A Review of Population-Level Actions Targeting Reductions in Food Portion Sizes to Address Obesity and Related Non-communicable Diseases

Simulation models of sugary drink policies: A scoping review

INTRODUCTION

Simulation modeling methods are an increasingly common tool for projecting the potential health effects of policies to decrease sugar-sweetened beverage (SSB) intake. However, it remains unknown which SSB policies are understudied and how simulation modeling methods could be improved. To inform next steps, we conducted a scoping review to characterize the (1) policies considered and (2) major characteristics of SSB simulation models.

METHODS

We systematically searched 7 electronic databases in 2020, updated in 2021. Two investigators independently screened articles to identify peer-reviewed research using simulation modeling to project the impact of SSB policies on health outcomes. One investigator extracted information about policies considered and key characteristics of models from the full text of included articles. Data were analyzed in 2021-22.

RESULTS

Sixty-one articles were included. Of these, 50 simulated at least one tax policy, most often an ad valorem tax (e.g., 20% tax, n = 25) or volumetric tax (e.g., 1 cent-per-fluid-ounce tax, n = 23). Non-tax policies examined included bans on SSB purchases (n = 5), mandatory reformulation (n = 3), warning labels (n = 2), and portion size policies (n = 2). Policies were typically modeled in populations accounting for age and gender or sex attributes. Most studies focused on weight-related outcomes (n = 54), used cohort, lifetable, or microsimulation modeling methods (n = 34), conducted sensitivity or uncertainty analyses (n = 56), and included supplementary materials (n = 54). Few studies included stakeholders at any point in their process (n = 9) or provided replication code/data (n = 8).

DISCUSSION

Most simulation modeling of SSB policies has focused on tax policies and has been limited in its exploration of heterogenous impacts across population groups. Future research would benefit from refined policy and implementation scenario specifications, thorough assessments of the equity impacts of policies using established methods, and standardized reporting to improve transparency and consistency.

The impact of food packaging on measured food intake: A systematic review of experimental, field and naturalistic studies

Chronic, excess energy intake contributes to overweight and obesity. Solutions are needed to guide consumers towards portion control, especially for high energy density (HED), palatable foods. Food packaging, a key element of the eating environment, offers a potential solution. To investigate whether packaging design influences measured food intake, a systematic search was undertaken in four electronic databases (Ovid Medline; Ovid PsycInfo; Ovid Embase and Web of Science) across the previous decade. This process yielded 1671 discrete papers, of which 23 articles containing 40 relevant studies were retrieved. Most (n = 36) of the manipulated packaging features influenced consumption quantity with the largest effect sizes observed for packaging which guided consumers either by on-pack cues or structural features. For example, images on the front of the pack, packaging size, as well as partitioning and resealability all helped to reduce food intake. However, individual differences and attentional focus mediate packaging effects. Overall, packaging features can help to limit intake of HED foods and increase intake of nutrient-dense foods (e.g., carrots). Future studies on packaging for portion control (downsizing) might benefit from long term, randomised control trials to test effects outside of the laboratory context and applied to everyday consumer usage.

Trends in Sales and Industry Perspectives of Package Sizes of Carbonates and Confectionery Products

Discretionary food package sizes are an important environmental cue that can affect the amount of food consumed. The aim of this study was to determine sales trends and reported food industry perspectives for changing food package sizes of carbonates and confectionery between 2005 and 2019. Changes in package sizes of carbonates and confectionery were investigated in Australia, the USA, Canada, and the UK. Sales data (units per capita and compound annual growth rate between 2005 and 2019) were extracted from the Euromonitor database. Qualitative data (market research reports) on industry perspectives on package size changes were extracted from industry and marketing databases. Carbonate sales data showed increased growth of smaller package sizes (<300 mL) and a decrease in sales of larger package sizes (≥2000 mL) in all four countries. In contrast, confectionery sales data showed no consistent trends across the selected countries. No growth was observed for smaller confectionery package sizes but an increase in growth of larger package sizes (50–99 g, >100 g), including share packages, was observed in Australia. Qualitative data (n = 92 articles) revealed key reasons identified by industry for changes in package size related to consumer health awareness, portion size control, convenience, market growth, and government or industry initiatives. Monitoring of discretionary food package sizes provides additional insights into consumers’ food environment.

Adolescents as Agents of Parental Healthy Lifestyle Behavior Change: COPE Healthy Lifestyles TEEN Program

INTRODUCTION

Obesity is a leading health crisis around the world. An intervention strategy scarcely utilized for behavior change is that of a child as change agent. The purpose of this study was to describe the impact of teens reviewing newsletters from a healthy lifestyle intervention with their parents.

