To what extent have sweetened beverages contributed to the obesity epidemic?

Examining the Role and Strategies of Advocacy Coalitions in California's Statewide Sugar-Sweetened Beverage Tax Debate (2001-2018)

PURPOSE

California's failed attempts to enact a statewide sugary beverage tax presents an opportunity to advance understanding of advocacy coalition behavior. We investigate the participation of advocacy coalitions in California's statewide sugar-sweetened beverage (SSB) tax policy debate.

DESIGN

Document analysis of legislative bills and newspaper articles collected in 2019.

SETTING

California.

METHOD

A total of 11 SSB tax-related bills were introduced in California's legislature between 2001-2018 according to the state's legislative website. Data sources include legislative bill documents (n = 94) and newspaper articles (n = 138). Guided by the Advocacy Coalition Framework (ACF), we identify advocacy coalitions involved in California's SSB tax debate and explore strategies and arguments used to advance each coalitions' position.

RESULTS

Two coalitions (public health, food/beverage industry) were involved in California's statewide SSB tax policy debate. The public health coalition had higher member participation and referred to scientific research evidence while the industry coalition used preemption and financial resources as primary advocacy strategies. The public health coalition frequently presented messaging on the health consequences and financial benefits of SSB taxes. The industry coalition responded by focusing on the potential negative economic impact of a tax.

CONCLUSION

Multiple attempts to enact a statewide SSB tax in California have failed. Our findings add insight into the challenges of enacting an SSB tax considering industry interference. Results can inform future efforts to pass evidence-based nutrition policies.

Ultraprocessed, hyper-palatable, and high energy density foods: Prevalence and distinction across 30 years in the United States

OBJECTIVE

Ultraprocessed foods (UPF), hyper-palatable foods (HPF), and high energy density (HED) foods may contribute to obesity risk. All have distinct definitions; however, it is unknown the degree to which they may identify overlapping or distinct foods. This study examined the availability of UPF, HPF, and HED foods in the US food system from 1988 to 2018 and the degree of distinction across definitions.

METHODS

Four data sets representing the US food system (1988, 2001, 2006, 2018) from the US Department of Agriculture were analyzed. UPF were identified based on the extent of industrialized processing. HPF were identified using the standardized definition that specifies palatability-inducing nutrient combinations. HED was characterized as >2.0 kcal/g.

RESULTS

Across years, 58% to 65% of foods were classified as UPF, 55% to 69% as HPF, and 37% to 47% as HED. Prevalence of UPF, HPF, and HED foods was higher in 2018 versus 1988 (p values < 0.001); HPF evidenced the largest increase (14%) and UPF evidenced the smallest (4%) over time. There was moderate to high overlap in foods (40%-70%) across definitions.

CONCLUSIONS

Together, UPF, HPF, and HED foods comprise most foods in the US food supply. Changes in availability varied across definitions, with substantial increases in HPF and HED and relative stability of UPF.

School health promotion and the consumption of water and sugar-sweetened beverages in secondary schools: a cross-sectional multilevel study

BACKGROUND

Overweight among adolescents remains a serious concern worldwide and can have major health consequences in later life, such as cardiovascular diseases and cancer. Still, 33% of secondary school adolescents in the Netherlands consume sugar-sweetened beverages daily and over 26% do not consume water every day. The Dutch Healthy School program was developed to support schools in stimulating healthier lifestyles by focusing on health education, school environments, identifying students' health problems, and school policy. We examined the variation between secondary schools regarding the daily consumption of water and sugar-sweetened beverages and whether this variation can be explained by differences between schools regarding Healthy School certification, general school characteristics, and the school population.

METHODS

We performed a cross-sectional multilevel study. We used data from the national Youth Health Monitor of 2019 on secondary schools (grades 8 and 10, age range about 12 to 18 years) of seven Public Health Services and combined these with information regarding Healthy School certification and general school- and school population characteristics. Our outcomes were daily consumption of water and sugar-sweetened beverages. In total, data from 51,901 adolescents from 191 schools were analysed. We calculated the intraclass correlation to examine the variation between schools regarding our outcomes. Thereafter, we examined whether we could explain this variation by the included characteristics.

RESULTS

The school-level explained 4.53% of the variation in the consumption of water and 2.33% of the variation in the consumption of sugar-sweetened beverages. This small variation in water and sugar-sweetened consumption could not be explained by Healthy School certification, yet some general school- and school population characteristics did: the proportion of the school population with at least one parent with high educational attainment, the educational track of the adolescents, urbanicity (only for water consumption) and school type (only for sugar-sweetened beverages consumption).

CONCLUSIONS

The low percentages of explained variation indicate that school-level characteristics in general (including Healthy School certification) do not matter substantially for the daily consumption of water and sugar-sweetened beverages. Future research should examine whether school health promotion can contribute to healthier lifestyles, and if so, under which level of implementation and school conditions.

Evolution of beverage portion sizes consumed in Brazil between 2008 and 2018

Objective

To describe the evolution of beverage portion sizes consumed in Brazil between 2008 and 2018.

Methods

Data from the dietary surveys of 2008-2009 and 2017-2018 Brazilian Household Budget Surveys, conducted with 34,003 and 46,164 individuals, respectively, were used to analyze the portion size of beverages. Food consumption data were used to group beverages according to nutritional characteristics, type and size of portions into eight groups: high-calorie soft drinks, fruit refreshments, alcoholic beverages, coffee/tea, fruit juices, milk and milk substitutes and ultra-processed milk-based beverages. The two-day food record and recall were considered to analyze the consumed portions. Comparisons between the surveys were done using Chi-Square tests and linear regression models.

Results

Between 2008 and 2018, the average portion consumed showed a significant increase for the group of alcoholic beverages (+29%), flavored juices (+11%), caloric soft drinks (+8%), milk and milk substitutes (+6%) and fruit juices (+5%); and reduction for the coffee/tea group (-11%). Analyzes by age group showed that among individuals between 20 and 40 years of age, the soft drinks and alcoholic beverage groups showed the greatest increase in portion size, +12 and +44%, respectively.

Conclusion

The beverage portion sizes consumed in Brazil between 2008 and 2018 increased for the group of alcoholic beverages, flavored juices, caloric soft drinks, milk and milk substitutes, and fruit juices.

Applying the temporal self-regulation theory to understand sugar-sweetened beverage consumption among Chinese college students

Objective

Worldwide, there is a growing trend that college students are consuming more and more sugar-sweetened beverages (SSBs). In order to develop effective intervention strategies, it is important to explore what social-cognitive factors impact on college students' SSB consumption. Building on the temporal self-regulation theory (TST), the current study aimed to examine the effects of intention, behavioral prepotency, and self-regulatory capacity on SSB consumption among college students.

Design

Data were collected from five hundred Chinese college students online. Participants self-reported their intention, behavioral prepotency (environmental cues and habits), self-regulatory capacity, and behaviors of SSB consumption.

Results

Study findings showed that intention, behavioral prepotency, and self-regulatory capacity accounted for 32.9% of variance in SSB consumption. In terms of the direct effects, intention, behavioral prepotency, and self-regulatory capacity were significantly associated with the SSB consumption among college students. In addition, self-regulatory capacity and habits but not the environmental cues showed significant moderation effects on the intention-SSB consumption path, indicating that individual factors rather than environmental cues influenced the intention-behavior path of SSB consumption among college students.

Conclusion

Findings of the current study demonstrated that the TST can be used to explain and understand the impacts of social-cognitive factors on college students' SSB consumption. Future research can apply TST to develop effective intervention programs targeting the reduction of SSB consumption among college students.

Implementation of sugar-sweetened beverages tax and its perception among public health stakeholders. A study from Poland

Background

One of tools to tackle growing problem of overweight and obesity are the taxation mechanisms applied to sugar-sweetened beverages, which are expected to influence the common eating behaviors, but also they have impact on the market and public finances. The solution is therefore highly entangled in the complex of social and intersectoral interests generating a number of opportunities and threats affecting its feasibility.

Aims

The study aims to depict the views of Polish stakeholders on the implementation of the sugar tax in Poland, particularly the perception of success determinants, barriers, as well as views on the features of the implemented solutions and possible alternatives.

Methods

We used semi-structured interviews with 18 individuals representing key public health stakeholders in Poland. The interview consisted of four parts, where first concentrated on the advantages and disadvantages of the SSB tax, the second part explored stakeholder involvement and stances, third concerned the feasibility of the project, and in the fourth part respondents were asked for suggestions for decision-makers regarding the content of the project and its implementation process. To reconstruct position of 4 main political parties we applied desk research. We used MAXQDA v2020 to analyse the collected data.

