Does neighborhood fast-food outlet exposure amplify inequalities in diet and obesity? A cross-sectional study12

BACKGROUND Greater exposures to fast-food outlets and lower levels of education are independently associated with less healthy diets and obesity. Little is known about the interplay between these environmental and individual factors. OBJECTIVE The purpose of this study was to test whether observed differences in fast-food consumption and obesity by fast-food outlet exposure are moderated by educational attainment. DESIGN In a population-based cohort of 5958 adults aged 29-62 y in Cambridgeshire, United Kingdom, we used educational attainment-stratified regression models to estimate the food-frequency questionnaire-derived consumption of energy-dense "fast foods" (g/d) typically sold in fast-food restaurants and measured body mass index (BMI; in kg/m(2)) across geographic information system-derived home and work fast-food exposure quartiles. We used logistic regression to estimate the odds of obesity (BMI ≥30) and calculated relative excess risk due to interaction (RERI) on an additive scale. Participant data were collected during 2005-2013 and analyzed in 2015. RESULTS Greater fast-food consumption, BMI, and odds of obesity were associated with greater fast-food outlet exposure and a lower educational level. Fast-food consumption and BMI were significantly different across education groups at all levels of fast-food outlet exposure (P < 0.05). High fast-food outlet exposure amplified differences in fast-food consumption across levels of education. The relation between fast-food outlet exposure and obesity was only significant among those who were least educated (OR: 2.05; 95% CI: 1.08, 3.87; RERI = 0.88), which suggested a positive additive interaction between education and fast-food outlet exposure. CONCLUSION These findings suggest that efforts to improve diets and health through neighborhood-level fast-food outlet regulation might be effective across socioeconomic groups and may serve to reduce observed socioeconomic inequalities in diet and obesity.