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Background: Inequalities in obesity pertain in part to differences in dietary intake in different socioeconomic groups. Examining the economic, social, physical and political food environment of low-income groups as a complex adaptive system – i.e. a system of multiple, interconnected factors exerting non-linear influence on an outcome, can enhance the development and assessment of effective policies and interventions by honouring the complexity of lived reality. We aimed to develop and apply novel causal loop diagramming methods in order to construct an evidence-based map of the underlying system of environmental factors that drives dietary intake in low-income groups. Methods: A systematic umbrella review was conducted on literature examining determinants of dietary intake and food environments in low-income youths and adults in high/upper-middle income countries. Information on the determinants and associations between determinants was extracted from reviews of quantitative and qualitative studies. Determinants were organised using the Determinants of Nutrition and Eating (DONE) framework. Associations were synthesised into causal loop diagrams that were subsequently used to interpret the dynamics underlying the food environment and dietary intake. The map was reviewed by an expert panel and systems-based analysis identified the system paradigm, structure, feedback loops and goals. Results: Findings from forty-three reviews and expert consensus were synthesised in an evidence-based map of the complex adaptive system underlying the food environment influencing dietary intake in low-income groups. The system was interpreted as operating within a supply-and-demand, economic paradigm. Five sub-systems (‘geographical accessibility’, ‘household finances’, ‘household resources’, ‘individual influences’, ‘social and cultural influences’) were presented as causal loop diagrams comprising 60 variables, conveying goals which undermine healthy dietary intake. Conclusions: Our findings reveal how poor dietary intake in low-income groups can be presented as an emergent property of a complex adaptive system that sustains a food environment that increases the accessibility, availability, affordability and acceptability of unhealthy foods. In order to reshape system dynamics driving unhealthy food environments, simultaneous, diverse and innovative strategies are needed to facilitate longer-term management of household finances and socially-oriented practices around healthy food production, supply and intake. Ultimately, such strategies must be supported by a system paradigm which prioritises health. ADMS, FvL, LT, GR, MPP, SKD, MS and ANP were funded through the PEN project. The PEN project (www.jpi-pen.eu) is funded by the Joint Programming Initiative “A Healthy Diet for a Healthy Life” (JPI HDHL), a research and innovation initiative of EU member states and associated countries. The funding agencies supporting this work are (in alphabetical order of participating countries): France: Institut National de la Recherche Agronomique (INRA); Germany: Federal Ministry of Education and Research (BMBF); Ireland: Health Research Board (HRB); Italy: Ministry of Education, University and Research (MIUR); The Netherlands: The Netherlands Organisation for Health Research and Development (ZonMw); New Zealand: The University of Auckland, School of Population Health; Norway: The Research Council of Norway (RCN); Poland: The National Centre for Research and Development (NCBR).

OBJECTIVES: We examined whether using repeatedly measured material and behavioral factors contributed differently to socioeconomic inequalities in all-cause mortality compared to one baseline measurement.STUDY DESIGN AND SETTING: Data from the Dutch prospective GLOBE cohort were linked to mortality register data (1991-2013; N = 4,851). Socioeconomic position was measured at baseline by educational level and occupation. Material factors (financial difficulties, housing tenure, health insurance) and behavioral factors (smoking, leisure time physical activity, sports participation, and body mass index) were self-reported in 1991, 1997, and 2004. Cox proportional hazards regression and bootstrap methods were used to examine the contribution of baseline-only and time-varying risk factors to socioeconomic inequalities in mortality.RESULTS: Men and women in the lowest educational and occupational groups were at an increased risk of dying compared to the highest groups. The contribution of material factors to socioeconomic inequalities in mortality was smaller when multiple instead of baseline-only measurements were used (25%-65% vs. 49%-93%). The contribution of behavioral factors was larger when multiple measurements were used (39%-51% vs. 19%-40%).CONCLUSION: Inclusion of time-dependent risk factors contributes to understanding socioeconomic inequalities in mortality, but careful examination of the underlying mechanisms and suitability of the model is required.

Background Social capital is an important determinant of health, but how specific sub-dimensions of social capital affect health and health-related behaviors is still unknown. To better understand its role for health inequalities, it is important to distinguish between bonding social capital (connections between homogenous network members; e.g. similar educational level) and bridging social capital (connections between heterogeneous network members). In this study, we test the hypotheses that, 1) among low educational groups, bridging social capital is positively associated with health-behavior, and negatively associated with overweight and obesity, and 2) among high educational groups, bridging social capital is negatively associated with health-behavior, and positively with overweight and obesity. Methods Cross-sectional data on educational level, health-behavior, overweight and obesity from participants (25–75 years; Eindhoven, the Netherlands) of the 2014-survey of the GLOBE study were used (N = 2702). Social capital (“How many of your close friends have the same educational level as you have?”) was dichotomized as: bridging (‘about half’, ‘some’, or ‘none of my friends’), or bonding (‘all’ or ‘most of my friends’). Logistic regression models were used to study whether bridging social capital was related to health-related behaviors (e.g. smoking, food intake, physical activity), overweight and obesity, and whether these associations differed between low and high educational groups. Results Among low educated, having bridging social capital (i.e. friends with a higher educational level) reduced the likelihood to report overweight (OR 0.73, 95% CI 0.52–1.03) and obesity (OR 0.58, 95% CI 0.38–0.88), compared to low educated with bonding social capital. In contrast, among high educated, having bridging social capital (i.e. friends with a lower educational level) increased the likelihood to report daily smoking (OR 2.11, 95% CI 1.37–3.27), no leisure time cycling (OR 1.55, 95% CI 1.17–2.04), not meeting recommendations for vegetable intake (OR 2.09, 95% CI 1.50–2.91), and high meat intake (OR 1.39, 95% CI 1.05–1.83), compared to high educated with bonding social capital. Conclusions Bridging social capital had differential relations with health-behavior among low and high educational groups. Policies aimed at reducing segregation between educational groups may reduce inequalities in overweight, obesity and unhealthy behaviors.

