Smart food policies for obesity prevention

A cross-sectional study of the association between food literacy and dietary intake among Danish adolescents

Food literacy is theorized to be associated with healthy dietary intake. However, empirical knowledge on the association between adolescents' food literacy and dietary intake is limited. The aim of this study was to investigate the association between food literacy and dietary intake among Danish schoolchildren aged 11-13 years. The study applied a cross-sectional design using baseline data from a cluster-based quasi-experimental controlled study in a sample (n = 377) of Danish school children. Mixed model analyses were performed to investigate the associations between overall food literacy as well as its five competencies ("to know", "to do", "to sense", "to care", and "to want") and dietary intake of vegetables, fruit, fish, meat, discretionary foods, and sugar-sweetened beverages. Positive associations were found between overall food literacy (E = 1.493, p = 0.002) as well as the competencies "to know" (E = 1.249, p = 0.027), "to do" (E = 1.236, p = 0.028), "to sense" (E = 1.183, p = 0.029), and "to care" (E = 1.249, p = 0.018) and intake of vegetables. The study also found a positive association between the competency "to want" and intake of fruit (E = 13.50, p = 0.037), "to care" and intake of fish (E = 2.050, p < 0.001), and a negative association between the competency "to want" and intake of meat (E = 0.748, p = 0.003) and sugar-sweetened beverages (E = 0.576, p = 0.0021). No associations were found between overall food literacy or any of its five competencies and intake of discretionary foods. These findings suggest that improving specific aspects of food literacy may have a potential to promote healthier dietary intake, though additional research is needed.

Planning healthy food environments: An analysis of local government municipal public health and wellbeing policy in regional Victoria

ISSUE ADDRESSED

While there has been an increased focus on how local governments can support the creation of healthy food environments through healthy public policy, little is known about how this is reflected in public health policy in regional areas. The aim of this study was to understand how improvements to the food environment are prioritised, implemented and evaluated by local governments in regional Victoria.

METHODS

Using a qualitative descriptive approach, content analysis was undertaken of Municipal Public Health and Wellbeing Plans and Council Plans from 10 regional local governments in Victoria, Australia.

RESULTS

Seventeen policy documents were analysed including 10 Council Plans, 6 Municipal Public Health and Wellbeing Plans and 1 Food Systems Strategy. Findings highlight regional public health and wellbeing plans have very few concrete actions in place to improve food environments.

CONCLUSION

There is an opportunity for Australian regional local governments to include in their public health and wellbeing plans a greater emphasis on supporting healthy food behaviours, and therefore seeking opportunities to improve food environments through clearly aligned priorities, objectives, actions and measures of success. SO WHAT?: Improving the quality of public health and wellbeing plans can support local government to use policy to drive improvements in food environments leading to improved health and wellbeing for regional communities.

Associations between breastfeeding duration and adherence to complementary feeding recommendations in Scotland

We aimed to describe how breastfeeding relates to adherence to complementary feeding (CF) recommendations, diet diversification and feeding skills development and whether sociodemographic factors explain any differences observed. The Scottish Maternal Infant and Nutrition Survey for infants aged 8-12 months collected breastfeeding history, CF practices, diet and sociodemographic data using a self-completion questionnaire. Non-healthful CF practices were starting CF < 6 months, any consumption of sugar-sweetened beverages (SSBs), sweet or salty snacks (treats) or unmodified cow's milk and regular consumption of commercial baby foods. Diet diversification and feeding skills were assessed by amount of self-feeding and number of food groups, meals and snacks eaten daily. Of the 2730 mothers, 20% were solely infant formula fed (IFF) and 48% continued breastfeeding ≥6 months. Compared to IFF babies, mothers who gave any breast milk ≥6 months were more likely to start CF ≥ 6 months compared to those IFF (66% vs. 37%) and less likely to give treats (15% vs. 45%), SSBs (11% vs. 20%) and commercial baby foods (31% vs. 53%). These associations remained highly significant (p < 0.001) even after sociodemographic factor adjustment. Despite starting CF later, infants breastfed ≥6 months ate the same number of food groups and meals as those IFF, were just as likely to self-feed purees and more likely to self-feed finger foods daily (87% vs. 81% p < 0.001). Mothers who breastfeed beyond 6 months adhere more to CF recommendations and start CF later compared to IFF, but their babies eat a similarly diverse diet and have similar feeding skills.

Long-term impact of unhealthy food tax on consumption and the drivers behind: A longitudinal study in Hungary

Several countries have introduced public health product taxes with the objective of reducing the absolute amount of consumption of unhealthy food and tackling obesity. This study aims to estimate the long-term impact of the Hungarian public health product tax introduced in 2011. To achieve this, a unique consumer purchase dataset was analysed to examine daily fast-moving consumer goods purchases from a representative sample of 2,000 households from 2010 to 2018. The results indicate that the tax has been fully reflected in consumer prices. A decline in consumption was observed initially, consistent with previous experiences in Hungary and other countries. However, over time, the data suggests a recovery and even an increase in line with the growth of disposable income. The proportion of taxed products in total fast-moving consumer goods purchases increased from 5.9 % (95 % CI: 5.7 % to 6.0 %) in 2010 to 7.4 % (95 % CI: 7.3 % to 7.6 %) in 2018. Furthermore, the tax has contributed to increased inequality as low-income households spend a higher proportion of their total expenditure on it. Although taxes on unhealthy foods have proven effective in the short-term, they may not be adequate for reducing overall consumption in the long-term, particularly as disposable income increases. In conclusion, implementing complex interventions is necessary to achieve sustainable positive changes in dietary habits.

Effectiveness of an Artificial Intelligence-Assisted App for Improving Eating Behaviors: Mixed Methods Evaluation

BACKGROUND

A plethora of weight management apps are available, but many individuals, especially those living with overweight and obesity, still struggle to achieve adequate weight loss. An emerging area in weight management is the support for one's self-regulation over momentary eating impulses.

OBJECTIVE

This study aims to examine the feasibility and effectiveness of a novel artificial intelligence-assisted weight management app in improving eating behaviors in a Southeast Asian cohort.

METHODS

A single-group pretest-posttest study was conducted. Participants completed the 1-week run-in period of a 12-week app-based weight management program called the Eating Trigger-Response Inhibition Program (eTRIP). This self-monitoring system was built upon 3 main components, namely, (1) chatbot-based check-ins on eating lapse triggers, (2) food-based computer vision image recognition (system built based on local food items), and (3) automated time-based nudges and meal stopwatch. At every mealtime, participants were prompted to take a picture of their food items, which were identified by a computer vision image recognition technology, thereby triggering a set of chatbot-initiated questions on eating triggers such as who the users were eating with. Paired 2-sided t tests were used to compare the differences in the psychobehavioral constructs before and after the 7-day program, including overeating habits, snacking habits, consideration of future consequences, self-regulation of eating behaviors, anxiety, depression, and physical activity. Qualitative feedback were analyzed by content analysis according to 4 steps, namely, decontextualization, recontextualization, categorization, and compilation.

RESULTS

The mean age, self-reported BMI, and waist circumference of the participants were 31.25 (SD 9.98) years, 28.86 (SD 7.02) kg/m2, and 92.60 (SD 18.24) cm, respectively. There were significant improvements in all the 7 psychobehavioral constructs, except for anxiety. After adjusting for multiple comparisons, statistically significant improvements were found for overeating habits (mean -0.32, SD 1.16; P<.001), snacking habits (mean -0.22, SD 1.12; P<.002), self-regulation of eating behavior (mean 0.08, SD 0.49; P=.007), depression (mean -0.12, SD 0.74; P=.007), and physical activity (mean 1288.60, SD 3055.20 metabolic equivalent task-min/day; P<.001). Forty-one participants reported skipping at least 1 meal (ie, breakfast, lunch, or dinner), summing to 578 (67.1%) of the 862 meals skipped. Of the 230 participants, 80 (34.8%) provided textual feedback that indicated satisfactory user experience with eTRIP. Four themes emerged, namely, (1) becoming more mindful of self-monitoring, (2) personalized reminders with prompts and chatbot, (3) food logging with image recognition, and (4) engaging with a simple, easy, and appealing user interface. The attrition rate was 8.4% (21/251).

CONCLUSIONS

eTRIP is a feasible and effective weight management program to be tested in a larger population for its effectiveness and sustainability as a personalized weight management program for people with overweight and obesity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04833803; https://classic.clinicaltrials.gov/ct2/show/NCT04833803.

Living with obesity in Ireland: determinants, policy and future perspectives

Globally, the prevalence of those living with obesity (≥30 kg/m2) is rising, with this trend expected to continue if firm and decisive policy interventions are not introduced. Across Europe, despite many consecutive policies aiming to reverse rising trends in weight status over recent decades, no country is currently on track to halt and reverse current trends in the coming years. This is evident in Ireland too, whereby the reporting of nationally representative weight status data show that targets have not been achieved since reporting began. The aim of this review is to critically appraise recent evidence relating to the key determinants of obesity including weight status, diet quality and physical activity with an emphasis on socioeconomic inequalities. And to consider these in the context of respective policy measures and propose future-focused recommendations. Furthermore, as with the complex nature of obesity, multifaceted approaches that shift the focus from the individual and place responsibility at a societal level will be reviewed.

