Food Additives in Ultra-Processed Packaged Foods: An Examination of US Household Grocery Store Purchases

BACKGROUND

Food additives have been used mainly in the past century to perform specific functions in foods. Some types of food additives have been linked to adverse health outcomes, yet there is little research examining food additives in the US food supply.

OBJECTIVE

To examine the proportion of products purchased by US households containing four common technical food additives using time-specific food composition data and examine whether purchases have changed over time.

PARTICIPANTS/SETTING

Nielsen Homescan Consumer Panels, 2001 and 2019.

MAIN OUTCOME MEASURES

The proportion of packaged food products containing common types of food additives purchased by US households was determined overall and by food category.

STATISTICAL ANALYSIS PERFORMED

Differences were examined using Student t test; P value < 0.001 was considered significant.

RESULTS

Between 2001 and 2019, the proportion of food products purchased by US households that contained additives increased from 49.6% to 59.5% (P < 0.001). The proportion of carbonated soft drinks purchased containing flavors decreased, with a subsequent increase in purchases containing nonnutritive sweeteners. Baby foods showed a 20% increase in the proportion of purchases containing additives and >15% increase in the proportion of purchases containing three or more additives.

CONCLUSIONS

There is convincing evidence that US household purchases of common types of technical food additives are increasing. Despite some positive changes such as a decrease in the use of added flavors in carbonated soft drinks, across most food categories an increase in purchases of all types of products containing additives was observed. In particular the finding that purchases of baby food products containing additives have increased substantially is crucial in informing future research in this area and warrants further investigation.

Caloric reductions needed to achieve obesity goals in Mexico for 2030 and 2040: A modeling study

BACKGROUND

In Mexico, obesity prevalence among adults increased from 23% in 2000 to 36% in 2018, approximately. Mexico has not defined short- or long-term obesity goals, obscuring the level of effort required to achieve a relevant impact. We aimed to explore potential obesity goals for 2030 and 2040 in Mexico and to estimate the required caloric reductions to achieve them.

METHODS AND FINDINGS

We obtained anthropometric and demographic information on the Mexican adult population (age ≥20 years) from the Health and Nutrition Surveys conducted in 2000, 2006, 2012, 2016, and 2018 (n = 137,907). Each survey wave is cross-sectional, multistage, and representative of the Mexican population at the national, regional, and urban/rural levels. Obesity prevalence was projected for 2030 and 2040 by combining population projections of energy intake by socioeconomic status (SES) with a weight-change microsimulation model taking into account individual-level information on sex, age, physical activity, and initial body weight and height. If current trends continue, Mexico's obesity prevalence is expected to increase from 36% (95% CI 35% to 37%) in 2018 to 45% (uncertainty interval [UI] 41% to 48%) in 2030 and to 48% (UI 41% to 55%) in 2040. Based on expert opinion, we identified 3 obesity goals scenarios: (1) plausible (38% in 2030 and 36% in 2040); (2) intermediate (33% in 2030 and 29% in 2040); and (3) ideal based on the average prevalence of Organization for Economic Co-operation and Development countries (OECD; 19%). We estimated the caloric reductions needed to achieve the goal scenarios using the microsimulation model. Obesity was projected to increase more rapidly in the low SES (around 34% in 2018 to 48% (UI 41% to 55%) in 2040), than in the middle (around 38% to 52% (UI 45% to 56%)), or high SES group (around 36% to 45% (UI 36% to 54%)). Caloric reductions of 40 (UI 13 to 60), 75 (UI 49 to 95), and 190 (UI 163 to 215) kcal/person/day would be needed to reach the plausible, intermediate, and the ideal (OECD) average scenarios for 2030, respectively. To reach the 2040 goals, caloric reductions of 74 (UI 28 to 114), 124 (UI 78 to 169), and 209 (UI 163 to 254) kcal/person/day would be required, respectively. Study limitations include assuming a constant and sedentary physical activity level, not considering cohort-specific differences that could occur in the future, and assuming the same caloric trends under no intervention and the obesity goal scenarios.

CONCLUSIONS

To reach the 3 obesity goals in 2040, caloric reductions between 74 and 209 kcal/day/person would be needed in Mexico. A package of new and stronger interventions should be added to existing efforts such as food taxes and warning labels on non-nutritious food.

