossRef Search ADS   9 Briggs L, Lake A. Exploring school and home food environments: perceptions of 8-10 year olds and their parents in Newcastle upon Tyne, UK. Public Health Nutr  2011; 14( 12): 2227– 35. Google Scholar CrossRef Search ADS PubMed  10 Ross A. Medway Obesity-based policies to restrict hot food takeaways: progress by local planning authorities in England. 2013. 11 Pettigrew M, Roberts H. Systematic Reviews in the Social Sciences: A Practical Guide . Victoria, Australia: Blackwell Publishing, 2006. Google Scholar CrossRef Search ADS   12 Spencer L, Ritchie J, Lewis J et al.  . Office C (ed). Quality in Qualitative Evaluation: A Framework for Assessing Research Evidence . London: Government Chief Social Researcher’s Office, 2003. 13 Greenhalgh T. How to read a paper: papers that summarise other papers (systematic reviews and meta-analyses). Br Med J  1997: 315. 14 Edwards K, Clarke G, Ransley J et al.  . The neighbourhood matters: studying exposures relevant to childhood obesity and the policy implications in Leeds, UK. J Epidemiol Coummun Health  2010; 64( 3): 194– 201. Google Scholar CrossRef Search ADS   15 Macdiarmid J, Wills W, Masson L et al.  . Food and drink purchasing habits out of school at lunchtime: a national survey of secondary school pupils in Scotland. Int J Behav Nut Phys Act  2015; 12: 98. Google Scholar CrossRef Search ADS   16 Devi A, Surender R, Rayner M. Improving the food environment in UK schools: policy opportunities and challenges. J Public Health Policy  2010; 31( 2): 212– 26. Google Scholar CrossRef Search ADS PubMed  17 Harrison F, Jones A, van Sluijs E et al.  . Environmental correlates of adiposity in 9–10 year old children: considering home and school neighbourhoods and routes to school. Social Sci Med  2011; 72( 9): 1411– 9. Google Scholar CrossRef Search ADS   18 Harrison F, Jones A. A framework for understanding school based physical environmental influences on childhood obesity. Health Place  2012; 18: 639– 48. Google Scholar CrossRef Search ADS PubMed  19 Griffiths C, Frearson A, Taylor A et al.  . A cross-sectional study investigating the association between exposure to food outlets and childhood obesity in Leeds, UK. Int J Behav Nutr Phys Act  2014; 11: 138. Google Scholar CrossRef Search ADS PubMed  20 Fraser L, Edwards K, Cade J et al.  . The georgraphy of fast food outlets: a review. Int J Environ Res Public Health  2010; 7: 2290– 308. Google Scholar CrossRef Search ADS PubMed  21 Food Standards Agency. Food Law Code of Practice: FSA; 2017. https://www.food.gov.uk/enforcement/codes-of-practice/food-law-code-of-practice. 22 Ellaway A, MacDonald L, Lamb K et al.  . Do obesity promoting food environments cluster around socially disadvantaged schools in Glasgow, Scotland? Health Place  2012; 18: 1335– 40. Google Scholar CrossRef Search ADS PubMed  23 Gallo R, Barrett L, Lake A. The food environment within the primary school fringe. Br Food J  2014; 116( 8): 1259– 75. Google Scholar CrossRef Search ADS   24 de Vet E, de Wit J, Luszczynska A et al.  . Access to excess: how do adolescents deal with unhealthy foods in their environment? Eur J Public Health  2013; 23( 5): 752– 6. Google Scholar CrossRef Search ADS PubMed  25 Fraser L, Edwards K, Cade J et al.  . Fast food, other food choices and body mass index in teenagers in the United Kingdom (ALSPAC): a structural equation modelling approach. Int J Obes  2011; 35: 1325– 30. Google Scholar CrossRef Search ADS   26 Estrade M, Dick S, Crawford F et al.  . A qualitative study of independent fast food vendors near secondary schools in disadvantaged Scottish neighbourhoods. BMC Public Health  2014; 14: 793. Google Scholar CrossRef Search ADS PubMed  27 Local Government Association. Waltham Forest Council—Banning Hot Food Takeaways to Reduce Health Inequalities: Local Government Association; 2008. http://www.local.gov.uk/health/-/journal_content/56/10180/3511421/ARTICLE. 28 Lobstein T, Baur L, Uauy R. IASO International Obsity Taskforce. Obesity in children and young people: a crisis in public health. Obes Rev  2004; 5( Suppl 1): 4– 104. Google Scholar CrossRef Search ADS PubMed  29 Cole T, Bellizzi M, Flegal K et al.  . Establishing a standard definition for child overweight and obesity worldwide: international survey. Br Med J  2000; 320( 7244): 1240– 3. Google Scholar CrossRef Search ADS   30 Procter R. The shameful past: the history of the discovery of the cigarette-lung cancer link: evidentiary traditions, corporate denial. Tob Control  2012; 2012( 21): 87– 91. Google Scholar CrossRef Search ADS   31 Burgoine T, Forouhi NG, Griffin SJ et al.  . Associations between exposure to takeaway food outlets, takeaway food consumption, and body weight in Cambridgeshire, UK: population based, cross sectional study. Br Med J  2014; 2014( 348): s.1. 32 Golding J, Pembrey M, Jones R, ALSPAC Study Team. ALSPAC—the Avon Longitudinal Study of Parents and Children. I. Study Methodology. Paediatr Perinat Epidemiol  2001; 15( 1): 74– 87. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Public Health Oxford University Press

The impact of hot food takeaways near schools in the UK on childhood obesity: a systematic review of the evidence

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Abstract

Abstract Background Obesity is the greatest health issue for this generation; schools have improved food offered within their grounds. The built environment surrounding schools and pupils’ journeys home have not received the same level of attention. This review identified papers on impacts of hot food takeaways surrounding schools in the UK. Methods Methods were informed by the PRISMA (QUORUM) guidelines for systematic reviews. Searches were completed in 12 databases. Results A total of 14 papers were included and quality assured before data extraction. Three descriptive themes were found; descriptions of hot food takeaway’s geography and impacts concerning schools, strategic food policy and pupils reported food behaviour. Conclusions Most included studies compared anthropometric measures with geographical location of hot food takeaways to find correlations between environment and childhood obesity. There was good evidence of more hot food takeaways in deprived areas and children who spend time in deprived neighbourhoods tend to eat more fast food and have higher BMIs. Few studies were able to quantify the correlation between school’s environment and obesity amongst pupils. This lack of evidence is likely a factor of the studies’ ability to identify