Results

Stakeholders tend to expressed conflicting views on the effectiveness, relevance and socio-economic impact of the SSB tax. All of them agreed that the tax may appear severe for the poorest groups, children and adolescents, while disagreeing about the economic impact of the levy. The allocation of additional tax revenues was raising doubts, with stakeholders believing that the fiscal aim is the basic reason for implementing the tax, while these resources should be primarily dedicated to health promotion intervention and prevention of diet-related diseases. On the other hand, the political debate on the tax was highly superficial with strong populism arising of the presented positions.

Conclusions

There is a need to conduct a thorough public debate and improvements in terms of public communication to increase social awareness, sealing and refining the implemented solutions. Close cooperation with market players and non-governmental organizations is highly recommended.

Effects of public policies in the prevention of cardiovascular diseases: a systematic review of global literature

OBJECTIVES

Given the growing interest worldwide in applying public policies to improve human health, we undertook a systematic review of studies investigating whether public policies targeting unhealthy products could reduce cardiovascular diseases.

STUDY DESIGN

This study was a systematic review of the literature.

METHODS

We searched research studies published in 2000-2020 from major databases, including MEDLINE and Embase. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and narratively synthesized the studies based on vote counting and direction of the intervention effect.

RESULTS

Ninety-eight studies, mostly from high-income countries, met the inclusion criteria. Most studies were on public policies targeting sugar-sweetened beverages and tobacco, followed by alcohol, sugar, salt, and junk foods. Overall, many reported that several fiscal, regulatory, and educational policies generated beneficial effects of reducing the diseases. Those studies that reported no or limited effects highlighted several sociodemographic and health risk characteristics and design and implementation aspects of the policy interventions as factors limiting the policy effects; most of these are modifiable with appropriate policy interventions. For instance, low magnitude of tax, substitution with other unhealthy products, firms' competitive response strategies, pre-existence of smoking bans, incremental enactment of smoking regulations, degree of enforcement, and various sociocultural factors minimized the effects of the policies.

CONCLUSION

The literature supports a growing consensus on the beneficial effects of public policy for improving human health. The design and implementation of public policies must address various impeding factors and incorporate appropriate remedial measures. Further research is needed from low- and middle-income countries and on whether and how multiple policy instruments work in tandem.

Evaluation of Seattle’s Sweetened Beverage Tax on Tax Support and Perceived Economic and Health Impacts

It is important to understand whether the publics’ attitudes towards sugary beverage taxes (SBT) change after tax implementation to ensure the long-term success of tax policies. Seattle’s SBT went into effect on January 1, 2018. We administered a mixed-mode survey to adults in Seattle and comparison areas, pre- and 2-years post-tax, to evaluate the impact of the SBT on 1) tax support and 2) perceived tax impacts (N = 2,933). Using a difference-in-differences approach, we employed adjusted income-stratified modified Poisson models to test the impacts of the tax on net changes in attitudes in Seattle versus the comparison areas, pre- to post-tax. Among lower-income individuals in Seattle, support for the tax increased by 14% (PR_DD: 1.14; 95% CI: 1.08, 1.21) and there was a 20% net-increase in the perception that the SBT would positively affect the economy (PR_DD: 1.20; 95% CI: 1.05, 1.39), compared to changes in the comparison areas. Among higher-income individuals in Seattle, support for the tax was not different (PR_DD: 0.93; 95% CI: 0.70, 1.22) pre- to post-tax, but there was a net-increase in the perception that the tax would have negative effects on small businesses (PR_DD: 1.44; 95% CI: 1.03, 2.00) and family finances (PR_DD: 1.86; 95% CI: 1.09, 3.19). After living with the tax for 2-years, support for the tax increased among lower-income individuals in Seattle. Tax support was high and unchanged among higher-income individuals, but overall attitudes became more negative. Policy makers should consider investing in ongoing campaigns that explain the benefits of SSB taxes and revenues.

The effects of a sugar-sweetened beverage tax and a nutrient profiling tax based on Nutri-Score on consumer food purchases in a virtual supermarket: a randomised controlled trial

OBJECTIVE

To investigate the effects of a sugar-sweetened beverage (SSB) tax and a nutrient profiling tax on consumer food purchases in a virtual supermarket.

DESIGN

A randomised controlled trial was conducted with a control condition with regular food prices (n 152), an SSB tax condition (n 130) and a nutrient profiling tax condition based on Nutri-Score (n 112). Participants completed a weekly grocery shop for their household. Primary outcome measures were SSB purchases (ordinal variable) and the overall healthiness of the total shopping basket (proportion of total unit food items classified as healthy). The secondary outcome measure was the energy (kcal) content of the total shopping basket. Data were analysed using regression analyses.

SETTING

Three-dimensional virtual supermarket.

PARTICIPANTS

Dutch adults aged ≥18 years are being responsible for grocery shopping in their household (n 394).

RESULTS

The SSB tax (OR = 1·62, (95 % CI 1·03, 2·54)) and the nutrient profiling tax (OR = 1·88, (95 %CI 1·17, 3·02)) increased the likelihood of being in a lower-level category of SSB purchases. The overall healthiness of the total shopping basket was higher (+2·7 percent point, (95 % CI 0·1, 5·3)), and the energy content was lower (-3301 kcal, (95 % CI -6425, -177)) for participants in the nutrient profiling tax condition than for those in the control condition. The SSB tax did not affect the overall healthiness and energy content of the total shopping basket (P > 0·05).

CONCLUSIONS

A nutrient profiling tax targeting a wide range of foods and beverages with a low nutritional quality seems to have larger beneficial effects on consumer food purchases than taxation of SSB alone.

The role of environmental cues in sugar-sweetened beverage consumption using a temporal self-regulation theory framework

Sugar-sweetened beverage consumption is related to adverse health outcomes such as obesity and Type 2 diabetes. The present research further examined the utility of the temporal self-regulation theory in predicting sugar-sweetened beverage consumption. In addition, the research aimed to identify salient cues that trigger intake. Two-hundred and eighty-seven participants were recruited using convenience sampling in US and Australian populations. Hierarchical multiple regression analyses were used, and the final model accounted for 27.1% of the variance in consumption, providing partial support for the temporal self-regulation theory (ƒ² = 0.37). Intention accounted for a significant 7.0% of variance (R² = 0.07, p < .001), behavioural prepotency variables (past behaviour, habit, and cues) together combined for an additional 15.1% of variance (R² = 0.15, p < .001), but neither measure of self-regulatory capacity (trait self-control, inhibition) was a significant predictor. No cues emerged as unique predictors, however the findings suggest that consumption may be influenced by a combination of cues across different situations. Behavioural prepotency moderated the intention-behaviour relationship such that as behavioural prepotency increased, the greater the influence intention had on behaviour. Further support for the role of both intention and automatic processes in sugar-sweetened beverage consumption was garnered, but more research is needed to identify when specific cues influence consumption most.

[Excise taxes on sugar-sweetened beverages in Latin America and the CaribbeanImposto especial de consumo sobre bebidas açucaradas na América Latina e no Caribe]

Objetivo.

Caracterizar el diseño de los impuestos selectivos al consumo de bebidas azucaradas en América Latina y el Caribe, y evaluar las oportunidades de aumentar su impacto en el consumo y la salud.

Métodos.

Se llevó a cabo una búsqueda y una evaluación exhaustivas de legislaciones vigentes a marzo del 2019, recopiladas mediante las herramientas de seguimiento ya existentes de la Organización Panamericana de la Salud y de la Organización Mundial de la Salud, fuentes secundarias, así como mediante una encuesta a ministerios de finanzas. El análisis se centró en el tipo de productos gravados y la estructura y la base de estos impuestos selectivos.

Resultados.

De los 33 países evaluados, en 21 se aplican impuestos selectivos al consumo de bebidas azucaradas. En siete países también se aplican impuestos selectivos sobre el agua embotellada y en al menos cuatro, se aplican tales impuestos sobre las bebidas lácteas azucaradas. Diez de estos impuestos selectivos al consumo son de tipo ad valorem con algunas bases imponibles fijadas en las primeras etapas de la cadena de valor, siete son de tipo específico y cuatro son de estructura combinada o mixta. En tres países se aplican impuestos selectivos al consumo en función de la concentración de azúcares del producto.

Conclusiones.

Si bien el número de países en que se aplican impuestos selectivos al consumo de bebidas azucaradas es prometedor, existe una gran heterogeneidad en su diseño en cuanto a la estructura, la base imponible y los productos gravados. Se podrían aprovechar aún más los impuestos selectivos existentes para tener un mayor impacto sobre el consumo de bebidas azucaradas y la salud si se incluyeran todas las categorías de bebidas azucaradas, excluyendo el agua embotellada, y si se recurriera más a impuestos específicos ajustados regularmente según la inflación y basados posiblemente en la concentración de azúcares del producto. Todos los países se beneficiarían si hubiera mayor orientación. Futuras investigaciones deberían tener como objetivo abordar esta brecha.

