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Table 1 Summary of included studies

From: Associations between the built environment and obesity: an umbrella review

First author, number of included studies, year of publication, range of publication of primary studies in years Study design and countries/populations covered Exposure domain Summary of results ROBIS results
Urban–rural Food Physical activity Social inequality Other
Allender et al. [17], 9 studies, 2008, 1997–2007 All cross-sectional
China, Russia, the Philippines, South Korea, South Africa, Cameroon, 1 global study
X      Low-strength evidence of the following findings: a positive relationship between BMI/ cholesterol and food share of household expenditure and proportion of population in urban areas; increasing urbanization improves micronutrients but increases body weight, blood pressure and cholesterol; lifetime exposure to urban environment is correlated with BMI; lifetime exposure to urban environment is correlated with obesity and there is rapid change in diet, obesity and physical activity among LMIC. Unclear
An et al. [49], 16 studies, 2018, 2008–2017 Half longitudinal half cross-sectional
US (9), Canada, Netherlands, Serbia, China, Italy, South Korea; adults study only in US, China, Italy and the Netherlands
     Air pollution Mixed associations, results vary by age sex and type of air pollutants. Associations between pollution and weight are probably not linear and mediated by health behaviours.
Ratios of associations between exposure to respective pollutants and weight in adults by expected/unexpected/ non-significant:
PM10: 5/0/1
PM2.5: 0/0/3
O3: 4/0/3
NO2: 3/1/3
SO2: 2/0/4
Overall: 1/2/6
Unclear
Angkurawaranon et al. [34], 45 studies, 2014, 1988–2013 All cross-sectional
Malaysia, Laos, Vietnam, Thailand Indonesia, Timor-Leste, Philippines, Myanmar
X      Overall significant association between urbanicity and obesity. Pooled OR is 1.99 (95% CI: 1.64, 2.41) for South East Asia, in studies of only adults OR is 1.65 (95% CI: 1.36, 1.99) suggesting higher risks of obesity in urban areas.
Heterogeneity in associations between and within countries, some can be attributed by economic status, age/sex, time of study, BMI classification used and populations studied.
35 studies have unclear risks, two studies have different response rate per area, the rest have low risks of bias.
Low
Black and Macinko [31], 36 studies, 2008, 1997–2006 STUDY DESIGN not clearly defined
US (17), Sweden (1), Netherlands (2, Eindhoven), Scotland (2), Canada (1), Australia (1), multicounty (1)
  X X X   PA environment is more consistently associated to obesity than the food environment
Neighbourhood SES is consistently negatively associated with weight outcomes after adjusting for personal SES.
Income inequality is positively associated to obesity but not on county level; racial composition studies have different results, but racial isolation is found to be associated with increased obesity prevalence.
Unclear
Casagrande et al. [50], 10 studies, 2009, 2002–2005 STUDY DESIGN not clearly reported
All US studies; on county, multi-site, state- or nationwide samples
   X    One study on the built environment and weight status, where higher BMI increased participants’ likelihood to report physical/ environmental barrier to exercising. Unclear
Chandrabose et al. [29], 36 studies, 2019, 2007–2017 35 observational and 1 natural experiment, all longitudinal
US, Canada, Sweden, Australia, Finland, Germany, UK (Wales), Lithuania
   X    Evidence for association between walkability, recreational facilities (except greenspace), urban sprawl and obesity- presented by weighted z-score with positive, statistically significant results.
Studies on stayers tend to have higher percentage of significant associations compared to movers.
There was mismatch between perceived versus measured walkability in association with weight outcome.
Methodological issues include residential self-selection and possible mediation by physical activity.
Low
Cobb et al. [21], 71 studies, 2015, 2005–2014 11 longitudinal, the rest cross-sectional
US (64) and Canada (7)
  X     Most of associations of food stores and weight are null, indices do have significant results more often but still dominated by nulls; quality of assessed studies sub-optimal- more than 30 studies have more than three errors.
Ratios of associations between the following food stores with weight in adults by expected/unexpected/ non-significant:
Supermarket: 4/22/67
Grocery store: 14/2/77
Fast food: 29/6/71
Relative healthiness food outlet index:16/1/20 (both adults and children)
Combined healthy outlets: 2/0/2
Combined unhealthy outlets: 0/0/2
Unclear
Durand et al. [62], 44 studies, 2011, 2002–2009 Cross sectional (39) and longitudinal/ quasi-longitudinal (5)
Sweden, US, Australia, UK, Belgium, Canada
X X X    Mostly non-significant associations between eight (over a total of ten) conceptual aspects of urban planning and weight. The other two aspects have no studies so far
Associations in expected direction 0–33% of all studies, non-significant associations 66–100%.
