Serving size guidance for consumers: is it effective?

Nutritional Quality of Breakfast Cereals on the French, Belgian and Luxembourg Markets: Which Cereals for Children?

Objective: Analyse the breakfast cereal market to help to help healthcare professionals to guide parents in choosing healthy products for their children. Study design: Observational study of the breakfast cereals available in the biggest supermarkets, discount stores and organic chains in France, Belgium and Luxembourg. Methods: An analysis of nutritional qualities using three indicators: Nutri-Score (initial and modified version), WHO Europe nutrient profile model, and Nova. Results: 645 products were listed; 559 excluding duplicates. A total of 28.8% are marketed to children and make up the group of "children's" cereals, 62.1% of cereals are Muesli, Oats and other cereal flakes (MOCF), and 54.9% are "organic". The study shows that "children's" cereals have a poorer nutritional profile: a higher proportion of Nutri-Score D, higher sugar content, lower fibre content, less conformity with the WHO Europe nutrient profile model and a higher proportion ofultra-processed. On the other hand, MOCF and "organic" products generally have a better nutritional profile: less sugar, more fibre, more Nutri-Score A, less Nutri-Score D and fewer ultra-processed products. Conclusions: Parents should therefore opt for cereals that do not bear any reference to children on the packaging.

Food portion sizes: trends and drivers in an obesogenic environment

The prevalence of overweight and obesity in children and adults has increased worldwide. A strong environmental factor contributing to the obesity epidemic is food portion size (PS). This review evaluates the current evidence linking food PS to obesity, examines the effects of PS on energy intake (EI), and discusses the drivers of food PS selection. The leading causes of the rise in PS include globalisation, intensive farming methods, the impact of World War II, due to shortage of staple foods, and the notion of 'waste not, want not'. Large PS of energy-dense foods may stimulate overconsumption, leading to high EI levels. However, the studies have not shown a cause-and-effect relationship, due to confounding factors. Important mechanisms explaining the attractiveness of larger PS leading to higher EI levels are value for money, portion distortion, labels on food packaging, and tableware. Consumers depend on external rather than internal PS cues to guide consumption, irrespective of satiety levels. Further research is recommended on food consumption patterns to inform policymakers and provide information and insights about changes in diet.

Role of Portion Size in the Context of a Healthy, Balanced Diet: A Case Study of European Countries

Over the past decades, a generalised increase in food portion sizes has probably contributed to the growing global obesity epidemic. Increasing awareness of appropriate portion sizes could contribute to reversing this trend through better control of calorie intake. In this study, a comparison of standard portion sizes in European countries for various food categories shows a wide variability of their importance for food, nutrient, and energy consumption according to government and institutional websites. On the other hand, the overall averages appear to be largely in line with the values indicated by the Italian Society of Human Nutrition, which is the most comprehensive and detailed document among those evaluated. The exceptions are milk and yoghurt, for which the reference portions in Europe are generally higher, and vegetables and legumes, for which portions are smaller than those reported in the Italian document. Moreover, the portion sizes of staple foods (e.g., pasta and potatoes) vary according to different food traditions. It is reasonable to consider that the creation of harmonised standard reference portions common to the European countries, based on international guidelines and scientific evidence, would significantly contribute to consumers' nutritional education and ability to make informed choices for a healthy diet.

Consumer Understanding of the Australian Dietary Guidelines: Recommendations for Legumes and Whole Grains

Dietary guidelines provide evidence-based guidance for healthy individuals to improve dietary patterns, although they are most often based on individual foods or food groups. Legumes are a class of food included in current Australian Dietary Guidelines (ADG), mentioned in two of the five food groups, as a vegetable and as an alternative to meat. Whole grain consumption is encouraged in ADG via the statement focused on cereal grains due to their health-promoting properties. Despite their prominence in guidelines, average legume and whole grain consumption in Australia remains lower than recommendations outlined in the ADG. This exploratory study aimed to understand consumer perspectives of wording utilised in dietary guidelines specifically focused on legumes and whole grains. Based on the analysis, there was a significant preference for the statement “each day, consume at least one serve of legumes either as a serve of vegetables or as an alternative to meat” (p < 0.05), which provides a specific frequency and quantification for legume consumption. For whole grain, the significantly preferred statement was “choose whole grain products over refined grains/white flour products whenever you can” indicating a less prescriptive option. Effective messaging in guidelines could consider greater specificity regarding frequency, quantity and quality of foods recommended. This exploratory study suggests an improvement in the adoption and consumption of legumes and whole grains in the Australian diet may be better facilitated through consumer-tested messaging.

Are foods 'healthy' or 'healthier'? Front-of-pack labelling and the concept of healthiness applied to foods

While food-based dietary guidelines have been widely disseminated for decades to improve nutritional knowledge in the population about healthy diets, more recent interventions such as front-of-pack labelling have made the differences between the two approaches apparent. While food-based dietary guidelines provide the overarching framework and benchmarks for a healthy diet, based on the current knowledge of the associations between various dietary components and health outcomes, front-of-pack labelling provides guidance to select a specific food, either within a food group or among similar foods belonging to various brands. Labelling foods as 'healthy' or 'unhealthy' raises multiple questions on the criteria used to define the terms and the implications of assigning an absolute healthiness value to an individual food in the context of complex diets. Gradual systems may provide more relative assessments and avoid dichotomisation. The present article presents the inherent differences and the complementarity of food-based dietary guidelines and food choice guidance in the context of food labelling.

Integrating nutrition into the mathematics curriculum in Australian primary schools: protocol for a randomised controlled trial

Background

Nutrition education programs in schools have been effective in improving children’s knowledge and behaviours related to food and nutrition. However, teachers find it challenging to implement such programs due to overcrowded curricula. Integrating nutrition with core subjects such as mathematics could potentially address time constraints and improve the learning of both. The primary aim of this randomized controlled trial (RCT) is to evaluate the impact of a cross-curricular nutrition and mathematics program on primary school students’ portion size estimation skills. Secondary aims include impact on their nutrition knowledge, attitudes towards mathematics and evaluating the quality of the lessons.

