Highlights

Abstract

Graphical abstract

Keywords

1. Introduction

2. Methods

3. Results

4. Discussion

5. Conclusion

Acknowledgments

Appendix. Supplementary materials

References

Abstract

Background
We compared body mass index (BMI), body fat, and skeletal muscle mass between (1) a mixed-sex nonathletic cohort of people with patellofemoral pain (PFP) and pain-free people, and (2) a nonathletic cohort of people with PFP and pain-free people subgrouped by sex (i.e., men and women with PFP vs. pain-free men and women).

Methods
This cross-sectional study included 114 people with PFP (71 women, 43 men) and 54 pain-free controls (32 women, 22 men). All participants attended a single testing session to assess body composition measures, which included BMI, percentage of body fat (%BFBioimpedance), and skeletal muscle mass (both assessed by bioelectrical impedance analysis), and percentage of body fat (%BFSkinfold) (assessed by skinfold caliper analysis). A one-way univariate analysis of covariance (age and physical activity levels as covariates) was used to compare body composition measures between groups (i.e., PFP vs. pain-free group; women with PFP vs. pain-free women; men with PFP vs. pain-free men).

Results
Women with PFP presented significantly higher BMI, %BFBioimpedance, and %BFSkinfold, and lower skeletal muscle mass compared to pain-free women (p ≤ 0.04; effect size = ‒0.47 to 0.85). Men with PFP and men and women combined had no differences in BMI, %BFBioimpedance, %BFSkinfold, and skeletal muscle mass compared to their respective pain-free groups (p > 0.05).

Conclusion
Our findings indicate that BMI and body composition measures should be considered as part of the evaluation and management of people with PFP, especially in women, who have demonstrated higher BMI and body fat and lower skeletal muscle mass compared to pain-free controls. Future studies should not assess body composition measures in a mixed-sex population without distinguishing men participants from women participants.

1. Introduction
The prevalence of overweight and obesity has been growing alarmingly across the world.1 In the past four decades, the number of adults with obesity worldwide has increased more than 6 times (100 million in 1975 to 671 million in 2016),1 whereas 1.3 billion adults (1 in 4) were considered overweight in 2016.1,2 Despite increasing the predisposition to multiple comorbidities,3,4 overweight and obesity are also detrimental to the musculoskeletal system,5, 6, 7 likely via both systemic and mechanical effects.8,9 Systemic effects include the production by adipose tissue of adipokines such as leptin10 and the amplification of the inflammation profile through an increase in the production of interleukin-611 and tumor necrosis factor-alpha.12 Both of these systemic changes are associated with deleterious effects to patellar cartilage (e.g., reduced patellar cartilage volume) and pain.13,14 Mechanically, the one joint most affected by overweight and obesity is the patellofemoral joint, which is subjected to loads 2 to 11 times bodyweight during stair ascent, squatting, and running activities.15, 16, 17

Summary

Keywords

1. Introduction

1.1. COVID-19 and malnutrition

1.2. Obesity and COVID-19: an additional risk factor with nutritional implications

2. Nutritional management of persons with obesity in the COVID-19 pandemic

3. Conclusions

Conflict of interest

Acknowledgements

References

Summary

The COVID-19 pandemics has created unprecedented challenges and threats to patients and healthcare systems worldwide. Acute respiratory complications that require intensive care unit (ICU) management are a major cause of morbidity and mortality in COVID-19 patients. Among other important risk factors for severe COVID-19 outcomes, obesity has emerged along with undernutrition-malnutrition as a strong predictor of disease risk and severity. Obesity-related excessive body fat may lead to respiratory, metabolic and immune derangements potentially favoring the onset of COVID-19 complications. In addition, patients with obesity may be at risk for loss of skeletal muscle mass, reflecting a state of hidden malnutrition with a strong negative health impact in all clinical settings. Also importantly, obesity is commonly associated with micronutrient deficiencies that directly influence immune function and infection risk. Finally, the pandemic-rvelated lockdown, deleterious lifestyle changes and other numerous psychosocial consequences may worsen eating behaviors, sedentarity, body weight regulation, ultimately leading to further increments of obesity-associated metabolic complications with loss of skeletal muscle mass and higher non-communicable disease risk. Therefore, prevention, diagnosis and treatment of malnutrition and micronutrient deficiencies should be routinely included in the management of COVID-19 patients in the presence of obesity; lockdown-induced health risks should also be specifically monitored and prevented in this population. In the current document, the European Society for Clinical Nutrition and Metabolism (ESPEN) aims at providing clinical practice guidance for nutritional management of COVID-19 patients with obesity in various clinical settings.