New insights into grocery store visits among east Los Angeles residents using mobility data

In this study, we employed spatially aggregated population mobility data, generated from mobile phone locations in 2021, to investigate patterns of grocery store visits among residents east and northeast of Downtown Los Angeles, in which 60% of the census tracts had previously been designated as "food deserts". Further, we examined whether the store visits varied with neighborhood sociodemographics and grocery store accessibility. We found that residents averaged 0.4 trips to grocery stores per week, with only 13% of these visits within home census tracts, and 40% within home and neighboring census tracts. The mean distance from home to grocery stores was 2.2 miles. We found that people visited grocery stores more frequently when they lived in neighborhoods with higher percentages of Hispanics/Latinos, renters and foreign-born residents, and a greater number of grocery stores. This research highlights the utility of mobility data in elucidating grocery store use, and factors that may facilitate or be a barrier to store access. The results point to limitations of using geographically constrained metrics of food access like food deserts.

Predicted impact of banning nonessential, energy-dense food and beverages in schools in Mexico: A microsimulation study

BACKGROUND

Childhood obesity is a growing concern worldwide. School-based interventions have been proposed as effective means to improve nutritional knowledge and prevent obesity. In 2023, Mexico approved a reform to the General Education Law to strengthen the ban of sales and advertising of nonessential energy-dense food and beverages (NEDFBs) in schools and surroundings. We aimed to predict the expected one-year change in total caloric intake and obesity prevalence by introducing the ban of NEDFBs sales in schools, among school-aged children and adolescents (6 to 17 years old) in Mexico.

METHODS AND FINDINGS

We used age-specific equations to predict baseline fat-free mass (FFM) and fat mass (FM) and then estimated total energy intake (TEI) per day. The TEI after the intervention was estimated under 4 scenarios: (1) using national data to inform the intervention effect; (2) varying law compliance; (3) using meta-analytic data to inform the intervention effect size on calories; and (4) using national data to inform the intervention effect by sex and socioeconomic status (SES). We used Hall's microsimulation model to estimate the potential impact on body weight and obesity prevalence of children and adolescents 1 year after implementing the intervention in Mexican schools. We found that children could reduce their daily energy intake by 33 kcal/day/person (uncertainty interval, UI, [25, 42] kcal/day/person), reducing on average 0.8 kg/person (UI [0.6, 1.0] kg/person) and 1.5 percentage points (pp) in obesity (UI [1.1, 1.9] pp) 1 year after implementing the law. We showed that compliance will be key to the success of this intervention: considering a 50% compliance the intervention effect could reduce 0.4 kg/person (UI [0.3, 0.5] kg/person). Our sensitivity analysis showed that the ban could reduce body weight by 1.3 kg/person (UI [0.8, 1.8] kg/person) and up to 5.4 kg/person (UI [3.4, 7.5] kg/person) in the best-case scenario. Study limitations include assuming that obesity and the contribution of NEDFBs consumed at school remain constant over time, assuming full compliance, and not considering the potential effect of banning NEDFBs in stores near schools.

CONCLUSIONS

Even in the most conservative scenario, banning sales of NEDFBs in schools is expected to significantly reduce obesity, but achieving high compliance will be key to its success.

WHY WAS THIS STUDY DONE?

- School-based interventions have been recognized as effective means to improve nutritional knowledge and prevent obesity-related diseases.- In December 2023, the Chamber of Representatives of Mexico approved an amendment that strengthens and updates the General Education Law (Article 75) and nutritional guidelines to ban the sales and advertising of nonessential energy-dense food and beverages (NEDFBs) in schools.

WHAT DID THE RESEARCHERS DO AND FIND?

- We used age-specific equations to predict baseline fat-free mass (FFM) and fat mass (FM) and total energy intake (TEI) per day.- We used microsimulation modeling to predict body weight and obesity prevalence of children and adolescents 1 year after implementing the intervention in Mexican schools.- Our modeling study suggests that an important impact on obesity prevalence can be expected if the law is implemented and enforced as intended.

WHAT DO THESE FINDINGS MEAN?

- If successful, this law could serve as an example beyond Mexico on how to achieve changes in body weight through school food regulation.- An important limitation of our main scenario is that we assumed full compliance of schools with the law, yet lower compliance will reduce its impact. We also did not consider historical trends on obesity or NEDFBs consumed in schools during our 1 year simulation, and we considered only the ban impact inside schools, excluding effects near and outside schools.

The Effects of an Educational Intervention About Front-of-Package Labeling on Food and Beverage Selection Among Children and Their Caregivers: Protocol for a Randomized Controlled Trial

BACKGROUND

Overweight and obesity pose a global public health challenge and have a multifactorial origin. One of these factors includes obesogenic environments, which promote ultraprocessed foods characterized by being high in calories, saturated fats, added sugars, and sodium. In Mexico, it has been estimated that 30% of the total energy consumed comes from processed foods. The Modification to the Official Mexican Standards introduces nutritional information through black octagonal seals that alert consumers about products with excessive amounts of some components for a better food selection in the population. However, the effects of warning labels on processed food selection and purchases among children remain unknown.

OBJECTIVE

We aimed to evaluate the impact of a digital educational intervention focusing on front-of-package warning labels on the food selection and purchasing behavior of elementary schoolchildren and their caregivers.

METHODS

Children from 4 elementary schools in Mexico City, 2 public and 2 private schools, will participate in a randomized controlled trial. The schools will be chosen by simple random sampling. Schools will be randomized into 2 groups: intervention and control. In the control group, the dyads (caregiver-schoolchildren) will receive general nutritional education, and in the intervention group, they will receive guidance on reading labels and raising awareness about the impact of consuming ultraprocessed products on health. The educational intervention will be conducted via a website. Baseline measurements will be taken for both groups at 3 and 6 months. All participants will have access to an online store through the website, allowing them to engage in exercises for selecting and purchasing food and beverages. In addition, other measures will include a brief 5-question exam to evaluate theoretical understanding, a 24-hour reminder, a survey on food habits and consumption, application of a food preference scale, anthropometric measurements, and recording of school lunch choices.

RESULTS

Registration and funding were authorized in 2022, and we will begin data collection in September 2024. Recruitment has not yet taken place, but the status of data analysis and expected results will be published in April 2025.

CONCLUSIONS

The study is expected to contribute to evaluating whether reinforcing front-of-package warning labels with education enhances its effects and makes them more sustainable. Conducting this study will allow us to propose whether or not it is necessary to develop new intervention strategies related to front-of-package labeling for a better understanding of the population, improved food choices, and better health outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06102473; https://clinicaltrials.gov/study/NCT06102473.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54783.

Barriers and facilitators to implementation of healthy food and drink policies in public sector workplaces: a systematic literature review

CONTEXT

Many countries and institutions have adopted policies to promote healthier food and drink availability in various settings, including public sector workplaces.

OBJECTIVE

The objective of this review was to systematically synthesize evidence on barriers and facilitators to implementation of and compliance with healthy food and drink policies aimed at the general adult population in public sector workplaces.

DATA SOURCES

Nine scientific databases, 9 grey literature sources, and government websites in key English-speaking countries along with reference lists.

DATA EXTRACTION

All identified records (N = 8559) were assessed for eligibility. Studies reporting on barriers and facilitators were included irrespective of study design and methods used but were excluded if they were published before 2000 or in a non-English language.

DATA ANALYSIS

Forty-one studies were eligible for inclusion, mainly from Australia, the United States, and Canada. The most common workplace settings were healthcare facilities, sports and recreation centers, and government agencies. Interviews and surveys were the predominant methods of data collection. Methodological aspects were assessed with the Critical Appraisal Skills Program Qualitative Studies Checklist. Generally, there was poor reporting of data collection and analysis methods. Thematic synthesis identified 4 themes: (1) a ratified policy as the foundation of a successful implementation plan; (2) food providers' acceptance of implementation is rooted in positive stakeholder relationships, recognizing opportunities, and taking ownership; (3) creating customer demand for healthier options may relieve tension between policy objectives and business goals; and (4) food supply may limit the ability of food providers to implement the policy.

CONCLUSIONS

Findings suggest that although vendors encounter challenges, there are also factors that support healthy food and drink policy implementation in public sector workplaces. Understanding barriers and facilitators to successful policy implementation will significantly benefit stakeholders interested or engaging in healthy food and drink policy development and implementation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021246340.

Global burden of esophageal cancer attributable to high BMI in 204 countries and territories: 1990-2019

BACKGROUND

Esophageal cancer (EC), a common and fatal disease, includes two histological subtypes; esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (ECA). To aid policymakers in the allocation of resources for the prevention and treatment of EC, updated data on EC deaths and disability-adjusted life years (DALYs) attributable to high body mass index (BMI) are necessary. The objective of this study was to identify trends in EC associated with high BMI between 1990 and 2019 using 2019 Global Burden of Disease data.

METHODS

In this observational population-based study, epidemiological data on the association between high BMI and EC were obtained from GBD 2019. The age-standardized mortality rate (ASMRs) and disability-adjusted life year rate (ASDRs) attributable to high BMI-related EC were stratified by year, age, country, and sociodemographic index (SDI). The estimated annual percentage change (EAPC) was calculated to evaluate the temporal trends of the ASMRs and ASDRs between 1990 and 2019.

