Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries

Ultra-processed foods and added sugars in the US diet: evidence from a nationally representative cross-sectional study

OBJECTIVES

To investigate the contribution of ultra-processed foods to the intake of added sugars in the USA. Ultra-processed foods were defined as industrial formulations which, besides salt, sugar, oils and fats, include substances not used in culinary preparations, in particular additives used to imitate sensorial qualities of minimally processed foods and their culinary preparations.

DESIGN

Cross-sectional study.

SETTING

National Health and Nutrition Examination Survey 2009-2010.

PARTICIPANTS

We evaluated 9317 participants aged 1+ years with at least one 24 h dietary recall.

MAIN OUTCOME MEASURES

Average dietary content of added sugars and proportion of individuals consuming more than 10% of total energy from added sugars.

DATA ANALYSIS

Gaussian and Poisson regressions estimated the association between consumption of ultra-processed foods and intake of added sugars. All models incorporated survey sample weights and adjusted for age, sex, race/ethnicity, family income and educational attainment.

RESULTS

Ultra-processed foods comprised 57.9% of energy intake, and contributed 89.7% of the energy intake from added sugars. The content of added sugars in ultra-processed foods (21.1% of calories) was eightfold higher than in processed foods (2.4%) and fivefold higher than in unprocessed or minimally processed foods and processed culinary ingredients grouped together (3.7%). Both in unadjusted and adjusted models, each increase of 5 percentage points in proportional energy intake from ultra-processed foods increased the proportional energy intake from added sugars by 1 percentage point. Consumption of added sugars increased linearly across quintiles of ultra-processed food consumption: from 7.5% of total energy in the lowest quintile to 19.5% in the highest. A total of 82.1% of Americans in the highest quintile exceeded the recommended limit of 10% energy from added sugars, compared with 26.4% in the lowest.

CONCLUSIONS

Decreasing the consumption of ultra-processed foods could be an effective way of reducing the excessive intake of added sugars in the USA.

Neglected chronic disease: The WHO framework on non-communicable diseases and implications for the global poor

The current global framework on noncommunicable disease (NCD), as exemplified by the WHO Action Plan of 2012, neglects the needs of the global poor. The current framework is rooted in an outdated pseudo-evolutionary theory of epidemiologic transition, which weds NCDs to modernity, and relies on global aggregate data. It is oriented around a simplistic causal model of behaviour, risk and disease, which implicitly locates 'risk' within individuals, conveniently drawing attention away from important global drivers of the NCD epidemic. In fact, the epidemiologic realities of the bottom billion reveal a burden of neglected chronic diseases that are associated with 'alternative' environmental and infectious risks that are largely structurally determined. In addition, the vertical orientation of the framework fails to centralise health systems and delivery issues that are essential to chronic disease prevention and treatment. A new framework oriented around a global health equity perspective would be able to correct some of the failures of the current model by bringing the needs of the global poor to the forefront, and centralising health systems and delivery. In addition, core social science concepts such as Bordieu's habitus may be useful to re-conceptualising strategies that may address both behavioural and structural determinants of health.

The alcohol harm paradox: using a national survey to explore how alcohol may disproportionately impact health in deprived individuals

Background

Internationally, studies show that similar levels of alcohol consumption in deprived communities (vs. more affluent) result in higher levels of alcohol-related ill health. Hypotheses to explain this alcohol harm paradox include deprived drinkers: suffering greater combined health challenges (e.g. smoking, obesity) which exacerbate effects of alcohol harms; exhibiting more harmful consumption patterns (e.g. bingeing); having a history of more harmful consumption; and disproportionately under-reporting consumption. We use a bespoke national survey to assess each of these hypotheses.

Methods

A national telephone survey designed to test this alcohol harm paradox was undertaken (May 2013 to April 2014) with English adults (n = 6015). Deprivation was assigned by area of residence. Questions examined factors including: current and historic drinking patterns; combined health challenges (smoking, diet, exercise and body mass); and under-reported consumption (enhanced questioning on atypical/special occasion drinking). For each factor, analyses examined differences between deprived and more affluent individuals controlled for total alcohol consumption.

Results

Independent of total consumption, deprived drinkers were more likely to smoke, be overweight and report poor diet and exercise. Consequently, deprived increased risk drinkers (male >168–400 g, female >112–280 g alcohol/week) were >10 times more likely than non-deprived counterparts to drink in a behavioural syndrome combining smoking, excess weight and poor diet/exercise. Differences by deprivation were significant but less marked in higher risk drinkers (male >400 g, female >280 g alcohol/week). Current binge drinking was associated with deprivation independently of total consumption and a history of bingeing was also associated with deprivation in lower and increased risk drinkers.

Conclusions

Deprived increased/higher drinkers are more likely than affluent counterparts to consume alcohol as part of a suite of health challenging behaviours including smoking, excess weight and poor diet/exercise. Together these can have multiplicative effects on risks of wholly (e.g. alcoholic liver disease) and partly (e.g. cancers) alcohol-related conditions. More binge drinking in deprived individuals will also increase risks of injury and heart disease despite total alcohol consumption not differing from affluent counterparts. Public health messages on how smoking, poor diet/exercise and bingeing escalate health risks associated with alcohol are needed, especially in deprived communities, as their absence will contribute to health inequalities.

Reduced reward-driven eating accounts for the impact of a mindfulness-based diet and exercise intervention on weight loss: Data from the SHINE randomized controlled trial

Many individuals with obesity report over eating despite intentions to maintain or lose weight. Two barriers to long-term weight loss are reward-driven eating, which is characterized by a lack of control over eating, a preoccupation with food, and a lack of satiety; and psychological stress. Mindfulness training may address these barriers by promoting awareness of hunger and satiety cues, self-regulatory control, and stress reduction. We examined these two barriers as potential mediators of weight loss in the Supporting Health by Integrating Nutrition and Exercise (SHINE) randomized controlled trial, which compared the effects of a 5.5-month diet and exercise intervention with or without mindfulness training on weight loss among adults with obesity. Intention-to-treat multiple mediation models tested whether post-intervention reward-driven eating and psychological stress mediated the impact of intervention arm on weight loss at 12- and 18-months post-baseline among 194 adults with obesity (BMI: 30-45). Mindfulness (relative to control) participants had significant reductions in reward-driven eating at 6 months (post-intervention), which, in turn, predicted weight loss at 12 months. Post-intervention reward-driven eating mediated 47.1% of the total intervention arm effect on weight loss at 12 months [β = -0.06, SE(β) = 0.03, p = .030, 95% CI (-0.12, -0.01)]. This mediated effect was reduced when predicting weight loss at 18 months (p = .396), accounting for 23.0% of the total intervention effect, despite similar weight loss at 12 months. Psychological stress did not mediate the effect of intervention arm on weight loss at 12 or 18 months. In conclusion, reducing reward-driven eating, which can be achieved using a diet and exercise intervention that includes mindfulness training, may promote weight loss (clinicaltrials.gov registration: NCT00960414).