Stakeholder views on taxation of sugar-sweetened beverages and its adoption in the Netherlands

An increasing number of governments worldwide have introduced a tax on sugar-sweetened beverages (SSB) for public health. However, the adoption of such a policy is still debated in many other countries, such as in the Netherlands. We investigated Dutch stakeholder views on taxation of SSB and perceived barriers and facilitators to its adoption in the Netherlands. Semi-structured interviews were conducted in 2019 with 27 stakeholders from health and consumer organizations, health professional associations, trade associations, academia, advisory bodies, ministries and parliamentary parties. Data were analysed using a thematic content approach. The findings reveal that, between and within sectors, stakeholders expressed contradictory views on the effectiveness, appropriateness and (socio)economic effects of an SSB tax. Perceived barriers to the adoption of an SSB tax in the Netherlands included an unfavourable political context, limited advocacy for an SSB tax, a strong lobby against an SSB tax, perceived public opposition, administrative load and difficulties in defining SSB. Perceived facilitators to its adoption included an increasing prevalence of overweight, disappointing results from voluntary industry actions, a change of government, state budget deficits, a shift in public opinion, international recommendations and a solid legal basis. In conclusion, this study shows that several challenges remain to be overcome for the adoption of an SSB tax in the Netherlands. Similar research on stakeholder views in other countries may further inform SSB tax policy processes.

Selling function: the advertising of sugar-containing beverages on Australian television

Reducing population consumption of sugar-containing beverages has become a public health priority in many countries due to causal evidence between high consumption, weight gain and non-communicable diseases. This study aims to explore how sugar-containing beverages are associated with health and wellness in television advertisements. Our sample consisted of all televised advertisements from sugar-containing beverage manufacturers aired on free-to-air television from one Australian network (four channels) in 2016 (n = 30 unique advertisements). We transcribed advertisements for audio and visual information. We analysed data inductively using methods from thematic, discourse and multi-modal analysis. Advertisements for sugar-containing beverages reflected both traditional (physical health and reduced risk of disease) and broader (wellbeing) conceptualizations of health. Beverages were positioned in advertisements as contributing a functional role to promote and enhance health and wellbeing within the physical, mental and social domains. Beverages were advertised as correcting suboptimal states of being to achieve desirable outcomes, including relaxation, increased resistance to disease, enhanced performance, better cognitive functioning and improved social connections. Positioning beverages within a wider conceptualization of health and wellbeing aligns with how health and nutrition are increasingly being understood and sought out by consumers, creating increased opportunities for the marketing of sugar-containing beverages as 'healthy'.

Gamification and Sugar: A School-Based Pilot Study of Social Marketing and Gamification Approaches to Reduce Sugary Drink Intake in Pasifika School Students

The aim of this study was to investigate a social marketing-gamification intervention to reduce sugary drink intake drawing on popular culture of Pasifika secondary school students in Auckland, New Zealand. Students aged 11 to 14 years from one coeducational high school participated in the 11-week pilot study. The 9-week intervention was undertaken in assemblies and classrooms. Baseline and follow-up measures were completed by 227 and 220 students, respectively, of 298 enrolled students. Retention of the "3-6-9" teaching related to maximum daily sugar intake increased from 9% at baseline to 97% at follow-up (P < .0001). Significant increases were observed of students who correctly answered sugar content of drinks. Overall consumption of sugary drink decreased at follow-up by 0.46 glasses per day. The main conclusion from this study was that this school-based gamification educational package to convey messages about sugar content of drinks using popular modes of engagement is a promising intervention that was acceptable and well supported by school staff and students.

Beverage Intake and the Risk of Gestational Diabetes Mellitus: The SECOST

The contribution and impact of beverage intake to total nutrient and energy intake may be substantial. Given the link between lifestyle, diet, and the risk of pregnancy complications, this study investigated the association between the quantity and types of beverages with gestational diabetes mellitus (GDM) risk. The study included 452 women from the Seremban Cohort Study (SECOST). The mean energy by beverage intake was 273 ± 23.83 kcal/day (pre-pregnancy), 349 ± 69.46 kcal/day (first trimester) and 361 ± 64.24 kcal/day (second trimester). Women significantly increased intake of maternal milks and malted drinks, but significantly reduced the intake of carbonated drinks and other drinks from before until the second trimester of pregnancy. For chocolate drinks, carbonated drinks, and soy milk, women increased intake from pre-conception to the first trimester, but reduced their intake from the first to the second trimester. While higher intake of cultured-milk drinks was associated with an increased risk of GDM, higher fruit juice intake was associated with a lower risk of GDM. However, these associations were only observed for intake prior to pregnancy and during the first trimester. Further research is needed to corroborate these findings and investigate the contributions of different beverages to overall diet quality as well as adverse health outcomes during pregnancy.

Excise taxes on sugar-sweetened beverages in Latin America and the Caribbean

Objective

To characterize the design of excise taxes on sugar-sweetened beverages (SSBs) in Latin America and the Caribbean and assess opportunities to increase their impact on SSB consumption and health.

Methods

A comprehensive search and review of the legislation in effect as of March 2019, collected through existing Pan American Health Organization and World Health Organization monitoring tools, secondary sources, and surveying ministries of finance. The analysis focused on the type of products taxed, and the structure and base of these excise taxes.

Results

Out of the 33 countries analyzed, 21 apply excise taxes on SSBs. Seven countries also apply excise taxes on bottled water and at least four include sugar-sweetened milk drinks. Ten of these excise taxes are ad valorem with some tax bases set early in the value chain, seven are amount-specific, and four have either a combined or mixed structure. Three countries apply excise taxes based on sugar concentration.

Conclusions

While the number of countries applying excise taxes on SSBs is promising, there is great heterogeneity in design in terms of structure, tax base, and products taxed. Existing excise taxes could be further leveraged to improve their impact on SSB consumption and health by including all categories of SSBs, excluding bottled water, and relying more on amount-specific taxes regularly adjusted for inflation and possibly based on sugar concentration. All countries would benefit from additional guidance. Future research should aim to address this gap.

Dietary factors associated with being overweight and obese among school-going adolescents in Region One, The Gambia

BACKGROUND

The purpose of this study was to determine the dietary factors associated with being overweight and obese among school-going adolescents in Region One, The Gambia.

METHOD

This was a school-based cross-sectional study and 1008 students from eight Senior Secondary Schools in Region one of The Gambia participated in it. Data were collected through questionnaire self-administered method, and weight and height measurements. Using the age and gender-specific cutoff points proposed by World Health Organization, body mass index (BMI) was calculated using the weight and height measures. The data were analyzed using frequencies for underweight, overweight, and obesity, and the association between dietary factors and weight status of participants was determined using the Chi-square test.

FINDINGS

Out of the 1008 students recruited in the study, 981 of them completed and returned the questionnaires, resulting in a total response rate of 97%. The mean age of the participants was 17.3 years (SD = 1.9) and 385 of them (39.2%) were from grade 10. There were 627 (63.9%) females. The mean BMI for all the students was 20.0 ± 3.4 kg/m2. Most of the students (n = 672; 68.5 %) had normal body weight, but 226 (23%), 76 (7.7 %) and 7 (0.7%) of them were underweight, overweight and obese respectively. There was a significantly higher number of female students who were overweight (n = 64, 10.2%) than their male counterparts (χ2 = 72.336, p < 0.001). The frequency of drinking sugar added juices and full cream milk, eating fish, shrimps, oysters, lobsters, and snacks such as cakes and biscuits were significantly associated with overweight and obesity among the participants (p < 0.05). In conclusion, the problem of under-nutrition and over-nutrition co-existed among the students which were associated with poor eating habits.

Evaluation of the Choose Health: Food, Fun, and Fitness 3rd- to 6th-Grade Curriculum: Changes in Obesity-Related Behaviors

BACKGROUND

Choose Health: Food, Fun, and Fitness (CHFFF) is aimed at 3rd to 6th graders, and uses experiential learning, food preparation, active games, goal setting, and a family newsletter to target behaviors shown to decrease childhood obesity and chronic disease risk. This study aimed to evaluate CHFFF as intended in low-income settings.

METHODS

A quasi-experimental design with delayed intervention was used. CHFFF participants in 27 after-school and 28 in-school groups in 5 New York counties in 2014 to 2015 completed a self-report survey at initial enrollment, after a no-intervention control period, and after receiving CHFFF. Statistical analyses were based on 561 3rd to 6th graders who completed all 3 surveys and participated in at least 4 of the 6 lessons.

RESULTS

Compared to their control period, after receiving CHFFF, youth significantly improved in the following multi-item dietary scores: overall dietary intake (p < .001), vegetable intake (p < .001), fruit intake (p < .01), soda/fast food intake (p < .05) and intent to consume soda/fast food (p < .001). Youth also reported reading Nutrition Facts labels and sharing about healthy eating with their family more often (both p < .001), and greater likelihood of having tried a new food (p < .001).