Background The importance of culture for food consumption is widely acknowledged, as well as the fact that culture-based resources (“cultural capital”) differ between educational groups. Since current explanations for educational inequalities in healthy and unhealthy food consumption (e.g. economic capital, social capital) are unable to fully explain this gradient, we aim to investigate a new explanation for educational inequalities in healthy food consumption, i.e. the role of cultural capital. Methods Data were obtained cross-sectionally by a postal survey among participants of the GLOBE study in the Netherlands in 2011 (N = 2953; response 67.1%). The survey measured respondents’ highest attained educational level, food-related cultural capital (institutionalised, objectivised and incorporated cultural capital), economic capital (e.g. home ownership, financial strain), social capital (e.g. social support, health-related social leverage, interpersonal relationships), and frequency of consumption of healthy and unhealthy food products. Two general outcomes (overall healthy food consumption, and overall unhealthy food consumption), and seven specific food consumption outcomes were constructed, and prevalence ratios (PR) were estimated in Poisson regression models with robust variance. Results Cultural capital was significantly associated with all food outcomes, also when social and economic capital were taken into account. Those with low levels of cultural capital were more likely to have a lower overall healthy food consumption (PR 1.35, 95% CI 1.22–1.49), a lower consumption of whole wheat bread (PR 1.21, 95% CI 1.05–1.38), vegetables (PR 1.55, 95% CI 1.40–1.71), and meat-substitutes and fish (PR 1.74, 95% CI 1.53–1.97), and a higher consumption of fried food (PR 1.59, 95% CI 1.31–1.93). Social capital was positively associated with overall healthy food consumption, whole wheat bread consumption, and the consumption of fish and meat-substitutes, and economic capital with none of the outcomes. The PR of the lowest educational group to have a low overall healthy food consumption decreased from 1.48 (95% CI 1.28–1.73) to 1.22 (95% CI 1.04–1.43) when cultural, social and economic capital were taken into account. Conclusions Cultural capital contributed to the explanation of educational inequalities in food consumption in The Netherlands, over and above economic and social capital. The socialisation processes through which cultural capital is acquired could offer new entry-points for the promotion of healthy food consumption among low educational groups. Electronic supplementary material The online version of this article (10.1186/s12939-018-0884-z) contains supplementary material, which is available to authorized users.

Background: Why lower socioeconomic groups behave less healthily can only partly be explained by direct costs of behaving healthily. We hypothesize that low income increases the risk of facing financial strain. Experiencing financial strain takes up cognitive 'bandwidth' and leads to less self-control, and subsequently results in more unhealthy behaviour. We therefore aim to investigate (i) whether a low income increases the likelihood of experiencing financial strain and of unhealthy behaviours, (ii) to what extent more financial strain is associated with less self-control and, subsequently, (iii) whether less self-control is related to more unhealthy behaviour.Methods: Cross-sectional survey data were obtained from participants (25-75 years) in the fifth wave of the Dutch GLOBE study (N = 2812) in 2014. The associations between income, financial strain, self-control and health-behaviour-related outcomes (physical inactivity in leisure-time, obesity, smoking, excessive alcohol intake, and weekly fruit and vegetable intake) were analysed with linear regression and generalized linear regression models (log link).Results: Experiencing great compared with no financial strain increased the risk of all health-behaviour-related outcomes, independent of income. Low self-control, as compared with high self-control, also increased the risk of an unhealthy lifestyle. Taking self-control into account slightly attenuated the associations between financial strain and the outcomes.Conclusion: Great financial strain and low self-control are consistently associated with unhealthy behaviours. Self-control may partly mediate between financial strain and unhealthy behaviour. Interventions that relieve financial strain may free up cognitive bandwidth and improve health behaviour.

Background Food literacy refers to the capability to make healthy food choices in different contexts, settings and situations. The aim of this study is to develop and validate the self-perceived food literacy (SPFL) scale, to assess individuals’ level of food literacy, including a knowledge, skills and behavior to plan, manage, select, prepare and eat food healthfully. Methods An initial set of 50 items for the SPFL scale were generated based on expert insights and literature. A cross-sectional online survey was conducted among a sample of Dutch adults (n = 755) in order to determine convergent, divergent and criterion validation against psychosocial variables that were expected to correlate with food literacy (self-control, impulsiveness) and against the expected outcome of high food literacy, namely healthy food consumption. Principal Component Analyses (PCA), Pearson correlation tests and linear regression analyses were conducted. The capacity to distinguish of the SPFL scale was determined by comparing SPFL scores of the general population with that of a sample of dieticians (n = 207). Results The participants in the general sample had an average age of 44.8 (SD:16.1), the majority were women (90.7%), they had a healthy weight (61.4%) and were highly educated (59.1%). Of the initial 50 items, 29 items remained after PCA and reflected eight domains of food literacy. SPFL was positively correlated with self-control (r = 0.51, p =

