Understanding rural food environments and malnutrition-related mortality disparities: A typological approach from Mexico.

Rural food environments (RFEs) are increasingly recognized as critical determinants of nutrition and health inequities, yet remain understudied in low- and middle-income countries. Despite growing attention to food environments, most frameworks have been developed in urban contexts, overlooking the structural and functional diversity of rural territories. Mexico offers a compelling case in which diverse agricultural landscapes and food systems intersect with rising burdens of malnutrition-related diseases. This study proposes a typology of RFEs and examines their association with population-level mortality patterns from malnutrition-related diseases. Using an ecological design, we analyze municipal-level data to characterize RFEs based on two central dimensions: food availability and spatial (potential) accessibility. The typology draws on established conceptual frameworks of food environments and agricultural value chains, complemented with expert knowledge, while integrating variables relevant to the Mexican rural context, including crop diversity, production destination, proximity to urban centers, and the presence of modern food retail outlets. We identify nine distinct RFEs, distributed along a gradient from remote subsistence-oriented municipalities to peri-urban, commercial integrated ones. The results show that peri-urban municipalities exhibited the highest median mortality from type 2 diabetes mellitus and the lowest levels of undernutrition. In contrast, ischemic heart disease mortality was greatest in remote RFEs, a pattern likely linked to structural inequalities in healthcare access. These findings underscore the importance of developing food environment frameworks that are sensitive to rural territorial diversity, capable of capturing spatial and functional gradients at subnational scales, and critical for understanding rural nutrition and health disparities in low- and middle-income countries.