CONCLUSIONS

Results provide evidence for the effectiveness of this curriculum in improving self-reported child diet and related behaviors.

Dietary Habits and their Association with Metabolic Syndrome in a sample of Iranian adults: A population-based study

BACKGROUND

Central obesity, insulin resistance, dyslipidemia, and hypertension are the core components of metabolic syndrome (MetS) which is coincident with unhealthy dietary habits in the Middle-Eastern countries. The aim of this study was to explore the association between dietary habits and MetS of the adult population living in Yazd Greater Area, Iran.

METHODS

This is a cross-sectional study that uses the data of a population-based cohort study on Iranian adults, known as Yazd Health Study (YaHS). The relationship between dietary habits and metabolic syndrome among adults (n = 2,896) was analyzed using multiple logistic regression method.

RESULTS

The prevalence of MetS among the participants was 32.2%. Outcomes from logistic regression examination show that breakfast consumption has a significant inverse effect on the occurrence of MetS after adjustment for age, education level, physical activity statue, history of chronic diseases, and smoking (odds ratio (OR) = 0.38, 95% confidence interval (CI) = 0.14, 0.97). This effect remains significant even after adjustment for body mass index (BMI) and reveals that odds of having MetS is 69% lower in breakfast consumers in contrast to nonconsumers (OR = 0.31, 95% CI = 0.11, 0.87). However, no significant relationship was observed between other dietary habits including consumption of sweetened drinks, sugar cubes, and fast foods and MetS after adjustment for all potential confounders.

CONCLUSIONS

This study revealed that eating breakfast has an inverse relationship with metabolic syndrome. To find out stronger evidence in relation to dietary habits and MetS, more researches especially population-based cohort studies are needed to be conducted.

Correlates of sugar-sweetened beverage intake among low-income women during the first 1000 days

OBJECTIVE

To describe prenatal and postpartum consumption of water, cows' milk, 100 % juice and sugar-sweetened beverages (SSB) among women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) programme in New York City (NYC) and to identify correlates of SSB intake in this population.

DESIGN

Cross-sectional data were collected from structured questionnaires that included validated beverage frequency questionnaires with the assistance of container samples. The association of maternal and household factors and non-SSB consumption with habitual daily energetic (kJ (kcal)) intake from SSB was assessed by using multivariable median regression.

SETTING

WIC programme in NYC, NY. Data were collected in 2017.

PARTICIPANTS

388 pregnant or postpartum women (infant aged <2 years) from the NYC First 1000 Days Study.

RESULTS

Median age was 28 years (interquartile range (IQR) 24-34); 94·1 % were Hispanic/Latina, and 31·4 % were pregnant. Overall, 87·7 % of pregnant and 89·1% of postpartum women consumed SSB ≥ once weekly, contributing to a median daily energetic intake of 410 kJ (98 kcal) (IQR (113-904 kJ) 27-216) and 464 kJ (111 kcal) (IQR (163-1013 kJ) 39-242), respectively. In adjusted analyses, only consumption of 100 % juice was associated with greater median energetic intake from SSB (adjusted β for each additional ounce = 13; 95% CI 8, 31 (3·2; 95 % CI 2·0, 7·3).

CONCLUSIONS

Among pregnant and postpartum women in WIC-enrolled families, interventions to reduce SSB consumption should include reduction of 100 % juice consumption as a co-target of the intervention.

Impact and acceptance of a state-wide policy to remove sugar-sweetened beverages in hospitals in New South Wales, Australia

ISSUE ADDRESSED

Policy and environmental approaches can reduce the accessibility and purchasing of sugar-sweetened beverages (SSBs), potentially reducing overweight and obesity. This study examined the impact of a state-wide policy on removal of SSBs from sale in NSW public hospitals (launched July 2017), and explored consumer awareness and support.

METHODS

A convenience sample of 81 food outlets in 26 hospitals were audited for SSB availability before and after the target date for SSB removal (31 December 2017). An interviewer-administered intercept survey in 10 randomly selected hospitals (March-May 2018), assessed staff and visitors' awareness of and support for SSB removal. Descriptive and χ² analyses assessed differences in: SSB availability; staff and visitor awareness and support. Open-ended survey responses were thematically analysed.

RESULTS

The proportion of outlets that removed SSBs increased from 58.0% to 96.3% (P < .001). The majority (79.5%) of the 2394 surveyed supported SSB removal, with nearly half (48.4%) reporting it would improve people's health. A minority (13.4%) did not support SSB removal, more than half (61.4%) of those said individuals should have free choice. More staff than visitors were aware of the change (61.9% vs 31.2%; P < .0001).

CONCLUSIONS

Availability of SSBs in NSW hospitals was significantly reduced after implementation of a policy to remove them from sale. There was strong staff and visitor support for the initiative. SO WHAT?: This study provides clear evidence that a policy designed to provide a healthy hospital retail drink environment can be successfully implemented at scale with high levels of support from staff and visitors.

SUMMARY

A state-wide policy initiative to remove SSBs from sale in NSW hospital food outlets in 2017 was successfully implemented, with a sample of outlets having nearly 100% compliance. The majority of staff and visitors (80%) supported the removal of SSBs, mostly because they believed it would improve individual and population health.

Projected impact of a reduction in sugar-sweetened beverage consumption on diabetes and cardiovascular disease in Argentina: A modeling study

BACKGROUND

Sugar-sweetened beverage (SSB) consumption is associated with obesity, diabetes, and hypertension. Argentina is one of the major consumers of SSBs per capita worldwide. Determining the impact of SSB reduction on health will inform policy debates.

METHODS AND FINDINGS

We used the Cardiovascular Disease Policy Model-Argentina (CVD Policy Model-Argentina), a local adaptation of a well-established computer simulation model that projects cardiovascular and mortality events for the population 35-94 years old, to estimate the impact of reducing SSB consumption on diabetes incidence, cardiovascular events, and mortality in Argentina during the period 2015-2024, using local demographic and consumption data. Given uncertainty regarding the exact amount of SSBs consumed by different age groups, we modeled 2 estimates of baseline consumption (low and high) under 2 different scenarios: a 10% and a 20% decrease in SSB consumption. We also included a range of caloric compensation in the model (0%, 39%, and 100%). We used Monte Carlo simulations to generate 95% uncertainty intervals (UIs) around our primary outcome measures for each intervention scenario. Over the 2015-2024 period, a 10% reduction in SSBs with a caloric compensation of 39% is projected to reduce incident diabetes cases by 13,300 (95% UI 10,800-15,600 [low SSB consumption estimate]) to 27,700 cases (95% UI 22,400-32,400 [high SSB consumption estimate]), i.e., 1.7% and 3.6% fewer cases, respectively, compared to a scenario of no change in SSB consumption. It would also reduce myocardial infarctions by 2,500 (95% UI 2,200-2,800) to 5,100 (95% UI 4,500-5,700) events and all-cause deaths by 2,700 (95% UI 2,200-3,200) to 5,600 (95% UI 4,600-6,600) for "low" and "high" estimates of SSB intake, respectively. A 20% reduction in SSB consumption with 39% caloric compensation is projected to result in 26,200 (95% UI 21,200-30,600) to 53,800 (95% UI 43,900-62,700) fewer cases of diabetes, 4,800 (95% UI 4,200-5,300) to 10,000 (95% UI 8,800-11,200) fewer myocardial infarctions, and 5,200 (95% UI 4,300-6,200) to 11,000 (95% UI 9,100-13,100) fewer deaths. The largest reductions in diabetes and cardiovascular events were observed in the youngest age group modeled (35-44 years) for both men and women; additionally, more events could be avoided in men compared to women in all age groups. The main limitations of our study are the limited availability of SSB consumption data in Argentina and the fact that we were only able to model the possible benefits of the interventions for the population older than 34 years.

CONCLUSIONS

Our study finds that, even under conservative assumptions, a relatively small reduction in SSB consumption could lead to a substantial decrease in diabetes incidence, cardiovascular events, and mortality in Argentina.

Perspective: Chaos in a Bottle-A Critical Evaluation of Beverage Categorization in Nutrition Research

Beverage consumption is an important contributor to total daily calorie intake among children and adolescents. While associations between excess calories from beverages and development of obesity are well established, a standardized approach for beverage categorization does not exist. As a result, there is marked heterogeneity in assessment and categorization of beverage intake across studies. The purpose of this article is to critically review beverage categorization in recent (published since 2010) observational studies that evaluated beverage intake in relation to weight/adiposity in US youth, and to put forth an initial proposal for a standardized beverage classification system. Standardized beverage classification is critical to ensure transparency in nutrition science research and facilitate comparison of findings across studies. A systematic literature search identified 37 eligible studies, across which beverage categorization varied considerably. The most heterogeneity was observed for categorization of "sugar-sweetened beverages" and the greatest consistency was observed for categorization of 100% juices. This review provides an evidence-based starting point for urgently needed, collaborative work to determine priorities for beverage categorization and leverage existing standards of identity in order to create and disseminate a standardized beverage classification system. A standardized approach will inform meaningful assessment of beverage consumption in research studies and facilitate impactful translation of research findings into public health nutrition policy.