BACKGROUND: The key mechanisms underlying socioeconomic inequalities in dietary intake are still poorly understood, hampering the development of interventions. An important, but sparsely mentioned mechanism is that of 'social distinction', whereby those in a higher socioeconomic position adopt dietary patterns by which they can distinguish themselves from lower socioeconomic groups. We investigated the importance of distinction as a mechanism, by testing the socioeconomic gradient in the consumption of so-called 'superfoods' and the contribution of a well-established indicator of distinction, cultural participation.METHODS: Data from participants (25-75 years) of the 2014 survey of the Dutch population-based GLOBE study were used (N = 2812). Multivariable regression models were used to analyse the association between education, income and cultural participation (e.g. visits to museums, opera, theatre, concerts) and the consumption of superfoods (spelt, quinoa and goji berries, chia seeds or wheatgrass).RESULTS: The consumption of superfoods is far more prevalent among higher socioeconomic groups. Adjusting for cultural participation strongly attenuated the educational and income gradient in superfoods consumption, whereas cultural participation remained strongly associated with superfoods consumption. Those in the highest quintile of cultural participation reported the highest consumption of spelt products (OR = 2.97, 95% CI = 2.10;4.18), quinoa (OR = 3.50, 95% CI = 2.12;5.79) and goji berries, chia seeds or wheatgrass (OR = 2.69, 95% CI = 1.73;4.17).CONCLUSIONS: The associations between socioeconomic position and the consumption of 'superfoods' seem to be partially driven by a process of social distinction. These findings suggest that distinction may be an important, but currently neglected mechanism in generating socioeconomic inequalities in dietary intake. It deserves a more prominent role in interventions to reduce these inequalities.

Background: The evidence on the association between politics and health is scarce considering the importance of this topic for population health. Studies that investigated the effect of different political regimes on health outcomes show inconsistent results. Methods: Bayesian time-series cross-section analyses are used to examine the overall impact of regional politics on variations in Italian regional life expectancy (LE) at birth during the period 1980–2010. Our analyses control for trends in and unobserved determinants of regional LE, correct for temporal as well as spatial autocorrelation, and employ a flexible specification for the timing of the political effects. Results: In the period from 1980 to 1995, we find no evidence that the communist, left-oriented coalitions and Christian Democratic, centre-oriented coalitions have had an effect on regional LE. In the period from 1995 onwards, after a major reconfiguration of Italy’s political regimes and a major healthcare reform, we again find no evidence that the Centre-Left and Centre-Right coalitions have had a significant impact on regional LE. Conclusion: The presented results provide no support for the notion that different regional political regimes in Italy have had a differential effect on regional LE, even though Italian regions have had considerable and increasing autonomy over healthcare and health-related policies and expenditures.

Background Since 2003, a harm reduction program for injecting drug users has been rolled out countrywide in China. It entails services for condom promotion, a needle and syringe program (NSP), and methadone maintenance treatment (MMT). However, it remains unknown if and to what extent the coverage of these services at city level is related to a reduced risk of HIV infection among drug users. Methods We wished to quantify the extent to which city-level characteristics (such as NSP and MMT service coverage) and individual-level determinants (e.g., self-reported exposure to NSP and MMT services, knowledge, motivation, and skills) were associated with the risk of HIV infection among drug users. In 2006, we conducted an integrated serological and behavioral survey among drug users in five cities of Yunnan Province, China (N = 685), constructing a multilevel logistic regression model with drug users clustered within these cities. Results Drug users who reported having received NSP or MMT services were about 50% less likely to be infected with HIV than those who reported not having received them (OR 0.45, 95% CI, 0.26–0.83 for NSP and 0.48, 95% CI, 0.31–0.73 for MMT). Despite a between-city variation of HIV infection risk (ICC 0.24, 95% CI 0.08–0.54), none of the city-level factors could explain this difference. Individual-level determinants such as perceived risk of infection and use of condoms were not associated with HIV infection. Conclusions Although people who had used NSP or MMT services were less likely to be HIV infected, this study found no relationship between city-level coverage of HIV prevention programs and variations in HIV infection between cities. This may have been due to the low number of cities in the analysis. Future research should include the analysis of data from a larger number of cities, which are collected widely in China through integrated behavioral and serological surveys. Electronic supplementary material The online version of this article (doi:10.1186/s12954-017-0137-2) contains supplementary material, which is available to authorized users.

Although physical activity is often believed to be influenced by both environmental and individual factors, little is known about their interaction. This study explores interactions of perceived safety and social neighborhood factors with psychosocial cognitions for leisure-time walking. Cross-sectional data were obtained from residents (age 25-75 years) of 212 neighborhoods in the South-East of the Netherlands, who participated in the Dutch GLOBE study in 2004 (N = 4395, survey response 64.4%). Direct associations of, and interactions between perceived neighborhood safety, social neighborhood factors (social cohesion, social network and feeling at home) and psychosocial cognitions (attitude, self-efficacy, social influence and intention) on two outcomes of leisure-time walking [yes versus no (binary), and among walkers: minutes per week (continuous)] were analyzed in multilevel regression models. The association between attitude and participating in leisure-time walking was stronger in those who felt less at home in their neighborhood. Social influence and attitude were stronger associated with participation in leisure-time walking in those who sometimes felt unsafe in their neighborhood. A positive intention was associated with more minutes walked in those who perceived their neighborhood as unsafe among those who walked. Only limited support was found for interactions between neighborhood perceptions and psychosocial cognitions for leisure-time walking.