1. Introduction

1.1. COVID-19 and malnutrition

COVID-19 is a primarily respiratory disease caused by SARS-CoV-2 infection that can spread from upper to lower airways, leading to respiratory insufficiency requiring respiratory support and intensive care, where it may be fatal [[1], [2], [3], [4], [5]]. Patient groups with pre-existing comorbidities ranging from diabetes and cardiovascular disease to cancer and chronic organ failures, as well as older age, are burdened with higher risk for complications and COVID-19 mortality [[1], [2], [3], [4], [5]]. Importantly, both older age and pre-existing chronic diseases in polymorbid individuals are per se associated with high risk and prevalence of undernutrition (which will be hereafter referred to as MALNUTRITION, to align with the utilization of this term in clinical practice as supported by clinical nutrition Societies) [6,7], due to catabolic derangements, low food intake and low physical activity whose various combinations result in loss of body and skeletal muscle mass and muscle function [[6], [7], [8]]. In COVID-19, infection with related inflammation and potential organ failure with systemic complications and immobilization may further contribute to enhance muscle loss and malnutrition risk. Also notably, malnutrition is an independent major cause of morbidity and mortality in most disease conditions, through mechanisms including high risk of infections or superinfection [9], caused by its deleterious impact on immune function [10] as well as respiratory and cardiac muscle function [11,12].

1- Introduction

2- Materials and methods

3- Results

4- Discussion

References

Abstract

Although hormonal and metabolic factors are well known to influence obesity, recent evidence suggests that obesity may be influenced also by changes in reward sensitivity akin to that seen in other ‘reward pathologies’, like substance use disorders. The current study sought to isolate changes in reward that may occur after the onset of diet-induced obesity by characterizing the economic demand for caloric (sucrose) and non-caloric (saccharin) reinforcers in a preclinical model of diet-induced obesity (DIO). We utilized economic demand analysis to measure baseline demand intensity (Q0) and demand elasticity (α) for sucrose and saccharin reinforcers in rats. After baseline measures were collected, rats were assigned randomly to a high-fat (HF) diet or low-fat (LF) control diet. After 8-weeks of diet exposure, HF rats were divided into obesity-resistant (OR) or obesity-prone (OP) groups based on weight after the 8-week HF diet exposure. Post-DIO demand data for each reinforcer were reassessed. At baseline, rats had higher demand intensity and lower elasticity for sucrose compared to saccharin. After 8-weeks of the high-fat diet, OP rats had significantly greater weight gain and lower demand elasticity for sucrose and saccharin and higher demand intensity for saccharin. The changes in sucrose and saccharin elasticity suggest that DIO-induced changes in food-related behavior are associated with changes in reward processes. The changes in demand intensity for saccharin suggest that demand intensity, as a measure of ‘set point’, is not directly linked to metabolic processes. The current study shows that microeconomic theory and demand analysis is able to isolate independent aspects of diet-induced reward changes related to caloric and non-caloric reinforcers.