Public acceptability of a sugar-sweetened beverage tax and its associated factors in the Netherlands

Objective:

To investigate the level of public acceptability of a sugar-sweetened beverage (SSB) tax and its associated factors.

Design:

Participants completed an online self-administered questionnaire. Acceptability of an SSB tax was measured on a seven-point Likert scale (strongly disagree to strongly agree). Associations between acceptability and sociodemographic factors, weight status, SSB consumption and beliefs about effectiveness (e.g., ‘An SSB tax would reduce people’s SSB consumption’), appropriateness, socioeconomic and economic benefit, implementation and trust were assessed using multivariable linear regression analyses.

Setting:

The Netherlands.

Participants:

Dutch adults aged ≥18 years representative of the Dutch population for age, sex, education level and location (n 500).

Results:

Of the participants, 40 % supported and 43 % opposed an SSB tax in general. Moreover, 42 % supported (43 % opposed) an SSB tax as a strategy to reduce overweight, and 55 % supported (32 % opposed) an SSB tax if revenue is used for health initiatives. Participants with a low education level (B = –0·82, 95 % CI –1·31, –0·32), overweight (B = –0·49, 95 % CI –0·89, –0·09), moderate or high SSB consumption (B = –0·86, 95 % CI –1·30, –0·43 and B = –1·01, 95 % CI –1·47, –0·56, respectively) and households with adolescents (B = –0·57, 95 % CI –1·09, –0·05) reported a lower acceptability of an SSB tax than their counterparts. Beliefs about effectiveness, appropriateness, socioeconomic and economic benefit, implementation and trust were associated with acceptability (P < 0·001).

Conclusions:

Public acceptability of an SSB tax tends to be higher if revenue is used for health initiatives. The factors associated with acceptability should be taken into consideration.

Social robots as treatment agents: Pilot randomized controlled trial to deliver a behavior change intervention

Social robots are increasingly demonstrating effectiveness as low-intensity behavior change agents. Key targets for these behavioral interventions include daily lifestyle behaviors with significant health consequences, such as the consumption of high-calorie foods and drinks ('snacks'). A pilot randomized controlled trial using a stepped-wedge design was conducted to determine the efficacy of a motivational intervention by an autonomous robot, to help reduce high-calorie snacks. Twenty-six adults were randomized to receive Immediate or 4-week Delayed treatment, with assessments at Baseline and Weeks 4 and 8. The treatment comprised motivation enhancement and self-management training using mental imagery (Functional Imagery Training). A significant condition by time effect for snack episode reduction was obtained, F(2, 32.06) = 4.30, p = .022. The Immediate condition significantly reduced snacking between Baseline and Week 4 (d = -1.06), while the Delayed condition did not (d = -0.08). Immediate participants maintained their improvement between Weeks 4 and 8 (d = -0.18), and Delayed participants then showed a significant fall (d = -1.42). Overall, 'Immediate' participants decreased their snack episodes by 54% and 'Delayed' decreased by 62% from Baseline to Week 8, and an average weight reduction of 4.4 kg was seen across over the first 2 weeks of treatment. Four weeks after starting the intervention, both conditions had significant increases in perceived confidence to control snack intake for time duration, specific scenarios and emotional states (d = 0.61 to 1.42). Working alliance was significantly correlated with reduced snack episodes. The pilot's results appear to suggest that the robot-delivered intervention may be as effective as a human clinician delivering a similar intervention. The robot-delivered pilot achieved similar snack episode reduction in the first four weeks (FIT-R, 55%) when compared with the human-delivered version by a trained clinician (FIT-H, 49%). Overall, the results provide preliminary evidence for an autonomous social robot to deliver a low-intensity treatment on dietary intake without the need for human intervention. Future trials should extend the deployment of the robot-delivered intervention protocol to other low-intensity behavioral outcomes.

Custodio MR. Food Sources and Nutrient Intakes of Filipino Working Adults

Nutrition is an integral part of economic development, since it influences workers' healthand productivity. This study evaluated the usual nutrient intakes and food sources of workingadults. We conducted a cross-sectional survey that involved 1264 selected working adults aged 19to 59 years old from randomly selected job sectors. Quantitative dietary data was collected by a 2-day, non-consecutive 24 h recall, while a dietary diversity questionnaire was used to assess the typesand frequency of foods consumed. Physical activity was measured using the World HealthOrganization global physical assessment questionnaire. The prevalence of inadequate intakes,defined as the percentage of adults with intakes less than the estimated average requirements (EAR)or acceptable macronutrient distribution ranges (AMDR) were estimated using the PC-Softwarefor Intake Distribution Estimation (PC-SIDE) program. The mean daily energy intake of workingadults was 1768 kcal/day or 74% of the Estimated Energy Requirements (EER) for this age group.The percentage contribution to the total energy of fats (58%) and proteins (34%) were excessivelyhigh. Consumption of fruits and vegetables was only 30% and 40% of the recommended nutrientintake, respectively. Salt intake was 52% above the adequate intake. Nutrient inadequacy was highin almost all nutrients, including iron (99%), folate (97.9%), riboflavin (95.8%), calcium (94.7%),vitamin C (87.3%), and thiamin (76.6%). The top five food sources of energy included rice (35.6%),pork (15.1%), fats and oils (4.7%), chicken (4.4%), and bread (3.8%). Energy and nutrient intakes ofworking adults is extremely sub-optimal due to the consumption of few nutrient-dense foods. Thismay pose a triple burden of malnutrition if left unsolved.

[Lancet Commission on Hypertension Group position statement on the global improvement of accuracy standards for devices that measure blood pressurePosicionamento do Grupo da Lancet Commission on Hypertension sobre a melhoria global dos padrões de acurácia para aparelhos que medem a pressão arterial]

The Lancet Commission on Hypertension identified that a key action to address the worldwide burden of high blood pressure (BP) was to improve the quality of BP measurements by using BP devices that have been validated for accuracy. Currently, there are over 3 000 commercially available BP devices, but many do not have published data on accuracy testing according to established scientific standards. This problem is enabled through weak or absent regulations that allow clearance of devices for commercial use without formal validation. In addition, new BP technologies have emerged (e.g. cuffless sensors) for which there is no scientific consensus regarding BP measurement accuracy standards. Altogether, these issues contribute to the widespread availability of clinic and home BP devices with limited or uncertain accuracy, leading to inappropriate hypertension diagnosis, management and drug treatment on a global scale. The most significant problems relating to the accuracy of BP devices can be resolved by the regulatory requirement for mandatory independent validation of BP devices according to the universally-accepted International Organization for Standardization Standard. This is a primary recommendation for which there is an urgent international need. Other key recommendations are development of validation standards specifically for new BP technologies and online lists of accurate devices that are accessible to consumers and health professionals. Recommendations are aligned with WHO policies on medical devices and universal healthcare. Adherence to recommendations would increase the global availability of accurate BP devices and result in better diagnosis and treatment of hypertension, thus decreasing the worldwide burden from high BP.

Projected impact of the Portuguese sugar-sweetened beverage tax on obesity incidence across different age groups: A modelling study

BACKGROUND

Excessive consumption of sugar has a well-established link with obesity. Preliminary results show that a tax levied on sugar-sweetened beverages (SSBs) by the Portuguese government in 2017 led to a drop in sales and reformulation of these products. This study models the impact the market changes triggered by the tax levied on SSBs had on obesity incidence across various age groups in Portugal.

METHODS AND FINDINGS

We performed a national market analysis and population-wide modelling study using market data for the years 2014-2018 from the Portuguese Association of Non-Alcoholic Drinks (GlobalData and Nielsen Consumer Panel), dietary data from a national survey (IAN-AF 2015-2016), and obesity incidence data from several cohort studies. Dietary energy density from SSBs was calculated by dividing the energy content (kcal/gram) of all SSBs by the total food consumption (in grams). We used the potential impact fraction (PIF) equation to model the projected impact of the tax-triggered change in sugar consumption on obesity incidence, through both volume reduction and reformulation. Results showed a reduction of 6.6 million litres of SSBs sold per year. Product reformulation led to a decrease in the average energy density of SSBs by 3.1 kcal/100 ml. This is estimated to have prevented around 40-78 cases of obesity per year between 2016 and 2018, with the biggest projected impact observed in adolescents 10 to <18 years old. The model shows that the implementation of this tax allowed for a 4 to 8 times larger projected impact against obesity than would be achieved though reformulation alone. The main limitation of this study is that the model we used includes data from various sources, which can result in biases-despite our efforts to mitigate them-related to the methodological differences between these sources.

