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

"Food faddists and pseudoscientists!": Reflections on the history of resistance to ultra-processed foods

The term 'ultra-processed food' emerged in the 1980s, mostly used in reference to highly-processed convenience foods and snacks, often energy-dense, poor in nutrients, and inclusive of various synthetic additives such as emulsifiers, colors, artificial sweeteners, and/or flavor enhancers. Concern over such foods was part of the growing holistic and environmental health movements of the 1970-80s; yet, those who raised alarm about the encroachment of ultra-processed foods were often labeled, especially by industry and their powerful allies, as 'food faddists' and 'pseudoscientists'. Today, the topic of ultra-processed foods is generating massive personal, public, and planetary health interest. However, other than discussing the history of the NOVA food classification system, a useful tool that has allowed researchers to more accurately separate foods based on processing, most lay media and academic articles are ahistorical. That is, there is a tendency to present the term ultra-processed food(s) as a relatively new entrance into the lexicon, and by default, the idea that health-related pushback on ultra-processed foods is a relatively new phenomenon. This omission overlooks decades of determined advocacy and clinical work, much of it by pioneers within the holistic medicine (now integrative, functional, and lifestyle medicine) movement. Here in this reflection paper, the authors will use historical research and reporting to fill in the historical gap and articulate the saliency of why it matters.

Capitalism and the 'commercial determinants of health': A more-than-human micropolitics

This paper argues that studies of the 'commercial determinants of health' (CDoH) need to acknowledge fully the part the capitalist mode of commodity production and exchange plays in producing negative health outcomes. This proposition is supported by recourse to a recent development in political economy that has established a more-than-human, relational and monist (or 'flat') ontology of capitalism, in place of the more conventional neo-Marxist perspective. This ontology reveals a dynamic to capitalism that operates beyond human intentionality, driven by the supply of, and demand for the capacities of commodities. This dynamic determines the production and consumption of all commodities, some among which (such as tobacco, alcohol and processed foods) contribute to ill-health. A case study of food consumption reveals how these supply and demand affects drive 'unhealthy' food choices by consumers. Ways to undermine this more-than-human dynamic are offered as an innovative approach to addressing the effects of commerce and capitalism upon health.

A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance

The UK Medical Research Council's widely used guidance for developing and evaluating complex interventions has been replaced by a new framework, commissioned jointly by the Medical Research Council and the National Institute for Health Research, which takes account of recent developments in theory and methods and the need to maximise the efficiency, use, and impact of research.

Ultra-processed food consumption and increased risk of metabolic syndrome in Korean adults: A cross-sectional analysis of the KNHANES 2016-2020

OBJECTIVE

This study aimed to investigate the association between ultra-processed food (UPF) intake and the risk for metabolic syndrome (MetS) in Korean adults.

METHODS

The study consisted of 22 688 Korean adults ≥19 y of age from the Korea National Health and Nutrition Examination Survey (KNHANES) 2016-2020. The NOVA classification categorizes foods according to the nature, extent, and purpose of industrial processing. MetS was defined based on the National Cholesterol Education Program Adult Treatment Panel III criteria and a modified waist circumference cut-off for Korean adults. We estimated the usual percent total food intake from UPFs. We used multivariate logistic regression to assess the association between UPFs and risk for MetS, adjusted for age, sex, education level, income level, smoking status, alcohol drinking, physical activity, and total energy intake. We further analyzed the association of UPFs with each component of MetS.

RESULTS

The median usual percent total food intake from UPFs was 22%, and the midpoint of intake ranged from 3% (quartile 1) to 48% (quartile 4). The group with the highest UPF consumption had a 19% higher risk for developing MetS than the lowest quartile of UPF consumption (odds ratio [OR],1.19; 95% confidence interval [CI], 1.06-1.33; Ptrend = 0.006). In analysis of the relationship between UPF intake and MetS components, a higher UPF was associated with an increased risk for hypertension (OR, 1.13; 95% CI, 1.01-1.26; Ptrend = 0.037) and abdominal obesity (OR, 1.19; 95% CI, 1.07-1.33; Ptrend = 0.001), but had no significant association with other components (hyperglycemia, hypertriacylglycerolmia, and low high-density lipoprotein cholesterol, all P > 0.05).

CONCLUSION

Higher UPF contribution to total daily food intake is associated with an increased risk for MetS, particularly with a higher risk for hypertension and abdominal obesity.

Ultra-processed food consumption and cardiovascular events rate: An analysis from Isfahan Cohort Study (ICS)

BACKGROUND AND AIMS

The contribution of ultra-processed foods (UPFs) to daily energy intake and, therefore, their health effects may vary between countries. We aimed to investigate the association between UPFs and the incidence risk of cardiovascular events (CVEs) and cardiovascular mortality in the Isfahan cohort study.

METHODS AND RESULTS

In 2001, 6504 participants aged ≥35 years were enrolled and followed until 2017. Dietary intake was assessed using a validated food frequency questionnaire, and the NOVA system was applied for UPF classification. Any new case of CVE, including fatal and non-fatal myocardial infarction (MI) or stroke, unstable angina (UA), and CVD death, was recorded. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated through Cox proportional hazards regression models. A total number of 819 CVE, 164 MI, 348 UA, 172 strokes, and 181 cardiovascular deaths were recorded during 61352.5 person-years of follow-up. The median (IQR) of UPF consumption was 2.47 (1.00-5.23) times/week. In the fully adjusted model, individuals in the fourth quartile of UPFs had no higher risk for incident MI and UA (HR = 1.12, 95% CI: 0.87, 1.46; P for trend = 0.364), stroke (HR = 0.93, 95% CI: 0.58, 1.46; P for trend = 0.601), cardiovascular mortality (HR = 0.95, 95% CI: 0.61, 1.47; P for trend = 0.596), and CVE (HR = 1.08, 95% CI: 0.88,1.34; P for trend = 0.515) in comparison with those in the first quartile.

CONCLUSION

This mid-term prospective cohort study provides no evidence for a significant association between UPF and CVE risk. Longer studies are required to confirm this association.

Ultra-processed foods and human health: An umbrella review and updated meta-analyses of observational evidence

BACKGROUND & AIMS

Ultra-processed food (UPF) intake has increased sharply over the last few decades and has been consistently asserted to be implicated in the development of non-communicable diseases. We aimed to evaluate and update the existing observational evidence for associations between ultra-processed food (UPF) consumption and human health.

METHODS

We searched Medline and Embase from inception to March 2023 to identify and update meta-analyses of observational studies examining the associations between UPF consumption, as defined by the NOVA classification, and a wide spectrum of health outcomes. For each health outcome, we estimated the summary effect size, 95% confidence interval (CI), between-study heterogeneity, evidence of small-study effects, and evidence of excess-significance bias. These metrics were used to evaluate evidence credibility of the identified associations.

RESULTS

This umbrella review identified 39 meta-analyses on the associations between UPF consumption and health outcomes. We updated all meta-analyses by including 122 individual articles on 49 unique health outcomes. The majority of the included studies divided UPF consumption into quartiles, with the lowest quartile being the reference group. We identified 25 health outcomes associated with UPF consumption. For observational studies, 2 health outcomes, including renal function decline (OR: 1.25; 95% CI: 1.18, 1.33) and wheezing in children and adolescents (OR: 1.42; 95% CI: 1.34, 1.49), showed convincing evidence (Class I); and five outcomes were reported with highly suggestive evidence (Class II), including diabetes mellitus, overweight, obesity, depression, and common mental disorders.

CONCLUSIONS

High UPF consumption is associated with an increased risk of a variety of chronic diseases and mental health disorders. At present, not a single study reported an association between UPF intake and a beneficial health outcome. These findings suggest that dietary patterns with low consumption of UPFs may render broad public health benefits.

Eating away cancer: the potential of diet and the microbiome for shaping immunotherapy outcome

The gut microbiome (GMB) plays a substantial role in human health and disease. From affecting gut barrier integrity to promoting immune cell differentiation, the GMB is capable of shaping host immunity and thus oncogenesis and anti-cancer therapeutic response, particularly with immunotherapy. Dietary patterns and components are key determinants of GMB composition, supporting the investigation of the diet-microbiome-immunity axis as a potential avenue to enhance immunotherapy response in cancer patients. As such, this review will discuss the role of the GMB and diet on anti-cancer immunity. We demonstrate that diet affects anti-cancer immunity through both GMB-independent and GMB-mediated mechanisms, and that different diet patterns mold the GMB's functional and taxonomic composition in distinctive ways. Dietary modulation therefore shows promise as an intervention for improving cancer outcome; however, further and more extensive research in human cancer populations is needed.

The rise and fall of the Queensland Government policy to restrict unhealthy food and alcohol advertising on publicly owned assets

OBJECTIVE

To examine the strategies employed by opponents of the Queensland Government's policy to restrict unhealthy food and alcohol advertising on publicly owned assets and identify which of the opposing arguments appeared to influence the policy outcomes.

METHODS

Retrospective qualitative policy analysis case study informed by the Policy Dystopia Model of corporate political activity. We used qualitative content analysis to examine data from stakeholder submissions to the 'Advertising content on Queensland Government advertising spaces' policies (v1 and 2), and Minister for Health's diaries.

RESULTS

Stakeholders from the food, beverage, alcohol and advertising industries and several not-for-profit health organisations opposed the policy. Industry actors used discursive strategies, coalition management (including co-option of not-for-profit health organisations), information management and direct involvement with policy makers to communicate their arguments against the policy. The second version of the policy was weaker regarding scope and key policy provisions, reflecting the arguments of industry actors.

