Association of a Community Campaign for Better Beverage Choices With Beverage Purchases From Supermarkets

Evaluation of the population-level impacts of the LiveLighter® obesity prevention campaign from 2012 to 2019 based on serial cross-sectional surveys

BACKGROUND

Halting and reversing the upward trend in obesity requires sustained implementation of comprehensive, evidence-based strategies at the population-level. The LiveLighter® program targets adults using a range of public education strategies, including mass media campaigns, to support healthy lifestyle changes to attain or maintain a healthy weight and reduce the risk of chronic disease. LiveLighter® has been implemented in Western Australia (WA) since 2012 and, to our knowledge, includes the longest running adult-targeted mass media campaign for healthy weight and lifestyle promotion and education globally. This evaluation assessed the impact of LiveLighter® on WA adults' knowledge, intentions and behaviours as they relate to healthy eating and body weight from 2012 to 2019.

METHODS

LiveLighter® mass media campaigns, which are TV-led and aired statewide, depict genuine, graphic imagery of visceral fat around internal organs to raise awareness about the link between excess body weight and chronic diseases; demonstrate how unhealthy food and drink consumption can contribute to unhealthy weight gain; and recommend healthy alternatives. Cross-sectional telephone surveys were conducted at baseline and following each campaign phase with an independent, randomly selected sample of WA adults aged 25 to 49 years (n = 501 to n = 1504 per survey) to assess their knowledge of the link between excess body weight and chronic diseases, and their intentions and behaviours related to healthy eating and weight. Multivariable logistic regression models were undertaken to assess differences in responses between baseline and each post-campaign survey.

RESULTS

Compared to baseline, there were significant increases in the proportion of respondents reporting knowledge of excess body weight as a risk factor for certain cancers and type 2 diabetes, intentions to eat more fruit and vegetables and drink less sugar sweetened beverages (SSBs) in the next seven days, and the proportion of respondents who reported meeting guidelines for daily vegetable intake. Reported consumption of SSBs significantly decreased.

CONCLUSIONS

LiveLighter® is associated with improvements in knowledge of the health risks associated with excess body mass, increased vegetable intake and reduced SSB consumption in WA adults. These findings support the use of sustained, well-designed healthy lifestyle promotion and education programs as part of a comprehensive obesity prevention strategy.

Impact of Health, Environmental, and Animal Welfare Messages Discouraging Red Meat Consumption: An Online Randomized Experiment

BACKGROUND

Reducing red meat consumption is a key strategy for curbing diet-related chronic diseases and mitigating environmental harms from livestock farming. Messaging interventions aiming to reduce red meat consumption have focused on communicating the animal welfare, health, or environmental harms of red meat. Despite the popularity of these 3 approaches, it remains unknown which is most effective, as limited studies have compared them side by side.

OBJECTIVE

Our aim was to evaluate responses to red-meat-reduction messages describing animal welfare, health, or environmental harms.

DESIGN

This was an online randomized experiment.

PARTICIPANTS

In August 2021, a convenience sample of US adults was recruited via an online panel to complete a survey (n = 2,773 nonvegetarians and vegans were included in primary analyses).

INTERVENTION

Participants were randomly assigned to view 1 of the 4 following messages: control (neutral, non-red meat message), animal welfare, health, or environmental red-meat-reduction messages.

MAIN OUTCOME MEASURES

After viewing their assigned message, participants ordered hypothetical meals from 2 restaurants (1 full service and 1 quick service) and rated message reactions, perceptions, and intentions.

STATISTICAL ANALYSES PERFORMED

Logistic and linear regressions were performed.

RESULTS

Compared with the control message, exposure to the health and environmental red-meat-reduction messages reduced red meat selection from the full-service restaurant by 6.0 and 8.8 percentage points, respectively (P = .02 and P < .001, respectively), while the animal welfare message did not (reduction of 3.3 percentage points, P = .20). None of the red-meat-reduction messages affected red meat selection from the quick-service restaurant. All 3 red-meat-reduction messages elicited beneficial effects on key predictors of behavior change, including emotions and thinking about harms.

CONCLUSIONS

Red-meat-reduction messages, especially those describing health or environmental harms, hold promise for reducing red meat selection in some types of restaurants. Additional interventions may be needed to discourage red meat selection across a wider variety of restaurants, for example, by making salient which menu items contain red meat.

Occasions, Locations, and Reasons for Consuming Sugar-Sweetened Beverages among U.S. Adults

Frequent intake of sugar-sweetened beverages (SSBs) is associated with adverse health outcomes such as obesity, type 2 diabetes, and cardiovascular disease. Little is known about when, where, and why U.S. adults consume SSBs. This study, using data from an online survey distributed in 2021, examined the occasions, locations, and reasons for consuming SSBs and the characteristics of the adults who consume them. Nearly 7 of 10 adults reported consuming a SSB (1-6 times) in the past 7 days, and more than a third (38%) reported doing so once or more per day (on average). For comparative purposes, the sample was limited to adults who reported consuming SSBs within the last 7 days. Mealtimes were reported as the most frequent occasion for the intake of SSBs (43%) and SSBs were most often consumed at home (70%). Over half of respondents (56%) reported they consume SSBs because they enjoy the taste. Younger adults (18-34 years old) were more likely to consume SSBs in social settings than older adults (≥50 years old). Hispanic adults were less likely to consume SSBs at the beginning of the day compared to non-Hispanic White adults. Younger (18-34 years old) and middle-aged (35-49 years old) adults were more likely to consume SSBs in restaurants, at work, and in cars than older adults (≥50 years old). Women were less likely to consume SSBs at work than men. Hispanic adults were less likely to consume SSBs in cars than non-Hispanic White adults, while those earning USD 50,000-<USD 100,000 were more likely to consume SSBs in cars than those earning ≥USD 100,000. Younger and middle-aged adults were more likely to consume SSBs due to cravings and enjoyment of the carbonation compared to older adults. These findings provide insights on specific populations for whom to tailor messaging and adapt interventions to help reduce SSB intake.

Should messages discourage sugary drinks, encourage water, or both? A randomized experiment with U.S. parents

Campaigns to improve beverage consumption typically focus on discouraging unhealthy beverages (e.g., soda), encouraging healthy beverages (e.g., water), or both. It remains unclear which of these strategies is most effective. We recruited a national convenience sample of U.S. parents of children ages 2-12 (n = 1078, 48% Latino[a]) to complete an online survey in 2019. We randomly assigned participants to view: 1) a control message, 2) a soda discouragement message, 3) a water encouragement message, or 4) both soda discouragement and water encouragement messages shown side-by-side in random arrangement. Intervention messages mimicked New York City's "Pouring on the Pounds" campaign. Participants rated messages on perceived effectiveness for discouraging soda consumption and encouraging water consumption (1-5 response scales) and reported feelings and intentions about drinking soda and water (1-7 scales). Compared to those with no exposure, participants who viewed the soda discouragement message reported higher perceived discouragement from drinking soda (Average Differential Effect [ADE] = 1.18), more negative feelings toward drinking soda (ADE = 0.83) and stronger intentions to avoid drinking soda (ADE = 0.45) (ps < 0.001). The soda discouragement message also exerted beneficial effects on perceived effectiveness, feelings, and intentions related to water consumption (ADEs = 0.33-0.68; ps < 0.001). Exposure to the water encouragement message had beneficial effects on outcomes related to water consumption (ADEs = 0.28-0.81, ps < 0.001), but limited impact on outcomes related to soda consumption. Across outcomes, results indicated diminishing returns from exposure to both message types. Messaging campaigns discouraging unhealthy beverages may be more promising for improving beverage consumption than messages only promoting healthier beverages.

