Health and economic benefits of reducing sugar intake in the USA, including effects via non-alcoholic fatty liver disease: a microsimulation model

Modelling impacts of a salt and sugar tax on hypothetical intra-category food substitutions, BMI and environmental footprints in the UK population

PURPOSE

Taxes on unhealthy foods can help improve population health in the United Kingdom (UK), but the health effects of food substitutions resulting from these taxes are often unclear. We investigated the potential impacts of a salt and sugar tax on hypothetical intra-category food substitutions, cost, body-mass index (BMI), and environmental footprints.

METHODS

Purchase panel data from Kantar (2017) were used to determine the most popular foods high in salt or sugar within eight 'salt-intensive'/'sugar-intensive' food categories. Within food categories, the most popular lower salt (≤ 1.5 g salt/100 g product) and lower sugar (≤ 22.5 g sugar/100 g product) substitutes were also identified. Hypothetical swaps between high salt/sugar foods and lower salt/sugar substitutes were explored, focusing on changes to cost, caloric intake and BMI, and environmental impacts in the UK population.

RESULTS

The suggested intra-category substitutions were largely like-for-like and did not accrue an added overall cost to consumers. The substitutions reduced calorie intake by about 200 kcal/day and lowered the prevalence of overweight and obesity in the UK from approximately 60-65% to about 40-45%. The proposed food substitutions led to a total reduction of -2.7Mt of greenhouse gases, ∼ -500.000 ha of land, -0.5km3 of blue water, -12km3 of scarcity weighted water, ∼ -12.000t of phosphorus, and nearly - 14.000t of sulphur dioxide over one year for the UK population due to reductions in calorie intake.

CONCLUSION

Food substitutions following a tax on salt and sugar could lead to significant benefits for health and the environment, without necessarily resulting in major changes to people's expenditure on familiar salty and sugary snacks.

NASH/NAFLD-Related Hepatocellular Carcinoma: An Added Burden

Hepatocellular carcinoma (HCC) is the most frequently found primary malignancy of the liver, showing an accelerated upward trend over the past few years and exhibiting an increasing relationship with metabolic syndrome, obesity, dyslipidemia and type 2 diabetes mellitus. The connection between these risk factors and the occurrence of HCC is represented by the occurrence of non-alcoholic fatty liver disease (NAFLD) which later, based on genetic predisposition and various triggers (including the presence of chronic inflammation and changes in the intestinal microbiome), may evolve into HCC. HCC in many cases is diagnosed at an advanced stage and can be an incidental finding. We present such a scenario in the case of a 41-year-old male patient who had mild obesity and mixed dyslipidemia, no family or personal records of digestive pathologies and who recently developed a history of progressive fatigue, dyspepsia and mild upper abdominal discomfort initially thought to be linked to post-COVID syndrome, as the patient had COVID-19 pneumonia a month prior. The abdominal ultrasound revealed a mild hepatomegaly with bright liver aspect of the right lobe (diffuse steatosis), a large zone of focal steatosis (segments IV, III and II) and a left lobe tumoral mass, highly suggestive of malignancy. Point shear wave elastography at the right lobe ruled out an end-stage chronic liver disease. Additional laboratory investigations, imaging studies (magnetic resonance imaging) and histopathological examination of liver fragments confirmed a highly aggressive HCC, with poorly differentiation-G3, (T4, N 1M 0) and stage IVA, associated with nonalcoholic steatohepatitis (NASH). A sorafenib course of treatment was attempted, but the patient discontinued it due to severe side effects. The subsequent evolution was extremely unfavorable, with rapid degradation, a few episodes of upper digestive bleeding, hepatic insufficiency and mortality in a couple of months. Conclusions: Diagnosis of NASH-related HCC is either an accidental finding or is diagnosed at an advanced stage. In order to earn time for a proper treatment, it becomes important to diagnose it at an early stage, for which regular check-ups should be performed in groups having the risk factors related to it. Patients suffering from obesity and mixed dyslipidemia should undergo periodic abdominal ultrasound examinations. This should be emphasized even more in the cases showing NASH. Complaints of any kind post-COVID-19 should be dealt with keenly as little is yet known about its virulence and its long-term side effects.

The Impact and Burden of Dietary Sugars on the Liver

NAFLD, or metabolic dysfunction-associated steatotic liver disease, has increased in prevalence hand in hand with the rise in obesity and increased free sugars in the food supply. The causes of NAFLD are genetic in origin combined with environmental drivers of the disease phenotype. Dietary intake of added sugars has been shown to have a major role in the phenotypic onset and progression of the disease. Simple sugars are key drivers of steatosis, likely through fueling de novo lipogenesis, the conversion of excess carbohydrates into fatty acids, but also appear to upregulate lipogenic metabolism and trigger hyperinsulinemia, another driver. NAFLD carries a clinical burden as it is associated with obesity, type 2 diabetes, metabolic syndrome, and cardiovascular disease. Patient quality of life is also impacted, and there is an enormous economic burden due to healthcare use, which is likely to increase in the coming years. This review aims to discuss the role of dietary sugar in NAFLD pathogenesis, the health and economic burden, and the promising potential of sugar reduction to improve health outcomes for patients with this chronic liver disease.

Supplementation with a high-glucose drink stimulates anti-tumor immune responses to glioblastoma via gut microbiota modulation

A high-sugar diet induces lifestyle-associated metabolic diseases, such as obesity and diabetes, which may underlie the pro-tumor effects of a high-sugar diet. We supply GL261 syngeneic glioblastoma (GBM) mice with a short-term high-glucose drink (HGD) and find an increased survival rate with no evidence of metabolic disease. Modulation of the gut microbiota through HGD supplementation is critical for enhancing the anti-tumor immune response. Single-cell RNA sequencing shows that gut microbiota modulation by HGD supplementation increases the T cell-mediated anti-tumor immune response in GBM mice. We find that the cytotoxic CD4+ T cell population in GBM is increased due to synergy with anti-programmed cell death protein 1 (anti-PD-1) immune checkpoint inhibitors, but this effect depends upon HGD supplementation. Thus, we determine that HGD supplementation enhances anti-tumor immune responses in GBM mice through gut microbiota modulation and suggest that the role of HGD supplementation in GBM should be re-examined.

Non-alcoholic fatty liver disease and diabetes mellitus as growing aetiologies of hepatocellular carcinoma

Obesity-related complications such as non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes (T2D) are well-established risk factors for the development of hepatocellular carcinoma (HCC). This review provides insights into the molecular mechanisms that underlie the role of steatosis, hyperinsulinemia and hepatic inflammation in HCC development and progression. We focus on recent findings linking intracellular pathways and transcription factors that can trigger the reprogramming of hepatic cells. In addition, we highlight the role of enzymes in dysregulated metabolic activity and consequent dysfunctional signalling. Finally, we discuss the potential uses and challenges of novel therapeutic strategies to prevent and treat NAFLD/T2D-associated HCC.