METHOD

Evaluation data from a randomized controlled trial, COPE Healthy Lifestyle TEEN Program, was analyzed. A descriptive study was conducted of parents' and teens' lifestyle behaviors as reported by parents.

RESULTS

One hundred sixty-nine parents completed evaluations. Two thirds of parents reported changing a behavior as a result of the program. Nearly three quarters of parents reported behavior changes in their teens. Over 90% reported they would recommend this or a similar program.

DISCUSSION

The obesity epidemic shows no signs of reversal, and hence multiple approaches to impact healthy lifestyles are urgent. Including children as a change agent is a potential target for interventions addressing obesity.

Comparison between serving sizes of cakes and muffins sold in Australian supermarkets and coffee shop chains

AIM

Cakes and muffins are commonly consumed discretionary foods that have increased significantly in portion size over the past decades. The present study aimed to (i) investigate serving sizes and energy per serving of cakes and muffins sold in supermarkets and coffee chains, (ii) compare to standard discretionary serves and (iii) propose feasible and appropriate serving size recommendations.

METHODS

Serving sizes and energy content of cakes and muffins were collected from four major Australian supermarkets (n = 219) and eight coffee chains (n = 248) between March and April 2017 and classified into eight categories and compared using Mann-Whitney tests. Median energy per serving of cakes and muffins from supermarkets and coffee chains were compared to the Australian Dietary Guidelines standard serve of 600 kJ for discretionary food.

RESULTS

The median serving size of cakes and muffins from supermarkets, 58 g (interquartile range, IQR: 47-83) and their energy content, 915 kJ (IQR: 745-1243) were significantly smaller compared with coffee chain equivalents, 148 g (IQR: 115-171, P < 0.001) and 1805 kJ (IQR: 1436-2004, P < 0.001), respectively. The majority of cakes and muffins exceeded the Australian Dietary Guidelines standard serve (78% from supermarkets and 99% from coffee chains).

CONCLUSIONS

The larger servings of cakes and muffins sold in coffee chains contain nearly double the energy content of smaller servings sold in supermarkets. We recommend reference serving sizes for industry and food retail are set for this category, in combination with consumer education to guide consumers to select appropriate portion sizes.

Shared Concerns and Opportunity for Joint Action in Creating a Food Environment That Supports Health

The food industry is a for-profit industry with high relevance to universal eating disorders prevention. To date, policy which targets the food industry and food environment has been underutilized in efforts to decrease the incidence of eating disorders and associated risk factors. In contrast, food policy has been extensively leveraged with the aim of reducing the incidence of obesity. While philosophical misalignments with these later efforts may have constituted an obstacle to identifying the food environment as a key target for eating disorders prevention, food policy is an area where shared interests can be found. Specifically, a shared goal of obesity and eating disorders prevention efforts is creating a food environment that supports health, while minimizing the influence of the food industry that profits from the sale of highly palatable, processed foods and “diet” foods and from increasing portions of foods served and eaten.

Corporate political activity of major food companies in Thailand: an assessment and policy recommendations

BACKGROUND

The food industry can influence individual and population level food consumption behaviours, shape public preferences and interfere with government policy on obesity prevention and NCDs. This paper identifies the Corporate Political Activity (CPA) of major food companies in Thailand which relate to obesity and NCDs.

METHODS

Using the INFORMAS framework to classify CPA, we reviewed publicly available information by 12 food companies between August 2011 and July 2016 in order to identify, analyse and classify the CPA contents. Semi-structured interviews with 17 key stakeholders who are experts in this field supplemented evidence from the document review. Data analysis applied a thematic approach.

RESULTS

Food industry in Thailand applied a variety of CPA strategies and practices. The two most common strategies were constituency building and information and messaging.

CONCLUSION

The diverse range of CPA strategies which influence government policy and public opinion can undermine efforts to prevent obesity and diet-related NCDs. We recommend systematic monitoring of their CPA, strengthening mechanisms to hold the food industry accountable for their role in protecting and promoting the nutrition and health of the population, introducing mandatory registration of lobbyists, mandatory disclosure of political donations, and stronger oversight of conflicts of interest among the government actors.