Impact of actions of food and nutrition education program in a population of adolescents

ABSTRACT Objective: To evaluate changes in food intake after adolescents attended a food and nutrition education program at a non-profit institution. Methods: Fifty-four adolescents aged 16 to 19 years, of low socioeconomic level, enrolled in an non-governmental organization in São Paulo, underwent a nutritional intervention of six months consisting of six meetings with dieticians, as well as strategic communication and relationship actions. Body weight, height, body mass index, questionnaire on knowledge on nutrition and feeding practices, 24-hour recall, and diet quality assessment using the Diet Quality Index associated with the Digital Food Guide were collected at baseline and after the intervention. Dietary pattern improvement was defined as an increase of at least 5 points in Diet Quality Index associated with the Digital Food Guide. Results: Understanding of food labels increased, and the dietary patterns on weekdays and weekends improved by 33 and 37%, respectively. The intake of legumes, milk, dairy products, fruits, and vegetables increased (adequacy components). However, intakes of nuts and whole grains were low, and intake of moderation components was high. Conclusion: The program improved the dietary patterns of adolescents, making it a viable and inexpensive method to prevent disease and improve health and quality of life. In addition, the Diet Quality Index associated with the Digital Food Guide has proven to be a good nutritional tool for assessing changes in food intake and for guiding future counseling and nutritional intervention actions for this population.

Enforcing the International Code of Marketing of Breast-milk Substitutes for Better Promotion of Exclusive Breastfeeding: Can Lessons Be Learned?

Exclusive breastfeeding, one of the best natural resources, needs protection and promotion. The International Code of Marketing of Breast-milk Substitutes (the Code), which aims to prevent the undermining of breastfeeding by formula advertising, faces implementation challenges. We reviewed frequently overlooked challenges and obstacles that the Code is facing worldwide, but particularly in Southeast Asia. Drawing lessons from various countries where we work, and following the example of successful public health interventions, we discussed legislation, enforcement, and experiences that are needed to successfully implement the Code. Successful holistic approaches that have strengthened the Code need to be scaled up. Community-based actions and peer-to-peer promotions have proved successful. Legislation without stringent enforcement and sufficient penalties is ineffective. The public needs education about the benefits and ways and means to support breastfeeding. It is crucial to combine strong political commitment and leadership with strict national regulations, definitions, and enforcement. National breastfeeding committees, with the authority to improve regulations, investigate violations, and enforce the laws, must be established. Systematic monitoring and reporting are needed to identify companies, individuals, intermediaries, and practices that infringe on the Code. Penalizing violators is crucial. Managers of multinational companies must be held accountable for international violations, and international legislative enforcement needs to be established. Further measures should include improved regulations to protect the breastfeeding mother: large-scale education campaigns; strong penalties for Code violators; exclusion of the formula industry from nutrition, education, and policy roles; supportive legal networks; and independent research of interventions supporting breastfeeding.

Australian Pregnant Women's Awareness of Gestational Weight Gain and Dietary Guidelines: Opportunity for Action

Background. Excessive gestational weight gain (GWG) can negatively impact on maternal and foetal health. Guidelines based on Institute of Medicine (IOM) encourage managing GWG by following healthy eating recommendations and increasing physical activity. This study investigated pregnant women's knowledge of their optimal GWG and recommended dietary approaches for GWG management. Method. English-speaking pregnant women were recruited from five hospitals in New South Wales (Australia) and an online link. Prepregnancy Body Mass Index (BMI) was calculated from self-reported height and prepregnancy weight. Participants identified their recommended GWG. A survey assessed practical dietary knowledge and asked about broad dietary recommendations to prevent excessive GWG. Chi square and logistic regression analyses were used. Results. N = 326 pregnant women completed the surveys; 49% entered pregnancy overweight (25.2%) or obese (23.6%); and knowledge of recommended GWG was lacking. Prepregnancy BMI was a significant predictor of GWG recommendation knowledge (P < 0.000). Pregnant women were highly knowledgeable about broad dietary recommendations but had poor knowledge of detailed recommendations. Conclusions. Limited knowledge of IOM's GWG guidelines and of specific dietary recommendations for pregnancy should be addressed by health care providers and education initiatives to assist the high number of women who enter pregnancy overweight or obese.

Maternal Nutrition and Glycaemic Index during Pregnancy Impacts on Offspring Adiposity at 6 Months of Age--Analysis from the ROLO Randomised Controlled Trial

Childhood obesity is associated with increased risk of adult obesity and metabolic disease. Diet and lifestyle in pregnancy influence fetal programming; however the influence of specific dietary components, including low glycaemic index (GI), remains complex. We examined the effect of a maternal low GI dietary intervention on offspring adiposity at 6 months and explored the association between diet and lifestyle factors in pregnancy and infant body composition at 6 months. 280 6-month old infant and mother pairs from the control (n = 142) and intervention group (n = 138), who received low GI dietary advice in pregnancy, in the ROLO study were analysed. Questionnaires (food diaries and lifestyle) were completed during pregnancy, followed by maternal lifestyle and infant feeding questionnaires at 6 months postpartum. Maternal anthropometry was measured throughout pregnancy and at 6 months post-delivery, along with infant anthropometry. No difference was found in 6 months infant adiposity between control and intervention groups. Maternal trimester three GI, trimester two saturated fats and trimester one and three sodium intake were positively associated with offspring adiposity, while trimester two and three vitamin C intake was negatively associated. In conclusion associations were observed between maternal dietary intake and GI during pregnancy and offspring adiposity at 6 months of age.