RESULTS

In 2019, the proportion of EC deaths and DALYs attributed to high BMI was 18.1% and 18.9%, respectively, resulting in 89 904 (95% confidence interval [CI]: 27 879-171 255) deaths and 2 202 314 (95% CI: 681 901-4 173 080) DALYs. High BMI-related deaths and DALYs showed a strong upward trend, increasing by more than two-fold since 1990. East Asia and Western Europe showed the highest risk of EC mortality and DALYs attributable to high BMI; China and the USA bear the greatest burden. The ASMR and ASDR increased in five SDI regions.

CONCLUSIONS

The incidence of EC is increasing, particularly in developing nations, which may be attributed to the prevalence of high BMI. To mitigate the impact of high BMI on the incidence of EC, it is important to increase awareness of its deleterious effects, which may alleviate the burden of this disease.

Burden of colorectal cancer and its risk factors in the North Africa and Middle East (NAME) region, 1990-2019: a systematic analysis of the global burden of disease study

OBJECTIVE

The geographical differences in incidence rates of colorectal cancer (CRC) and its burden due to modifiable risk factors warrant investigating the CRC burden and its risk factors in different regions. In the current study, we aimed to estimate the burden of CRC and the share of its risk factors in the North Africa and Middle East (NAME), from 1990 to 2019.

STUDY DESIGN

Systematic review.

METHODS

The rates of incidence, prevalence, death, years of life lost (YLL), years lived with disability (YLD), and disability adjusted life years (DALYs) of CRC were estimated through the framework of the Global Burden of Diseases (GBD), Injuries and Risk Factors Study 2019 by age, sex, between 1990 and 2019. The CRC-related DALYs attributable to each lifestyle and metabolic risk factor was also estimated through a comparative risk assessment approach.

RESULTS

In NAME region, the trends of incidence, prevalence, death, YLL, YLD, and DALYs of CRC were increasing, with higher rates in males than females over this period. High and high-middle socio-demographic index (SDI) countries had greater CRC DALYs rate compared with middle- and low-SDI countries in 2019, except for Palestine [434.66 (95% UI: 368.82, 503.88)]. In NAME region, like the global, dietary risk (33.18%), low whole grain intake (19.79%), and low intake of milk (15.77%) were the major contributing risk factors to DALYs due to CRC in 2019.

CONCLUSIONS

Due to increasing trend of CRC burden and the considerable role of lifestyle and metabolic factors in its burden in NAME region, implementing fundamental strategies to minimize CRC burden and its risk factors is imperative.

Socioeconomic circumstances, health-related behaviours and paediatric infections: a mediation analysis

OBJECTIVE

To examine how the effect of disadvantaged socioeconomic circumstances on the risk of paediatric infections is mediated by pregnancy smoking, excess weight during pregnancy and breast feeding in children under 5 years of age.

DESIGN

A population-level, retrospective cohort study. The Swedish Medical Birth Register was combined with the National Patient Register, the longitudinal integration database for health insurance and labour market studies, the Cause of Death Register and a local register held by the Child Health Care Unit in Uppsala Region.

SETTING

Uppsala Region, Sweden.

PATIENTS

63 216 term and post-term singletons born to women who resided in Uppsala Region, Sweden between 1997 and 2015.

MAIN OUTCOME MEASURES

Number of hospital admissions for infectious diseases. Secondary outcomes were the number of hospitalisations for respiratory and enteric infections, respectively.

RESULTS

The effect of disadvantaged socioeconomic circumstances, that is, low maternal education on the overall risk of paediatric infections was mediated to a considerable (33%-64%) proportion by pregnancy smoking, excess weight during pregnancy and breast feeding.

CONCLUSIONS

Pregnancy smoking, excess weight during pregnancy and breast feeding mediate a considerable proportion of the association between deprived socioeconomic circumstances and paediatric infectious diseases. Therefore, inequalities in paediatric infectious diseases may be reduced by public health policies addressing these health-related behaviours.

Investigation of the 1-week effect of traffic light nutrition labeling on diet selection among Japanese university students: a randomized controlled trial

BACKGROUND

The method of displaying nutrition information labels on the front of food packaging (FOP: Front of Pack) has been implemented worldwide to prevent lifestyle-related diseases. This study aimed to investigate whether the use of the UK's Traffic Light Food (TLF) label, known as the FOP label, influences the dietary choices of Japanese youth and promotes healthy dietary choices.

METHODS

Diet selection was performed for one week each during the baseline and intervention periods. During the intervention period, TLF labels were displayed on meal images of the intervention group. Participants chose what they would like to have for dinner of the day from 15 images. Each meal was scored based on the color of the nutrition label, and a comparison between groups was made to determine whether TLF labeling influenced meal selection for dinner. The psychological stress caused by the presence or absence of nutrition labels and nutritional components when choosing meals was also evaluated.

RESULTS

A total of 69 participants were randomly assigned to two groups. Dietary choice scores indicated that the TLF-labeled group made significantly healthier dietary choices than the unlabeled group. Additionally, the TLF-labeled group showed a significant increase in the percentage of people conscious of nutritional components when choosing meals. Furthermore, a significant increase in the number of people conscious of protein, a nutritional ingredient not indicated on the TLF label, was observed. During the test period, no difference in psychological stress caused by the presence and absence of the TLF labels was observed.

CONCLUSIONS

The use of TLF labels also encouraged healthy dietary choices among Japanese university students. The use of FOP nutrition labels should be considered in Japan to prevent lifestyle-related diseases through healthy dietary choices.

TRIAL REGISTRATION

UMIN Clinical Trials Registry Number: UMIN000047268. Registered March 23, 2022.

Validation of a short food group questionnaire to determine intakes from healthy and unhealthy food groups in 5-9-year-old South African children

BACKGROUND

Reliable dietary data for children are necessary to investigate associations with health outcomes. The present study aimed to develop and validate a questionnaire to determine the frequency of intakes of specific healthy and unhealthy food groups in young children.

METHODS

Participants were 5-9-year-old South African children (n = 920) from 10 urban schools. Their parents completed a demographic questionnaire and the food intake questionnaire with food pictures. Based on the literature, four healthy food groups (fruits, vegetables, milk, meat/fish/poultry/eggs) and six unhealthy food groups (hot and cold sugar-sweetened beverages, candy, salty snacks, cakes and fast foods) were included, with five different frequency responses. Six experienced nutritionists assessed the face validity and content validity. After pilot testing, construct validity and homogeneity were determined in the participants. Convergent validity was determined using urinary sodium and potassium concentrations as biological intake markers.

RESULTS

Nutritionists confirmed face and content validity. Caregivers confirmed understanding of the questionnaire. Three factors explained 50.2% of the variance, with most unhealthy food groups as factor 1, fruits and vegetables as factor 2, and animal source protein and milk groups clustered with sugar-sweetened beverages as factor 3. The frequency of milk group, fruits and vegetables intake correlated negatively, whereas the frequency of salty snacks and fast foods intakes correlated positively with the urinary sodium:potassium ratio.

CONCLUSIONS

The healthy and unhealthy food group questionnaire has advantages of low respondent burden, as well as acceptable content and convergent validity in South African children. The questionnaire may be used to investigate associations between food intakes and health outcomes.

The return on investment for the prevention and treatment of childhood and adolescent overweight and obesity in China: a modelling study

Background

The rapid increase in child and adolescent overweight and obesity (OAO) in China has a significant health and economic impact. This study undertook an investment case analysis to evaluate the health and economic impacts of child and adolescent OAO in China and the potential health and economic returns from implementing specific policies and interventions.

Methods

The analysis estimates the reduction in mortality and morbidity from implementing a set of evidence-based interventions across China between 2025 and 2092 using a deterministic Markov cohort model. Modelled interventions were identified by literature review and expert recommendation and include fiscal and regulatory policies, eHealth breastfeeding promotion, school-based interventions, and nutritional counselling by physicians. The study applies a societal costing perspective to model the economic impact on healthcare cost savings, wages, and productivity during adulthood. By projecting and comparing the costs between a status quo scenario and an intervention scenario, the study estimates the return on investment (ROI) for interventions separately and in combination.

Findings

Without intervention China will experience 3.3 billion disability-adjusted life years (DALYs) due its current levels of child and adolescent OAO and a lifetime economic impact of CNY 218 trillion (USD 31.6 trillion), or a lifetime CNY 2.5 million loss per affected child or adolescent (USD 350 thousand). National implementation of all five interventions would avert 179.4 million DALYs and result in CNY 13.1 trillion of benefits over the model cohort's lifetime. Implementing fiscal and regulatory policies had the strongest ROI, with benefits accruing at least 10 years after implementation. Scaling up China's current school-based interventions offers China significant health and economic gains, however, the ROI is lower than other modelled interventions.

Interpretation

Effective prevention and treatment of child and adolescent OAO is critical to China's health and economic development. Multiple interventions offer a comprehensive approach to address the various factors that increase risk of child and adolescent OAO. Nonetheless, fiscal and regulatory policies offer the strongest health and economic gains.

Funding

Funding was provided by UNICEF China.

"Good food equals good health": a focus group study of adolescent boys' perceptions of eating and weight

BACKGROUND

Disordered eating refers to unhealthy, sometimes excessive eating including so-called compensatory behaviours such as extreme dieting or voluntary vomiting. Between 24% and 30% of adolescent boys are suggested to engage in disordered eating, making it a significant public health issue. However, current instruments for assessing disordered eating among adolescents have been primarily developed and validated for girls and women, which may make for flawed assessment of boys. The aim of this study is to shed light on adolescent boys' perceptions of eating, weight, and food intake to better understand their perspectives in service of disordered eating research.

