The influence of the urban food environment on diet, nutrition and health outcomes in low-income and middle-income countries: A systematic review

Susannah Westbury, Iman Ghosh, Helen Margaret Jones, Daniel Mensah, Folake Samuel, Ana Irache, Nida Azhar, Lena Al-Khudairy, Romaina Iqbal, Oyinlola Oyebode

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28 Citations (Scopus)
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Diet and nutrition are leading causes of global morbidity and mortality. Our study aimed to identify and synthesise evidence on the association between food environment characteristics and diet, nutrition and health outcomes in low-income and middle-income countries (LMICs), relevant to urban settings, to support development and implementation of appropriate interventions. 


We conducted a comprehensive search of 9 databases from 1 January 2000 to 16 September 2020 with no language restrictions. We included original peer-reviewed observational studies, intervention studies or natural experiments conducted in at least one urban LMIC setting and reporting a quantitative association between a characteristic of the food environment and a diet, nutrition or health outcome. Study selection was done independently in duplicate. Data extraction and quality appraisal using the National Heart Lung and Blood Institute checklists were completed based on published reports using a prepiloted form on Covidence. Data were synthesised narratively. 


74 studies met eligibility criteria. Consistent evidence reported an association between availability characteristics in the neighbourhood food environment and dietary behaviour (14 studies, 10 rated as good quality), while the balance of evidence suggested an association with health or nutrition outcomes (17 of 24 relevant studies). We also found a balance of evidence that accessibility to food in the neighbourhood environment was associated with diet (10 of 11 studies) although evidence of an association with health outcomes was contradictory. Evidence on other neighbourhood food environment characteristics was sparse and mixed. Availability in the school food environment was also found to be associated with relevant outcomes. Studies investigating our other primary outcomes in observational studies of the school food environment were sparse, but most interventional studies were situated in schools. We found very little evidence on how workplace and home food environments are associated with relevant outcomes. This is a substantial evidence gap. Conclusion 'Zoning' or 'healthy food cart' interventions to alter food availability may be appropriate in urban LMIC. PROSPERO registration number CRD42020207475.

Original languageEnglish
Article numbere006358
Pages (from-to)e006358
JournalBMJ Global Health
Issue number10
Publication statusPublished - 11 Oct 2021

Bibliographical note

Funding Information:
1School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria, Australia 2Warwick Medical School, University of Warwick, Coventry, UK 3School of Life Sciences, Coventry University, Coventry, UK 4Department of Human Nutrition and Dietetics, University of Ibadan, Ibadan, Oyo, Nigeria 5Department of Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan Acknowledgements OO, RI and AI are supported by the UK’s National Institute of Health Research (NIHR) Global Health Research Unit on Improving Health in Slums. LA-K is supported by the NIHR Applied Research Centre-West Midlands. DM is supported by a University of Warwick Chancellor’s International Scholarship. The authors wish to acknowledge support from Samantha Johnson, academic librarian at University of Warwick, on developing the search strategy. The authors wish to acknowledge Dr. Yen-Fu Chen, associate professor at University of Warwick, for screening a study in Chinese.

Funding Information:
Funding OO, RI and AI are supported by the NIHR Global Health Research Unit on Improving Health in Slums.

Publisher Copyright:
© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.


  • health policy
  • nutrition
  • nutritional and metabolic disorders
  • public health
  • systematic review

ASJC Scopus subject areas

  • Health Policy
  • Public Health, Environmental and Occupational Health


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