Strategic nutrition: a vision for the twenty-first century

It is now widely accepted that poor nutrition plays a major role in the epidemic of various diseases, including obesity, type 2 diabetes and CVD. There has also been much research regarding the role of related factors such as advertising and food prices. Many intervention studies have been carried out where attempts have been made to persuade people to modify their behaviour, such as by making dietary changes, in order to enhance health (health promotion). There has also been much debate on the potential of government policy as a tool for achieving these goals. Various proposals have been made, such as a tax on sugary drinks, the redirection of food subsidies and how the salt content of food can be reduced. However, the great majority of previous papers have considered only single aspects of the topics discussed here. The present paper reviews strategies for improving public health, both health promotion interventions and the use of government policy approaches. Topics discussed include providing advice for the general population and the design of food guides and food labels. This leads to the conclusion that we need an overall strategy that integrates this diverse body of information and formulates a comprehensive action plan. I propose the term 'strategic nutrition'. The implementation of this plan opens up a path to a major advance in public health.

Ultra-processed food purchases in Norway: a quantitative study on a representative sample of food retailers

OBJECTIVE

To identify the use of ultra-processed foods - vectors of salt, sugar and fats - in the Norwegian diet through an assessment of food sales.

DESIGN

Sales data from a representative sample of food retailers in Norway, collected in September 2005 (n 150) and September 2013 (n 170), were analysed. Data consisted of barcode scans of individual food item purchases, reporting type of food, price, geographical region and retail concept. Foods were categorized as minimally processed, culinary ingredients, processed products and ultra-processed. Indicators were share of purchases and share of expenditure on food categories.

SETTING

Six geographical regions in Norway.

SUBJECTS

The barcode data included 296 121 observations in 2005 and 501 938 observations in 2013.

RESULTS

Ultra-processed products represented 58·8 % of purchases and 48·8 % of expenditure in 2013. Minimally processed foods accounted for 17·2 % of purchases and 33·0 % of expenditure. Every third purchase was a sweet ultra-processed product. Food sales changed marginally in favour of minimally processed foods and in disfavour of processed products between 2005 and 2013 (χ 2 (3)=203 195, P<0·001, Cramer's V=0·017, P<0·001).

CONCLUSIONS

Ultra-processed products accounted for the majority of food sales in Norway, indicating a high consumption of such products. This could be contributing to rising rates of overweight, obesity and non-communicable diseases in the country, as findings from other countries indicate. Policy measures should aim at decreasing consumption of ultra-processed products and facilitating access (including economic) to minimally processed foods.

Characterisation of UK diets according to degree of food processing and associations with socio-demographics and obesity: cross-sectional analysis of UK National Diet and Nutrition Survey (2008-12)

Background

Food processing alters food from its natural state for safety, convenience, taste or palatability. Previous research suggests that industrially processed foods, and diets high in these products, tend to be less healthful. However, most previous work is based on household, rather than individual-level, data. Little has been reported on the relationship between processed food consumption and markers of health; or on socio-demographic correlates of processed food consumption.

Our objective was to describe: the nutritional content of foods classified according to degree of processing; the nutritional content of diets with different relative intakes of processed foods; the socio-demographic characteristics of individuals with different relative intakes of processed foods; and the association between intake of processed foods and body weight.

Methods

Secondary analysis of data from the UK National Diet and Nutrition Survey (2008–12), a large national cross-sectional study of diet. Dietary information was collected using four-day, unweighed, food-diaries. Foods were classified as: unprocessed or minimally processed (MPF; foods with no processing or mostly physical processes applied to single whole foods), processed ingredients (PI; extracted and purified components of single whole foods), or ultra-processed food products (UPF; products produced from industrial combining of MPF and PI).

Results

Two thousand one hundred seventy four adults were included. MPF and diets high in these foods, had the most healthful nutritional profile. UPF did not necessarily have the least healthful nutritional profile, but diets high in these foods did. Women, and older adults consumed more energy from MPF, and less from UPF. Those living in lower occupation social class households consumed less energy from MPF, but no more from UPF. Only higher intake of PI was consistently, inversely, associated with body weight.

Conclusions

This is the first study to explore correlates of processed food consumption, using individual-level data from a large, national sample. Although higher intakes of MPF and lower intakes of UPF were associated with the most healthful dietary profiles, only intake of PI was consistently associated with body weight. Consumption of UPF varied by age and gender, but, unexpectedly, not by occupational social class. Longitudinal work is required to confirm relationships with health markers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-015-0317-y) contains supplementary material, which is available to authorized users.

Massive open online nutrition and cooking course for improved eating behaviors and meal composition

Background

Behavioral shifts in eating, favoring the increased consumption of highly processed foods over healthier, home-cooked alternatives, have led to widespread health problems. This study reports on the effectiveness of a massive open online course (MOOC), offering integrated nutrition and cooking instruction, for improving eating behaviors and meal composition among course participants.

Methods

The course, consisting of 47 short (4–6 min.) videos, was offered through Coursera, an open, online learning platform, available to individuals worldwide who have access to the Internet. Beginning in January 2014, participants viewed course videos, completed quizzes and participated in optional cooking assignments, over a 5-week period. Participants were invited to complete optional pre- and post-course surveys assessing their eating behaviors, typical meal composition and perceived barriers to home cooking. McNemar-Bowker tests of symmetry and within subject t-tests were conducted to evaluate pre-post survey changes in the primary variables measured.

Results

7,422 participants from more than 80 countries completed both pre- and post-course surveys, while 19,374 participants completed the pre-survey only. Class participants were primarily women in the child-rearing ages (20–49 years of age). There were significant positive changes in eating behaviors and meal composition over time, including an increase in the percentage of participants who reported cooking dinner at home using mostly fresh ingredients 5–7 times in the previous week (63.4 % to 71.4 %), and who felt that yesterday’s dinner was very/extremely healthy (39.3 % to 56.4 %) and enjoyable (55.2 % to 66.7 %) (all p values < .0001).

Conclusions

Integrated nutrition and cooking courses, delivered via open online learning platforms, offer a free and flexible venue for reaching adults worldwide and have the potential to catalyze powerful behavioral shifts that align well with efforts to improve eating behaviors and meal composition.

Consumption of ultra-processed foods and obesity in Brazilian adolescents and adults

OBJECTIVES

The aim of this study was to evaluate the relationship between the consumption of ultra-processed foods and obesity indicators among Brazilian adults and adolescents.