METHODS

This exploratory study was conducted from May to November 2022 using focus groups with a total of 39 adolescent boys (aged 12-19 years) who attended 7th to 12th grade in one of four schools in Southern Sweden. In addition, participants completed a form with questions on background demographics and eating habits. The transcripts of the focus group discussions were analysed using thematic analysis.

RESULTS

The quantitative data showed that around one third of the adolescent boys were overweight or obese. They ate at least one meal per day with the family and ate healthy food about five days per week and unhealthy food about three. Analysis of the qualitative data yielded six themes: The intertwined relationship between food and one's health, "Don't worry, food makes you happy," "To be hungry or not. That is the question," Boys DO care about appearances, Dieting and weight gain, and Disordered eating is a tricky matter.

CONCLUSION

Adolescent boys appeared to have a good understanding of food and healthy eating. They also experienced body positivity and seemed to have only minor issues regarding their weight. The primarily pathological perspective used to measure disordered eating among girls seems in need of revision to adhere to boys' thoughts and ideas regarding eating and weight.

Background commentary on the Researching the Obesogenic Food Environment (ROFE) project

OBJECTIVE

The objective of this commentary is to provide an overview of the rationale and objectives of the Researching the Obesogenic Food Environment (ROFE) project that was conducted in Ghana and South Africa.

DESIGN

Narration has been used to describe the main objectives, phases as well as the methods used for the conduct of this project.

SETTING

The project described in this commentary was conducted in Khayelitsha and Mount Frere in South Africa and Ahodwo and Ejuratia for Ghana.

PARTICIPANT

Participants of the study described here include households in South Africa and Ghana, stakeholders and policymakers, and various actors within the food chain in both countries.

RESULTS

The ROFE findings provide a good understanding of the extent of the impact of the food environment on consumption, characteristics of value chains of healthy and unhealthy foods, as well as the potential for improved governance and policy that is relevant to the region. The supplement provides the opportunity to share the extensive findings of the ROFE project. Nine papers that describe the process and findings of the three phases of the ROFE project have been presented. Some of the papers focus on phases of the ROFE, while others cut across different phases and explore the linkages between the phases. Briefly descriptions of key findings of some of the papers in the supplement are provided.

CONCLUSION

Together, the findings of the ROFE study presented in this supplement have increased understanding of how communities in SA and Ghana interact with their food supplies and have led to identification of specific opportunities to improve food supply policies, in ways that create incentives for the production and consumption of healthy, relative to unhealthy foods.

Beyond sugar: Exploring the influence of health and naturalness framing on attitudes towards products with sweet proteins in Europe

Amidst rising obesity rates in the EU and the significant public health impact of excessive sugar consumption, the debate on reducing sugar through reformulation with sweet proteins derived from precision fermentation gains prominence, presenting a viable alternative to traditional sugars and conventional sweeteners. We conducted two studies to investigate the effects of health (emphasizing sugar reduction) versus naturalness (highlighting sweet proteins as alternatives to artificial sweeteners) message framing on the acceptance of products reformulated with sweet proteins. Study 1 (N = 296, Denmark) evaluated the impact of health and naturalness message framing on attitudes towards such reformulations. Study 2, in a cross-cultural sample (N = 3,000 Denmark, Germany, and Poland), tested the mediating role of health perceptions and the moderating effects of BMI and guilt (Study 2a), as well as naturalness perceptions, sweetener use, and pleasure (Study 2b) on product attitudes. Results of Study 1 indicated that healthiness perceptions had a more persuasive influence than naturalness perceptions. The cross-cultural findings of Studies 2a and 2b revealed that BMI, sweetener usage frequency, anticipatory guilt, and pleasure can modulate these effects. These insights suggest that while both perceived healthiness and naturalness shape attitudes towards sweet protein-enriched products, the significance of health perceptions prevails, with anticipatory emotions of guilt enhancing this influence, particularly when sweet proteins substitute added sugar. Such evidence holds substantial implications for strategies aimed at reducing sugar consumption and fostering the acceptance of products containing alternative sweeteners.

Settings, populations, and time: a conceptual framework for public health interventions

This paper presents a conceptual framework displaying how combinations of settings and populations seen in a long-term perspective may guide public health and health promotion planning and research. The notion of settings constitutes a key element of health promotion as stipulated by the Ottawa Charter from 1986. The setting approach highlights the individual, social and structural dimensions of health promotion. Likewise, the notion of populations and how they are selected forms a center pillar of public health. By joining the two perspectives, four combinations of intervention strategies appear by addressing: (1) a single population segment within a single setting, (2) multiple population segments within a single setting, (3) a single population segment within multiple settings or (4) multiple population segments within multiple settings. Furthermore, the addition of a time dimension inspired by the life-course perspective illustrates how trajectories of individuals and projects change settings and population segments as time goes by. The conceptual framework displays how systematic awareness of long-term, multi-setting, multi-population trajectories allow health promotion planners and researchers to systematically develop, plan and analyze their projects.

Enabling mothers of young children in a low SES area to co-design the support they are seeking for the adoption of healthy behaviours

AIMS

There is a need for interventions that meet the needs of low socioeconomic status (SES) groups, to encourage the adoption of healthy diets and physical activity, in line with current public health guidance. This qualitative research used co-production, a method which actively involves the relevant community, to identify and describe public health interventions to support a group of mothers of young children living in a low SES area.

METHODS

A group of 20 mothers took part in three in-depth qualitative interviews to discuss in detail the type of support that would be of value to them for the adoption and maintenance of healthy behaviours. The mothers were subsequently invited to take part in a public engagement project, a community-based self-help group.

RESULTS

Four themes explained the principles of interventions that would be of value in supporting the mothers with the adoption of healthy behaviours, namely, a community-based self-help group, support for the whole family and support in the home and influencing the environment. These were then further developed into two types of intervention (1) learning for self-help and family care, which encompassed the first three learning-based themes and (2) community of support, which covered influencing the environment and the experience of the community-based self-help group.

CONCLUSION

Co-production enabled a group of mothers of young children, from a low SES area, to describe the type of support that would help them with the establishment and maintenance of healthy lifestyle behaviours. A community-based self-help group warrants further research.

Child-directed marketing on packaged breakfast cereals in South Africa

OBJECTIVE

Childhood obesity is on the rise in South Africa (SA), and child-directed marketing (CDM) is one of the contributing factors to children's unhealthy food choices. This study assessed CDM on packaged breakfast cereals available in SA supermarkets and their nutritional quality.

DESIGN

Photographic images were examined in a descriptive quantitative study. A codebook of definitions of CDM was developed for this purpose. REDCap, an online research database, was used for data capturing, and SPSS was used for data analyses including cross-tabulations and one-way ANOVA.

SETTING

The current study was set in the Western Cape province of SA.

SUBJECTS

Photographic images of all packaged breakfast cereals sold in major retailers in the Western Cape province of SA in 2019 were studied.

RESULTS

CDM strategies were classified as direct (to the child) or indirect (through the parent). A total of 222 breakfast cereals were studied, of which 96·9 % had a nutritional or health claim, 95·0 % had illustrations, 75·2 % had product and consumption appeals, 10·8 % had characters, 10·8 % consisted of different appeals, 8·6 % alluded to fantasy and 7·7 % had role models. In breakfast cereals with direct CDM, the protein and fibre content was significantly lower than in breakfast cereals without direct CDM. This study found a significantly higher total carbohydrate and total sugar content in breakfast cereals with direct CDM than those without direct CDM.

CONCLUSION

CDM was highly prevalent in breakfast cereals sold in SA. Regulations to curb the marketing of packaged foods high in nutrients of concern is recommended.

Food purchasing practices in various retail settings and dietary intake: A cross-sectional survey of Australian adolescents

BACKGROUND/AIMS

Discretionary, energy-dense, nutrient-poor food and drinks are heavily marketed and readily available in retail settings frequented by adolescents. This study examines associations between food purchasing practices in various retail settings and dietary intake among Australian adolescents.

METHODS

Participants were students in years 8 to 11 (ages 12-17 years) who completed the 2009-10 (n = 13 790), 2012-13 (n = 10 309) or 2018 (n = 9102) National Secondary Students' Diet and Activity (NaSSDA) cross-sectional survey. Multistage stratified random sampling was used. An online survey completed at school assessed self-reported frequency of food purchasing practices in various retail settings and consumption of discretionary food, sugary drinks, fruit and vegetables. Generalised linear regression models examined associations between food purchasing practices and dietary behaviour.

RESULTS

Relative to students who brought lunch from home, those who purchased lunch from school or nearby outlets reported higher intake of discretionary food and sugary drinks and lower fruit intake. Buying lunch from school was also associated with lower vegetable intake. Buying food or drinks on the school commute, outside school grounds during school hours, from supermarket checkouts, and using mobile phone apps were each associated with higher discretionary food and sugary drink intake (all P < .01).

CONCLUSIONS

Purchasing food or drink in various retail settings is associated with higher intake of discretionary food and drink among Australian adolescents, and some purchasing practices appeared to displace fruit and vegetable intake. SO WHAT?: These findings highlight a need to improve the accessibility and promotion of healthier food and drink options in schools and other retail settings.