Background: Behavioural, material and psychosocial risk factors may explain educational inequalities in general health. To what extent these risk factors have similar or different contributions to educational inequalities in mental health is unknown. Methods: Data were derived from the Norwegian Survey of Level of Living from 2005, comprising 5791 respondents aged ≥25 years. The study objectives were addressed by means of a series of logistic regression analyses in which we examined: (i) educational inequalities in self-reported general and mental health; (ii) the associations between behavioural, material and psychosocial risk factors and general and mental health, controlled for sex, age and education; and (iii) the contribution of risk factors to the observed health gradients. Results: The lower educated were more likely to be in poor health [odds ratio (OR): 3.46 (95% confidence interval, CI: 2.84–4.21)] and to be in poor mental health [OR: 1.41 (95% CI: 1.12–1.78)] than the highest educated. The joint contribution of behavioural, material and psychosocial risk factors explained all the variations of mental health inequalities, whereas these were able to explain ∼40% of the inequalities in general health. Both behavioural and material risk factors contributed substantially to the explanation of general and mental health inequalities, whereas the psychosocial risk factor (i.e. having close persons to communicate with) only seemed to make a larger difference for the explanation of mental health inequalities. Conclusion: Policies and interventions to reduce health inequalities should have a broad focus. Combined strategies should be applied to improve physical activity, decrease smoking and improve material and psychosocial conditions among lower educated groups, to achieve the true potential of reducing inequalities in both general and mental health.

Background Living longer independently may be facilitated by an attractive and safe residential area, which stimulates physical activity. We studied the association between area characteristics and disabilities and whether this association is mediated by transport-related physical activity (TPA). Methods Longitudinal data of 271 Dutch community-dwelling adults aged 65 years and older participating in the Elderly And their Neighbourhood (ELANE) study in 2011–2013 were used. Associations between objectively measured aesthetics (range 0–22), functional features (range 0–14), safety (range 0–16), and destinations (range 0–15) within road network buffers surrounding participants’ residences, and self-reported disabilities in instrumental activities of daily living (range 0–8; measured twice over a 9 months period) were investigated by using longitudinal tobit regression analyses. Furthermore, it was investigated whether self-reported TPA mediated associations between area characteristics and disabilities. Results A one unit increase in aesthetics within the 400 m buffer was associated with 0.86 less disabilities (95% CI −1.47 to −0.25; p

Socioeconomic inequalities in body weight have been demonstrated in numerous cross-sectional studies; however, little research has investigated these inequalities from a life course and longitudinal perspective. We examined the association between child- and adulthood socioeconomic position (SEP) and BMI and overweight/obesity in 1991 ( baseline) and changes in BMI and the prevalence of overweight and obesity between 1991 and 2004. Data from the 1991 and 2004 waves of the longitudinal Dutch GLOBE study were used. Participants ( n = 1,465) were aged 40-60 years at baseline. BMI was calculated from self-reported height and weight collected by postal questionnaire. Retrospective recall of father's occupation was used as childhood socioeconomic indicator, and adulthood SEP was measured by the occupation of the main income earner of the household. The findings showed that among women, childhood SEP exerted a greater influence on body weight than SEP in adulthood: at baseline, women from disadvantaged backgrounds in childhood had a higher BMI and were more likely to be overweight or obese, and they gained significantly more weight between baseline and follow-up. In contrast, adult SEP had a greater impact than childhood circumstances on men's body weight: those from disadvantaged households had a higher mean BMI and were more likely to be overweight or obese at baseline, and they gained significantly more weight between 1991 and 2004. The findings suggest that exposure to disadvantaged circumstances at critically important periods of the life course is associated with body weight and weight gain in adulthood. Importantly, these etiologically relevant periods differ for men and women, suggesting gender-specific pathways to socioeconomic inequalities in body weight in adulthood.

Purpose: To examine the contribution of neighborhood, household, and individual factors to socioeconomic inequalities in sports participation in a multilevel design. Methods: Data were obtained by a large-scale postal survey among a stratified sample of the adult population (age 25-75 yr) of Eindhoven (the fifth-largest city of the Netherlands) and surrounding areas, residing in 213 neighborhoods (N = 4785; response rate 64.4%). Multilevel logistic regression analyses were performed with sports participation as a binary outcome (no vs yes); that is, respondents not doing any moderate- or high-intensity sports at least once a week were classified as nonparticipants. Results: Unfavorable perceived neighborhood factors (e.g., feeling unsafe, small social network), household factors (material and social deprivation), and individual physical activity cognitions (e.g., negative outcome expectancies, low self-efficacy) were significantly associated with doing no sports and were reported more frequently among lower socioeconomic groups. Taking these factors into account reduced the odds ratios of doing no sports among the lowest educational group by 57%, from 3.99 (95% Cl, 2.99-5.31) to 2.29 (95% Cl, 1.70-3.07), and among the lowest income group by 67%, from 3.02 (95% C, 2.36-3.86) to 1.66 (95% Cl, 1.22-2.27). Conclusions: A combination of neighborhood, household, and individual factors can explain socioeconomic inequalities in sports participation to a large extent. Interventions and policies should focus on all three groups of factors simultaneously to yield a maximal reduction of socioeconomic inequalities in sports participation.

Background Moderate to vigorous physical activity (MVPA) is considered important to prevent disability among community-dwelling older people. To develop MVPA programs aimed at reducing or preventing disability more insight is needed in the contributions of exercise duration and intensity and the interplay between the two. Methods Longitudinal data of 276 Dutch community-dwelling persons aged 65 years and older participating in the Elderly And their Neighbourhood (ELANE) study were used. MVPA exercise (yes/no), duration (hours per two weeks), intensity (Metabolic Equivalent of Task; METs), and energy expenditure (MET-hours per two weeks), and disability in instrumental activities of daily living (range 0–8) were measured twice within 9 months to account for fluctuations over time. Associations between the four exercise measures and disability were tested with longitudinal tobit regression analyses. Results MVPA exercise was associated with fewer disabilities. While exercise duration was not associated with disability, whereas an increase of one MET in exercise intensity was associated with 0.14 fewer disabilities (95 % CI: -0.26 to -0.02). For exercise energy expenditure, an increase of one MET-hour exercise per two weeks was associated with 0.03 fewer disabilities (95 % CI: -0.05 to -0.01). Conclusions Higher-intensity exercise may help to prevent disability among community-dwelling older people. Further investigation is needed to explore the preventive effects in more detail.