CONCLUSIONS

The tax triggered both a reduction in demand and product reformulation. These, together, can reduce obesity levels among frequent consumers of SSBs. Such taxation is an effective population-wide intervention. Reformulation alone, without the decrease in sales, would have had a far smaller effect on obesity incidence in the Portuguese population.

Sugar-Sweetened and Diet Beverage Consumption in Philadelphia One Year after the Beverage Tax

In January 2017, Philadelphia (Pennsylvania) implemented an excise tax ($ 0.015/ounce) on sugar-sweetened and diet beverages. This study is a general population-based study to report on the longer-term impacts of the tax on within-person changes in consumption 12 months after implementation. A quasi-experimental difference-in-difference design was used to contrast Philadelphia vs. nearby comparison cities (Trenton, New Jersey; Camden, New Jersey; and Wilmington, Delaware) at baseline (December 2016-January 2017) vs. 12-month follow-up (December 2017-February 2018). A random-digit-dialing phone survey was administered to a population-based cohort. Analyses assessed changes in 30-day consumption frequency and ounces of sugar-sweetened and diet beverages (and a substitution beverage, bottled water) in the analytic sample (N = 515). After 12 months, relative to the comparison group, Philadelphians were slightly more likely to decrease their frequency of sugar-sweetened beverage consumption (39.2% vs. 33.5%), and slightly less likely to increase their frequency of sugar-sweetened beverage consumption (38.9% vs. 43.0%). The effects of the tax estimated in the adjusted difference-in-difference analysis were very small (for example, changes in monthly sugar-sweetened beverage consumption in Philadelphia relative to comparison cities was -3.03 times or -51.65 ounces) and confidence intervals were very wide. Results suggested that, one year after implementation, there was no major overall impact of the tax on general population-level consumption of sugar-sweetened or diet beverages, or bottled water. Future studies should test whether the tax's effect differs in vulnerable sub-populations.

Modelling the Effects of Beverage Substitution during Adolescence on Later Obesity Outcomes in Early Adulthood: Results from the Raine Study

High sugar-sweetened beverage (SSB) consumption has been linked with obesity. The present study examined the associations between adolescent SSB intake and body mass index (BMI), waist circumference (WC), and overweight status in early adulthood, and modelled the association of alternative beverage substitution with BMI and WC. Data of offspring from the Western Australian Pregnancy Cohort (Raine) Study at ages 14 and 22 years were used (n = 667). SSB intake at 14 years (100 g/day) was associated with higher BMI (β = 0.19 kg/m², 95% CI 0.04, 0.33), WC (β = 0.41cm, 95% CI 0.04, 0.78), and being overweight at 22 years (OR 1.10, 95% CI 1.02, 1.18). Every 100g modelled substitution of SSB with milk at age 14 years was associated with lower BMI (−0.19 kg/m²) and WC (−0.52 cm) at age 22 years. Replacement of SSB with diet drink was associated with higher BMI and WC. No association was found for substitutions of SSB with water, tea/coffee, or 100% fruit juice with BMI or WC. SSB intake during adolescence was associated with higher BMI, WC, and being overweight in early adulthood. Milk as an alternative to SSB was associated with less adiposity. Caution is necessary in recommending diet drinks as a SSB alternative.

Health Warnings on Sugar-Sweetened Beverages: Simulation of Impacts on Diet and Obesity Among U.S. Adults

INTRODUCTION

Overconsumption of sugar-sweetened beverage (SSB) is a significant contributor to obesity. Policymakers have proposed requiring health warnings on SSBs to reduce SSB consumption. Randomized trials indicate that SSB warnings reduce SSB purchases, but uncertainty remains about how warnings affect population-level dietary and health outcomes.

METHODS

This study developed a stochastic microsimulation model of dietary behaviors and body weight using the 2005-2014 National Health and Nutrition Examination Surveys, research on SSB health warnings, and a validated model of weight change. In 2019, the model simulated a national SSB health warning policy's impact on SSB intake, total energy intake, BMI, and obesity among U.S. adults over 5 years. Sensitivity analyses varied assumptions about: (1) how warning efficacy changes over time, (2) the magnitude of warnings' impact on SSB intake, and (3) caloric compensation.

RESULTS

A national SSB health warning policy would reduce average SSB intake by 25.3 calories/day (95% uncertainty interval [UI]= -27.0, -23.6) and total energy intake by 31.2 calories/day (95% UI= -32.2, -30.1). These dietary changes would reduce average BMI by 0.64 kg/m² (95% UI= -0.67, -0.62) and obesity prevalence by 3.1 percentage points (95% UI= -3.3%, -2.8%). Obesity reductions persisted when assuming warning efficacy wanes over time and when using conservative estimates of warning impact and caloric compensation. Benefits were larger for black and Hispanic adults than for white adults, and for adults with lower SES than for those with higher SES.

CONCLUSIONS

A national SSB health warning policy could reduce adults' SSB consumption and obesity prevalence. Warnings could also narrow sociodemographic disparities in these outcomes.

A Geospatial Analysis of Health, Mental Health, and Stressful Community Contexts in Los Angeles County

Introduction

Despite numerous federal investments, chronic disease continues to disproportionately affect certain communities across the United States. Understanding the regional distribution (including any overlaps) of factors that extend beyond built and food environments, especially factors that may adversely affect chronic disease–related behaviors, is important. This case study of Los Angeles County’s geospatial landscape sought to address these gaps in research and practice.

Methods

We examined the distributions and geographic overlaps between economic hardship, psychological distress, soda consumption, and availability of publicly funded mental health facilities in 8 Service Planning Areas in Los Angeles County. We categorized the geospatial presence of each variable as low, intermediate, or high. We imported all data, collected during 2014–2018, into ArcGIS Pro version 2.3.3 to create 5 bivariate choropleth maps.

Results

Levels of economic hardship were not equally distributed across communities; the county was characterized by intermediate levels of soda consumption and psychological distress. Most areas had low or intermediate availability of publicly funded mental health facilities. We also found some discordance between psychological distress and availability of publicly funded mental health facilities, and between economic hardship and availability of these facilities.

Conclusion

The need exists to address disparities in economic hardship and to increase access to publicly funded mental health supports and providers in Los Angeles County. The information collected in this case study has policy implications for health, public health, and mental health services planning at the local level.

Development of a diet quality index to assess adherence to Canadian dietary recommendations in 3-year-old children

OBJECTIVE

Little is known about the diet quality of preschool children in Canada. We adapted an established diet quality index for European preschool children to align with the Canadian context and applied the index to dietary data of 3-year-old children to assess patterns of diet quality.

DESIGN

Our diet quality index (DQI-C) consists of four components that align with Canada's Food Guide (Vegetables and Fruit, Grain Products, Milk and Alternatives and Meat and Alternatives) and two components that account for less healthy intakes (Candy/Snacks, and Sugar-Sweetened Beverages (SSB)). The ratio between consumption v. recommended intakes is calculated for each component and summed to give a total score from 0 to 6.

SETTING

Alberta, Canada.

PARTICIPANTS

The DQI-C was applied to FFQ data from 1260 3-year-old children.

RESULTS

Mean DQI-C was 3·69 (sd 0·6). Most children met recommendations for Vegetables and Fruit (73 %) and Meat and Alternatives (70 %); however, fewer met recommendations for Milk and Alternatives (38 %) and Grain Products (13 %). Children in the lowest quartile for DQI-C score consumed a mean of 82 g of Candy/Snacks and 193 g of SSB daily, whereas those in the highest quartile consumed 45 g/d and 17 g/d of Candy and Snacks and SSB, respectively.

CONCLUSION

This DQI-C score is useful for ranking Canadian preschool children according to their overall diet quality. There is room for improvement for consumptions of Grain Products, Meat and Alternatives, Candy/Snacks and SSB, which could be a target for initiatives to improve diet quality of preschool children in Canada.

Political and public acceptability of a sugar-sweetened beverages tax: a mixed-method systematic review and meta-analysis

BACKGROUND

Taxation of sugar-sweetened beverages (SSBs), as a component of a comprehensive strategy, has emerged as an apparent effective intervention to counteract the rising prevalence of overweight and obesity. Insight into the political and public acceptability may help adoption and implementation in countries with governments that are considering an SSBs tax. Hence, we aimed to conduct a systematic review and meta-analysis to synthesize the existing qualitative and quantitative literature on political and public acceptability of an SSBs tax.

METHODS

Four electronic databases (PubMed, Embase, Scopus, Web of Science) were searched until November 2018. The methodological quality of the included studies was assessed using the Mixed Methods Appraisal Tool. Qualitative studies were analyzed using a thematic synthesis. Quantitative studies were analyzed using a random-effects meta-analysis for the pooling of proportions.