Children's reaction to sugar reduced dairy desserts in the context of the implementation of nutritional warning labels: An exploratory study

The aim of the present work was to explore children's reaction to sugar reduction in the context of the implementation of nutritional warnings in Uruguay. The study was composed of two sessions involving three evaluation conditions: tasting without package information, package evaluation without tasting, and tasting with package information. A total of 122 children, ages ranging between 6 and 13 years old (47% girls) were involved in the study. In the first session, children's hedonic and emotional response to a regular and a sugar-reduced chocolate dairy dessert (without other sweeteners) was evaluated. In the second session, children first evaluated their expected liking, emotional associations and choice of packages differing in the presence of warning labels for excessive sugar content and cartoon character (2x2 design). Finally, they tasted the selected sample in the presence of the package and evaluated their liking, emotional associations, and intention to re-taste it. Although sugar reduction led to a significant reduction in overall liking, the dessert with 40% sugar reduction showed a mean overall score of 6.5 in a 9-point hedonic scale and was described using positive emoji (, , ). When the desserts were tasted with package information, no significant differences in the expected overall liking of the regular and sugar-reduced dessert were found. Regarding the effect of packaging elements, the presence of a warning label highlighting excessive content of sugar did not have a significant effect on children's choice. Instead, children's choices were defined by the presence of a cartoon character. Results from the present work provide additional evidence about the feasibility of reducing the sugar content and sweetness of dairy products targeted at children and stress the need to regulate the use of cartoon characters on products with an unfavorable nutritional profile. Methodological recommendations for sensory and consumer research with children are also discussed.

Impact of front-of-pack nutrition labelling in consumer understanding and use across socio-economic status: A systematic review

An unhealthy diet is a leading contributor to the increasing burden of overweight and obesity. Front-of-pack labelling (FOPL) is being recognized as a policy strategy to promote healthier choices yet there is limited evaluation of FOPL to suggest if it is effective for all population subgroups. This systematic review aimed to assess the impact of FOPL on consumer understanding and usage across socio-economic gradients. Six electronic databases were searched through a systematic search process using key terms for FOPL and socioeconomic status (SES) from 2011 to March 2022 to include studies evaluating the effectiveness of FOPL. A narrative synthesis was conducted and the results were assessed according to the effects of FOPL on consumer awareness, understanding, and usage across SES. The review included 36 articles. In general, people of all SES groups were aware of and more likely to pay attention towards FOPL than the nutrition information panel provided on the back of the package. However, the understanding and usage were relatively poor, particularly in low SES groups. While studies conducted in low SES populations suggest FOPL increased the purchase intention of healthy products, the stratified analysis across SES showed less beneficial effects in low SES individuals. The findings highlight simplified and easy-to-understand FOPLs such as Nutri-score and traffic light labelling are likely to be effective for all populations including low SES groups. Overall, the review suggests FOPLs are more visible than the nutrition information panel and may guide healthier food choices for people of all SES backgrounds. It is unclear whether FOPL influences actual purchasing and food intake as there are insufficient studies comparing the effects among higher and lower SES populations.

Qualitative exploration of the impact of COVID-19 on the food environment of urban informal settlements of Dhaka, Bangladesh

OBJECTIVE

Our study explored the impact of the COVID-19 pandemic on the food environment from the perspective of the urban poor and food vendors.

DESIGN

This was a qualitative study conducted during September 2020 and February 2021.

SETTING

The study was carried out in two purposively selected informal settlements of Dhaka City, Bangladesh.

PARTICIPANTS

We conducted 21 in-depth interviews with residents of informal settlements and 10 key informant interviews with food vendors and food aid workers.

RESULT

The availability of staple foods was not disrupted during the pandemic but some perishables foods became more expensive due to supply chain disruptions and increased transportation costs. Limited market hours affected market access and mobility restrictions adversely affected local vendors. Cart vendors selling perishables incurred business losses they could ill afford. Demand for food reduced as employment disruption lead to reduced purchasing power and, therefore, reduction of quantity, quality and desirability of foods purchased. Respondents reported skipping meals and going hungry. The aid received was considered inadequate to meet needs.

CONCLUSION

The food environment of the urban poor was disrupted from both supply and demand sides and the organisational response (both government and non-government) was severely inadequate. The social safety net needs to be extended and redesigned to ensure food security and health for the urban working poor in the future.

Child Nutrition Outcomes and Maternal Nutrition-Related Knowledge in Rural Localities of Mbombela, South Africa

Poor nutrition outcomes among children have become one of the major public health concerns in South Africa, attributed to poor feeding practices and maternal nutrition-related knowledge with conflicting data. In view of this, a cross-sectional study was conducted to determine the association of nutrition outcomes of children aged under two years with feeding practices and maternal nutrition-related knowledge in Mbombela, South Africa. Mothers' nutrition-related knowledge was estimated using an adapted structured questionnaire on colostrum, continued breastfeeding, diarrhea prevention and treatment using oral rehydration solution, immunization, and family planning, and scored as excellent (80-100), good (60-79), average (40-59), and fair (0-39). This was along with questions on socio-demographic factors and obstetric history, as well as anthropometric measurements. Child nutrition outcomes were estimated by WHO classification using z-scores for stunting (length-for-age (LAZ)), underweight (weight-for-age (WAZ)), and thinness (body mass index-for-age (BAZ)). Using STATA 17, 400 pairs of children (8 ± 6 months) and their mothers (29 ± 6 years) participated in the study and were living in a poor socio-economic status environment. Half of children were stunted (50%) and over half (54%) were obese, while mothers were underweight (39%) and overweight (34%). In addition to one third of mothers reporting obstetric complications, two thirds, initiated breastfeeding within one hour of delivery, 30% exclusively breastfed, 48% introduced early complementary feeding, and 70% practiced mixed feeding. Twenty-eight percent (28%) of mothers had fair nutrition-related knowledge, while 66% had average knowledge, 6% good knowledge, and none of the mothers had excellent knowledge. A chi-square test showed that mothers' nutrition-related knowledge was significantly associated with child stunting. The final hierarchical logistic regression showed significant associations of stunting with mothers' nutrition-related knowledge (average: AOR = 1.92, 95%CI: 1.12-3.29), child's age (6-11 months: AOR = 2.63, 95%CI: 1.53-4.53 and 12-23 months: AOR = 3.19, 95%CI: 1.41-7.25), and education (completing Grade 12: AOR = 0.36, 95%CI: 0.15-0.86). Contextual and intensified interventions on continued education for mothers to gain accurate information on nutrition-related knowledge and feeding practices could ultimately enhance child nutrition outcomes in poorer settings. Efforts should therefore be made to ensure that nutrition knowledge is appropriately provided based on the phases of child growth from 0 to 2 years, even beyond infancy into school age.

BMI and well-being in people of East Asian and European ancestry: a Mendelian randomisation study

Previous studies have linked higher body mass index (BMI) to lower subjective well-being in adult European ancestry populations. However, our understanding of these relationships across different populations is limited. Here, we investigated the association between BMI and well-being in people of (a) East Asian and (b) European ancestry in the China Kadoorie Biobank (CKB) and UK Biobank (UKB), respectively. Mendelian randomisation (MR) methods were used to test the relationship between BMI with (a) health satisfaction and (b) life satisfaction. One-sample MR enabled us to test effects in men and women separately and to test the role of cultural contexts by stratifying our analyses by urban and rural home location in both China and the UK. Further, we implemented a control function method to test the linearity of the BMI-well-being relationship. We found evidence of different associations between BMI and well-being in individuals of East Asian versus European ancestry. For example, a genetically instrumented higher BMI tentatively associated with higher health satisfaction in people of East Asian ancestry, especially in females (ß: 0.041, 95% CI: 0.002, 0.081). In contrast, there was a robust inverse association between higher genetically instrumented BMI and health satisfaction in all European ancestry UKB participants (ß: -0.183, 95% CI: -0.200, -0.165, Pdifference < 1.00E-15). We also showed the importance of considering non-linear relationships in the MR framework by providing evidence of non-linear relationships between BMI and health and life satisfaction. Overall, our study suggests potential setting-specific causality in the relationship between BMI and subjective well-being, with robust differences observed between East Asians and Europeans when considering very similar outcomes. We highlight the importance of (a) considering potential non-linear relationships in causal analyses and (b) testing causal relationships in different populations, as the casual nature of relationships, especially relationships influenced by social processes, may be setting-specific.

Participatory prioritisation of interventions to improve primary school food environments in Gauteng, South Africa

BACKGROUND

In South Africa, overweight and obesity affect 17% of children aged 15-18. School food environments play a vital role in children's health, influencing dietary behaviours and resulting in high obesity rates. Interventions targeting schools can contribute to obesity prevention if evidence-based and context-specific. Evidence suggests that current government strategies are inadequate to ensure healthy school food environments. The aim of this study was to identify priority interventions to improve school food environments in urban South Africa using the Behaviour Change Wheel model.