CONCLUSIONS

Influence from industries with a clear conflict of interest should be minimised throughout policy development to ensure public health is prioritised over corporate gain.

IMPLICATIONS FOR PUBLIC HEALTH

Our findings can support other jurisdictions to prepare for industry opposition when designing policies to restrict unhealthy food and alcohol marketing.

The relationship between the price and demand of alcohol, tobacco, unhealthy food, sugar-sweetened beverages, and gambling: an umbrella review of systematic reviews

BACKGROUND

The WHO highlight alcohol, tobacco, unhealthy food, and sugar-sweetened beverage (SSB) taxes as one of the most effective policies for preventing and reducing the burden of non-communicable diseases. This umbrella review aimed to identify and summarise evidence from systematic reviews that report the relationship between price and demand or price and disease/death for alcohol, tobacco, unhealthy food, and SSBs. Given the recent recognition as gambling as a public health problem, we also included gambling.

METHODS

The protocol for this umbrella review was pre-registered (PROSPERO CRD42023447429). Seven electronic databases were searched between 2000-2023. Eligible systematic reviews were those published in any country, including adults or children, and which quantitatively examined the relationship between alcohol, tobacco, gambling, unhealthy food, or SSB price/tax and demand (sales/consumption) or disease/death. Two researchers undertook screening, eligibility, data extraction, and risk of bias assessment using the ROBIS tool.

RESULTS

We identified 50 reviews from 5,185 records, of which 31 reported on unhealthy food or SSBs, nine reported on tobacco, nine on alcohol, and one on multiple outcomes (alcohol, tobacco, unhealthy food, and SSBs). We did not identify any reviews on gambling. Higher prices were consistently associated with lower demand, notwithstanding variation in the size of effect across commodities or populations. Reductions in demand were large enough to be considered meaningful for policy.

CONCLUSIONS

Increases in the price of alcohol, tobacco, unhealthy food, and SSBs are consistently associated with decreases in demand. Moreover, increasing taxes can be expected to increase tax revenue. There may be potential in joining up approaches to taxation across the harm-causing commodities.

Alcohol industry-sponsored music festivals, alcohol marketing and drinking practices among young Nigerians: Implications for policy

INTRODUCTION

The global alcohol industry sponsors social/music events targeting young people; however, existing literature focuses on Westernised contexts. Given the decline in young people's drinking in many Western countries, it appears that multinational alcohol companies are importing the strategies they have used in high-income countries to the Global South countries like Nigeria to recoup profits. This study aims to examine the Guinness Show- a free one-month annual music festival, alcohol marketing at the festival and the extent to which the event encourages diverse drinking practices among its attendees.

METHODS

We observed the music festival before collecting data through 53 interviews and 3 focus groups (N = 26). Data were analysed to generate themes with the aid of NVivo 12 software.

FINDINGS

Over 6000 participants attend the Guinness Show daily, and participants gave detailed descriptions of the music festival, alcohol marketing activities that occur in it and the drinking practices of attendees, indicating that they were highly knowledgeable of the event. The Guinness Show attracts famous music artistes and other entertainers. Therefore, young people attend to see them perform free of charge. However, diverse alcohol promotions (e.g., quantity deals, low prices, giveaways) that happen daily, the strategic use of young women as 'beer promoters', and the pleasure the event induces by fusing music/entertainment into alcogenic environments, encourage drinking and drunkenness. All the attendees drank alcohol, and some engaged in impulse buying, while many consumed excessively due to promotions (e.g., buy-two-get-one free), which facilitated intoxication and the loss of control.

CONCLUSIONS

Guinness Nigeria organises the event for strategic brand communication, generating brand capital, and encouraging alcohol purchases and consumption among young people. Policymakers should reconsider self-regulation and implement national alcohol control policies and other public health interventions to restrain the alcohol industry from sponsoring such events.

Ultraprocessed Food Consumption and Cardiometabolic Risk Factors in Children

Importance

High intake of ultraprocessed foods (UPFs) has been associated with higher cardiometabolic risk in adults; however, the evidence in children is limited.

Objective

To investigate the association between UPF consumption and cardiometabolic risk factors in the Childhood Obesity Risk Assessment Longitudinal Study (CORALS).

Design, Setting, and Participants

This baseline cross-sectional analysis was conducted using the data of CORALS participants recruited between March 22, 2019, and June 30, 2022. Preschool children (aged 3-6 years) were recruited from schools and centers in 7 cities in Spain. Inclusion criteria included informed consent signed by parents or caregivers and having a completed a set of questionnaires about the child's prenatal history at home. Exclusion criteria included low command of Spanish or unstable residence.

Exposure

Energy-adjusted UPF consumption (in grams per day) from food frequency questionnaires and based on the NOVA food classification system.

Main Outcomes and Measures

Age- and sex-specific z scores of adiposity parameters (body mass index [BMI], fat mass index, waist-to-height ratio, and waist circumference) and cardiometabolic parameters (diastolic and systolic blood pressure, fasting plasma glucose, homeostasis model assessment for insulin resistance, high-density and low-density lipoprotein cholesterol, and triglycerides) were estimated using linear regression models.

Results

Of 1509 enrolled CORALS participants, 1426 (mean [SD] age, 5.8 [1.1] years; 698 boys [49.0%]) were included in this study. Mothers of children with high UPF consumption were younger, had a higher BMI, were more likely to have overweight or obesity, and had lower education levels and employment rates. Compared with participants in the lowest tertile of energy-adjusted UPF consumption, those in the highest tertile showed higher z scores of BMI (β coefficient, 0.20; 95% CI, 0.05-0.35), waist circumference (β coefficient, 0.20; 95% CI, 0.05-0.35), fat mass index (β coefficient, 0.17; 95% CI, 0.00-0.32), and fasting plasma glucose (β coefficient, 0.22; 95% CI, 0.06-0.37) and lower z scores for HDL cholesterol (β coefficient, -0.19; 95% CI, -0.36 to -0.02). One-SD increments in energy-adjusted UPF consumption were associated with higher z scores for BMI (β coefficient, 0.11; 95% CI, 0.05-0.17), waist circumference (β coefficient, 0.09; 95% CI, 0.02-0.15), fat mass index (β coefficient, 0.11; 95% CI, 0.04-1.18), and fasting plasma glucose (β coefficient, 0.10; 95% CI, 0.03-0.17) and lower HDL cholesterol (β coefficient, -0.07; 95% CI, -0.15 to -0.00). Substituting 100 g of UPFs with 100 g of unprocessed or minimally processed foods was associated with lower z scores of BMI (β coefficient, -0.03; 95% CI, -0.06 to -0.01), fat mass index (β coefficient, -0.03; 95% CI, -0.06 to 0.00), and fasting plasma glucose (β coefficient, -0.04; 95% CI, -0.07 to -0.01).

Conclusions and Relevance

These findings suggest that high UPF consumption in young children is associated with adiposity and other cardiometabolic risk factors, highlighting the need for public health initiatives to promote the replacement of UPFs with unprocessed or minimally processed foods.

Challenges and way forward for implementation of sugar taxation in the Middle East and North Africa (MENA)

BACKGROUND

Over consumption of added sugar beyond the World Health Organization (WHO) recommended level of 10% of daily energy intake has well-established negative health consequences including oral diseases. However, the average consumption of added sugar in the Middle East and North Africa region (MENA-World Bank's regional classification) is 70% higher than the WHO recommended level. Imposing taxes on added sugar has been proposed by the WHO to decrease its consumption. Yet, only 21.6% of the total MENA population are covered by taxation policies targeting added sugar.

CHALLENGES

Well-recognized challenges for the implementation of sugar taxation in MENA include the tactics used by the food and beverage industry to block these type of policies. However, there are also other unfamiliar hurdles specific to MENA. Historically, there have been incidents of protest and riots partially sparked by increased price of basic commodities, including sugar, in MENA countries. This may affect the readiness of policy makers in the region to impose added sugar taxes. In addition, there are also cultural, lifestyle and consumption behavioural barriers to implementing added sugar taxation. Ultra-processed foods and sugar-sweetened-beverages (SSBs) rich in added sugar are perceived by many in MENA as essential treats regardless of their health risks. Furthermore, some countries even provide subsidies for added sugar. Also, (oral) healthcare providers generally do not engage in policy advocacy mainly due to limited training on health policy.

WAYS FORWARD

Here, we discuss these challenges and suggest some ways forward such as (1) support from a health-oriented political leadership, (2) raising public awareness about the health risks of over consumption of sugar, (3) transparency during the policy-cycle development process, (4) providing a free and safe environment for a community dialogue around the proposed policy, (5) training of (oral) healthcare professionals on science communication and policy advocacy in local lay language/dialect, ideally evidence informed from local/regional studies, (6) selecting the appropriate political window of opportunity to introduce a sugar tax policy, and (7) clear and strict conflict of interest regulations to limit the influence of commercial players on health policy.

The Challenges of Tobacco Fiscal Policy Implementation in Mexico From the Perspective of Key Actors

INTRODUCTION

Raising tobacco taxes is considered the most effective strategy to avoid smoking initiation and discourage its use, especially among vulnerable groups. However, few low- and middle-income countries have adopted high tobacco taxes. Raising taxes is, therefore, an opportunity to strengthen and accelerate tobacco control. The objective of this study is to analyze the barriers and facilitators to the tobacco tax increase in Mexico.