Methods

Twelve Year 3–4 classes from Catholic schools in New South Wales, Australia will be randomised to intervention (n = 6) or control (n = 6) groups. Teachers in the intervention group will receive a professional development workshop and resources to teach 4–5 lessons on portion size and measurements across 1–4 weeks. Outcome measures include portion size estimation skills, nutrition knowledge and attitudes towards mathematics, with data collected during three school visits (pre-intervention, immediately post-intervention, 4 weeks post-intervention). Additionally, teaching quality will be assessed in both intervention and control groups and process evaluation undertaken using teacher interviews and student focus groups.

Discussion

This RCT uses an innovative approach to improve both nutrition and mathematics related learning outcomes among primary school children. It has the potential to impact teaching practices regarding integration of nutrition into curricula and enhance the implementation of nutrition education interventions.

Trial registration

Australian and New Zealand Clinical Trials Register ACTRN12619001071112 31/07/2019.

Translating "protein foods" from the new Canada's Food Guide to consumers: knowledge gaps and recommendations

The revised version of Canada's Food Guide, released in January 2019, issued new guidance by combining meat and alternatives with milk and alternatives into a single group called "protein foods" and emphasized selecting plant-based foods from this category more often. Though the changes represent a simple depiction of a healthy plate, the new Food Guide has opened knowledge gaps about protein foods and exposed new concerns about the interpretation and implementation of the Food Guide among vulnerable groups, particularly children and the elderly. To address key knowledge and research gaps, nutrition leaders need to reach a consensus on key messages to best inform the development of tools and resources to support practitioners in translating messages to consumers, including foodservice standards. Among consumers, families with young children are a primary target for these resources as they develop their life-long habits to ensure they have the knowledge and skills to select, prepare, and consume nutrient-rich protein foods. The new Food Guide provides an opportunity to address the existing knowledge gaps, develop tools and resources to support health professionals, and design interventions that will help Canadian families choose, prepare, and eat nutrient-rich protein foods. Novelty An updated Canadian regulatory framework is needed for protein labelling and content/health claims. There are knowledge gaps about protein foods consumption and food literacy needed to optimize nutritional health. Mandatory nutrition policies are needed to safeguard the provision of high-quality protein foods across institutions that serve children and older adults.

A systematic review of recall errors associated with portion size estimation aids in children

To reduce errors in portion size estimation, a number of aids have been developed and tested. This systematic review synthesizes what is known about error associated with use of different portion size estimation aids (PSEAs) within self-reported dietary recall studies in children (aged ≤18 years). Eight electronic databases were searched using relevant keywords. From 8184 records identified and screened, 327 full texts were retrieved, with 10 records representing 9 studies meeting inclusion criteria. Studies using proxy reporting were excluded. Thirteen PSEAs were identified. To facilitate comparisons between different types of aids they were categorized into 'physical 2-dimensional (2D)', 'digital 2D' and '3-dimensional' PSEAs. Seven were physical 2D (e.g. food atlas), two were digital 2D (i.e. computer-based), and four were 3D (e.g. modelling clay, household items). Comparisons of PSEAs within studies found the smallest estimation errors for digital 2D and largest for 3D aids. Errors in relation to food type were varied, with portions of amorphous foods overestimated in multiple studies. No effects for recall interval time or sex were identified. One study reported a significant improvement in estimation error with increasing age. Across studies, large variations in study design and reporting of estimation error hindered the synthesis of evidence regarding the influence of different types of PSEAs on accuracy. While a definitive conclusion about the most accurate PSEA could not be drawn, a check-list to guide future PSEA development and testing has been proposed in the current review. This will assist comparability with future studies of PSEAs for children facilitate development of more accurate PSEAs in the future.

The nutritional content of children's breakfast cereals: a cross-sectional analysis of New Zealand, Australia, the UK, Canada and the USA

OBJECTIVE

To compare the Nutrition Information Panel (NIP) content, serving size and package size of children's ready-to-eat breakfast cereals (RTEC) available in five different Western countries.

DESIGN

NIP label information was collected from RTEC available for purchase in major supermarket chains. Kruskal-Wallis, Mann-Whitney U and χ2 tests were applied to detect differences between countries on manufacturer-declared serving size, total energy (kJ), total protein, fat, saturated fat, carbohydrate, total sugar, Na and fibre content. The Nutrient Profiling Scoring Criterion (NPSC) was used to evaluate the number of products deemed to be 'unhealthy'.

SETTING

Supermarkets in Australia, Canada, New Zealand, the UK and the USA.

PARTICIPANTS

Children's breakfast cereals (n 636), including those with and without promotional characters.

RESULTS

The majority of children's RTEC contained substantial levels of total sugar and differences were apparent between countries. Median sugar content per serving was higher in US cereals than all other countries (10·0 v. 7·7-9·1 g; P < 0·0001). Median fat and saturated fat content were lowest in Australia and New Zealand RTEC, while the Na content of RTEC was 60-120 % higher in the USA and Canada than in Australia and the UK (all P ≤ 0·01).

CONCLUSIONS

Across all countries, there was a high proportion of RTEC marketed for children that had an unhealthy nutrient profile. Strategies and policies are needed to improve the nutrient value of RTEC for children, so they provide a breakfast food that meets nutrition guidelines.

Influence of the nutrition and health information presented on food labels on portion size consumed: a systematic review

Context

In recent decades, portion sizes have increased significantly. Although previous research indicates that food labels impact on product choice and healthiness perception, their impact on portion sizes consumed is less clear.

Objective

This systematic review examined whether food label information influenced portion size consumption.

Data sources

A search of 7 major electronic databases for studies published from 1980 to April 2016 was conducted.

Data extraction

Two reviewers independently screened 11 128 abstracts. Data were extracted from 32 articles (comprising 36 studies).

Results

Based on the test food used, the overall effects were found to be: no effect, a positive effect, or a negative effect. Labels displaying energy content (n = 15 studies, 17 effects) and fat content information (n = 13 studies, 14 effects) were evaluated most commonly, with exercise equivalent labels evaluated least (n = 2 studies, 2 effects).