High
Feng et al. [33], 63 studies, 2009, 2001–2008 61 cross-sectional, 4 longitudinal
US (52), Australia (5), Canada (2), Denmark, Sweden, UK, European countries
  X X    Most consistent associations with sprawl index and land use mix, mixed results for fast food density.
The overall ratio of expected/ unexpected/ non-significant associations is 40/2/38.
There is difference in definition of “place” across studies, heterogeneity in metrics to measure the built environment and geographic range. There is added value in composite scores and indices compared to single measures in obesity studies; there is dominance of cross-sectional studies reduces causation or inference power.
Unclear
Ferdinand et al. [53], 169 studies, 2012, 1995–2010 164 quantitative observational and 5 qualitative observational; no specification whether cross-sectional or longitudinal
Most studies within US (69), 60 outside and 40 with unknown locations
  X X    173/194 significant associations between food and PA environment with health benefits, results are similar in Southern states compared to others.
Characteristics associated with higher scientific vigour have fewer significant associations with health benefits.
Unclear
Fleischghacker et al. [40], 40 studies, 2011, 1998–2008 Cross sectional except for Sturm and Datar (longitudinal, children)
US, UK, Canada Australia, New Zealand
  X     Six out of ten adult studies reported increased BMI with higher fast food access.
Most studies do not have the same definition for fast food outlets or consistent sources of information or exposure methodologies.
Fast food access is also associated to increased percent of minorities and lower SES
Unclear
Fraser et al. [38], 33 studies, 2010, 2002–2009 Cross-sectional and ecological, except for Sturm and Datar (longitudinal)
US (12), Canada, UK, New Zealand (1), Australia (1)
  X     Weak association between fast food access and obesity/ overweight. There are some associations between fast food and deprivation. Overall ratios of expected/ non-expected/ non-significant associations are 6/2/5; associations are significant especially when weights are self-reported.
Highlighting inconsistencies in definition of fast food, various measures of access and geographical settings.
Unclear
Gamba et al. [39], 51 studies, 2015, 2004–2014 40 cross-sectional, 7 longitudinal, 4 repeated cross-sectional
Only US
  X     32% of all associations are significant in expected direction. Measure of presence of food stores is most likely to identify significant findings.
Community nutrition environment should include more food store and food store types. Definition of fast food restaurants is not consistent across studies and quality of food data sources is sometimes questionable.
High
Giskes et al. [41], 28 studies, 2011, 2003–2009 Cross sectional except for 1 experiment (consumption)
US, UK (obesity), Australia, Netherlands, Japan, New Zealand
    X   Studies with weight-related outcome are mostly about access to/ density or presence of food sources; associations with weight as outcomes are notably more consistent than with diet.
Ratios of associations in adults by expected/unexpected/ non-significant for weight status is 12:3:11 and for diet is 7:0:13.
Unclear
Grasser et al. [19], 34 studies, 2013, 1997–2010 33 cross-sectional, 1 prospective
US, UK, Australia, Canada, EU
   X    Walkability is more consistently associated with walking than weight outcomes; associations with weight outcomes were mixed and sometimes in the unexpected direction (especially for connectivity measure); some were significant in only a subpopulation (one city/ one gender etc.). Overall level of evidence was concluded to be low.
In terms of quality: 8 good, 16 fair and 10 poor studies.
Unclear
Hernández et al [35], 18 studies, 2012, 1964–2010 14 cross-sectional, 1 retrospective 3 prospective cohorts
Chile, Iran, Senegal, Kenya, China, Papua New Guinea, Peru, Panama, Guatemala, Tanzania, Poland, Bangladesh, India, Indonesia
X      Higher BMI in migrants compared to rural, lower BMI in migrants compared to urban, higher obesity in migrants compared to rural, lower obesity in migrant compared to urban in almost all measures of weight.
Meta-analyses show no differences between urban and rural areas. Studies are highly heterogeneous.
Same health profile observed for other cardiovascular conditions.
Low
Holsten [37], 7 studies, 2009, 2004–2006 6 studies were cross-sectional, 1 was ecologic
All US except for Simmons (Australia)
  X     Inconclusive results due to inconsistent correlations and various methods used.