The impact of a community social marketing campaign on children's meal orders and consumption: main outcomes from a group randomised controlled trial

OBJECTIVE

Restaurants may be important settings for interventions to reduce children's energy intake. The objective of this study was to test the impact of a parent-focused social marketing campaign to promote healthy children's meals on calories ordered and consumed by children at quick-service restaurants (QSR).

DESIGN

Using a repeated cross-sectional study design, two urban communities were randomised to intervention (IN) v. control (C) condition. A community-wide social marketing campaign was implemented in the IN community to empower Black and Latinx mothers who frequent QSR (priority population) to select healthier options for their child.

SETTING

Data were collected in 2016 at QSR located within the communities pre- and post-IN and analysed in 2017.

PARTICIPANTS

Parents (n 1686; n 819 and n 867 for I and C conditions, respectively) were recruited after placing their QSR order; a survey, receipt and their child's leftovers were collected.

RESULTS

Calories ordered did not differ significantly between the IN and C conditions (changeadj = -146·4 kJ (-35·0 kcal); 95 % CI -428·0 kJ (-102·3 kcal), 134·6 kJ (32·2 kcal)). In a sub-analysis of only the priority audience, children in the IN community ordered significantly fewer calories compared to C children in unadjusted models (changeunadj = -510·4 kJ (-122·0 kcal); 95 % CI -1013·4 kJ (-242·2 kcal), -7·5 kJ (-1·8 kcal)), but the trend did not persist after adjusting for covariates (changeadj = -437·2 kJ (-104·5 kcal); 95 % CI -925·5 kJ (-221·2 kcal), 50·6 kJ (12·1 kcal)). Calories consumed followed similar trends.

CONCLUSION

The campaign did not significantly reduce children's QSR calories ordered or consumed. However, a quantitatively important mean reduction in calories was suggested among the priority audience, indicating potential for community-wide promotion of healthful children's meals.

LiveLighter® 'Junk Food' mass media campaign increases behavioural strategies to reduce consumption

The LiveLighter® 2016 'Junk Food' campaign ran for 5 weeks in Western Australia (WA) and urged adults to reduce their junk food consumption to avoid weight gain and associated chronic disease. A cohort design assessed campaign impact on knowledge, beliefs and behaviour. Pre-campaign (n = 1501) and post-campaign (n = 737) telephone surveys of WA adults aged 25-49 were undertaken. A post-campaign-only sample (n = 501) controlled for pre-test effects. The campaign reached 57% of respondents and increased knowledge of the link between overweight and non-alcoholic fatty liver disease (78% cf. 87%; P < 0.01). Following campaign activity, respondents were more likely to avoid purchasing food from settings depicted in the advertisements (fast food outlets: 63% cf. 77%; service stations: 82% cf. 93%; vending machines: 87% cf. 96%; all P < 0.001), particularly among pre-campaign consumers of fast food and salty snacks (≤2 times/week). Weight-loss self-efficacy increased among adults with higher body weight and campaign exposure (89% cf. 97%; P < 0.01), and there was no increased endorsement of overweight stereotypes among the full sample. Support for fiscal disincentives and nutritional disclosure policies increased among healthy weight adults. LiveLighter® positively influenced knowledge, beliefs and behaviours, along with attitudes towards policies to encourage healthy eating, supporting LiveLighter® as an advocacy campaign.

Retail Soda Purchases Decrease and Water Purchases Increase: 6-Year Results From a Community-Based Beverage Campaign

Introduction

This study aimed to document the long-term impacts on beverage sales of a 6-year intervention campaign to reduce consumption of sugar-sweetened beverages.

Methods

In 2013, a multicomponent intervention campaign designed to reduce the intake of sugary drinks was launched in Howard County, Maryland. A difference-in-differences regression approach was used to compare data on Howard County supermarket beverage sales (in ounces) from 2013 to 2018 with a set of control supermarkets. Outcome variables were average weekly sales by store of top brands of sugar-sweetened beverages (regular soda, sports drinks, fruit drinks) as well as diet soda and 100% juice. Trends in the sales of water products from 2016 to 2018 were estimated separately using a linear regression model.

Results

In Howard County, the sales of regular soda, fruit drinks, and 100% juice decreased significantly more than predicted each year. These changes correspond to a 29.7% decrease in sales for regular soda, a 7.5% decrease for fruit drinks, and a 33.5% drop for 100% juice between 2012 and 2018 in Howard County stores. There was a significant trend such that the net reduction in regular soda sales in Howard County stores became larger over time. The amount of plain water sold in Howard County increased significantly from 2016 to 2018.

Conclusions

Multicomponent efforts by local government, nonprofit organizations, and other community-based organizations are needed to decrease sugar-sweetened beverage consumption at the population level. Substantial and sustained improvements in retail beverage sales can be achieved through coordinated messaging, community organizing, and targeted advocacy for policy changes.

How have media campaigns been used to promote and discourage healthy and unhealthy beverages in the United States? A systematic scoping review to inform future research to reduce sugary beverage health risks

Sugary beverage consumption is associated with many health risks. This study used a proof-of-concept media campaign typology to examine U.S. beverage campaigns that promoted healthy beverages and encouraged or discouraged sugary beverages. We used a three-step systematic scoping review to identify, organize, analyze, and synthesize evidence. Step 1 used Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines to search four electronic databases and gray literature through 2021. Step 2 categorized relevant media campaigns using a media campaign typology. Step 3 examined campaign evaluation outcomes. We identified 280 campaigns organized into six campaign typology categories. The media landscape was dominated by corporate marketing campaigns for branded sugary beverages (65.8%; n = 184) followed by public awareness (9.6%; n = 27), public policy (8.2%; n = 23), social marketing (7.1%; n = 20), corporate social responsibility (5.7%; n = 16), and countermarketing (3.6%; n = 10) campaigns. Evaluations for 20 unique campaigns implemented over 30 years (1992-2021) across 14 states showed reduced sugary beverage or juice and increased water or low-fat milk sales and intake. Positive short-term cognitive and mid-term retail and behavioral changes were reported. There was limited evidence for long-term policy, social norm, and population health outcomes. Future research is needed to use media campaigns in strategic communications to reduce sugary beverage health risks for Americans.

