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

Early weaning and family characteristics are associated with greater sodium intake in children between 13 and 35 months: BRISA birth cohort

Children are consuming less healthy foods, and this eating behaviour exposes the child to greater Na intake. The association between family, maternal and child characteristics with Na intake by children aged 13-35 months was evaluated. A study carried out with retrospective data on 1,185 children from the Brisa cohort. The children's dietary Na intake was assessed by a 24-h diet recall survey. Values ≥ 1200 mg were considered excessive intake. The association between Na intake and independent variables was assessed by a three-level logistic hierarchical regression model. Variables with P-value < 0·05 were retained in the model. Most children were male (51·2 %), eutrophic (63·2 %) and not exclusively breast-feeding (EBF) for 6 months (58·4 %). The average Na intake was 925 mg (±410·4). The prevalence of excessive Na intake was 18·5 % and was associated with the variables children of younger mothers (< 20 years old OR = 4·04, 95 % CI 1·64, 9·99; ≥ 20 to < 35 years old OR = 2·48, 95 % CI 1·10, 5·63), having four or more children (OR = 2·51, 95 % CI 1·29, 4·89), lower family income (≥ 1 and < 3 minimum wages OR = 0·60, 95 % CI 0·39, 0·93; ≥ 3 minimum wages OR = 0·50, 95 % CI 0·30, 0·82) and not being EBF until 6 months (OR = 1·64, 95 % CI 1·14, 2·34). The average Na intake of children was higher than the recommendation for adequate intake, pointing to a high consumption of this micronutrient in the first years of life. Excessive Na intake seems to be linked to unfavourable socio-economic conditions. Avoiding early weaning is the only possible intervention in this scenario.

Analysis of Content, Social Networks, and Sentiment of Front-of-Pack Nutrition Labeling in the European Union on Twitter

In recent years, concerted political efforts have been made at the national and European Union (EU) level to promote the consumption of healthy foods. The European Commission (EC) expressed the need for a harmonized and mandatory front-of-pack nutrition labeling (FOPL) system at the EU level. The EC will adopt the proposal by the end of 2022. Our research work aims to understand the public discourse on FOPL in the EU via Twitter, by analyzing tweet content, sentiment, and mapping network characteristics. Tweet search and data collection were performed using the Twitter application programming interface (API), with no time or language restrictions. The content was coded with the QRS Nvivo software package and analyzed thematically. Automatic sentiment analysis was performed with QSR Nvivo, and network analysis was performed with Gephi 0.9.2. A total of 4,073 tweets were posted, mostly from the UK, Spain, and France. Themes that have emerged from the discussion on Twitter include the types of food labeling, food industry, healthy vs. unhealthy foods in the context of food labeling, EU regulation, political conflicts, and science and education. Nutri-Score dominated the discussion on Twitter. General topics were perceived negatively by Twitter users with more positive sentiments toward the food industry, while negative sentiments were observed toward the discourse of political conflicts. The network analysis showed that a centralized communication was hardly existed between countries. Our results reveal that the discussion of FOPL on Twitter is limited to a very limited group of people, and it seems necessary to inform a wide range of consumers about existing and upcoming FOPL schemes. Educational programs should empower consumers to understand what a healthy diet is and how it relates to FOPL, regardless of the existing labeling system.

Availability and Nutritional Composition of Street Food in Urban Central Asia: Findings From Almaty, Kazakhstan

Objective: To describe the availability and nutritional composition of commonly available street foods in Almaty, Kazakhstan. Methods: 384 street food vending sites (in 10 public markets) were assessed; information on vending sites' characteristics and food availability and samples of the most commonly available street foods (81 homemade; 40 industrial) were collected for chemical analysis. Results: Fruit, beverages and food other than fruit were available in 1.0%, 47.4% and 92.7% of all vending sites. Homemade food other than fruit (e.g., bread, main dishes, snacks, pastries, sandwiches, and cakes) were available in 63.4% of stationary vending sites, while industrial (e.g., snacks, chocolate, cakes, and cookies) in 45.6% of them. Industrial foods were the most energy-dense [median kcal/100 g: 438.8 vs. 267.2, p < 0.001 (homemade)]. Traditional homemade dishes were high in sodium, reaching 2,248 mg/serving (lagman) and major contributors of protein and fat to energy content (shashlik: 22.8% from protein, 68.3% from fat). Industrial chocolate and homemade cake presented the highest saturated (14.6 g/serving) and trans-fat (3.20 g/serving) contents. Conclusion: These findings advocate for the implementation of health promotion strategies targeted at vendors, consumers and other stakeholders.

Controlling the obesity pandemic: Geoffrey Rose revisited

The ongoing obesity pandemic threatens the health of hundreds of millions globally. However, to date, no country has had much success in limiting its growth, let alone reversing it. This commentary demonstrates the relevance to the obesity pandemic of the public health conceptual framework of epidemiologist Geoffrey Rose, first published as "Sick Individuals and Sick Populations" in 1985. That framework provides a useful way to analyze the pandemic's prevention and control options, based on the notions of primordial, primary, secondary and tertiary prevention-the full spectrum of "more upstream and more downstream" approaches, each with its pros and cons. Based on an analysis of key studies to date, this commentary argues strongly that only the primordial prevention approach is likely to be successful against the obesity pandemic-but its onerous requirements for society-wide behavioural and cultural change may make that public health struggle a long one.

Social, political, commercial, and corporate determinants of rural health equity in Canada: an integrated framework

People in rural and remote areas often experience greater vulnerability and higher health-related risks as a result of complex issues that include limited access to affordable health services and programs. During disruptive events, rural populations face unique barriers and challenges due to their remoteness and limited access to resources, including digital technologies. While social determinants of health have been highlighted as a tool to understand how health is impacted by various social factors, it is crucial to create a holistic framework to fully understand rural health equity. In this commentary, we propose an integrated framework that connects the social determinants of health (SDOH), the political determinants of health (PDOH), the commercial determinants of health (ComDOH), and the corporate determinants of health (CorpDOH) to address health inequity in rural and remote communities in Canada. The goal of this commentary is to situate these four determinants of health as key to inform policy-makers and practitioners for future development of rural health equity policies and programs in Canada.

Gamblers' perceptions of responsibility for gambling harm: a critical qualitative inquiry

BACKGROUND

Gambling has traditionally been conceptualised as an issue of addiction and personal responsibility. While there are now clear public health models that recognise that gambling harm is caused by a range of socio-cultural, environmental, commercial and political determinants, government and industry messages about gambling are still largely personal responsibility focused. Given the well-recognised issues associated with personal responsibility paradigms, this study sought to understand how gamblers themselves conceptualised responsibility for gambling harm.

METHODS

A qualitatively led online panel survey was conducted with 363 adult gamblers in New South Wales and Victoria, Australia. Participants were asked to respond to what they thought were the causes of gambling harm, and what could be done to prevent harm. A reflexive thematic analysis was conducted.