Conclusions

Nutrition and health information presented on food labels has varying impacts on portion sizes consumed, from increased to decreased intake. Recommendations for future research include evaluating more recent food label types and achieving more consistent reporting standards.

Cross-Sectional Survey of the Amount of Sugar and Energy in Chocolate Confectionery on Sold in the UK in 1992 and 2017

The study aimed to compare the sugar (1992, 2017) and energy (2017) content of chocolate confectionery available in the UK between 1992 and 2017 using cross-sectional surveys. All major UK retailers operating at the time were included. Sugar content in 1992 was obtained from a booklet and sugar and energy content from 2017 were collected from product packaging in-store. In 1992, the average sugar content of chocolate confectionery was 46.6 ± 10.3 g/100 g and in 2017 it was 47.3 ± 12.1 g/100 g. Sugar content ranged from 0.5 to 75.2 g/100g, with large variations between different categories of chocolate and within the same category of chocolate. There were 23 products found in both 1992 and 2017. The average sugar content per 100 g for these products was 44.6 ± 9.4 g in 1992 and 54.7 ± 6.3 g in 2017, representing a 23% increase in sugar content (p < 0.001). The results show that the sugar content of chocolate confectionery has increased since 1992, which is concerning. However, they also suggest sugar levels can be reduced because (a) lower sugar versions of the same products existed in 1992 and (b) there is a large variation in sugar and energy content between different categories of chocolate and within the same category in 2017.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of the effectiveness and usability of an educational portion size tool, ServARpreg, for pregnant women

BACKGROUND

Elevated blood glucose levels in pregnancy increases the risk of adverse pregnancy outcomes. Modifying consumption of carbohydrate-rich foods is important for blood glucose regulation; however, the tools commonly used to assist in guiding portion control are impractical. The present study aimed to evaluate usability of ServARpreg, a mobile phone-based nutrition tool, and its effectiveness with respect to improving carbohydrate and standard serve size knowledge in pregnant women.

METHODS

A baseline survey assessed knowledge of carbohydrates and standard serve sizes of pregnant women. A subset of women living in Newcastle were invited to use ServARpreg, containing pregnancy nutrition information and augmented reality guidance on portion control. A follow-up survey was sent to all women 4 weeks after baseline and women who received ServARpreg also received a process evaluation survey after 10 weeks.

RESULTS

Responses were received from 186 pregnant women for the baseline survey, with 97 completing the follow-up (52.2%). Of the 56 women eligible to receive ServARpreg in the sub-study, 47 accepted (83.9%) and, of these, 40 completed the process evaluation survey (85.1%). At follow-up, there was a significant group × time interaction in favour of the ServARpreg group for carbohydrate quantification knowledge (F_1,279  = 9.705, P = 0.002). Standard serve size knowledge did not change between groups. In the process evaluation survey, 80% strongly agreed/agreed that ServARpreg made them more aware of how much they ate and 72.5% found ServARpreg easy to use.

CONCLUSIONS

ServARpreg has shown potential to educate pregnant women about carbohydrate quantification and increase portion size awareness. Further refinement of the tool and evaluation is needed to improve standard serve size knowledge.

The top five selling UK energy drinks: implications for dental and general health

Aim Energy drinks are widely consumed worldwide and are recognised for their adverse health effects, usually due to their high caffeine content. However, little is known about their impact on oral and general health. The aim of this investigation was to review the most popular energy drinks sold in the UK, for their possible effect on oral health and contribution to obesity. Materials and methods Five drinks representing 75% of the UK energy drinks market were purposively selected (Lucozade, Red Bull, Monster, Rockstar and Relentless). pH and sugar content were measured and their ingredients reviewed in the context of oral and general health, focusing on dental caries and erosion and obesity. Results All five energy drinks investigated had pH values below the critical value (5.5) associated with dental erosion; the lowest pH was 2.72 (Lucozade) and the highest was 3.37 (Monster). The drinks also contained excessive amounts of free sugars, ranging from 25.5 g (Red Bull) to 69.2 g (Rockstar). Differences in sugar content were mainly explained by portion size. Other ingredients contained within the energy drinks, caffeine and various acids, are also linked to oral and general health. Conclusion Regular consumption of energy drinks could contribute to dental erosion and the development of obesity. Lucozade and Rockstar were found to potentially have the greatest impact on oral health and obesity. Achieving a healthy product by reformulation is highly unlikely due to the very high initial free sugar content. Thus, health professionals need to acknowledge the popularity of these products and help their clients to reduce their use. This is the first study which compares in detail the potential oral and general health consequences of overuse of a selection of energy drinks popular in the UK.

Structural responses to the obesity and non-communicable diseases epidemic: Update on the Chilean law of food labelling and advertising

Chile approved the law of food labelling and advertising in 2012; this law aims to address the obesity epidemic, particularly in children. The implementation details were published in 2015, and the law was implemented finally in 2016, as described in the current article. Regulated foods were defined based on a specially developed nutrient profiling, which considered natural foods as gold standard. For liquid foods, amounts of energy, sugars, saturated fats, and sodium in 100 mL of cow's milk were used as cut-offs. For solid foods, values within the 90th - 99th percentile range for energy and critical nutrients were selected as cut-off within a list of natural foods. A stop sign stating "High in <nutrient>" was chosen as warning label for packaged regulated foods. Regulated foods were also forbidden to be sold or offered for free at kiosks, cafeterias, and feeding programme at schools and nurseries. Besides, regulated foods cannot be promoted to children under 14 years. A staggered implementation of the regulation was decided, with nutrients cut-offs becoming increasingly stricter over a 3-year period. These regulatory efforts are in the right direction but will have to be sustained and complemented with other actions to achieve their ultimate impact of halting the obesity epidemic.