AIMS AND METHODS

Based on the Governance Analytical Framework, data were generated through 17 in-depth interviews with key intersectoral actors for fiscal policy. The interviews were transcribed and coded according to Hufty's theory of governance.

RESULTS

Robust scientific evidence, intersectoral coordination, and the presence of "champions" boosted progress in tobacco control (facilitators). The main barriers were the incomplete implementation of the World Health Organization-Framework Convention on Tobacco Control (WHO-FCTC) and MPOWER package and lack of commitment ("political will") by government decision makers and legislators, misinformation about the effects of tobacco taxes, and strong tobacco industry interference.

CONCLUSIONS

Robust evidence is necessary but not sufficient to advance the implementation of the MPOWER (WHO-FCTC) actions. To achieve tobacco tax increases and public policies that protect people from unhealthy products in general, the implementation of policies or legal frameworks against industry interference in the development of public policies is imperative.

IMPLICATIONS

By analyzing the barriers and facilitators to increasing the tobacco tax in Mexico, this study identifies two key messages: (1) The need to sensitize legislators and the general population to the problem of smoking not only through epidemiological data but also through testimonies that highlight the life experiences and adversities faced by people who smoke. (2) The need for a regulatory framework to prevent industry interference in public affairs and conflicts of interest. The same framework could be very useful for public health policies to control the consumption of ultra-processed food products or alcohol.

Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults

BACKGROUND

Underweight and obesity are associated with adverse health outcomes throughout the life course. We estimated the individual and combined prevalence of underweight or thinness and obesity, and their changes, from 1990 to 2022 for adults and school-aged children and adolescents in 200 countries and territories.

METHODS

We used data from 3663 population-based studies with 222 million participants that measured height and weight in representative samples of the general population. We used a Bayesian hierarchical model to estimate trends in the prevalence of different BMI categories, separately for adults (age ≥20 years) and school-aged children and adolescents (age 5-19 years), from 1990 to 2022 for 200 countries and territories. For adults, we report the individual and combined prevalence of underweight (BMI <18·5 kg/m2) and obesity (BMI ≥30 kg/m2). For school-aged children and adolescents, we report thinness (BMI <2 SD below the median of the WHO growth reference) and obesity (BMI >2 SD above the median).

FINDINGS

From 1990 to 2022, the combined prevalence of underweight and obesity in adults decreased in 11 countries (6%) for women and 17 (9%) for men with a posterior probability of at least 0·80 that the observed changes were true decreases. The combined prevalence increased in 162 countries (81%) for women and 140 countries (70%) for men with a posterior probability of at least 0·80. In 2022, the combined prevalence of underweight and obesity was highest in island nations in the Caribbean and Polynesia and Micronesia, and countries in the Middle East and north Africa. Obesity prevalence was higher than underweight with posterior probability of at least 0·80 in 177 countries (89%) for women and 145 (73%) for men in 2022, whereas the converse was true in 16 countries (8%) for women, and 39 (20%) for men. From 1990 to 2022, the combined prevalence of thinness and obesity decreased among girls in five countries (3%) and among boys in 15 countries (8%) with a posterior probability of at least 0·80, and increased among girls in 140 countries (70%) and boys in 137 countries (69%) with a posterior probability of at least 0·80. The countries with highest combined prevalence of thinness and obesity in school-aged children and adolescents in 2022 were in Polynesia and Micronesia and the Caribbean for both sexes, and Chile and Qatar for boys. Combined prevalence was also high in some countries in south Asia, such as India and Pakistan, where thinness remained prevalent despite having declined. In 2022, obesity in school-aged children and adolescents was more prevalent than thinness with a posterior probability of at least 0·80 among girls in 133 countries (67%) and boys in 125 countries (63%), whereas the converse was true in 35 countries (18%) and 42 countries (21%), respectively. In almost all countries for both adults and school-aged children and adolescents, the increases in double burden were driven by increases in obesity, and decreases in double burden by declining underweight or thinness.

INTERPRETATION

The combined burden of underweight and obesity has increased in most countries, driven by an increase in obesity, while underweight and thinness remain prevalent in south Asia and parts of Africa. A healthy nutrition transition that enhances access to nutritious foods is needed to address the remaining burden of underweight while curbing and reversing the increase in obesity.

FUNDING

UK Medical Research Council, UK Research and Innovation (Research England), UK Research and Innovation (Innovate UK), and European Union.

Exploring the association between ultra-processed foods and COPD: a case-control study

BACKGROUND

While it is known that the overconsumption of ultra-processed foods (UPFs) is associated with a heightened risk of respiratory ailments, the specific effects of UPF intake on COPD remain unclear. This study was designed to explore the potential link between COPD and the consumption of UPFs among adult individuals in Iran.

METHODS

In this hospital-based case-control study conducted at Alzahra University Hospital in Isfahan, Iran, we enrolled 84 patients newly diagnosed with COPD, along with 252 healthy controls matched for age and sex. COPD was defined based on the results of spirometry tests, specifically when the forced expiratory volume per second (FEV1) was less than 80% or the ratio of FEV1 to forced vital capacity (FVC) was less than 70%. To evaluate the dietary intake of the participants, we utilized a validated food frequency questionnaire (FFQ) consisting of 168 items. Additionally, we gathered data on potential confounding factors using a pre-tested questionnaire.

RESULTS

The mean ages for the case and control groups were 57.07 and 55.05 years, respectively. Our study found no significant association between the intake of ultra-processed foods (UPFs) and the likelihood of COPD, with an odds ratio (OR: 0.78, 95% CI: 0.34-1.77). This lack of association persisted even after adjusting for factors such as energy intake, sex, and age (OR: 0.48; 95% CI: 0.19-1.21). Further controlling for potential confounders like body mass index (BMI), physical activity, and smoking status did not alter this finding (OR: 0.367; 95% CI: 0.123-1.1008, P = 0.074).

CONCLUSIONS

In our study, we observed no significant association between the intake of Ultra-Processed Foods (UPFs) and the odds of Chronic Obstructive Pulmonary Disease (COPD). This finding remained consistent even after adjusting for factors such as energy intake, sex, age, Body Mass Index (BMI), physical activity, and smoking status. Therefore, within the scope of our study, it appears that the consumption of UPFs does not significantly impact the likelihood of developing COPD. However, we recommend further research to deepen our understanding of the intricate relationship between dietary habits and respiratory health.

Legal and regulatory instruments for NCD prevention: a scoping review and descriptive analysis of evaluations in OECD countries

CONTEXT

Public health law is an important tool in non-communicable disease (NCD) prevention. There are different approaches available for achieving policy objectives, including government, co-, quasi- and self-regulation. However, it is often unclear what legal design features drive successes or failures in particular contexts. This scoping review undertakes a descriptive analysis, exploring the design characteristics of legal instruments that have been used for NCD prevention and implemented and evaluated in OECD countries.

METHODS

A scoping review was conducted across four health and legal databases (Scopus, EMBASE, MEDLINE, HeinOnline), identifying study characteristics, legal characteristics and regulatory approaches, and reported outcomes. Included studies focused on regulation of tobacco, alcohol, unhealthy foods and beverages, and environmental pollutants.

FINDINGS

We identified 111 relevant studies evaluating 126 legal instruments. Evaluation measures most commonly assessed implementation, compliance and changes to the built and lived environment. Few studies evaluated health or economic outcomes. When examining the design and governance mechanisms of the included legal instruments, government regulation was most commonly evaluated (n = 90) and most likely to be reported effective (64%). Self-regulation (n = 27) and quasi-regulation (n = 5) were almost always reported to be ineffective (93% and 100% respectively). There were few co-regulated instruments evaluated (n = 4) with mixed effectiveness. When examining public health risks, food and beverages including alcohol were more likely to be self- or quasi-regulated and reported as ineffective more often. In comparison, tobacco and environmental pollutants were more likely to have government mandated regulation. Many evaluations lacked critical information on regulatory design. Monitoring and enforcement of regulations was inconsistently reported, making it difficult to draw linkages to outcomes and reported effectiveness.

CONCLUSIONS

Food and alcohol regulation has tended to be less successful in part due to the strong reliance on self- and quasi-regulation. More work should be done in understanding how government regulation can be extended to these areas. Public health law evaluations are important for supporting government decision-making but must provide more detail of the design and implementation features of the instruments being evaluated - critical information for policy-makers.

Corporate interest groups and their implications for global food governance: mapping and analysing the global corporate influence network of the transnational ultra-processed food industry

BACKGROUND

A major challenge to transforming food systems to promote human health and sustainable development is the global rise in the manufacture and consumption of ultra-processed foods (UPFs). A key driver of this dietary transition is the globalization of UPF corporations, and their organized corporate political activity (CPA) intended to counter opposition and block government regulation. UPF industry CPA and the corporate interest groups who lobby on their behalf have been well described at the national level, however, at the global level, this network has not been systematically characterized. This study aims to map, analyse, and describe this network, and discuss the implications for global food policy action on UPFs, global food governance (GFG), and food systems transformation.

METHODS

We conducted a network analysis of the declared interest group memberships of the world's leading UPF corporations, extracted from web sources, company reports, and relevant academic and grey literature. Data on the characteristics of these interest groups were further extracted for analysis, including year founded, level, type, and headquarter location.