Sugar and Dyslipidemia: A Double-Hit, Perfect Storm

The availability of sugar has expanded over the past 50 years, due to improved industrial processes and corn subsidies, particularly in the form of sweetened beverages. This correlates with a surge in the prevalence of cardiometabolic disorders, which has brought this issue back into the spotlight for public health. In this narrative review, we focus on the role of fructose in the genesis of cardiometabolic dyslipidemia (an increase in serum triglyceride-rich lipoproteins (TRL): VLDL, chylomicrons (CM), and their remnants) bringing together the most recent data on humans, which demonstrates the crucial interaction between glucose and fructose, increasing the synthesis while decreasing the catabolism of these particles in a synergistic downward spiral. After reviewing TRL metabolism, we discuss the fundamental principles governing the metabolism of fructose in the intestine and liver and the effects of dysregulated fructolysis, in conjunction with the activation of carbohydrate-responsive element-binding protein (ChREBP) by glucose and the resulting crosstalk. The first byproduct of fructose catabolism, fructose-1-P, is highlighted for its function as a signaling molecule that promotes fat synthesis. We emphasize the role of fructose/glucose interaction in the liver, which enhances de novo lipogenesis, triglyceride (TG) synthesis, and VLDL production. In addition, we draw attention to current research that demonstrates how fructose affects the activity of lipoprotein lipase by increasing the concentration of inhibitors such as apolipoprotein CIII (apoCIII) and angiopoietin-like protein 3 (ANGPTL3), which reduce the catabolism of VLDL and chylomicrons and cause the building up of their atherogenic remnants. The end outcome is a dual, synergistic, and harmful action that encourages atherogenesis. Thus, considering the growing concerns regarding the connection between sugar consumption and cardiometabolic disease, current research strongly supports the actions of public health organizations aimed at reducing sugar intake, including dietary guidance addressing "safe" limits for sugar consumption.

Effect of price and income on the demand for sugar-sweetened beverages in Nigeria: an analysis of household consumption data using an almost ideal demand system (AIDS)

OBJECTIVES

To estimate the own-price, cross-price and income elasticities for carbonated soft drinks (CSDs), malt drinks, chocolate powder, sachet water and sugar in Nigeria. These elasticities can be used to estimate the potential demand response to the recently-introduced sugar tax in Nigeria.

SETTING

The study uses household data from the 2018/2019 Nigeria Living Standards Survey (NLSS).

PARTICIPANTS

The NLSS is a national household survey. 21 114 households were included in the final sample for this analysis.

PRIMARY AND SECONDARY OUTCOMES

We used Deaton's almost ideal demand system, which controls for the goods' quality, to estimate the effect of price and income changes on the demand for CSDs, chocolate powder, malt drinks, sachet water and sugar.

RESULTS

We found that the own-price elasticity (ordered from most to least price-responsive) was -0.99 (p<0.01) for sachet water, -0.76 (p<0.01) for CSDs, -0.72 (p<0.01) for chocolate powder, -0.62 (p<0.01) for sugar and -0.19 (p<0.01) for malt drinks. The cross-price elasticities indicate that malt drinks and chocolate powders are substitutes of CSDs. The income elasticities indicate that all the commodities are normal goods. Sachet water had the highest income elasticity at 0.62 (p<0.01), followed by chocolate powder at 0.54 (p<0.01), CSDs at 0.47 (p<0.01), malt drinks at 0.43 (p<0.01) and sugar at 0.13 (p<0.01).

CONCLUSION

Even though the price elasticities for CSDs, malt drinks and chocolate powder are less than one, in absolute terms, they are significantly different from zero. Increases in the sugar-sweetened beverage tax could curb the demand for these beverages, and, in turn, reduce the incidence and prevalence of sugar-attributable diseases.

The Metabolic Matrix: Re-engineering ultraprocessed foods to feed the gut, protect the liver, and support the brain

Ultraprocessed food is established as a metabolic disruptor acting to increase adiposity, reduce mitochondrial efficiency, drive insulin resistance, alter growth, and contribute to human morbidity and mortality. Consumer packaged goods (CPG) companies are beginning to understand the detrimental impact of the food they market, and have employed substitution strategies to reduce salt, sugar, and fat. However, the harms of ultraprocessed foods are far more complex than any single component, and are not ameliorated by such simple substitutions. Over the past 2 years, the authors have worked with the Kuwaiti Danish Dairy Company (KDD) to conduct a comprehensive scientific evaluation of their entire commercial food and beverage portfolio. Assay of the macronutrients, micronutrients, additives, and toxins contained in each of their products was undertaken to determine the precise nature of each product’s ingredients as well as the health impacts of processing. The authors formed a Scientific Advisory Team (SAT) and developed a tiered “Metabolic Matrix” founded in three science-based principles: (1) protect the liver, (2) feed the gut, and (3) support the brain. The Metabolic Matrix categorizes each product and provides the criteria, metrics, and recommendations for improvement or reformulation. Real-time consultation with the KDD Executive and Operations teams was vital to see these procedures through to fruition. This scientific exercise has enabled KDD to lay the groundwork for improving the health, well-being, and sustainability of their entire product line, while maintaining flavor, economic, and fiscal viability. This process is easily transferrable, and we are sharing this effort and its approaches as a proof-of-concept. The key aim of our work is to not only make ultraprocessed food healthier but to urge other food companies to implement similar analysis and reformulation of their product lines to improve the metabolic health and well-being of consumers worldwide.

Disease Progression Modeling for Economic Evaluation in Nonalcoholic Fatty Liver Disease-A Systematic Review

BACKGROUND & AIMS

Globally, 25% of people have nonalcoholic fatty liver disease (NAFLD), and, currently, there are no approved pharmacologic treatments for NAFLD. With a slow disease progression, long-term impact of pharmacologic treatments can be assessed only by complementing emerging clinical trial evidence with data from other sources in disease progression modeling. Although this modeling is crucial for economic evaluation studies assessing the clinical and economic consequences of new treatments, the approach to modeling the natural history of NAFLD differs in contemporary research. This systematic literature review investigated modeling of the natural history of NAFLD.

METHODS

A systematic literature review was conducted searching PubMed, Scopus, Cochrane, and the National Health Service Economic Evaluation Database to identify articles focusing on modeling of the natural history of NAFLD. Model structure and transition probabilities were extracted from included studies.

RESULTS

Of the 28 articles identified, differences were seen in model structure and data input. Clear definitions of nonalcoholic steatohepatitis and NAFLD often were lacking; differences in the granularity of modeling fibrosis progression, the approach to disease regression, and modeling of advanced liver disease varied across studies. Observed transition probabilities for F0 to F1, F1 to F2, F2 to F3, and F3 to compensated cirrhosis varied between 0.059 to 0.095, 0.023 to 0.140, 0.018 to 0.070, and 0.040 to 0.118, respectively.