Awareness of and reactions to health and environmental harms of red meat among parents in the United States

OBJECTIVE

Evidence of the health and environmental harms of red meat is growing, yet little is known about which harms may be most impactful to include in meat reduction messages. This study examined which harms consumers are most aware of and which most discourage them from wanting to eat red meat.

DESIGN

Within-subjects randomised experiment. Participants responded to questions about their awareness of, and perceived discouragement in response to, eight health and eight environmental harms of red meat presented in random order. Discouragement was assessed on a 1-to-5 Likert-type scale.

SETTING

Online survey.

PARTICIPANTS

544 US parents.

RESULTS

A minority of participants reported awareness that red meat contributes to health harms (ranging from 8 % awareness for prostate cancer to 28 % for heart disease) or environmental harms (ranging from 13 % for water shortages and deforestation to 22 % for climate change). Among specific harms, heart disease elicited the most discouragement (mean = 2·82 out of 5), followed by early death (mean = 2·79) and plants and animals going extinct (mean = 2·75), though most harms elicited similar discouragement (range of means, 2·60-2·82). In multivariable analyses, participants who were younger, identified as Black, identified as politically liberal, had higher general perceptions that red meat is bad for health and had higher usual red meat consumption reported being more discouraged from wanting to eat red meat in response to health and environmental harms (all P < 0·05).

CONCLUSIONS

Messages about a variety of health and environmental harms of red meat could inform consumers and motivate reductions in red meat consumption.

Grandparental care and childhood obesity in China

Ongoing increases in childhood obesity have become a serious public health concern. Meanwhile, caregiving by grandparents becomes a worldwide social phenomenon. This study estimates the effect of grandparental care on childhood obesity and explores its pathways. Utilizing five waves of panel data from the China Family Panel Studies, we found that grandparental care significantly increases the probability of childhood obesity, adding 3.6 percentage points. The effect is heterogeneous between boys and girls and between grandparents with different education attainments. The channels through which grandparents contribute to childhood obesity include inappropriate dietary patterns and insufficient physical activities. Additionally, we found that grandparents' famine experience generates a long-term fear of hunger, which translates into overfeeding their grandchildren, thus aggravating childhood obesity in China.

•

We estimate the longitudinal causal relationship of grandparental care on childhood obesity.

•

Our multiple robustness checks support the positive effect of grandparental care on childhood obesity.

•

Grandparents' famine experience generates a long-term fear of hunger, which aggravates childhood obesity in China.

Conceptualization of the Public Health Model of Reporting through Application: The Case of the Cincinnati Enquirer's Heroin Beat

This case study seeks to demonstrate the Cincinnati Enquirer's use of the public health model of reporting and public health news frames. The Enquirer created the first newspaper heroin beat in January 2016. Enquirer reporters framed the heroin epidemic as a public health issue, focusing on solutions, contextualizing the issue through societal determinants of health, and incorporating the voices of constituent groups. Findings are discussed using news framing and the public health model of reporting.

Sugar-Sweetened Beverage Reduction Policies: Progress and Promise

Evidence showing the effectiveness of policies to reduce the consumption of sugar-sweetened beverages (SSBs) is growing. SSBs are one of the largest sources of added sugar in the diet and are linked to multiple adverse health conditions. This review presents a framework illustrating the various types of policies that have been used to reduce SSB exposure and consumption; policies are organized into four categories (financial, information, defaults, and availability) and take into consideration crosscutting policy considerations (feasibility, impact, and equity). Next, for each category, we describe a specific example and provide evidence of impact. Finally, we discuss crosscutting policy considerations, the challenge of choosing among the various policy options, and important areas for future research. Notably, no single policy will reduce SSB consumption to healthy levels, so an integrated policy approach that adapts to changing market and consumption trends; evolving social, political, and public health needs; and emerging science is critical.

Countermarketing About Fruit Drinks, Alone or With Water Promotion: A 2019 Randomized Controlled Trial in Latinx Parents

Objectives. To test whether fruit drink countermarketing messages alone or combined with water promotion messages reduce Latinx parents' purchases of fruit drinks for children aged 0 to 5 years. Methods. We performed a 3-arm randomized controlled online trial enrolling 1628 Latinx parents in the United States during October and November 2019. We assessed the effect of culturally tailored fruit drink countermarketing messages (fruit drink‒only group), countermarketing and water promotion messages combined (combination group), or car-seat safety messages (control) delivered via Facebook groups for 6 weeks on parental beverage choices from a simulated online store. Results. The proportion of parents choosing fruit drinks decreased by 13.7 percentage points in the fruit drink‒only group (95% confidence interval [CI] = -20.0, -7.4; P < .001) and by 19.2 percentage points in the combination group (95% CI = -25.0, -13.4; P < .001) relative to control. Water selection increased in both groups. Conclusions. Fruit drink countermarketing messages, alone or combined with water promotion messages, significantly decreased parental selection of fruit drinks and increased water selection for their children. Public Health Implications. Countermarketing social media messages may be an effective and low-cost intervention for reducing parents' fruit drink purchases for their children. (Am J Public Health. 2021;111(11):1997-2007. https://doi.org/10.2105/AJPH.2021.306488).

Race, Ethnicity, and Neighborhood Food Environment Are Associated with Adolescent Sugary Drink Consumption During a 5-Year Community Campaign

Background

A multi-level county-wide campaign to reduce sugary drink consumption was associated with significant decreases in retail sales of soda and fruit drinks. The aim of the current study was to examine changes in adolescent beverage consumption during the campaign by race/ethnicity and neighborhood food environment.

Methods

Beverage consumption among adolescents was evaluated at four time points in a repeated cross-sectional survey of a racially and ethnically diverse sample of sixth graders (N = 13,129) from public middle schools in the county. Each school’s surrounding attendance zone (i.e., neighborhoods where students live) was characterized as providing high or low exposure to unhealthy food retail (e.g., convenience stores, fast-food restaurants). Logistic and multiple linear regression models were used to evaluate changes in beverage consumption over time by student race/ethnicity and high versus low unhealthy food exposure.

Results

Over the 5 years, there were significant declines in the overall share of students who reported daily sugary drink consumption (49.4 to 36.9%) and their reported daily calories from these products (220 to 158 calories). However, disparities were observed, with higher levels of consumption among Black and Hispanic youth and among youth living in neighborhoods with more unhealthy food retail. Notably, Black students living in healthier neighborhood food environments reported significant decreases in daily consumption and calories after 5 years, while Black students living in neighborhoods with more convenience stores and fast-food outlets did not.

Conclusion

These findings suggest that both race/ethnicity and neighborhood food environments are important considerations when designing interventions to reduce sugary drink consumption among adolescents.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40615-021-01074-9.

The Effect of a Priest-Led Intervention on the Choice and Preference of Soda Beverages: A Cluster-Randomized Controlled Trial in Catholic Parishes

Background

Latin America ranks among the regions with the highest level of intake of sugary beverages in the world. Innovative strategies to reduce the consumption of sugary drinks are necessary.