RESULTS

Six common tropes were constructed from gamblers' responses: (1) Gambling in moderation; (2) Personal responsibility for rational behaviour; (3) Character flaws; (4) Personal responsibility to seek help; (5) More education is needed; and (6) Governments are responsible for action - but motivation and efficacy are questioned. Gamblers primarily understood gambling harm as being a matter of personal responsibility, and government responsibility was generally seen as limited to providing information to facilitate informed gambling choices.

CONCLUSIONS

This study demonstrates that gamblers' perceptions of gambling harm are similar to the personal responsibility framings and tropes present in industry and government messaging strategies. Refocusing public communication strategies away from 'responsible gambling' messaging, and towards evidence-based approaches, will be an important part of addressing the harms associated with gambling.

Prevention and Control Strategies for Non-Communicable Disease: Goldberger, Pellagra and Rose Revisited

This paper argues that the public health conceptual framework of epidemiologist Geoffrey Rose, first published as "Sick Individuals and Sick Populations" in 1985, provides a useful way to critically analyze prevention and control options for modern non-communicable diseases (NCD) and their forerunner, obesity, a pandemic now engulfing Lower-and-Middle-Income-Countries. That framework is based on the notions of primordial, primary, secondary and tertiary prevention-the full spectrum of "more upstream and more downstream" approaches, each with its pros and cons. These are illustrated using the pellagra epidemic in the southeastern USA from 1900 to the 1940s, which still has much to teach us about these same basic policy options for controlling the modern NCD pandemic. In particular, Rose's dictum, "Seek the causes of (population) incidence, not of (individual) cases", points up the compelling advantages of upstream prevention for controlling both epidemics.

Level of understanding and consumption of ultra-processed food in a Mediterranean population: A cross-sectional study

BACKGROUND AND AIMS

Since the population may not be aware of ultra-processed food (UPF) consumption as a result of ignorance or non-recognition, this study aimed to ascertain the main characteristics of subjects regarding their knowledge of different easily acquired foods through a questionnaire in Google Forms format with 52 questions. Secondary objectives were to determine whether the profile of UPF consumers can be defined based on sex, age, sociodemographic factors, and lifestyle.

METHODS AND RESULTS

Responses were received from 1037 participants from a convenience sample; of these, 83 (8.0%) were sporadic or non-users, and 954 (92.0%) were frequent UPF consumers. The participants of the upper tertile correctly matched >12 food items, those of the medium tertile matched 12-9 items, and those of the lower tertile matched <9 items. Factors independently associated with participants who better identified UPF (upper tertile) compared to those of the lower tertile (reference) were female sex (OR: 2.54, 95%CI: 1.70-3.79; p < 0.001), age between 21 and 50 (OR: 3.63, 95% CI: 2.56-5.15; p < 0.001), living with family (OR: 0.64, 95% CI: 0.41-9.96; p = 0.033), and eating more fruit (≥3 pieces/day, OR: 2.30, 95% CI: 1.61-3.27; p < 0.001).

CONCLUSIONS

These findings highlight the high consumption and low degree of awareness of UPF among consumers based mainly on food composition.

'The second mother': How the baby food industry captures science, health professions and civil society in France

Most babies in France are fed with infant formula and then commercial complementary foods, many of which are ultra-processed and harmful to health. Internationally, there is opposition by the baby food industry to the introduction of public health policies that would limit the marketing and consumption of such products. Our aim was to identify the key baby food industry actors, describe their history and corporate political activity (CPA) in France. We sourced publicly available information, which we triangulated with data from 10 semi-structured interviews. Qualitative thematic analysis was undertaken simultaneously to data collection, guided by an existing classification of the CPA of the food industry. The baby food industry in France has shaped the science on infant and young child nutrition and nurtured long-established relationships with health professionals. This corporate science and these relationships helped baby food companies to portray themselves as experts on child-related topics. The baby food industry has also engaged with a broad range of civil society organisations, particularly through the concept of the first 1000 days of life, and during the covid-19 pandemic. We found evidence, although limited, that the baby food industry directly lobbied the French government. Since its early development in France in the 19th century, the baby food industry used its CPA to promote its products and protect and sustain its market. Our findings can be used to recognise, anticipate and address the CPA of this industry, and to minimise any negative influence it may have on babies' and mother's health.

Tracing the connections between international business and communicable diseases

We posit that international business and the emergence and spread of communicable diseases are intrinsically connected. To support our arguments, we first start with a historical timeline that traces the connections between international business and communicable diseases back to the sixth century. Second, following the epidemiology of communicable diseases, we identify two crucial transitions related to international business: the emergence of epidemics within a host country and the shift from epidemics to global pandemics. Third, we highlight international business contextual factors (host country regulatory quality, urbanization, trade barriers, global migration) and multinationals' activities (foreign direct investment, corporate political activity, global supply chain management, international travel) that could accelerate each transition. Finally, building on public health insights, we suggest research implications for business scholars on how to integrate human health challenges into their studies and practical implications for global managers on how to help prevent the emergence and spread of communicable diseases.

How can National Government Policies Improve Food Environments in the Netherlands?

Objectives: Government policies are essential to create food environments that support healthy diets. The aims of this study were 1) to benchmark the implementation of Dutch government policies influencing food environments, and 2) to identify and prioritize actions to improve food environments in the Netherlands.

Methods: The Healthy Food Environment Policy Index (Food-EPI) was applied. The Food-EPI includes 46 indicators of food environment policy and infrastructure support. Independent experts (n = 28) rated the extent of implementation on these indicators against international best practices, and formulated and prioritized policy and infrastructure support actions to improve food environments.

Results: Most policy indicators were rated as having a low (50%) or very low (41%) level of implementation. Most infrastructure support indicators were rated as having a fair (42%) or medium (42%) level of implementation. 18 policy and 11 infrastructure support actions were recommended by experts to improve food environments in the Netherlands.

Conclusion: There is large potential for the Dutch national government to strengthen its policy action and infrastructure support in order to improve the healthiness of food environments in the Netherlands.

From silos to policy coherence: tobacco control, unhealthy commodity industries and the commercial determinants of health

Tobacco control has achieved remarkable successes, underpinned by the distinctive norms codified in Article 5.3 of the WHO Framework Convention on Tobacco Control. Tobacco control's experience in managing conflicts of interest is increasingly recognised as relevant for addressing other non-communicable disease epidemics. At the same time, the wider environmental and social harms of tobacco-and other unhealthy commodity industries-underline the potential for enhanced strategic collaboration across health, development and environmental agendas. Such collaboration is increasingly necessary to address key challenges shared across tobacco control and related policy spheres, including the extent to which the harms of tobacco (and other unhealthy commodities) are underpinned by economic and social inequities. Here we demonstrate the relevance of a commercial determinants of health perspective, both for advancing tobacco control and for linking it with health and development more broadly. This perspective is already evident in many areas of research, policy and advocacy, where innovative approaches support the development of closer links with actors in related fields. We draw on the concepts of policy coordination, coherence and integration to show how tobacco control can advance key strategic goals via information sharing, complementary approaches to common problems and collective action with other related movements. Embrace of a commercial determinants perspective will help in building on tobacco control's successes and reorienting strategies in other sectors to more effectively manage health risks and promote sustainable development.