RESULTS

Thirty-seven articles reporting on forty studies were eligible for inclusion. Five themes derived from the thematic synthesis: (i) beliefs about effectiveness and cost-effectiveness, (ii) appropriateness, (iii) economic and socioeconomic benefit, (iv) policy adoption and implementation, and (v) public mistrust of the industry, government and public health experts. Results of the meta-analysis indicated that of the public 42% (95% CI = 0.38-0.47) supports an SSBs tax, 39% (0.29-0.50) supports an SSBs tax as a strategy to reduce obesity, and 66% (0.60-0.72) supports an SSBs tax if revenue is used for health initiatives.

CONCLUSIONS

Beliefs about effectiveness and cost-effectiveness, appropriateness, economic and socioeconomic benefit, policy adoption and implementation, and public mistrust of the industry, government and public health experts have important implications for the political and public acceptability of an SSBs tax. We provide recommendations to increase acceptability and enhance successful adoption and implementation of an SSBs tax: (i) address inconsistencies between identified beliefs and scientific literature, (ii) use raised revenue for health initiatives, (iii) communicate transparently about the true purpose of the tax, and (iv) generate political priority for solutions to the challenges to implementation.

Sugar-Containing Beverages Consumption and Obesity in Children Aged 4-5 Years in Spain: the INMA Study

The consumption of sugar-containing beverages (SCB) has been associated with obesity although the evidence in preschool children is scarce. Cross-sectional analyses were performed to assess the association between obesity and SCB consumption (packaged juices and sugar-sweetened soft drinks) in 1823 children at the age of 4-5 years from the INfancia y Medio Ambiente (INMA) Project. One drink was defined as a glass of 175 mL, and the consumption of SCB was categorized in <1, 1-7 drinks/week and > 1 drink/day. We used multiple logistic regression to estimate odds ratios (OR). The average SCB consumption was 79.1 mL/day, mainly from packaged juices (80.9%). The SCB consumption was lower in non-obese children than in children with obesity, 76.6 vs 118.4 mL/day (p = 0.02). After adjusting for covariates, children who consumed >1 drink/day showed elevated odds of obesity, OR = 3.23 (95% confidence interval (CI): 1.48-6.98) compared to children who consumed <1 SCB drink a week. Each additional SCB drink per day was associated with higher odds of obesity, OR = 1.55 (1.14-2.09). Higher consumption of packaged juices, but not sugar-sweetened soft drinks, was significantly associated with higher odds of obesity, OR = 1.55 (1.09-2.15) and OR = 1.59 (0.76-3.39), respectively. A higher SCB consumption is associated with obesity in preschool children, mainly due to the consumption of packaged juices.

Dietary patterns of pregnant women, maternal excessive body weight and gestational diabetes

OBJECTIVE

To investigate the relationship between the dietary patterns of pregnant women with maternal excessive body weight and gestational diabetes mellitus.

METHODS

A cross-sectional study conducted with a convenience sample of 785 adult pregnant women attended by the Unified Health System of Ribeirão Preto, state of São Paulo, between 2011 and 2012. Two 24-hour dietary recalls, corrected by the multiple source method, were employed . For the classification of the body mass index and the diagnosis of gestational diabetes mellitus, the criteria by Atalah and the World Health Organization were used, respectively. Dietary patterns were obtained by principal component analysis using the Varimax rotation method. The relationship between adherence to patterns, overweight and obesity was analyzed by multinomial logistic regression models and the relationship with gestational diabetes mellitus by adjusted unconditional logistic regression models.

RESULTS

We identified four dietary patterns: “traditional Brazilian”; “snacks”; “coffee” and “healthy”. Women with a higher adherence to the “Healthy” (OR = 0.52; 95%CI 0.33–0.83) and “Brazilian Traditional” patterns (OR = 0.61; 95%CI 0.38–0.96) presented a lower chance of obesity, when compared to women with lower adherence, regardless of confounding factors. After adjustment for maternal excessive body weight, there was no association between dietary patterns and gestational diabetes mellitus.

CONCLUSIONS

Among the pregnant women, greater adherence to “traditional Brazilian” and “healthy” patterns was inversely associated with obesity, but no relationship was identified with gestational diabetes mellitus after adjusting for excessive body weight. Prospective studies are recommended to investigate the relationship between dietary patterns, overweight and gestational diabetes mellitus, reducing the chance of reverse causality.

Sugar sweetened beverage consumption during pregnancy is associated with lower diet quality and greater total energy intake

OBJECTIVE

Identify the socio-economic correlates of sugar sweetened beverage (SSB) consumption among pregnant women and analyze to what extent SSB consumption is associated with diet quality and total energy intake. Additionally, we aim to predict how diet quality scores and totally energy intakes would change if SSB consumption was artificially set to 0.

DESIGN

Repeated Cross Sectional Study.

SETTING

United States.

SUBJECTS

SSB consumption was estimated from 1-2 24-hour dietary recalls from 1,154 pregnant women who participated in the 1999-2006 National Health and Nutrition Examination Survey.

METHODS

Linear regression models were used to identify socioeconomic and demographic factors associated with SSB consumption and to assess the associations between SSB consumption and diet quality and total energy intake. Diet quality was measured with the Alternate Healthy Eating Index modified for Pregnancy (AHEI-P).

RESULTS

The mean SSB intake was 1.3 servings per day (sd 1.5). Having a household income ≤100% of the Federal Poverty Level, being born in the United States, and not being married or living with a partner were positively associated with SSB consumption. Every 12 oz. of SSBs consumed was associated with a 2.3 lower AHEI-P score (95% CI: 1.6, 2.9) and the consumption of 124 more calories (95% CI: 85, 163), after adjusting for age, country of birth, race/ethnicity, educational attainment, marital status, household income, survey year and day/s of the week the recall/s were collected. Our predictive models indicated that average AHEI-P would be 6.4 (5.4, 7.6) higher and average total energy intakes would be 203.5 calories (122.2, 284.8) lower if SSB intake was set to 0.

CONCLUSIONS

SSB consumption is associated with poorer diet quality and higher total energy intake among pregnant women.

Warning Labels on Sugar-sweetened Beverages: An Eye Tracking Approach

Objectives: In this study, we examined visual attention of a warning label on a sugar-sweetened beverage (SSB) and its effects on visual attention to SSB product descriptors and perceptions of SSB using eye tracking technology. Methods: We had 180 young adults view an image of a generic soda can with or without a text warning on a computer monitor. Results: Participants spent less time looking at marketing elements on the can in the "Warning" condition compared to the "No warning" (control) condition. Compared to the control, participants in the "Warning" condition viewed the sugar-sweetened beverage as less healthy (1.78 warning vs 2.21 control, p < .01) and believed that drinking SSBs contributed to diabetes (5.70 warning vs 5.27 control, p < .01). Visual attention to warning label was associated with correct recall of the warning and opting out of purchasing the can. Conclusions: Textual warning on SSB reduced visual attention to marketing elements on the can. Although there were few statistically significant differences between the conditions on most measures of product appeal or risk perception, warnings increased some perceived risks of SSBs indicating that warning labels on SSBs might be a promising strategy in informing consumers, particularly young adults, about risks of added sugars.

Development of a sweetened beverage tax, Philippines

Problem

Both sugar-sweetened beverage consumption and the incidence of obesity have increased in the Philippines in recent years.

Approach

A proposal to tax sugar-sweetened beverages was introduced in the House of Representatives and merged into a proposed comprehensive Tax Reform for Acceleration and Inclusion (TRAIN) Bill to increase the likelihood of acceptance. The health department and finance department recommended a policy that would maximize benefits to both public health and government revenue. To advance discussions, the health department expanded the health argument to include the country’s poor performance in oral health. The approved TRAIN Law adopted the term sweetened beverage to emphasize that the tax covers both sugar and non-sugar sweetened beverages. The tax rate was set to 6.00 Philippine pesos (0.111 United States dollars) per litre of sweetened beverages. The sugar industry successfully lobbied for higher tax rates on beverages containing high-fructose corn syrup, resulting in a differential rate of 12.00 Philippine pesos per litre.

Local setting

Despite a 12% value-added tax on sugar-sweetened beverages, sales had been sustained by enhanced marketing and product variants being offered in small portions.

Relevant changes

One month after implementation of the tax in 1 January 2018, prices of taxable sweetened beverages had increased by 16.6 to 20.6% and sales in sari-sari (convenience) stores had declined 8.7%.

Lessons learnt

The tax benefited from high-level government commitment and support, keeping policy simple reduced opportunities for tax avoidance and evasion, and taking both health and non-health considerations into account were helpful in arguing for the tax.

The Short-Term Impacts of the Philadelphia Beverage Tax on Beverage Consumption

INTRODUCTION

On January 1, 2017, Philadelphia implemented a beverage tax of $0.015/ounce on sugar ("regular") and sugar-substitute ("diet") beverages. The purpose of this study was to evaluate the immediate impact of the tax on residents' consumption of soda, fruit drinks, energy drinks, and bottled water.

