Purpose

This study aims to test the hypothesis that in addition to a direct effect of food environment on obesity, food environment is indirectly associated with obesity through consuming Mediterranean diet (MD).

Design

Cross-sectional secondary data analysis.

Setting

Nationwide community-dwelling residency.

Sample

A total of 20 897 non-Hispanic black and white adults aged ≥45 years who participated in the REasons for Geographic and Racial Differences in Stroke study and completed baseline assessment during January 2003 and October 2007.

Measures

The Modified Retail Food Environment Index (mRFEI; 0-100) was used as food environment indicator. The MD score (0-9) was calculated to indicate the dietary pattern adherence. Body mass index (BMI; kg/m² ) was used to estimate obesity.

Analysis

Path analysis was used to quantify the pathways between food environment, MD adherence, and obesity. Proper data transformation was made using Box-Cox power transformation to meet certain analysis assumptions.

Results

The participants were from 49 states of the United States, with the majority (64.42%) residing in the South. Most of the participants were retired, female, white, married, having less than college graduate education, having annual household income ≤75 000, and having health insurance. The means of mRFEI was 10.92 (standard deviation [SD] = 10.19), MD score was 4.36 (SD = 1.70), and the BMI was 28.96 kg/m² (SD = 5.90). Access to healthy food outlets (β = .04, P < .0001) and MD adherence (β = .08, P < .0001) had significant and inverse relationships with BMI, respectively. Mediterranean diet adherence mediated the relationship between food environment and obesity among a subpopulation who had an annual household income of <$75 000 (β = -.02, P = .0391).

Conclusion

Population-tailored interventions/policies to modify food environment and promote MD consumption are needed in order to combat the obesity crisis in the United States.