Purpose

Evaluate the effect of a one-off priest-led intervention on the choice and preference of soda beverages.

Methods

We conducted a pragmatic cluster-randomized trial in Catholic parishes, paired by number of attendees, in Chimbote, Peru between March and June of 2017. The priest-led intervention, a short message about the importance of protecting one’s health, was delivered during the mass. The primary outcome was the proportion of individuals that choose a bottle of soda instead of a bottle of water immediately after the service. Cluster-level estimates were used to compare primary and secondary outcomes between intervention and control groups utilizing nonparametric tests.

Results

Six parishes were allocated to control and six to the intervention group. The proportion of soda selection at baseline was ~60% in the intervention and control groups, and ranged from 56.3% to 63.8% in Week 1, and from 62.7% to 68.2% in Week 3. The proportion of mass attendees choosing water over soda was better in the priest-led intervention group: 8.2% higher at Week 1 (95% confidence interval 1.7%–14.6%, p = .03), and 6.2% higher at 3 weeks after baseline (p = .15).

Conclusions

This study supports the proof-of-concept that a brief priest-led intervention can decrease sugary drink choice.

Clinical Trial information

ISRCTN, ISRCTN24676734. Registered 25 April 2017, https://www.isrctn.com/ISRCTN24676734

Awareness of and reactions to the health harms of sugary drinks: An online study of U.S. parents

Evidence about the health problems associated with sugary drink consumption is well-established. However, little is known about which sugary drink health harms are most effective at changing consumers' behavior. We aimed to identify which harms people were aware of and most discouraged them from wanting to buy sugary drinks. Participants were a national convenience sample of diverse parents (n = 1,058), oversampled for Latino parents (48%). Participants rated a list of sugary drink-related health harms occurring in children (7 harms) and in adults (15 harms). Outcomes were awareness of each harm and how much each harm discouraged parents from wanting to purchase sugary drinks. Most participants were aware that sugary drinks contribute to tooth decay in children (75%) and weight gain in both children (73%) and adults (69%). Few participants were aware that sugary drinks contribute to adult infertility (16%), arthritis (18%), and gout (18%). All health harms were rated highly in terms of discouraging parents from wanting to buy sugary drinks (range: 3.59-4.11 on a 1-5 scale), with obesity, pre-diabetes, and tooth decay eliciting the highest discouragement ratings. Harm-induced discouragement was higher for participants who were aware of more health harms (B = 0.05, p < 0.0001), identified as female (B = 0.15 compared to male, p = 0.02), or had an annual household income of $50,000 or more (B = 0.16 compared to less than $50,000, p = 0.03). These findings suggest health messages focused on a variety of health harms could raise awareness and discourage sugary drink purchases.

A rapid review of stocking and marketing practices used to sell sugar-sweetened beverages in U.S. food stores

Sugar-sweetened beverages (SSBs) are a primary source of added sugars in the American diet. Habitual SSB consumption is associated with obesity and noncommunicable disease and is one factor contributing to U.S. health disparities. Public health responses to address marketing-mix and choice-architecture (MMCA) strategies used to sell SSB products may be required. Thus, our goal was to identify original research about stocking and marketing practices used to sell SSB in U.S. food stores. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the World Health Organization (WHO) protocol for rapid reviewing. We searched six databases and Google Scholar using key terms focused on store type and SSB products. We characterized results using an MMCA framework with categories place, profile, portion, pricing, promotion, priming or prompting, and proximity. Our search resulted in the identification of 29 articles. Most results focused on profile (e.g., SSB availability) (n = 13), pricing (e.g., SSB prices or discounts) (n = 13), or promotion (e.g., SSB advertisements) (n = 13) strategies. We found some evidence of targeted MMCA practices toward at-risk consumers and differences by store format, such as increased SSB prominence among supermarkets. The potential for systematic variations in MMCA strategies used to sell SSB requires more research. We discuss implications for public health, health equity, and environmental sustainability.

A cluster randomised controlled trial of a secondary school intervention to reduce intake of sugar-sweetened beverages: Mid-intervention impact of switchURsip environmental strategies

ISSUE ADDRESSED

Secondary schools provide an opportune setting for interventions addressing excessive sugar-sweetened beverage (SSB) intake in adolescence. This trial aimed to assess the impact of school environmental strategies, delivered as part of a broader intervention, among Year 7-9 students' SSB consumption.

METHODS

Between March and July 2018, we conducted a cluster randomised controlled trial with 862 students attending six secondary schools (3 intervention and 3 control) in New South Wales. The intervention targeted SSB availability, placement, promotion and pricing, and increased availability and promotion of water. Control schools followed their usual programmes. Primary outcomes included mean daily SSB consumption (millilitres) and mean daily percentage energy from SSB (kilojoules). Sub-group analysis explored primary outcomes for gender, school year level and frequency of canteen use.

RESULTS

Of the 2265 eligible students, 1092 (50.2%) provided active parental consent and 940 (86.0%) participated in baseline data collection. No significant differences were observed between groups at follow-up for mean daily SSBs consumed (-10.17 mL, CI: -24.78; 45.12, P = 0.57) or mean daily percentage energy from SSBs (-0.20%, CI: -0.87; 0.47, P = .56). Significant effects were observed among girls in intervention compared to girls in control schools for mean daily SSB consumption (-52.02 mL, CI 99.8; 94.14, P = .03) and mean daily percentage of energy from SSBs (-0.90%, CI: -1.82; 0.02, P = .05).

CONCLUSIONS

At 3-month mid-intervention evaluation, the intervention failed to impact on mean daily consumption and mean percentage energy from SSBs, overall. However, an intervention effect was observed in girls. The limited overall effect is likely due to inadequate intervention dose related to the short duration, limiting opportunities for schools to fully implement the environmental strategies. SO WHAT?: A longer intervention duration with additional implementation support to allow adequate time to embed the strategies within the school is recommended. Implementation support strategies would ensure staff are supported throughout the process.

The drivers, trends and dietary impacts of non-nutritive sweeteners in the food supply: a narrative review

Poor diets, including excess added sugar consumption, contribute to the global burden of disease. Subsequently, many nutrition policies have been implemented to reduce added sugar intake and improve population health, including taxes, education, labelling and environmental interventions. A potential consequence of these policy actions is the substitution of added sugars with non-nutritive sweeteners (NNS) in a variety of foods and beverages. NNS are used to reduce the energy and sugar content of foods and beverages while maintaining their palatability. Evidence of the toxicological risks of NNS is inconsistent, though concerns have been raised over the potential substitution effects of ultra-processed foods containing NNS for whole foods. This review aimed to provide an overview of current NNS food supply and consumption patterns, assess added sugar-reduction policies and their impact on NNS, and determine the impact of NNS on food choice, energy intake and diet quality. NNS are widely available in a variety of products, though most commonly in carbonated beverages, dairy products, confectionery, table-top sweeteners and fruit drinks. However, the longitudinal trends of different product categories, and differences between geographies and economy-income levels, require further study. Few studies have examined NNS consumption trends globally, though an increase in NNS consumption in beverages has been observed in some regions. Research examining how the increased availability of low-sugar, NNS-containing products affects global dietary patterns is limited, particularly in terms of their potential substitution effects.