the correlation rather than lack of a correlation between the two variables. fast food, food environment, obesity, systematic review Introduction Obesity is the greatest health issue facing the current generation; type two diabetes and other lifestyle related illnesses continue to rise within the population.1 Since ‘Jamie’s School Dinners’ was broadcast on UK television in 2005, drawing attention to the way food was managed in schools, many schools have worked hard to improve the food offer within their grounds and to influence food behaviour positively amongst their pupils. The built environment surrounding schools have not received the same attention. The term obesogenic was first identified by Boyd Swinburn,2 who defined it as the ‘sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations’. Recent guidance from the National Institute for Clinical Excellence (NICE) and Public Health England (PHE) recommend the ‘use of local planning policy to restrict development of hot food takeaways around schools, leisure centres and other areas where children accumulate’.3,4 Planning and PH professionals have demanded evidence of what makes a healthy neighbourhood.5–7 A focus has been the restriction of hot food takeaways around schools. Hot food takeaways are defined under planning guidance as providing hot food to the public without making seating available to customers to eat their meals inside the premises. They can serve any form of hot food but have been shown to serve foods which are high in salt, sugar and saturated fat;8 increased consumption of which is associated with higher risk of obesity and co-morbidities of CVD, diabetes and osteoarthritis.6 Lake has categorized hot food takeaways as ‘Convenience and instant food outlets’ providing ‘food ordered at till, food predominantly pre-prepared and held at temperature but can be prepared on ordering. Food for takeaway or immediate consumption only’.9 As the link between high fat, salt, sugar foods and obesity is more strongly evidenced, calls for controls on these foods have increased.1,3,4 Local authorities have begun to introduce policies restricting hot food takeaways, which focus most commonly on the ‘school food environment’ to enable change in individuals and their environment.10 One counterargument is hot food takeaways ‘could’ serve healthy foods. Planning legislation allows any form of hot food to be served by an ‘A5 takeaway’. The balance between encouraging or discouraging premises from opening concerns planning officers. For example, The Chartered Institute of Environmental Health’s (CIEH) ‘takeaway toolkit’ encouraged local council Environmental Health Practitioners to promote hot food takeaway owners to reduce impact on their customer’s health. The aim of this review was to identify all papers published since the identification of the obesogenic environment in 1998 focused on the impact of hot food takeaways in the food environment surrounding schools in the UK on childhood obesity. Methods The methodology of this review was informed by the PRISMA (QUORUM) guidelines for systematic reviews. Eligibility criteria Exclusion and inclusion criteria listed below in Table 1 were developed by the three researchers. Table 1 Inclusion and exclusion criteria for the systematic review Inclusion criteria  Papers reporting impacts of food environment around schools on obesity Papers reporting impacts of food environment on schools Papers based on analysis and discussion of obesity in relation to leadership, education, attitudes and behaviours Papers discussing obesity views, opinions or developments in relation to the built environment’s spatial planning Policy documents relating to obesity, children, fast food and school food cultures Papers published in English and relating to the UK  Exclusion criteria  News articles Non English Letters to academic journals Editorials Commentaries Papers not reporting empirical research Papers not published in peer reviewed journals Papers not studying the UK Papers published before 1998 Papers not mentioning fast food  Inclusion criteria  Papers reporting impacts of food environment around schools on obesity Papers reporting impacts of food environment on schools Papers based on analysis and discussion of obesity in relation to leadership, education, attitudes and behaviours Papers discussing obesity views, opinions or developments in relation to the built environment’s spatial planning Policy documents relating to obesity, children, fast food and school food cultures Papers published in English and relating to the UK  Exclusion criteria  News articles Non English Letters to academic journals Editorials Commentaries Papers not reporting empirical research Papers not published in peer reviewed journals Papers not studying the UK Papers published before 1998 Papers not mentioning fast food  Table 1 Inclusion and exclusion criteria for the systematic review Inclusion criteria  Papers reporting impacts of food environment around schools on obesity Papers reporting impacts of food environment on schools Papers based on analysis and discussion of obesity in relation to leadership, education, attitudes and behaviours Papers discussing obesity views, opinions or developments in relation to the built environment’s spatial planning Policy documents relating to obesity, children, fast food and school food cultures Papers published in English and relating to the UK  Exclusion criteria  News articles Non English Letters to academic journals Editorials Commentaries Papers not reporting empirical research Papers not published in peer reviewed journals Papers not studying the UK Papers published before 1998 Papers not mentioning fast food  Inclusion criteria  Papers reporting impacts of food environment around schools on obesity Papers reporting impacts of food environment on schools Papers based on analysis and discussion of obesity in relation to leadership, education, attitudes and behaviours Papers discussing obesity views, opinions or developments in relation to the built environment’s spatial planning Policy documents relating to obesity, children, fast food and school food cultures Papers published in English and relating to the UK  Exclusion criteria  News articles Non English Letters to academic journals Editorials Commentaries Papers not reporting empirical research Papers not published in peer reviewed journals Papers not studying the UK Papers published before 1998 Papers not mentioning fast food  Search strategies Systematic searches were