CONCLUSIONS

The difference in disease progression modeling for seemingly similar models warrants further inquiry regarding how to model the natural course of NAFLD. Such differences may have a large impact when assessing the value of emerging pharmacologic treatments.

Formulating elafibranor and obeticholic acid with phospholipids decreases drug-induced association of SPARC to extracellular vesicles from LX-2 human hepatic stellate cells

Chronic hepatic diseases often compromise liver function and are directly responsible for up to two million yearly deaths world-wide. There are yet no treatment options to solve this global medical need. Experimental drugs elafibranor (Ela) and obeticholic acid (OA) appeared promising in numerous earlier studies, but they recently struggled to show significant benefits in patients. Little is known on the drugs' impact on hepatic stellate cells (HSCs), key players in liver fibrogenesis. We recently reported a beneficial effect of polyenylphosphatidylcholines (PPCs)-rich formulations in reverting fibrogenic features of HSCs, including differences in their extracellular vesicles (EVs). Here, we newly formulated Ela and OA in PPC liposomes and evaluated their performance on the LX-2 (human HSC) cell line through our rigorous methods of EV-analysis, now expanded to include lipidomics. We show that direct treatments with Ela and OA increase EV-associated secreted protein acidic and cysteine rich (SPARC), a matricellular protein overexpressed in fibrogenesis. However, our results suggest that this potentially damaging drugs' action to HSCs could be mitigated when delivering them with lipid-based formulations, most notably with a PPC-rich phospholipid inducing specific changes in the cellular and EV phospholipid composition. Thus, EV analysis substantially deepens evaluations of drug performances and delivery strategies.

Recent advance in technological innovations of sugar-reduced products

Sugar is crucial as an essential nutrient for humans as well as for providing texture, sweetness and so on to food. But with the rise in people's pursuit of health, it is becoming increasingly clear that excessive consumption of sugar can locate a load on the body. It has been that excessive sugar is associated with many diseases, such as dental caries, obesity, diabetes, and coronary heart disease. Therefore, researchers and industries are trying to reduce or substitute sugar in food without affecting the sensory evaluation. Substituting sugar with sweeteners is alternatively becoming the most traditional way to minimize its use. So far, the sweeteners such as stevia and xylitol have been are commercially applied. Several studies have shown that technological innovation can partially compensate for the loss in sweetness as a result of sugar reduction, such as cross-modal interactions that stimulate sweetness with aroma, nanofiltration that filters disaccharides and above, enzyme-catalyzed sugar hydrolysis, and microbial fermentation that turns sugar into sugar alcohol. This review summarizes these studies to enhance the safety and quality of sugar-reduced products, and will provide some theoretical frameworks for the food industry to reduce sugar in foods, meet consumers' needs, and promote human health.

The Contribution of Nutrients of Concern to the Diets of 18-to-30-Year-Old Australians from Food Prepared Outside Home Differs by Food Outlet Types: The MYMeals Cross-Sectional Study

Young adults are frequent consumers of food prepared outside the home (FOH). In a cross-sectional survey, the MYMeals study, we showed FOH provided one-third of meals and snacks for young Australian adults, yet it contributed higher proportions of energy and nutrients of concern, such as saturated fat and sodium. This study aimed to determine the detailed proportional contribution of nutrients of concern from the nine food outlet types captured in the MYMeals study. Young adults residing in New South Wales (NSW), Australia, (n = 1001) used a validated smartphone app to report all types and amounts of food and beverages consumed for three consecutive days, as well as their preparation location. The proportions of daily energy, macronutrients, sodium, total sugars, and saturated fat were calculated for each of the nine following outlet types: bakeries or patisseries, coffee chains, cold-drink chains, fast-food chains, ice creamery or frozen yoghurt outlets, independent cafes or restaurants, pubs (hotels) and clubs, service stations or convenience stores, and others not fitting the above categories. Of all FOH outlet types, independent cafes or restaurants contributed the most energy (17.5%), sodium (20.0%) and saturated fat (17.8%) to the total diet, followed by fast-food chains (12.0% energy, 15.8% sodium, and 12.0% saturated fat) and other outlets, with smaller proportions. For males, the proportion of energy and nutrients contributed by fast-food outlets was higher than for females (14.8% versus 9.8% energy). Menu labelling at independent cafes and restaurants is recommended, comprising, in addition to the energy labels already in use in fast-food restaurants, the labelling of nutrients of concern. The feasibility of this recommendation warrants further exploration.

The Effect of Steviol Glycosides on Sensory Properties and Acceptability of Ice Cream

There has been a challenge in overcoming the bitter aftertaste of stevia, a natural non-caloric sweetener. Recent research focuses on investigating various types of steviol glycosides, the sweet compounds in stevia leaves, as they exhibit different sensory characteristics. This study determined the sensory properties and acceptability of ice cream sweetened solely with three steviol glycosides, rebaudioside (Reb) A, D, and M (0.09% w/v), using sucrose-sweetened ice cream as a control (14% w/v). Ice cream consumers (n = 92) rated their overall liking, attribute liking, and sweetness and bitterness intensities and described the aftertastes of each sample using check-all-that-apply. The liking scores of Reb D- and M-sweetened ice creams were significantly higher than those of Reb A-sweetened ice cream. Among the three glycosides, only Reb M showed a sweetness intensity comparable with that of sucrose. Consumers perceived the aftertastes of Reb D and M ice creams as being more sweet, pleasant, creamy, and milky, while Reb A was more artificial and chemical. Reb D and M ice creams were also plotted close to sucrose in the correspondence analysis graph, meaning that their aftertaste characteristics were similar to those of sucrose. The present study clearly highlights that Reb D and M have better tastes and provide better perceptions to consumers than Reb A, which is the most widely used glycoside in food industry.

Prevention and regression of megamitochondria and steatosis by blocking mitochondrial fusion in the liver

Non-alcoholic steatohepatitis (NASH) is a most common chronic liver disease that is manifested by steatosis, inflammation, fibrosis, and tissue damage. Hepatocytes produce giant mitochondria termed megamitochondria in patients with NASH. It has been shown that gene knockout of OPA1, a mitochondrial dynamin-related GTPase that mediates mitochondrial fusion, prevents megamitochondria formation and liver damage in a NASH mouse model induced by a methionine-choline-deficient (MCD) diet. However, it is unknown whether blocking mitochondrial fusion mitigates NASH pathologies. Here, we acutely depleted OPA1 using antisense oligonucleotides in the NASH mouse model before or after megamitochondria formation. When OPA1 ASOs were applied at the disease onset, they effectively prevented megamitochondria formation and liver pathologies in the MCD model. Notably, even when applied after mice robustly developed NASH pathologies, OPA1 targeting effectively regressed megamitochondria and the disease phenotypes. Thus, our data show the efficacy of mitochondrial dynamics as a unique therapy for megamitochondria-associated liver disease.