Analysis of the National Adult Nutrition Survey (Ireland) and the Food4Me Nutrition Survey Databases to Explore the Development of Food Labelling Portion Sizes for the European Union

The present study set out to explore the option of developing food portion size for nutritional labelling purposes using two European Union (EU) dietary surveys. The surveys were selected as they differed in (a) methodologies (food diary versus food frequency questionnaire), (b) populations (Irish National Adult Nutrition Survey (NANS) versus a seven-country survey based on the pan EU study Food4Me), (c) food quantification (multiple options versus solely photographic album) and (d) duration (4 consecutive days versus recent month). Using data from these studies, portion size was determined for 15 test foods, where portion size was defined as the median intake of a target food when consumed. The median values of the portion sizes derived from both the NANS and Food4Me surveys were correlated (r = 0.823; p < 0.00) and the mean of the two survey data sets were compared to US values from the Recognized as Customarily Consumed (RACC) database. There was very strong agreement across all food categories between the averaged EU and the US portion size (r = 0.947; p < 0.00). It is concluded that notwithstanding the variety of approaches used for dietary survey data in the EU, the present data supports using a standardized approach to food portion size quantification for food labelling in the EU.

Can front-of-pack labels influence portion size judgements for unhealthy foods?

OBJECTIVE

By clearly conveying the healthiness of a food, front-of-pack (FOP) labels have the potential to influence the portion size considered appropriate for consumption. The present study examined the how the Daily Intake Guide (DIG), Multiple Traffic Lights (MTL) and Health Star Rating (HSR) FOP labels affect judgements of appropriate portion sizes of unhealthy foods compared with when no FOP label is present.

DESIGN

Respondents viewed mock packages of unhealthy variations of pizzas, cookies, yoghurts and cornflakes featuring the DIG, MTL, HSR or no FOP label, and indicated the portion size they believed should be eaten of each food on a single occasion.

SETTING

The survey was completed on the respondent's personal computer.

SUBJECTS

A total of 1505 Australian adults provided 4166 ratings across 192 mock packages relating to four product categories: pizza, yoghurt, cornflakes and cookies.

RESULTS

Compared with no FOP label, the HSR resulted in a small but significant reduction in the portion size selected as appropriate for consumption of pizzas and cornflakes (P<0·05). The MTL resulted in smaller portions of cornflakes being selected compared with no FOP label (P<0·05).

CONCLUSIONS

Respondents perceived smaller portion sizes as appropriate for some, but not all, of the foods tested when FOP labels with more interpretative formats (HSR, MTL) appeared on-pack compared with no FOP label. No effect was found for the less interpretive FOP label (the DIG). Interpretive FOP labels may have the potential to influence portion size judgements, albeit at modest levels.

Serving Size and Nutrition Labelling: Implications for Nutrition Information and Nutrition Claims on Packaged Foods

The presentation of nutrition information on a serving size basis is a strategy that has been adopted by several countries to promote healthy eating. Variation in serving size, however, can alter the nutritional values reported on food labels and compromise the food choices made by the population. This narrative review aimed to discuss (1) current nutrition labelling legislation regarding serving size and (2) the implications of declared serving size for nutrition information available on packaged foods. Most countries with mandatory food labelling require that serving size be presented on food labels, but variation in this information is generally allowed. Studies have reported a lack of standardisation among serving sizes of similar products which may compromise the usability of nutrition information. Moreover, studies indicate that food companies may be varying serving sizes as a marketing strategy to stimulate sales by reporting lower values of certain nutrients or lower energy values on nutrition information labels. There is a need to define the best format for presenting serving size on food labels in order to provide clear and easily comprehensible nutrition information to the consumer.

Large Variations in Declared Serving Sizes of Packaged Foods in Australia: A Need for Serving Size Standardisation?

Declared serving sizes on food packaging are unregulated in Australia, and variations in serving size within similar products reduces the usability of this information. This study aimed to (i) assess the variations in declared serving sizes of packaged foods from the Five Food Groups, and (ii) compare declared serving sizes to the Australian Dietary Guidelines standard serves and typical portion sizes consumed by Australian adults. Product information, including serving size, was collected for 4046 products from four major Australian retailers. Within product categories from the Five Food Groups, coefficients of variation ranged from 0% to 59% for declared serving size and 9% to 64% for energy per serving. Overall, 24% of all products displayed serving sizes similar (within ±10%) to the standard serves, and 23–28% were similar to typical portion sizes consumed by adults, for females and males, respectively. In conclusion, there is substantial variation in the declared serving sizes of packaged foods from the Five Food Groups, and serving sizes are not aligned with either the Dietary Guidelines or typical portion sizes consumed. Future research into effective means of standardising serving sizes is warranted.

The nutritional quality of New Zealand breakfast cereals: an update

Objective

To compare the nutritional quality of New Zealand breakfast cereals in 2013 and 2017.

Design

Nutrition Information Panel data were collected from all cereals available from two large supermarket chains in 2017 and compared with earlier published data collected in 2013.

Setting

Urban New Zealand supermarkets.

Subjects

The nutritional content of breakfast cereals (‘biscuits and bites’, ‘brans’, ‘bubbles, flakes and puffs’, ‘children’s cereals’, ‘muesli’ and ‘oats’) was analysed for total energy, protein, fat (total and saturated), carbohydrate, sugar, fibre and Na. The Nutrient Profile Scoring Criterion (NPSC) for each cereal was calculated to determine the proportion of ‘less healthy’ cereals (NPSC≥4) in each product category.

Results

The energy and fat content of bubbles, flakes and puffs, muesli and oats were significantly higher in 2017 compared with 2013 (all P≤0·01). However, there was a small reduction in Na overall in 2017 (P<0·05). There was no change between 2013 and 2017 in the proportion of ‘healthy’ or ‘less healthy’ breakfast cereals available.

Conclusions

The nutrient profile of breakfast cereals has not improved since 2013, suggesting that industry self-regulation of the nutritional composition of cereals in New Zealand is not working and needs urgent reconsideration.

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

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

ServAR: An augmented reality tool to guide the serving of food

Background

Accurate estimation of food portion size is a difficult task. Visual cues are important mediators of portion size and therefore technology-based aids may assist consumers when serving and estimating food portions. The current study evaluated the usability and impact on estimation error of standard food servings of a novel augmented reality food serving aid, ServAR.

