Eating disorders are equally prevalent across socioeconomic status, and yet individuals facing socioeconomic adversity are far less likely to receive evidence-based treatments. A range of barriers contribute to this disparity, including limited awareness and provider training about eating disorders leading to underdiagnosis; a shortage of available services and long waitlists due to a lack of trained therapists, associated treatment costs (e.g. transportation expenses and costly treatment materials) and an insufficient understanding of the impact of an individual’s cultural context. While these barriers are experienced by many individuals with eating disorders, those with low income are particularly vulnerable. To ensure equitable access to effective eating disorder treatment, therapists should actively consider and address the barriers faced by these patients. In this paper, we share guidance based on our experience treating a socioeconomically diverse patient population, on factors to consider when extending the reach of recommended psychological treatments for eating disorders and suggest areas of future research. We emphasize the opportunities available to therapists to improve equity in eating disorders treatment by making accommodations that enhance access to existing evidence-based approaches rather than by making modifications to the treatments.

1. (1) To identify obstacles experienced by individuals with eating disorders and low income in accessing and engaging in treatment.

2. (2) To learn practical strategies to reduce or eliminate barriers preventing the uptake of evidence-based psychological eating disorder interventions for individuals with low income.

3. (3) To appreciate the intersectionality of low income with other factors impacting equity of eating disorder treatment access.

The aim of this study was to investigate the social and environmental factors involved in the food decision-making processes of families living on lower incomes on the Island of Ireland.

A qualitative design was employed for this study, using photovoice and creative mapping methods. Parents were requested to take photos and draw maps of their food environments. Interviews were then conducted with parents, using the materials produced by parents as a cue to discuss their food environments, influences and decision-making processes around food choices.

The participants were interviewed online via Microsoft Teams.

The participants were parents or guardians of children between the ages of 2 and 18 who self-defined as ‘living on a tight budget’.

Twenty-eight participants were recruited and interviewed for this study, including twelve parents in Northern Ireland and sixteen in the Republic of Ireland. The findings were mapped on to Bronfenbrenner’s Ecological Systems Theory and showed that multiple, overlapping and intersecting factors at the individual, micro-, meso-, exo-, macro- and chrono-system were implicated in family food choices. Upstream factors in particular, including structural, policy and commercial determinants, appear to be significant drivers of behaviour.

While the findings suggest that a complex range of factors are involved in family food choices, it is clear that policy measures and regulations are needed to stave off the impacts of rising social inequality and food poverty. Health promoters should strive to find non-stigmatising interventions to bridge the nutritional divide experienced by lower-income families.

Given the rapidly changing food environment and proliferation of ultra-processed foods (UPF) in South Africa (SA), this study aimed to critically evaluate dietary quality and adequacy of low-income adults using the Nova classification system and WHO and World Cancer Research Fund dietary guidelines.

Secondary household data and 1-d 24-h recalls were analysed from two cross-sectional studies conducted in 2017–2018. Foods consumed were classified according to the Nova classification system. Compliance with WHO dietary guidelines and UPF consumption trends were evaluated.

Three low-income areas (Langa, Khayalitsha and Mount Frere) in SA were included.

In total, 2521 participants (18–50 years) were included in the study.

Participants had a mean energy intake of 7762 kJ/d. Most participants were within the acceptable WHO guideline range for saturated fat (80·4 %), total fat (68·1 %), Na (72·7 %) and free sugar (57·3 %). UPF comprised 39·4 % of diets among the average adult participant. Only 7·0 % of all participants met the WHO guideline for fruit and vegetables and 18·8 % met the guideline for fibre. Those within the highest quartile of share of energy from UPF consumed statistically higher amounts of dietary components to limit and were the highest energy consumers overall.

Low-income adults living in SA are consuming insufficient protective dietary components, while UPF consumption is prevalent. Higher UPF consumers consume larger amounts of nutrients linked to increased chronic disease risk. Policy measures are urgently needed in SA to protect against the proliferation of harmful UPF and to promote and enable consumption of whole and less UPF.

In 2016, a Whole Foods Market© opened in the Englewood community of Chicago, IL – a predominately low-income African American community. This study aimed to examine changes to food and beverage availability and marketing in Englewood’s existing food stores after the opening of this supermarket.

Quasi-experimental study.

Two low-income African American communities in Chicago, IL.

Fieldworkers audited all small grocery and limited service stores (e.g. convenience stores, liquor stores and dollar/discount stores) located within one-square mile of the new supermarket and a one-square mile area of a demographically comparable community that also lacked a supermarket. Stores were audited before (2016) and after (2017 and 2018) the supermarket opened.