Introduction

Obesity is a growing world-wide problem with incidence in adults nearly tripling since 1975 [55] .To date, the majority of research on obesity has focused on the metabolic aspects (i.e., caloric intake and macronutrient distribution, hormonal signaling). However, recent evidence suggests that reward-related factors and associated brain changes also may play a role in obesity [52]. For example, obese individuals exhibit similarities in behavior relative to those with substance use disorders, although the focus is food rather than drug. Specifically, obese individuals show a lack of control over eating, difficulty achieving satiety, and an increased preoccupation with food [18,51]. Further, decreased dopamine D2 receptor signaling in the dorsal and ventral striatum as well as decreased baseline glucose metabolism in the prefrontal cortex are found in both those with substance use disorders and obese individuals [21,30,38,48,52,53]. Thus, reward-related brain dysfunctions may be related to the development and maintenance of obesity. However, the relative importance of reward-related vs. metabolic aspects of obesity currently is unknown. Specifically isolating the reward aspects of obesity from the metabolic aspects will further our understanding of the etiology. Isolation of the reward aspects of obesity from the metabolic aspects (here specifically food nutrient content) may be accomplished by systematically comparing the value changes in a caloric reinforcer such as sucrose to those of a non-caloric reinforcer such as saccharin [45]. Saccharin is non-caloric and does not directly alter metabolism or energy balance [47]. Thus, a change in saccharin value, as a function of diet, amount of diet consumed, and weight gain, is related more directly to changes in reward sensitivity.

Exercise mitigates obesity-associated pathologies; however, there is controversy regarding optimal exercise interventions. Autophagy, is known to decrease during obesity and is an important moderator for exercise adaptations. Purpose: To investigate individual and combined effects of different exercise interventions and autophagy inhibition on exercise adaptations during obesity. Methods: C57BL/6J mice initiated 45% high fat diet at 8 weeks of age. After 6 weeks of diet, animals were divided into moderate (MOD) or high intensity interval training interventions (HIIT), animals were further divided into autophagy inhibition or vehicle conditions (n ¼ 10/group). Animals exercised and autophagy was inhibited 3X/ week by NSC185058 injections, thereby blocking autophagosome formation. Interventions continued for 4 weeks. Results: High fat diet impaired glucose handling ~17%; exercise interventions normalized glucoregulation to prehigh fat diet levels, without differences between any interventions. High fat diet induced ~25% decrease in aerobic capacity, which returned to baseline after exercise interventions, with no differences between any interventions. No effects of autophagy inhibition were noted. Conclusions: HIIT and MOD training confer similar health-related adaptations.

Introduction

Obesity, metabolic syndrome, and type 2 diabetes mellitus (T2DM) remain significant maladies in Western society.1 Insulin medication costs have more than doubled, causing significant economic burdens and a reduction in overall quality of life for millions of patients.2 Exercise is known to decrease T2DM-associated insulin resistance (IR) and mortality regardless of weight loss.3 Recently, controversy surrounding the relative effectiveness of high intensity interval training (HIIT) compared to moderate intensity continuous training (MOD) has emerged.4 HIIT has become exponentially more popular over the past decade, finishing in the top three fitness trends in each of the last five years.5 Clinically, HIIT has become increasingly widespread as an exercise intervention across a greater breadth of populations, including those with metabolic impairments.4,6–9 More so, recent meta-analyses suggest HIIT to be more effective compared to traditional moderate intensity continuous training (MOD) to improve insulin sensitivity.10 However, mechanisms that may correspond to the purported augmented benefits have yet to be elucidated. More so, it is difficult to draw strong conclusions regarding any potential additional benefits associated with HIIT compared to MOD, as many “comparative” protocols in the past did not match total work completed or average intensity of exercise.7,11,12 One cellular mechanism recently implicated in the development of exercise adaptations is autophagy.13–15 Autophagy is a process that removes dysfunctional cellular components by sequestering organelles within an autophagosome and degrading them by lysosomal reaction.16 Previous research has demonstrated reductions in autophagy during IR.17,18 and transgenic models blocking autophagy initiation demonstrate diminished glucose handling capacity compared to healthy controls.19 Additionally, inhibition of Beclin-mediated autophagy impairs exercise training adaptations in otherwise healthy mice.20 Conversely, exercise interventions are known to increase autophagy.20–22 Yet, the precise stimuli needed to activate autophagy with exercise training and the subsequent effects on IR remain uninvestigated, specifically the exercise intensity or volume necessary to induce adaptations.