METHODS

We used cross-sectional data on 30,243 individuals aged ≥10 years from the 2008-2009 Brazilian Dietary Survey. Food consumption data were collected through 24-h food records. We classified food items according to characteristics of food processing. Ultra-processed foods were defined as formulations made by the food industry mostly from substances extracted from foods or obtained with the further processing of constituents of foods or through chemical synthesis, with little if any whole food. Examples included candies, cookies, sugar-sweetened beverages, and ready-to-eat dishes. Regression models were fitted to evaluate the association of the consumption of ultra-processed foods (% of energy intake) with body-mass-index, excess weight, and obesity status, controlling for socio-demographic characteristics, smoking, and physical activity.

RESULTS

Ultra-processed foods represented 30% of the total energy intake. Those in the highest quintile of consumption of ultra-processed foods had significantly higher body-mass-index (0.94 kg/m(2); 95% CI: 0.42,1.47) and higher odds of being obese (OR=1.98; 95% CI: 1.26,3.12) and excess weight (OR=1.26; 95% CI: 0.95,1.69) compared with those in the lowest quintile of consumption.

CONCLUSION

Our findings support the role of ultra-processed foods in the obesity epidemic in Brazil.

Price elasticity of the demand for sugar sweetened beverages and soft drinks in Mexico

A large and growing body of scientific evidence demonstrates that sugar drinks are harmful to health. Intake of sugar-sweetened beverages (SSB) is a risk factor for obesity and type 2 diabetes. Mexico has one of the largest per capita consumption of soft drinks worldwide and high rates of obesity and diabetes. Fiscal approaches such as taxation have been recommended as a public health policy to reduce SSB consumption. We estimated an almost ideal demand system with linear approximation for beverages and high-energy food by simultaneous equations and derived the own and cross price elasticities for soft drinks and for all SSB (soft drinks, fruit juices, fruit drinks, flavored water and energy drinks). Models were stratified by income quintile and marginality index at the municipality level. Price elasticity for soft drinks was -1.06 and -1.16 for SSB, i.e., a 10% price increase was associated with a decrease in quantity consumed of soft drinks by 10.6% and 11.6% for SSB. A price increase in soft drinks is associated with larger quantity consumed of water, milk, snacks and sugar and a decrease in the consumption of other SSB, candies and traditional snacks. The same was found for SSB except that an increase in price of SSB was associated with a decrease in snacks. Higher elasticities were found among households living in rural areas (for soft drinks), in more marginalized areas and with lower income. Implementation of a tax to soft drinks or to SSB could decrease consumption particularly among the poor. Substitutions and complementarities with other food and beverages should be evaluated to assess the potential impact on total calories consumed.

Liberalising agricultural policy for sugar in Europe risks damaging public health

Emilie Aguirre and colleagues discuss what changes to Europe’s agricultural policy might mean for our health

Beyond the Golden Era of public health: charting a path from sanitarianism to ecological public health

The paper considers the long-term trajectory of public health and whether a 'Golden Era' in Public Health might be coming to an end. While successful elements of the 20th century policy approach need still to be applied in the developing world, two significant flaws are now apparent within its core thinking. It assumes that continuing economic growth will generate sufficient wealth to pay for the public health infrastructure and improvement needed in the 21st century when, in reality, externalised costs are spiralling. Secondly, there is evidence of growing mismatch between ecosystems and human progress. While 20th century development has undeniably improved public health, it has also undermined the capacity to maintain life on a sustainable basis and has generated other more negative health consequences. For these and other reasons a rethink about the role, purpose and direction of public health is needed. While health has to be at the heart of any viable notion of progress the dominant policy path offers new versions of the 'health follows wealth' position. The paper posits ecological public health as a radical project to reshape the conditions of existence. Both of these broad paths require different functions and purposes from their institutions, professions and politicians. The paper suggests that eco-systems pressures, including climate change, are already adding to pressure for a change of course.

Ultra-processed foods: Consumption among children at day-care centers and their classification according to Traffic Light Labelling system

Objective: To identify the age at which ultra-processed foods are introduced in the diet of infants enrolled in public daycare centers and analyze these foods' nutritional composition according to the Traffic Light Labelling system adapted to the Brazilian norms and recommendations.Methods: Cross-sectional study including 636 nursery age children attending day care centers. Their mothers were interviewed about the age of introduction of instant noodles, snack chips, encased meat, chocolate, ice cream, and stuffed cookies. The proximate composition of these foods was evaluated according to the Traffic Light Labelling adapted to the Brazilian norms and recommendations, which classifies total fat, saturated fat, trans fat, fiber, and sodium amounts as green, yellow, or red indicators.Results: It was found that before 12 months of age 70.6% of children had consumed instant noodles, 65.9% snack chips, 54.7% encased meat, 67.1% chocolate, 36.9% ice cream, and 68.7% stuffed cookies. In addition, all foods were classified as red for saturated fat and sodium and 50.0% were classified as red for total fat.Conclusion: The introduction of ultra-processed foods in the children's diets occurred early, but it is worth mentioning that such foods have an inadequate nutritional composition, contributing to the excess consumption of total fat, saturated fat, and sodium, as well as low fiber.

Using a Qualitative Vignette to Explore a Complex Public Health Issue

This article discusses how qualitative vignettes were combined with interviews to explore a complex public health issue; that is, promoting unhealthy foods and beverages to children and adolescents. It outlines how the technique was applied in practice and the combination of vignette-based interviews with a broader approach involving Gadamerian hermeneutics. Twenty-one participants from the public health community and the marketing and food and beverage industries took part in vignette-based interviews between March and September 2012. Overall, the qualitative vignette method afforded an efficient, generally well-received technique that effectively explored the issue of promoting unhealthy foods and beverages to children and adolescents. The vignette provided structure to interviews but allowed certain responses to be investigated in greater depth. Through this research, we argue that qualitative vignettes allow researchers to explore complex public health issues. This article also provides a valuable resource for researchers seeking to explore this technique.

Health information priorities for more effective implementation and monitoring of non-communicable disease programs in low- and middle-income countries: lessons from the Pacific

BACKGROUND

Non-communicable diseases (NCDs) place enormous burdens on individuals and health systems. While there has been significant global progress to guide the development of national NCD monitoring programs, many countries still struggle to adequately establish critical information systems to prioritise NCD control approaches.