Of the 78 stores audited at baseline, 71·8 % were limited service stores and 85·9 % accepted Supplemental Nutrition Assistance Program (SNAP) benefits. Overall, the availability of healthy food and beverage options in nearby small stores was low at baseline and both follow-up periods. Difference-in-difference regression models revealed a significant increase in: (1) the percentage of stores in the intervention community (i.e. Englewood) offering regular cheese and promoting salty snacks at check-out from 2016 to 2017; and (2) the percentage of stores in the comparison community with interior store promotions for other sweetened beverages from 2016 to 2018.

Minimal changes in food and beverage availability and marketing occurred 1 and 2 years after the opening of a new supermarket. However, the wide range of staple food items offered by the supermarket expanded healthy food retail in Chicago’s Englewood community.

To test the feasibility of implementing and evaluating a healthier checkout pilot study in a convenience store chain.

A quasi-experimental study was conducted comparing a 3-month ‘healthier checkouts’ intervention in ten convenience stores which stocked eight healthier items in the checkout space and ten comparison stores assigned to continue stocking their current checkout space product mix. All aspects of the intervention were implemented by the retailer. The research team conducted in-person fidelity checks to assess implementation. Sales data were collected from the retailer in order to compare mean baseline to intervention sales of the eight healthier items in intervention and comparison groups while controlling for overall store sales.

Convenience store chain.

Twenty convenience stores in New Hampshire.

The increases in sales of healthier items between the baseline and intervention periods among the intervention and comparison stores were not statistically significant; however, the overall pattern of the results showed promising changes that should be expanded on in future studies. Intervention fidelity checks indicated that results may have been attenuated by variability in intervention implementation.

This study advances the evidence for effective promotion of healthier food purchases in the convenience store chain setting and adds to the current literature on retail checkout space interventions. Additional research is needed to confirm and expand these results.

Food insecurity is associated with a greater risk of depression among low-income adults in the USA. Members of food-insecure households have lower diet diversity than their food-secure counterparts. This study examined whether diet diversity moderates the association between food insecurity and depression.

Multiple logistic regression was conducted to examine independent associations between food insecurity and depression, between diet diversity and depression, and the moderating effect of diet diversity in the food insecurity–depression link.

Cross-sectional data from the National Health and Nutrition Examination Survey (2013–2014).

2636 low-income adults aged 18 years and older.

There was a positive association between food insecurity and depression among low-income adults. Diet diversity was not associated with depression. Diet diversity had a moderating effect on the association between food insecurity and depression among low-income adults.

Food insecurity is independently associated with depression among low-income adults in the USA. However, this association differs across levels of diet diversity. Longitudinal studies are needed to confirm the role diet diversity may play in the pathway between food insecurity and depression.

To describe prenatal and postpartum consumption of water, cows’ milk, 100 % juice and sugar-sweetened beverages (SSB) among women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) programme in New York City (NYC) and to identify correlates of SSB intake in this population.

Cross-sectional data were collected from structured questionnaires that included validated beverage frequency questionnaires with the assistance of container samples. The association of maternal and household factors and non-SSB consumption with habitual daily energetic (kJ (kcal)) intake from SSB was assessed by using multivariable median regression.

WIC programme in NYC, NY. Data were collected in 2017.

388 pregnant or postpartum women (infant aged <2 years) from the NYC First 1000 Days Study.

Median age was 28 years (interquartile range (IQR) 24–34); 94·1 % were Hispanic/Latina, and 31·4 % were pregnant. Overall, 87·7 % of pregnant and 89·1% of postpartum women consumed SSB ≥ once weekly, contributing to a median daily energetic intake of 410 kJ (98 kcal) (IQR (113–904 kJ) 27–216) and 464 kJ (111 kcal) (IQR (163–1013 kJ) 39–242), respectively. In adjusted analyses, only consumption of 100 % juice was associated with greater median energetic intake from SSB (adjusted β for each additional ounce = 13; 95% CI 8, 31 (3·2; 95 % CI 2·0, 7·3).

Among pregnant and postpartum women in WIC-enrolled families, interventions to reduce SSB consumption should include reduction of 100 % juice consumption as a co-target of the intervention.

Low socio-economic groups (SEG) in Australia suffer poorer diet-related health than the rest of the population. Therefore, it is expected that low SEG are less likely to consume diets conforming to Australian Dietary Guidelines (ADG) than higher SEG. However, dietary intake of low SEG in Australia has not been synthesised methodically. This systematic scoping review aims to explore detailed dietary intake of low SEG in Australia in comparison to higher SEG.

A systematic search of peer-reviewed literature and websites, since 1999. Data were extracted, synthesised and analysed in relation to study populations, dietary assessment methods, food groups studied, socio-economic measures and dietary intake.

Australia.

Persons of any age and gender, differentiated by a socio-economic measure.

Results from thirty-three included studies confirmed that overall dietary nutritional value/quality tended to be lower in low SEG than higher SEG in Australia. However, findings were inconsistent across studies for all food groups or all socio-economic measures. Large variations were found between study metrics, definitions, dietary assessment methods, granularity of results and conclusions. Quantitative intakes of all ADG food groups by SEG were not reported in most studies and, where reported, were not comparable.