carried out using the following search terms (Table 2). Table 2 Search terms Search term string  1  Obes* OR BMI OR ‘Body Mass Index’ OR ‘obesity cause*’ OR ‘obesity attitude*’ OR fat* OR adiposity OR overweight OR over-weight OR ‘over weight’  2  School* OR child* OR adolesen* OR teenag* OR ‘ school* children’ OR youth OR young* OR primary OR secondary  3  ‘hot food takeaway*’ OR HFSS OR ‘High Fat Salt Sugar’ OR A5 OR ‘Food environment’ OR ‘food culture’ OR environment OR ‘fast food’ OR takeaway  Search term string  1  Obes* OR BMI OR ‘Body Mass Index’ OR ‘obesity cause*’ OR ‘obesity attitude*’ OR fat* OR adiposity OR overweight OR over-weight OR ‘over weight’  2  School* OR child* OR adolesen* OR teenag* OR ‘ school* children’ OR youth OR young* OR primary OR secondary  3  ‘hot food takeaway*’ OR HFSS OR ‘High Fat Salt Sugar’ OR A5 OR ‘Food environment’ OR ‘food culture’ OR environment OR ‘fast food’ OR takeaway  Table 2 Search terms Search term string  1  Obes* OR BMI OR ‘Body Mass Index’ OR ‘obesity cause*’ OR ‘obesity attitude*’ OR fat* OR adiposity OR overweight OR over-weight OR ‘over weight’  2  School* OR child* OR adolesen* OR teenag* OR ‘ school* children’ OR youth OR young* OR primary OR secondary  3  ‘hot food takeaway*’ OR HFSS OR ‘High Fat Salt Sugar’ OR A5 OR ‘Food environment’ OR ‘food culture’ OR environment OR ‘fast food’ OR takeaway  Search term string  1  Obes* OR BMI OR ‘Body Mass Index’ OR ‘obesity cause*’ OR ‘obesity attitude*’ OR fat* OR adiposity OR overweight OR over-weight OR ‘over weight’  2  School* OR child* OR adolesen* OR teenag* OR ‘ school* children’ OR youth OR young* OR primary OR secondary  3  ‘hot food takeaway*’ OR HFSS OR ‘High Fat Salt Sugar’ OR A5 OR ‘Food environment’ OR ‘food culture’ OR environment OR ‘fast food’ OR takeaway  The interdisciplinary nature of the subject matter required a wide range of databases to be searched: Cochrane Library; NICE guidance, Medline; pubmed; Web of Science; AMED; CINAHL; Embase; psycinfo; SOCINDEX; TRIP (Turning Research into Practice) BMJ. These databases cover medical, educational and social science databases and were likely to find the most relevant papers from each field of study. Searches were completed in June 2016 using all three search strings simultaneously except on TRIP which prevented combined search strings. Individual search strings were used with hand searching of returned papers. Study identification Search results study titles were screened, irrelevant titles removed, remaining titles were collected and organized using ENDNOTE X4. Duplicates were removed and abstracts were downloaded for investigation. Abstracts not meeting inclusion criteria were removed. Full text copies of 18 papers were downloaded and reviewed by one researcher (C.T.); papers not meeting inclusion criteria were excluded at this stage. Overall, 15 papers were screened independently by two researchers (J.R. and C.P.) to confirm inclusion and one paper was excluded using exclusion/inclusion criteria. Quality assurance of included papers was carried out before data extraction. See Fig. 1 for selection process and results. Fig. 1 View largeDownload slide Systematic review flowchart. Fig. 1 View largeDownload slide Systematic review flowchart. Results Included studies Quality assessment and data extraction Three quality assessment processes were used as included studies applied a range of methods. Observational studies were quality assessed using criteria adapted from the CRD handbook.11 Qualitative papers were assessed using criteria adapted from Spencer’s framework for Quality in Qualitative Evaluation.12 Systematic reviews were quality assessed using criteria adapted from Greenhalgh’s ‘Improving the quality of reports of meta-analyses of randomized controlled trials: the QUORUM statement’.13 Results are listed below in Table 3. Table 3 Quality assessment of included papers Paper  Focus  Quality issues  Quality rating  Fraser et al.20  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  If QA of included papers was undertaken it is not described. No flowchart. Population, intervention, context and follow-up of included papers not described  Low  Harrison and Jones18  Correlation between food environment and weight  No QA of included papers carried out. No weighting of results was reported. Sensitivity of results was not reported  Medium  Fraser et al.25  Correlation of consumption of fast food and BMI  No quality issues identified  Good  Caraher et al.7  Food environment, policy, foods eaten  Consent for focus groups was not described  Medium  de Vet et al.24  Correlation between self-regulation ability and self-reported food behaviour  It was not clear why and how the included schools were selected. (Possibly a convenient sample?) Validity of questionnaire used was not described  Good  Edwards et al.14  Correlation between food behaviour and location of hot food takeaway  Home address used to categorize socio-economic status—can be inaccurate  Good  Ellaway et al.22  Description of location of hot food takeaway  No comparison group  Good  Gallo et al.23  Description of location of hot food takeaway  No issues identified  Good  Griffiths et al.19  Correlation between food environment and weight  Collapsing of food categories into one category could mask influence on BMI  Medium  Harrison et al.17  Correlation between physical environments around school, home and route from school and FMI  Definition of healthy and unhealthy food premises could mask influence on FMI  Medium  Macdiarmid et al.15  Description of school lunch time purchasing behaviour  Study focuses on identifying patterns in the data collected and describing behaviour—does not cover causes  Medium  Briggs and Lake9  Description of food behaviour  No description of how analysis was completed in report. Poor description of subject’s recruitment. Analysis is referred to but not described  Medium  Devi et al.16  Correlation between food policies in schools and food behaviour  Study subjects were not intended to be representative  Medium  Estrade et al.26  Description of location of hot food takeaway in relation to schools  Struggled to recruit vendors into the study. Results may not be generalizable. Potential bias introduced due to difficulty of recruiting subjects  Good  Paper  Focus  Quality issues  Quality rating  Fraser et al.20  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  If QA of included papers was undertaken it is not described. No flowchart. Population, intervention, context and