RESULTS

We identified 268 interest groups affiliated with the UPF industry. The UPF manufacturers Nestlé (n = 171), The Coca-Cola Company (n = 147), Unilever (n = 142), PepsiCo (n = 138), and Danone (n = 113) had the greatest number of memberships, indicating strong centrality in coordinating the network. We found that this network operates at all levels, yet key actors now predominantly coordinate globally through multistakeholder channels in GFG. The most common interest group types were sustainability/corporate social responsibility/multistakeholder initiatives, followed by branding and advertising, and food manufacturing and retail. Most corporate interest groups are headquartered where they can access powerful government and GFG decision-makers, nearly one-third in Washington DC and Brussels, and the rest in capital cities of major national markets for UPFs.

CONCLUSIONS

The UPF industry, and especially its leading corporations, coordinate a global network of interest groups spanning multiple levels, jurisdictions, and governance spaces. This represents a major structural feature of global food and health governance systems, which arguably poses major challenges for actions to attenuate the harms of UPFs, and to realising of healthy and sustainable food systems.

Addressing the global obesity burden: a gender-responsive approach to changing food environments is needed

Obesity is a leading cause of death and disability globally. There is a higher proportion of women living with obesity than men, with differences in prevalence rates between women and men particularly staggering in low- and middle-income countries. The food environments that most people live in have been defined as 'obesogenic', characterised by easy access to energy dense, highly palatable foods with poor nutritional value. There is an established need to intervene to change food environments to prevent obesity. However, minimal successes are evident with no country set to meet the WHO goal of reducing obesity prevalence to 2010 numbers by 2025. In this review, we provide a narrative around the sex (biological)- and gender (sociocultural)-related considerations for the relationship between nutrition, interactions with the food environment and obesity risk. We provide an argument that there are gendered responses to food environments that place women at a higher risk of obesity particularly in relation to food industry influences, due to gendered roles and responsibilities in relation to paid and unpaid labour, and due to specific food security threats. This review concludes with hypotheses for addressing the obesity burden in a gender-responsive manner, with a call for gender equity to be a key component of the development, implementation and monitoring of obesity prevention focused policies going forward.

Trends and disparities in non-communicable diseases in the Western Pacific region

The WHO Western Pacific region bears disproportionate deaths from non-communicable diseases (NCDs), with increased overall NCD proportional mortality over the past two decades. The disease burden of mental health increased, resulting from rapid ageing, enhanced stress, and the COVID-19 pandemic, but it was largely neglected. The highly diverse cultures, religions, political systems, socioeconomic contexts, lifestyles, and environmental factors probably have led to massive disparities across countries in NCD mortality, risk factors, and NCD management. Geographically, East Asia had the lowest NCD mortality whilst Pacific islands had the highest. Economic booms, ageing, nutrition transition, social stress, prevalent tobacco use, and fast-increasing obesity and hyperglycaemia are important drivers of NCDs. Men tended to have more adverse behavioural and metabolic risk factors. Rural residents are catching up with their urban counterparts in metabolic risk factors and conditions. Sustainable strategies tailored to NCD patterns are needed to fight the NCD epidemic and related disparities.

Policy Actors' Perceptions of Conflicts of Interest and Alcohol Industry Engagement in UK Policy Processes

BACKGROUND

Alcohol industry organisations occupy a prominent position in UK alcohol policy, but their involvement has been contested by public health bodies on the basis that a conflict of interest (COI) exists between their economic objectives and those of public health. There are ongoing debates in the research literature about how to conceptualise COI and mitigate this in health research and practise. However, less attention has been paid to these issues in relation to the alcohol industry specifically. This article explores similarities and differences in beliefs among alcohol policy actors regarding COI and the implications of engagement with the alcohol industry in the context of UK public health policy.

METHODS

Semi-structured interviews with a range of policy actors (n=26) including medical professionals, parliamentarians, civil servants, academic researchers, health campaigners, and alcohol industry representatives. Interviews with alcohol industry representatives were supplemented with an analysis of industry responses to a public consultation. All data was thematically coded using NVivo software.

RESULTS

Two competing "coalitions" were identified, expressing beliefs about COI linked to alcohol industry engagement. Both divergent and convergent beliefs were expressed by the two coalitions in relation to the type of industry actor, form of engagement, the policy issue under discussion and the stage of policy process.

CONCLUSION

Alcohol policy is a complex and contested space in which policy actors have differing, nuanced and contingent understandings of COI and identify varying risks associated with alcohol industry engagement. In identifying the areas of convergence and diversion in both understanding and evaluation of COI in alcohol-specific settings, these findings will assist both decision-makers and non-governmental actors in developing policies and guidelines to manage potential COI in future.

Dietary intake of low-income adults in South Africa: ultra-processed food consumption a cause for concern

OBJECTIVE

Given the rapidly changing food environment and proliferation of ultra-processed foods (UPF) in South Africa (SA), this study aimed to critically evaluate dietary quality and adequacy of low-income adults using the Nova classification system and WHO and World Cancer Research Fund dietary guidelines.

DESIGN

Secondary household data and 1-d 24-h recalls were analysed from two cross-sectional studies conducted in 2017-2018. Foods consumed were classified according to the Nova classification system. Compliance with WHO dietary guidelines and UPF consumption trends were evaluated.

SETTING

Three low-income areas (Langa, Khayalitsha and Mount Frere) in SA were included.

PARTICIPANTS

In total, 2521 participants (18-50 years) were included in the study.

RESULTS

Participants had a mean energy intake of 7762 kJ/d. Most participants were within the acceptable WHO guideline range for saturated fat (80·4 %), total fat (68·1 %), Na (72·7 %) and free sugar (57·3 %). UPF comprised 39·4 % of diets among the average adult participant. Only 7·0 % of all participants met the WHO guideline for fruit and vegetables and 18·8 % met the guideline for fibre. Those within the highest quartile of share of energy from UPF consumed statistically higher amounts of dietary components to limit and were the highest energy consumers overall.

CONCLUSIONS

Low-income adults living in SA are consuming insufficient protective dietary components, while UPF consumption is prevalent. Higher UPF consumers consume larger amounts of nutrients linked to increased chronic disease risk. Policy measures are urgently needed in SA to protect against the proliferation of harmful UPF and to promote and enable consumption of whole and less UPF.

US tobacco companies selectively disseminated hyper-palatable foods into the US food system: Empirical evidence and current implications

BACKGROUND AND AIMS

US tobacco companies owned leading US food companies from 1980 to 2001. We measured whether hyper-palatable foods (HPF) were disproportionately developed in tobacco-owned food companies, resulting in substantial tobacco-related influence on the US food system.

DESIGN

The study involved a review of primary industry documents to identify food brands that were tobacco company-owned. Data sets from the US Department of Agriculture were integrated to facilitate longitudinal analyses estimating the degree to which foods were formulated to be hyper-palatable, based on tobacco ownership.

SETTING AND CASES

United States Department of Agriculture data sets were used to identify HPF foods that were (n = 105) and were not (n = 587) owned by US tobacco companies from 1988 to 2001.

MEASUREMENTS

A standardized definition from Fazzino et al. (2019) was used to identify HPF. HPF items were identified overall and by HPF group: fat and sodium HPF, fat and sugar HPF and carbohydrates and sodium HPF.

FINDINGS

Tobacco-owned foods were 29% more likely to be classified as fat and sodium HPF and 80% more likely to be classified as carbohydrate and sodium HPF than foods that were not tobacco-owned between 1988 and 2001 (P-values = 0.005-0.009). The availability of fat and sodium HPF (> 57%) and carbohydrate and sodium HPF (> 17%) was high in 2018 regardless of prior tobacco-ownership status, suggesting widespread saturation into the food system.

CONCLUSIONS

Tobacco companies appear to have selectively disseminated hyper-palatable foods into the US food system between 1988 and 2001.

Dietary intakes of hypertensive patients in rural India: Secondary outcomes of a randomised, double-blind, controlled trial

Background

Hypertension is highly prevalent in India; however, little is known about the dietary intakes of those living with hypertension, particularly in rural areas. The primary aim was to assess the dietary intakes of individuals living in rural India with self-reported history of hypertension. As secondary analyses, we explored the dietary impact of a salt substitute in this population group.

Materials and methods

This study used data from a large randomised controlled trial conducted in seven villages across rural India. Participants received either regular salt (100% sodium chloride) or the salt substitute (70% sodium chloride/30% potassium chloride) to replace all home salt use. Dietary intake at baseline and end-of-trial was assessed using 24-h dietary recalls. A range of dietary outcomes were assessed including energy intake, macronutrient intake and overall diet quality according to the Alternate Healthy Eating Index (AHEI).

Results

A total of 454 participants were included in the analysis. At baseline, mean (SE) energy intakes in regular salt group and salt substitute group were similar at 5240 (110) kJ/day and 5120 (106) kJ/day, respectively. This was largely attributable to intakes of carbohydrates (74.4% of total energy intakes for regular salt group vs 75.4% for the salt substitute group) followed by total fat (15.8% vs 15.4%) and protein (10.4% vs 10.3%). Both groups also had similar AHEI scores at baseline, with mean (SE) total scores equating to 33.0 (0.4) (out of a total 90) for the regular salt group and 32.7 (0.4) for the salt substitute group. Both groups received lowest AHEI scores across the following components: vegetables, fruit and wholegrains. At baseline, the mean (SE) intakes of sodium across the regular salt and salt substitute groups were similar at 2349 (67) mg/day and 2396 (64) mg/day, respectively. In the salt substitute group, there was a significant reduction in total sodium intakes over time (-264 mg/day, 95% CI, -442 to -85), driven by the use of the salt substitute.