Socioeconomic Patterns in Budget Share Allocations of Regulated Foods and Beverages in Chile: A Longitudinal Analysis

Chile has enacted stringent legislation regulating food and beverage labeling and advertising. This study assesses the changes in the average relative allocations of food and beverage budgets for regulated versus not regulated products in households of different socioeconomic and demographic backgrounds. A household fixed effect before-after model is estimated and the marginal effects in the changes of levels and trends in budget shares and purchased volumes after the implementation of the regulations are examined. The results highlight how impactful food policies can shift consumption toward healthier products.

Front-of-Package Labels on Unhealthy Packaged Foods in India: Evidence from a Randomized Field Experiment

Policies to require front-of-package labels (FOPLs) on packaged foods may help Indian consumers to better identify foods high in nutrients of concern, including sugar, saturated fat, and sodium, and discourage their consumption, which are outcomes that are critical for preventing rises in diet-related non-communicable disease. The objective was to test whether FOPLs helped Indian consumers identify “high-in” packaged foods and reduce intentions to purchase them. We conducted an in-person randomized experiment (n = 2869 adults between ages 18 and 60 years old) in six states of India in 2022. Participants were randomized to one of five FOPLs: a control label (barcode), warning label (octagon with “High in [nutrient]”), Health Star Rating (HSR), Guideline Daily Amount (GDA), or traffic light label. Participants then viewed a series of packaged foods high in sugar, saturated fat, or sodium with the assigned FOPL, and rated product perceptions and label reactions. Fewer than half of participants in the control group (39.1%) correctly identified all products high in nutrient(s) of concern. All FOPLs led to an increase in this outcome, with the biggest differences observed for the warning label (60.8%, p < 0.001), followed by the traffic light label (54.8%, p < 0.001), GDA (55.0%, p < 0.001), and HSR (45.0%, p < 0.01). While no FOPLs led to a reduction in intentions to purchase the packaged foods, the overall pattern of results suggested that warning labels are the most effective FOPL to help Indian consumers identify unhealthy foods.

Whole Grain and Refined Grains: An Examination of US Household Grocery Store Purchases

BACKGROUND

The health benefits related to intake of whole grain foods are well established. Consumption of whole grains in the US population is low, and whole grain content can vary greatly depending upon the specific products that are purchased.

OBJECTIVES

To examine the proportion of products purchased by US households containing whole grain and refined grain ingredients using time-specific food composition data, and examine whether purchases differ between income, race or ethnicity, and household make-up.

METHODS

Nationally representative Nielsen Homescan 2018 data were used. Each barcoded product captured in Nielsen Homescan 2018 was linked with ingredient information using commercial nutrition databases in a time-relevant manner. Packaged food products containing whole grain ingredients, refined grain ingredients, neither, or both were identified. The percentage of packaged food products containing whole grain and refined grain ingredients purchased by US households was determined overall, by demographic subgroup, and by food category.

RESULTS

The proportion of packaged food purchases containing refined grain ingredients was significantly higher than whole grain ingredients (30.9% compared with 7.9%; P < 0.0001). Lower income households and households with children purchased a significantly higher proportion of products containing refined grain ingredients, with no nutritionally meaningful racial or ethnic differences observed. Concerningly, across all demographic subgroups >90% of bread purchases contained refined grain ingredients, and the 5 categories with the largest proportion of whole grain ingredients contributed to <20% of overall US household packaged food purchases.

CONCLUSIONS

US households are purchasing a significantly higher proportion of packaged food products containing refined grain ingredients than whole grain ingredients. Future policy changes are needed to provide incentives and information (e.g., front-of-pack labels) to aid in encouraging manufacturers to increase whole grain product offerings while decreasing refined grain offerings, and to encourage consumers to substitute away from refined grain products toward whole grain products.

Changes in food purchases after the Chilean policies on food labelling, marketing, and sales in schools: a before and after study

BACKGROUND

In 2016, Chile implemented a unique law mandating front-of-package warning labels, restricting marketing, and banning school sales for products high in calories, sodium, sugar, or saturated fat. We aimed to examine changes in the calorie, sugar, sodium, and saturated fat content of food and beverage purchases after the first phase of implementation of this law.

