Laura A. van der Velde

Background: Pattern-based approaches to characterising neighbourhood environments have been applied across cities and regions, but it is less clear whether they can identify independent environmental effects within a single dense urban area, the scale at which most local public-health interventions are designed. Furthermore, research has primarily focused on general populations, leaving a gap in understanding how environmental factors relate to health behaviours in high-risk groups. This study aimed to (1) describe how a broad set of food-environment, green-space and walkability indicators co-occur in a highly urbanised Dutch city and how the resulting patterns relate to population density and neighbourhood socioeconomic position; and (2) explore whether these patterns are associated with weight status, diet quality and physical activity in primary-care patients at high cardiovascular risk. Methods: This cross-sectional study used baseline data from the Healthy Heart study in The Hague, Netherlands ( N = 475 participants from 73 postal codes). Twenty-three indicators across food environment, green space and walkability domains were assessed at two spatial scales. Correlation analyses examined intercorrelations among indicators and contextual characteristics. Neighbourhood patterns were identified using principal component analysis (PCA). Associations of component scores with weight status, diet quality and physical activity were examined using (multinomial) logistic and linear regression, adjusted for individual and neighbourhood-level covariates. Results: Four components explained 87% of the variance in the environmental indicators. The dominant neighbourhood pattern, characterised by high food-retail density, high walkability and low vegetation cover, correlated very strongly with population density and this coupling persisted within the most highly urbanised stratum. The “Relative food environment advantage” pattern showed the most consistent association across models with lower odds of being overweight, but also counterintuitively with lower fruit and vegetable diet quality. There was some indication of effect modification by neighbourhood socioeconomic position for this pattern. Conclusions: Within a single dense urban area, neighbourhood characteristics cluster into structured patterns in urban settings. Food environment measures remained coupled to population density even within high-density areas, fundamentally challenging independent effect estimation. Modest, paradoxical associations suggest limited environmental influence on lifestyle behaviours and weight in medically supervised high-risk populations.

Socioeconomic disparities in dietary behavior are often partially attributed to differences in the residential food environment, yet evidence linking food outlet availability to diet quality remains inconsistent. The Environmental Research framework for weight Gain prevention (EnRG) proposes that environmental influences operate through both a cognitive pathway, mediated by Theory of Planned Behavior (TPB) constructs, and a direct, automatic pathway. We tested both pathways in a Dutch sample of 1,033 adults with oversampling of low socioeconomic position (SEP), while additionally examining the role of food insecurity and financial scarcity. Outlet density and distance to nearest fast-food and fruit and vegetable outlet were measured at the postal code level. Dietary behavior, TPB constructs, food insecurity, and financial scarcity were assessed by self-report. Path analyses tested cognitive mediation; subgroup and moderation analyses examined whether food insecurity altered food environment effects. The food environment showed minimal associations with dietary consumption: only one of eight direct associations reached significance (fast-food distance and fast-food consumption), and was attenuated in path analyses. All paths from food environment characteristics to TPB constructs were non-significant, indicating no support for cognitive mediation. Food insecurity did not moderate food environment effects. In contrast, food insecurity and financial scarcity were consistently associated with lower fruit and vegetable consumption and poorer diet quality, but not with fast-food consumption. These findings suggest that, for low-SEP populations, the physical food environment plays a limited role in shaping dietary behavior, while financial constraints emerge as a key barrier. Policies that improve the affordability of healthy foods may be more effective than those targeting outlet availability alone.

Since 2020, Europe has faced several system shocks which have led to a cost-of-living crisis and an increase in prevalence of food insecurity. These events

Background: Healthy eating behaviour is an essential determinant of overall health. This behaviour is generally poor among people at risk of experiencing food insecurity, which may be caused by many factors including perceived higher costs of healthy foods, financial stress, inadequate nutritional knowledge, and inadequate skills required for healthy food preparation. Few studies have examined how these factors influence eating behaviour among people at risk of experiencing food insecurity. We therefore aimed to gain a better understanding of the needs and perceptions regarding healthy eating in this target group. Methods: We conducted a qualitative exploration with 10 participants at risk of experiencing food insecurity in the Netherlands. Results and conclusions: The analysis using an inductive approach identified four core factors influencing eating behaviour: Health related topics; Social and cultural influences; Influences by the physical environment; and Financial influences. Overall, participants showed adequate nutrition knowledge. However, eating behaviour was strongly influenced by social factors and physical environmental factors. Perceived barriers for healthy eating behaviour included poor mental health, financial stress, and high food prices. Participants had a generally conscious attitude towards their financial situation, reflected in their strategies to cope with a limited budget. Participants were familiar with several existing resources to reduce food-related financial strain and generally had a positive attitude towards these resources. An exception was the Food Bank, of which the food parcel content was not well appreciated. Proposed interventions to reduce food-related financial strain included facilitating social contacts, increasing healthy food supply in the neighbourhood, and lowering prices of healthy foods. The insights from this study increase understanding of factors influencing eating behaviour of people at risk of food insecurity.