Manufacturing doubt: Assessing the effects of independent vs industry-sponsored messaging about the harms of fossil fuels, smoking, alcohol, and sugar sweetened beverages

Background Manufacturers of harmful products engage in misinformation tactics long employed by the tobacco industry to emphasize uncertainty about scientific evidence and deflect negative attention from their products. This study assessed the effects of one type of tactic, the use of "alternative causation" arguments, on public understanding. Methods In five trials (one for each industry) anonymized Qualtrics panel respondents were randomized to receive a message on the risk in question from one of four industry sponsored organizations (exposure), or from one of four independent organizations (control), on risks related to alcohol, tobacco, fossil fuel and sugar sweetened beverages. Logistic regression models were used to evaluate the effect of industry arguments about uncertainty on the primary outcome of public certainty about product risk, adjusting for age, gender and education. The results from all five trials were pooled in a random-effects meta-analysis. Findings In total, n=3284 respondents were exposed to industry-sponsored messaging about product-related risks, compared to n=3297 exposed to non-industry messages. Across all industries, exposure to industry-sponsored messages led to greater reported uncertainty or false certainty about risk, compared to non-industry messages [Summary odds ratio (OR) 1·60, confidence interval (CI) 1·28-1·99]. The effect was greater among those who self-rated as not/slightly knowledgeable (OR 2·24, CI 1·61-3·12), or moderately knowledgeable (OR 1·85, CI 1·38-2·48) compared to those very/extremely knowledgeable (OR 1·28, CI 1·03-1·60). Conclusions This study demonstrates that exposure to industry sponsored messages which appear intended to downplay risk significantly increases uncertainty or false certainty, with the effect being greater in less knowledgeable participants.

Assessing the Nutritional Impact of an Increase in Orphan Crops in the Kenyan Diet: The Case of Millet

Orphan crops are those crops that did not receive the same attention of the research community as in the case of staples such as wheat, maize, or rice despite their regional and nutritional importance. A relatively recent trend has been promoting their research to improve their productivity and resilience to environmental shocks. However, their impact on consumers’ nutrition has been analysed only considering the crops individually and not in the context of the diet. This is important because an increase in the consumption of one product may trigger changes in the other products that conform to the diet. The purpose of this paper is to assess the potential impact, in terms of food choices and nutrition, of increasing the consumption of orphan crops (represented by millet) in the Kenyan diet. This is carried out using a microeconomic-based methodology, which augments the original consumer problem with a constraint regarding the amount of the orphan crop on the diet. To compute the required elasticities for the method, three demand systems—i.e., for rural, less affluent urban, more affluent urban households—were estimated using the 2015–16 Kenyan Integrated Household Survey and the two-step approach to address the zero consumption for some food categories; the second step was modelled using the Linquad demand model. The results indicate that although the orphan crops have the capacity to improve some of the nutrients (e.g., vitamins and minerals), in net terms, as measured by the aggregated nutritional indicator the improvement is somewhat limited, the improvements occur in the rural and the less affluent population.

Strategies to expand corporate autonomy by the tobacco, alcohol and sugar-sweetened beverage industry: a scoping review of reviews

BACKGROUND

Noncommunicable diseases contribute to over 70% of global deaths each year. Efforts to address this epidemic are complicated by the presence of powerful corporate actors. Despite this, few attempts have been made to synthesize existing evidence of the strategies used to advance corporate interests across industries. Given this, our study seeks to answer the questions: 1) Is there an emergent taxonomy of strategies used by the tobacco, alcohol and sugar-sweetened beverage (SSB) industries to expand corporate autonomy? 2) How are these strategies similar and how are they different?

METHODS

Under the guidance of a framework developed by Arksey and O'Malley, a scoping review was carried out whereby six databases were searched in June 2021 to identify relevant peer-reviewed literature. To be included in this review, studies had to explicitly discuss the strategies used by the tobacco, alcohol, and/or sugar-sweetened beverage multinational corporations and be considered review articles aimed to synthesize existing evidence from at least one of the three industries. Eight hundred and fifty-eight articles were selected for full review and 59 articles were retained for extraction, analysis, and categorization.

RESULTS

Results identified six key strategies the industries used: 1) influencing government policy making and implementation, 2) challenging unfavorable science, 3) creating a positive image, 4) manipulating markets, 5) mounting legal challenges, and 6) anticipating future scenarios. Despite these similarities, there are few but important differences. Under the strategy of influencing government policy making and implementation, for example, literature showed that the alcohol and SSB industries have been "privileged with high levels of participation" within international public health organizations.

CONCLUSIONS

Understanding how industries resist efforts to control them is important for public health advocates working to reduce consumption of and death and diseases resulting from harmful commodities. Moreover, there is a greater need for the public health community to generate consensus about how to ethically engage or not engage with industries that produce unhealthy commodities. More studies are also needed to build the evidence base of industry tactics to resist regulation, particularly in the case of SSB, and in low-and middle-income countries.

Confronting potential food industry ‘front groups’: case study of the international food information Council’s nutrition communications using the UCSF food industry documents archive

Abstract

Background

There are growing concerns that the public’s trust in science is eroding, including concerns that vested interests are corrupting what we know about our food. We know the food industry funds third-party ‘front groups’ to advance its positions and profits. Here we ask whether this is the case with International Food Information Council (IFIC) and its associated Foundation, exploring its motivations and the potential for industry influence on communications around nutritional science.

Method

We systematically searched the University of California San Francisco’s Food Industry Documents Archive, for all documents pertaining to IFIC, which were then thematically evaluated against a science-communication influence model.

Results

We identified 75 documents which evidence that prominent individuals with long careers in the food industry view IFIC as designed to: 1) advance industry public relations goals; 2) amplify the messages of industry-funded research organizations; and 3) place industry approved experts before the press and media, in ways that conceal industry input. We observed that there were in some cases efforts made to conceal and dilute industry links associated with IFIC from the public’s view.

Discussion

Instances suggesting IFIC communicates content produced by industry, and other industry-funded organisations like ILSI, give rise to concerns about vested interests going undetected in its outputs. IFIC’s deployment to take on so-called “hard-hitting issues” for industry, summating evidence, while countering evidence that industry opposes, give rise to concerns about IFIC’s purported neutrality. IFIC’s role in coordinating and placing industry allies in online and traditional press outlets, to overcome industry’s global scientific, legislative, regulatory and public relations challenges, leads also to concerns about it thwarting effective public health and safety measures.