METHODS

This before and after study used longitudinal data on food and beverage purchases from 2381 Chilean households from Jan 1, 2015, to Dec 31, 2017. Nutrition facts panel data from food and beverage packages were linked to household purchases at the product level using barcode, brand name, and product description. Nutritionists reviewed each product for nutritional accuracy and categorised it as high-in if it contained added sugar, sodium, or saturated fat and exceeded phase 1 nutrient or calorie thresholds, and thus was subject to the labelling, marketing, and school regulations. Using fixed-effects models, we examined the mean nutrient content (overall calories, sugar, saturated fat, and sodium) of purchases in the post-policy period compared to a counterfactual scenario based on pre-policy trends.

FINDINGS

Compared with the counterfactual scenario, overall calories purchased declined by 16·4 kcal/capita/day (95% CI -27·3 to -5·6; p=0·0031) or 3·5%. Overall sugar declined by 11·5 kcal/capita/day (-14·6 to -8·4; p<0·0001) or 10·2%, and saturated fat declined by 2·2 kcal/capita/day (-3·8 to -0·5; p=0·0097) or 3·9%. The sodium content of overall purchases declined by 27·7 mg/capita/day (-46·3 to -9·1; p=0·0035) or 4·7%. Declines from high-in purchases drove these results with some offset by increases in not-high-in purchases. Among high-in purchases, relative to the counterfactual scenario, there were notable declines of 23·8% in calories purchased (-49·4 kcal/capita/day, 95% CI -55·1 to -43·7; p<0·0001), 36·7% in sodium purchased (-96·6 mg/capita/day,-105·3 to -87·8; p<0·0001), and 26·7% in sugar purchased (-20·7 kcal/capita/day, -23·4 to -18·1; p<0·0001).

INTERPRETATION

The Chilean phase 1 law of food labelling and advertising policies were associated with reduced high-in purchases, leading to declines in purchased nutrients of concern. Greater changes might reasonably be anticipated after the implementation of phases 2 and 3.

FUNDING

Bloomberg Philanthropies, International Development Research Center, and Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health.

Junk Food Intake Among Adults in the United States

BACKGROUND

There is no consensus on how to define "junk food." In 2016, Chile implemented the most comprehensive set of obesity-preventive regulations in the world, including criteria to define unhealthy foods.

OBJECTIVES

The objective of this study was to examine the amount of energy, sodium, sugar, and saturated fat consumed by US adults defined as junk food using the Chilean criteria.

METHODS

We used 2 nationally representative surveys of food intake in 10,001 US adults: NHANES 2015-2016 and NHANES 2017-2018. The main outcome measures were the contributions of energy, total sugars, saturated fat, and sodium deriving from junk food sources. Mean intake and proportion of energy, sugar, saturated fat, and sodium for junk food overall and each food category were calculated.

RESULTS

Overall, 47% of energy, 75% of total sugar, 46% of sodium, and 48% of saturated fat consumed by US adults derived from junk food sources. Sugar-sweetened beverages (SSBs) were responsible for more than 40% of total sugar intake deriving from junk foods. Non-Hispanic black adults had the highest mean energy, total sugar, and sodium intake deriving from junk foods, with non-Hispanic white adults having the highest saturated fat intake. Non-Hispanic black adults had the highest intake of total sugar deriving from junk food sources of SSBs (26.7 g/d), with SSBs representing >40% of total sugar intake deriving from junk food sources for all race/ethnic groups.

CONCLUSIONS

Foods that meet the Chilean criteria for junk food provide approximately half or more daily energy and food components to limit in the diet of US adults, with important differences observed between race/ethnic groups. Policy efforts to reduce junk food intake, particularly the intake of SSBs, must be expanded to improve the cardiometabolic health equitably in the United States.

Changes in beverage purchases following the announcement and implementation of South Africa's Health Promotion Levy: an observational study

BACKGROUND

In 2016, South Africa announced an intention to levy a tax on sugar-sweetened beverages (SSBs). In 2018, the country implemented an SSB tax of approximately 10%, known as the Health Promotion Levy (HPL). We aimed to assess changes in the purchases of beverages before and after the HPL announcement and implementation.