METHODS

A three-phased iterative study design was implemented. First, we identified contextual drivers of unhealthy school food environments through a secondary framework analysis of 26 interviews with primary school staff. Transcripts were deductively coded in MAXQDA software using the Behaviour Change Wheel and the Theoretical Domains Framework. Second, to identify evidence-based interventions, we utilised the NOURISHING framework and matched interventions to identified drivers. Third, interventions were prioritised using a Delphi survey administered to stakeholders (n = 38). Consensus for priority interventions was defined as an intervention identified as being 'somewhat' or 'very' important and feasible with a high level of agreement (quartile deviation ≤ 0.5).

RESULTS

We identified 31 unique contextual drivers that school staff perceived to limit or facilitate a healthy school food environment. Intervention mapping yielded 21 interventions to improve school food environments; seven were considered important and feasible. Of these, the top priority interventions were to: 1) "regulate what kinds of foods can be sold at schools", 2) "train school staff through workshops and discussions to improve school food environment", and affix 3) "compulsory, child-friendly warning labels on unhealthy foods".

CONCLUSION

Prioritising evidence-based, feasible and important interventions underpinned by behaviour change theories is an important step towards enhanced policy making and resource allocation to tackle South Africa's childhood obesity epidemic effectively.

Perceptions of food environments in the school and at home during Covid-19: An online cross-sectional study of parents, teachers and experts from Latin America

BACKGROUND

The high prevalence of overweight and obesity in children from Latin America (LA) have been related to obesogenic food environments. Besides, the negative effects of the Covid-19 pandemic should also be considered. The objective of this research was to describe and compare the perceptions of parents, teachers, and experts in LA of food environments at home and school that favor healthy habits in schoolchildren in pre Covid-19 stage and during the pandemic.

METHODS

This study used a survey self-reporting regarding conditions at home and the school favoring healthy habits, for three profiles: parents, primary school teachers, and experts. A fisher exact test was used to establish the difference between the response categories between countries and profiles. Logistic regression models were used to determine the probability of response in the levels of importance adjusted for sex and nationality.

RESULTS

Information from 954 questionnaires was reported: 48.4% experts, 32.0% teachers, and 19.6% parents. There were differences in the perception of food environments at school between profiles (p<0.001). In multivariate logistic regression models, experts and teachers were 20% more likely to give greater importance to elements of the food environment at school compared to parents (p<0.001).

CONCLUSIONS

Our findings showed that parents were less likely to perceive important elements of the school food environment compared to experts and teachers. Interventions are required to improve healthy eating environments that consider children's interpersonal mediators.

Adult food choices in association with the local retail food environment and food access in resource-poor communities: a scoping review

BACKGROUND

There is a growing body of research on local retail food environments globally in both urban and rural settings. Despite this, little research has been conducted on adult food choices, local retail environments, and healthy food access in resource-poor communities. The purpose of this study is therefore to provide an overview of the evidence on adult food choices (measured as dietary intake) in association with the local retail food environment and food access in resource-poor communities (defined as low-income communities and/or households).

METHODS

We searched nine databases for studies published from July 2005 to March 2022 and identified 2426 records in the primary and updated search. Observational studies, empirical and theoretical studies, focused on adults ≤ 65 years, published in English peer-reviewed journals, examining local retail food environments and food access, were included. Two independent reviewers screened identified articles using the selection criteria and data extraction form. Study characteristics and findings were summarized for all studies and relevant themes summarized for qualitative and mixed methods studies.

RESULTS

A total of 47 studies were included in this review. Most studies were cross sectional (93.6%) and conducted in the United States of America (70%). Nineteen (40.4%) studies assessed the association between food choice outcomes and local retail food environment exposures, and evidence on these associations are inconclusive. Associations of certain food choice outcomes with healthy food retail environments were positive for healthy foods (in 11 studies) and unhealthy foods (in 3 studies). Associations of certain food choice outcomes with unhealthy retail food environment exposures were positive for unhealthy foods in 1 study and negative for healthy foods in 3 studies. In 9 studies, some of the food choice outcomes were not associated with retail food environment exposures. A healthy food store type and lower food prices were found to be major facilitators for healthy food access in resource-poor communities, while cost and transportation were the main barriers.

CONCLUSIONS

More research is needed on the local retail food environment in communities in low- and middle-income countries to develop better interventions to improve food choices and access to healthy foods in resource-poor communities.

Front-of-Package Nutrition Labeling and Its Impact on Food Industry Practices: A Systematic Review of the Evidence

The obesity epidemic has become a major public health concern globally, and the food supply is a significant driver of this trend. Front-of-package (FOP) labels have been implemented in many countries to encourage healthier food choices. This systematic review aimed to examine the effect of FOP label implementation on food manufacturers' practices. A comprehensive search of multiple databases was conducted following PRISMA guidelines, identifying 39 relevant articles from 1990 to 2021. The studies indicated that FOP labels conveying intuitive information influenced product reformulation, whereas those with numerical information without specific guidance had no impact on reducing unhealthy nutrients. The most common outcomes were sodium, sugar, and calorie reduction. Mandatory policies reported higher and more consistent effects on product reformulation compared to voluntary approaches. Voluntary FOP labeling resulted in low uptake and tended to be applied to healthier products. Food manufacturers responded to FOP labeling heterogeneously, depending on the label design and type of enforcement. FOP label implementation can reduce nutrients of concern but food manufacturers behave strategically by labeling healthier choices. This review provides recommendations for maximizing the benefits of using FOP labels to prevent obesity, and findings can inform future public health research and policymaking.

National income and macro-economic correlates of the double burden of malnutrition: an ecological study of adult populations in 188 countries over 42 years

BACKGROUND

The double burden of malnutrition (DBM) represents a growing global challenge with adverse health and economic consequences. We aimed to investigate the associative roles of national income (gross domestic product per capita [GDPPC]) and macro-environmental factors on the DBM trends among national adult populations.

METHODS

In this ecological study we assembled extensive historical data on GDPPC from the World Bank World Development Indicators database and population-level DBM data of adults (aged ≥18 years) from the WHO Global Health Observatory database in 188 countries over 42 years (1975-2016). In our analysis, a country was considered to have the DBM in a year when adult overweight (BMI ≥25·0 kg/m²) and underweight (BMI <18·5 kg/m²) prevalence was each 10% or more in that year. We used a Type 2 Tobit model to estimate the association of GDPPC and selected macro-environmental factors (globalisation index, adult literacy rate, female share in the labour force, share of agriculture in the national gross domestic product [GDP], prevalence of undernourishment, and percentage of principal display area mandated to be covered by health warnings on cigarette packaging) with DBM in 122 countries.

FINDINGS

We find a negative association between GDPPC and the likelihood of a country having the DBM. However, conditional on its presence, DBM level exhibits an inverted-U shaped association with GDPPC. We found an upward shift in DBM levels from 1975 to 2016 across countries at the same level of GDPPC. Among the macro-environmental variables, share of females in the labour force and share of agriculture in the national GDP are negatively associated with DBM presence in a country, whereas the prevalence of undernourishment in the population is positively associated. Further, globalisation index, adult literacy rate, share of females in the labour force, and health warnings on cigarette packaging are negatively associated with DBM levels in countries.

INTERPRETATION

DBM level in national adult populations rises with GDPPC until US$11 113 (in 2021 constant dollar terms) and then starts declining. Given their current GDPPC levels, most low-income and middle-income countries are thus unlikely to have a decline in the DBM levels in the near future, ceteris paribus. Those countries will also be expected to experience a higher DBM level at similar levels of national income than were historically experienced by the current high-income countries. Our findings point to a further intensification of the DBM challenge in the near future for the low-income and middle-income countries as they continue to have income growth.

FUNDING

None.

Estimation of cancer mortality attributable to excess body weight during 2006–2015 in China

BACKGROUND

Cancer is one of the most common causes of death. Excess body weight (EBW), a risk factor for cancer, is highly prevalent in China. We aimed to estimate the number and proportion of cancer deaths attributed to EBW and their changes during 2006-2015 in China.

METHODS

Population attributable fractions in 2006, 2010, and 2015 were calculated with 1) prevalence of overweight/obesity, exacted from the China Health and Nutrition Survey conducted in 8-9 provinces of China in 1997, 2000, and 2004; 2) relative risks for EBW and site-specific cancers, obtained from previous studies; 3) data on cancer deaths in 2006, 2010, and 2015, originated from the Chinese Cancer Registry Annual Report.

RESULTS

In 2015, EBW contributed to 45,918 (3.1% of all) cancer deaths in China, with 24,978 (2.6%) in men and 20,940 (3.8%) in women. By region, the fraction of cancer deaths attributable to EBW ranged from 1.6% (West) to 4.1% (Northeast). Cancers of liver, stomach, and colorectum were the main EBW-attributable cancers. The fractions of cancer deaths attributable to EBW were 2.4% (95%CI: 0.8-4.2%) in 2006, 2.9% (95%CI: 1.0-5.2%) in 2010, and 3.1% (95%CI: 1.0-5.4%) in 2015, respectively, and increased for all gender, region, and cancer site during 2006-2015.

CONCLUSIONS

The proportion of cancer deaths attributed to EBW was higher in women and Northeastern China, with an upward trend in the recent decade. A combination of comprehensive and individualized measures is necessary to reduce the prevalence of EBW and related cancer burden in China.

Trends in adults' energy imbalance gaps over two decades in Belgium using system dynamics modelling

BACKGROUND

The energy imbalance gap (EIG) represents the average daily difference between energy intake and energy expenditure. The maintenance energy gap (MEG) captures the increased energy intake needed to maintain a higher average bodyweight compared with an initial distribution of bodyweight. This study quantified the dynamics of the EIG and MEG over time and across different genders/regions/BMI groups for Belgian adults.