Most studies focus only on fast food restaurants and associations are only significant in one subset of populations.
High
Kondo et al. [47], 68 studies, 2018, 1991–2017 Experimental studies between (14) or within (21) subjects. 20 longitudinal, 3 case–control crossover, 9 quasi-experimental
US (27), UK (13), Netherlands (5), Canada (5), Japan (4), Australia (3), Lithuania (3), Denmark (2), Germany (2), Finland, Italy and Spain (1 each)
   X    Studies focusing on adult population found no association between BMI and green space exposure.
There is a general lack of consistency in defining urban nature and measurement of its exposure hinders study quality and generalizability.
Unclear
Lachowycz et al. [18], 60 studies, 2011, 2002–2009 All cross-sectional
Australia, Canada, England, Europe, New Zealand, Portugal, Sweden, Netherlands, US
   X    Three studies with obesity-related outcome finds association between higher green space and lower adverse obesity-related outcome.
Most studies found some sort of evidence for a relationship between greenspace and weight or reported mixed results across subgroups, according to measure of greenspace.
Ratios of associations in adults by positive/ mixed/ negative/ non-significant is 3:6:1:4.
Unclear
Larson et al. [52], 54 studies, 2009, 1986–2008 Study type not mentioned in review, however discussion mentioned that they are mainly cross-sectional
US only
  X     Higher access to fresh supermarkets and limited access to corner stores are negatively associated with obesity while restaurant availability has mixed results. In general, more access to full restaurants & limited access to fast food restaurant is associated to less obesity.
There is inequality in access to supermarkets, corner stores and restaurants (lower SES—more fast food, higher SES—healthier restaurants).
Unclear
Leal and Chaix [32], 131 studies, 2011, 1985–2009 14 longitudinal (9 on weight), the rest cross sectional
US (86), Sweden, UK, Canada, Netherlands, Germany & Czech Republic, France, Italy, Lithuania, Portugal, Slovakia, Switzerland, Australia, Japan, New Zealand, Spain
X X   X   Most consistent association is between low SES and increased weight; low urbanized associated with high weight; high supermarket low convenience store low fast food associated with low weight; high street connectivity, high density of intersections and services associated with lower obesity; criminality and insecurity associated with high weight.
High traffic noise associated with high triglyceride level.
Unclear
Lovasi et al. [51], 45 studies, 2009, 1995–2009 Study type not mentioned in review, either individually or in statistics summary
All US
  X X X   Targeted groups disadvantaged in terms of access to food stores, fast food outlets, places to exercise, aesthetics and safety. Strongest support for importance of food stores, exercise facilities and safety.
The built environment might affect the high SES group more than the low SES groups due to low exposure.
Built environment interventions are more effective if targeted to the disadvantaged; especially those that help reduce disparities.
Unclear
Mackenbach et al. [23], 92 studies, 2014 2003–2013 6 longitudinal, 84 cross-sectional, 2 both
US (74), Canada, Australia, New Zealand, UK, Belgium, Portugal, EU, France, Denmark
  X X    Heterogeneity in metrics used and findings, except for urban sprawl and land use mix with clear associations with obesity within North America.
Stratification results show remaining heterogeneity within continents, mode of measurement, methodological quality. Overall weak associations between environment and weight status.
29 strong, 53 moderate and 8 weak primary studies methodologically. Reporting was moderate or strong in quality.
Low
Malambo et al. [45], 18 studies, 2016, 2005–2015 17 cross-sectional and 1 longitudinal (study on stroke)
US, New Zealand, Australia, China, Sweden, Canada
  X X    BMI is lower in walkable neighbourhoods with recreationally dense neighbourhood. BMI is higher in places with high densities of fast food restaurants not supermarkets (both American studies in somewhat older populations). High
McCormack et al. [43], 55 studies, 2019, 1998–2017 Cross-sectional (36), prospective and retrospective cohort, longitudinal, case–control, case-crossover, time series, quasi-experimental
Canadian provinces Ontario, BC, Quebec, Alberta, Nova Scotia
  X X    Consistent associations between aggregate built environment score, greenness, land use, food environment and weight status.
Somewhat less consistent associations for population/ dwelling density and mostly non-significant for route characteristics.
