The DONE framework: Creation, evaluation, and updating of an interdisciplinary, dynamic framework 2.0 of determinants of nutrition and eating

The question of which factors drive human eating and nutrition is a key issue in many branches of science. We describe the creation, evaluation, and updating of an interdisciplinary, interactive, and evolving “framework 2.0” of Determinants Of Nutrition and Eating (DONE). The DONE framework was created by an interdisciplinary workgroup in a multiphase, multimethod process. Modifiability, relationship strength, and population-level effect of the determinants were rated to identify areas of priority for research and interventions. External experts positively evaluated the usefulness, comprehensiveness, and quality of the DONE framework. An approach to continue updating the framework with the help of experts was piloted. The DONE framework can be freely accessed (http://uni-konstanz.de/DONE) and used in a highly flexible manner: determinants can be sorted, filtered and visualized for both very specific research questions as well as more general queries. The dynamic nature of the framework allows it to evolve as experts can continually add new determinants and ratings. We anticipate this framework will be useful for research prioritization and intervention development.

Smartphone Apps for Measuring Human Health and Climate Change Co-Benefits: A Comparison and Quality Rating of Available Apps

Background

Climate change and the burden of noncommunicable diseases are major global challenges. Opportunities exist to investigate health and climate change co-benefits through a shift from motorized to active transport (walking and cycling) and a shift in dietary patterns away from a globalized diet to reduced consumption of meat and energy dense foods. Given the ubiquitous use and proliferation of smartphone apps, an opportunity exists to use this technology to capture individual travel and dietary behavior and the associated impact on the environment and health.

Objective

The objective of the study is to identify, describe the features, and rate the quality of existing smartphone apps which capture personal travel and dietary behavior and simultaneously estimate the carbon cost and potential health consequences of these actions.

Methods

The Google Play and Apple App Stores were searched between October 19 and November 6, 2015, and a secondary Google search using the apps filter was conducted between August 8 and September 18, 2016. Eligible apps were required to estimate the carbon cost of personal behaviors with the potential to include features to maximize health outcomes. The quality of included apps was assessed by 2 researchers using the Mobile Application Rating Scale (MARS).

Results

Out of 7213 results, 40 apps were identified and rated. Multiple travel-related apps were identified, however no apps solely focused on the carbon impact or health consequences of dietary behavior. None of the rated apps provided sufficient information on the health consequences of travel and dietary behavior. Some apps included features to maximize participant engagement and encourage behavior change towards reduced greenhouse gas emissions. Most apps were rated as acceptable quality as determined by the MARS; 1 was of poor quality and 10 apps were of good quality. Interrater reliability of the 2 evaluators was excellent (ICC=0.94, 95% CI 0.87-0.97).

Conclusions

Existing apps capturing travel and dietary behavior and the associated health and environmental impact are of mixed quality. Most apps do not include all desirable features or provide sufficient health information. Further research is needed to determine the potential of smartphone apps to evoke behavior change resulting in climate change and health co-benefits.

Socioeconomic and demographic drivers of red and processed meat consumption: implications for health and environmental sustainability

Red and processed meat (RPM) intake varies widely globally. In some high-income countries (HIC) the last decade has witnessed an overall decline or stabilisation in the consumption of RPM, in contrast to emerging economies where its consumption continues to increase with rising income and rapid urbanisation. The production and consumption of RPM have become major concerns regarding the environmental impacts of livestock in particular, but also because of associations between high RPM consumption and diet-related non-communicable disease. Therefore, it is important to identify socioeconomic and demographic drivers of the consumption of RPM. This paper explores how consumption of RPM differs with age, gender, socioeconomic status and in different global contexts. There are some key socioeconomic and demographic patterns in RPM consumption. Men tend to consume RPM more often and in higher quantities, and there is evidence of a social gradient in HIC, with lower socioeconomic groups consuming RPM more often and in larger quantities. Patterns for consumption with age are less clear cut. It is apparent that consumers in HIC are still consuming high levels of RPM, although the downward shifts in some socioeconomic and demographic groups is encouraging and suggests that strategies could be developed to engage those consumers identified as high RPM consumers. In low- and middle-income countries, RPM consumption is rising, especially in China and Brazil, and in urban areas. Ways of encouraging populations to maintain their traditional healthy eating patterns need to be found in low- and middle-income countries, which will have health, environmental and economic co-benefits.