Research for leveraging food policy in universal eating disorder prevention

Policy and legislation have emerged as important levers for universal prevention efforts in the context of eating disorders. However, to date, little attention has been paid to generating research that will inform opportunities to regulate the food environment, specifically the way that food is produced and marketed. The present paper aims to lay out a framework for research that will examine (1) the ways in which food industry may influence risk for eating disorders and (2) the impact of legislative efforts on eating disorder cognitions and behaviors. For these two pathways, specific examples of research that would serve to inform policy efforts aiming to decrease the risk for eating disorders by targeting the food environment are proposed. Overall, the present paper aims to issue a call for the eating disorder field to become involved in food policy and regulation.

Healthiness of Food and Beverages for Sale at Two Public Hospitals in New South Wales, Australia

(1) Background: Our aim was to conduct objective, baseline food environment audits of two major western Sydney public hospitals and compare them to recently revised state nutritional guidelines. (2) Methods: A cross-sectional assessment was conducted (June-July2017) across 14 fixed food outlets and 70 vending machines in two hospitals using an audit tool designed to assess the guideline's key food environment parameters of availability, placement, and promotion of 'Everyday' (healthy) and 'Occasional' (less healthy) products. (3) Results: Availability: Overall, Everyday products made up 51% and 44% of all products available at the two hospitals. Only 1/14(7%) fixed outlets and 16/70(23%) vending machines met the guideline's availability benchmarks of ≥75% Everyday food and beverages. Proportion of Everyday products differed among different types of food outlets (café, cafeteria, convenience stores). Placement: On average, food outlets did not meet recommendations of limiting Occasional products in prominent positions, with checkout areas and countertops displaying over 60% Occasional items. Promotion: Over two-thirds of meal deals at both hospitals included Occasional products. (4) Conclusion: Baseline audit results show that substantial improvements in availability, placement, and promotion can be made at these public hospitals to meet the nutrition guidelines. Audits of other NSW hospitals using the developed tool are needed to investigate similarities and differences in food environment between sites. These findings highlight the need for ongoing tracking to inform whether the revised guidelines are leading to improved food environments in health facilities.

Modelled Cost-Effectiveness of a Package Size Cap and a Kilojoule Reduction Intervention to Reduce Energy Intake from Sugar-Sweetened Beverages in Australia

Interventions targeting portion size and energy density of food and beverage products have been identified as a promising approach for obesity prevention. This study modelled the potential cost-effectiveness of: a package size cap on single-serve sugar sweetened beverages (SSBs) >375 mL (package size cap), and product reformulation to reduce energy content of packaged SSBs (energy reduction). The cost-effectiveness of each intervention was modelled for the 2010 Australia population using a multi-state life table Markov model with a lifetime time horizon. Long-term health outcomes were modelled from calculated changes in body mass index to their impact on Health-Adjusted Life Years (HALYs). Intervention costs were estimated from a limited societal perspective. Cost and health outcomes were discounted at 3%. Total intervention costs estimated in AUD 2010 were AUD 210 million. Both interventions resulted in reduced mean body weight (package size cap: 0.12 kg; energy reduction: 0.23 kg); and HALYs gained (package size cap: 73,883; energy reduction: 144,621). Cost offsets were estimated at AUD 750.8 million (package size cap) and AUD 1.4 billion (energy reduction). Cost-effectiveness analyses showed that both interventions were “dominant”, and likely to result in long term cost savings and health benefits. A package size cap and kJ reduction of SSBs are likely to offer excellent “value for money” as obesity prevention measures in Australia.

Changes in Typical Portion Sizes of Commonly Consumed Discretionary Foods among Australian Adults from 1995 to 2011-2012

This study aimed to examine the changes in typical portion sizes of commonly consumed discretionary foods among Australian adults from 1995 to 2011–2012. Data of adults (age ≥19 years) from the 1995 Australian National Nutrition Survey and 2011–2012 National Nutrition and Physical Activity Survey were used. Typical portion sizes (median portion) of fourteen discretionary foods that contributed the most to energy intake were determined. Ten out of fourteen food categories demonstrated a significant change in kJ per typical portion from 1995 to 2011–2012 (p ≤ 0.001). kJ per typical portion increased for pizza, cake, sausage, cereal bar, processed meat, ice cream and wine, with pizza and cake demonstrating the largest increases (+570 kJ and +950 kJ in 2011–2012, respectively; both +66% above 1995). In contrast, kJ per typical portion of pastry, snack food and potato fries decreased by 10–40% over time, and did not change for biscuit, chocolate, sugar-sweetened beverage and beer. Similar changes were observed for grams per typical portion consumed. Temporal trends in typical portion sizes were similar according to age group, gender and socioeconomic status. The findings suggest that population-wide strategies that enable consumers to choose smaller portions of discretionary foods are needed to reduce the excess consumption of these products.