Methods

Participants were randomised into one of three groups: 1) no information/aid (control); 2) verbal information on standard serving sizes; or 3) ServAR, an aid which overlayed virtual food servings over a plate using a tablet computer. Participants were asked to estimate the standard serving sizes of nine foods (broccoli, carrots, cauliflower, green beans, kidney beans, potato, pasta, rice, and sweetcorn) using validated food replicas. Wilcoxon signed-rank tests compared median served weights of each food to reference standard serving size weights. Percentage error was used to compare the estimation of serving size accuracy between the three groups. All participants also performed a usability test using the ServAR tool to guide the serving of one randomly selected food.

Results

Ninety adults (78.9% female; a mean (95%CI) age 25.8 (24.9–26.7) years; BMI 24.2 (23.2–25.2) kg/m²) completed the study. The median servings were significantly different to the reference portions for five foods in the ServAR group, compared to eight foods in the information only group and seven foods for the control group. The cumulative proportion of total estimations per group within ±10%, ±25% and ±50% of the reference portion was greater for those using ServAR (30.7, 65.2 and 90.7%; respectively), compared to the information only group (19.6, 47.4 and 77.4%) and control group (10.0, 33.7 and 68.9%). Participants generally found the ServAR tool easy to use and agreed that it showed potential to support optimal portion size selection. However, some refinements to the ServAR tool are required to improve the user experience.

Conclusions

Use of the augmented reality tool improved accuracy and consistency of estimating standard serve sizes compared to the information only and control conditions. ServAR demonstrates potential as a practical tool to guide the serving of food. Further evaluation across a broad range of foods, portion sizes and settings is warranted.

Depicted serving size: cereal packaging pictures exaggerate serving sizes and promote overserving

Background

Extensive work has focused on the effects of nutrition label information on consumer behavior on the one hand, and on the effects of packaging graphics on the other hand. However, little work has examined how serving suggestion depictions - graphics relating to serving size - influence the quantity consumers serve themselves. The current work examines the prevalence of exaggerated serving size depictions on product packaging (study 1) and its effects on food serving in the context of cereal (study 2).

Methods

Study 1 was an observational field survey of cereal packaging. Study 2 was a mixed experimental cross-sectional design conducted at a U.S. university, with 51 student participants. Study 1 coded 158 US breakfast cereals and compared the serving sizes depicted on the front of the box with the suggested serving size stated on the nutrition facts panel. Study 2 measured the amount of cereal poured from exaggerated or accurate serving size depictions. Study 1 compared average servings via t-tests. Study 2 used a mixed model with cereal type as the repeated measure and a compound symmetry covariance matrix.

Results

Study 1 demonstrated that portion size depictions on the front of 158 cereal boxes were 64.7% larger (221 vs. 134 calories) than the recommended portions on nutrition facts panels of those cereals. Study 2 showed that boxes that depicted exaggerated serving sizes led people to pour 17.8% more cereal compared to pouring from modified boxes that depicted a single-size portion of cereal matching suggested serving size. This was 42% over the suggested serving size.

Conclusions

Biases in depicted serving size depicted on cereal packaging are prevalent in the marketplace. Such biases may lead to overserving, which may consequently lead to overeating. Companies should depict the recommended serving sizes, or otherwise indicate that the depicted portion represents an exaggerated serving size.

The Role of Social Norms in the Portion Size Effect: Reducing Normative Relevance Reduces the Effect of Portion Size on Consumption Decisions

People typically eat more from large portions of food than from small portions. An explanation that has often been given for this so-called portion size effect is that the portion size acts as a social norm and as such communicates how much is appropriate to eat. In this paper, we tested this explanation by examining whether manipulating the relevance of the portion size as a social norm changes the portion size effect, as assessed by prospective consumption decisions. We conducted one pilot experiment and one full experiment in which participants respectively indicated how much they would eat or serve themselves from a given amount of different foods. In the pilot (N = 63), we manipulated normative relevance by allegedly basing the portion size on the behavior of either students of the own university (in-group) or of another university (out-group). In the main experiment (N = 321), we told participants that either a minority or majority of people similar to them approved of the portion size. Results show that in both experiments, participants expected to serve themselves and to eat more from larger than from smaller portions. As expected, however, the portion size effect was less pronounced when the reference portions were allegedly based on the behavior of an out-group (pilot) or approved only by a minority (main experiment). These findings suggest that the portion size indeed provides normative information, because participants were less influenced by it if it communicated the behaviors or values of a less relevant social group. In addition, in the main experiment, the relation between portion size and the expected amount served was partially mediated by the amount that was considered appropriate, suggesting that concerns about eating an appropriate amount indeed play a role in the portion size effect. However, since the portion size effect was weakened but not eliminated by the normative relevance manipulations and since mediation was only partial, other mechanisms may also play a role.

Food and the consumer: could labelling be the answer?

Extensive research into the impact of nutrition labelling across Europe has shown that many consumers can effectively use a nutrition label to rank a food for healthiness. The present paper considers observational and laboratory evidence which has examined the impact of nutrition labelling (on food packaging and at point of purchase) on dietary behaviour. In addition, the potential counterproductive effects of foods bearing 'healthy' nutrition labels are examined. The observational evidence provides a useful insight into the key characteristics of nutrition label use. Those most likely to engage with nutrition labels are more likely to have a diet related disease and/or be on a weight loss diet and have a good overall diet quality. Experimental evidence, while limited, suggests that serving size information may be overlooked by consumers. In fact, there may be a tendency among consumers to overeat foods that are perceived to be healthier. The findings from the present paper suggest that if nutrition labelling is to be considered a strategy to facilitate consumers in managing their energy intake, it must coincide with salient, consistent and simple serving size information on the front of food packages and at the point of purchase. There is a clear need for more experimental research using robust methodologies, to examine the impact of nutrition information on dietary intake. In the meantime, there should be greater attention given to portion size within national dietary guidance.