follow-up of included papers not described  Low  Harrison and Jones18  Correlation between food environment and weight  No QA of included papers carried out. No weighting of results was reported. Sensitivity of results was not reported  Medium  Fraser et al.25  Correlation of consumption of fast food and BMI  No quality issues identified  Good  Caraher et al.7  Food environment, policy, foods eaten  Consent for focus groups was not described  Medium  de Vet et al.24  Correlation between self-regulation ability and self-reported food behaviour  It was not clear why and how the included schools were selected. (Possibly a convenient sample?) Validity of questionnaire used was not described  Good  Edwards et al.14  Correlation between food behaviour and location of hot food takeaway  Home address used to categorize socio-economic status—can be inaccurate  Good  Ellaway et al.22  Description of location of hot food takeaway  No comparison group  Good  Gallo et al.23  Description of location of hot food takeaway  No issues identified  Good  Griffiths et al.19  Correlation between food environment and weight  Collapsing of food categories into one category could mask influence on BMI  Medium  Harrison et al.17  Correlation between physical environments around school, home and route from school and FMI  Definition of healthy and unhealthy food premises could mask influence on FMI  Medium  Macdiarmid et al.15  Description of school lunch time purchasing behaviour  Study focuses on identifying patterns in the data collected and describing behaviour—does not cover causes  Medium  Briggs and Lake9  Description of food behaviour  No description of how analysis was completed in report. Poor description of subject’s recruitment. Analysis is referred to but not described  Medium  Devi et al.16  Correlation between food policies in schools and food behaviour  Study subjects were not intended to be representative  Medium  Estrade et al.26  Description of location of hot food takeaway in relation to schools  Struggled to recruit vendors into the study. Results may not be generalizable. Potential bias introduced due to difficulty of recruiting subjects  Good  Table 3 Quality assessment of included papers Paper  Focus  Quality issues  Quality rating  Fraser et al.20  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  If QA of included papers was undertaken it is not described. No flowchart. Population, intervention, context and follow-up of included papers not described  Low  Harrison and Jones18  Correlation between food environment and weight  No QA of included papers carried out. No weighting of results was reported. Sensitivity of results was not reported  Medium  Fraser et al.25  Correlation of consumption of fast food and BMI  No quality issues identified  Good  Caraher et al.7  Food environment, policy, foods eaten  Consent for focus groups was not described  Medium  de Vet et al.24  Correlation between self-regulation ability and self-reported food behaviour  It was not clear why and how the included schools were selected. (Possibly a convenient sample?) Validity of questionnaire used was not described  Good  Edwards et al.14  Correlation between food behaviour and location of hot food takeaway  Home address used to categorize socio-economic status—can be inaccurate  Good  Ellaway et al.22  Description of location of hot food takeaway  No comparison group  Good  Gallo et al.23  Description of location of hot food takeaway  No issues identified  Good  Griffiths et al.19  Correlation between food environment and weight  Collapsing of food categories into one category could mask influence on BMI  Medium  Harrison et al.17  Correlation between physical environments around school, home and route from school and FMI  Definition of healthy and unhealthy food premises could mask influence on FMI  Medium  Macdiarmid et al.15  Description of school lunch time purchasing behaviour  Study focuses on identifying patterns in the data collected and describing behaviour—does not cover causes  Medium  Briggs and Lake9  Description of food behaviour  No description of how analysis was completed in report. Poor description of subject’s recruitment. Analysis is referred to but not described  Medium  Devi et al.16  Correlation between food policies in schools and food behaviour  Study subjects were not intended to be representative  Medium  Estrade et al.26  Description of location of hot food takeaway in relation to schools  Struggled to recruit vendors into the study. Results may not be generalizable. Potential bias introduced due to difficulty of recruiting subjects  Good  Paper  Focus  Quality issues  Quality rating  Fraser et al.20  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  If QA of included papers was undertaken it is not described. No flowchart. Population, intervention, context and follow-up of included papers not described  Low  Harrison and Jones18  Correlation between food environment and weight  No QA of included papers carried out. No weighting of results was reported. Sensitivity of results was not reported  Medium  Fraser et al.25  Correlation of consumption of fast food and BMI  No quality issues identified  Good  Caraher et al.7  Food environment, policy, foods eaten  Consent for focus groups was not described  Medium  de Vet et al.24  Correlation between self-regulation ability and self-reported food behaviour  It was not clear why and how the included schools were selected. (Possibly a convenient sample?) Validity of questionnaire used was not described  Good  Edwards et al.14  Correlation between food behaviour and location of hot food takeaway  Home address used to categorize socio-economic status—can be inaccurate  Good  Ellaway et al.22  Description of location of hot food takeaway  No comparison group  Good  Gallo et al.23  Description of location of hot food takeaway  No issues identified  Good  Griffiths et al.19  Correlation between food environment and weight  Collapsing of food categories into one category could mask influence on BMI  Medium  Harrison et al.17  Correlation between physical environments around school, home and route from school and FMI  Definition of healthy and unhealthy food premises could mask influence on FMI  Medium  Macdiarmid et al.15  Description of school lunch time purchasing behaviour  Study focuses on identifying patterns in the data collected and describing behaviour—does not cover causes  Medium  Briggs and Lake9  Description of food behaviour  No description of how analysis was completed