Food environment and obesity: a systematic review and meta-analysis.

Background: Obesity is influenced by a complex, multifaceted system of determinants, including the food environment. Governments need evidence to act on improving the food environment. The aim of this study was to review the evidence from spatial environmental analyses and to conduct the first series of meta-analyses to assess the impact of the retail food environment on obesity. Methods: We performed a systematic review and random-effects meta-analyses, focusing on geographical-statistical methods to assess the associations between food outlet availability and obesity. We searched OvidSP-Medline, Scielo, Scopus and Google Scholar databases up to January 2022. The search terms included spatial analysis, obesity and the retail food environment. Effect sizes were pooled by random-effects meta-analyses separately according to food outlet type and geographical and statistical measures. Findings: Of the 4118 retrieved papers, we included 103 studies. Density (n=52, 50%) and linear and logistic regressions (n=68, 66%) were the main measures used to assess the association of the food environment with obesity. Multilevel or autocorrelation analyses were used in 35 (34%) studies. Fast-food outlet proximity was positively and significantly associated with obesity (OR: 1.15, 95% CI: 1.02 to 1.30, p=0.02). Fresh fruit and vegetable outlet density and supermarket proximity were inversely associated with obesity (OR: 0.93, 95% CI: 0.90 to 0.96, p<0.001; OR: 0.90, 95% CI: 0.82 to 0.98, p=0.02). No significant associations were found for restaurants, convenience stores or any of the body mass index measures. Conclusions: Food outlets which sell mostly unhealthy and ultra-processed foods were associated with higher levels of obesity, while fruit and vegetable availability and supermarket accessibility, which enable healthier food access, were related to lower levels of obesity. The regulation of food outlets through zoning laws may not be enough to tackle the burden of obesity. Regulations that focus on increasing the availability of healthy food within stores and ensure overall healthy food environments require further attention. PROSPERO registration number: CRD42018111652.