Conclusions

IFIC’s promotion of evidence for the food industry should be interpreted as marketing strategy for those funders. Effective science communication may be obfuscated by undeclared conflicts of interests.

Global inequalities in the double burden of malnutrition and associations with globalisation: a multilevel analysis of Demographic and Healthy Surveys from 55 low-income and middle-income countries, 1992–2018

Background

Low-income and middle-income countries (LMICs) face a double burden of malnutrition (DBM), whereby overnutrition and undernutrition coexist within the same individual, household, or population. This analysis investigates global inequalities in household-level DBM, expressed as a stunted child with an overweight mother, and its association with economic, social, and political globalisation across country income and household wealth.

Methods

We pooled anthropometric and demographic data for 1 132 069 children (aged <5 years) and their mothers (aged 15–49 years) from 189 Demographic and Health Surveys in 55 LMICs between 1992 and 2018. These data were combined with country-level data on economic, social, and political globalisation from the Konjunkturforschungsstelle Globalisation Index and gross national income (GNI) from the World Bank. Multivariate associations between DBM and household wealth, GNI, and globalisation and their interactions were tested using multilevel logistic regression models with country and year fixed-effects and robust standard errors clustered by country.

Findings

The probability of DBM was higher among richer households in poorer LMICs and poorer households in richer LMICs. Economic globalisation was associated with higher odds of DBM among the poorest households (odds ratio 1·49, 95% CI 1·20–1·86) compared with the richest households. These associations attenuated as GNI increased. Social globalisation was associated with higher odds of DBM (1·39, 95% CI 1·16–1·65), independently of household wealth or country income. No associations were identified between political globalisation and DBM.

Interpretation

Increases in economic and social globalisation were associated with higher DBM, although the impacts of economic globalisation were mostly realised by the world's poorest. The economic patterning of DBM observed in this study calls for subpopulation-specific double-duty actions, which should further aim to mitigate the potential negative and unequal impacts of globalisation.

Funding

UK Biotechnology and Biological Sciences Research Council.

Translations

For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Implementing healthy food environment policies in New Zealand: nine years of inaction

BACKGROUND

The INFORMAS [International Network for Food and Obesity/Non-communicable Diseases (NCDs) Research, Monitoring and Action Support] Healthy Food Environment Policy Index (Food-EPI) was developed to evaluate the degree of implementation of widely recommended food environment policies by national governments against international best practice, and has been applied in New Zealand in 2014, 2017 and 2020. This paper outlines the 2020 Food-EPI process and compares policy implementation and recommendations with the 2014 and 2017 Food-EPI.

METHODS

In March-April 2020, a national panel of over 50 public health experts participated in Food-EPI. Experts rated the extent of implementation of 47 "good practice" policy and infrastructure support indicators compared to international best practice, using an extensive evidence document verified by government officials. Experts then proposed and prioritized concrete actions needed to address the critical implementation gaps identified. Progress on policy implementation and recommendations made over the three Food-EPIs was compared.

RESULTS

In 2020, 60% of the indicators were rated as having "low" or "very little, if any" implementation compared to international benchmarks: less progress than 2017 (47%) and similar to 2014 (61%). Of the nine priority actions proposed in 2014, there was only noticeable action on one (Health Star Ratings). The majority of actions were therefore proposed again in 2017 and 2020. In 2020 the proposed actions were broader, reflecting the need for multisectoral action to improve the food environment, and the need for a mandatory approach in all policy areas.

CONCLUSIONS

There has been little to no progress in the past three terms of government (9 years) on the implementation of policies and infrastructure support for healthy food environments, with implementation overall regressing between 2017 and 2020. The proposed actions in 2020 have reflected a growing movement to locate nutrition within the wider context of planetary health and with recognition of the social determinants of health and nutrition, resulting in recommendations that will require the involvement of many government entities to overcome the existing policy inertia. The increase in food insecurity due to COVID-19 lockdowns may provide the impetus to stimulate action on food polices.

Effect of reducing ultraprocessed food consumption on obesity among US children and adolescents aged 7-18 years: evidence from a simulation model

BACKGROUND

Children and adolescents in the USA consume large amounts of daily calories from ultraprocessed foods (UPFs). Recent evidence links UPF consumption to increased body fat in youth. We aimed to estimate the potential impact of reducing UPF consumption on childhood obesity rate in the USA.

METHODS

We developed a microsimulation model to project the effect of reducing UPF consumption in children's diet on reducing the prevalence of overweight or obesity among US youth. The model incorporated nationally representative data on body mass index (BMI) percentile and dietary intake of 5804 children and adolescents aged 7-18 years from the National Health and Nutrition Examination Survey 2011-2016, and the effect of reducing UPF consumption on calorie intake from a recent randomised controlled trial. Uncertainties of model inputs were incorporated using probabilistic sensitivity analysis with 1000 simulations.

RESULTS

Reducing UPFs in children's diet was estimated to result in a median of -2.09 kg/m² (95% uncertainty interval -3.21 to -0.80) reduction in BMI among children and adolescents aged 7-18 years. The median prevalence of overweight (BMI percentile ≥85th) and obesity (BMI percentile ≥95th percentile) was reduced from 37.0% (35.9%, 38.1%) to 20.9% (15.1%, 29.9%) and from 20.1% (19.2%, 21.0%) to 11.0% (7.86%, 15.8%), respectively. Larger BMI and weight reductions were seen among boys than girls, adolescents than children, non-Hispanic black and Hispanic youth than non-Hispanic white youth, and those with lower levels of parental education and family income.

CONCLUSIONS

Reducing UPF consumption in children's diet has the potential to substantially reduce childhood obesity rate among children and adolescents in the USA.

Distilling the curriculum: An analysis of alcohol industry-funded school-based youth education programmes

BACKGROUND AND AIM

For decades, corporations such as the tobacco and fossil fuel industries have used youth education programmes and schools to disseminate discourses, ideas and values favourable to their positions, and to pre-empt regulation that threatens profits. However, there is no systematic research into alcohol industry-funded youth education programmes. This article serves to address this important gap in the literature.

METHODS

Using a discourse theoretical approach informed by poststructural discourse theory and critical discourse analysis, we analysed teaching materials from three school-based youth education initiatives which focus on alcohol consumption and health harms: Drinkaware for Education, The Smashed Project (funded by Diageo), and Talk About Alcohol (Alcohol Education Trust). These materials, some of which are disseminated internationally, are provided to schools through intermediary bodies in receipt of alcohol industry funding.

FINDINGS

The analysis found that these materials drew from and presented discourses of personal responsibility, moderate alcohol consumption, and involved a narrowing of the problem definition and causes. The locus of the problem is located by the discourses within individuals including youth, with causes of youth alcohol consumption repeatedly presented as peer pressure and 'poor choices', with little or no mention of alcohol industry marketing or other practices. All programmes promoted familiarisation and normalisation of alcohol as a 'normal' adult consumer product which children must learn about and master how to use responsibly when older. The discourses constructed in these materials closely align with those of other alcohol industry corporate social responsibility discourses which employ selective presentation of harms, including misinformation about cancer, and ambiguous terms such as "responsible drinking". Furthermore, the role of alcohol price, availability and access, and the impacts of alcohol and the industry on inequities were not articulated within the discourses. The research was limited to an analysis of teaching materials and further research is needed to explore their impact on youth, teachers and wider discourses and social norms.

