# Association of activity-based food environment index with obesity-related cancer mortality in the US

## TL;DR

This study finds that food environment measured by actual visits to healthy food stores is linked to lower obesity-related cancer deaths in US counties.

## Contribution

A novel activity-based food environment index is developed and shown to have stronger associations with obesity-related cancer mortality than traditional location-based indices.

## Key findings

- Activity-based food environment index showed significant negative association with obesity-related cancer mortality rates.
- Each standard deviation increase in the activity-based index reduced high-risk area odds by 18%.
- Location-based index showed weaker and non-significant effects compared to the activity-based index.

## Abstract

Obesity and obesity-related cancers contribute to rising healthcare costs and declining life expectancy in the US and improving diet quality plays a crucial role in reversing such trends. Existing studies on the relationship between healthy food access and obesity-related cancer mortality present mixed findings, whereas food procurement activities are largely overlooked. The paper aims to construct a novel food environment index based on residents’ food retailer visits, and then compare it with the location-based food environment index regarding the strength of associations with obesity-related cancer mortality rates.

This cross-sectional ecologic study used business location data from InfoGroup and aggregated GPS-based food retailer visit data from SafeGraph in 2018–2019, and mortality data from the Centers for Disease Control and Prevention in 2015–2020. A total of 2925 counties or equivalents with complete information were included. Activity-based index was calculated as the percentage of visits to healthy food retailers out of total visits to all qualified food retailers for residents in each county. Location-based index was calculated as the percentage of healthy food retailers out of all qualified food retailers in each county. The main outcome is age-adjusted obesity-related cancer (13 types of cancer based on evidence from the International Agency for Research on Cancer) mortality rates, which were calculated for each county and counties were further categorized into high- and low-risk (≥ 60.2 and < 60.2 cases per 100,000 population) areas. Linear, non-linear, logistic, and spatial regression analyses were performed to examine the association between each food environment index and obesity-related cancer mortality rates.

The activity-based index demonstrated significant negative association with the 2015–2020 obesity-related cancer mortality rates (coefficient [95% CI]: − 0.980 [− 1.385, − 0.575], P < 0.001), and each standard deviation increase in the activity-based index was associated with an 18% decrease in the odds of being in a high-risk area (odds ratio [95% CI]: 0.821 [0.749, 0.900], P < 0.001), while the location-based index showed much weaker and non-significant effects.

Our findings suggest that health policies and initiatives that combat obesity and obesity-related cancers should consider incorporating food retailer visits into policy formation.

The online version contains supplementary material available at 10.1186/s12916-025-03967-6.