DISCUSSION

In this paper, we use the recent experience of the Pacific as a case study to highlight four key lessons about prioritising strategies for health information system development for monitoring NCDs: first, NCD interventions must be chosen strategically, taking into account local disease burden and capacities; second, NCD monitoring efforts must align with those interventions so as to be capable of evaluating progress; third, in order to ensure efficiency and sustainability, NCD monitoring strategies must be integrated into existing health information systems; finally, countries should monitor the implementation of key policies to control food and tobacco industries. Prioritising NCD interventions to suit local needs is critical and should be accompanied by careful consideration of the most appropriate and feasible monitoring strategies to track and evaluate progress.

"We're Part of the Solution": Evolution of the Food and Beverage Industry's Framing of Obesity Concerns Between 2000 and 2012

We investigated how industry claim-makers countered concerns about obesity and other nutrition-related diseases in newspaper coverage from 2000, the year before the US Surgeon General's Call to Action on obesity, through 2012. We found that the food and beverage industry evolved in its response. The defense arguments were made by trade associations, industry-funded nonprofit groups, and individual companies representing the packaged food industry, restaurants, and the nonalcoholic beverage industry. Individual companies used the news primarily to promote voluntary self-regulation, whereas trade associations and industry-supported nonprofit groups directly attacked potential government regulations. There was, however, a shift away from framing obesity as a personal issue toward an overall message that the food and beverage industry wants to be "part of the solution" to the public health crisis.

Diet and physical activity for children's health: a qualitative study of Nepalese mothers' perceptions

OBJECTIVES

Non-communicable diseases account for 50% of all deaths in Nepal and 25% result from cardiovascular diseases. Previous studies in Nepal indicate a high burden of behavioural cardiovascular risk factors, suggesting a low level of knowledge, attitude and practice/behaviour regarding cardiovascular health. The behavioural foundation for a healthy lifestyle begins in early childhood, when mothers play a key role in their children's lives. This qualitative study, conducted in a Nepalese peri-urban community, aimed to explore mothers' perception of their children's diet and physical activity.

DESIGN

We notated, tape-recorded and transcribed all data collected from six focus group discussions, and used qualitative content analysis for evaluation and interpretation.

SETTING

The study was conducted in the Jhaukhel-Duwakot Health Demographic Surveillance Site in the Bhaktapur district of Nepal.

PARTICIPANTS

Local health workers helped recruit 61 women with children aged 5-10 years. We distributed participants among six different groups according to educational status.

RESULTS

Although participants understood the importance of healthy food, they misunderstood its composition, perceiving it as unappetising and appropriate only for sick people. Furthermore, participants did not prioritise their children's physical activities. Moreover, mothers believed they had limited control over their children's dietary habits and physical activity. Finally, they opined that health educational programmes would help mothers and recommended various intervention strategies to increase knowledge regarding a healthy lifestyle.

CONCLUSIONS

Our data reveal that mothers of young children in a peri-urban community of Nepal lack adequate and accurate understanding about the impact of a healthy diet and physical activity. Therefore, to prevent future cardiovascular disease and other non-communicable diseases among children, Nepal needs health education programmes to improve mothers' cardiovascular health knowledge, attitude and behaviour.

Whole-of-government approaches to NCDs: the case of the Philippines Interagency Committee-Tobacco

To address the rise in non-communicable diseases (NCDs), governments are now being urged to 'put forward a multisectoral approach for health at all government levels, to address NCD risk factors and underlying determinants of health comprehensively and decisively' [UN, 2011. Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases (No. A/66/L.1). New York, NY: United Nations]. There is a global consensus that whole-of-government approaches (WG) can be particularly effective in regulating products such as tobacco, pre-packaged foods and alcohol, which are or can be major risk factors for NCDs. Despite the overwhelming push towards interagency arrangements for health policymaking and implementation, including in contemporary efforts to prevent and control NCDs, there has been minimal investigation into how countries have pursued WG and which types of institutional designs and arrangements offer particular utility to achieve health objectives. This article examines these issues through a case study concerning the interagency mechanism that the Philippine government currently utilizes to govern tobacco control, the Interagency Committee-Tobacco (IAC-T). We conducted key informant interviews (n = 33) with government officials, and representatives from civil society organizations, health professional associations and intergovernmental organizations. We targeted informants who have been involved in the work of the IAC-T and/or tobacco control policy more broadly. We also analysed public documents to contribute to our analysis of the structure, functioning and legal status of the IAC-T. Our findings highlight two salient challenges that arose in the Philippines case: (1) the inclusion of industry representation on the IAC-T and (2) the attempt to consolidate the responsibilities of the different departments through a policy of 'balance' between health and commercial interests. We analyse how health proponents navigated this challenging institutional arrangement and the various barriers they faced in achieving the intended health objectives. We draw from this case to discuss the lessons that can inform broad calls for WG to NCDs.

Dietary guidelines to nourish humanity and the planet in the twenty-first century. A blueprint from Brazil

OBJECTIVE

To present and discuss the dietary guidelines issued by the Brazilian government in 2014.

DESIGN

The present paper describes the aims of the guidelines, their shaping principles and the approach used in the development of recommendations. The main recommendations are outlined, their significance for the cultural, socio-economic and environmental aspects of sustainability is discussed, and their application to other countries is considered.

SETTING

Brazil in the twenty-first century.

SUBJECTS

All people in Brazil, now and in future.

RESULTS

The food- and meal-based Brazilian Dietary Guidelines address dietary patterns as a whole and so are different from nutrient-based guidelines, even those with some recommendations on specific foods or food groups. The guidelines are based on explicit principles. They take mental and emotional well-being into account, as well as physical health and disease prevention. They identify diet as having cultural, socio-economic and environmental as well as biological and behavioural dimensions. They emphasize the benefits of dietary patterns based on a variety of natural or minimally processed foods, mostly plants, and freshly prepared meals eaten in company, for health, well-being and all relevant aspects of sustainability, as well as the multiple negative effects of ready-to-consume ultra-processed food and drink products.