Objectives To determine the prevalence of food insecurity among individuals with coeliac disease (CeD) and non-coeliac gluten sensitivity (NCGS) in the Netherlands and explore its association with diet quality and other barriers to adherence to a gluten-free diet. Design Mixed-method design comprising a survey and semistructured interviews. Setting An online survey was distributed through social media accounts and the newsletter of the Dutch Association for Celiac Disease. Community-dwelling patients were surveyed and interviewed between June and November 2023. Participants and outcome measures In total 548 adults with CeD and NCGS in the Netherlands who adhered to a gluten-free diet completed the survey including questions related to demographics, household food insecurity, financial stress and diet quality. Regression analyses were conducted to assess associations between food insecurity and diet quality, and between food insecurity and perceived difficulty of gluten-free eating and cooking. Additionally, semistructured interviews with eight food insecure adults with CeD were conducted. Results The prevalence of food insecurity was 23.2%, with 10.4% reporting very low food security. Very low food insecurity was associated with poorer diet quality (β=−5.5; 95% CI=−9.2 to –1.9; p=0.003). Food insecurity was associated with heightened perceived barriers across multiple themes. In age, income and education adjusted models, compared with food secure participants, low food secure participants were more likely to experience difficulty regarding skills (OR=2.5; 95% CI=1.5 to 4.3; p≤0.001), social circumstances (OR=2.6; 95% CI=1.1 to 6.4; p=0.038), resources (OR=2.5; 95% CI=1.5 to 4.4; p=0.001) and naturally gluten-free products (OR=1.8; 95% CI=1.0 to 3.1; p=0.045) in gluten-free eating and cooking. Participants with very low food security were more likely to experience difficulty regarding skills (OR=4.4; 95% CI=2.4 to 8.1; p≤0.001) and resources (OR=4.2; 95% CI=2.3 to 7.8; pConclusion These findings indicate that food insecurity is prevalent among Dutch people with CeD and NCGS, with potential impact on diet quality and adherence to a gluten-free diet. It further provided insight into perceived barriers to adhering to a gluten-free diet among this target population. These challenges should be taken into account by clinicians and policy makers.

Background: Interoception, the perception of the internal state of the body, offers an underrepresented and intriguing potential avenue for altering lifestyle-related behaviors. Interoception is intrinsically related to maintaining homeostasis and the flexible allostatic regulation of complex demands. Internal bodily states may also be influenced by lifestyle factors and related problems. This systematic review aimed to provide insight into the current state of evidence about the role of interoception in lifestyle factors. Methods: Studies from three databases (PubMed, Embase, and Web of Science) were screened for eligibility based on two inclusion criteria: 1) at least one measure of interoception (e.g., interoceptive accuracy, attention, or awareness), and 2) at least one measure of a lifestyle factor (i.e., alcohol consumption, cognitive leisure and relaxation activities, eating behavior, exercise, sleep, or smoking). Risk of bias was assessed using an adjusted quality score checklist, consisting of five items related to study design, population size, exposure measurement, outcome measurement, and adjustment for confounders. Results: The review included 73 studies. Out of the included studies, 51 measured interoceptive accuracy and 36 measured interoceptive attention. Six studies quantified interoceptive awareness. In terms of lifestyle factors, 26 studies on cognitive leisure and relaxation activities, 19 studies on eating behavior, 12 studies focused on alcohol consumption, 10 studies on exercise, five studies on smoking, and four studies on sleep were identified. Findings show positive relations between interoception and cognitive leisure and relaxation activities, eating behavior, and exercise. Conversely, the consumption of alcohol is negatively related to interoception. Studies in the smoking and sleep lifestyle factors were sparse and of varying methodological quality. Discussion: The findings of this review show that interoceptive domains are associated with various lifestyle factors, but the quality of the evidence is limited. Future longitudinal studies with more objective measures of interoception are needed in order to better understand the interrelations between interoception and lifestyle factors. Highlights: Strong support for importance of mindfulness in interoception Less strong positive relations between interoception, eating behavior, and exercise Less strong negative relation between interoception and alcohol consumption Results show lack of articles using objective interoceptive attention measures Results show lack of quantification of interoceptive awareness