Socio-economic groups differ in their material, living, working and social circumstances, which may result in different priorities about their daily-life needs, including the priority to make healthy food choices. Following Maslow's hierarchy of human needs, we hypothesised that socio-economic inequalities in healthy food choices can be explained by differences in the levels of need fulfilment. Postal survey data collected in 2011 (67·2 % response) from 2903 participants aged 20–75 years in the Dutch GLOBE (Gezondheid en Levens Omstandigheden Bevolking Eindhoven en omstreken) study were analysed. Maslow's hierarchy of human needs (measured with the Basic Need Satisfaction Inventory) was added to age- and sex-adjusted linear regression models that linked education and net household income levels to healthy food choices (measured by a FFQ). Most participants (38·6 %) were in the self-actualisation layer of the pyramid. This proportion was highest among the highest education group (47·6 %). Being in a higher level of the hierarchy was associated with a higher consumption of fruits and vegetables as well as more healthy than unhealthy bread, snack and dairy consumption. Educational inequalities in fruit and vegetable intake (B= − 1·79, 95 % CI − 2·31, − 1·28 in the lowest education group) were most reduced after the hierarchy of needs score was included (B= − 1·57, 95 % CI − 2·09, − 1·05). Inequalities in other healthy food choices hardly changed after the hierarchy of needs score was included. People who are satisfied with higher-level needs make healthier food choices. Studies aimed at understanding socio-economic inequalities in food choice behaviour need to take differences in the priority given to daily-life needs by different socio-economic groups into account, but Maslow's pyramid offers little help.

BACKGROUND Healthiness, price, and convenience are typically indicated as important motives for food choices; however, it is largely unknown to what extent older adults from high and low socioeconomic groups differ in these underlying motives. A discrete choice experiment (DCE) is an innovative way to elicit implicit motives for food choices. OBJECTIVE The aim was to investigate differences in food motives between socioeconomic groups by means of a DCE. DESIGN A DCE was carried out during a face-to-face interview among older adults as part of the Health and Living Conditions in Eindhoven and surrounding cities (GLOBE) cohort study, The Netherlands. Participants (n = 399; mean age: 63.3 y) were offered a series of choice sets about a usual dinner at home and were asked to choose in each choice set between 2 meals and an opt-out choice, with different combinations of attribute levels. We included 5 meal attributes (taste, healthiness, preparation time, travel time to shops, and price) and 3 or 4 levels for each attribute. Data were analyzed by multinomial logit models. RESULTS Healthiness, taste, price, and travel time to the grocery store proved to significantly influence older adults' meal decisions; preparation time was not significant. Healthiness was the most important attribute for all of the participants. More highly educated participants rated a healthy and less expensive meal to be more important than did less educated participants. Those with a high income rated a meal that was healthy and very tasteful to be more important than did those with a lower income. CONCLUSIONS Healthiness, taste, price, and travel time to grocery shops influenced older adults' meal decisions. Higher socioeconomic groups valued health more than did lower socioeconomic groups. DCEs represent a promising method to gain insight into the relative importance of motives for food choices. This trial was registered at www.isrctn.com as ISRCTN60293770.

Purpose: The purpose of this longitudinal study is to identify risk groups for disengagement from sports during adolescence. In addition, it will be explored whether cognitive and environmental factors can explain socio-demographic differences in disengagement from sports. Methods: Data were obtained from the Environmental Determinants of Obesity in Rotterdam Schoolchildren study, and 357 adolescents were eligible for analysis. Socio-demographics (gender, ethnicity, education), individual cognitions and neighbourhood perceptions were assessed at baseline (2005/2006), and sports participation at baseline and at follow-up (2007/2008). Two dichotomous outcome variables were constructed: (i) disengagement from sports (yes/no) and (ii) ceased compliance with the fitnorm (i.e. cease engaging in sports epsilon 3 times/wk) (yes/no). In logistic regression and mediation analyses, we identified socio-demographic differences in the two outcomes. Subsequently, we applied mediation analyses to identify the contribution of cognitive and environmental explanatory factors of the socio-demographic differences. Results: Girls [odds ratio (OR): 2.5, 95% confidence interval (CI): 1.5-4.5] were more likely than boys to disengage from sports. Girls (OR: 2.5, 95% CI: 1.4-4.2), adolescents of non-Western background (OR: 1.8, 95% CI: 1.0-3.0) and those in lower educational levels (OR: 1.7, 95% CI: 1.0-2.9) were more likely to cease compliance with the fitnorm. Perceived neighbourhood safety partly explained gender differences in disengagement from sports (8%). Intention partly explained ethnical (32%) and educational differences (37%) in ceasing compliance with the fitnorm. Conclusions: Girls, lower-educated adolescents and those with a non-Western background showed more pronounced reductions in sports participation and compliance with the fitnorm. Intention and perceived neighbourhood safety could partially explain these differences.