in report. Poor description of subject’s recruitment. Analysis is referred to but not described  Medium  Devi et al.16  Correlation between food policies in schools and food behaviour  Study subjects were not intended to be representative  Medium  Estrade et al.26  Description of location of hot food takeaway in relation to schools  Struggled to recruit vendors into the study. Results may not be generalizable. Potential bias introduced due to difficulty of recruiting subjects  Good  Study focus Fourteen papers met the inclusion criteria. Four descriptive categories were expected within the papers,1 describing fast food impacts in the environment around schools2 describing policies in food environments surrounding schools,3 describing food related behaviour by pupils in fast food restaurants in the food environment surrounding schools and4 evaluation of interventions into the food environment designed to influence one of the three categories above (environment, behaviour and policy). The papers found were categorized into themes as described (Table 4), no papers reporting theme four were found and only three categories were used in the table below. Problems, effects or impacts of hot food takeaways in the food environment surrounding schools on BMI/weight/obesity. Strategic policy for food environments surrounding schools. Food related behaviour by pupils or adults in the environment surrounding schools. Table 4 Included papers organized by theme, showing focus, hot food takeaway definition and variables measured Title  Theme  Focus  Definition of hot food takeaway used  Variables measured  Fraser et al.25  1  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  Various: n = 26 used national or international franchises only, n = 1 macdonald’s only, n = 5 included small independent outlets plus franchises. N = 2 no definition  None  Semi-systematic review  Harrison et al.18 Observational  1  Correlation between food environment and weight  Food outlets (all) - healthy = supermarkets, green grocers and unhealthy = convenience stores and takeaways  BMI, FMI, height, socio-economic  Fraser et al.25  1  Consumption of fast food vs BMI  List of foods bought by children: chips, burgers, pizza, sandwich, pies or pasties, chocolate, crisps, fruit and other food  BMI  Survey  de Vet et al.24  1  Self-regulation ability influence on food behaviour  Unhealthy eating = sweet and salty snacks, sugar-sweetened beverages  Weight  Survey  Ellaway et al.22 Observational  1  Location of hot food takeaway  Food premises register—categories cafes, takeaways, food stores, multi-national fast food chains, fixed stance vans  None  Gallo et al.23 Observational  1  Location of hot food takeaway  Five categories—sit down eatery, convenience and instant food outlets, traditional shops, convenience shops, other food outlets  None  Griffiths et al.19 Observational  1  Correlation between food environment and weight  Food premises list—supermarkets, takeaways and retail (including petrol stations)  BMI  Estrade et al.26 Observational  1  Location of hot food takeaway in relation to schools  Independent establishments selling foods prepared on site for takeaway consumption during the school lunch period  None  Caraher et al.7 Triangulation of observations  2  Food environment, policy, foods eaten  Food premises register—category takeaway  Food premises visited by school children during lunch times  Edwards et al.14 Survey and Observational  3  Food behaviour and location of hot food takeaway  None given  BMI  Harrison and Jones18  3  School’s physical environments and behaviour  No definition given  None  Systematic review  Macdiarmid et al.15 Observational  3  School lunch time purchasing behaviour  No definition given  BMI  Briggs and Lake9  3  School food behaviour  None given  None  Descriptive  Devi et al.16 Observational  3  Food behaviour  None given  None  Title  Theme  Focus  Definition of hot food takeaway used  Variables measured  Fraser et al.25  1  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  Various: n = 26 used national or international franchises only, n = 1 macdonald’s only, n = 5 included small independent outlets plus franchises. N = 2 no definition  None  Semi-systematic review  Harrison et al.18 Observational  1  Correlation between food environment and weight  Food outlets (all) - healthy = supermarkets, green grocers and unhealthy = convenience stores and takeaways  BMI, FMI, height, socio-economic  Fraser et al.25  1  Consumption of fast food vs BMI  List of foods bought by children: chips, burgers, pizza, sandwich, pies or pasties, chocolate, crisps, fruit and other food  BMI  Survey  de Vet et al.24  1  Self-regulation ability influence on food behaviour  Unhealthy eating = sweet and salty snacks, sugar-sweetened beverages  Weight  Survey  Ellaway et al.22 Observational  1  Location of hot food takeaway  Food premises register—categories cafes, takeaways, food stores, multi-national fast food chains, fixed stance vans  None  Gallo et al.23 Observational  1  Location of hot food takeaway  Five categories—sit down eatery, convenience and instant food outlets, traditional shops, convenience shops, other food outlets  None  Griffiths et al.19 Observational  1  Correlation between food environment and weight  Food premises list—supermarkets, takeaways and retail (including petrol stations)  BMI  Estrade et al.26 Observational  1  Location of hot food takeaway in relation to schools  Independent establishments selling foods prepared on site for takeaway consumption during the school lunch period  None  Caraher et al.7 Triangulation of observations  2  Food environment, policy, foods eaten  Food premises register—category takeaway  Food premises visited by school children during lunch times  Edwards et al.14 Survey and Observational  3  Food behaviour and location of hot food takeaway  None given  BMI  Harrison and Jones18  3  School’s physical environments and behaviour  No definition given  None  Systematic review  Macdiarmid et al.15 Observational  3  School lunch time purchasing behaviour  No definition given  BMI  Briggs and Lake9  3  School food behaviour  None given  None  Descriptive  Devi et al.16 Observational  3  Food behaviour  None given  None  Table 4 Included papers organized by theme, showing focus, hot food takeaway definition and variables measured Title  Theme  Focus  Definition of hot food takeaway used  Variables measured  Fraser et al.25  1  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  Various: n = 26 used national or international franchises only, n = 1 macdonald’s only, n = 5 included small independent outlets plus franchises. N = 2 no definition  None  Semi-systematic review  Harrison et al.18 Observational  1  Correlation between food environment and weight  Food outlets (all) - healthy = supermarkets, green grocers and unhealthy = convenience stores and takeaways  BMI, FMI, height, socio-economic  Fraser et al.25  1  Consumption of fast food vs BMI  List of foods bought by children: chips, burgers, pizza, sandwich, pies or pasties, chocolate, crisps, fruit and other food  BMI  Survey  de Vet et al.24  1  Self-regulation ability influence on food behaviour  Unhealthy eating = sweet and salty snacks, sugar-sweetened beverages  Weight  Survey  Ellaway et al.22 Observational  1  Location of hot food takeaway  Food premises register—categories cafes, takeaways, food stores, multi-national fast food chains, fixed stance vans  None  Gallo et al.23 Observational  1  Location of hot food takeaway  Five categories—sit down eatery, convenience and instant food outlets, traditional shops, convenience shops, other food outlets  None  Griffiths et al.19 Observational  1  Correlation between food environment and weight  Food premises list—supermarkets, takeaways and retail (including petrol stations)  BMI  Estrade et al.26 Observational  1  Location of hot food takeaway in relation to schools  Independent establishments selling foods prepared on site for takeaway consumption during the school lunch period  None  Caraher et al.7 Triangulation of observations  2  Food environment, policy, foods eaten  Food premises register—category takeaway  Food premises visited by school children during lunch times  Edwards et al.14 Survey and Observational  3  Food behaviour and location of hot food takeaway  None given  BMI  Harrison and Jones18  3  School’s physical environments and behaviour  No definition given  None  Systematic review  Macdiarmid et al.15 Observational  3  School lunch time purchasing behaviour  No definition given  BMI  Briggs and Lake9  3  School food behaviour  None given  None  Descriptive  Devi et al.16 Observational  3  Food behaviour  None given  None  Title  Theme  Focus  Definition of hot food takeaway used  Variables measured  Fraser et al.25  1  Location of hot food takeaway, definition of hot food takeaway, availability of other food outlets  Various: n = 26 used national or international franchises only, n = 1 macdonald’s only, n = 5 included small independent outlets plus franchises. N = 2 no definition  None  Semi-systematic review  Harrison et al.18 Observational  1  Correlation between food environment and weight  Food outlets (all) - healthy = supermarkets, green grocers and unhealthy = convenience stores and takeaways  BMI, FMI, height, socio-economic  Fraser et al.25  1  Consumption of fast food vs BMI  List of foods bought by children: chips, burgers, pizza, sandwich, pies or pasties, chocolate, crisps, fruit and other food  BMI  Survey  de Vet et al.24  1  Self-regulation ability influence on food behaviour  Unhealthy eating = sweet and salty snacks, sugar-sweetened beverages  Weight  Survey  Ellaway et al.22 Observational  1  Location of hot food takeaway  Food premises register—categories cafes, takeaways, food stores, multi-national fast food chains, fixed stance vans  None  Gallo et al.23 Observational  1  Location of hot food takeaway  Five categories—sit down eatery, convenience and instant food outlets, traditional shops, convenience shops, other food outlets  None  Griffiths et al.19 Observational  1  Correlation between food environment and weight  Food premises list—supermarkets, takeaways and retail (including petrol stations)  BMI  Estrade et al.26 Observational  1  Location of hot food takeaway in relation to schools  Independent establishments selling foods prepared on site for takeaway consumption during the school lunch period  None  Caraher et al.7 Triangulation of observations  2  Food environment, policy, foods eaten  Food premises register—category takeaway  Food premises visited by school children during lunch times  Edwards et al.14 Survey and Observational  3  Food behaviour and location of hot food takeaway  None given  BMI  Harrison and Jones18  3  School’s physical environments and behaviour  No definition given  None  Systematic review  Macdiarmid et al.15 Observational  3  School lunch time purchasing behaviour  No definition given  BMI  Briggs and Lake9  3  School food behaviour  None given  None  Descriptive  Devi et al.16 Observational  3  Food behaviour  None given  None  Main findings from the evidence in the included papers Theme 1: Problems, effects or impacts of hot food takeaways in the food environment surrounding schools The definition of hot food takeaway used in all papers was heterogeneous. Edwards, Macdiarmid, Briggs, Lake, Devi and Harrison did not define hot food takeaways although they referred to them within their paper’s text.9,14–17 Harrison, Jones and Griffiths categorized hot food takeaways and corner shops as unhealthy and supermarkets and green grocers as healthy.18,19 Fraser et al.20 found children accessing supermarkets to purchase crisps, chocolate and fizzy drinks therefore the categorization of a supermarket as healthy may mask health impact. The Food Standards Agency standardized coding category allows any hot food to be sold; healthy or unhealthy in a hot food takeaway.21 Caraher, Madelin, Ellaway, Griffiths, Harrison, Jones and Gallo all used food premises registration data held by the local authority to describe the food environment surrounding schools.7,17–19,22,23 Harrison used the yellow pages to confirm the location of hot food takeaways.17 Harrison and Gallo carried out a foot survey recording the location and type of all food businesses within the survey area.17,23 Using anthropometric measures Harrison, de Vet, Fraser, Edwards, Griffiths and Macdiarmid categorized children’s obesity/overweight status.14,15,18–20,24 Harrison et al.17 used both BMI and FMI to categorize their study participants. FMI is a non-standardized way of categorizing obesity, it is calculated by dividing fat mass by the height of a person, this is different to BMI where weight is divided by height to categorize. Fat mass is measured by the use of bioelectrical impedance assessment (BIA). Edwards, Fraser, Griffiths and Macdiarmid used BMI to categorize children in their studies.14,15,19,25 De Vet et al.24 used weight. BMIs were calculated using secondary data