Examining Trends in Beverage Sales in New York City During Comprehensive Efforts to Reduce Sugary Drink Consumption, 2010-2015

Since 2006, New York City (NYC) has attempted to reduce sugary drink consumption through several population-based initiatives, media campaigns and policy proposals. We estimated trends in the relative market share of sugary drinks and other beverage categories in NYC, using over 5 years of weekly, point-of-sale data from a retailer sample. We used an interrupted time series approach to assess whether changes in NYC beverage purchasing patterns occurred following the announcement of a proposed portion cap rule for consumer purchases of sugary drinks. Overall, market share of sugary drinks declined in NYC between 2010 and 2015. While the proportion of beverage volume sold that was sugary drinks was stable prior to the May 2012 portion cap rule announcement, decreases of 1.25% per year were observed in the period following the announcement compared to the period before (95% confidence interval (CI) - 1.60, - 0.90). Water/seltzer market share was increasing prior to the announcement and increased by an additional 1.03% per year in the post-announcement period (95% CI 0.48, 1.57). City-led efforts to increase public awareness about sugary drink-associated health risks in NYC may have led to reductions in consumer purchases of these beverages. Though never implemented, the portion cap proposal and accompanying media coverage may have contributed to decreases in sugary drink sales.

Environmental Interventions to Reduce the Consumption of Sugar-Sweetened Beverages: Abridged Cochrane Systematic Review

BACKGROUND

Regular consumption of sugar-sweetened beverages (SSB) can increase the risk for obesity, type 2 diabetes, cardiovascular disease, and dental caries. Interventions that alter the physical or social environment in which individuals make beverage choices have been proposed to reduce the consumption of SSB.

METHODS

We included randomised controlled, non-randomised controlled, and interrupted time series studies on environmental interventions, with or without behavioural co-interventions, implemented in real-world settings, lasting at least 12 weeks, and including at least 40 individuals. Studies on the taxation of SSB were not included, as these are subject of a separate Cochrane review. We used standard Cochrane methods for data extraction, risk of bias assessment, and evidence grading and synthesis. Searches were updated to January 24, 2018.

RESULTS

We identified 14,488 unique records and assessed 1,030 full texts for eligibility. We included 58 studies comprising a total of 1,180,096 participants and a median length of follow-up of 10 months. We found moderate-certainty evidence for consistent associations with decreases in SSB consumption or sales for the following interventions: traffic light labelling, price increases on SSB, in-store promotion of healthier beverages in supermarkets, government food benefit programs with incentives for purchasing fruits and vegetables and restrictions on SSB purchases, multi-component community campaigns focused on SSB, and interventions improving the availability of low-calorie beverages in the home environment. For the remaining interventions we found low- to very-low-certainty evidence for associations showing varying degrees of consistency.

CONCLUSIONS

With observed benefits outweighing observed harms, we suggest that environmental interventions to reduce the consumption of SSB be considered as part of a wider set of measures to improve population-level nutrition. Implementation should be accompanied by evaluations using appropriate methods. Future studies should examine population-level effects of interventions suitable for large-scale implementation, and interventions and settings not yet studied thoroughly.

Factors associated with sugar-sweetened beverage consumption in adults with children in the home after a statewide health communications program

Background

In 2016, Oklahoma launched "Shape Your Future - Rethink Your Drink" (SYF/RYD), an obesity prevention health communication program targeting parents and caregivers of children. The aims of this study are to compare sugar-sweetened beverage (SSB) consumption before and after the program and to report factors associated with SSB consumption, knowledge, and attitudes.

Methods

This repeated cross-sectional study involved 2656 Oklahoma adults with ≥ one child under 18 years in the home. Weighted prevalence estimates were calculated and the relationship between SSB consumption and covariates of interest were examined using logistic regression techniques appropriate for survey data.

Results

Following the SYF/RYD program, SSB consumption decreased 18.6% (p = 0.0232) and heavy SSB consumption, ≥ three SSB per day, decreased 42.9% (p = 0.0083). Factors associated with SSB consumption, 1 year after the launch of SYF/RYD included high school education or less (AOR = 1.33 with 95% CI = 1.02, 1.73), fair or poor health status (AOR = 2.02 with 95% CI = 1.47, 2.78), drinking less than eight cups of water daily (AOR = 1.77 with 95% CI = 1.39, 2.25), inability to afford healthy foods (AOR = 1.33 with 95% CI = 1.06, 1.67), and self-identifying as American Indian/Alaska Native (AOR = 1.59 with 95% CI = 1.10, 2.29).

Conclusions

Health communication campaigns, such as SYF/RYD, are an evidence-based strategy for health behavior change and likely contributed to the declines observed in SSB consumption. Important differences in SSB consumption by population subgroups persist and have implications for future message development.

Dietary policies and programs in the United States: A narrative review

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School-based and youth targeted programs and policies were most frequently studied.

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Research has rather neglected older adult, Asian, Native Hawaiian and American Indian populations.

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Despite existing research indicating effectiveness, faith-based were understudied.

Prior reviews describing approach, methodological quality and effectiveness of dietary policies and programs may be limited in use for practitioners seeking to introduce innovative programming, or academic researchers hoping to understand and address gaps in the current literature. This review is novel, assessing the “where, who, and in whom” of dietary policies and programs research in the United States over the past decade – with results intended to serve as a practical guide and foundation for innovation. This study was conducted from October 2018 to March 2019. Papers were selected through a tailored search strategy on PubMed as well as citation searches, to identify grey literature. A total of 489 papers were relevant to our research objective. The largest proportion of papers described school-based strategies (31%) or included economic incentives (19%). In papers that specified demographics, the study populations most often included children, adults and adolescents (54%, 46%, and 42% respectively); and White, Black and Hispanic populations (77%, 76% and 70%, respectively). Results highlight opportunities for future research within workplace and faith-based settings, among racial/ethnic minorities, and older adults.

Ethical Considerations for Food and Beverage Warnings

Several countries have implemented warnings on unhealthy foods and beverages, with similar policies under consideration in the U.S. and around the world. Research demonstrating food warnings' effectiveness is emerging, but limited scholarship has evaluated the ethics of food warning policies. Using a public health ethics framework for evaluating obesity prevention policies, we assessed the ethical strengths and weaknesses of food warnings along multiple dimensions: 1) Health behaviors and physical health, 2) Psychosocial well-being, 3) Social and cultural values, 4) Informed choice, 5) Equality, 6) Attributions of responsibility, 7) Liberty, and 8) Privacy. Our analysis identifies both ethical strengths and weaknesses of food warnings, including that: 1) warnings are likely to generate important benefits including increased consumer understanding and informed choice, healthier purchases, and potential reductions in obesity prevalence; 2) warnings evoke negative emotional reactions, but these reactions are an important mechanism through which food warnings encourage healthier behaviors and promote informed choice; 3) warnings appear unlikely to have ethically unacceptable effects on social and cultural values, attributions of responsibility, liberty, or privacy. Current research suggests we continue to pursue food warnings as a policy option for improving public health while simultaneously conducting additional research on the ethics of these policies. Future research is especially needed to clarify warnings' effects on stigma and to characterize the balance and distribution of costs of and benefits from implementing warning policies.