1- Introduction

2- Materials and methods

3- Results

4- Discussion

References

Abstract

Almost a third of Irish children are now overweight and the country ranks 58th out of 200 countries for its proportion of overweight youths. With the rising obesity epidemic, and the impaired immune responses of this population, it is vital to understand the effects that obesity has on the immune system and to design future therapeutics, adjuvants and vaccines with overweight and obese populations in mind. Many current vaccines use adjuvants that have been found to be less effective at stimulating the immune response in children compared with adults and there is now substantial effort to design paediatric-focused adjuvants. Additionally, vaccine responses have been shown to be less effective in obese populations indicating that this is a particularly vulnerable population. We have recently identified cytosolic nucleic acids (CNAs), as novel candidate adjuvants for childhood vaccines. Here we investigated whether immune responses to these candidate adjuvants were adversely affected in infants born to overweight or obese mothers, and in overweight and obese children. Type I Interferon (IFN) and proinflammatory cytokines such as Tumor Necrosis Factor α (TNFα) are vital for driving innate and adaptive immune responses. We found that childhood obesity conferred no significant adverse effect on CNA-induced Type I IFN responses when compared with lean children. Similarly, Type I IFN responses were intact in the cord blood of babies delivered from overweight and obese mothers, when compared with lean mothers. There was also no significant impact of obesity on CNA-induced TNFα responses in children or from cord blood of infants born to overweight/obese mothers. In all cases, there was a tendency towards decreased production of innate cytokine Type I Interferon and TNFα, however there was no significant negative correlation. Interestingly, high maternal BMI showed weak and moderate positive correlation with IL-12p70 and IFNγ, respectively, in response to CNA stimulation. This study demonstrates that future adjuvants can be tailored for these populations through the use of activators of CNA sensors.

Introduction

Obesity has become a global epidemic over a period of only two decades. It now represents an urgent medical and a major societal challenge for which the solution certainly requires a multidisciplinary approach. Obese individuals are at higher risk of a wide range of infections including postoperative infections and other nosocomial infections, and also of developing serious complications resulting from common infections [1]. Obese individuals have been shown to be at increased risk of infection from certain vaccine-preventable diseases, such as tetanus, hepatitis B and influenza, due to poorer responses to vaccines in these individuals [2–4]. Although there is limited data concerning the effect of obesity on vaccine efficacy in neonates born to obese mothers, limited data from overweight and obese children suggest that responses to vaccinations are impaired in these groups [2,5]. Data from obese adults would also suggest that obesity increases the chances of a poor vaccine-induced immune response [3,4,6,7]. One study investigating the effect of increased body mass index (BMI) on vaccination responses showed that overweight children had reduced tetanus titers following vaccination when compared to lean children [2]. Another study in adults receiving Hepatitis B vaccination showed that obese adults have limited protection against the disease compared to lean adults [3]. Influenza vaccine responses are also affected by obesity, with increased risk of influenza among vaccinated adults who are obese [4]. Interestingly, initial antibody production is intact in obese individuals, however at later sampling, 12 months post vaccination, these antibody titers decreased below healthy weight individuals [7]. CD4+ and CD8+ T cell responses ex vivo were also decreased in obesity [7,8]. Obesity in adults is defined as a BMI ≥ 30 kg/m [6], while for children it is more appropriate to use a BMI z-score. BMI zscores are measures of relative weight adjusted for child age and sex [5].

Introduction

Methods

Results

Discussion

Conclusions

References

Abstract

Objective. To investigate the epidemiological features of obesity in rural Northeast China. Design. This was a 2017–2018 cross-sectional study of 10,891 participants aged ≥40 years that was designed to investigate the prevalence of obesity in rural areas of Liaoning Province. Demographic data, biochemical parameters, and physical examinations were completed by well-trained personnel. Logistic regression analyses were then carried out to investigate independent risk factors and associated cardiometabolic comorbidities of obesity. Results. The proportions of general obesity only, central obesity only, and combined obesity were 1.0%, 31.3%, and 17.4%, respectively. Overall, 49.8% of our subjects were obese. Female gender, being married, being separated/divorced/widowed, or eating more meat were significantly associated with obesity. Smoking, higher family income, or regular physical exercise were negatively associated with obesity. General obesity only was significantly correlated with hypertension, diabetes, and high triglycerides (OR = 2.79, OR = 2.79, and OR = 3.37, resp.). General obesity only was irrelevant to high total cholesterol, low high-density lipoprotein cholesterol, and high low-density lipoprotein cholesterol, although central obesity only, or combined obesity, was relevant to these factors. Prehypertension and prediabetes showed a positive association with different types of obesity. Conclusions. We identified a high prevalence of general and central obesity in rural Northeast China, with similar independent risk factors. Participants with combined obesity had the highest risk of cardiometabolic comorbidities, indicating that the combined use of both waist circumference and body mass index is useful in practice.