Rethinking COVID-19 and Beyond: Prevention, Remedies, and Recovery

In a relatively short timeframe, millions of deaths and illnesses associated with COVID-19 have been reported, accompanied by substantial economic losses, and overall, negatively impacting society. This experience should serve as a wakeup call to those in public health and healthcare, along with politicians and citizens: COVID-19 is considered a predictable and preventable disaster. While various reactive responses to address the pandemic were implemented, some with adverse effects, proactive measures in the years before COVID-19 were neglected. Predominately this involved the development of a preventable overfat pandemic, which played a key role in both rising rates of chronic disease, the comorbidities that increase the risk for COVID-19, along with associated inflammation and malnutrition. This increased the risk of infection in billions of people worldwide, which, in essence, primed society for high rates of COVID-19 infection. Excess body fat evolves primarily from poor nutrition, particularly the overconsumption of sugar and other refined carbohydrates, which replace the vital nutrients needed for optimal immune function. Sugar and refined carbohydrates must be considered the new tobacco, as these foods are also devoid of nutrients, and underly inflammatory chronic diseases. A balanced diet of nutrient-dense wholefood must be emphasized to combat infectious and inflammatory diseases. Implementing proactive preventive lifestyle changes must begin now, starting with simple, safe, and inexpensive dietary modifications that can quickly lead to a healthier population.

Sleep disruption in nonalcoholic fatty liver disease: What is the role of lifestyle and diet?

BACKGROUND

Patients with nonalcoholic fatty liver disease (NAFLD) have sleep disruption. The aim of this study is to understand how underlying factors such as diet, degree of liver disease and morningness-eveningness tendencies contribute to this sleep disruption.

METHODS

Patients with NAFLD were recruited from liver clinics at a University and Veterans Affairs practice. Patients with decompensated cirrhosis were excluded. Patients completed self-reported surveys to evaluate sleep disturbance using the Epworth Sleepiness Scale (ESS) and chronotype (circadian preference) using the morningness-eveningness questionnaire (MEQ). Information on occupation, physical activity and dietary intake were collected at clinic intake. Dietary intake was evaluated via food-frequency questionnaire and analyzed as individual categories or grouped on the basis of dietary composition.

RESULTS

A 54 patients completed the survey; 37% were female. Median ESS was 8 ± 4.2 and 37% of NAFLD patients were found to have sleep disturbance as defined by ESS >10. Sleep disturbance was common in NAFLD regardless of the liver disease stage. Dietary factors, including higher added sugar (P = 0.01), candy intake (P = 0.01), elevated Ferritin level (P = 0.04) and elevated platelet count (P = 0.05), were significantly associated with sleep disturbance. Chronotype, time to sleep, and duration of sleep were not associated with sleep disruption.

CONCLUSIONS

Sleep disruption is present in NAFLD regardless of underlying cirrhosis. Interventions aimed at improving dietary and lifestyle practices such as reduced sugar intake may help mitigate the risk for sleep disruption in NAFLD. Further longitudinal studies are needed to further delineate these links.

Microsimulation Modelling in Food Policy: A Scoping Review of Methodological Aspects

Food policies for the prevention and management of diet-related non-communicable diseases (NCDs) have been increasingly relying on microsimulation models (MSMs) to assess effectiveness. Given the increased uptake of MSMs, this review aims to provide an overview of the characteristics of MSMs that link diets with NCDs. A comprehensive review was conducted in PubMed and Web of Knowledge. Inclusion criteria were: (i) findings from a MSM, (ii) diets, foods or nutrients as main exposure of interest, (iii) NCDs, such as overweight/obesity, type 2 diabetes, coronary heart disease, stroke or cancer as disease outcome for impact assessment. This review included information from 33 studies using MSM in analyzing diet and diverse food policies on NCDs. Hereby, most models employed stochastic, discrete-time, dynamic microsimulation techniques to calculate anticipated (cost-)effectiveness of strategies based on food pricing, food reformulation or dietary (lifestyle) interventions. Currently available models differ in the methodology used for quantifying the effect of the dietary changes on disease, and in the method for modelling disease incidence and mortality. However, all studies provided evidence that the models were sufficiently capturing the close-to-reality situation by justifying their choice of model parameters and validating externally their modelled disease incidence and mortality with observed or predicted event data. With the increasing use of various MSMs, between-model comparisons, facilitated by open access models and good reporting practices, would be important for judging model's accuracy, leading to continued improvement in the methodologies for developing and applying MSMs, and subsequently a better understanding of the results by policymakers.

A STATEMENT OF SIGNIFICANCE

Given the advancement in the application of microsimulation modelling in evaluating food policies and measuring diet-related disease burdens, the present scoping review serves as an exercise to inform future modelling, hereby highlighting the need for transparency in model development, application and dissemination to advance and safeguard accuracy and relevance in modelling efforts.

The Contribution of Foods Prepared Outside the Home to the Diets of 18- to 30-Year-Old Australians: The MYMeals Study

Young adults are the highest consumers of food prepared outside home (FOH) and gain most weight among Australian adults. One strategy to address the obesogenic food environment is menu labelling legislation whereby outlets with >20 stores in one state and >50 Australia-wide must display energy content in kJ. The aim of this study was to assess the contribution of FOH to the energy and macronutrients, saturated fat, total sugars and sodium intakes of young Australians. One thousand and one 18 to 30-year-olds (57% female) residing in Australia’s most populous state recorded all foods and beverages consumed and the location of preparation for three consecutive days using a purpose-designed smartphone application. Group means for the daily consumption of energy, percentage energy (%E) for protein, carbohydrate, total sugars, total and saturated fats, and sodium density (mg/1000 kJ) and proportions of nutrients from FOH from menu labelling and independent outlets were compared. Overall, participants consumed 42.4% of their energy intake from FOH with other nutrients ranging from 39.8% (sugars) to 47.3% (sodium). Independent outlets not required to label menus, contributed a greater percentage of energy (23.6%) than menu labelling outlets (18.7%, p < 0.001). Public health policy responses such as public education campaigns, extended menu labelling, more detailed nutrition information and reformulation targets are suggested to facilitate healthier choices.