To describe educational inequalities in cancer survival and to what extent these can be explained by comorbidity and health behaviours (smoking, physical activity and alcohol consumption).The GLOBE study sent postal questionnaires to individuals in The Netherlands in 1991 resulting in 18 973 respondents (response 70%). Questions were asked on education, health and health-related behaviours. Participants were linked for cancer diagnosis (1991-2008), comorbidity and survival (up to 2010) with the population-based Eindhoven Cancer Registry; 1127 tumours were included in the analyses.5-year crude survival was best in highly educated patients as compared with low educated patients for all cancers combined: 49% versus 32% in male subjects (log rank: p0.0001), 65% versus 49% in female subjects (p=0.0001). Compared with highly educated, low educated prostate cancer patients had an increased risk of death (HR 2.9 (95% CI 1.7 to 5.1), adjusted for age, stage and year). No or inconsistent associations between educational level and risk of death were seen in multivariable analyses for breast, colon and non-small cell lung cancer. Although survival in prostate cancer patients was affected by comorbidities (HR2_vs_0_comorbidities: 2.6 (1.5 to 4.4)), physical activity (HRno/little_vs__moderate_physical__activity: 2.0 (1.2 to 3.4)) and smoking (HRcurrent_vs_never_smokers: 2.6 (1.0-6.8)), these did not contribute to educational inequalities in prostate cancer survival (HRlow_vs_high_education: 3.1 (1.6 to 5.8) with adjustment for comorbidity and lifestyle).Compared with low educated, highly educated prostate cancer patients had better survival. Although presence of comorbidities, physical activity levels and smoking status affected survival from prostate cancer, these did not contribute to educational inequalities in survival. The role of other factors for inequalities in cancer survival needs to be explored.

Background Our goal was to study associations between childhood socioeconomic position (SEP), adulthood SEP, adulthood risk factors and cardiovascular disease (CVD) mortality, by investigating the critical period and pathway models. Methods The prospective GLOBE study in the Netherlands, with baseline data from 1991, was linked with cause of death register data from Statistics Netherlands in 2007. At baseline, respondents reported information on childhood SEP (i.e. occupational level of respondent's father), adulthood SEP (educational level), and adulthood risk factors (health behaviours, material circumstances, and psychosocial factors). Analyses included 4894 men and 5572 women. Data were analysed by Cox proportional hazard ratios (HR) with CVD mortality as the outcome. Results Childhood SEP was associated with CVD mortality among men with the lowest childhood SEP only (HR 1.32, 95% CI 1.00–1.74), and not among women. The majority of childhood SEP inequalities in CVD mortality among men (88%) were explained by material, behavioural and psychosocial risk factors in adulthood, and adulthood SEP. This was mostly due to the association of childhood SEP with adulthood SEP, and the interrelations of adulthood SEP with risk factors, and partly via the direct association of childhood SEP with adulthood risk factors, independent of adulthood SEP. Conclusion This study supports the pathway model for men, but found no evidence that socioeconomic conditions in childhood are critical for CVD mortality in later life independent of adulthood conditions. Developing effective methods to reduce material and behavioural risk factors among lower socioeconomic groups should be a top priority in cardiovascular disease prevention.

Objective To describe and explain the association between maternal educational level and television viewing time among preschool children. Method We analyzed data from 2786 preschoolers enrolled in a birth cohort study in Rotterdam, The Netherlands, between 2002 and 2006. Odds ratios of watching television ≥ 2 hours/day and ≥ 1 hour/day were calculated for children of mothers with low, mid-low, and mid-high educational level (reference group: high educational level), before and after adjustment for mediators. Results Children of low, mid-low, and mid-high educated mothers were more likely to watch television ≥ 2 hours/day compared to children of high educated mothers, with children of low educated mother showing the highest risk (OR: 11.32; 95% CI: 6.58, 19.46). Adjustment for mediators (i.e. maternal body mass index, parental television viewing, presence of a television set in the child's bedroom, and financial difficulties) led to a nearly 50% reduction in odds ratio for the lowest educational group (OR: 6.61; 95% CI: 3.69, 11.84). A similar educational gradient was found for watching television ≥ 1 hour/day, although effect estimates were smaller. Conclusion Maternal education is inversely associated with preschoolers' television viewing time. This association was partly explained by known correlates of children's television viewing.

To successfully stimulate cycling, it is necessary to understand the factors that facilitate or inhibit cycling. Little is known about how changes in the neighborhood environment are related to changes in cycling behavior.This study aimed to identify environmental determinants of the uptake of cycling after relocation.The RESIDential Environment Project (RESIDE) is a longitudinal natural experiment of people moving into new housing developments in Perth (Western Australia). Self-reported usual transport and recreational cycling behavior, as well as self-reported and objective built environmental factors were measured before and after residential relocation. Participants who did not usually cycle at baseline in 2003-2004 were included in the study. Logistic regression models were used to relate changes in built environmental determinants to the probability of taking up cycling after relocation (2005-2006). Analyses were carried out in 2010-2011.At baseline, 90% (n=1289) of the participants did not cycle for transport and 86% (n=1232) did not cycle for recreation. After relocation, 5% of the noncyclists took up transport-related cycling, and 7% took up recreational cycling. After full adjustment, the uptake of transport-related cycling was determined by an increase in objective residential density (OR=1.54, 95% CI=1.04, 2.26) and self-reported better access to parks (OR=2.60, 95% CI=1.58, 4.27) and other recreation destinations (OR=1.57, 95% CI=1.12, 2.22). Commencing recreational cycling mostly was determined by an increase in objective street connectivity (OR=1.20, 95% CI=1.06, 1.35).Changes in the built environment may support the uptake of cycling among formerly noncycling adults.