CONCLUSION

Alcohol industry-sponsored youth education programmes serve industry interests and promote moderate consumption while purportedly educating children about harms and influences of alcohol use. There are considerable conflicts of interest in the delivery of alcohol education programmes funded by the alcohol industry and intermediary bodies in receipt of such funding. Alcohol education materials should be developed independent from industry, including funding, and should empower children and young people to understand and think critically about alcohol, including harms and drivers of consumption, and effective interventions needed to protect them and others from alcohol-related harms. Independent organisations can use this analysis to critique their materials to strengthen alignment with meeting student and public health interests. The ongoing exposure of children and young people to such conflicted and misleading materials needs urgent attention from policymakers, practitioners, teachers and parents, and resources dependent on industry support should cease being used in schools.

Mediterranean Diet Social Network Impact along 11 Years in the Major US Media Outlets: Thematic and Quantitative Analysis Using Twitter

Background: Media outlets influence social attitudes toward health. Thus, it is important that they share contents which promote healthy habits. The Mediterranean diet (MedDiet) is associated with lower cardiovascular disease risk. Analysis of tweets has become a tool for understanding perceptions on health issues. Methods: We investigated tweets posted between January 2009 and December 2019 by 25 major US media outlets about MedDiet and its components as well as the retweets and likes generated. In addition, we measured the sentiment analysis of these tweets and their dissemination. Results: In total, 1608 tweets, 123,363 likes and 48,946 retweets about MedDiet or its components were analyzed. Dairy (inversely weighted in MedDiet scores) accounted for 45.0% of the tweets (723/1608), followed by nuts 19.7% (317/1608). MedDiet, as an overall dietary pattern, generated only 9.8% (157/1608) of the total tweets, while olive oil generated the least number of tweets. Twitter users’ response was quantitatively related to the number of tweets posted by these US media outlets, except for tweets on olive oil and MedDiet. None of the MedDiet components analyzed was more likely to be liked or retweeted than the MedDiet itself. Conclusions: The US media outlets analyzed showed reduced interest in MedDiet as a whole, while Twitter users showed greater interest in the overall dietary pattern than in its particular components.

Dietary intake patterns, nutrient adequacy and associated factors in a multi-ethnic Caribbean population

Background: Diet is a significant contributor to health and wellbeing of individuals. Aim: In this study we investigated patterns of dietary intakes, levels of nutrient inadequacies and associated sociodemographic, anthropometric and lifestyle factors among adults in Trinidad and Tobago. Method: The study was cross-sectional in nature. A convenience sample of 11783 persons from districts throughout Trinidad and Tobago completed a self-administered questionnaire comprising socio-demographic and lifestyle items. Anthropometry was self-reported with 15% of participants having measurements done according to recommended procedures. Dietary patterns were determined by principal component analysis (PCA) while nutrient intakes and adequacy were assessed using the NutriGenie 7.0 software and nutrient adequacy ratio (MAR) respectively. Foods were categorised as unprocessed/minimally processed and processed/ultra-processed. The University of The West Indies Ethics Committee approved the study. Results: Approximately 72.5% of participants met the Goldberg criteria for plausible reporting. The three predominant dietary patterns 'Typical', 'Fruits and Vegetables', and 'High Fat' explained 45% of the total variance in foods consumed. Processed/ultra-processed foods accounted for most of the energy (80%) and nutrients consumed. Nutrient inadequacies were observed for potassium, vitamins B₁₂, D, E, K, fibre, magnesium; and iron among females. The mean adequacy ratio (MAR) for participants was 67%. MAR was positively associated with predominant dietary patterns independent of socioe demographic and lifestyle factors (p < 0.001). Conclusion: Irrespective of their nature, the predominant dietary pattern was associated with nutrient adequacy among participants. Reducing the risk of inadequate nutrient intakes may be addressed by increasing availability, access and consumption of appropriate sources of these micronutrients.

Exploring the effects of increasing underutilized crops on consumers' diets: the case of millet in Uganda

Known in the literature as underutilized, neglected or orphan crops, these crops have been cited as having the potential to improve food and nutritional security. The literature also highlights however that consumers in developing countries are increasingly abandoning their traditional diets that these crops are part of, and are replacing them by western diets. In this context, the purpose of this paper is to investigate the consumption and nutritional implications of expanding the participation of underutilized crops in current diets. This was done using a modified version of the microeconomic consumer problem. This was augmented with a linear constraint using generalized rationing theory that can be found in the economics literature. The method was applied to the case study of the consumption of millet (finger millet, botanical name: Eleusine coracana) by rural, urban-poor and urban-affluent Ugandan socioeconomic groups. The results indicated that millet could contribute to improving the intake of macronutrients and of some micronutrients, though the overall picture is complex. However, under current preferences and given its demand inelasticity, to achieve a substantial increase in the quantity of millet in the diet will require a significant reduction of its price. Otherwise, the net impact on nutrition as measured by the mean adequacy ratio will be only slightly positive for rural and urban-poor households. Our findings indicate that supply-side initiatives aimed at increasing the productivity of underutilized crops (reducing crop price) are likely to produce disappointing results in restoring their importance unless accompanied by specific interventions to expand demand.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s40100-021-00206-3.

Public Health Roles in Addressing Commercial Determinants of Health

The shared challenges posed by the production and distribution of health-harming products have led to growing recognition of the need for policy learning and transfer across problems, populations, and social contexts. The commercial determinants of health (CDoH) can serve as a unifying concept to describe the population health consequences arising from for-profit actors and activities, along with the social structures that sustain them. Strategies to mitigate harms from CDoH have focused on behavioral change, regulation, fiscal policies, consumer and citizen activism, and litigation. While there is evidence of effective measures for each strategy, approaches that combine strategies are generally more impactful. Filling gaps in evidence can inform ways of adapting these strategies to specific populations and social contexts. Overall, CDoH are addressed most effectively not through siloed efforts to reduce consumption of health-harming products, but instead as a set of integrated strategies to reduce exposures to health-harming commercial actors and activities.

Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Tendência temporal (2008-2018) da prevalência de excesso de peso em lactentes e pré-escolares brasileiros de baixa renda

Resumo O objetivo deste estudo foi analisar a tendência temporal da prevalência de excesso de peso (EP) em crianças menores de cinco anos assistidas pelo Programa Bolsa Família (PBF) entre 2008 e 2018. O painel de dados foi baseado nos relatórios de estado nutricional do Sistema de Vigilância Alimentar e Nutricional (SISVAN) (n=30.574.118) e analisado por meio de modelos de regressão joinpoint específicos para idade (lactentes e pré-escolares) e macrorregião. Ainda, calculou-se a cobertura do SISVAN para o PBF e a representatividade nacional, segundo projeção censitária. Na década analisada, o EP em lactentes reduziu de 11,9% (11,8; 12,0 IC95%) para 8,5% (8,4; 8,6 IC95%) (-3,6%/ano [-5,1; -2,0 IC95%]); quanto aos pré-escolares, a prevalência EP aumentou em 3,1%/ano (2,0; 4,2 IC95%) até 2015, seguida por uma retração até 2018 (-6,4%/ano [-10,1; -2,6 IC95%]). Em ambos os grupos etários, a região Norte apresentou a menor prevalência em toda série histórica e a Nordeste o pior desempenho no controle do EP infantil. A cobertura do SISVAN no PBF foi elevada e a representatividade dos dados variou entre 13,9% (Sul) e 42,2% (Nordeste). Apesar da prevalência estar acima do esperado, após 2014, identificou-se redução linear no EP em lactentes e desaceleração na taxa de crescimento nos pré-escolares.

The nutrition transition to a stage of high obesity and noncommunicable disease prevalence dominated by ultra-processed foods is not inevitable

The Nutrition Transition model is presented with the nature and pace of change in key stages varying by location and subpopulations. At present, all high-income and many low- and middle-income countries are in a stage of the transition where nutrition-related noncommunicable diseases including obesity, type 2 diabetes, and hypertension are dominating adult morbidity and mortality and are very high or growing rapidly in prevalence. Some countries still have key subpopulations facing hunger and undernutrition defined by stunting or extreme thinness among adults. We call these double burden of malnutrition countries. All low- and middle-income countries face rapid growth in consumption of ultra-processed food and beverages, but it is not inevitable that these countries will reach the same high levels of consumption seen in high-income countries, with all the negative impacts of this diet on health. With great political and civil society commitment to adoption of policies shown in other countries to have improved dietary choices and social norms around foods, we can arrest and even reverse the rapid shift to diets dominated by a stage of high ultra-processed food intake and increasing prevalence of nutrition-related noncommunicable diseases.

Assessing the readiness of small cities in Ghana to tackle overweight and obesity

The rapid rise in the prevalence of overweight and obesity, and the associated health problems, is an emerging challenge in Ghana, and for women in particular. This study contributes to the understanding of this emerging phenomenon in Ghana by analyzing it from a community perspective, applying the Community Readiness Model in two small cities in Ghana. A series of Key Informant Interviews were undertaken and analyzed, using the model’s scoring structure and supplementary textual analysis. We find that communities are aware of overweight and obesity as a health issue, but that it is not prioritized or championed. Furthermore, the diet counseling and keep-fit programs put the responsibility on individuals to address, rather than considering the upstream and structural causes and solutions.

Availability, healthiness, and price of packaged and unpackaged foods in India: A cross-sectional study

Background: Vulnerable populations are the most prone to diet-related disease. The availability, healthiness, and price of foods have established associations with diet-related disease in communities. However, data describing this in India are sparse, particularly in urban slums and rural areas. Aim: To quantify and compare availability, healthiness, and price of packaged and unpackaged foods and beverages in India, and to identify opportunities to improve diets and health of vulnerable populations. Methods: Nutrition data and price were collected on foods and beverages available at 44 stores in urban, urban slum, and rural areas in four states in India between May and August 2018. Healthiness was assessed using the Australasian Health Star Rating system and product retail prices were examined. Comparisons in the findings were made across state, community area type, and adherence to current and draft Indian food labeling regulations. Results: Packaged foods and beverages (n = 1443, 89%) were more prevalent than unpackaged (n = 172, 11%). Unpackaged products were healthier than packaged (mean Health Star Rating = 3.5 vs 2.0; p < 0.001) and lower in price (median price per 100 g/ml: 13.42 Indian rupees vs 25.70 Indian rupees; p < 0.001), a pattern observed across most community area types and states. 96% of packaged products were compliant with current Indian labeling regulations but only 23% were compliant with proposed labeling regulations. Conclusions: Unpackaged products were on average much healthier and lower in price than packaged foods and beverages. Food policies that support greater availability, accessibility and consumption of unpackaged foods, while limiting consumption of packaged foods, have enormous potential for sustaining the health of the Indian population.

Ultra-Processed Food Impairs Bone Quality, Increases Marrow Adiposity and Alters Gut Microbiome in Mice

Ultra processed foods (UPF) consumption is becoming dominant in the global food system, to the point of being the most recent cause of malnutrition. Health outcomes of this diet include obesity and metabolic syndrome; however, its effect on skeletal development has yet to be examined. This project studied the influence of UPF diet on the development and quality of the post-natal skeleton. Young female mice were fed with regular chow diet, UPF diet, UPF diet supplemented with calcium or with multivitamin and mineral complex. Mice fed UPF diet presented unfavorable morphological parameters, evaluated by micro-CT, alongside inferior mechanical performance of the femora, evaluated by three-point bending tests. Growth-plate histology evaluation suggested a modification of the growth pattern. Accumulation of adipose tissue within the bone marrow was significantly higher in the group fed UPF diet. Finally, microbiome 16SrRNA sequencing was used to explore the connection between diets, gut microbial community and skeletal development. Together, we show that consumption of UPF diet during the postnatal developmental period alters the microbiome and has negative outcomes on bone parameters and bone marrow adiposity. Micronutrients improved these phenotypes only partially. Thus, consuming a wholesome diet that contributes to a healthy microbiota is of a great significance in order to achieve healthy skeletal development.

Earth Dreams: Reimagining ARPA for Health of People, Places and Planet

Bold new approaches are urgently needed to overcome global health challenges. The proposed Advanced Research Projects Agency for Health (ARPA-H) is intended to provide rapid health breakthroughs. While new technologies for earlier disease detection and more effective treatment are critical, we urge equal attention be given to the wider (physical, emotional, social, political, and economic) environmental ecosystems driving the non-communicable disease (NCD) crisis in the first place. This requires an integrated, cross-sectoral vision that spans the interwoven connections affecting health across the scales of people, places, and planet. This wider "exposome" perspective considers biopsychosocial factors that promote resilience and reduce vulnerabilities of individuals and communities over time-the many variables driving health disparities. Since life course health is strongly determined by early life environments, early interventions should be prioritized as a matter of effectiveness and social justice. Here, we explore the origins of the Advanced Research Project Agency and point to its potential to build integrated solutions, with wisdom and ethical value systems as a compass. Since the planned ARPA-H is anticipated to spawn international collaborations, the imagined concept is of relevance to a broad audience of researchers. With appropriate input, the quest for health equity through personalized, precision medicine while deconstructing unacceptable structural inequities may be accelerated.