High
Papas et al. [20], 20 studies, 2007, 2002–2006 18 cross-sectional investigations, three of which were ecologic studies. Two longitudinal studies
US, Australia, and Europe
  X X    Food environment is less well studied than PA environment, associations differ by age groups or races. 17/20 studies found statistically significant associations between aspects of the built environment and weight.
Concerns include inconsistency of measurements of the built environment across studies, the cross-sectional design of most investigations, and the focus on aspects of either diet or physical activity but not both.
Unclear
Patterson et al. [48], 10 studies, 2019, 2008–2017 Longitudinal, controlled trials or natural/ quasi experiments
US (6), UK and China
   X    Meta-analysis of five studies show initiating public transport use was associated with 0.30 units BMI reduction 95% CI (0.14, 0.47).
Distance from the residential address to the nearest bus route had mixed associations with adiposity.
Low
Renalds et al. [46], 23 studies, 2010, 2005–2008 Mostly cross-sectional, 1 experiment, 1 retrospective review of longitudinal study
Countries not listed but seem mostly US
  X X    Mixed land use alone is not sufficient for BMI research, more investigation into specific land use (type of business within a residential neighbourhood) is needed.
Urbanity, low land use mix, crime, low street connectivity, automobile dependency increases overweight in adults.
High
Schüle and Bolte [30], 33 studies, 2015, 2005–2013 Most cross-sectional except for one British study
Belgium, Australia, Canada, US, Sweden, Germany, UK
  X X X   Nine studies looked at adult obesity and/or BMI. Eight out of 11 studies had significant associations between neighbourhood SES (NSES) and BMI/ overweight/ obesity: four high SES—low BMI and four low SES—low BMI; seven studies found significant association between built environment and BMI independent of NSES.
Two studies found associations between NSES and individual characteristics (sex/ race); six studies found interaction between BE and individual SES (ISES, in other words, associations are only significant for some subgroups: women, whites, car owners etc.)
Differences between NSES and ISES should be considered: it is not clear how NSES, built environment and sex interacted with one another.
High
Sugiyama et al. [22], 41 studies, 2014, 2010—2013 34/41 cross-sectional, 6 prospective, 1 both
US (23), Canada, UK, Australia, France, Brazil, Egypt, Belgium & Nigeria
   X    Composite environmental indices have significant associations with weight related outcome (sprawl index, pedestrian + public transport + residential density) unless it is walkability. Among the walkability components, land use mix is most consistently correlated to weight outcomes.
Utilitarian destinations also have significant associations. Leisure-activity related attributes do not contribute to obesity/ weight. Transport-related physical activity should be a target for future studies.
Ratios of associations in adults by expected: unexpected: non-significant in cross-sectional studies is 56/6/86 and in prospective studies is 9/1/10.
Unclear
Tseng et al. [42], 17 studies, 2018, 2008—2018 17 natural experiments
UK, Australia but mostly US (12)
  X X    Low level of evidence for weight/ BMI change in intervention groups.
Four out of nine interventions in PA has significant BMI reduction (ratio reduction/ inconsistent/ no difference is 4/3/2). None of the five food interventions shows BMI reduction.
The mixed environment studies (both food and PA) also have low level of evidence. Studies with significant results show associations with low clinical significance. Most studies have high risk of biases.
Low
Wilkins et al. [36], 113 studies, 2019, 2005–2018 87 cross-sectional, 26 longitudinal
US, UK, Australia, Germany, New Zealand
  X X    Overall, null associations dominated other associations. Fast food outlets associations more positive when defined more narrowly, measured in proximity rather than presence, and in low SES groups.
Percentage of associations in adults by expected/unexpected/ non-significant for each outlet is:
Fast food: 20.8/4.2/75.0 (404 associations in total)
Convenience stores: 10.9/8.5/79.6
Supermarkets/groceries store: 6.6/12.9/80.5
Restaurants: 6.3/18.4/75.3
Diverse methods used to measure food environment in five different aspects: exposure data source, extraction method, methods and definitions of food outlets, geocoding method and retail food environment metrics. Measurement methods are not well reported.
Low
  1. BMI body mass index, LMIC low and middle-income countries, SES socioeconomic status, OR odd ratio, CI confidence interval, PA physical activity, BE built environment, US United States of America, UK United Kingdom. For ROBIS result, the final judgment presented here as “low”, “high”, “unclear” risk was reached by answering a string of questions regarding multiple aspects of the original review. Unclear risks mean that there was insufficient information reported to judge whether risk of bias was high or low