Introduction

Obesity is now a worldwide epidemic, with an estimated 57.8% of adults worldwide expected to be classified as obese by 2030 according to figures released by the World Health Organization (WHO) [1]. Obesity is characterized by an excessive accumulation of body fat that gives rise to significant comorbidities, such as diabetes, hypertension, dyslipidemia, cardiovascular disease, and many cancers [2–4]. Therefore, obesity is invariably referred to as a crucial public health problem that requires urgent attention in order to prevent obesity-related health outcomes. Although body mass index (BMI) is a simple index that is commonly used for classifying obesity, it has inherent limitations that can lead to some obese individuals being disregarded [5]. Recently, evidence has been growing to suggest that an additional indicator of central obesity, waist circumference (WC), may be more closely associated with metabolic risks compared to BMI because it reflects body fat distribution and upper body adiposity [6, 7]. However, this remains debatable as a recent study reported that the predictive values of BMI and WC for obesity were equivalent [8]. Consequently, there is a suggestion that both BMI and WC should be taken into consideration and adopted when investigating the associations between obesity and risk factors. We believe that the combined use of both WC and BMI allows more accurate monitoring of obesity.

We examine the association between living in an urban area with more or less green space and the probability of being obese. This work involves the creation of a new dataset which combines geo-coded data at the individual level from the Irish Longitudinal Study on Ageing with green space data from the European Urban Atlas 2012. We find evidence suggestive of a u-shaped relationship between green space in urban areas and obesity; those living in areas with the lowest and highest shares of green space within a 1.6 km buffer zone have a higher probability of being classified as obese (BMI ⩾ 30). The unexpected result that persons in areas with both the lowest and highest shares of green space have a higher probability of being obese than those in areas with intermediate shares, suggests that other characteristics of urban areas may be mediating this relationship.

Introduction

Over half of the world’s population (54%) currently lives in urban areas (UN, 2015). Growing urbanisation is set to continue with a projected two-thirds of the global population expected to reside in urban areas by 2050 (UN, 2015). Given the worldwide trend of urbanisation, there has been renewed focus on the physical health impacts of living within these urban areas, and in particular the importance of ensuring adequate green space provision. Indeed the United Nations Sustainable Development Goal 11.7 states a target of providing “…universal access to safe, inclusive and accessible, green and public spaces, in particular for women and children, older persons and persons with disabilities” by 2030. The benefits arising from green spaces can be examined from a multitude of angles e.g. mitigation of the urban heat island effect, promotion of local ecosystems, improved air quality and, health and wellbeing effects (see Carlin, Cormican, and Gormally (2016) for full review). This paper focuses on the physical health benefits of green space; in particular whether the presence of green space in urban areas has the potential to reduce an individual’s probability of being obese. The WHO estimates that the prevalence of obesity has more than doubled worldwide between 1980 and 2014 (WHO, 2016), with 1.9 billion adults classified as overweight in 2014, and of these, 600 million classified as obese. This is particularly concerning given that obesity substantially increases the risk of developing other noncommunicable diseases such as cardiovascular disease, diabetes, osteoarthritis and some cancers (WHO, 2016). The primary cause of obesity is an energy imbalance between calories consumed and calories expended (WHO, 2016). This imbalance is the result of increased consumption of highenergy foods and decreased physical activity. Obesity can therefore be considered a side effect of increased urbanisation, which has led to a rise in sedentary life-style patterns. Coined by Swinburn, Egger, and Raza (1999), the term obesogenic environment refers to “the sum of influences that the surroundings, opportunities, or conditions of life have on promoting obesity in individuals or populations”. This definition which recognises the importance of an individual’s social, economic and physical environment, shifts the focus of solving the obesity epidemic from the individual to the systemic level. As identified by Mackenbach et al. (2014), several features of the physical environment are proposed to impact obesity including urban sprawl, land-use mix, food environment, crime rate, walkability, and green space. The primary channel through which urban green space is proposed to impact obesity is through increased physical activity. However, as identified by Lachowycz and Jones (2011) who performed a systematic review of the pre-existing literature, there is a large amount of conflicting evidence regarding the association between obesity and urban green space. In particular self-selection effects can be difficult to control for due to data limitations (Boone-Heinonen, Gordon-Larsen, Guilkey, Jacobs, and Popkin, 2011).