Conclusion

This study found individuals with hypertension living in rural India had poor dietary intakes, including low intakes of fruits, vegetables and wholegrains, and high intakes of sodium. Salt substitutes may be an effective strategy for reducing sodium intake in this population group.

The role of the private sector in noncommunicable disease prevention and management in low- and middle-income countries: a series of systematic reviews and thematic syntheses

PURPOSE

Conduct six systematic reviews investigating for-profit private sector roles in NCD prevention and management in low- and middle-income countries (LMICs) through our a priori framework's pillars.

METHODS

Six systematic reviews and thematic syntheses were performed between March-August 2021, Six databases, websites of relevant organizations, and references lists of included studies were comprehensively searched. Studies published in English from 2000 onwards involving the pillar of interest, for-profit private sector, NCD prevention/management, and LMIC context were included. Results were synthesized using an inductive thematic synthesis approach.

RESULTS

Ultimately, 25 articles were included in the PPP review, 33 in Governance and Policy, 22 in Healthcare Provision, 15 in Innovation, 14 in Knowledge Educator, and 42 in Investment and Finance. The following themes emerged: PPPs (coordination; financial resources; provision; health promotion; capacity building; innovation; policy); Governance/Policy (lobbying; industry perception; regulation); Healthcare Provision (diagnosis/treatment; infrastructure; availability/accessibility/affordability); Innovation (product innovation; process innovation; marketing innovation; research; innovation dissemination); Knowledge Educator (training; health promotion; industry framework/guideline formation); Investment and Finance (treatment cost; regulation; private insurance; subsidization; direct investment; collaborative financing; innovative financing; research).

CONCLUSION

These findings will be instrumental for LMICs considering private sector engagement. Potential conflicts of interest must be considered when implementing private sector involvement.

Dietary diversity, nutritional status, and agricultural commercialization: evidence from adult men of rural farm households

Access to healthy and affordable diet hinged on the realization of Sustainable Development Goal 2, higher productivity and, economic prosperity while it is difficult for a poorly nourished people to achieve optimum production of goods and services. This study assessed whether dietary diversity (DD) and nutritional status of adult men are associated with crop commercialization index (CCI) levels of agricultural households in two states of Southwestern Nigeria. This research utilized 352 farm households, comprising 277 adult male members. The individual version of dietary diversity score (DDS) of 9 food groups was used to calculate adult men's DDS over a 24-h recall. Anthropometric data was obtained using body mass index (BMI) while CCI levels was estimated for each agricultural household. Logistic regression and ordered logit models were used to examine the determinants of adult men's dietary diversity and nutritional status respectively. Hundred percent of adult men consumed starchy staples, with 11.2% consuming egg, 5.8% milk and milk products and 0.4% consuming organ meat over 24-h recall. Adult men of CCI 2 and CCI 4 agricultural households recorded overweight prevalence of >20% in Ogun state while the association between DDS and CCI was statistically insignificant suggesting that being a member of any of the CCI households may not guarantee the consumption of healthy diets among adult men. From Logit regression analysis, it is more likely for adult men with higher farm size to attain the minimum DDS of 4 food groups than those with smaller size of farmland (OR = 4.78; 95% CI: 1.94, 11.76; p = 0.001). The age, farm experience, and cassava marketing experience were positively related to the likelihood of obtaining the minimum DDS. For adult men to achieve a healthy diet, their diet pattern must incorporate a more diversified intake of food from different food groups capable of improving their nutritional status. This study emphasized the need for relevant stakeholders to provide adequate nutrition knowledge intervention programmes capable of improving the diets and nutrition of adult men and other members of farm households.

Characterizing restrictions on commercial advertising and sponsorship of harmful commodities in local government policies: a nationwide study in England

BACKGROUND

Commercial advertising and sponsorship drive the consumption of harmful commodities. Local authorities (LAs) have considerable powers to reduce such exposures. This study aimed to characterize local commercial policies across all English LAs.

METHODS

We conducted a census of all English LAs (n = 333) to identify local commercial policies concerning advertising and sponsorship of tobacco, alcohol, less healthy foods and gambling, through online searches and Freedom of Information requests. We explored policy presence, commodity frequency and type, and associations with LA characteristics (region, urban/rural and deprivation).

RESULTS

Only a third (106) of LAs in England had a relevant policy (32%). These included restrictions on tobacco (91%), gambling (79%), alcohol (74%) and/or less healthy foods (24%). Policy prevalence was lowest in the East of England (22%), North East (25%) and North West (27%), higher in urban areas (36%) than rural areas (28%) and lower in the least (27%) compared with the most (38%) deprived areas. Definitions in policies varied, particularly for alcohol and less healthy foods.

CONCLUSIONS

English LAs currently underutilize their levers to reduce the negative impacts of harmful commodity industry marketing, particularly concerning less healthy foods. Standardized guidance, including clarity on definitions and application, could inform local policy development.

Association between ultra-processed food consumption and the incidence of type 2 diabetes: the ELSA-Brasil cohort

BACKGROUND

Ultra-processed food (UPF) consumption increases the risk of type 2 diabetes in various high-income countries, with some variation in the magnitude across studies. Our objective was to investigate the association of UPF consumption and specific subgroups with incident type 2 diabetes in Brazilian adults.

METHODS

The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a multicenter cohort study of 15,105 adults (35-74 years) enrolled in public institutions in Brazil (2008-2010). We followed participants with two clinic visits (2012-2014; 2017-2019) and annual telephone surveillance. After excluding those with diabetes at baseline, who died or were lost in the follow-up, with missing data, with implausible energy food intake, or reporting bariatric surgery, there were 10,202 participants. We used the NOVA classification to assess UPF consumption based on a food frequency questionnaire. We defined type 2 diabetes by self-report, medication use, or comprehensive laboratory tests. We estimated relative risks (RR) and 95% confidence intervals (95% CI) using robust Poisson regression.

RESULTS

Median UPF consumption was 372 g/day. Over 8.2 (0.7) years of follow-up, we detected 1799 (17.6%) incident cases. After adjustment for socio-demographics, family history of diabetes, and behavioral risk factors, comparing the fourth (≥ 566 g/day) with the first (< 236 g/day) quartile of UPF distribution, RR was 1.24 (1.10-1.39); every 150 g/day increments in UPF consumption resulted in a RR of 1.05 (1.03-1.07). Reclassifying natural beverages with added sweeteners as UPF increased risk (RR 1.40; 1.25-1.58). Among UPF subgroupings, consumption of processed meats and sweetened beverages increased diabetes risk, while yogurt and dairy sweets decreased the risk (p < 0.05).

CONCLUSIONS

UPF consumption increased the incidence of type 2 diabetes in Brazilian adults, with heterogeneity across specific food items. These findings add to previous evidence for the role of UPFs in the development of diabetes and other chronic diseases, supporting recommendations to avoid their intake in diabetes prevention and management.

The Awareness of the Role of Commercial Determinants of Health and the Readiness to Accept Restrictions on Unhealthy Food Advertising in Polish Society

The negative consequences of commercial determinants of health (CDoH) have become a major challenge for public health systems, especially in terms of non-communicable diseases (NCDs). CDoH are defined as profit-driven factors that influence health. In this study, we assessed the awareness of CDoH and the attitudes toward potential restrictions on advertising, as well as fiscal interventions targeting food products with harmful effects on health in Polish society. Our analysis is based on data from a computer-based web interviewing (CAWI) survey performed in May 2022 among 2008 adult internet users from Poland. Multivariable logistic regression models were developed for variables derived from three items exploring the respondents' understanding of the relationship between CDoH and NCDs, as well as three items asking about their acceptance of a prohibition of advertising unhealthy products during sports events, a general ban on unhealthy food advertising, and their attitudes toward sugar-sweetened beverages (SSBs). Food (FL) and e-health literacy (eHL) levels were consistently positive predictors of both awareness of CDoH and acceptance of the proposed actions. Both higher FL and eHL were significantly associated with the opinion that advertising unhealthy food is associated with the prevalence of NCDs (OR, 95% CI: 1.03, 1.02-1.05, and 1.04, 1.02-1.06, respectively). Health literacy was less frequently a significant predictor of the dependent variables. Among sociodemographic factors, a respondent's level of education and age showed a significant relationship with their awareness and acceptance of countermeasures against CDoH. Respondents with a university master's level of education were more likely to agree with the statement on the relationship between big industry profits and harm to society's health (OR, 95% CI: 1.96, 1.42-2.69) and to support a ban on advertising unhealthy food similar to that for tobacco products (OR, 95% CI: 1.66, 1.21-2.27). Respondents suffering from chronic diseases were also consistently more likely to show a greater understanding of the harmful impact of CDoH and support proposed restrictions. For example, they were more likely to agree with restrictions on advertising harmful products during sports events (OR, 95% CI: 1.23, 1.02-1.50) and the introduction of a sugar tax (OR, 95% CI: 1.26, 1.03-1.54). Our study revealed that more than 50% of the Polish population is conscious of the problem of the harmful effects of big industries producing and selling processed food, sugar-sweetened beverages, and alcoholic beverages. Interestingly, slightly more than half of the respondents supported the introduction of restrictions on advertising such products. Still, only approximately 30% of them accepted a sugar tax to counter the obesity epidemic. The results of our study indicate that Polish society is open to the introduction of regulations aimed at limiting the impact of commercial determinants of health. To our knowledge, this is one of the first studies to assess the awareness of CDoH and the acceptance of restrictions to limit their impact.

