The impact of food environment on residents’ health: a hierarchical linear analysis of urban-rural inequality

Unhealthy food environments not only increase residents’ risk of chronic diseases but also undermine the sustainability of healthy dietary patterns. Particularly noteworthy is the disproportionate impact of inequitable food environments on low-income groups, especially those living in poverty. Therefore, an equitable and healthy food environment is critical to improving the health of rural residents and promoting integrated urban-rural development. This study aims to analyze the association between the food environment and health outcomes and to illustrate how the quality and quantity of the food environment influence urban-rural health disparities. Drawing on a dataset of 586,331 food service point of interest (POI), this study analyzes both the quantity and quality of the food environment across 95 districts in Jiangsu Province, China. By matching these data with 4,643 survey responses, we employ Hierarchical Linear Model to investigate how individual residential areas and regional food environment affect residents’ health, while also examining the moderating role of the food environment in the impact of residential areas on health outcomes. Our findings reveal that: (1) the number of food outlets in rural areas is not only low per capita and scattered, but there is also a lack of variety and quantity of healthy food options; (2) rural residents exhibit a higher prevalence of diet-related chronic diseases; (3) improved quality of food environment significantly reduces these diseases, while increased quantity shows limited effect; and (4) both quantity and quality of the food environment moderate the relationship between residential area and health, with higher levels of the food environment reducing the health effects of residential areas. This study provides policy insights that could be applied in other developing countries facing similar challenges in reducing urban-rural health disparities. The results highlight the need for an equitable food environment, particularly in terms of enhancing access to healthy food in rural areas, in order to reduce health disparities.