Background: Evidence suggests involvement in youth sport does not guarantee daily guidelines for moderate-to-vigorous physical activity (MVPA) are met, and participation may not mitigate the risks associated with physical inactivity. The need to promote higher habitual MVPA engagement among children active in the youth sport context has therefore been underlined. Framed by self-determination theory, the aim of the present study was to examine the implications of the motivational climate created in youth sport, for children’s daily engagement in MVPA and associated adiposity. Specifically, we sought to test a motivational sequence in which children’s perceptions of an empowering coach-created motivational climate were related to autonomous and controlled motivation, which in turn predicted sport-related enjoyment. Finally, enjoyment is assumed to predict accelerometer assessed daily MVPA and, following this, adiposity Method: Male and female youth sport participants aged 9-16 years (N = 112) completed multi-section questionnaires assessing their perceptions of the motivational climate created in youth sport (i.e., autonomy supportive, task involving, socially supportive), autonomous and controlled motivation, and sport-related enjoyment. Daily MVPA engagement was determined via 7 days of accelerometry. Percent body fat (BF%) was estimated using bioelectrical impedance analysis. Results: Path analysis revealed perceptions of an empowering motivational climate positively predicted players’ autonomous motivation, and in turn, sport-related enjoyment. Enjoyment was also significantly negatively related to players’ BF%, via a positive association with daily MVPA. Conclusion: Fostering more empowering youth sport environments may hold implications for the prevention of excess adiposity, through encouraging higher habitual MVPA engagement. Findings may inform the optimal design of youth sport settings for MVPA promotion, and contribute towards associated healthy weight maintenance among youth active in this context. Longitudinal and intervention studies are required to confirm these results.

Introduction

Evidence based guidelines indicate school-aged youth should engage in ≥ 60 min of moderate-to-vigorous physical activity (MVPA) per day.1-4 Several government reports have underlined youth sport as a context through which children and adolescents may achieve these recommendations, advocating involvement in sport to encourage youth to lead more physically active lifestyles.5, 6 Accordingly, the role of youth sport for preventing overweight and obesity among children and adolescents has also been argued5 . However, recent studies have revealed that, whilst sport involvement may indeed offer a number of children and adolescents the opportunity to engage in substantial amounts of MVPA, participation in youth sport does not necessarily guarantee daily MVPA recommendations are met.7-9 Moreover, research has demonstrated that 1 in 4 youth sport participants are overweight or obese, with 48% of obese youth report participation in sport.10-12 Such findings point to the need to promote MVPA engagement even in this group of children and adolescents (i.e., youth sport participants) whom are traditionally thought to be amongst the most healthy and active in the population. In order to advance engagement in MVPA among children and adolescents active in the youth sport setting, we must first identify factors within this context that are related to habitual MVPA participation (i.e., daily MVPA). Self-determination theory (SDT) 13 and achievement goal theory (AGT)14 are two contemporary theories of motivation successfully used to understand the correlates and determinants of behavioral outcomes (e.g., PA engagement) across diverse settings, including youth sport. Specifically, these theoretical frameworks have guided researchers in their attempts to understand the interaction between the PA environment and the motivational processes pertinent to PA engagement.