Systematic mapping review of the factors influencing dietary behaviour in ethnic minority groups living in Europe: a DEDIPAC study

Background

Europe has a growing population of ethnic minority groups whose dietary behaviours are potentially of public health concern. To promote healthier diets, the factors driving dietary behaviours need to be understood. This review mapped the broad range of factors influencing dietary behaviour among ethnic minority groups living in Europe, in order to identify research gaps in the literature to guide future research.

Methods

A systematic mapping review was conducted (protocol registered with PROSPERO 2014: CRD42014013549). Nine databases were searched for quantitative and qualitative primary research published between 1999 and 2014. Ethnic minority groups were defined as immigrants/populations of immigrant background from low and middle income countries, population groups from former Eastern Bloc countries and minority indigenous populations. In synthesizing the findings, all factors were sorted and structured into emerging clusters according to how they were seen to relate to each other.

Results

Thirty-seven of 2965 studies met the inclusion criteria (n = 18 quantitative; n = 19 qualitative). Most studies were conducted in Northern Europe and were limited to specific European countries, and focused on a selected number of ethnic minority groups, predominantly among populations of South Asian origin. The 63 factors influencing dietary behaviour that emerged were sorted into seven clusters: social and cultural environment (16 factors), food beliefs and perceptions (11 factors), psychosocial (9 factors), social and material resources (5 factors), accessibility of food (10 factors), migration context (7 factors), and the body (5 factors).

Conclusion

This review identified a broad range of factors and clusters influencing dietary behaviour among ethnic minority groups. Gaps in the literature identified a need for researchers to explore the underlying mechanisms that shape dietary behaviours, which can be gleaned from more holistic, systems-based studies exploring relationships between factors and clusters. The dominance of studies exploring ‘differences’ between ethnic minority groups and the majority population in terms of the socio-cultural environment and food beliefs suggests a need for research exploring ‘similarities’. The evidence from this review will feed into developing a framework for the study of factors influencing dietary behaviours in ethnic minority groups in Europe.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-016-0412-8) contains supplementary material, which is available to authorized users.

Socioeconomic Indicators Are Independently Associated with Nutrient Intake in French Adults: A DEDIPAC Study

Studies have suggested differential associations of specific indicators of socioeconomic position (SEP) with nutrient intake and a cumulative effect of these indicators on diet. We investigated the independent association of SEP indicators (education, income, occupation) with nutrient intake and their effect modification. This cross-sectional analysis included 91,900 French adults from the NutriNet-Santé cohort. Nutrient intake was estimated using three 24-h records. We investigated associations between the three SEP factors and nutrient intake using sex-stratified analysis of covariance, adjusted for age and energy intake, and associations between income and nutrient intake stratified by education and occupation. Low educated participants had higher protein and cholesterol intakes and lower fibre, vitamin C and beta-carotene intakes. Low income individuals had higher complex carbohydrate intakes, and lower magnesium, potassium, folate and vitamin C intakes. Intakes of vitamin D and alcohol were lower in low occupation individuals. Higher income was associated with higher intakes of fibre, protein, magnesium, potassium, beta-carotene, and folate among low educated persons only, highlighting effect modification. Lower SEP, particularly low education, was associated with lower intakes of nutrients required for a healthy diet. Each SEP indicator was associated with specific differences in nutrient intake suggesting that they underpin different social processes.

The relevance of the side-view in body image scales for public health: an example from two African populations

Background

Body size scales are a common method for diagnosing body image disturbances and assessing the cultural valorisation of stoutness, a phenomenon that plays a role in the development of overweight, especially among African populations. Traditionally, body size scales present a front view. In this study, we evaluated a complementary model of representing body shape: the side view of body outlines. In particular, we examined the association between the side-view and a set of bio-anthropometric indices in men and women.

Methods

To cover the inter-ethnic variability in the Niger-Congo area, we selected a balanced sex-ratio sample of 80 Cameroonians and 81 Senegalese. Individuals wearing close-fitting clothes were photographed from the front-and side-view, and measured following a bio-anthropometric protocol synthesizing body shape variation: Body Mass Index, percentage body fat, somatotype profile, waist circumference, waist-to-hip ratio, mean blood pressure and glycaemia. The shape of each front and side body outline was extracted and characterised by Normalized Elliptic Fourier Descriptors (NEFD). Finally, we assessed associations between NEFD and bio-anthropometric indices.