Samenvatting: Inleiding: Stichting Boeren voor Buren (BvB) is een initiatief dat groente, fruit en kruiden aanbiedt tegen een lage prijs voor mensen met een laag inkomen. Ons onderzoek richt zich op de volgende vragen: wat zijn de karakteristieken, financiële status, en ervaren voedselzekerheid, gezondheid, welzijn en groente- en fruitinname van BvB-klanten? Wat is de ervaren invloed van het gebruik van BvB op groente- en fruitinname? Wat zijn redenen voor gebruik en ervaringen met het gebruik van BvB? Methoden: Het betreft een mixed-methods crosssectioneel onderzoek. Er werden interviews en vragenlijsten afgenomen onder klanten van BvB met vragen over karakteristieken, financiële status, en ervaren voedselzekerheid, gezondheid en welzijn en groente- en fruitinname, alsmede redenen voor het gebruik van BvB en ervaringen met het gebruik ervan. Resultaten en conclusie: In totaal werden 129 vragenlijsten ingevuld en 8 interviews afgenomen. De resultaten laten zien dat BvB een gemengde doelgroep bereikt: mensen met een laag inkomen en ervaren voedselonzekerheid, maar ook met relatief vaak een hbo-/universitaire opleiding en een hoge groente- en fruitinname. Deelnemers hadden minder vaak overgewicht dan de algemene bevolking, maar wel even vaak chronische aandoeningen. BvB wordt over het algemeen goed gewaardeerd door klanten. Een hoge groente- en fruitinname kan een reden zijn om klant van BvB te worden, maar er lijkt voor een deel van de klanten ook een extra positieve invloed te bestaan van BvB op de groente- en fruitinname.

Objectives To determine the prevalence of food insecurity among individuals with celiac disease (CeD) and non-celiac gluten sensitivity (NCGS) in the Netherlands and explore its association with diet quality and other barriers to adherence to a gluten-free diet. Design Mixed-method design comprising a survey and semi-structured interviews. Setting An online survey was distributed through social media accounts and the newsletter of the Dutch Association for Celiac Disease. Community-dwelling patients were surveyed and interviewed between June and November 2023. Participants and outcome measures In total 548 adults with CeD and NCGS in the Netherlands who adhered to a gluten-free diet completed the survey including questions related to demographics, household food security, financial stress and dietary quality. Regression analyses were conducted to assess associations between food insecurity and diet quality, and between food insecurity and perceived difficulty of gluten-free eating and cooking. Additionally, semi-structured interviews with 8 food insecure adults with CeD were conducted. Results The prevalence of food insecurity was 23.2%, with 10.4% reporting very low food security. Very low insecurity was associated with poorer diet quality (β=-5.5; 95%CI=-9.2,-1.9; p=0.003). Food insecurity was associated with heightened perceived barriers across multiple themes, including skills, social circumstances, resources and gluten-free products, with odds ratios ranging between 1.9-4.7 for crude models (very low food security vs food security). The qualitative analysis provided a deeper understanding of these challenges, including employed strategies to manage costs and insights into the mental burden associated with adhering to a gluten-free diet. Conclusion These findings indicate that food insecurity is prevalent among Dutch people with CeD and NCGS, with potential impact on dietary quality and adherence to a gluten-free diet. It further provided insight into perceived barriers to adhering to a gluten-free diet among this target population. These challenges should be taken into account by clinicians and policy makers. STRENGTHS AND LIMITATIONS The study provides previously unexplored insights in food insecurity among people with CeD and NCGS in the Netherlands. By employing a mixed-methods study design, the quantitative findings gained added depth as they were enriched by the personal experiences elucidated in the qualitative analysis. These provided a richer understanding of the challenges individuals face, including employed strategies to manage costs and insights into the mental burden associated with adhering to a GF diet. An inherent limitation of the study is its cross-sectional design, which prevents drawing causal conclusions regarding factors associated with food insecurity. The study relied on self-reported data through anonymous surveys, which introduces the possibility of recall bias and social desirability bias In the context of this study, food insecurity might be limited to ‘gluten-free food insecurity’ in otherwise food secure households.