METHODS

We used Kantar Europanel data on monthly household purchases between January, 2014, and March, 2019, among a sample of South African households (n=113 653 household-month observations) from all nine provinces to obtain per-capita sugar, calories, and volume from taxable and non-taxable beverages purchased before and after the HPL announcement and implementation. We describe survey-weighted means for each period, and regression-controlled predictions of outcomes and counterfactuals based on pre-HPL announcement trends, with bootstrapped 95% CIs, and stratify results by socioeconomic status.

FINDINGS

Mean sugar from taxable beverage purchases fell from 16·25 g/capita per day (95% CI 15·80-16·70) to 14·26 (13·85-14·67) from the pre-HPL announcement to post-announcement period, and then to 10·63 g/capita per day (10·22-11·04) in the year after implementation. Mean volumes of taxable beverage purchases fell from 518·99 mL/capita per day (506·90-531·08) to 492·16 (481·28-503·04) from pre-announcement to post announcement, and then to 443·39 mL/capita per day (430·10-456·56) after implementation. Across these time periods, there was a small increase in the purchases of non-taxable beverages, from 283·45 mL/capita per day (273·34-293·56) pre-announcement to 312·94 (296·29-329·29) post implementation. When compared with pre-announcement counterfactual trends, reductions in taxable beverage purchase outcomes were significantly larger than the unadjusted survey-weighted observed reductions. Households with lower socioeconomic status purchased larger amounts of taxable beverages in the pre-announcement period than did households with higher socioeconomic status, but demonstrated bigger reductions after the tax was implemented.

INTERPRETATION

The announcement and introduction of South Africa's HPL were followed by reductions in the sugar, calories, and volume of beverage purchases.

FUNDING

Bloomberg Philanthropies, International Development Research Centre, South African Medical Research Council, and the US National Institutes of Health.

Estimating the potential impact of Australia's reformulation programme on households' sodium purchases

Background

On average, Australian adults consume 3500 mg sodium per day, almost twice the recommended maximum level of intake. The Australian government through the Healthy Food Partnership initiative has developed a voluntary reformulation programme with sodium targets for 27 food categories. We estimated the potential impact of this programme on household sodium purchases (mg/day per capita) and examined potential differences by income level. We also modelled and compared the effects of applying the existing UK reformulation programme targets in Australia.

Methods

This study used 1 year of grocery purchase data (2018) from a nationally representative consumer panel of Australian households (Nielsen Homescan) that was linked with a packaged food and beverage database (FoodSwitch) that contains product-specific sodium information. Potential reductions in per capita sodium purchases were calculated and differences across income level were assessed by analysis of variance. All analyses were modelled to the Australian population in 2018.

Results

A total of 7188 households were included in the analyses. The Healthy Food Partnership targets covered 4307/26 728 (16.1%) unique products, which represented 22.3% of all packaged foods purchased by Australian households in 2018. Under the scenario that food manufacturers complied completely with the targets, sodium purchases will be reduced by 50 mg/day per capita, equivalent to 3.5% of sodium currently purchased from packaged foods. Reductions will be greater in low-income households compared with high-income households (mean difference -7 mg/day, 95% CI -4 to -11 mg/day, p<0.001). If Australia had adopted the UK sodium targets, this would have covered 9927 unique products, resulting in a reduction in per capita sodium purchases by 110 mg/day.

Conclusion

The Healthy Food Partnership reformulation programme is estimated to result in a very small reduction to sodium purchases. There are opportunities to improve the programme considerably through greater coverage and more stringent targets.

Types and Amounts of Nonnutritive Sweeteners Purchased by US Households: A Comparison of 2002 and 2018 Nielsen Homescan Purchases

BACKGROUND

Purchases of foods containing nonnutritive sweetener (NNS) alone or in combination with caloric sweeteners (CS) has increased in recent years in the United States. At the same time clinical evidence is emerging of different cardiometabolic effects of each NNS type.

OBJECTIVE

To examine the prevalence and volume purchased of commonly consumed types of NNS in packaged food and beverage products comparing 2002 and 2018 using data from nationally representative samples of US households.

PARTICIPANTS/SETTING

Nielsen Homescan Consumer Panels (The Nielsen Company); 2002 and 2018.