Results

Variation in the shape of both front and side body outlines was associated with all bio-anthropometrics for at least one sex-population combination. Overall, the side view best captured body shape variation related to changes in almost all bio-anthropometrics in both sexes and populations, with the exceptions of female mesomorphy, male blood pressure and glycaemia (in both sexes). We found that the details of the relationship between bio-anthropometrics and body shape differed between the two male populations, a finding that was reflected in side-views for all criteria, but not front-views.

Conclusions

Variation in body shape assessed by several bio-anthropometrics related to health and nutritional status was larger for side than front body outlines. Integrating side views in body size scales would improve the accuracy of body size assessment and thus, the assessment of behaviours leading to overweight, as well as symptoms of body image disturbances, in Africa and potentially in other populations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2511-x) contains supplementary material, which is available to authorized users.

The role of social networks in the development of overweight and obesity among adults: a scoping review

BACKGROUND

Although it is increasingly acknowledged that social networks are important to our understanding ofoverweight and obesity, there is limited understanding about the processes by which such networks shapetheir progression. This paper reports the findings of a scoping review of the literature that sought to identify the key processes through which social networks are understood to influence the development of overweight and obesity.

METHODS

A scoping review was conducted. Forty five papers were included in the final review, the findings of which were synthesised to provide an overview of the main processes through which networks have been understood to influence the development of overweight and obesity.

RESULTS

Included papers addressed a wide range of research questions framed around six types of networks: a paired network (one's spouse or intimate partner); friends and family (including work colleagues and people within social clubs); ephemeral networks in shared public spaces (such as fellow shoppers in a supermarket or diners in a restaurant); people living within the same geographical region; peers (including co-workers, fellow students, fellow participants in a weight loss programme); and cultural groups (often related toethnicity). As individuals are embedded in many of these different types of social networks at any one time, the pathways of influence from social networks to the development of patterns of overweight and obesity are likely to be complex and interrelated. Included papers addressed a diverse set of issues: body weight trends over time; body size norms or preferences; weight loss and management; physical activity patterns; and dietary patterns.

DISCUSSION

Three inter-related processes were identified: social contagion (whereby the network in which people are embedded influences their weight or weight influencing behaviours), social capital (whereby sense of belonging and social support influence weight or weight influencing behaviours), and social selection (whereby a person's network might develop according to his or her weight).

CONCLUSIONS

The findings have important implications for understanding about methods to target the spread of obesity, indicating that much greater attention needs to be paid to the social context in which people make decisions about their weight and weight influencing behaviours.

African stakeholders' views of research options to improve nutritional status in sub-Saharan Africa

BACKGROUND

Setting research priorities for improving nutrition in Africa is currently ad hoc and there is a need to shift the status quo in the light of slow progress in reducing malnutrition. This study explored African stakeholders' views on research priorities in the context of environmental and socio-demographic changes that will impact on nutritional status in Africa in the coming years.

METHODS

Using Multi-Criteria Mapping, quantitative and qualitative data were gathered from 91 stakeholders representing 6 stakeholder groups (health professionals, food Industry, government, civil society, academics and research funders) in Benin, Mozambique, South Africa, Tanzania, Togo and Uganda. Stakeholders appraised six research options (ecological nutrition, nutritional epidemiology, community nutrition interventions, behavioural nutrition, clinical nutrition and molecular nutrition) for how well they could address malnutrition in Africa.

RESULTS

Impact (28.3%), research efficacy (23.6%) and social acceptability (22.4%) were the criteria chosen the most to evaluate the performance of research options. Research on the effectiveness of community interventions was seen as a priority by stakeholders because they were perceived as likely to have an impact relatively quickly, were inexpensive and cost-effective, involved communities and provided direct evidence of what works. Behavioural nutrition research was also highly appraised. Many stakeholders, particularly academics and government were optimistic about the value of ecological nutrition research (the impact of environmental change on nutritional status). Research funders did not share this enthusiasm. Molecular nutrition was least preferred, considered expensive, slow to have an impact and requiring infrastructure. South Africa ranked clinical and molecular nutrition the highest of all countries.