METHODS

A validated system dynamics model was adapted to estimate the trends/dynamics of the EIG among different subpopulations over two decades in Belgium. The model was calibrated using data from the six Belgian national Health Interview Surveys (1997, 2001, 2004, 2008, 2013, 2018).

RESULTS

EIG was negative for all BMI groups among Belgian females in 2018, implying the start of a decrease in prevalence of overweight/obesity in this subpopulation. However, this was not the case among Belgian males. Flemish and Walloon males had positive EIGs across BMI groups in 2018, however, Brussels' males showed negative EIGs across BMI groups. Flemish and Brussels' females showed negative EIGs across all BMI groups in 2018, while Walloon females showed positive EIGs across almost all BMI groups. According to the MEG, Belgian men consumed (and expended) on average 59 kcal/day more in 2018 than in 1997 to maintain their heavier body weight. The MEG for Belgian women was 46 kcal/day in 2018, triple the MEG in 2004.

CONCLUSIONS

The detailed heterogeneous trends of the EIG describe the obesity patterns for different subpopulations in Belgium and could be used to model the differential effects of specific nutrition policies targeting energy intake.

Beyond the Plate: Uncovering Inequalities in Fruit and Vegetable Intake across Indonesian Districts

BACKGROUND

Non-communicable diseases (NCDs) are responsible for the deaths of 41 million individuals every year, with 77% of them occurring in low- and middle-income countries. Among the main NCD risk factors, inadequate intake of fruits and vegetables (FV) was one of the leading causes of death in 2019. Our study aims to identify disparities in inadequate FV intake among adults in 514 districts. We utilized the latest Indonesian Basic Health Survey 2018 to conduct geospatial and quantitative analyses. We used the World Health Organization's definition of inadequate FV intake, which refers to consuming less than five servings of fruit and vegetables daily. We analyzed inadequate FV intake among adults over the age of 18 years, as well as by gender and age group (including young adults 18-24 years, adults 25-59 years, and older adults 60+ years). Our study showed an alarmingly high prevalence of inadequate FV intake among adults, with 96.3% in 2018. The prevalence of inadequate FV intake drastically varied across 514 districts, ranging from 70.1% to 100%. Notable geographic and socioeconomic disparities were observed across the districts studied. Rural districts exhibited a higher prevalence of inadequate FV intake, translating to poorer diets, particularly among females and older adults, when compared to their urban counterparts. Interestingly, districts within more developed regions had poorer FV diets than those in less developed regions. Although districts with lower incomes generally had poorer FV diets, the association was not significant in multivariate analysis. However, districts with lower levels of education demonstrated poorer FV diets, especially among females, adults, and older adults. Despite its limitations, our study provides crucial insights for health policies in Indonesia and other LMICs.

Resilience and vulnerabilities of urban food environments in the Asia-Pacific region

Rapid urbanisation in the Asia-Pacific region is associated with complex changes to urban food environments. The impact of changing food environments on food purchasing and consumption and the diets and nutritional status of vulnerable groups, especially women and young children, is not well researched in low- and middle-income country cities. This paper aimed to examine: the risks and opportunities for healthy diets for low income populations offered by modernising urban centres; the concept of food deserts in relation to urban food environments in the Asia-Pacific region and how these could be mitigated; and measures to strengthen the resilience of food environments in the region using a case study of the impact of COVID-19 on informal food vendors. Our findings indicate that the dynamic changes in urban food environments in the Asia- Pacific region need to be understood by examining not only modern retail food outlets but also wet markets and informal food outlets, including street foods. Efforts should be made to ensure both modern and traditional outlets provide complementary platforms for convenient, affordable and accessible nutritious foods for urban populations. The resilience of urban food environments to environmental, physical and socio-economic shocks can be strengthened by shortening food supply chains and maximising food production in cities. Support mechanisms targeting urban informal food outlets and street vendors can also strengthen resilience and improve food security. Further research is needed on the impact of urbanising food environments on consumer choices, preferences, diets and health outcomes.

Understanding Misimplementation in U.S. State Health Departments: An Agent-Based Model

INTRODUCTION

The research goal of this study is to explore why misimplementation occurs in public health agencies and how it can be reduced. Misimplementation is ending effective activities prematurely or continuing ineffective ones, which contributes to wasted resources and suboptimal health outcomes.

METHODS

The study team created an agent-based model that represents how information flow, filtered through organizational structure, capacity, culture, and leadership priorities, shapes continuation decisions. This agent-based model used survey data and interviews with state health department personnel across the U.S. between 2014 and 2020; model design and analyses were conducted with substantial input from stakeholders between 2019 and 2021. The model was used experimentally to identify potential approaches for reducing misimplementation.

RESULTS

Simulations showed that increasing either organizational evidence-based decision-making capacity or information sharing could reduce misimplementation. Shifting leadership priorities to emphasize effectiveness resulted in the largest reduction, whereas organizational restructuring did not reduce misimplementation.

CONCLUSIONS

The model identifies for the first time a specific set of factors and dynamic pathways most likely driving misimplementation and suggests a number of actionable strategies for reducing it. Priorities for training the public health workforce include evidence-based decision making and effective communication. Organizations will also benefit from an intentional shift in leadership decision-making processes. On the basis of this initial, successful application of agent-based model to misimplementation, this work provides a framework for further analyses.

Do Peers Matter? Unhealthy Food and Beverages Preferences among Children in a Selected Rural Province in China

With the growing problem of childhood obesity, unhealthy dietary preferences among children have become an issue of worldwide concern. This article examines the class-peer effect of these preferences using random class assignment data from a field survey. The results show significant positive peer effects for both unhealthy food and beverages preference. These results remained robust after controlling for endogeneity issues using instrumental variables. Further analysis of the mechanism of peer effect shows that the better the relationship between classmates, the greater the influence peers have on unhealthy diet preferences among rural children. The same peer effect is found in situations where it is easy for children to obtain unhealthy food and beverages. The analysis of heterogeneity finds that the peer effects of unhealthy dietary preferences are stronger for girls, older students, and obese students. This paper also discusses the role of parents and schools in mitigating the peer effect. This paper proposes policy recommendations for rural areas in China to improve dietary preferences in children. These results may also provide useful guidelines for policy in other developing countries.

Sex modifies the renal consequences of high fructose consumption introduced after weaning

After lactation, many children consume fructose-rich processed foods. However, overconsumption of these foods can predispose individuals to non-communicable chronic diseases, which can have different repercussions depending on the sex. Thus, we evaluated the effects of fructose overload introduced after weaning on the renal function of young rats of both sexes.

Methods: After weaning, male and female offspring of Wistar rats were assigned to drink water (the male/water and female/water groups) or 20% D-fructose solution (male/fructose and female/fructose groups). Food and water or fructose solution was offered ad libitum. Rats were evaluated at 4 months. Parameters analyzed: blood pressure, body weight, triglyceride levels, glomerular filtration rate, sodium, potassium, calcium, and magnesium excretion, macrophage infiltration, and eNOS and 8OHdG expression in renal tissue. CEUA-UNIFESP: 2757270117.

Results: Fructose intake affected the blood pressure, body weight, and plasma triglyceride in all rats. Glomerular filtration rate was significantly reduced in males that received fructose when compared to that of the control group. Sodium and potassium excretion decreased in all fructose-treated rats; however, the excreted load of these ions was significantly higher in females than in males. In the female control group, calcium excretion was higher than that of the male control group. Fructose overload increased magnesium excretion in females, and also increased macrophage infiltration and reduced eNOS expression in both males and females.

Conclusion: Fructose overload introduced after weaning caused metabolic and renal changes in rats. Renal function was more affected in males; however, several significant alterations were also observed in the female-fructose group.

Barriers and Facilitators Related to the Adoption of Policies to Reduce Ultra-Processed Foods Consumption: A Scoping Review

Cost-effective regulatory and fiscal interventions are recommended to address non-communicable diseases. While some countries are advancing regarding these actions, others have found it difficult to approve them.

AIM

to conduct a scoping review to answer the question "What factors have influenced the adoption of food taxes, front-of-pack labeling and restrictions on marketing to children?".

METHODS

A scoping review was developed from four databases. Studies that described and analyzed policy processes were included. Analysis was performed to identify the barriers and enablers mentioned under the guidance of Swinburn et al., Huang et al., Mialon et al., and Kingdon.

RESULTS

168 documents were identified, describing experiences from five regions or groups and 23 countries, which have generated 1584 examples of 52 enablers (689 examples; 43.5%) and 55 barriers (895 examples; 56.5%) that may have influenced policies. The main enablers were related to the government environment and governance and to civil society strategies. Corporate political activity strategies were the main examples of barriers.

CONCLUSIONS

This scoping review consolidated barriers and facilitators related to policies aimed at reducing ultra-processed foods consumption, demonstrating that factors related to the actions of governments and civil society are the main facilitators. On the other hand, as the most interested actor in promoting the consumption of these products, the strategies adopted by the companies that produce these products constitute the main barrier to these policies in all the studied countries and should be overcome.