CONCLUSIONS

The guidelines' recommendations are designed to be sustainable personally, culturally, socially, economically and environmentally, and thus fit to face this century. They are for foods, meals and dietary patterns of types that are already established in Brazil, which can be adapted to suit the climate, terrain and customs of all countries.

Alcohol and public health in Africa: can we prevent alcohol-related harm from increasing?

AIMS

According to the World Health Organization (WHO), the total amount of alcohol consumed in the African region is expected to increase due to the growth of new alcohol consumers, especially young people and women. With the changing alcohol environment, increases in the alcohol-attributable burden of disease are inevitable. To our knowledge, there has not been a comprehensive analysis of the factors that could be driving those increases. The objective of this study was to examine the evidence from peer reviewed literature regarding the factors that could be instrumental in this process, in order to inform strategic policy-related decisions.

METHOD

A narrative review was conducted using a thematic analysis approach. We searched papers published between January 2000 and July 2014 in PubMed, the WHO's Global Health Library and African Journals Online.

RESULTS

Our analysis identified seven factors (demographics, rapid urbanization, economic development, increased availability, corporate targeting, weak policy infrastructure and trade agreements) which are potentially tied to changes in alcohol consumption in Africa. Driven largely by globalization, a potential convergence of these various factors is likely to be associated with continued growth in alcohol consumption and alcohol-related morbidity and mortality.

CONCLUSIONS

To address the emerging risk factors associated with increased alcohol consumption, African governments need to take a more active role in protecting the public's health. In particular, important strategic shifts are needed to increase implementation of intersectoral strategies, community involvement in the policy dialogue, health services re-orientation and better regulation of the alcohol beverage industry.

Sugar and health in South Africa: Potential challenges to leveraging policy change

A growing body of evidence indicates that excessive sugar consumption is driving epidemics of obesity and related non-communicable diseases (NCDs) around the world. South Africa (SA), a major consumer of sugar, is also the third most obese country in Africa, and 40% of all deaths in the country result from NCDs. A number of fiscal, regulatory, and legislative levers could reduce sugar consumption in SA. This paper focuses on a sugar-sweetened beverage (SSB) tax. The purpose of the paper is to highlight the challenges that government might anticipate. Policies cannot be enacted in a vacuum and discussion is focused on the industrial, economic, and societal context. The affected industry actors have been part of the SA economy for over a century and remain influential. To deflect attention, the sugar industry can be expected either to advocate for self-regulation or to promote public-private partnerships. This paper cautions against both approaches as evidence suggests that they will be ineffective in curbing the negative health impacts caused by excessive sugar consumption. In summary, policy needs to be introduced with a political strategy sensitive to the various interests at stake. In particular, the sugar industry can be expected to be resistant to the introduction of any type of tax on SSBs.

[Socioeconomic, cultural and demographic maternal factors associated with dietary patterns of infants]

Objective:

To analyze dietary patterns of infants and its association with maternal socioeconomic, cultural, and demographic variables.

Methods:

A cross-sectional study was conducted with two groups of mothers of children up to 24 months (n=202) living in the city of Maceió, Alagoas, Northeast Brazil. The case group consisted of mothers enrolled in a Family Health Unit. The comparison group consisted of mothers who took their children to two private pediatric offices of the city. Dietary intake was assessed using a qualitative and validated food frequency questionnaire (FFQ). The evaluation of the FFQ was performed by a method in which the overall rate of consumption frequency is converted into a score.

Results:

Children of higher income families and mothers with better education level (control group) showed the highest median of consumption scores for fruits and vegetables (p<0.01) and meat, offal, and eggs (p<0.01), when compared with children of the case group. On the other hand, the median of consumption scores of manufactured goods was higher among children in the case group (p<0.01).

Conclusions:

Maternal socioeconomic status influenced the quality of food offered to the infant. In the case group, children up to 24 months already consumed industrial products instead of healthy foods on their menu.

Does school health and home economics education influence adults' food knowledge?

Home economics and health teachers are to be found in many parts of the world. They teach students about food in relation to its nutritional, safety and environmental properties. The effects of such teaching might be expected to be reflected in the food knowledge of adults who have undertaken school education in these areas. This study examined the food knowledge associations of school home economics and health education among Australian adults. Two separate online surveys were conducted nationwide among 2022 (November 2011) and 2146 Australian adults (November-December 2012). True/false and multiple choice questions in both surveys were used to assess nutrition, food safety and environmental knowledge. Knowledge scores were constructed and compared against respondents' experience of school health or home economics education via multiple regression analyses. The results from both studies showed that home economics (and similar) education was associated with higher levels of food knowledge among several age groups. The associations of home economics education with food knowledge differed across several Australian states and recall of home economics themes differed across the age groups. These findings suggest that home economics education may bring about long-lasting learning of food knowledge. Further research is required, however, to confirm the findings and to test the causal influence of home economics education on adults' food knowledge.

A journey into a Mediterranean diet and type 2 diabetes: a systematic review with meta-analyses

OBJECTIVES

To summarise the evidence about the efficacy of a Mediterranean diet on the management of type 2 diabetes and prediabetic states.

DESIGN

A systematic review of all meta-analyses and randomised controlled trials (RCTs) that compared the Mediterranean diet with a control diet on the treatment of type 2 diabetes and prediabetic states was conducted. Electronic searches were carried out up to January 2015. Trials were included for meta-analyses if they had a control group treated with another diet, if they were of sufficient duration (at least 6 months), and if they had at least 30 participants in each arm. A random-effect model was used to pool data.

PARTICIPANTS

Adults with or at risk for type 2 diabetes.

INTERVENTIONS

Dietary patterns that described themselves as using a 'Mediterranean' dietary pattern.

OUTCOME MEASURES

The outcomes were glycaemic control, cardiovascular risk factors and remission from the metabolic syndrome.

RESULTS

From 2824 studies, 8 meta-analyses and 5 RCTs were eligible. A 'de novo' meta-analysis of 3 long-term (>6 months) RCTs of the Mediterranean diet and glycaemic control of diabetes favoured the Mediterranean diet as compared with lower fat diets. Another 'de novo' meta-analysis of two long-term RCTs showed a 49% increased probability of remission from the metabolic syndrome. 5 meta-analyses showed a favourable effect of the Mediterranean diet, as compared with other diets, on body weight, total cholesterol and high-density lipoprotein cholesterol. 2 meta-analyses demonstrated that higher adherence to the Mediterranean diet reduced the risk of future diabetes by 19-23%.