Participation of Women and Older Participants in Randomized Clinical Trials of Lipid-Lowering Therapies: A Systematic Review

IMPORTANCE

Randomized clinical trials (RCTs) of lipid-lowering therapies form the evidence base for national and international guidelines. However, concerns exist that women and older patients are underrepresented in RCTs.

OBJECTIVE

To determine the trends of representation of women and older patients (≥65 years) in RCTs of lipid-lowering therapies from 1990 to 2018.

DATA SOURCES

The electronic databases of MEDLINE and ClinicalTrials.gov were searched from January 1990 through December 2018.

STUDY SELECTION

RCTs of lipid-lowering therapies with sample sizes of at least 1000 patients and follow-up periods of at least 1 year were included.

DATA EXTRACTION AND SYNTHESIS

Two independent investigators abstracted the data on a standard data collection form.

MAIN OUTCOMES AND MEASURES

Patterns of representation of women and older adults were examined overall in lipid-lowering RCTs and according to RCT-level specific characteristics. The participation-to-prevalence ratio (PPR) metric was used to estimate the representation of women compared with their share of disease burden.

RESULTS

A total of 60 RCTs with 485 409 participants were included. The median (interquartile range) number of participants per trial was 5264 (1062-27 564). Overall, representation of women was 28.5% (95% CI, 24.4%-32.4%). There was an increase in the enrollment of women from the period 1990 to 1994 (19.5%; 95% CI, 18.4%-20.5%) to the period 2015 to 2018 (33.6%; 95% CI, 33.4%-33.8%) (P for trend = .01). Among common limiting factors were inclusion of only postmenopausal women or surgically sterile women (28.3%; 95% CI, 18.5%-40.7%) or exclusion of pregnant (23.3%; 95% CI, 14.4%-35.4%) and lactating (16.6%; 95% CI, 9.3%-28.1%) women. Women were underrepresented compared with their disease burden in lipid RCTs of diabetes (PPR, 0.74), heart failure (PPR, 0.27), stable coronary heart disease (PPR, 0.48), and acute coronary syndrome (PPR, 0.51). Only 23 RCTs with 263 628 participants reported the proportion of older participants. Overall representation of older participants was 46.7% (95% CI, 46.5%-46.9%), which numerically increased from 31.6% (95% CI, 30.8%-32.3%) in the period 1995 to 1998 to 46.2% (95% CI, 46.0%-46.5%) in the period 2015 to 2018 (P for trend = .43). A total of 53.0% (95% CI, 41.8%-65.3%) and 36.6% (95% CI, 25.6% to 49.3%) trials reported outcomes according to sex and older participants, respectively, which did not improve over time.

CONCLUSIONS AND RELEVANCE

In this systematic review of RCTs of lipid-lowering therapies, the enrollment of women and older participants increased over time, but women and older participants remained consistently underrepresented. This limits the evidence base for efficacy and safety in these subgroups.

A systematic review of the effectiveness of promoting water intake to reduce sugar-sweetened beverage consumption

Objective

To examine whether the promotion of water intake could reduce sugar‐sweetened beverage (SSB) consumption or purchases independent of interventions that target SSBs.

Methods

Seven databases were systematically searched. Included studies used water promotion as the primary intervention; used a controlled trial, single group pre‐post, or prospective cohort study design; included a measure of SSB consumption or purchase; enrolled human participants of any age who lived in high‐income or middle‐income countries; contained original data; and appeared in a peer‐reviewed English‐language article published from 1 January 2000 to January 4, 2019. The search yielded 7068 publications, from which 108 were chosen for full‐text review. Seventeen were included in this review.

Results

Nine of the 17 studies were randomized controlled trials, six were nonrandomized controlled trials, and 2 were single‐group pre‐post studies. Participants were primarily children and adolescents. Interventions included water provision, education or promotion activities. Ten of 17 studies were at low or some/moderate risk of bias. Seven studies showed a statistically significant decrease in SSB consumption of which only 2 were at low or some/moderate risk of bias.

Conclusions

This review found limited evidence that interventions aimed solely at increasing water consumption reduce SSB intake. Further research is needed to investigate whether interventions that combine water promotion and SSB reduction strategies could be synergistic for reducing SSB intake.

Energy imbalance: obesity, associated comorbidities, prevention, management and public health implications

The prevalence of obesity has been continually increasing, as have its associated comorbidities and health care costs. Effective management of obesity and early intervention measures are necessary to overcome this global issue. The responsibility for preventing and managing this global epidemic does not lie solely on an individual, but also on the entire health care system. Policy makers-nationally and globally-must play their roles to solve the issue. In this review article, we examine methods of controlling and managing obesity through interventions, such as a low caloric diet, physical exercise, pharmacological guidance, and bariatric surgical procedures. While health care professionals should educate patients about all available treatment options for severe obesity, bariatric surgical procedures have increased in popularity and are considered very beneficial with outcomes fruitful in managing severe obesity.

Trends in Intake of Energy and Total Sugar from Sugar-Sweetened Beverages in the United States among Children and Adults, NHANES 2003-2016

Consumption of sugar-sweetened beverages (SSBs) increases total caloric intake, is linked to cardiometabolic outcomes as well as dental caries, and sugar in SSBs is associated with mortality and frailty among adults. We describe energy and total sugar intake trends among the United States (US) population from SSBs, soft drinks, other beverage groups, and the total diet based on the first 24-h recall data from the National Health and Nutrition Examination Survey (NHANES) cycles (2003-2004 through 2015-2016). SSBs included soft drinks, sports drinks, energy drinks, and fruit drinks, but excluded sports beverages with protein and sweetened teas/coffees. Among the total population (age ≥2 years: 57,026), energy intake from SSBs declined significantly from 183.9 ± 6.9 mean kcal/d (±SE) in 2003-2004 to 95.0 ± 3.5 in 2015-2016, while total sugar intake declined from 43.6 ± 1.7 mean g/d to 22.3 ± 0.8 (p-trend < 0.0001). Decreases were found for energy and total sugar intake, as well as percentage of energy and total sugar intake from SSBs, soft drinks, and all beverages for all age groups examined (≥2, 2-19, ≥20 years) (p-trend < 0.0001). From 2003 to 2016, energy and sugar intake from all beverages, SSBs, soft drinks, and the total diet decreased among the total population, children, and adults.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

BACKGROUND

Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.

OBJECTIVES

To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.

SEARCH METHODS

We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.

SELECTION CRITERIA

We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables.