METHODS

A repeat cross-sectional study design used data from a random-digit-dialing phone survey during a no-tax period (December 6-31, 2016) and a tax period (January 15-February 31, 2017) among 899 respondents in Philadelphia, Pennsylvania, and 878 respondents in three nearby comparison cities. Survey questions included frequency and volume of bottled water and beverages. Outcomes were daily consumption, and 30-day consumption frequency and volume. Propensity score-weighted difference-in-differences regression was used to control for secular time trend and confounding. Covariates were sociodemographics, BMI, health status, smoking, and alcohol use. Analyses were conducted in 2017.

RESULTS

Within the first 2 months of tax implementation, relative to the comparison cities, in Philadelphia the odds of daily consumption of regular soda was 40% lower (OR=0.6, 95% CI=0.37, 0.97); energy drink was 64% lower (OR=0.36, 95% CI=0.17, 0.76); bottled water was 58% higher (OR=1.58, 95% CI=1.13, 2.20); and the 30-day regular soda consumption frequency was 38% lower (ratio of consumption frequency=0.62, 95% CI=0.40, 0.98).

CONCLUSIONS

Early results suggest that the tax influenced daily consumption of regular soda, energy drinks, and bottled water. Future studies are needed to evaluate longer-term impact of the tax on sugared beverage consumption and substitutions.

High intake of orange juice and cola differently affects metabolic risk in healthy subjects

BACKGROUND

Higher consumption of sugar-containing beverages has been associated with an elevated risk of type 2 diabetes and gout. Whether this equally applies to cola with an unhealthy image and orange juice (OJ) having a healthy image remains unknown.

METHODS

In order to investigate whether OJ and cola differently affect metabolic risk 26 healthy adults (24.7 ± 3.2 y; BMI 23.2 ± 3.3 kg/m²) participated in a 2 × 2-wk intervention and consumed either OJ or caffeine-free cola (20% Ereq as sugar from beverages) in-between 3 meals/d at ad libitum energy intake. Glycemic control, uric acid metabolism and gut microbiota were assessed as outcome parameters.

RESULTS

Fecal microbiota, body weight, basal and OGTT-derived insulin sensitivity remained unchanged in both intervention periods. Levels of uric acid were normal at baseline and did not change with 2-wk cola consumption (-0.03 ± 0.67 mg/dL; p > 0.05), whereas they decreased with OJ intervention (-0.43 ± 0.56 mg/dL; p < 0.01) due to increased uric acid excretion (+130.2 ± 130.0 mg/d; p < 0.001). Compared to OJ, consumption of cola led to a higher daylong glycemia (ΔiAUC: 36.9 ± 83.2; p < 0.05), an increase in glucose variability (ΔMAGE-Index: 0.29 ± 0.44; p < 0.05), and a lower 24 h-insulin secretion (ΔC-peptide excretion: -31.76 ± 38.61 μg/d; p < 0.001), which may be explained by a decrease in serum potassium levels (-0.11 ± 0.24 mmol/L; p < 0.05).

CONCLUSION

Despite its sugar content, regular consumption of large amounts of OJ do not increase the risk of gout but may even contribute to lower uric acid levels. The etiology of impaired insulin secretion with cola consumption needs to be further investigated.

Consumo de refrigerantes e índice de massa corporal em adolescentes brasileiros: Pesquisa Nacional de Saúde do Escolar

RESUMO: Objetivo: Estimar a associação entre consumo de refrigerantes e o índice de massa corporal (IMC) em adolescentes eutróficos e com excesso de peso. Métodos: Foram utilizados dados da Pesquisa Nacional de Saúde do Escolar (PeNSE) de 2009. Considerou-se como variável de desfecho os tercis do escore de IMC (zIMC) e como variável de exposição principal, o consumo de refrigerantes adoçados com açúcar. Idade, tipo de escola, escore de bens e serviços do domicílio e escolaridade materna foram incluídos nos modelos como variáveis de ajuste. Modelos de regressão multinomial, estratificados por sexo e pelos subgrupos de eutrofia e de excesso de peso foram utilizados para estimar a associação entre exposição e desfecho. Resultados: Dos adolescentes avaliados, 23,8% apresentaram excesso de peso e 21,7% relataram o consumo de refrigerantes diariamente. Nos meninos eutróficos, o consumo de refrigerantes esteve associado à maior chance de estar nos tercis mais altos de zIMC comparados aos não consumidores. Já nos adolescentes com excesso de peso, tanto do sexo masculino quanto feminino, o consumo de refrigerantes esteve associado à menor chance de estar no tercil mais alto de escore zIMC. Conclusão: Os resultados evidenciam a possibilidade de causalidade reversa entre o consumo de refrigerantes adoçados e zIMC no grupo de adolescentes com excesso de peso. Nos adolescentes eutróficos do sexo masculino, o consumo de refrigerantes pode, potencialmente, aumentar as chances de ter zIMC mais alto, o que reforça a necessidade de medidas visando à ampla redução do consumo dessa bebida.

Marketing of food and beverage in Brazil: scientific literature review on regulation and self-regulation of advertisements

The effects of marketing strategies for promotion of foods and beverages have been investigated due to its potential impacts on populations’ food choices, particularly among children and adolescents. The paper presents an academic literature review on regulation and self-regulation of food and beverage advertisements in Brazil, based on search performed in electronic databases. Majority of studies were based on law analysis or qualitative study of advertisements. There are sufficient evidences on the need for government regulation of advertisements addressed to children and adolescents complementarily to institutional self-regulation in order to tackle ethical transgressions on food and beverage advertisements identified in Brazil. Additionally, there should be imposition of rigorous penalties for noncompliance to ethical rules and proposition of incentives towards actions encouraging healthy food consumption patterns, in order to comprise an actual system for promotion of public health.

DNA methylation patterns at sweet taste transducing genes are associated with BMI and carbohydrate intake in an adult population

Individual differences in taste perception may influence appetite, dietary intakes, and subsequently, disease risk. Correlations of DNA methylation patterns at taste transducing genes with BMI and dietary intakes were studied. A nutriepigenomic analysis within the Methyl Epigenome Network Association (MENA) project was conducted in 474 adults. DNA methylation in peripheral white blood cells was analyzed by a microarray approach. KEGG pathway analyses were performed concerning the characterization and discrimination of genes involved in the taste transduction pathway. Adjusted FDR values (p < 0.0001) were used to select those CpGs that showed best correlation with BMI. A total of 29 CpGs at taste transducing genes met the FDR criteria. However, only 12 CpGs remained statistically significant after linear regression analyses adjusted for age and sex. These included cg15743657 (TAS1R2), cg02743674 (TRPM5), cg01790523 (SCN9A), cg15947487 (CALHM1), cg11658986 (ADCY6), cg04149773 (ADCY6), cg02841941 (P2RY1), cg02315111 (P2RX2), cg08273233 (HTR1E), cg14523238 (GABBR2), cg12315353 (GABBR1) and cg05579652 (CACNA1C). Interestingly, most of them were implicated in the sweet taste signaling pathway, except CACNA1C (sour taste). In addition, TAS1R2 methylation at cg15743657 was strongly correlated with total energy (p < 0.0001) and carbohydrate intakes (p < 0.0001). This study suggests that methylation in genes related to sweet taste could be an epigenetic mechanism associated with obesity.

Do You Know What Your Kids Are Drinking? Evaluation of a Media Campaign to Reduce Consumption of Sugar-Sweetened Beverages

OBJECTIVE

This study evaluates a citywide media campaign that targeted reducing sugar-sweetened beverage (SSB) consumption as a strategy for addressing obesity.

DESIGN

Rolling cross-sectional survey data, collected before and during the media campaign, with 1367 parents to assess exposure to and effect of a televised public service advertisement (TV PSA) developed using a reasoned action approach.

SETTING

Televised public service advertisement campaign created by the Philadelphia Department of Public Health and disseminated on cable television channels within the Philadelphia market.

PARTICIPANTS

Philadelphia parents/primary caregivers with a child between the ages of 3 and 16.

RESULTS

Linear regression analysis shows that exposure to the TV PSA was significantly associated with intention to substitute nonsugary drinks for SSBs for the parent ( P = .04) and the child ( P = .02). The effect of exposure on intention to reduce child's SSB consumption increased the longer the campaign was in the field. Exposure was also significantly associated with the belief that reducing SSB consumption decreases the risk of diabetes ( P = .04) and was significantly negatively related to the belief that reducing SSB consumption would make mealtimes less enjoyable ( P = .04).

CONCLUSION

These findings suggest that a theory-based mass media campaign can achieve positive changes in intention related to SSB consumption by changing relevant and salient underlying beliefs.