Food marketers have responded with numerous self-regulatory actions intended to address childhood obesity. While research on corporate social responsibility (CSR) generally provides strong evidence with regard to the economic benefits enjoyed by socially responsible corporations, it is unclear how and why consumers respond to different levels of CSR, especially in the food industry. Our research examines the effects of CSR activities, intended to combat childhood obesity, on consumers’ company evaluations and subsequent purchase intentions, while assessing the mediating role of attributions, in a product-failure setting. Results indicate that a food company’s high commitment toward a major social issue may trigger less blame to the food marketer for a product failure, which in turn positively affects consumers’ attitudes toward the company. Our findings offer strong evidence that food corporations can truly do well by doing good.

Introduction

Corporate social responsibility (CSR) has become an imperative business practice in today’s national and global marketplace (Carvalho, Sen, de Oliveira Mota, & de Lima, 2010). This view derives not only from companies’ obligations to enhance society’s well-being, but also from their capability to prosper, increase competitive advantage, and improve company performance. Academics and practitioners alike have realized that CSR is more than an ethical imperative, it also represents an economic requirement in today’s marketplace (Sen & Bhattacharya, 2001); this business practice being incorporated into long-term strategic plans to maintain and/or enhance market performance (Mahoney & Thorne, 2005; Tian, Wang, & Yang, 2011). Moreover, the literature on CSR suggests a well-established link between CSR and consumers’ attitudes toward the company and intentions to repurchase its products (Inoue, Funk, & McDonald, 2017). As Sen, Du, and Bhattacharya (2016) argue in their review of the substantial work on corporate social responsibility, there is a strong consensus among CSR scholars that consumers make their purchases based on the company’s socially responsible behavior. Importantly, CSR-related outcomes that include increased loyalty and purchase intentions, willingness to pay premium prices, and positive company and/or product evaluations, unequivocally contribute to enhanced firm financial performance (Peloza & Shang, 2011). Nevertheless, consumers’ CSR awareness remains considerably low (Park, Kim, & Kwon, 2017). A strong belief in the literature is that CSR should be done right (Carvalho et al., 2010) and consumers’ responses to CSR depend on how corporations manifest their CSR (Green & Peloza, 2011). Consumers do not perceive all CSR actions in the same manner (Andreu, Casado-Díaz, & Mattila, 2015); this reality merits further attention (Green & Peloza, 2011). Different levels of CSR produce different stakeholder reactions (Torugsa, O’Donohue, & Hecker, 2012); this insight should be considered when predicting CSR critical outcomes such as attitudes and purchase intentions (Kim, 2017). In their systematic review of corporate social responsibility, Peloza and Shang (2011) called for research that explores the effects of various CSR activities on consumer attitudes. This is instrumental because different CSR initiatives may be perceived as higher or lower commitments to a cause, which in turn are expected to lead to more positive or negative consumer responses.

The restaurant industry in the United States (U.S.) and globally is highly competitive, dynamic and profitable. The National Restaurant Association projected U.S. sales to exceed $780 billion in 2016 (1) (Table 1). The top 20 U.S.-headquartered quick-service (QSR), fast-casual (FCR) and full-service restaurant (FSR) chains generated over $155 billion dollars between 2015 and 2016 (2). Several U.S.-headquartered chains (i.e. McDonald’s, Subway, Yum! Brands, Burger King and Domino’s Pizza) operate franchise businesses in 70 to 100 countries worldwide (3–7). Table 1 provides definitions of commonly used terms to describe the restaurant sector. Recent marketing research suggests that nearly two-thirds of Americans visit fast food restaurants (hereafter called QSRs) and 40% visit FCRs every week (8). Yet half of Americans struggle to find healthy options at restaurants (9). An international study of adults across 10 countries found that less than 20% were satisfied with healthy restaurant menu options (10). Extensive evidence reveals that people’s consumption of food and beverage products sold by or purchased at FSRs and limited-service restaurants (LSRs), which include QSRs and FCRs, are high in fat, sugar and sodium (HFSS), which is associated with poor diet quality and increased risk of obesity and diet-related non-communicable diseases (NCDs) (11–19). In 2014, more than two-thirds (70.7%) of American adults were overweight or obese (20), and 32.4% of American children and adolescents, ages 2–19 years, were overweight or obese (21). Nearly 2.7 billion adults will be overweight or obese worldwide by 2025 (22). Reducing the frequency and amount of HFSS restaurant offerings may help to reduce obesity and NCD risks, especially among children and adolescents (23). Restaurant owners and managers currently use marketing mix principles (i.e. product, place, price and promotion) to build corporate brand awareness and loyalty among individuals who purchase and consume products that generate revenue to maximize company profits (24,25). Wansink (26) has emphasized the importance of restaurants using marketing principles to make healthy food and beverage choices more convenient (to see, order, pick up and consume); attractive (via name, appearance, price and expectations); and normal (to order, purchase, serve and eat) to promote healthy dietary goals among individuals and populations. However, restaurant owners do not comprehensively combine marketing mix principles with choice architecture strategies, which include interventions that design choices in different ways to influence people’s decision-making and behaviours in micro-environments.