The review showed detailed dietary data are lacking to inform policy and practice and help develop targeted interventions to improve diet-related health of Australian low SEG. There is urgent need for regular, granular assessment of population dietary data to enable comparison of intake between SEG in the context of national food-based dietary guidelines in Australia.

Economic hardship (EH) may link to poorer child diet, however whether this association is due to resource limitations or effects on family functioning is unknown. This study examines whether parenting stress mediates the association between EH and child consumption of foods high in saturated fats and added sugars (SFAS).

Data were collected from the Fragile Families and Child Wellbeing study. EH was assessed using eight items collected when children were between 1–9 years old. Mothers reported parenting stress and frequency of child consumption of high SFAS foods when children were 9 years old. Latent growth curve modelling (LGCM) and structural equation modelling tested direct associations between the starting level/rate of change in EH and high SFAS food consumption, and parenting stress as a mediator of the association.

Twenty US cities.

Mothers/children (n 3846) followed birth through age 9 years, oversampled ‘high-risk’, unmarried mothers.

LGCM indicated a curvilinear trend in EH from ages 1–9, with steeper increases from ages 3–9 years. EH did not directly predict the frequency of high SFAS foods. Average EH at 3 and 5 years and change in EH from ages 1–9 predicted higher parenting stress, which in turn predicted more frequent consumption of high SFAS foods.

Findings suggest it may be important to consider parenting stress in early prevention efforts given potential lasting effects of early life EH on child consumption of high SFAS foods. Future research should explore how supports and resources may buffer effects of EH-related stress on parents and children.

To utilise a community-based participatory approach in the design and implementation of an intervention targeting diet-related health problems on Navajo Nation.

A dual strategy approach of community needs/assets assessment and engagement of cross-sectorial partners in programme design with systematic cyclical feedback for programme modifications.

Navajo Nation, USA.

Navajo families with individuals meeting criteria for programme enrolment. Participant enrolment increased with iterative cycles.

The Navajo Fruit and Vegetable Prescription (FVRx) Programme.

A broad, community-driven and culturally relevant programme design has resulted in a programme able to maintain core programmatic principles, while also allowing for flexible adaptation to changing needs.

To examine whether the association between soft drinks consumption and child behaviour problems differs by food security status and sleep patterns in young children.

Cross-sectional observational data from the Fragile Families and Child Wellbeing Study (FFCWS), which collected information on food insecurity, soft drinks consumption, sleep patterns and child behaviour problems. Bivariate and multivariate ordinary least-squares regression analyses predicting child behaviour problems and accounting for socio-economic factors and household characteristics were performed.

Twenty urban cities in the USA with a population of 200 000 or more.

Parental interviews of 2829 children who were about 5 years old.

Soft drinks consumption was associated with aggressive behaviours, withdrawn and attention problems for children aged 5 years. However, the association differed by food security status. The association was mostly statistically insignificant among food-secure children after accounting for socio-economic and demographic characteristics. On the other hand, soft drinks consumption was associated with behaviour problems for food-insecure children even after accounting for these factors. However, after accounting for child sleep patterns, the association between soft drinks consumption and child behaviour problems became statistically insignificant for food-insecure children.

The negative association between soft drinks consumption and child behaviour problems could be explained by sleep problems for food-insecure children. Since about 21 % of households with children are food insecure, targeted efforts to reduce food insecurity would help improve dietary (reduce soft drinks consumption) and health behaviours (improve sleep) and reduce child behaviour problems.

Breast-feeding rates reflect sociodemographic discrepancies. In Mexico, exclusive breast-feeding under 6 months of age has deteriorated among the poor, rural and indigenous populations from 1999 to 2012. Our objective of the present study was to identify the main social obstacles to breast-feeding in a low-income population in Tijuana, Mexico.

Qualitative study using a socio-ecological framework for data collection.

Low-income communities in Tijuana, Mexico.

Mothers (n 66), fathers (n 11), grandparents (n 27) and key informants (n 25).

One hundred and twenty-nine individuals participated in the study: six focus groups (n 53) and fifty-one interviews among mothers, fathers and grandparents; and twenty-five interviews among key informants. Seven social themes were identified: (i) embarrassment to breast-feed in public; (ii) migrant experience; (iii) women’s role in society; (iv) association of formula with higher social status; (v) marketing by the infant food industry; (vi) perception of a non-breast-feeding culture; and (vii) lack of breast-feeding social programmes.

Socio-structural factors influence infant feeding practices in low-income communities in Tijuana. We hypothesize that messages emphasizing Mexican traditions along with modern healthy practices could help to re-establish and normalize a breast-feeding culture in this population. The target audience for these messages should not be limited to mothers but also include family, health-care providers, the work environment and society as a whole.