News Release

Unhealthy food environments may play a role in increasing rates of childhood obesity in low- and middle-income countries

Peer-Reviewed Publication

Arnold School of Public Health

Hala Ghattas


Hala Ghattas is a health promotion, education, and behavior associate professor at the University of South Carolina's Arnold School of Public Health. 

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Credit: Anna Wippold

Research led by health promotion, education, and behavior associate professor Hala Ghattas in collaboration with scientists at the American University of Beirut and the Tunisian National Institute of Nutrition and Food Technology has revealed what may be a major factor in the rise of childhood obesity in the Middle East and North Africa. Published in Public Health Nutrition, the study found that 60% of food retailers and advertisements in urban school neighborhoods of Greater Tunis, Tunisia were unhealthy.

“Over the last decades, childhood overweight and obesity have dramatically increased in low- and middle-income countries, with the Middle East and North Africa region experiencing one of the largest increases in childhood obesity rates,” Ghattas says. “Complex and intertwined factors have been shown to influence children’s diet and nutritional status, with school neighborhood food environments potentially playing a major role in shaping children’s food choices and subsequently their weight status.”

To better understand the role of the food available and promoted to children living in these areas with increasing rates of obesity, the researchers examined the offerings of more than 3600 retailers and nearly 2100 advertisements in proximity (within 800 meters) to 50 primary schools in Greater Tunis. Their analysis of these built food environments revealed that about two-thirds of these retailer-advertisement sets were classified as unhealthy.

Their mapping also showed that traditional corner stores made up the largest proportion (22%) of retailers, while fruit and vegetables stands claimed only 6% of the market. Carbonated and sugar-sweetened beverages accounted for the largest food group promoted (22%).

As is typical of contexts going through a nutrition transition, the proportion of unhealthy retailers was significantly higher in richer areas, which contrasts with findings from high-income countries, where unhealthy food options and higher obesity rates disproportionately impact members of lower socioeconomic groups..

“Schools and their neighborhoods are key sites that influence food choices as children spend a large portion of their day in schools and their surrounding areas – whether before or after school or sometimes even during lunch or recess,” Ghattas says. “Food environments might influence food habits through direct access to foods or through food cues and desire.”

This research therefore contributes to documenting the impact of the nutrition transition on children’s diets and helps to inform policies and interventions to curb the emergent childhood obesity epidemic.

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