Maximising the wealth of few at the expense of the health of many: a public health analysis of market power and corporate wealth and income distribution in the global soft drink market

Background

Many of the harms created by the global soft drink industry that directly influence human and planetary health are well documented. However, some of the ways in which the industry indirectly affects population health, via various socio-economic pathways, have received less attention. This paper aimed to analyse the extent to which market power and corporate wealth and income distribution in the global soft drink market negatively impact public health and health equity. In doing so, the paper sought to contribute to the development of a broad-based public health approach to market analysis. A range of dimensions (e.g., market concentration; financial performance; corporate wealth and income distribution) and indicators (e.g., Herfindahl Hirschman Index; earnings relative to the industry average; effective tax rates; and shareholder value ratios) were descriptively analysed. Empirical focus was placed on the two dominant global soft drink manufacturers.

Results

Coca-Cola Co, and, to a lesser extent, PepsiCo, operate across an extensive patchwork of highly concentrated markets. Both corporations control vast amounts of wealth and resources, and are able to allocate relatively large amounts of money to potentially harmful practices, such as extensive marketing of unhealthy products. Over recent decades, the proportion of wealth and income transferred by these firms to their shareholders has increased substantially; whereas the proportion of wealth and income redistributed by these two firms to the public via income taxes has considerably decreased. Meanwhile, the distribution of soft drink consumption is becoming increasingly skewed towards population groups in low and middle-income countries (LMICs).

Conclusions

Market power and corporate wealth and income distribution in the global soft drink market likely compound the market’s maldistribution of harms, and indirectly influence health by contributing to social and economic inequalities. Indeed, a ‘double burden of maldistribution’ pattern can be seen, wherein the wealth of the shareholders of the market’s dominant corporations, a group over-represented by a small and wealthy elite, is maximised largely at the expense of the welfare of LMICs and lower socioeconomic groups in high-income countries. If this pattern continues, the appropriate role of the global soft drink market as part of sustainable economic development will require rethinking.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12992-021-00781-6.

Meta-substituted piperlongumine derivatives attenuate inflammation in both RAW264.7 macrophages and a mouse model of colitis

Piperlongumine (PL) has been showed to have multiple pharmacological activities. In this study, we reported the synthesis of three series of PL derivatives, and evaluation of their anti-inflammatory effects in both lipopolysaccharide (LPS)-induced Raw264.7 macrophages and a dextran sulfate sodium (DSS)-induced mouse model of colitis. Our results presented that two meta-substituent containing derivatives 1-3 and 1-6, in which γ-butyrolactam replaced α,β-unsaturated δ-valerolactam ring of PL, displayed low cytotoxicity and effective anti-inflammatory activity. Molecular docking also showed that the meta-substituted derivative, compared with the corresponding ortho- or para-substituted derivative, had significant interactions with the amino acid residues of CD14, which was the core receptors recognizing LPS. In vitro and in vivo studies, 1-3 and 1-6 could inhibit the expression of pro-inflammatory cytokines, and the excessive production of reactive nitrogen species and reactive oxygen species. Oral administration of 100 mg/kg/day of 1-3 or 1-6 alleviated the severity of clinical symptoms of colitis in mice, and significantly reduced the colonic tissue damage to protect the colonic tissue from the DSS-induced colitis. These results suggested that meta-substituted derivatives 1-3 and 1-6 were potential anti-inflammatory agents, which may lead to future pharmaceutical development.

"Part of the Solution": Food Corporation Strategies for Regulatory Capture and Legitimacy

BACKGROUND

For decades, the food industry has sought to deflect criticisms of its products and block public health legislation through a range of offensive and defensive strategies. More recently, food corporations have moved on to present themselves as "part of the solution" to the health problems their products cause. This strategic approach is characterised by appeasement, co-option and partnership, and involves incremental concessions and attempts to partner with health actors. This paper details how corporate practices have evolved and changed over the past two decades and gives some definition to what this new political economy signifies for the wider behaviours of corporations producing and selling harmful commodities.

METHODS

This paper draws on public health and political science literature to classify the food industry's "part of the solution" strategy into three broad components: regulatory responses and capture; relationship building; and market strategies. We detail the key characteristics and consequences of each component.

RESULTS

The three components of the food industry's "part of the solution" strategy all involve elements of appeasement and co-option. They also improve the political environment and resources of the food industry. Regulatory responses offer incremental concessions that seek to maintain corporate influence over governance processes and minimise the threat of regulations; relationship building fosters access to health and government stakeholders, and opportunities to acquire and maintain channels of direct influence; and market strategies to make products and portfolios healthier bolster the market share and revenue of food corporations while improving their public image.

CONCLUSION

Rather being a signal of lost position and power, the food industry's repositioning as "part of the solution" has created a highly profitable political economy of 'healthy' food production, alongside continued production of unhealthy commodities, a strategy in which it is also less burdensome and conflictual for corporations to exercise political power and influence.

Defining Priorities for Action and Research on the Commercial Determinants of Health: A Conceptual Review

In recent years, the concept of commercial determinants of health (CDoH) has attracted scholarly, public policy, and activist interest. To date, however, this new attention has failed to yield a clear and consistent definition, well-defined metrics for quantifying its impact, or coherent directions for research and intervention. By tracing the origins of this concept over 2 centuries of interactions between market forces and public health action and research, we propose an expanded framework and definition of CDoH. This conceptualization enables public health professionals and researchers to more fully realize the potential of the CDoH concept to yield insights that can be used to improve global and national health and reduce the stark health inequities within and between nations. It also widens the utility of CDoH from its main current use to study noncommunicable diseases to other health conditions such as infectious diseases, mental health conditions, injuries, and exposure to environmental threats. We suggest specific actions that public health professionals can take to transform the burgeoning interest in CDoH into meaningful improvements in health. (Am J Public Health. 2021;111(12):2202-2211. https://doi.org/10.2105/AJPH.2021.306491).

The Political Economy of Healthy and Sustainable Food Systems: An Introduction to a Special Issue

Today's food systems are contributing to multiple intersecting health and ecological crises. Many are now calling for transformative, or even radical, food systems change. Our starting assumption in this Special Issue is the broad claim that the transformative changes being called for in a global food system in crisis cannot - and ultimately will not - be achieved without intense scrutiny of and changes in the underlying political economies that drive today's food systems. The aim is to draw from diverse disciplinary perspectives to critically evaluate the political economy of food systems, understand key challenges, and inform new thinking and action. We received 19 contributions covering a diversity of country contexts and perspectives, and revealing inter-connected challenges and opportunities for realising the transformation agenda. We find that a number of important changes in food governance and power relations have occurred in recent decades, with a displacement of power in four directions. First, upwards as globalization has given rise to more complex and globally integrated food systems governed increasingly by transnational food corporations (TFCs) and international financial actors. Second, downwards as urbanization and decentralization of authority in many countries gives cities and sub-national actors more prominence in food governance. Third, outwards with a greater role for corporate and civil society actors facilitated by an expansion of food industry power, and increasing preferences for market-orientated and multi-stakeholder forms of governance. Finally, power has also shifted inwards as markets have become increasingly concentrated through corporate strategies to gain market power within and across food supply chain segments. The transformation of food systems will ultimately require greater scrutiny of these challenges. Technical 'problem-solving' and overly-circumscribed policy approaches that depoliticise food systems challenges, are insufficient to generate the change we need, within the narrow time-frame we have. While there will be many paths to transformation, rights-based and commoning approaches hold great promise, based on principles of participation, accountability and non-discrimination, alongside coalition building and social mobilization, including social movements grounded in food sovereignty and agroecology.