Effects of home quarantine during COVID-19 lockdown on physical activity and dietary habits of adults in Saudi Arabia

Public health endorsements during the present COVID-19 pandemic has led the governments of largely affected countries to imply policies that restrict social mobility to slow COVID-19 spread. The study aimed to explore the effects of COVID-19 home quarantine on lifestyle and health behavior of Saudi residents. An online survey in Saudi Arabia was launched from May 11 to June 6, 2020. The survey was designed by multidisciplinary scientists and academics uploaded and shared through the Google platform in Arabic and English languages. Questions presented related to responses "before" and "during" COVID-19 home quarantine. A total of 1965 respondents participated and were included in the analysis [921 (47.0%) males and 1044 (53.0%) females]. Non-Saudis were more likely to increase their physical activity during quarantine [odds ratio (95% confidence interval 1.41 (1.11-1.79); p < 0.005]. Prevalence of participants walking daily for more than 4 times per week significantly decreased during pandemic (before vs during, 30.5% vs 29.1%) which was in parallel to the significant increase in the prevalence of participants who did not perform daily walking during the quarantine (21% vs 22.9%; p < 0.001). The prevalence of participants who often consume snacks between meals increased during quarantine (27.4% vs 29.4%, p < 0.001), while the prevalence of participants who never consumed fresh fruits and vegetables significantly increased during home quarantine (2.4% vs 3.7%; p = 0.019). The lockdown imposed in Saudi Arabia modestly but significantly impacted physical activity and dietary behaviors of several citizens and residents in an unhealthy way. Interventions to alleviate these acute adverse lifestyle behaviors during pandemic should be formulated.

Ultraprocessed Food: Addictive, Toxic, and Ready for Regulation

Past public health crises (e.g., tobacco, alcohol, opioids, cholera, human immunodeficiency virus (HIV), lead, pollution, venereal disease, even coronavirus (COVID-19) have been met with interventions targeted both at the individual and all of society. While the healthcare community is very aware that the global pandemic of non-communicable diseases (NCDs) has its origins in our Western ultraprocessed food diet, society has been slow to initiate any interventions other than public education, which has been ineffective, in part due to food industry interference. This article provides the rationale for such public health interventions, by compiling the evidence that added sugar, and by proxy the ultraprocessed food category, meets the four criteria set by the public health community as necessary and sufficient for regulation—abuse, toxicity, ubiquity, and externalities (How does your consumption affect me?). To their credit, some countries have recently heeded this science and have instituted sugar taxation policies to help ameliorate NCDs within their borders. This article also supplies scientific counters to food industry talking points, and sample intervention strategies, in order to guide both scientists and policy makers in instituting further appropriate public health measures to quell this pandemic.

Quarantine during COVID-19 outbreak: Changes in diet and physical activity increase the risk of cardiovascular disease

AIMS

CoV-19/SARS-CoV-2 is a highly pathogenic virus that is causing a global pandemic with a high number of deaths and infected people. To contain the diffusion of infection, several governments have enforced restrictions on outdoor activities or even collective quarantine on the population. The present commentary briefly analyzes the effects of quarantine on lifestyle, including nutrition and physical activity and the impact of new technologies in dealing with this situation.

DATA SYNTHESIS

Quarantine is associated with stress and depression leading to unhealthy diet and reduced physical activity. A diet poor in fruit and vegetables is frequent during isolation, with a consequent low intake of antioxidants and vitamins. However, vitamins have recently been identified as a principal weapon in the fight against the Cov-19 virus. Some reports suggest that Vitamin D could exert a protective effect on such infection. During quarantine, strategies to further increase home-based physical activity and to encourage adherence to a healthy diet should be implemented. The WHO has just released guidance for people in self-quarantine, those without any symptoms or diagnosis of acute respiratory illness, which provides practical advice on how to stay active and reduce sedentary behavior while at home.

CONCLUSION

Quarantine carries some long-term effects on cardiovascular disease, mainly related to unhealthy lifestyle and anxiety. Following quarantine, a global action supporting healthy diet and physical activity is mandatory to encourage people to return to a good lifestyle routine.

Lifestyle information and access to a commercial weight management group to promote maternal postnatal weight management and positive lifestyle behaviour: the SWAN feasibility RCT

Background

Increasing numbers of UK women have overweight or obese body mass index scores when they become pregnant, or gain excessive weight in pregnancy, increasing their risk of adverse outcomes. Failure to manage postnatal weight is linked to smoking, non-healthy dietary choices, lack of regular exercise and poorer longer-term health. Women living in areas of higher social deprivation are more likely to experience weight management problems postnatally.

Objectives

The objectives were to assess the feasibility of conducting a definitive randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of lifestyle information and access to a commercial weight management group focusing on self-monitoring, goal-setting and motivation to achieve dietary change commencing 8–16 weeks postnatally to achieve and maintain weight management and positive lifestyle behaviour.

Design

The design was a randomised two-arm feasibility trial with a nested mixed-methods process evaluation.

Setting

The setting was a single centre in an inner city setting in the south of England.

Participants

Participants were women with body mass index scores of > 25 kg/m2 at antenatal ‘booking’ and women with normal body mass index scores (18.0–24.9 kg/m2) at antenatal booking who developed excessive gestational weight gain as assessed at 36 weeks’ gestation.

Main outcome measures

Recruitment, retention, acceptability of trial processes and identification of relevant economic data were the feasibility objectives. The proposed primary outcome was difference between groups in weight at 12 months postnatally, expressed as percentage weight change and weight loss from antenatal booking. Other proposed outcomes included assessment of diet, physical activity, smoking, alcohol consumption, body image, maternal esteem, mental health, infant feeding and NHS costs.

Results

Most objectives were achieved. A total of 193 women were recruited, 98 allocated to the intervention arm and 95 to the control arm. High follow-up rates (> 80%) were achieved to 12 months. There was an 8.8% difference in weight loss at 12 months between women allocated to the intervention arm and women allocated to the control arm (13.0% vs. 4.2%, respectively; p = 0.062); 47% of women in the intervention arm attended at least one weight management session, with low risk of contamination between arms. The greatest benefit was among women who attended ≥ 10 sessions. Barriers to attending sessions included capability, opportunity and motivation issues. Data collection tools were appropriate to support economic evaluation in a definitive trial, and economic modelling is feasible to quantify resource impacts and outcomes not directly measurable within a trial.

Limitations

The trial recruited from only one site. It was not possible to recruit women with normal body mass index scores who developed excessive pregnancy weight gain.

Conclusions

It was feasible to recruit and retain women with overweight or obese body mass index scores at antenatal booking to a trial comparing postnatal weight management plus standard care with standard care only and collect relevant data to assess outcomes. Approaches to recruit women with normal body mass index scores who gain excessive gestational weight need to be considered. Commercial weight management groups could support women’s weight management as assessed at 12 months postnatally, with probable greater benefit from attending ≥ 10 sessions. Process evaluation findings highlighted the importance of providing more information about the intervention on trial allocation, extended duration of time to commence sessions following birth and extended number of sessions offered to enhance uptake and retention. Results support the conduct of a future randomised controlled trial.

Trial registration

Current Controlled Trials ISRCTN39186148.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.