MAIN RESULTS

We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption.

AUTHORS' CONCLUSIONS

The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.

Innovation to Create a Healthy and Sustainable Food System: A Science Advisory From the American Heart Association

Current dietary intakes of North Americans are inconsistent with the Dietary Guidelines for Americans . This occurs in the context of a food system that precludes healthy foods as the default choices. To develop a food system that is both healthy and sustainable requires innovation. This science advisory from the American Heart Association describes both innovative approaches to developing a healthy and sustainable food system and the current evidence base for the associations between these approaches and positive changes in dietary behaviors, dietary intakes, and when available, health outcomes. Innovation can occur through policy, private sector, public health, medical, community, or individual-level approaches and could ignite and further public-private partnerships. New product innovations, reformulations, taxes, incentives, product placement/choice architecture, innovative marketing practices, menu and product labeling, worksite wellness initiatives, community campaigns, nutrition prescriptions, mobile health technologies, and gaming offer potential benefits. Some innovations have been observed to increase the purchasing of healthy foods or have increased diversity in food choices, but there remains limited evidence linking these innovations with health outcomes. The demonstration of evidence-based improvements in health outcomes is challenging for any preventive interventions, especially those related to diet, because of competing lifestyle and environmental risk factors that are difficult to quantify. A key next step in creating a healthier and more sustainable food system is to build innovative system-level approaches that improve individual behaviors, strengthen industry and community efforts, and align policies with evidence-based recommendations. To enable healthier food choices and favorably impact cardiovascular health, immediate action is needed to promote favorable innovation at all levels of the food system.

The Needle and the Damage Done: Framing the Heroin Epidemic in the Cincinnati Enquirer

This case study focuses on the Cincinnati Enquirer's coverage of the heroin epidemic. The Enquirer started the first heroin beat in January 2016, and it could serve as a model for other news organizations. Reporters used combinations of episodic, thematic, public health, and crime and law enforcement frames in their coverage. These news frames are discussed in terms of how individualism-collectivism, geographic location, available resources, and social determinants inform journalistic and societal discussions of the heroin epidemic in terms of solutions instead of responsibility or blame.

Association of the LiveLighter mass media campaign with consumption of sugar-sweetened beverages: Cohort study

ISSUE ADDRESSED

Evaluation of the behavioural impact of Western Australia's LiveLighter healthy weight and lifestyle campaign focussed on decreasing consumption of sugar-sweetened beverages (SSBs) using graphic imagery, as well as monitoring unintended consequences.

METHODS

A cohort design with pre-campaign telephone survey of Western Australian adults aged 25-49 (Time 1 May/Jun 2013: N = 1504) undertaken and repeated following the campaign (Time 2 Aug/Sep 2013: N = 822).

RESULTS

Post-campaign awareness was 67% with respondents in low socio-economic areas most likely to report viewing the campaign frequently. There was evidence of reduced SSB intake from baseline to follow-up among frequent (4+/week) SSB consumers (22% cf. 16%; P = 0.003) and some evidence among overweight (BMI 25+) weekly SSB consumers (56% cf. 48%; P = 0.013). There was also some evidence consumption of sweet food decreased (3+/week: 53% cf. 48%; P = 0.035) while fruit, vegetable and fast food consumption remained stable. Knowledge of potential health consequences of SSBs increased (70% cf. 82%; P < 0.001) with no change in knowledge of potential health consequences of overweight generally (86% cf. 89%). Importantly, there was no increase in endorsement of overweight stereotypes.

CONCLUSIONS

The LiveLighter "Sugary Drinks" campaign positively impacted adults' knowledge and behaviour with regard to SSB consumption in a pattern specific to the campaign messaging and without adverse impact on weight-related stereotypes. SO WHAT?: Findings support the use of mass media for healthy lifestyle change. They suggest the public are receptive to undertaking the campaign's simple concrete lifestyle recommendation and provide an indication of the campaign dose required to achieve positive behaviour change.

Tackling Obesity and Disease: The Culprit Is Sugar; the Response Is Legal Regulation

It is staggering to observe the new normal in America: 37.9 percent of adults are obese, and 70.7 percent are either obese or overweight. One out of every five minors is obese. The real tragedy, of course, is the disability, suffering, and early death that devastates families and communities. But all of society pays, with the annual medical cost estimated at $147 billion. The causal pathways are complex, but if we drill down, sugar is a deeply consequential pathway to obesity, and the single greatest dietary source is sugar-sweetened beverages (SSBs). The copious amount of sugar in the American diet is no accident. Industry practices and regulatory failures have fueled this explosion. Yet there are sensible, effective interventions that would create the conditions for healthier behaviors. What are the key interventions, and how can we overcome the social, political, and constitutional roadblocks? Tobacco control offers a powerful model, suggesting that success requires a suite of interventions working in concert: labeling, warnings, taxation, portion sizes, product formulation, marketing restrictions, and bans in high-risk settings such as schools and hospitals. Each intervention deserves detailed analysis, but I'm kick-starting scholarly and policy conversation by systematically laying out the major legal tools.

How has big data contributed to obesity research? A review of the literature

There has been growing interest in the potential of ‘big data’ to enhance our understanding in medicine and public health. Although there is no agreed definition of big data, accepted critical components include greater volume, complexity, coverage and speed of availability. Much of these data are ‘found’ (as opposed to ‘made’), in that they have been collected for non-research purposes, but could include valuable information for research. The aim of this paper is to review the contribution of ‘found’ data to obesity research to date, and describe the benefits and challenges encountered. A narrative review was conducted to identify and collate peer-reviewed research studies. Database searches conducted up to September 2017 found original studies using a variety of data types and sources. These included: retail sales, transport, geospatial, commercial weight management data, social media, and smartphones and wearable technologies. The narrative review highlights the variety of data uses in the literature: describing the built environment, exploring social networks, estimating nutrient purchases or assessing the impact of interventions. The examples demonstrate four significant ways in which ‘found’ data can complement conventional ‘made’ data: firstly, in moving beyond constraints in scope (coverage, size and temporality); secondly, in providing objective, quantitative measures; thirdly, in reaching hard-to-access population groups; and lastly in the potential for evaluating real-world interventions. Alongside these opportunities, ‘found’ data come with distinct challenges, such as: ethical and legal questions around access and ownership; commercial sensitivities; costs; lack of control over data acquisition; validity; representativeness; finding appropriate comparators; and complexities of data processing, management and linkage. Despite widespread recognition of the opportunities, the impact of ‘found’ data on academic obesity research has been limited. The merit of such data lies not in their novelty, but in the benefits they could add over and above, or in combination with, conventionally collected data.

Chile's 2014 sugar-sweetened beverage tax and changes in prices and purchases of sugar-sweetened beverages: An observational study in an urban environment

BACKGROUND

On October 1, 2014, the Chilean government modified its previous sugar-sweetened beverage (SSB) tax, increasing the tax rate from 13% to 18% on industrialized beverages with high levels of sugar (H-SSBs) (greater than 6.25 grams [g] sugar/100 milliliters [mL]) and decreasing the tax rate from 13% to 10% on industrialized beverages with low or no sugar (L-SSBs) (less than 6.25 g sugar/100 mL). This study examines changes in beverage prices and household beverage purchases following the implementation of the tax reform.