Ultra-processed foods consumption and diet quality among preschool children and women of reproductive age from Argentina

OBJECTIVE

To assess the association between the consumption of ultra-processed foods (UPF) and diet quality among preschool children and women of reproductive age from Argentina.

DESIGN

Cross-sectional and nationally representative survey. The food items were classified according to the NOVA system. Consumption of fruits, vegetables, legumes, nuts, seeds and wholegrains was estimated, and the energy and nutrients related to non-communicable disease (NCD) intake. Linear regression was used to assess the associations.

SETTING

Argentina.

PARTICIPANTS

Children aged 2-5 years (n 7022), female adolescent aged 10-19 years (n 2165) and women aged 20-49 years (n 4414).

RESULTS

UPF represented more than a quarter of total energy intake, 27 % in children, 31 % in female adolescents and 26 % in women. Across all age groups, the major contributors to UPF consumption were cookies and pastries (about 6·0-7·0 %), soft drinks (about 2·7-3·7 %), candies (about 1·8-4·6 %), and juices (about 1·3-1·7 %). The consumption of fresh vegetables, fresh fruits and legumes was negatively associated with UPF consumption. A significant positive association was found between the dietary share of UPF and the dietary content of NCD-promoting nutrients such as free sugars and total saturated and trans-fats. In contrast, a significant negative association was found with the content of NCD-protective such as fibre and protein.

CONCLUSIONS

UPF were associated with lower consumption of healthy foods and higher intake of nutrients related to NCD in children and women of reproductive age in Argentina. It is necessary to design food policies that simultaneously reduce the consumption of UPF while promoting the intake of fresh and whole foods to improve the dietary quality.

Why did Swiss citizens vote to ban tobacco advertising?

In February 2022, Swiss citizens agreed to modify the Swiss Constitution to ban tobacco advertising reaching children and adolescents. This case study analyses the arguments used by both opponents and supporters of the constitutional amendment. Opponents argued that the proposed regulation went too far, threatened the economy, restricted personal freedom, was superfluous as the current law already protected youth and that it opened the door to marketing bans of other harmful products. Proponents focused on youth protection and invoked the burden of smoking on public health and the fact that advertising bans are an effective evidence-based measure. A comparison with previous campaigns to ban tobacco advertising that had failed suggests factors accounting for the positive vote in 2022. These include the strategic framing of youth protection, the separation of tobacco from other issues (such as alcohol advertising), the deteriorating image of the tobacco industry and the ability of the proponents to mobilise a broad coalition of health and youth organisations, with improved funding and communication. The lessons may be instructive for other campaigns seeking to regulate commercial determinants of health.

A framework of NGO inside and outside strategies in the commercial determinants of health: findings from a narrative review

BACKGROUND

Public health scholarship has uncovered a wide range of strategies used by industry actors to promote their products and influence government regulation. Less is known about the strategies used by non-government organisations to attempt to influence commercial practices. This narrative review applies a political science typology to identify a suite of 'inside' and 'outside' strategies used by NGOs to attempt to influence the commercial determinants of health.

METHODS

We conducted a systematic search in Web of Science, ProQuest and Scopus. Articles were eligible for inclusion if they comprised an empirical study, explicitly sought to examine 'NGOs', were in English, and identified at least one NGO strategy aimed at commercial and/or government policy and practice.

RESULTS

One hundred forty-four studies met the inclusion criteria. Eight industry sectors were identified: extractive, tobacco, food, alcohol, pharmaceuticals, weapons, textiles and asbestos, and a small number of general studies. We identified 18 types of NGO strategies, categorised according to the target (i.e. commercial actor or government actor) and type of interaction with the target (i.e. inside or outside). Of these, five NGO 'inside' strategies targeted commercial actors directly: 1) participation in partnerships and multistakeholder initiatives; 2) private meetings and roundtables; 3) engaging with company AGMs and shareholders; 4) collaborations other than partnerships; and 5) litigation. 'Outside' strategies targeting commercial actors through the mobilisation of public opinion included 1) monitoring and reporting; 2) protests at industry sites; 3) boycotts; 4) directly engaging the public; and 5) creative use of alternative spaces. Four NGO 'inside' strategies directly targeting government actors included: 1) lobbying; 2) drafting legislation, policies and standards; 3) providing technical support and training; and 4) litigation. NGO 'outside' strategies targeting government included 1) protests and public campaigns; 2) monitoring and reporting; 3) forum shifting; and 4) proposing and initiating alternative solutions. We identified three types of NGO impact: substantive, procedural, and normative.

CONCLUSION

The analysis presents a matrix of NGO strategies used to target commercial and government actors across a range of industry sectors. This framework can be used to guide examination of which NGO strategies are effective and appropriate, and which conditions enable NGO influence.

Mapping of food environment policies in Zambia: a qualitative document analysis

BACKGROUND

The food environment in which people exercise food choices significantly impacts their dietary patterns. Policies that limit the availability, affordability, and access to unhealthy food while increasing that of healthier alternatives help build healthy food environments, which are required to address the double burden of malnutrition. This study aimed to assess the availability of food environment policies in Zambia.

METHOD

We applied a two-step qualitative document analysis to identify policy content relating to healthy food environments from global and Zambia-specific nutrition-related policy documents. In the first step, global policy documents were analyzed to develop a reference point for globally recommended policies for healthy food environments. In the second step, Zambia's nutrition-related policies were analyzed to identify content relating to healthy food environments. The identified policy content was then mapped against the global reference point to identify food environment policy gaps.

RESULTS

Our analysis of global policy recommendations identified five broad categories of policy provisions: information and education based; regulatory and legislative tools; strategies to promote production and access to healthy food production; social protection-based strategies and guiding principles for governments relating to multisectoral collaboration and governance. Our analysis found that Zambian Government policy documents in the health, agriculture, education, and national planning and development sectors have policy provisions for healthy food environments. While these policy provisions generally covered all five reference categories, we found policy gaps in the regulatory and legislative tools category relative to global recommendations.

CONCLUSION

Zambia's food environment policy landscape must include globally recommended regulatory and legislative policy measures like restricting the marketing of unhealthy foods and non-alcoholic beverages to children. Nutrition policy reforms are required to facilitate the introduction of regulatory and legislative policy measures that effectively address the double burden of malnutrition in Zambia.

International food trade contributes to dietary risks and mortality at global, regional and national levels

Food trade is generally perceived to increase the availability and diversity of foods available to consumers, but there is little empirical evidence on its implications for human health. Here we show that a substantial proportion of dietary risks and diet-related mortality worldwide is attributable to international food trade and that whether the contributions of food trade are positive or negative depends on the types of food traded. Using bilateral trade data for 2019 and food-specific risk-disease relationships, we estimate that imports of fruits, vegetables, legumes and nuts improved dietary risks in the importing countries and were associated with a reduction in mortality from non-communicable diseases of ~1.4 million deaths globally. By contrast, imports of red meat aggravated dietary risks in the importing countries and were associated with an increase of ~150,000 deaths. The magnitude of our findings suggests that considering impacts on dietary risks will become an important aspect of health-sensitive trade and agriculture policies, and of policy responses to disruptions in food chains.

Framing health taxes: a scoping review

Health taxes are increasingly positioned as effective policy instruments for curbing non-communicable disease, improving health and raising government revenues. Their allure has caused many health advocates to look beyond tobacco and alcohol to other harmful products such as sugar-sweetened beverages (SSBs), salty foods, fatty foods and fossil fuels. These efforts, however, directly conflict with commercial actors' interests. Both pro-tax health advocates and anti-tax industry representatives seek to frame health tax policy in favourable ways. Yet, little is known about which types of frames resonate in which settings, or how they deploy morals and values in their attempts to persuade. To fill this gap, we conducted a scoping review on framing health taxes using six databases in 2022. A total of 40 peer-reviewed empirical research articles, from 2006 to 2022, were identified from 20 different countries. Most research was conducted in high-income countries, published in the last 4 years and increasingly focused on excise taxes for SSBs. Studies captured multiple actors constructing context-specific frames, often tied to broader economic, health and administrative considerations. Actors also engaged in a range of political activities in addition to framing. We found some evidence that anti-tax framing strategies potentially incorporated a broader array of morals and social values. More in-country comparative research, particularly from low/middle-income countries, is needed to understand the politics of framing health taxes. We argue that these insights can improve efforts to advance health taxes by constraining corporate power, improving population level health and promoting greater social harmony.

A sweet deal for domestic industry: the political economy and framing of Vanuatu's sugar-sweetened beverage tax

INTRODUCTION

The Government of Vanuatu introduced an excise tax on sugar-sweetened beverages (SSBs) in 2015. While lauded for its alignment with the WHO's Best Buys recommendations for addressing non-communicable diseases (NCDs), little is known about the tax's adoption process or whose interests it serves.

METHODS

Using case study methodology, this study examined how and why Vanuatu's SSB tax was introduced. Policy documents, key informant interviews (n=33) and direct observations were analysed using theories of policy analysis, power analysis and postcolonial theory to map the policy's adoption, surrounding political economy and the ideas, interests and institutions that shaped the tax and its framing.