CONCLUSIONS

The Mediterranean diet was associated with better glycaemic control and cardiovascular risk factors than control diets, including a lower fat diet, suggesting that it is suitable for the overall management of type 2 diabetes.

Gambling advocacy: lessons from tobacco, alcohol and junk food

OBJECTIVE

To explore the attitudes and opinions of public health experts in gambling and related unhealthy commodity industries towards the tactics used by the gambling industry to prevent reform and the advocacy responses to these tactics.

METHODS

In-depth interviews (30-60 minutes) with a convenience sample of 15 public health experts and stakeholders with a public health approach to gambling (n=10), or other unhealthy commodity industries (food, alcohol, tobacco, n=5).

RESULTS

Participants described the influences of political lobbying and donations on public policy, and industry framing of problem gambling as an issue of personal responsibility. Industry funding of, and influence over, academic research was considered to be one of the most effective industry tactics to resist reform. Participants felt there was a need to build stronger coalitions and collaborations between independent academics, and to improve the utilisation of media to more effectively shift perceptions of gambling harm away from the individual and towards the product.

CONCLUSIONS AND IMPLICATIONS

Gambling industry tactics are similar to the tactics of other unhealthy commodity industries. However, advocacy initiatives to counter these tactics in gambling are less developed than in other areas. The formation of national public health coalitions, as well as a strong evidence base regarding industry tactics, will help to strengthen advocacy initiatives.

Impact of ultra-processed foods on micronutrient content in the Brazilian diet

OBJECTIVE To evaluate the impact of consuming ultra-processed foods on the micronutrient content of the Brazilian population's diet. METHODS This cross-sectional study was performed using data on individual food consumption from a module of the 2008-2009 Brazilian Household Budget Survey. A representative sample of the Brazilian population aged 10 years or over was assessed (n = 32,898). Food consumption data were collected through two 24-hour food records. Linear regression models were used to assess the association between the nutrient content of the diet and the quintiles of ultra-processed food consumption - crude and adjusted for family income per capita. RESULTS Mean daily energy intake per capita was 1,866 kcal, with 69.5% coming from natural or minimally processed foods, 9.0% from processed foods and 21.5% from ultra-processed foods. For sixteen out of the seventeen evaluated micronutrients, their content was lower in the fraction of the diet composed of ultra-processed foods compared with the fraction of the diet composed of natural or minimally processed foods. The content of 10 micronutrients in ultra-processed foods did not reach half the content level observed in the natural or minimally processed foods. The higher consumption of ultra-processed foods was inversely and significantly associated with the content of vitamins B12, vitamin D, vitamin E, niacin, pyridoxine, copper, iron, phosphorus, magnesium, selenium and zinc. The reverse situation was only observed for calcium, thiamin and riboflavin. CONCLUSIONS The findings of this study highlight that reducing the consumption of ultra-processed foods is a natural way to promote healthy eating in Brazil and, therefore, is in line with the recommendations made by the Guia Alimentar para a População Brasileira (Dietary Guidelines for the Brazilian Population) to avoid these foods.

Commentary: Moving towards policy coherence in trade and health

International trade has brought economic benefits to many countries, but the association of trade and investment liberalisation with poor health outcomes concerns the public health community. The need to secure more 'healthy' trade is a recognised priority, especially as countries move from global to regional/bilateral trade agreements - with greater public health risks. However, a transition towards 'healthier trade' may be hindered by worldview differences between the trade and health communities. There is a tendency for health actors to perceive trade as a threat to population health, and for trade actors to view health as a constraint to trade objectives of reducing barriers to cross-border commercial flows and economic growth. Unless such differing worldviews can be aligned, finding ways forward for addressing public health in trade policy is likely to be difficult. Moving forward will involve understanding the values and drivers of the respective groups, and developing solutions palatable to their various interests. Given the power imbalances between the two areas, it is likely that the health community will have to make the first moves in this respect. This article outlines the key issues involved and suggests areas where such moves have been, and may be made.

Guest Commentary: Fat and other taxes, lessons for the implementation of preventive policies

Fat, sugar or sweetened beverage taxes are part of an overall public health nutrition approach to healthy eating. They are not approaches that on their own are likely to bring about change. Policy evidence from existing food tax implementation suggest that taxes need to be paralleled by subsidies and other interventions to encourage healthy eating. Such dual methods help not only contribute to nutrition outcomes but also ensure political support for food taxes. Politicians and policy makers are suspicious of taxes, using subsidies and revenue monies from taxes to support healthy eating is more likely to encourage both political and public support. Building support for policies is never just a matter of academic evidence. Public health advocates need to show more ambition by developing skills in implementing pricing policies to support healthy eating. Key opponents to taxes are the food industry who use a range of arguments to prevent taxation being implemented. Public health advocates are weak in tackling the issues of corporate power and providing evidence to maintain policy and political support. The public health movement needs to continue to develop the political will among politicians and the public for taxes on food. A new way of looking at policy formation is required and this includes addressing the power of corporate interests and the role of professionals in shaping or combating these influences.

The food retail revolution in China and its association with diet and health

The processed food sector in low- and middle-income countries has grown rapidly. Little is understood about its effect on obesity. Using data from 14,976 participants aged two and older in the 2011 China Health and Nutrition Survey, this paper examines patterns of processed food consumption and their impacts on obesity while considering the endogeneity of those who purchase processed foods. A major assumption of our analysis of the impact of processed foods on overweight and obesity was that the consumption of processed foods is endogenous due to their accessibility and urbanicity levels. The results show that 74.5% of participants consumed processed foods, excluding edible oils and other condiments; 28.5% of participants' total daily energy intake (EI) was from processed foods. Children and teenagers in megacities had the highest proportion of EI (40.2%) from processed foods. People who lived in megacities or highly urbanized neighborhoods with higher incomes and educational achievement consumed more processed foods. When controlling for endogeneity, only the body mass index (BMI) and risk of being overweight of children ages two to eighteen are adversely associated with processed foods (+4.97 BMI units, 95% confidence interval (CI): 1.66-8.28; odds ratio (OR) = 3.63, 95% CI: 1.45-9.13). Processed food purchases represent less than a third of current Chinese food purchases. However, processed food purchases are growing at the rate of 50% per year, and we must begin to understand the implications for the future.