METHODS AND FINDINGS

We used longitudinal data collected between January 1, 2013, and December 31, 2015, from 2,000 households. We defined the pretax period as January 1, 2013, to September 30, 2014, and the posttax period as October 1, 2014, to December 31, 2015. We conducted a pre-post analysis for changes in prices and purchases, with the latter examined by volume and calories. We compared posttax changes in prices and purchases to a counterfactual, defined as what would have been expected in the posttax period based on pretax trends. All results are stated as comparisons to this counterfactual. We linked beverages at the bar code level to nutrition facts panel data collected by a team of Chilean nutritionists who categorized them by taxation level and beverage subcategory, which included carbonated and noncarbonated H-SSBs and concentrated, ready-to-drink L-SSBs and untaxed beverages. We reconstituted concentrated beverages and analyzed all beverages using as-consumed volumes and calories. Posttax monthly prices of H-SSBs increased, but these changes were small. Prices of carbonated H-SSBs increased by 2.0% (95% confidence interval [CI] 1.0%-3.0%), while those of noncarbonated H-SSBs increased by 3.9% (95% CI 1.6%-6.2%). Prices of L-SSB concentrates decreased after the tax by 6.7% (95% CI -8.2%--4.6%), and prices of ready-to-drink L-SSBs increased by 1.5% (95% CI 0.3%-2.7%). Households decreased monthly per capita purchases of H-SSBs by 3.4% by volume (95% CI -5.9%--0.9%) and 4.0% by calories (95% CI -6.3%--1.9%), and this change was greater among high socioeconomic status (SES) households. The volume of household purchases of L-SSBs increased 10.7% (95% CI 7.5%-13.9%), while that of untaxed beverage purchases decreased by 3.1% (95% CI -5.1%--1.1%). The main limitation of this study was that there was no control group, so we were unable to assess the causal impact of the tax.

CONCLUSIONS

The modifications of Chile's SSB tax were small, and observed changes in prices and purchases of beverages after the tax were also small. Our results are consistent with previous evidence indicating that small increases in SSB taxes are unlikely to promote large enough changes in SSB purchases to reduce obesity and noncommunicable diseases (NCDs).

Childhood obesity in China: Does grandparents' coresidence matter?

Childhood obesity in China has been increasingly cited as a major public health issue in recent decades. The effect of grandparents on grandchildren's weight outcome is under-analyzed. Using data from the China Health and Nutrition Survey, we examine the effect of grandparents' coresidence on childhood weight outcome with a sample of 2-13-year-old children in China. We use instrumental variables to address the potential endogeneity of grandparents' coresidence. We show that the effect of grandparents' coresidence on childhood weight outcome is significantly positive. Grandparents' coresidence affects a grandchild's weight outcome through changes in dietary patterns and physical activity. The effects on dietary patterns exist in urban areas and significantly lower in rural areas. Grandparents' coresidence decreases physical activity more in rural areas than in urban areas. Furthermore, the effects of coresidence on protein intake and physical activities of children above 6 are significantly higher for males than females. A robustness check, including an ordered logit model with a body mass index category and estimation with additional data, validates our findings.

Controlled cohort evaluation of the LiveLighter mass media campaign's impact on adults' reported consumption of sugar-sweetened beverages

OBJECTIVE

To evaluate the LiveLighter 'Sugary Drinks' campaign impact on awareness, knowledge and sugar-sweetened beverage (SSB) consumption.

DESIGN

Cohort study with population surveys undertaken in intervention and comparison states at baseline (n=900 each), with 78% retention at follow-up (intervention: n=673; comparison: n=730). Analyses tested interactions by state (intervention, comparison) and time (baseline, follow-up).

SETTING AND PARTICIPANTS

Adults aged 25-49 years residing in the Australian states of Victoria and South Australia.

INTERVENTION

The 6-week mass media campaign ran in Victoria in October/November 2015. It focused on the contribution of SSBs to the development of visceral 'toxic fat', graphically depicted around vital organs, and ultimately serious disease. Paid television advertising was complemented by radio, cinema, online and social media advertising, and stakeholder and community engagement.

PRIMARY OUTCOME MEASURE

Self-reported consumption of SSBs, artificially sweetened drinks and water.

SECONDARY OUTCOME MEASURES

Campaign recall and recognition; knowledge of the health effects of overweight and SSB consumption; perceived impact of SSB consumption on body weight and of reduced consumption on health.

RESULTS

A significant reduction in frequent SSB consumption was observed in the intervention state (intervention: 31% compared with 22%, comparison: 30% compared with 29%; interaction p<0.01). This was accompanied by evidence of increased water consumption (intervention: 66% compared with 73%; comparison: 68% compared with 67%; interaction p=0.09) among overweight/obese SSB consumers. This group also showed increased knowledge of the health effects of SSB consumption (intervention: 60% compared with 71%, comparison: 63% compared with 59%; interaction p<0.05) and some evidence of increased prevalence of self-referent thoughts about SSB's relationship to weight gain (intervention: 39% compared with 45%, comparison: 43% compared with 38%; interaction p=0.06).

CONCLUSIONS

The findings provide evidence of reduced SSB consumption among adults in the target age range following the LiveLighter campaign. This is notable in a context where public health campaigns occur against a backdrop of heavy commercial product advertising promoting increased SSB consumption.

Nutritional Status of Korean Children and Adolescents with Attention Deficit Hyperactivity Disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) has been associated with an elevated risk for obesity but this seems to be paradoxical to the fact that many youths with ADHD have symptoms of hyperactivity. People diagnosed with ADHD tend to have a high risk of developing undesirable diet habits and consequently have health related problems. However, less attention has been paid to obesity in ADHD while many efforts have been devoted to the prevention of childhood obesity in mentally normal people. Hence the purpose of this study was to explore the nutritional status and life habits of children and adolescents with ADHD (n = 76) based on degree of obesity by utilizing the Korean National Health and Nutrition Examination Survey (KNHANES) data from 2005–2013. As results the levels of blood pressure, total triglycerides and the fat intake relative to total energy intake in overweight ADHD group were higher than those in normal weight group. Interestingly, overweight ADHD subjects consumed significantly less amount of iron compared to normal weight ADHD subjects and the level of serum ferritin was lower in the overweight ADHD group (59.0 ng/mL) than in the normal weight ADHD group (47.9 ng/mL). After adjusting total energy intake, total vegetable consumption was 14.3% lower in overweight group compared to the consumption in normal weight group. These results indicate a plausible relationship of iron status and obesity in ADHD subjects but this relationship may not be specific to ADHD. A future study with case-control design is necessary to investigate the association of obesity, nutrient intake, and cognitive/mental status of ADHD.