CONCLUSION

Research funders should redirect research funds in Africa towards the priorities identified by giving precedence to develop the evidence for effective community nutrition interventions. Expanding research funding in behavioural and ecological nutrition was also valued and require multi-disciplinary collaborations between nutritionists, social scientists, agricultural and climate change scientists.

Deprivation, clubs and drugs: results of a UK regional population-based cross-sectional study of weight management strategies

Background

Despite rising levels of obesity in England, little is known about slimming club and weight loss drug (medication) use or users. In order to inform future commissioning, we report the prevalence of various weight management strategies and examine the associations between slimming club and medication use and age, gender, deprivation and body mass index.

Methods

A population based cross-sectional survey of 26,113 adults was conducted in South Yorkshire using a self-completed health questionnaire. Participants were asked whether they had ever used the following interventions to manage their weight: increasing exercise, healthy eating, controlling portion size, slimming club, over the counter weight loss medication, or meal replacements. Factors associated with slimming club and weight-loss medication use were explored using logistic regression.

Results

Over half of the sample was either overweight (36.6%) or obese (19.6%). Obesity was more common in the most deprived areas compared to the least deprived (26.3% vs. 12.0%). Healthy eating (49.0%), controlling portion size (43.4%), and increasing exercise (43.0%) were the most commonly reported weight management strategies. Less common strategies were attending a slimming club (17.2%), meal replacements (3.4%) and weight-loss medication (3.2%). Adjusting for BMI, age, deprivation and long standing health conditions, women were significantly more likely to report ever using a slimming club (adjusted OR = 18.63, 95% CI = 16.52–21.00) and more likely to report ever using over the counter weight-loss medications (AOR = 3.73, 95% CI = 3.10-4.48), while respondents from the most deprived areas were less likely to report using slimming clubs (AOR = 0.60, 95% CI = 0.53-0.68), and more likely to reporting using weight loss medications (AOR =1.38, 95% CI = 1.05-1.82).

Conclusion

A large proportion of individuals report having used weight management strategies. Slimming clubs and over-the-counter weight loss medication account for a smaller proportion of the overall uptake. Those from less deprived areas were more likely to use slimming clubs while those from more deprived areas were more likely to use weight-loss medications. Future NHS and Local Authority commissioning of weight management services must be aware of this varying social gradient in weight management strategies.

A conceptual framework for healthy eating behavior in ecuadorian adolescents: a qualitative study

OBJECTIVE

The objective of this study was to identify factors influencing eating behavior of Ecuadorian adolescents - from the perspective of parents, school staff and adolescents - to develop a conceptual framework for adolescents' eating behavior.

STUDY DESIGN

Twenty focus groups (N=144 participants) were conducted separately with adolescents aged 11-15 y (n (focus groups)=12, N (participants)=80), parents (n=4, N=32) and school staff (n=4, N=32) in rural and urban Ecuador. A semi-structured questioning route was developed based on the 'Attitude, Social influences and Self-efficacy' model and the socio-ecological model to assess the relevance of behavioral and environmental factors in low- and middle-income countries. Two researchers independently analyzed verbatim transcripts for emerging themes, using deductive thematic content analysis. Data were analyzed using NVivo 8.

RESULTS

All groups recognized the importance of eating healthily and key individual factors in Ecuadorian adolescents' food choices were: financial autonomy, food safety perceptions, lack of self-control, habit strength, taste preferences and perceived peer norms. Environmental factors included the poor nutritional quality of food and its easy access at school. In their home and family environment, time and convenience completed the picture as barriers to eating healthily. Participants acknowledged the impact of the changing socio-cultural environment on adolescents' eating patterns. Availability of healthy food at home and financial constraints differed between settings and socio-economic groups.

CONCLUSION

Our findings endorse the importance of investigating behavioral and environmental factors that influence and mediate healthy dietary behavior prior to intervention development. Several culture-specific factors emerged that were incorporated into a conceptual framework for developing health promotion interventions in Ecuador.