RESULTS

The SSB tax emerged during a politically and economically unstable time in Vanuatu's history. The tax's links to the national health agenda were tenuous despite its ostensible framing as a way to combat NCDs. Rather, the tax was designed to respond to tightening economic and trade conditions. Spearheaded by several finance-focused bureaucrats, and with limited input from health personnel, the tax targeted less frequently consumed carbonated SSBs (which are mostly imported) without any revenue reinvestments into health. Driven by the desire to generate much-needed government revenue and instal domestic protections via selective implementation and carve-outs for local producers, the Vanuatu SSB tax did meet national objectives, just not the dual health and economic 'win-win' projected by the NCD Best Buys.

CONCLUSION

Vanuatu's SSB tax adoption process reveals the limitations of decontextualised policy recommendations, such as the NCD Best Buys, whose framing may be overcome by local political realities. This research highlights the need for further political economy considerations in global health recommendations, since contextual forces and power dynamics are key to shaping both how and why policies are enacted and also whose interest they serve.

Understanding the role of the state in dietary public health policymaking: a critical scoping review

Despite evidence that dietary population health interventions are effective and widely accepted, they remain the topic of intense debate centring on the appropriate role of the state. This review sought to identify how the role of the state in intervening in individuals' food practices is conceptualized across a wide range of literatures. We searched 10 databases and 4 journals for texts that debated dietary population health interventions designed to affect individuals' health-affecting food practices. Two co-authors independently screened these texts for eligibility relative to inclusion and exclusion criteria. Thirty-five texts formed our final corpus. Through critical reflexive thematic analysis (TA), we generated 6 themes and 2 subthemes concerning choice, responsibility for health, balancing benefits and burdens of intervention, the use of evidence, fairness, and the legitimacy of the state's actions. Our analysis found that narratives that aim to prevent effective regulation are entrenched in academic literatures. Discourses that emphasized liberty and personal responsibility framed poor health as the result of 'lifestyle choices'. Utilitarian, cost-benefit rationales pervaded arguments about how to best balance the benefits and burdens of state intervention. Claims about fairness and freedom were used to evoke powerful common meanings, and evidence was used politically to bolster interests, particularly those of the food industry. This review identifies and critically analyses key arguments for and against population dietary public health policies. Our findings should motivate public health researchers and practitioners to avoid unreflexively embracing framings that draw on the languages and logics of free market economics.

The Role of the Western Diet on Atopic Dermatitis: Our Experience and Review of the Current Literature

The correlation between health and diet has always been a subject of interest in the field of dermatology and medicine in general. However, studies in the literature are still scarce, and need further investigation in the field of inflammatory skin diseases. In this paper, we report a case of a patient with atopic dermatitis whose complete recovery occurred only after combining dupilumab therapy with a Mediterranean diet regimen.

Trend analysis of noncommunicable diseases and their risk factors in Afghanistan

Background

Afghanistan is suffering from 40-year chronic conflicts, displacement, and demolition of its infrastructure. Afghanistan mortality survey 2010 shows nearly 46% of all deaths in the country were attributed to noncommunicable diseases (NCDs). In this study, we aimed to understand the differences in mortality and premature death due to NCDs by sex and the trend for the next 8 years.

Methods

We applied trend analysis using the secondary data from the Institute for Health Metrics and Evaluation, Global Burden of Diseases 2019. The information on NCD mortality, NCD deaths attributed to its risk factors, NCD percent of total years lived with disability (YLDs) attribution to each risk factor extracted from this database from 2008 to 2019. We investigated the trend from 2008 to 2019 for the mentioned factors and then forecast their trends until 2030.

Results

Our study shows that Afghanistan has had an increasing death number due to NCDs from 2008 to 2019 (50% for both sexes) and this will reach nearly 54% by 2030. Currently, half of NCDs deaths are premature in Afghanistan. The mortality rate and prevalence of risk factors are higher among women. More than 70% of YLDs will be due to NCDs in Afghanistan till 2030. Five risk factors including high systolic blood pressure (28.3%), high body mass index (23.4%), high blood glucose (20.6%), high low-density lipoprotein cholesterol (16.3%), and smoking (12.3%) will have the highest contribution to NCDs death in 2030, respectively.

Conclusions

In general, our study indicates that without any specific intervention to address NCDs in Afghanistan, not only the Sustainable Development Goal target for NCDs will not be met, but an increase in almost all risk factors prevalence, as well as NCD mortality, will be seen in Afghanistan.

Intuitive and mindful eating to improve physiological health parameters: a short narrative review of intervention studies

OBJECTIVES

This brief narrative review aims to give an up-to-date overview of intuitive and mindful eating (I/ME) interventions with specific focus on cardiometabolic risk factors, including glucose, lipid profile, blood pressure and inflammatory markers.

CONTENT

I/ME intervention studies in adults which measured at least one physiological parameter other than weight were identified from PubMed. The clinical trial/randomized controlled trial filters and publication dates 2001 through April 2021 with variations of the following keywords were applied: intuitive eating, mindful eating, weight neutral. Ten articles were identified.

SUMMARY AND OUTLOOK

Of the 10 studies, seven showed I/ME interventions were more effective than control in at least one cardiometabolic outcome, two showed significant I/ME within-group improvements but no between-group differences, and one showed neither within-group nor between-group differences. Specifically, I/ME improved glucose levels among pregnant women with or without gestational diabetes, lipid profile among adults with overweight or obesity, blood pressure among participants with overweight and inflammatory markers among post-menopausal women with obesity. However, the positive impact of I/ME on each of these cardiometabolic parameters was not consistent across studies: of the six studies that examined glucose regulation, two demonstrated positive outcomes for I/ME group, whereas four found no effect compared to control. Three out of five studies had positive lipid effects, one out of five demonstrated systolic blood pressure (SBP) improvements and one of two showed improvements in inflammatory markers. Given these mixed results, more research is needed to understand the possible effectiveness of I/ME to improve cardiometabolic health.

Interactions Between Nutrition Professionals and Industry: A Scoping Review

BACKGROUND

In recent years, interactions between nutrition professionals (NPs) and the food industry, such as sponsorship arrangements, have raised concerns, particularly as these may negatively impact the trustworthiness and credibility of the nutrition profession. This study aimed to map the literature and identify knowledge gaps regarding interactions between NPs and industry. We sought to examine the nature of such interactions and NPs perspectives about these, as well as the risks and solutions.

METHODS

We conducted a scoping review according to a pre-registered protocol, searching eight electronic databases and grey literature sources in March 2021 to identify documents for inclusion. Two independent reviewers screened citations for inclusion and conducted data extraction. Quantitative and qualitative syntheses were conducted.

RESULTS

We identified 115 documents for analysis, published between 1980 to 2021, with a majority from the United States (n=59, 51%). Only 32% (n=37) were empirical studies. The food industry was the most frequent industry type discussed (n=91, 79%). We identified 32 types of interactions between NPs and industry, such as continuing education provided by industry and sponsorship of professional bodies and health and nutrition organizations. The financial survival of nutrition organizations and continuing education access for NPs were the most frequently cited advantages of industry-NPs interactions. On the other hand, undermining public trust, NPs credibility and public health nutrition recommendations were pointed out as risks of these interactions. Following a code of ethics, policies, or guidelines was the most frequently proposed solution for managing these interactions.

CONCLUSION

Despite the increasing attention given to this issue, few empirical papers have been published to date. There is a need for more research to better and systematically document industry interactions with NPs and the impacts associated with these, as well as more research on effective management strategies. Registry Name and Number: Interactions between nutrition professionals and industry actors: A scoping review protocol. doi:10.17605/OSF.IO/Q6PUA.

An evolutionary perspective on social inequality and health disparities: Insights from the producer-scrounger game

There is growing concern with social disparities in health, whether relating to gender, ethnicity, caste, socio-economic position or other axes of inequality. Despite addressing inequality, evolutionary biologists have had surprisingly little to say on why human societies are prone to demonstrating exploitation. This article builds on a recent book, 'The Metabolic Ghetto', describing an overarching evolutionary framework for studying all forms of social inequality involving exploitation. The dynamic 'producer-scrounger' game, developed to model social foraging, assumes that some members of a social group produce food, and that others scrounge from them. An evolutionary stable strategy emerges when neither producers nor scroungers can increase their Darwinian fitness by changing strategy. This approach puts food systems central to all forms of human inequality, and provides a valuable lens through which to consider different forms of gender inequality, socio-economic inequality and racial/caste discrimination. Individuals that routinely adopt producer or scrounger tactics may develop divergent phenotypes. This approach can be linked with life history theory to understand how social dynamics drive health disparities. The framework differs from previous evolutionary perspectives on inequality, by focussing on the exploitation of foraging effort rather than inequality in ecological resources themselves. Health inequalities emerge where scroungers acquire different forms of power over producers, driving increasing exploitation. In racialized societies, symbolic categorization is used to systematically assign some individuals to low-rank producer roles, embedding exploitation in society. Efforts to reduce health inequalities must address the whole of society, altering producer-scrounger dynamics rather than simply targeting resources at exploited groups.