Background: This study assessed the contributions of individual, household and neighbourhood-level factors to socio-economic inequalities in smoking. Methods: Data came from 2706 participants of the 2004 wave of the Dutch GLOBE study. Participants were asked about several social and material characteristics of their households, neighbourhoods and smoking in their environment. Indicators of socio-economic position were education and income. Associations with daily smoking were examined using logistic regression analyses. Results: Education and income were independently associated with daily smoking (mutually adjusted odds ratios for the lowest education and income groups: odds ratio (OR): 2.87, 95% confidence interval (95% CI): 1.78-4.62; OR: 1.55, 95% CI: 1.09-2.23, respectively). Individual beliefs about smoking contributed most to the association of education with daily smoking. Individual beliefs about smoking and household material adversity contributed most to the association of income with daily smoking. We found no evidence that negative perceptions of the neighbourhood contributed to smoking inequalities. In fully adjusted models, associations between income and smoking were fully attenuated, but an independent association between education and smoking remained. Conclusion: Education and income were related to smoking through partly different pathways. Reducing inequalities in smoking may require a multidimensional approach targeting material and social factors, with strategies targeted towards the individual and the household level. © The Author 2011. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

Compared to people with a high socioeconomic status, those with a lower socioeconomic status are more likely to perceive their neighbourhood as unattractive and unsafe, which is associated with their lower levels of physical activity. Agreement between objective and perceived environmental factors is often found to be moderate or low, so it is questionable to what extent 'creating supportive neighbourhoods' would change neighbourhood perceptions. This study among residents (N=814) of fourteen neighbourhoods in the city of Eindhoven (the Netherlands), investigated to what extent socioeconomic differences in perceived neighbourhood safety and perceived neighbourhood attractiveness can be explained by five domains of objective neighbourhood features (i.e. design, traffic safety, social safety, aesthetics, and destinations), and to what extent other factors may play a role. Unfavourable neighbourhood perceptions of low socioeconomic groups partly reflected their actual less aesthetic and less safe neighbourhoods, and partly their perceptions of low social neighbourhood cohesion and adverse psychosocial circumstances. (C) 2010 Elsevier Ltd. All rights reserved.

Objective: To examine whether compositional and/or contextual area characteristics are associated with area socioeconomic inequalities and between-area differences in recreational cycling. Setting: The city of Melbourne, Australia. Participants: 2349 men and women residing in 50 areas (58.7% response rate). Main outcome measure: Cycling for recreational purposes ( at least once a month vs never). Design: In a cross-sectional survey participants reported their frequency of recreational cycling. Objective area characteristics were collected for their residential area by environmental audits or calculated with Geographic Information Systems software. Multilevel logistic regression models were performed to examine associations between recreational cycling, area socioeconomic level, compositional characteristics ( age, sex, education, occupation) and area characteristics ( design, safety, destinations or aesthetics). Results: After adjustment for compositional characteristics, residents of deprived areas were less likely to cycle for recreation ( OR 0.66; 95% CI 0.43 to 1.00), and significant between-area differences in recreational cycling were found ( median odds ratio 1.48 ( 95% credibility interval 1.24 to 1.78). Aesthetic characteristics tended to be worse in deprived areas and were the only group of area characteristics that explained some of the area deprivation differences. Safety characteristics explained the largest proportion of between-area variation in recreational cycling. Conclusion: Creating supportive environments with respect to safety and aesthetic area characteristics may decrease between-area differences and area deprivation inequalities in recreational cycling, respectively.

There is increased recognition that determinants of health should be investigated in a life-course perspective. Retirement is a major transition in the life course and offers opportunities for changes in physical activity that may improve health in the aging population. The authors examined the effect of retirement on changes in physical activity in the GLOBE Study, a prospective cohort study known by the Dutch acronym for "Health and Living Conditions of the Population of Eindhoven and surroundings," 1991-2004. They followed respondents (n = 971) by postal questionnaire who were employed and aged 40-65 years in 1991 for 13 years, after which they were still employed (n = 287) or had retired (n = 684). Physical activity included 1) work-related transportation, 2) sports participation, and 3) nonsports leisure-time physical activity. Multinomial logistic regression analyses indicated that retirement was associated with a significantly higher odds for a decline in physical activity from work-related transportation (odds ratio (OR) = 3.03, 95% confidence interval (CI): 1.97, 4.65), adjusted for sex, age, marital status, chronic diseases, and education, compared with remaining employed. Retirement was not associated with an increase in sports participation (OR = 1.12, 95% CI: 0.71, 1.75) or nonsports leisure-time physical activity (OR = 0.80, 95% CI: 0.54, 1.19). In conclusion, retirement introduces a reduction in physical activity from work-related transportation that is not compensated for by an increase in sports participation or an increase in nonsports leisure-time physical activity.

Background: Lower educated older persons are at increased risk of becoming frail as compared with higher educated older persons. To reduce educational inequalities in the development of frailty, we investigated whether lifestyle, health and social participation mediate this relationship. Methods: Longitudinal data of 14 082 European community-dwelling persons aged 55 years and older participating in the Survey on Health, Ageing, and Retirement in Europe (SHARE) in 2004 and 2006, were used. Associations of lifestyle (smoking behaviour and alcohol consumption), health (depression, memory function, chronic diseases) and social participation, with educational level and frailty worsening were investigated using regression models. In multinomial logistic regression analysis, mediators were added to models in which educational level was associated with worsening in frailty over 2 years follow-up. Results: In all countries, frailty worsening was more prevalent among lower as compared with higher educated persons, although odds ratios were only statistically significant in five of the 11 countries included [ORs varying from 1.40 (95% CI: 1.06-1.84) to 1.61 (95% CI: 1.21-2.14)]. Except for smoking behaviour and memory function, the factors under study all showed associations with educational level and frailty worsening that met the conditions for mediation. After inclusion of the four relevant mediators, attenuation of odds ratios varied between 4.9 and 31.5%. Conclusion: While lifestyle, health and social participation were associated with frailty worsening over 2 years among European community-dwelling older persons, only small to moderate parts of educational inequalities in frailty worsening were explained by these factors.