Developing a sustainable nutrition research agenda in sub-Saharan Africa--findings from the SUNRAY project

Patrick Kolsteren and colleagues present the findings of a collaborative effort by stakeholders in sub-Saharan Africa to identify priorities for nutrition research. They propose a new approach that stimulates demand from policy makers for research and holds them accountable for incorporating research into policy and practice. Please see later in the article for the Editors' Summary

How can the operating environment for nutrition research be improved in sub-Saharan Africa? The views of African researchers

Optimal nutrition is critical for human development and economic growth. Sub-Saharan Africa is facing high levels of food insecurity and only few sub-Saharan African countries are on track to eradicate extreme poverty and hunger by 2015. Effective research capacity is crucial for addressing emerging challenges and designing appropriate mitigation strategies in sub-Saharan Africa. A clear understanding of the operating environment for nutrition research in sub-Saharan Africa is a much needed prerequisite. We collected data on the barriers and requirements for conducting nutrition research in sub-Saharan Africa through semi-structured interviews with 144 participants involved in nutrition research in 35 countries in sub-Saharan Africa. A total of 133 interviews were retained for coding. The main barriers identified for effective nutrition research were the lack of funding due to poor recognition by policymakers of the importance of nutrition research and under-utilisation of research findings for developing policy, as well as an absence of research priority setting from within Africa. Current research topics were perceived to be mainly determined by funding bodies from outside Africa. Nutrition researchers argued for more commitment from policymakers at national level. The low capacity for nutrition research was mainly seen as a consequence of insufficient numbers of nutrition researchers, limited skills and a poor research infrastructure. In conclusion, African nutrition researchers argued how research priorities need to be identified by African stakeholders, accompanied by consensus building to enable creating a problem-driven national research agenda. In addition, it was considered necessary to promote interactions among researchers, and between researchers and policymakers. Multidisciplinary research and international and cross-African collaboration were seen as crucial to build capacity in sub-Saharan nutrition research.

Reproducibility and relative validity of a brief quantitative food frequency questionnaire for assessing fruit and vegetable intakes in North-African women

BACKGROUND

In the context of a rapidly increasing prevalence of noncommunicable diseases, fruit and vegetables could play a key preventive role. To date, there is no rapid assessment tool available for measuring the fruit and vegetable intakes of North-African women. The present study aimed to investigate the reproducibility and relative validity of an eight-item quantitative food frequency questionnaire that measures the fruit and vegetable intakes (FV-FFQ) of Moroccan women.

METHODS

During a 1-week period, 100 women, living in the city of Rabat, Morocco (aged 20-49 years) completed the short FV-FFQ twice: once at baseline (FV-FFQ1) and once at the end of the study (FV-FFQ2). In the mean time, participants completed three 24-h dietary recalls. All questionnaires were administered by interviewers. Reproducibility was assessed by computing Spearman's correlation coefficients, intraclass correlation (ICC) coefficients and kappa statistics. Relative validity was assessed by computing Wilcoxon signed-rank tests and Spearman's correlation coefficients, as well as by performing Bland-Altman plots.

RESULTS

In terms of reproducibility, Spearman's correlation coefficient was 0.56; ICC coefficient was 0.68; and weighted kappa was 0.35. In terms of relative validity, compared with the three 24-h recalls, the FV-FFQ slightly underestimated mean fruit and vegetable intakes (-10.9%; P = 0.006); Spearman's correlation coefficient was 0.69; at the individual level, intakes measured by the FV-FFQ were between 0.39 and 2.19 times those measured by the 24-h recalls.

CONCLUSIONS

The brief eight-item FV-FFQ is a reliable and relatively valid tool for measuring mean fruit and vegetable intakes at the population level, although this is not the case at the individual level.

Developing national obesity policy in middle-income countries: a case study from North Africa

Background The prevalence of overweight and obesity is a rapidly growing threat to public health in both Morocco and Tunisia, where it is reaching similar proportions to high-income countries. Despite this, a national strategy for obesity does not exist in either country. The aim of this study was to explore the views of key stakeholders towards a range of policies to prevent obesity, and thus guide policy makers in their decision making on a national level.

Methods Using Multicriteria Mapping, data were gathered from 82 stakeholders (from 33 categories in Morocco and 36 in Tunisia) who appraised 12 obesity policy options by reference to criteria of their own choosing.