from programmes such as the National Child Measurement Programme (NCMP) or its local antecedent. Theme 2: Strategic policy for food environments surrounding schools Fraser and Edwards found children in schools were exposed to more hot food takeaways than expected and suggested this had implications for obesity control policies.25 Ellaway supported this finding; in Glasgow there are on average 35 food outlets within a 10 min walk of each secondary school.22 Harrison found some associations between obesity and the design of home and school environments, with the strongest associations observed amongst the girls in her study.17 Griffiths et al.19 paper's found ‘while consumption of fast food may be associated with obesity…the evidence from their study was not strong enough to say exposure to fast food and other food outlets in the home, school and commuting neighbourhoods increases the risk of obesity in children’. Gallo described the school fringe environment in the UK and found the provision of ‘traditional sit down eateries’ more common in affluent neighbourhoods, and there were more ‘Convenience and Instant food outlets’ in deprived areas.23 Harrison and Jones’s18 second paper included in this review suggested the physical environment of schools has an impact on children’s diet and physical activity; however, the hot food takeaway element of this study was very small. Caraher identified the need for a comprehensive public health strategy which linked across formal public health services and local authority planning services in order to impact on the foods eaten by children during the whole school day. Caraher et al.7 also recommended nutrition and education services be involved in any programmes designed to impact on obesity in children. Edwards and Clarke recommended solutions to the currently obesogenic environment around schools be designed specifically for each geographical area, raising issues of the generalizability of their work. They warned what was successful in one food environment may not work in another; they cautioned their work in Leeds was not generalizable unless local issues are taken into account as well.14 Devi et al.16 concluded the impact of treating pupils as ‘consumers’ of school catering services is they are able to undermine the financial viability of their school’s catering service. This acts as a lever to force canteens to produce food which is both popular and profitable; in today’s society this is likely to be highly processed and unhealthy. Devi also concluded treating pupils as consumers will ultimately undermine any health promoting ethos within the school canteen setting. Estrade and Dick offered a similar conclusion in their paper focusing on independent food shops in disadvantaged areas of Glasgow. They found business owners faced ‘significant barriers to offering healthy food choices’ including competition and pricing policies within neighbouring businesses.26 Theme 3: Food related behaviour by pupils or adults in the environment surrounding schools De Vet found easy access to unhealthy food products was associated with higher consumption of unhealthy foods. This was contradicted by the Griffiths review which found no evidence of a link between increased exposure to fast food and increased consumption of fast food.19,24 De Vet also found this effect was lower amongst children who used ‘self-regulation strategies to facilitate healthy eating’. Fraser et al.25 found teenagers who ate at hot food takeaways consumed more unhealthy foods and were more likely to have higher BMI SDS than those teenagers who did not eat frequently at hot food takeaways. In contrast, Macdiarmid et al.15 identified a need for wider public health strategies to improve the dietary intakes of young people across the whole day, not solely during school hours. They also found <10% of the secondary school pupils in their survey purchased high sugar foods, such as non-diet soft drinks and confectionery, every day at lunch time. Macdiarmid identified a need for wider public health strategies to improve the dietary intakes of young people across the whole day, not solely during school hours. This was supported by the work carried out by Briggs which concluded parents were the ‘key moderators of (children’s) food availability and accessibility’.9 Discussion Main findings This review found analysis of interventions that change the food environment around schools is missing from the literature. Most studies included in this review compared anthropometric measures with geographical location of hot food takeaways in order to search for correlations between environmental factors and obesity in children. Through following a standardized and wide search strategy this review aimed to locate papers focused on the hot food takeaways in the environment around schools in the UK. These areas have become the focus of attention since the first UK local authority used the planning legal process to prevent the development of fast food retail outlets in their borough.27 This review aimed to build on the evidence already published on this topic and provide insight into the potential focus of future studies. The design of the review was intended to provide the widest selection of relevant papers; the papers identified show much is known about the design of the environment surrounding schools, comparisons between deprived areas and less deprived areas were well represented in the papers found. The location of fast food outlets in relation to schools has been repeatedly documented and described. The literature also indicates the definition of hot food takeaways varies between studies. This makes comparing results difficult and may be obscuring the link between fast food geography and weight status. BMI was used as the obesity comparator because it is non-invasive, easy and cheap to gather. BMI however has drawbacks when used to categorize children.28 The use of BMI to describe children’s health status can be biased, as body composition changes substantially as children age and this is more important in the analysis of BMI in children. BMI takes no account of different body shapes, puberty or ethnicity which all affects the accuracy of a BMI calculation in children.29 FMI is rarely used in clinical settings so was used only in studies where primary anthropometric data was collected. According to Cole using the percentage of fat body mass to calculate obesity is the ideal weight categorization tool; however fat mass percentage is impractical to