A focus group study was conducted to explore how perceptions of environmental influences on health behaviours pattern across socioeconomic groups in the Netherlands. Participants perceived their spouse's and friend's health behaviour and support as highly important. People from lower socioeconomic backgrounds reported poor neighbourhood aesthetics, safety concerns and poor access to facilities as barriers for being physically active, while easy accessibility to sports facilities was mentioned by high socioeconomic participants. The availability of fruits and vegetables at home was perceived as good by all particpants. Overall, lower socioeconomic groups expressed more price concerns. Possible pathways between socioeconomic status, environmental factors and health behaviours are represented in a framework, and they should be investigated further in longitudinal research.

Background Little is known about the interaction between individual and environmental determinants of physical activity, although this may be important information for the development of effective interventions. The goal of this paper is to investigate whether perceived neighborhood safety modifies associations between individual cognitions and sports participation. Methods Cross-sectional data were obtained from residents (age 25-75) of 87 neighborhoods in the city of Eindhoven, who participated in the Dutch GLOBE study in 2004 (N = 2474). We used multilevel logistic regression to analyze the interactions between perceived neighborhood safety and individual cognitions (attitude, self-efficacy, social influence, and intention) on sports participation (yes/no). Results In its association with sports participation, perceived neighborhood safety interacted significantly with self-efficacy and attitude (p < 0.05). Among persons who perceived their neighborhood as safe, a positive attitude was strongly associated with sports participation (OR = 2.00, 95%CI = 1.48-2.71). In contrast, attitude was not associated with sports participation in persons who perceived their neighborhood as unsafe (OR = 0.65, 95%CI = 0.34-1.24). Further, self-efficacy was significantly stronger associated with sports participation in persons who perceived their neighborhood as unsafe (OR = 1.85, 95%CI = 1.31-2.60) than in those who perceived their neighborhood as safe (OR = 1.19, 95%CI = 1.05-1.36). Social influence and intention did not interact with perceived neighborhood safety. Conclusions Associations between individual cognitions and sports participation depend on neighborhood circumstances, such as perceived neighborhood safety. Interventions to promote sports participation in adults should take the interaction between environmental and individual characteristics into account. More research is needed to find out the causal pathways in individual-environment interactions.

Background The mechanisms underlying socioeconomic inequalities in mortality from cardiovascular diseases (CVD) are largely unknown. We studied the contribution of childhood socioeconomic conditions and adulthood risk factors to inequalities in CVD mortality in adulthood. Methods The prospective GLOBE study was carried out in the Netherlands, with baseline data from 1991, and linked with the cause of death register in 2007. At baseline, participants reported on adulthood socioeconomic position (SEP) (own educational level), childhood socioeconomic conditions (occupational level of respondent’s father), and a broad range of adulthood risk factors (health behaviours, material circumstances, psychosocial factors). This present study is based on 5,395 men and 6,306 women, and the data were analysed using Cox regression models and hazard ratios (HR). Results A low adulthood SEP was associated with increased CVD mortality for men (HR 1.84; 95% CI: 1.41-2.39) and women (HR 1.80; 95%CI: 1.04-3.10). Those with poorer childhood socioeconomic conditions were more likely to die from CVD in adulthood, but this reached statistical significance only among men with the poorest childhood socioeconomic circumstances. About half of the investigated adulthood risk factors showed significant associations with CVD mortality among both men and women, namely renting a house, experiencing financial problems, smoking, physical activity and marital status. Alcohol consumption and BMI showed a U-shaped relationship with CVD mortality among women, with the risk being significantly greater for both abstainers and heavy drinkers, and among women who were underweight or obese. Among men, being single or divorced and using sleep/anxiety drugs increased the risk of CVD mortality. In explanatory models, the largest contributor to adulthood CVD inequalities were material conditions for men (42%; 95% CI: −73 to −20) and behavioural factors for women (55%; 95% CI: -191 to −28). Simultaneous adjustment for adulthood risk factors and childhood socioeconomic conditions attenuated the HR for the lowest adulthood SEP to 1.34 (95% CI: 0.99-1.82) for men and 1.19 (95% CI: 0.65-2.15) for women. Conclusions Adulthood material, behavioural and psychosocial factors played a major role in the explanation of adulthood SEP inequalities in CVD mortality. Childhood socioeconomic circumstances made a modest contribution, mainly via their association with adulthood risk factors. Policies and interventions to reduce health inequalities are likely to be most effective when considering the influence of socioeconomic circumstances across the entire life course and in particular, poor material conditions and unhealthy behaviours in adulthood.

Background This study examined whether characteristics of the residential built environment (i.e. population density, level of mixed land use, connectivity, accessibility of facilities, accessibility of green) contributed to educational inequalities in walking and cycling among adults. Methods Data from participants (32–82 years) of the 2011 survey of the Dutch population-based GLOBE study were used (N = 2375). Highest attained educational level (independent variable) and walking for transport, cycling for transport, walking in leisure time and cycling in leisure time (dependent variables) were self-reported in the survey. GIS-systems were used to obtain spatial data on residential built environment characteristics. A four-step mediation-based analysis with log-linear regression models was used to examine to contribution of the residential built environment to educational inequalities in walking and cycling. Results As compared to the lowest educational group, the highest educational group was more likely to cycle for transport (RR 1.13, 95% CI 1.04–1.23), walk in leisure time (RR 1.12, 95% CI 1.04–1.21), and cycle in leisure time (RR 1.12, 95% CI 1.03–1.22). Objective built environment characteristics were related to these outcomes, but contributed minimally to educational inequalities in walking and cycling. On the other hand, compared to the lowest educational group, the highest educational group was less likely to walk for transport (RR 0.91, 95% CI 0.82–1.01), which could partly be attributed to differences in the built environment. Conclusion This study found that objective built environment characteristics contributed minimally to educational inequalities in walking and cycling in the Netherlands. Electronic supplementary material The online version of this article (doi:10.1186/s12942-017-0083-y) contains supplementary material, which is available to authorized users.