Are the Public Health Responsibility Deal alcohol pledges likely to improve public health? An evidence synthesis

AIMS

The English Public Health Responsibility Deal (RD) is a public-private partnership involving voluntary pledges between industry, government and other actors in various areas including alcohol, and designed to improve public health. This paper reviews systematically the evidence underpinning four RD alcohol pledges.

METHODS

We conducted a systematic review of reviews of the evidence underpinning interventions proposed in four RD alcohol pledges, namely alcohol labelling, tackling underage alcohol sales, advertising and marketing alcohol, and alcohol unit reduction. In addition, we included relevant studies of interventions where these had not been covered by a recent review.

RESULTS

We synthesized the evidence from 14 reviews published between 2002 and 2013. Overall, alcohol labelling is likely to be of limited effect on consumption: alcohol unit content labels can help consumers assess the alcohol content of drinks; however, labels promoting drinking guidelines and pregnancy warning labels are unlikely to influence drinking behaviour. Responsible drinking messages are found to be ambiguous, and industry-funded alcohol prevention campaigns can promote drinking instead of dissuading consumption. Removing advertising near schools can contribute to reducing underage drinking; however, community mobilization and law enforcement are most effective. Finally, reducing alcohol consumption is more likely to occur if there are incentives such as making lower-strength alcohol products cheaper.

CONCLUSIONS

The most effective evidence-based strategies to reduce alcohol-related harm are not reflected consistently in the RD alcohol pledges. The evidence is clear that an alcohol control strategy should support effective interventions to make alcohol less available and more expensive.

The Public Health Responsibility deal: has a public-private partnership brought about action on alcohol reduction?

BACKGROUND AND AIMS

The Public Health Responsibility Deal (RD) in England is a public-private partnership involving voluntary pledges between industry, government and other organizations, with the aim of improving public health. This paper aims to evaluate what action resulted from the RD alcohol pledges.

METHODS

We analysed publically available data on organizations' plans and progress towards achieving key alcohol pledges of the RD. We assessed the extent to which activities pledged by signatories could have been brought about by the RD, as opposed to having happened anyway (the counterfactual), using a validated coding scheme designed for the purpose.

RESULTS

Progress reports were submitted by 92% of signatories in 2013 and 75% of signatories in 2014, and provided mainly descriptive feedback rather than quantifiable performance metrics. Approximately 14% of 2014 progress reports were identical to those presented in 2013. Most organizations (65%) signed pledges that involved actions to which they appear to have been committed already, regardless of the RD. A small but influential group of alcohol producers and retailers reported taking measures to reduce alcohol units available for consumption in the market. However, where reported, these measures appear to involve launching and promoting new lower-alcohol products rather than removing units from existing products.

CONCLUSIONS

The RD is unlikely to have contributed significantly to reducing alcohol consumption, as most alcohol pledge signatories appear to have committed to actions that they would have undertaken anyway, regardless of the RD. Irrespective of this, there is considerable scope to improve the clarity of progress reports and reduce the variability of metrics provided by RD pledge signatories.

Ultra-processed foods have the worst nutrient profile, yet they are the most available packaged products in a sample of New Zealand supermarkets

Objective

To examine the availability of packaged food products in New Zealand supermarkets by level of industrial processing, nutrient profiling score (NPSC), price (energy, unit and serving costs) and brand variety.

Design

Secondary analysis of cross-sectional survey data on packaged supermarket food and non-alcoholic beverages. Products were classified according to level of industrial processing (minimally, culinary and ultra-processed) and their NPSC.

Setting

Packaged foods available in four major supermarkets in Auckland, New Zealand.

Subjects

Packaged supermarket food products for the years 2011 and 2013.

Results

The majority (84 % in 2011 and 83 % in 2013) of packaged foods were classified as ultra-processed. A significant positive association was found between the level of industrial processing and NPSC, i.e. ultra-processed foods had a worse nutrient profile (NPSC=11·63) than culinary processed foods (NPSC=7·95), which in turn had a worse nutrient profile than minimally processed foods (NPSC=3·27), P<0·001. No clear associations were observed between the three price measures and level of processing. The study observed many variations of virtually the same product. The ten largest food manufacturers produced 35 % of all packaged foods available.

Conclusions

In New Zealand supermarkets, ultra-processed foods comprise the largest proportion of packaged foods and are less healthy than less processed foods. The lack of significant price difference between ultra- and less processed foods suggests ultra-processed foods might provide time-poor consumers with more value for money. These findings highlight the need to improve the supermarket food supply by reducing numbers of ultra-processed foods and by reformulating products to improve their nutritional profile.

Regional trade and the nutrition transition: opportunities to strengthen NCD prevention policy in the Southern African Development Community

BACKGROUND

Addressing diet-related non-communicable diseases (NCDs) will require a multisectoral policy approach that includes the food supply and trade, but implementing effective policies has proved challenging. The Southern African Development Community (SADC) has experienced significant trade and economic liberalization over the past decade; at the same time, the nutrition transition has progressed rapidly in the region. This analysis considers the relationship between regional trade liberalization and changes in the food environment associated with poor diets and NCDs, with the aim of identifying feasible and proactive policy responses to support healthy diets.

DESIGN

Changes in trade and investment policy for the SADC were documented and compared with time-series graphs of import data for soft drinks and snack foods to assess changes in imports and source country in relation to trade and investment liberalization. Our analysis focuses on regional trade flows.

RESULTS

Diets and the burden of disease in the SADC have changed since the 1990s in parallel with trade and investment liberalization. Imports of soft drinks increased by 76% into SADC countries between 1995 and 2010, and processed snack foods by 83%. South Africa acts as a regional trade and investment hub; it is the major source of imports and investment related to these products into other SADC countries. At the same time, imports of processed foods and soft drinks from outside the region - largely from Asia and the Middle East - are increasing at a dramatic rate with soft drink imports growing by almost 1,200% and processed snack foods by 750%.

CONCLUSIONS

There is significant intra-regional trade in products associated with the nutrition transition; however, growing extra-regional trade means that countries face new pressures in implementing strong policies to prevent the increasing burden of diet-related NCDs. Implementation of a regional nutrition policy framework could complement the SADC's ongoing commitment to regional trade policy.