Economic evaluations of public health interventions for physical activity and healthy diet: A systematic review

Physical inactivity and unhealthy dietary habits are associated with an increased disease and economic burden. The aim of this systematic review was to identify economic evaluations of public health interventions targeting physical activity and healthy diet, and assess the quality and transferability of the findings to the Swedish context. A search of published economic evaluations was conducted through electronic databases including PubMed, Web of Science, PsycINFO, National Health Service Economic Evaluation Databases (NHS EED) and the Health Technology Assessment Database (HTA). An additional search was done using references of relevant systematic reviews and websites of relevant organizations were checked to find grey literature. Quality and transferability of the economic evaluations were appraised using a quality assessment tool developed by the Swedish Agency for Health Technology Assessment. Thirty-two economic evaluations, rated as moderate or high quality, of 178 interventions were included; thirteen studies targeting physical activity, thirteen targeting healthy diet and six targeting both. The interventions varied in terms of their content, setting, mode of delivery and target populations. A majority of the economic evaluations reported that the interventions were likely to be cost-effective; however, considerable variations in the methodological and reporting qualities were observed. Only half of the economic evaluations were rated to have a high probability of transferring to the Swedish context. Public health interventions targeting physical activity and dietary habits have a high potential to be cost-effective. However, decision makers should consider the variation in quality and transferability of the available evidence.

Prevalence of liver fibrosis in an unselected general population with high prevalence of obesity and diabetes mellitus. Time for screening?

INTRODUCTION

Cirrhosis and liver cancer are currently common causes of death worldwide. The global epidemic of obesity has increased the incidence of nonalcoholic fatty liver disease (NAFLD) and cirrhosis in recent years. Advanced fibrosis increases the morbimortality rate in NAFLD. The Mexican population has one of the highest prevalence of obesity and diabetes mellitus (DM) worldwide.

AIM

To determine the prevalence of advanced liver fibrosis in Mexican general population.

METHODS

Adult individuals, without a history of liver disease nor heavy alcohol consumption were randomly sampled from 20,919 participants of a health and nutrition survey applied to the general population. Clinical and laboratory evaluations were performed to calculate the NAFLD fibrosis score (NFS) (an extensively validated non-invasive method). Two cut-off points were used. Advanced fibrosis was defined as a result >0.676.

RESULTS

In total 695 individuals were included. The mean age was 47.8±16.4. The majority were between 20 and 50 years (59%), 70.2% were female, 35.5% showed obesity and 15.8% DM. The 93% had normal serum ALT. Based on the NFS results, 56 individuals (8.1%) had a high probability of fibrosis. Most patients from this subgroup showed normal serum ALT (92.9%), 89.3% were >45yr. old, 52% were obese and 27% suffered from DM.

CONCLUSIONS

Based on these results, 8.1% of Mexican general population without a history of liver disease is at high risk of having advanced liver fibrosis and complications and death derived from cardiovascular disease and cirrhosis. Most of them showed normal ALT serum levels.

What's on the Menu? Policies to Reduce Young People's Sugar Consumption

Young people in the UK consume far above the maximum recommended levels of added sugar. It is likely that neither they nor their parents fully take account of the future health, social and economic costs of this high sugar consumption. This provides a rationale for policy intervention. The majority of young people's added sugar consumption occurs in the home, where purchases are typically made by parents. This means that understanding the purchase decisions of adults is important for policy design, even if the policies aim to reduce the consumption of young people. We discuss the merits of popular policies, including taxes, advertising restrictions and restrictions on the availability of specific foods, and we identify promising avenues for future research.

Nonalcoholic Fatty Liver Disease: Pathogenesis and Treatment in Traditional Chinese Medicine and Western Medicine

Nonalcoholic Fatty Liver Disease (NAFLD) is one of the most important causes of liver disease worldwide and probably destined to become the leading cause of end-stage liver disease in the coming decades, affecting both adults and children. Faced with the severe challenges for the prevention and control of NAFLD, this article discusses the understanding and mechanism of NAFLD from Chinese and Western medicine. Moreover, the progress regarding its treatment in both Chinese and Western medicine is also summarized. Both Chinese medicine and Western medicine have their own characteristics and clinical efficacy advantages in treating diseases. The purpose of this article is to hope that Chinese and Western medicine have complementary advantages, complementing each other to improve clinical NAFLD therapy prevention and treatment methods to receive more and more attention throughout the global medical community.

Association of a Workplace Sales Ban on Sugar-Sweetened Beverages With Employee Consumption of Sugar-Sweetened Beverages and Health

IMPORTANCE

Reductions in sugar-sweetened beverage (SSB) intake can improve health, but are difficult for individuals to achieve on their own.

OBJECTIVES

To evaluate whether a workplace SSB sales ban was associated with SSB intake and cardiometabolic health among employees and whether a brief motivational intervention provides added benefits to the sales ban.

DESIGN, SETTING, AND PARTICIPANTS

This before-after study and additional randomized trial conducted from July 28, 2015, to October 16, 2016, at a Northern California university and hospital assessed SSB intake, anthropometrics, and cardiometabolic biomarkers among 214 full-time English-speaking employees who were frequent SSB consumers (≥360 mL [≥12 fl oz] per day) before and 10 months after implementation of an SSB sales ban in a large workplace, with half the employees randomized to receive a brief motivational intervention targeting SSB reduction.

INTERVENTIONS

The employer stopped selling SSBs in all workplace venues, and half the sample was randomized to receive a brief motivational intervention and the other half was a control group that did not receive the intervention. This intervention was modeled on standard brief motivational interventions for alcohol used in the workplace that promote health knowledge and goal setting.

MAIN OUTCOMES AND MEASURES

Outcomes included changes in SSB intake, Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), and measures of abdominal adiposity. The primary associations tested were the correlation between changes in SSB intake and changes in HOMA-IR.

RESULTS

Among the 214 study participants, 124 (57.9%) were women, with a mean (SD) age of 41.2 (11.0) years and a baseline mean (SD) body mass index of 29.4 (6.5). They reported a mean daily intake of 1050 mL (35 fl oz) of SSBs at baseline and 540 mL (18 fl oz) at follow-up-a 510-mL (17-fl oz) (48.6%) decrease (P < .001). Reductions in SSB intake correlated with improvements in HOMA-IR (r = 0.16; P = .03). Those not randomized to receive the brief intervention reduced their SSB intake by a mean (SD) of 246.0 (84.0) mL (8.2 [2.8] fl oz), while those also receiving the brief intervention reduced SSB intake by 762.0 (84.0) mL (25.4 [2.8] fl oz). From baseline to follow-up, there were significant reductions in mean (SE) waist circumference (2.1 [2.8] cm; P < .001).

CONCLUSIONS AND RELEVANCE

This study's findings suggest that the workplace sales ban was associated with a reduction in SSB intake and a significant reduction in waist circumference among employees within 10 months. The randomized clinical trial portion of this study found that targeting those at high risk with a brief motivational intervention led to additional improvements. Workplace sales bans may offer a promising new private-sector strategy for reducing the health harms of SSB intake.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02585336.