obtain within clinical settings for epidemiological use. Percentage fat mass is measured by passing a low voltage electrical current through the body, electrical resistance is equated to percentage fat.28 BMI status is a distal measurement, it does not change quickly, it has been difficult to prove a causal relationship between obesity status in children and adult disease.28,29 Small changes monitored in a short time period (e.g. 12 weeks) often do not equate to changes over a long period (e.g. 12 months). It is therefore difficult to rely on short-term changes in BMI as a measure of success of interventions. Proximal measurements such as food behaviour may be more accurate measures of an intervention, however these are difficult, time consuming and expensive to collect. This may explain why so many included studies relied on BMI. Using geographical data about fast food retail locations to identify saturation of hot food takeaways in a geographical location has limitations. This data is ‘point in time’; the local authority holds data on category of food premises at its last inspection but this data could be up to two years old. The accuracy of the geographical information therefore varied between studies. NCMP data was used by several of the papers as a measure of obesity. There is no guarantee the children measured in the NCMP have been exposed to the geographical area in which they are measured due to children moving house/schools. What is already known on this topic? The design and building of the environment within our cities is iterative. Planning policy is difficult to change; years may pass between the first inclination to change a policy and the change. Several more years may then pass before the built environment is significantly impacted by the policy. This makes the study of this impact difficult to analyse and time consuming. This is reminiscent of the study of exposure to cigarette smoke and its impact on health. Tobacco smoking was identified as harmful to health in the 1940s and 1950s. The prevention of exposure to tobacco smoke in the working environment was a hard won change to the built environment and was legally enshrined in the Health Act 2005.30 Similarly the correlation between fast food retail location, fast food consumption and obesity is still disputed. This lack of evidence may however indicate the inability of many papers to measure the impact of hot food takeaway exposure accurately. Cohort studies such as the Fenland Study, Cambridgeshire31 and the ALSPC32 are beginning to identify more substantial evidence for this link. Despite the lack of good evidence on hot food takeaways and health, planning policies around the UK are being changed to reduce exposure to fast food, a review by Medway Council in 2013 found 21 local authorities in England with a hot food takeaway related policy in place.10 It is therefore timely to investigate the impact of interventions that change the food environment outside the school grounds. What this study adds In future studies the location of hot food takeaways should be confirmed and the ‘healthiness’ of foods available should be rated. The assumption all hot food takeaways sell solely unhealthy foods could mask the correlation between unhealthy hot food takeaways and obesity. Future research should investigate the impact of spatial planning around schools on food behaviour. A standardized definition of fast food such as Lake’s should be used in future studies. This would allow comparisons between data sets. Analysis of the impact of changes to the food environment around schools should be undertaken. Some data are available from existing cohort studies where food behaviour has been collected over several years along with anthropometric measures. There is good evidence of higher numbers of hot food takeaways in more deprived neighbourhoods. The literature showed children who live, work and socialize in deprived neighbourhoods tend to eat more fast food and have higher BMIs. Few studies found were able to adequately quantify a correlation between the food environment surrounding schools and obesity amongst pupils attending those schools. The lack of reliable evidence found in this review is more a factor of the ability of the studies found to identify the correlation than the actual lack of a correlation between the two variables. Limitations of this study This review was not able to carry out a meta-analysis due to the heterogeneous nature of the papers found. Fast food around schools is a live topic and new research which is relevant may have been published since the database search was completed. Key points The literature provides good evidence there are higher numbers of hot food takeaways in more deprived neighbourhoods. Few studies found were able to adequately quantify a correlation between the food environment surrounding schools and obesity amongst pupils attending those schools. The lack of reliable evidence found in this systematic review regarding the impact of hot food takeaways in the food environment around schools on obesity in children attending those schools is more a factor of the ability of the studies found to identify the correlation than the actual lack of a correlation between the two variables. Future research should investigate the impact of spatial planning around schools on food behaviour amongst the population and a standardized definition of fast food such as Lake’s should be used in future studies to aid with meta-analysis. Acknowledgements Chartered Institute of Environmental Health for funding this review. Conflicts of interest None declared. References 1 Public Health England. Government H (ed). Healthy Lives, Healthy People: A Call to Action on Obesity in England . London: HM Government, 2011. 2 Swinburn BaE G, Swinburn B, Egger G. Preventive strategies against weight gain and obesity. Obes Rev  2002; 3( 4): 289– 301. doi:10.1046/j.1467-789×.2002.00082.x. Google Scholar CrossRef Search ADS PubMed  3 Public Health England, Chartered Institute of Environmental Health, Local Government Association. Obesity and the environment: regulating the growth of fast food outlets. Public Health England; 2014. 4 NICE. Guidance 42: Obesity: Working With Local Communities . 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Paediatr Perinat Epidemiol  2001; 15( 1): 74– 87. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Journal of Public HealthOxford University Press

Published: Mar 24, 2018

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