Results The feasibility of policies in practical or political terms and their cost were perceived as more important than how effective they would be in reducing obesity. There was most consensus and preference for options targeting individuals through health education, compared with options that aimed at changing the environment, i.e. modifying food supply and demand (providing healthier menus/changing food composition/food sold in schools); controlling information (advertising controls/mandatory labelling) or improving access to physical activity. In Tunisia, there was almost universal consensus that at least some environmental-level options are required, but in Morocco, participants highlighted the need to raise awareness within the population and policy makers that obesity is a public health problem, accompanied by improving literacy before such measures would be accepted.

Conclusion Whilst there is broad interest in a range of policy options, those measures targeting behaviour change through education were most valued. The different socioeconomic, political and cultural contexts of countries need to be accounted for when prioritizing obesity policy. Obesity was not recognized as a major public health priority; therefore, convincing policy makers about the need to prioritize action to prevent obesity, particularly in Morocco, will be a crucial first step.

Effectiveness of preventive school-based obesity interventions in low- and middle-income countries: a systematic review

BACKGROUND

The prevalence of childhood obesity is increasing rapidly in low- and middle-income countries, and informed policies to tackle the problem must be defined.

OBJECTIVE

We systematically reviewed the evidence on the effectiveness of school-based interventions targeting dietary behavior and/or physical activity for the primary prevention of obesity in children and adolescents aged 6-18 y in low- and middle-income countries.

DESIGN

We searched the MEDLINE, EMBASE, Web of Science, CENTRAL, ERIC, Cochrane Library, and Centre for Reviews and Dissemination databases for peer-reviewed controlled studies published in English, Spanish, French, German, or Dutch between January 1990 and July 2011. The quality of the included studies was appraised independently by 2 authors who used the Effective Public Health Practice Project tool.

RESULTS

From a total of 7218 unique references, we retained 22 studies. Most of the interventions (82%) had a positive effect on dietary behavior and physical activity behavior (effect size ranged from -0.48 to 1.61). BMI decreased in 8 studies (effect size ranged from -0.7 to 0.0). Effective interventions targeted both diet and physical activity, involved multiple stakeholders, and integrated educational activities into the school curriculum.

CONCLUSIONS

School-based interventions have the potential to improve dietary and physical activity behavior and to prevent unhealthy body weights in low- and middle-income countries. To reach their full potential, interventions should conduct process evaluations to document program implementation. The effect and the pathways through which interventions have this effect need to be better documented through rigorous evaluation studies.

The acceptability to stakeholders of mandatory nutritional labelling in France and the UK--findings from the PorGrow project

BACKGROUND

Implementing a European Union (EU)-wide mandatory nutrition labelling scheme has been advocated as part a multi-pronged strategy to tackle obesity. The type of scheme needs to be acceptable to all key stakeholders. This study explored stakeholders' viewpoints of labelling in two contrasting food cultures (France and the UK) to see whether attitudes were influenced by sectoral interests and/or national context.

METHODS

Using Multi Criteria Mapping, a decision analysis tool that assesses stakeholder viewpoints, quantitative and qualitative data were gathered during tape-recorded interviews. In France and the UK, 21 comparable stakeholders appraised nutritional labelling with criteria of their own choosing (i.e. feasibility, societal benefits, social acceptability, efficacy in addressing obesity, additional health benefits) and three criteria relating to cost (to industry; public sector; individuals). When scoring, interviewees provided both optimistic (best case) and pessimistic (worst case) judgements.

RESULTS

Overall, mandatory nutritional labelling was appraised least favourably in France. Labelling performed worse under optimistic (best case) scenarios in France, for five out of eight sets of criteria. French stakeholders viewed labelling as expensive, having fewer benefits to society and as being marginally less effective than UK stakeholders did. However, French interviewees thought implementing labelling was feasible and would provide additional health benefits. British and French stakeholders made similar quantitative judgements on how socially acceptable mandatory labelling would be.

CONCLUSIONS

There is agreement between some stakeholder groups in the two different countries, especially food chain operators. However, cultural differences emerged that could influence the impact of an EU-wide mandatory labelling scheme in both countries.

The potential role of taxes and subsidies on food in the prevention of obesity in Europe

BACKGROUND

Obesity implies costs not only for the individual but also for society. The authors explore the opinions of stakeholders on the potential of taxes or subsidies, as measures for tackling obesity in Europe.