A cross-sectional study of the public health response to non-alcoholic fatty liver disease in Europe

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) is a growing public health problem worldwide and has become an important field of biomedical inquiry. We aimed to determine whether European countries have mounted an adequate public health response to NAFLD and non-alcoholic steatohepatitis (NASH).

METHODS

In 2018 and 2019, NAFLD experts in 29 European countries completed an English-language survey on policies, guidelines, awareness, monitoring, diagnosis and clinical assessment in their country. The data were compiled, quality checked against existing official documents and reported descriptively.

RESULTS

None of the 29 participating countries had written strategies or action plans for NAFLD. Two countries (7%) had mentions of NAFLD or NASH in related existing strategies (obesity and alcohol). Ten (34%) reported having national clinical guidelines specifically addressing NAFLD and, upon diagnosis, all included recommendations for the assessment of diabetes and liver cirrhosis. Eleven countries (38%) recommended screening for NAFLD in all patients with either diabetes, obesity and/or metabolic syndrome. Five countries (17%) had referral algorithms for follow-up and specialist referral in primary care, and 7 (24%) reported structured lifestyle programmes aimed at NAFLD. Seven (24%) had funded awareness campaigns that specifically included prevention of liver disease. Four countries (14%) reported having civil society groups which address NAFLD and 3 countries (10%) had national registries that include NAFLD.

CONCLUSIONS

We found that a comprehensive public health response to NAFLD is lacking in the surveyed European countries. This includes policy in the form of a strategy, clinical guidelines, awareness campaigns, civil society involvement, and health systems organisation, including registries.

LAY SUMMARY

We conducted a survey on non-alcoholic fatty liver disease with experts in European countries, coupled with data extracted from official documents on policies, clinical guidelines, awareness, and monitoring. We found a general lack of national policies, awareness campaigns and civil society involvement, and few epidemiological registries.

Sugar-free Workplace: A Step for Fighting Obesity

Currently, there is a worldwide obesity pandemic with an incidence that has increased progressively over the last few decades. Obesity is considered a global health hazard and is associated with a significant economic impact on the healthcare system. It has been linked to several serious medical conditions, including heart disease, hypertension, stroke, diabetes mellitus, and cancer. Obesity is also related to social and psychological problems such as anxiety and depression. Several factors predispose the population to obesity, including decreased physical activity and non-healthy dietary habits. Sugar is the most important key contributor to the pandemic of obesity, and implementing a sugar-free workplace policy will provide a promising strategy for fighting obesity.

Modeling the natural history of fatty liver using lifestyle-related risk factors: Effects of body mass index (BMI) on the life-course of fatty liver

Background

Incident fatty liver increases the risk of non–alcoholic fatty liver disease (NAFLD), which may lead to end-stage liver diseases, and increase the risk of cardiovascular disease and diabetes. For its prevention, modeling the natural history of fatty liver is useful to demonstrate which lifestyle-related risk factors (e.g. body mass index and cholesterol) play the greatest role in the life-course of fatty liver.

Methods

Model predictors and their predictive algorithms were determined by prospective regression analyses using 5–year data from approximately 2000 Japanese men aged 20–69 years. The participants underwent health examinations and completed questionnaires on their lifestyle behaviors annually from 2012 to 2016. The life–course of fatty liver was simulated based on this participant data using Monte Carlo simulation methods. Sensitivity analyses were performed. The validity of the model was discussed.

Results

The body mass index (BMI) and low–density/high–density lipoprotein cholesterol (LDL–C/HDL–C) ratio significantly aided in predicting incident fatty liver. When the natural history of fatty liver was simulated using the data of participants aged 30–39 years, the prevalence increased from 20% to 32% at 40–59 years before decreasing to 24% at 70–79 years. When annual updates of BMI and LDL–C/HDL–C ratio decreased/increased by 1%, the peak prevalence of fatty liver (32%) changed by −8.0/10.7% and −1.6/1.4%, respectively.

Conclusions

We modeled the natural history of fatty liver for adult Japanese men. The model includes BMI and LDL‒C/HDL‒C ratio, which played a significant role in predicting the presence of fatty liver. Specifically, annual changes in BMI of individuals more strongly affected the life‒course of fatty liver than those in the LDL–C/HDL–C ratio. Sustainable BMI control for individuals may be the most effective option for preventing fatty liver in a population.

I was truly addicted to sugar: A consumer-focused classification system of behaviour change strategies for sugar reduction

The reduction of free sugars has been identified as a priority issue internationally. A range of public health initiatives have been recommended, including the provision of information and support for sugar reduction. To inform these approaches, it is important to know what people actually do in real world settings to reduce their consumption. This study documents and defines the range of consumer-based behaviour change strategies for sugar reduction. A total of 1145 strategies were extracted from 47 internet sources (i.e., consumer, popular and professional). Using a pragmatic content analysis, hundreds of strategies were organized into 25 discrete categories of strategies. Categories were grouped into the Rubicon Model of Action Phases and classified as pre-decisional (i.e., decisional balance, feedback, realisation, seek knowledge and information), post-decisional (i.e., action planning, coping planning, set goal intention, sugar guidelines) and actional phase. Actional strategies were the most prolific and included avoidance, consumption control, consumption planning, environmental restructuring, healthy eating focus, maintain readiness, professional support, refocusing, self-monitoring, social support, substance substitution, tapering, address underlying issues, urge management, well-being and withdrawal management. There was one post-actional strategy which was associated with self-evaluation (i.e., reviewing a change attempt in order to plan for the future). Four categories of strategies differed according to the source. Substance substitution was substantially less frequently discussed by consumers than professionals and few professional sites acknowledged or advised strategies to manage the struggle of maintaining readiness following a change attempt. Hundreds of individual strategies are discussed or promoted in online settings, and more information is needed on the effectiveness of these self-initiated approaches.

Childhood Fructoholism and Fructoholic Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is an emerging entity, becoming the most prevalent pediatric chronic liver disease. Its broad spectrum of histological findings, comorbidities, and complications, including cirrhosis and liver failure, can occur in childhood, emphasizing the severity of pediatric NAFLD. Current lifestyle and diet modifications have been linked to the increasing prevalence of NAFLD, including the rise of fructose consumption, a monosaccharide present in foods that contain added sugar, such as sugar‐sweetened beverages. Excessive fructose consumption is believed to cause addiction like alcohol and other drugs. As such, the new term “fructoholism” refers to the consumption of a substance (fructose) that can cause psychological and physical damage and become a major public health concern, highlighting the seriousness of the excessive consumption of fructose in the pediatric age. Hepatic fructose metabolization leads to hepatic steatosis and progression to fibrosis through mechanisms comparable to alcoholic liver disease, hence the term “fructoholic liver disease.” Conclusion: The importance of implementing reliable global strategies, such as education campaigns to promote healthy diet, increasing taxes on foods that contain added sugars, subsidies to promote accessibility to fruit and vegetables, and strict food industry regulation to reduce sugar intake in children and adolescents, cannot be overemphasized.