Trends in baseline HbA1c and body-mass index in randomised placebo-controlled trials of type 2 diabetes from 1987 to 2022: a systematic review and meta-analysis

BACKGROUND

Curbing or reversing high glycated hemoglobin (HbA1c) and body mass index (BMI) are two essential parts in the clinical management of type 2 diabetes (T2D). We delineated the changing patterns of the baseline HbA1c and BMI in patients with T2D from placebo-controlled randomised trials to reflect the unmet clinical needs.

METHODS

PubMed, Medline, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched from inception to December 19, 2022. Placebo-controlled trials of T2D with reports of baseline HbA1c and BMI were included, of which summary data from published reports were extracted. Pooled effect sizes of baseline HbA1c and BMI of from studies published in the same year were computed in Random-effects model due to the high level of heterogeneity among studies. The main outcome was correlations between the pooled baseline HbA1c, the pooled baseline BMI, and study years. This study was registered in PROSPERO as CRD42022350482.

FINDINGS

We identified 6102 studies, of which 427 placebo-controlled trials with 261, 462 participants were finally included in the study. Baseline HbA1c level declined with time (Rs = -0.665, P ＜ 0.0001, I² = 99.4%). Baseline BMI increased over the past 35 years (R = 0.464, P = 0.0074, I² = 99.4%), rising by around 0.70 kg/m² per decade. Patients with BMI ≤25.0 kg/m² dropped substantially from the half in 1996 to none in 2022. Patients with BMI ranging from 25 kg/m² to 30 kg/m² stabilized at 30-40% since 2000.

INTERPRETATION

A substantial decline in baseline HbA1c levels and a constant increase in baseline BMI levels was found in placebo-controlled trials through the past 35 years, which indicated the improvement in glycemic control and the urgency for the management of obesity in T2D.

FUNDING

National Natural Science Foundation of China (No.81970698), Beijing Natural Science Foundation (No.7202216) and National Natural Science Foundation of China (No.81970708).

The Neural Processes in Food Decision-making and their Effect on Daily Diet Management in Successful and Unsuccessful Restrained Eaters

This study aimed to explore the neural mechanisms underlying food decision making in unsuccessful restrained eaters (US-REs) and successful restrained eaters (S-REs). During a functional magnetic resonance imaging scan, participants were required to choose between pairs of high- and low-calorie foods under the following conditions: the congruent condition (choose between high- and low-calorie foods with the same level of tastiness) and incongruent condition (choose between high-calorie foods tastier than the corresponding low-calorie foods). Subsequently, the participants' diets were monitored for one week. The behavioral results showed that US-REs (n = 28) chose more high-calorie foods than S-REs (n = 26); in contrast, S-REs spent more time in choosing for the incongruent than the congruent condition. The fMRI results found that US-REs exhibited more activity in reward regions (caudate and thalamus) than S-REs in the congruent condition. In the incongruent condition, S-REs showed stronger functional connectivity between the conflict-monitoring region (anterior cingulate cortex) and inhibitory-control regions (inferior frontal gyrus [IFG] and medial frontal gyrus) than US-REs. In both the conditions, increased activation of the insula, putamen, middle frontal gyrus, and IFG could predict increased food intake among US-REs in the following week. Furthermore, in both the conditions, increased IFG activation could predict decreased food cravings among S-REs during the following week. Our results suggest that US-REs have a strong reward response to food. Compared to US-REs, S-REs are more guided more by the goal of weight control, and exhibit strong functional connections between the conflict-monitoring and inhibitory-control regions. Therefore, eating enjoyment and weight-control goals influence restrained eating in daily life.

Exploring Intended and Unintended Reactions to Healthy Weight and Lifestyle Advertisements: An Online Experiment

BACKGROUND

To address concerns that healthy weight and lifestyle campaigns (HWLCs) could have unintended psychological or behavioral consequences, this study tested reactions to TV advertisements from two HWLCs: LiveLighter^® (employs graphic health effects messaging) and Swap It Don't Stop It (employs animation and light-hearted messaging).

METHODS

An online between-subjects experiment tested reactions to one of five advertisements: "Toxic Fat"; "Sugary Drinks" (both from LiveLighter); "Become a Swapper"; "How to Swap It" (both from Swap It); and "HSBC Bank" (control) among 2,208 adults from Western Australia and Victoria, Australia. Responses assessed were cognitive and emotional reactions, behavioral intentions, internalized weight bias, antifat attitudes, self-esteem and body dissatisfaction.

RESULTS

The HWLC advertisements prompted favorable cognitive reactions and weak to neutral positive and negative emotional responses. HWLC advertisements promoted stronger intentions to engage in adaptive lifestyle behaviors compared with the control advertisement. Intention to engage in maladaptive behaviors (e.g., skipping meals) was low overall and did not differ by condition. Compared with the control condition, participants who saw LiveLighter "Sugary Drinks" showed weaker disagreement with antifat attitudes; however, mean antifat attitude scores were still at the low end of the scale. HWLC advertisements did not promote internalized weight bias, reduced self-esteem or body dissatisfaction compared with the control advertisement.

CONCLUSIONS

Overall, HWLC advertisements performed favorably compared with the control advertisement and showed no clear evidence of adverse impacts. Findings suggest HWLC advertisements may not promote negative psychological and behavioral consequences and can continue to be used in obesity prevention efforts.

Effectiveness of Displaying Traffic Light Food Labels on the Front of Food Packages in Japanese University Students: A Randomized Controlled Trial

Nutrition labeling on the front of food packages has been implemented worldwide to help improve public health awareness. In this randomized double-blind controlled trial, we used a Google Forms questionnaire to evaluate the effectiveness of nutrition labeling on food packages in university students. The questionnaire, ultimately completed by 247 students, included 15 dietary images from which they were asked to choose what they wanted to eat for breakfast, lunch, and dinner the following day. For the interventional (traffic light food [TLF]) group only, TLF labels were displayed on dietary images. This group had a significantly higher proportion of people conscious of healthy eating during all meals than the control group, and the effect of TLF labeling on choosing meals was the highest for lunch. In addition to the indicated nutritional components, the TLF group had a significantly higher proportion of people who were conscious of the ones of protein and dietary fiber that were not indicated on the label. The use of TLF labels resulted in an increase in the proportion of people choosing a healthy diet as well as being conscious of their nutritional components. Therefore, the use of TLF labels may help promote healthy dietary choices in Japan.

Health and Economic Outcomes Associated With Musculoskeletal Disorders Attributable to High Body Mass Index in 192 Countries and Territories in 2019

Importance

The degree to which health and economic outcomes of musculoskeletal disorders are attributable to high body mass index (BMI) has not been quantified on a global scale.

Objective

To estimate global health and economic outcomes associated with musculoskeletal disorders-low back pain (LBP), gout, and osteoarthritis attributable to high BMI in 2019.

Design, Setting, and Participants

This cross-sectional study used data of 192 countries and territories from the Global Burden of Diseases, Injuries, and Risk Factors Study, World Health Organization Global Health Expenditure, World Bank, and International Labour Organization databases. Data analyses were conducted from February 24 to June 16, 2022.

Main Outcomes and Measures

Prevalence, years lived with disability (YLDs), health care costs, and productivity losses due to morbidity from LBP, gout, and osteoarthritis attributable to high BMI by region and country. Prevalence and YLDs were calculated with the population attributable fraction approach. The economic burden, including health care costs and productivity losses due to morbidity, was also quantified. Health care costs borne by the public, private, and out-of-pocket sectors were estimated based on their corresponding payment shares. Productivity losses were estimated based on the output per worker. A sensitivity analysis was conducted to arrive at the base, minimum, and maximum estimates (ie, uncertainty interval [UI]) by using the mean, lower, and upper bounds of all input variables.

Results

High BMI was estimated to be responsible for 36.3 million (UI, 18.4-61.0 million), 16.9 million (UI, 7.5-32.5 million), and 73.0 million (UI, 32.4-131.1 million) prevalent cases of LBP, gout, and osteoarthritis, respectively, which accounted for 7.3 million (UI, 3.0-15.0 million) YLDs across 192 countries and territories in 2019. Globally, the YLDs of musculoskeletal disorders attributable to high BMI accounted for 1.0% of all-cause YLDs in the working-age population aged 15 to 84 years. The global total costs of musculoskeletal disorders attributable to high BMI reached $180.7 billion (UI, $83.8-$333.1 billion), including $60.5 billion (UI, $30.7-$100.5 billion) in health care costs and $120.2 billion (UI, $53.1-$232.7 billion) in productivity losses. In terms of the global health care costs, 58.9% ($35.6 billion; UI, $17.8-$59.6 billion) was borne by the public sector, 24.0% ($14.5 billion; UI, $7.8-$23.2 billion) by the private sector, and 17.1% ($10.3 billion; UI, $5.1-$17.6 billion) by the out-of-pocket sector. On average, the total costs accounted for 0.2% of global gross domestic product. Great inequalities in the disease and economic burden existed across regions and countries. Nearly 80% of global health care (82.4%) and morbidity-related costs (82.9%) were paid by high-income countries, whereas more than 60% (61.4%) of global YLDs occurred in middle-income countries.

Conclusions and Relevance

In this cross-sectional study of 192 countries and territories, a substantial amount of the health and economic impact of musculoskeletal disorders was attributable to high BMI. Developing effective policies and active participation from health professionals to prevent excessive weight gain are needed. More available estimates are also needed to facilitate a global analysis.