High variation in manufacturer-declared serving size of packaged discretionary foods in Australia

Despite the potential of declared serving size to encourage appropriate portion size consumption, most countries including Australia have not developed clear reference guidelines for serving size. The present study evaluated variability in manufacturer-declared serving size of discretionary food and beverage products in Australia, and how declared serving size compared with the 2013 Australian Dietary Guideline (ADG) standard serve (600 kJ). Serving sizes were obtained from the Nutrition Information Panel for 4466 packaged, discretionary products in 2013 at four large supermarkets in Sydney, Australia, and categorised into fifteen categories in line with the 2013 ADG. For unique products that were sold in multiple package sizes, the percentage difference between the minimum and the maximum serving size across different package sizes was calculated. A high variation in serving size was found within the majority of food and beverage categories – for example, among 347 non-alcoholic beverages (e.g. soft drinks), the median for serving size was 250 (interquartile range (IQR) 250, 355) ml (range 100–750 ml). Declared serving size for unique products that are available in multiple package sizes also showed high variation, particularly for chocolate-based confectionery, with median percentage difference between minimum and maximum serving size of 183 (IQR 150) %. Categories with a high proportion of products that exceeded the 600 kJ ADG standard serve included cakes and muffins, pastries and desserts (≥74 % for each). High variability in declared serving size may confound interpretation and understanding of consumers interested in standardising and controlling their portion selection. Future research is needed to assess if and how standardising declared serving size might affect consumer behaviour.

An evaluation of portion size estimation aids: precision, ease of use and likelihood of future use

OBJECTIVE

The present study aimed to evaluate the precision, ease of use and likelihood of future use of portion size estimation aids (PSEA).

DESIGN

A range of PSEA were used to estimate the serving sizes of a range of commonly eaten foods and rated for ease of use and likelihood of future usage.

SETTING

For each food, participants selected their preferred PSEA from a range of options including: quantities and measures; reference objects; measuring; and indicators on food packets. These PSEA were used to serve out various foods (e.g. liquid, amorphous, and composite dishes). Ease of use and likelihood of future use were noted. The foods were weighed to determine the precision of each PSEA.

SUBJECTS

Males and females aged 18-64 years (n 120).

RESULTS

The quantities and measures were the most precise PSEA (lowest range of weights for estimated portion sizes). However, participants preferred household measures (e.g. 200 ml disposable cup) - deemed easy to use (median rating of 5), likely to use again in future (all scored either 4 or 5 on a scale from 1='not very likely' to 5='very likely to use again') and precise (narrow range of weights for estimated portion sizes). The majority indicated they would most likely use the PSEA preparing a meal (94 %), particularly dinner (86 %) in the home (89 %; all P<0·001) for amorphous grain foods.

CONCLUSIONS

Household measures may be precise, easy to use and acceptable aids for estimating the appropriate portion size of amorphous grain foods.

Usage and Understanding of Serving Size Information on Food Labels in the United States

Purpose.

To investigate consumer understanding and usage of serving size (SS) information on Nutrition Facts (NF) labels.

Design.

We analyzed three data sources: (1) U.S. Food and Drug Administration (FDA) Health and Diet Survey (HDS) 1994 (n = 1945), 1995 (n = 1001), and 2008 (n = 2584); (2) National Health and Nutrition Examination Survey (NHANES) 2005–2006 and 2007–2008 (n = 10,750); and (3) 2011 FDA Nutrition Facts Label Experimental Study (NFLES) (n = 9493). Data from FDA are cross-sectional and we focused on usage and meaning of SS.

Setting.

United States.

Subjects.

Adults (18+ years).

Measures.

Both HDS and NHANES addressed how often participants used SS information and HDS also asked how SS is determined. Both NHANES and NFLES contained similar questions on the meaning of SS but NFLES also included an open-ended response option.

Analysis.

We included both quantitative and qualitative measures. Questions were analyzed by demographic variables and body mass index with frequencies, cross-tabulations, and χ2 statistics reported.

Results.

HDS showed that the percentage of consumers who used SS information often or sometimes increased from 54% in 1994 to 64% in 2008. NHANES and NFLES data indicated that a majority of respondents had misinterpreted the meaning of SS. Women and obese individuals were more likely to use SS often or sometimes, but were also more likely to misinterpret the meaning of SS. A small subsample of NFLES participants expressed a distrust of the SS information.

Conclusion.

There is a widespread misunderstanding about SS, suggesting the need for clearer NF labels or enhanced education efforts.

Variations in serving sizes of Australian snack foods and confectionery

This study examined the serving size and energy content per serving of Australian packaged snack foods and confectionery products. Nutrition Information Panel data for 23 sub-categories of packaged snack foods (n = 3481) were extracted from The George Institute for Global Health's 2013 branded food composition database. Variations in serving size and energy content per serving were examined. Energy contents per serving were compared to recommendations in the Australian Dietary Guidelines. Serving sizes varied within and between snack food categories. Mean energy content per serving varied from 320 kJ to 899 kJ. More energy per serving than the recommended 600 kJ was displayed by 22% (n = 539) of snack foods classified in the Australian Dietary Guidelines as discretionary foods. The recommendation for energy content per serving was exceeded in 60% (n = 635) of snack foods from the Five Food Groups. Only 37% (n = 377) of confectionery products displayed the industry-agreed serving size of 25 g. Energy content per serving of many packaged snack foods do not align with the Australian Dietary Guidelines and the industry agreed serving size has not been taken up widely within the confectionery category. Given the inconsistencies in serving sizes, featuring serving size in front-of-pack information may hinder the objective of a clear and simple nutrition message. Messaging to help consumers make healthier choices should consider the variation in serving sizes on packaged snack foods.

Package size and manufacturer-recommended serving size of sweet beverages: a cross-sectional study across four high-income countries

OBJECTIVE

To assess the mean package size and manufacturer-recommended serving size of sweet beverages available in four high-income countries: Australia, Canada, the Netherlands and New Zealand.

DESIGN

Cross-sectional surveys.

SETTING

The two largest supermarket chains of each country in 2012/2013.