Exposure to green space has been suggested to reduce the risk of several adverse health outcomes by multiple pathways including physical activity (James et al., 2015). Green space could reduce the likelihood of being overweight by offering suitable spaces that encourage physical activity (Hartig et al., 2014; Lee and Maheswaran, 2011). Overweight and physical inactivity are important risk factors for cardiovascular disease, diabetes and mental illness (Lachowycz and Jones, 2011). Green space is inconsistently associated with physical activity and being overweight, according to reviews of epidemiological studies (Hartig et al., 2014; James et al., 2015; Lachowycz and Jones, 2011; Bancroft et al., 2015; Nieuwenhuijsen et al., 2017; Durand et al., 2011; Hansen et al., 2015; Mayne et al., 2015; Hunter et al., 2015). Green space was negatively associated with being overweight in some studies (Liu et al., 2007; Pereira et al., 2013), however in other studies, green space was either not associated or positively associated with being overweight (Mowafi et al., 2012; Richardson et al., 2013; Picavet et al., 2016; Cummins and Fagg, 2012; Witten et al., 2008). These inconsistent associations across studies have been attributed to the use of different green space measures, the focus on quantity instead of quality and the use of green space, different populations and definitions of physical activity (e.g. self-reported vs. accelerometry, total versus vs. outdoor) and lack of control for important confounders (Lachowycz and Jones, 2011; James et al., 2015). Studies in large populations evaluating some of these sources of heterogeneity are needed. The most commonly used way to objectively assess exposure to green space is to determine the greenness within a circular buffer of the residential address (James et al., 2015). The radius of the buffers used to define surrounding green space varied among studies and ranged from 30 (McMorris et al., 2015) to 3000 m (Maas et al., 2008). Green space within a buffer can be assessed by using the Normalized Difference Vegetation Index (NDVI) or by using national land-use databases (James et al., 2015). Another common measure to determine exposure to green space is the distance (Euclidian or network) of the residential address to the nearest park entrance (James et al., 2015). So far, only a few epidemiological studies have investigated the effects of different types of green space (Hartig et al., 2014; Lee and Maheswaran, 2011). Green spaces can be subdivided into publically accessible and private green; or into natural, agricultural and urban green. Variance in greenness within the surrounding area can also be used as a measure (Pereira et al., 2013). In addition, most studies assumed a linear association of exposure to green spaces with the health outcome of interest (Shanahan et al., 2015) without providing information about the validity of this assumption. Non-linear associations between green space and overweight and physical activity are plausible. For instance, high levels of green space tend to be associated with higher distances to facilities (e.g. shops, work). Distance is probably the most important determinant for choosing an active or non-active mode of transportation (Heinen et al., 2010). Assessing exposure-response curves could provide information on how changes in quantity of green space could affect overweight and physical activity (Shanahan et al., 2015). The goal of this cross-sectional study is to evaluate whether the association between exposure to green space and being overweight (body mass index (BMI) ≥ 25 kg/m2 ) and outdoor physical activity depends on the definition of green space, adjustment for potential confounders, population characteristics and assumed shape of the association.