The negative and detrimental effects of high fructose on the liver, with special reference to metabolic disorders

The increased consumption of fructose in the average diet through sweeteners such as high-fructose corn syrup (HFCS) and sucrose has resulted in negative outcomes in society through producing a considerable economic and medical burden on our healthcare system. Ingestion of fructose chronically has contributed to multiple health consequences, such as insulin resistance, obesity, liver disorders, and diabetes. Fructose metabolism starts with fructose phosphorylation by fructose kinase in the liver, and this process is not feedback regulated. Therefore, ingestion of high fructose can deplete ATP, increase uric acid production, and increase nucleotide turnover. This review focuses the discussion on the hepatic manifestations of high fructose-implicated liver metabolic disorders such as insulin resistance, obesity due to enhanced lipogenesis, non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), and type 2 diabetes. The detrimental effects of high fructose on the liver, contributed potentially by microbiome and leptin, were also discussed. The authors believe that, together with diet management, further studies focusing on disrupting or blocking fructose metabolism in the liver may help with designing novel strategies for prevention and treatment of fructose-induced chronic liver metabolic diseases.

Burden of liver disease in Europe: Epidemiology and analysis of risk factors to identify prevention policies

The burden of liver disease in Europe continues to grow. We aimed to describe the epidemiology of liver diseases and their risk factors in European countries, identifying public health interventions that could impact on these risk factors to reduce the burden of liver disease. As part of the HEPAHEALTH project we extracted information on historical and current prevalence and mortality from national and international literature and databases on liver disease in 35 countries in the World Health Organization European region, as well as historical and recent prevalence data on their main determinants; alcohol consumption, obesity and hepatitis B and C virus infections. We extracted information from peer-reviewed and grey literature to identify public health interventions targeting these risk factors. The epidemiology of liver disease is diverse, with variations in the exact composition of diseases and the trends in risk factors which drive them. Prevalence and mortality data indicate that increasing cirrhosis and liver cancer may be linked to dramatic increases in harmful alcohol consumption in Northern European countries, and viral hepatitis epidemics in Eastern and Southern European countries. Countries with historically low levels of liver disease may experience an increase in non-alcoholic fatty liver disease in the future, given the rise of obesity across most European countries. Liver disease in Europe is a serious issue, with increasing cirrhosis and liver cancer. The public health and hepatology communities are uniquely placed to implement measures aimed at reducing their causes: harmful alcohol consumption, child and adult obesity, and chronic infection with hepatitis viruses, which will in turn reduce the burden of liver disease.

Unhealthy sponsorship in sport: a case study of the AFL

OBJECTIVE

To analyse the presence of unhealthy sponsorship on Australian Football League (AFL) club websites and player uniforms.

METHODS

An audit of AFL club websites and playing uniforms identified sponsors and used a traffic light system to categorise sponsors. Food and beverage sponsors were classified as Red, Amber or Green using nutrient criteria. Alcohol sponsors were classified as Red. Gambling sponsors were classified as Red (wagering companies and casinos) or Amber (venues that provide gambling and other services). Sponsors promoting healthy lifestyle concepts were classified as Green. All other sponsors were classified as Other.

RESULTS

Unhealthy sponsorship on AFL club websites and player uniforms is extensive. All 18 clubs had at least one Red sponsor. Fifteen clubs were sponsored by alcohol companies. Five clubs featured Red sponsor logos on their playing uniforms. Twelve clubs had Green sponsors. No clubs displayed Green sponsors on their playing uniforms.

CONCLUSIONS

This study identified that unhealthy sponsorship is prevalent on AFL club websites and playing uniforms. Implications for public health: Sponsorship offers companies an avenue to expose children and young people to their brand, encouraging a connection with that brand. The AFL could reinforce healthy lifestyle choices by shifting the focus away from the visual presence of unhealthy sponsorship, while taking steps to ensure that clubs remain commercially viable. Policy makers are encouraged to consider innovative health promotion strategies and work with sporting clubs and codes to ensure healthy messages are prominent.

Carbohydrates and diet patterns in nonalcoholic fatty liver disease in children and adolescents

PURPOSE OF REVIEW

The primary treatment for nonalcoholic fatty liver disease (NAFLD) in children is lifestyle change, including a healthier diet. However, there are no agreed upon expert recommendations for a specific diet in the prevention or treatment of NAFLD. In this study, we review studies published between 2015 and 2017 contributing to further understanding of the role of diet in the development and progression of NAFLD, particularly those addressing sugars and dietary patterns.

RECENT FINDINGS

Multiple recent studies have expanded on earlier evidence that suggests that high intake of sugars plays a causal role in the development of NAFLD, including several recent experimental studies in adults and children that support a unique effect of fructose consumption on liver fat accumulation. Evidence also points to protective effects of dietary patterns that include but are not limited to minimizing sugar intake, Dietary Approaches to Stop Hypertension (DASH), high protein and the Mediterranean diet. The effect of diet may act through its impact on the microbiome, and may be modified by presence or absence of genetic polymorphisms (nutrigenomics) and several new studies demonstrate this.

SUMMARY

Diet appears to be a powerful tool in the prevention and treatment of NAFLD. It is imperative that researchers and clinicians continue to hone in on the mechanistic pathways and specific diets to reverse the growing morbidity and mortality of NAFLD.

The science against sugar, alone, is insufficient in tackling the obesity and type 2 diabetes crises – We must also overcome opposition from vested interests

No abstract available.

Total and Added Sugar Intake: Assessment in Eight Latin American Countries

Non-communicable diseases are growing at an alarming rate in Latin America. We assessed total and added sugar intake in Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Peru, and Venezuela, to verify the adequacy of the World Health Organization’s recommendations, considering gender, socioeconomic level (SEL) and age. A total of 9218 non-institutionalized individuals living in urban areas (age range 15–65 years) were assessed in the Latin American Study of Nutrition and Health (ELANS), a multicenter household population-based cross-sectional survey. Socio-demographic data were collected. Total and added sugar intakes were measured using two non-consecutive 24-h dietary recalls. The prevalence of excessive sugar intake was estimated. A large proportion of individuals showed high consumption of total and added sugar intake, which reflected in the high prevalence of excessive sugar intake. With minimal differences across countries, in general, women, individuals with high SEL, and younger people had higher percentages of total energy intake from total and added sugar intake, and of contribution of carbohydrates from total and added sugars. Thus, there is high consumption of total and added sugar intake in the Latin American countries with some peculiarities considering socio-demographic variables, which should be considered in each country’s health intervention proposals.