SUBJECTS

Individual pack size (IPS) drinks (n 891) and bulk pack size (BPS) drinks (n 1904).

RESULTS

For all IPS drinks, the mean package size was larger than the mean serving size (mean (sd)=412 (157) ml and 359 (159) ml, respectively). The mean (sd) package size of IPS drinks was significantly different for all countries (range: Australia=370 (149) ml to New Zealand=484 (191) ml; P<0·01). The mean (sd) package size of Dutch BPS drinks (1313 (323) ml) was significantly smaller compared with the other countries (New Zealand=1481 (595) ml, Australia=1542 (595) ml, Canada=1550 (434) ml; P<0·01). The mean (sd) serving size of BPS drinks was significantly different across all countries (range: Netherlands=216 (30) ml to Canada=248 (31) ml; P<0·00). New Zealand had the largest package and serving sizes of the countries assessed. In all countries, a large number of different serving sizes were used to provide information on the amount appropriate to consume in one sitting.

CONCLUSIONS

At this point there is substantial inconsistency in package sizes and manufacturer-recommended serving sizes of sweet beverages within and between four high-income countries, especially for IPS drinks. As consumers do factor serving size into their judgements of healthiness of a product, serving size regulations, preferably set by governments and global health organisations, would provide consistency and assist individuals in making healthier food choices.

Quantifying consumer portion control practices. A cross-sectional study

The use of portion control practices has rarely been quantified. The present study aimed to: (1) explore which portion control practices are actually used by the general population and their association with cognitive restraint, demographic background and general health interest (GHI), and (2) examine how the usage of portion control practices predicts the estimated consumption of an energy dense food (i.e. pizza). Twenty-two portion control practices were rated in terms of their frequency of use from 'never' to 'very often' by a representative sample of 1012 consumers from the island of Ireland. Three factors were extracted and named: measurement-strategy scale, eating-strategy scale, and purchasing-strategy scale. The eating-strategy scale score was the highest, while the measurement-strategy scale carried the lowest frequency score. For each strategy scale score, the strongest predictor was GHI, followed by gender. Having higher GHI and being female were independently associated with more frequent portion control. Both the eating-strategy scale score and the purchasing-strategy scale score were negatively associated with pizza portion size consumption estimates. In conclusion, while this study demonstrates that the reported use of portion control practices is low, the findings provide preliminary evidence for their validity. Further studies are needed to explore how portion control practices are used in different kinds of portion size decisions and what their contribution is to the intake of food over an extended period of time.

Small, medium, large or supersize? The development and evaluation of interventions targeted at portion size

In the past decades, portion sizes of high-caloric foods and drinks have increased and can be considered an important environmental obesogenic factor. This paper describes a research project in which the feasibility and effectiveness of environmental interventions targeted at portion size was evaluated. The studies that we conducted revealed that portion size labeling, offering a larger variety of portion sizes, and proportional pricing (that is, a comparable price per unit regardless of the size) were considered feasible to implement according to both consumers and point-of-purchase representatives. Studies into the effectiveness of these interventions demonstrated that the impact of portion size labeling on the (intended) consumption of soft drinks was, at most, modest. Furthermore, the introduction of smaller portion sizes of hot meals in worksite cafeterias in addition to the existing size stimulated a moderate number of consumers to replace their large meals by a small meal. Elaborating on these findings, we advocate further research into communication and marketing strategies related to portion size interventions; the development of environmental portion size interventions as well as educational interventions that improve people's ability to deal with a 'super-sized' environment; the implementation of regulation with respect to portion size labeling, and the use of nudges to stimulate consumers to select healthier portion sizes.

Reference amounts utilised in front of package nutrition labelling; impact on product healthfulness evaluations

BACKGROUND/OBJECTIVES

The research question addressed in this paper is how different reference amounts utilised in front of package nutrition labelling influence evaluation of product healthfulness.

SUBJECTS/METHODS

A total of 13,117 participants from six European countries (Germany, UK, Spain, France, Poland and Sweden) were recruited via online panels. A mixed between/within-subject factorial design was employed with food (biscuits, sandwiches, yogurts), healthfulness and presence of Guideline Daily Amounts as within-subjects factors and reference amount ('per 100 g', 'typical portion', 'half portion') and country as between-subjects factors.

RESULTS

Overall, people correctly ranked foods according to their objective healthfulness as defined by risk nutrients alone, and could distinguish between more and less healthful variants of foods. General healthfulness associations with the three product categories do not appear to have had a strong influence on product ratings. This study shows that where the reference amount of 'per 100 g' is very different from the 'typical' portion size, as was the case for biscuits, products with a 'per 100 g' label are rated significantly less healthful than the 'typical' or 'half typical' portions.

CONCLUSION

The results indicate that across the three food categories, consumers do factor the reference amount, that is, the quantity of food for which the nutritional information is being presented, into their judgements of healthfulness. Therefore, appropriate reference amounts are also of importance for the effective presentation of nutritional information.

Influencing and modifying children's energy intake: the role of portion size and energy density

Childhood obesity is of concern worldwide. The portion size (PS) and energy density (ED) of food are two major determinants of children's energy intake (EI). Trends towards increasing PS are most apparent and best documented in the USA, where PS of numerous food products have increased in the marketplace over the past three decades, particularly high-energy dense foods. Analyses of population-level dietary surveys have confirmed this trend in children for both in- and out-of-home eating, and a plethora of observational evidence positively associates PS, ED and adiposity in children. A limited number of intervention studies provide clear evidence that children, even as young as 2 years, respond acutely to increasing PS, with some studies also demonstrating the additive effects of increased ED in promoting excessive EI. However, most of the evidence is based on children aged 3-6 years and there is a paucity of data in older children and adolescents. It is unclear whether decreasing PS can have the opposite effect on children's EI but recent acute studies have demonstrated that the incorporation of lower energy dense foods, such as fruit and vegetables, into children's meals down-regulates EI. Although a direct causal link between PS and obesity remains to be established, the regular consumption of larger PS of energy dense foods do favour obesity-promoting eating behaviours in children. Further research is required to establish the most feasible and effective interventions and policies to counteract the deleterious impact of PS and ED on children's EI.