Soda Consumption Among Mexican Construction Workers in the Context of the Sugar-Sweetened Beverage Tax

This study explored the psychosocial determinants of consumption of soda and other taxed sugar-sweetened beverages (SSBs) in Mexican construction workers (CWs) and whether consumption changed as a result of the 2014 SSB tax. We conducted a qualitative case study involving in-depth interviews and focus groups (FGs) with 30 Mexican CWs; supplemented with descriptions of the food and beverages consumed during lunch breaks. We used NVivo 10 to classify information according to the analysis categories, primarily informed by the Reasoned Action Approach (RAA). CWs reported not having changed their consumption of soda and other taxed SSBs as a result of the SSB tax, despite the price increase and "knowing" the potential negative consequences of soda drinking. The most important determinants of soda consumption are a deep-seated social norm of soda drinking and use of soda drinking as part of their professional identity; their likeness for soda; a wide availability of soda in their environments; and a low perceived behavioral control (because they thought themselves as addicted to it). Participants indicated that the best way for them not to consume soda would be if it were not available. These findings lend support for the tight regulation of the availability of SSBs. To have a meaningful impact on these consumers, the SSB tax may need to be much higher. Policy-level interventions should be coupled with interventions at the individual and community levels that aim at denormalizing soda consumption, create new meanings in relation to water consumption, and develop behavioral control to decrease soda consumption.

The informal governance of public-private partnerships in UK obesity policy: Collaborating on calorie reduction or reducing effectiveness?

Collaboration between governments and non-state actors has emerged as the dominant mode of policy making to address a wide range of public and global health issues, particularly via public-private partnerships and multi-stakeholder platforms. Despite its paradigmatic status in contemporary health governance, political claims and promises of partnership approaches as more effective than state regulation have received limited attention. This study addresses this gap by tracing negotiations over a calorie reduction 'pledge' within the Public Health Responsibility Deal: a public-private partnership between the UK Department of Health, food industry and civil society organisations focusing on obesity policy. It demonstrates how political claims-making by the Department of Health that a public-private partnership as an effective substitute for legislation, contrasted with protracted and conflictual negotiations with food industry business associations. Employing Erving Goffman's distinction between frontstage and backstage interaction and the concept of informal governance, this study traces a shift to informal back stage governance as a mechanism to cope with acute tensions between economic interests and nutrition policy goals. The study illustrates how this shift to the back stage had substantive public health implications, privileging commercial sector perspectives and marginalising civil society participation. Informalization served to reframe calorie reduction from industry-focused to personal responsibility for lifestyle behaviours, in the process reducing its effectiveness. The results suggest that, while partnership and multi-stakeholder approaches are widely promoted as a legitimate tool in health governance, visible tensions between commercial sector and public health interests challenge political claims about public-private collaboration as consensus-oriented and effective. Informal governance, when used as a coping mechanism to manage tensions public health and commercial sector interests, may be symptomatic of wider dysfunctions and conflicts of interest in partnership approaches. This suggests that there may be limited scope for effective policy innovations where commercial sector actors perceive core interests as threatened.

Addressing complex pharmacy consultations: methods used to develop a person-centred intervention to highlight alcohol within pharmacist reviews of medications

BACKGROUND

Alcohol is challenging to discuss, and patients may be reluctant to disclose drinking partly because of concern about being judged. This report presents an overview of the development of a medications review intervention co-produced with the pharmacy profession and with patients, which breaks new ground by seeking to give appropriate attention to alcohol within these consultations.

METHODS

This intervention was developed in a series of stages and refined through conceptual discussion, literature review, observational and interview studies, and consultations with advisory groups. In this study we reflect on this process, paying particular attention to the methods used, where lessons may inform innovations in other complex clinical consultations.

RESULTS

Early work with patients and pharmacists infused the entire process with a heightened sense of the complexity of consultations in everyday practice, prompting careful deliberation on the implications for intervention development. This required the research team to be highly responsive to both co-production inputs and data gathered in formally conducted studies, and to be committed to working through the implications for intervention design. The intervention thus evolved significantly over time, with the greatest transformations resulting from patient and pharmacist co-design workshops in the second stage of the process, where pharmacists elaborated on the nature of the need for training in particular. The original research plans provided a helpful structure, and unanticipated issues for investigation emerged throughout the process. This underscored the need to engage dynamically with changing contexts and contents and to avoid rigid adherence to any early prescribed plan.

CONCLUSIONS

Alcohol interventions are complex and require careful developmental research. This can be a messy enterprise, which can nonetheless shed new insights into the challenges involved in optimising interventions, and how to meet them, if embraced with an attitude of openness to learning. We found that exposing our own research plans to scrutiny resulted in changes to the intervention design that gained the confidence of different stakeholders. Our understanding of the methods used, and their consequences, may be bounded by the person-centred nature of this particular intervention.

Global and Regional Patterns in Noncommunicable Diseases and Dietary Factors across National Income Levels

Background: Noncommunicable diseases (NCDs) are the leading global cause of death and share common risk factors. Little quantitative data are available on the patterns of each NCDs death and dietary factors by national income level and region. We aimed to identify the trend of NCDs deaths and dietary factors with other health-related behaviors across national income levels and geographical regions. Methods: Three databases were collected, including the World Health Organization, Food and Agriculture Organization, and World Bank in 2014. These were analyzed to describe the trend for NCDs deaths and dietary factors with health-related behaviors across national income levels (high income, upper-middle income, lower-middle income, and low income) from 151 countries using variance-weighted least-squares linear regression. Results: Lower-middle-income and low-income countries in Africa and Asia had higher death rates of NCDs. More than 30% of the population had raised blood pressure with higher carbohydrate intake and lower protein and fat intake compared to high-income European countries in 2014. High-income countries had the highest prevalence of raised total cholesterol, overweight, and obesity, the highest total energy, fat, and protein intake, and the highest supplies of animal fat, stimulants, sugar and sweetener, vegetable oil, and milk, as well as insufficient activity with an increasing trend (p for trend < 0.001). Conclusion: There were differences in NCDs risk factors and dietary factors by national income and region. Accordingly, measures should be taken to suit the situation in each country. Our findings have significance for health workers and health policies preventing and controlling the rise of NCDs.