Association of ultra-processed food consumption with incident depression and anxiety: a population-based cohort study

Background: Global ultra-processed food (UPF) consumption has risen rapidly. The development and prognosis of depression and anxiety remain unclarified. Herein, we aimed to examine the association between UPF consumption and the incidence and progression trajectory of depression and anxiety. Methods: In our study, participants were recruited between 2006 and 2010. UPF consumption was expressed as UPF servings, energy ratio, and weight ratio. The relationships between UPF consumption and depression or anxiety were assessed using the Cox proportional hazards model. Multi-state models were used to explore the association between UPF consumption and the risks of all transitions from a healthy state to depression or anxiety and then to all-cause mortality. Results: Among the 183 474 participants, 5453 were diagnosed with depression and 6763 with anxiety during the follow-up of 13.1 years. The participants in the highest quartile (Q4) of UPF servings, energy ratio, and weight ratio had an increased risk of depression compared to those in the lowest quartile (Q1), with hazard ratios (HRs) and 95% confidence intervals [CIs] of 1.22 (1.13-1.31), 1.13 (1.05-1.22), and 1.26 (1.17-1.36), respectively. Similarly, participants in Q4 of UPF consumption had a higher risk of anxiety, with HRs (95% CIs) of 1.13 (1.06-1.21), 1.13 (1.05-1.21), and 1.11 (1.04-1.19), compared to those in Q1. The study also found a significant association between UPF consumption and all-cause mortality, which disappeared for participants with depression or anxiety. Conclusions: Our findings revealed that UPF consumption is associated with depression or anxiety.

Investigating gender differences in the co-occurrence of PTSD and food addiction

OBJECTIVE

Post-traumatic stress disorder (PTSD) commonly co-occurs with substance use disorders (SUDs). Past studies suggest PTSD is also associated with food addiction (compulsive intake of highly processed foods containing refined carbohydrates and/or added fat). However, research investigating gender differences has been limited (e.g., restricted samples) and mixed. We aim to investigate the risk of co-occurring PTSD and food addiction in a community sample for all participants and stratified by gender. Additionally, we conducted risk ratios for problematic substance use and obesity to allow for within-sample comparisons.

METHOD

We utilized a sample of 318 participants recruited from Amazon Mechanical Turk (mean age = 41.2, 47.8% men, 78.0% white) to address existing gaps in the literature on PTSD and food addiction. We calculated risk ratios (adjusted for sociodemographic covariates) using modified Poisson regression with 95% confidence intervals. Results were also gender stratified.

RESULTS

Risk of food addiction (Risk Ratio (RR) = 6.42, 95% CI [4.10, 10.07], problematic alcohol use (RR) = 3.86, 95% CI [2.25,6.62], problematic smoking (RR) = 3.93, 95% CI [2.22, 6.97], and problematic nicotine vaping (RR) = 5.41, 95% CI [2.41, 11.14] were higher for those meeting criteria for PTSD. Risk of problematic cannabis use, and risk of obesity were not significantly higher for those meeting criteria for PTSD. Gender-stratified results suggest risk of food addiction may be higher for men (RR) = 8.54, 95% CI [4.49, 16.25] compared to women (RR) = 4.32, 95% CI [2.16, 8.62].

DISCUSSION

Food addiction, but not obesity, appears to co-occur with PTSD more strongly than other types of problematic substance use (alcohol, cannabis, cigarettes, nicotine vaping). This risk appears to be particularly high for men compared to women. Assessing for food addiction in those with PTSD, particularly in men, may assist in identifying high-risk groups.

Beyond Plants: The Ultra-Processing of Global Diets Is Harming the Health of People, Places, and Planet

Global food systems are a central issue for personal and planetary health in the Anthropocene. One aspect of major concern is the dramatic global spread of ultra-processed convenience foods in the last 75 years, which is linked with the rising human burden of disease and growing sustainability and environmental health challenges. However, there are also calls to radically transform global food systems, from animal to plant-derived protein sources, which may have unintended consequences. Commercial entities have moved toward this "great plant transition" with vigor. Whether motivated by profit or genuine environmental concern, this effort has facilitated the emergence of novel ultra-processed "plant-based" commercial products devoid of nutrients and fiber, and sometimes inclusive of high sugar, industrial fats, and synthetic additives. These and other ingredients combined into "plant-based" foods are often assumed to be healthy and lower in calorie content. However, the available evidence indicates that many of these products can potentially compromise health at all scales-of people, places, and planet. In this viewpoint, we summarize and reflect on the evidence and discussions presented at the Nova Network planetary health meeting on the "Future of Food", which had a particular focus on the encroachment of ultra-processed foods into the global food supply, including the plant-sourced animal protein alternatives (and the collective of ingredients therein) that are finding their way into global fast-food chains. We contend that while there has been much uncritical media attention given to the environmental impact of protein and macronutrient sources-meat vs. novel soy/pea protein burgers, etc.-the impact of the heavy industrial processing on both human and environmental health is significant but often overlooked, including effects on cognition and mental health. This calls for a more nuanced discourse that considers these complexities and refocuses priorities and value systems towards mutualistic solutions, with co-benefits for individuals, local communities, and global ecology.

Engaging with the Private Sector for Noncommunicable Disease Prevention and Control: Is it Possible to Create "Shared Value?"

Noncommunicable diseases (NCDs) are the leading cause of premature mortality worldwide. Corporate interests are sometimes well-aligned with public health, but profiteering from the consumption of products that are known to be the major contributors to the noncommunicable disease burden undermines public health. This paper describes the key industry actors shaping the NCD landscape; highlights the unhealthy commodities' impact on health and the growing burden of NCDs; and outlines challenges and opportunities to reduce exposure to those risk factors. Corporations deploy a wide array of strategies to maximize profits at the expense of health, including sophisticated marketing techniques, interference in the policy-making process, opposition and distortion of research and evidence, and whitewashing of health-harming activities through corporate social responsibility initiatives. There can be no shared value for industries that sell goods that harm health irrespective of consumption patterns (such as tobacco and likely alcohol), so government actions such as regulation and legislation are the only viable policy instruments. Where shared value is possible (for example, with the food industry), industry engagement can potentially realign corporate interests with the public health interest for mutual benefit. Deliberate, careful, and nuanced approaches to engagement are required.

Binge-Eating Precursors in Children and Adolescents: Neurodevelopment, and the Potential Contribution of Ultra-Processed Foods

Binge-eating disorder (BED) is a highly prevalent disorder. Subthreshold BED conditions (sBED) are even more frequent in youth, but their significance regarding BED etiology and long-term prognosis is unclear. A better understanding of brain findings associated with BED and sBED, in the context of critical periods for neurodevelopment, is relevant to answer such questions. The present narrative review starts from the knowledge of the development of emotional self-regulation in youth, and the brain circuits supporting emotion-regulation and eating behaviour. Next, neuroimaging studies with sBED and BED samples will be reviewed, and their brain-circuitry overlap will be examined. Deficits in inhibition control systems are observed to precede, and hyperactivity of reward regions to characterize, sBED, with overlapping findings in BED. The imbalance between reward/inhibition systems, and the implication of interoception/homeostatic processing brain systems should be further examined. Recent knowledge of the potential impact that the high consumption of ultra-processed foods in paediatric samples may have on these sBED/BED-associated brain systems is then discussed. There is a need to identify, early on, those sBED individuals at risk of developing BED at neurodevelopmental stages when there is a great possibility of prevention. However, more neuroimaging studies with sBED/BED pediatric samples are needed.

Pharmaceutical company responses to Canadian opioid advertising restrictions: A framing analysis

The pharmaceutical industry's promotion of opioids in North America has been well-documented. Yet despite the clear consequences of improperly classifying pharmaceutical company messaging and frequently permissive approaches that allow the pharmaceutical industry to self-regulate its own advertising, there has been scarce investigation to date of how pharmaceutical industry stakeholders interpret definitions of "advertising." This study explores how variations of "marketing" and "advertising" are strategically framed by the different actors involved in the manufacturing and distribution of pharmaceutical opioids. We employed a framing analysis of industry responses to Health Canada's letter to Canadian manufacturers and distributors of opioids requesting their commitment to voluntarily cease all marketing and advertising of opioids to health care professionals. Our findings highlight companies' continuing efforts to frame their messaging as "information" and "education" rather than "advertising" in ways that serve their interests. This study also calls attention to the industry's continual efforts to promote self-regulation and internal codes of conduct within a highly permissive federal regulatory framework with little concern for violations or serious consequences. While this framing often occurring out of public sight, this study highlights the subtle means through which the industry attempts to frame their promotion strategies away from "marketing". These framing strategies have significant consequences for the pharmaceutical industry's capacity to influence healthcare professionals, patients, and the general public.

Enhancing global health diplomacy for non-communicable diseases: application of the global health network framework

BACKGROUND AND AIM

Understanding the characteristics of global policy actors and the political context in which they address diplomatic issues in the field of NCDs can play an important role in advancing NCD-related goals. The purpose of this study was to identify and analyze the network of global health actors in the field of NCDs in Iran.

METHODS

This study was conducted in 2020 using a qualitative methodology and framework analysis. In-depth semi-structured interviews were conducted with subject-matter experts from all levels of diplomacy, including global, regional, and national, who had managerial, administrative, and academic experience.

FINDINGS

A total of 21 interviews were conducted with individuals who met the inclusion criteria. Following the framework of the World Health Network, the findings were divided into three general areas: the features of the network and the actors; the policy environment; and the characteristics of the issue.

CONCLUSION

A successful and sustainable program to combat NCDs requires the participation of multiple actors from governments, the private sector, and civil society at international, national, and local levels. The Global Network for Prevention and Control of NCDs should enhance the effectiveness of NCDs policies by highlighting the need to simultaneously improve the internal factors of the network, including relationships among the actors; external factors, including the policy environment; and the complex nature of NCDs.