Reference serving sizes for the Brazilian population: An analysis of processed food labels

OBJECTIVE: To compare serving sizes reported on processed food labels with reference serving sizes according to nutrition labeling legislation and the "Food Guide for the Brazilian Population". METHODS: This cross-sectional study analyzed the labels of 2,072 processed foods in a supermarket of Florianópolis, Santa Caratina, Brazil. The foods were classified according to the Brazilian food labeling legislation. Central tendency and variability values were calculated for the serving sizes and energy values reported on the labels, as well as the ratio between the reported and reference energy value. The Spearman correlation test was performed between the reference serving size and the reference energy density, and also between the reference serving size and energy density of each study food. RESULTS: Nutrition labeling and the Food Guide presented reference servings with different sizes and energy values. The serving sizes reported on the labels did not follow either of the references and presented heterogeneous values, with a maximum range of 55-240 g among ready and semi-ready pre-prepared dishes. The reported energy values were between 0.1 times smaller and 2.4 times larger than the reference values. The reference serving sizes presented a highly inverse correlation with the reference energy density (Spearman coefficient= 0.9) and a very low inverse correlation with the energy density of the foods analyzed (Spearman coefficient= 0.2). CONCLUSION: This study showed the need for standardizing reference serving size information for the Brazilian population as well as reviewing nutrition labeling legislation in order to standardize the serving sizes reported on labels and to update the reference energy density used to calculate serving sizes.

Food and beverage portion sizes in Australian children: a secondary analysis of 1995 and 2007 national data

Background

Portion size of foods is reported to contribute to the rise in obesity prevalence. However, evidence of changes in portion size for commonly consumed foods in Australia is lacking. The aim was to evaluate whether Australian child and adolescent portion sizes of selected foods changed from 1995 to 2007.

Methods

Time-series study, comparing dietary data from two national cross-sectional surveys in nationally representative population survey of Australian households. The dietary data was from children aged 2–16 years who participated in the 1995 National Nutrition Survey (n = 2198) and 2007 Australian National Children’s Nutrition and Physical Activity Survey (n = 4799).

Results

Differences were found across survey years in median portion size of common foods and beverages assessed by 24-hour recalls for age and sex categories. Of the 61 foods items evaluated across the whole population sample, portion size increased in 18 items, decreased in 22, with no change in 20, although the magnitude of change varied by age and sex. Decreases in portion size were detected for most dairy products, breakfast cereal, some packaged snack foods and vegetables, p < 0.0001. Increases were detected for cooked chicken, mixed chicken dishes, bacon and ham (p < 0.0001), cooked meat (p < 0.05), fish (p < 0.01) and pizza (p < 0.0001). No significant changes were detected for many items including white and wholemeal bread, mincemeat, chocolate and soft drink.

Conclusions

Small changes in portion sizes were detected over 12 years in Australian children and adolescents with the degree of change varying by sex, age and food group. Knowledge of usual portion sizes could inform programs targeting appropriate serving sizes selection in children and adolescents.

A qualitative study of psychological, social and behavioral barriers to appropriate food portion size control

Background

Given the worldwide prevalence of overweight and obesity, there is a clear need for meaningful practical healthy eating advice - not only in relation to food choice, but also on appropriate food portion sizes. As the majority of portion size research to date has been overwhelmingly quantitative in design, there is a clear need to qualitatively explore consumers’ views in order to fully understand how food portion size decisions are made. Using qualitative methodology this present study aimed to explore consumers’ views about factors influencing their portion size selection and consumption and to identify barriers to appropriate portion size control.

Methods

Ten focus groups with four to nine participants in each were formed with a total of 66 persons (aged 19–64 years) living on the island of Ireland. The semi-structured discussions elicited participants’ perceptions of suggested serving size guidance and explored the influence of personal, social and environmental factors on their food portion size consumption. Audiotapes of the discussions were professionally transcribed verbatim, loaded into NVivo 9, and analysed using an inductive thematic analysis procedure.

Results

The rich descriptive data derived from participants highlight that unhealthy portion size behaviors emanate from various psychological, social and behavioral factors. These bypass reflective and deliberative control, and converge to constitute significant barriers to healthy portion size control. Seven significant barriers to healthy portion size control were apparent: (1) lack of clarity and irrelevance of suggested serving size guidance; (2) guiltless eating; (3) lack of self-control over food cues; (4) distracted eating; (5) social pressures; (6) emotional eating rewards; and (7) quantification habits ingrained from childhood.

Conclusions

Portion size control strategies should empower consumers to overcome these effects so that the consumption of appropriate food portion sizes becomes automatic and habitual.

Behavioral lifestyle intervention in the treatment of obesity

This article provides an overview of research regarding adult behavioral lifestyle intervention for obesity treatment. We first describe two trials using a behavioral lifestyle intervention to induce weight loss in adults, the Diabetes Prevention Program (DPP) and the Look AHEAD (Action for Health in Diabetes) trial. We then review the three main components of a behavioral lifestyle intervention program: behavior therapy, an energy- and fat-restricted diet, and a moderate- to vigorous-intensity physical activity prescription. Research regarding the influence of dietary prescriptions focusing on macronutrient composition, meal replacements, and more novel dietary approaches (such as reducing dietary variety and energy density) on weight loss is examined. Methods to assist with meeting physical activity goals, such as shortening exercise bouts, using a pedometer, and having access to exercise equipment within the home, are reviewed. To assist with improving weight loss outcomes, broadening activity goals to include resistance training and a reduction in sedentary behavior are considered. To increase the accessibility of behavioral lifestyle interventions to treat obesity in the broader population, translation of efficacious interventions such as the DPP, must be undertaken. Translational studies have successfully altered the DPP to reduce treatment intensity and/or used alternative modalities to implement the DPP in primary care, worksite, and church settings; several examples are provided. The use of new methodologies or technologies that provide individualized treatment and real-time feedback, and which may further enhance weight loss in behavioral lifestyle interventions, is also discussed.