METHODS

Structured interviews were conducted using Multicriteria Mapping, a computer-based, decision-support tool, with 189 interviewees drawn from 21 different stakeholder categories across nine members of the EU interviews, to appraise 20 predefined policy options aimed at reducing obesity, including 'taxing obesity-promoting foods' and 'subsidising healthy foods.' A four-step approach involved selecting options, defining criteria, scoring options quantitatively and weighting criteria to provide overall rankings of options. Interviews were recorded and transcribed to yield qualitative data.

RESULTS

Compared with other policy options appraised, taxation and subsidies were not favourably received, mainly because they were considered difficult to implement. Overall, trade unions rated both options more favourably than all other stakeholder groups. As anticipated, both options received their lowest scores from representatives of the farming, food processing and advertising industries. Nutritional/obesity advisory experts and public sector caterers gave the most positive ratings to subsidies overall. Along with public health professionals, large commercial retailers were most in favour of taxation.

CONCLUSIONS

Taxation and subsidies were poorly appraised compared with other policy measures, with stakeholders expressing reservations mainly focussed on the practicalities and cost of introducing such measures. Although applying taxes/subsidies could be useful to combat obesity, the study suggests that most stakeholders still need to be convinced of their viability and acceptability when compared with other measures.

Interstitial glucose profile associated with symptoms attributed to hypoglycemia by otherwise healthy women

BACKGROUND

Reports of postprandial symptoms attributed to hypoglycemia by otherwise healthy individuals appear to be relatively common in UK women. Whether these symptoms are related to blood glucose is a contentious issue, which periodic ambulatory blood glucose measurement has failed to resolve.

OBJECTIVE

The authors investigated, using continuous glucose monitoring technology, whether postprandial symptoms are associated with interstitial glucose concentrations (IG) in the hypoglycemic range or with a previous fall in IG.

DESIGN

Thirty healthy nonobese women (age 20-48 y) who reported symptoms attributable to hypoglycemia and 20 nonsymptomatic controls wore a subcutaneous probe in abdominal fat for 4-7 d (median: 5 d) and kept a diet and activity diary during this time.

RESULTS

Twenty women reported postprandial symptoms; 41 episodes were recorded. When symptomatic, IG was < or =3.3 mmol/L in 5% of cases. A significant fall in IG over the preceding 60 min was observed before autonomic symptoms (P < 0.005). The proportion of total energy intake derived from dietary fat in the symptomatic group was higher than that in the controls (P < 0.05). The proportion of total sugars was similar between groups; however, the meal preceding symptoms had a higher percentage of energy derived from total sugars when compared with the individuals' diet over the study period (P < 0.05).

CONCLUSIONS

Most symptoms attributable to hypoglycemia were not associated with an IG concentration in the hypoglycemic range. A previous fall in IG may be implicated in the etiology of autonomic symptoms, with the consumption of meals high in sugars potentially playing a role in symptom initiation.

'All under one roof?' differences in food availability and shopping patterns in Southern France and Central England

BACKGROUND

This study investigates patterns of food shopping and availability of fruit and vegetables and snack foods in a northern European (Central England) and southern European region (Southern France).

METHODS

Two studies were conducted in England (Nottingham) and France (Montpellier): (i) Cross-sectional population surveys using self-administered postal questionnaires to assess type of outlets used for food shopping in random population samples (England: n = 826; Montpellier: n = 766). (ii) Food availability studies to determine: the number of food outlets in defined comparable geographical areas; the number stocking fruit and vegetables, their quality and energy dense snacks.

RESULTS

The English respondents used supermarkets most regularly (P < 0.001), whereas the French preferred to use smaller local shops, such as bakers (P < 0.001), butchers (P < 0.001) and markets (P < 0.001). Overall a larger proportion of outlets in Montpellier than Nottingham sold fresh fruit and vegetables and a wider variety of fresh fruit. However, a range of vegetables and all other types of fruit were as widely available in English shops. Although the quality of fresh fruit and vegetables tended to be better in Montpellier, the difference was not significant. Crisps (P < 0.05) and confectionary items (P < 0.05) were more widely available in England.

CONCLUSIONS

Food shopping was done 'under one roof' more often in England, whereas in France, shopping was done in smaller specialist shops, which was reflected in their presence within the locality. Even though availability of fruit and vegetables was good in both countries, snack foods were more abundant in England. This clearly impacts on the food environment and could explain the higher prevalence of obesity in England, factors which are also influenced by culture, habits and convenience.