MAIN OUTCOME MEASURES

Prevalence and volume of foods and beverages purchased containing CS, NNS, both CS and NNS, or neither CS nor NNS, as well as prevalence and volume of products containing specific NNS types.

STATISTICAL ANALYSES PERFORMED

Differences examined using Student t test, P value of <.05 considered significant.

RESULTS

Volume of products purchased containing CS decreased comparing 2002 and 2018 (436.6 ± 1.6 to 362.4 ± 1.3 g/d; P < .05), yet increased for products containing both CS and NNS (10.8-36.2 g/d; P < .05). Regarding specific types of NNS, changes were noted in the prevalence of households purchasing products containing saccharin (1.3%-1.1%; P < .05), aspartame (60.0%-49.4%; P < .05), rebaudioside A (0.1%-25.9%) and sucralose (38.7%-71.0%). Non-Hispanic whites purchased twice the volume of products containing NNS compared to Hispanics and non-Hispanic blacks in both years. Beverages were predominantly responsible for larger volume per capita purchases of products containing only NNS as well as both CS and NNS.

CONCLUSIONS

A decline in purchases of products containing CS occurred in tandem with an increase in purchases of products containing both CS and NNS, along with a large shift in the specific types of NNS being purchased by US households. New NNS types enter the market regularly, and it is important to monitor changes in the amount of NNS and products containing NNS that consumers purchase.

Changes in the amount of nutrient of packaged foods and beverages after the initial implementation of the Chilean Law of Food Labelling and Advertising: A nonexperimental prospective study

BACKGROUND

In June 2016, the first phase of the Chilean Food Labelling and Advertising Law that mandated front-of-package warning labels and marketing restrictions for unhealthy foods and beverages was implemented. We assess foods and beverages reformulation after this initial implementation.

METHODS AND FINDINGS

A data set with the 2015 to 2017 nutritional information was developed collecting the information at 2 time periods: preimplementation (T0: January-February 2015 or 2016; n = 4,055) and postimplementation (T1: January-February 2017; n = 3,025). Quartiles of energy and nutrients of concern (total sugars, saturated fats, and sodium, per 100 g/100 mL) and the proportion of products with energy and nutrients exceeding the cutoffs of the law (i.e., products "high in") were compared pre- and postimplementation of the law in cross-sectional samples of products with sales >1% of their specific food or beverage groups, according to the Euromonitor International Database; a longitudinal subsample (i.e., products collected in both the pre- and postimplementation periods, n = 1,915) was also analyzed. Chi-squared, McNemar tests, and quantile regressions (simple and multilevel) were used for comparing T0 and T1. Cross-sectional analysis showed a significant decrease (T0 versus T1) in the proportion of product with any "high in" (from 51% [95% confidence interval (CI) 49-52] to 44% [95% CI 42-45]), mostly in food and beverage groups in which regulatory cutoffs were below the 75th percentile of the nutrient or energy distribution. Most frequent reductions were in the proportion of "high in" sugars products (in beverages, milks and milk-based drinks, breakfast cereals, sweet baked products, and sweet and savory spreads; from 80% [95% CI 73-86] to 60% [95% CI 51-69]) and in "high in sodium" products (in savory spreads, cheeses, ready-to-eat meals, soups, and sausages; from 74% [95% CI 69-78] to 27% [95% CI 20-35]). Conversely, the proportion of products "high in" saturated fats only decreased in savory spreads (p < 0.01), and the proportion of "high in" energy products significantly decreased among breakfast cereals and savory spreads (both p < 0.01). Quantile analyses showed that most of the changes took place close to the cutoff values, with only few exceptions of overall left shifts in distribution. Longitudinal analyses showed similar results. However, it is important to note that the nonexperimental nature of this study does not allow to imply causality of these findings.

CONCLUSIONS

Our results show that, after initial implementation of the Chilean Law of Food Labelling and Advertising, there was a significant decrease in the amount of sugars and sodium in several groups of packaged foods and beverages. Further studies should clarify how food reformulation will impact dietary quality of the population.

Do Sugary Drink Policies Increase Purchases of Non-Calorically Sweetened Beverages? Evidence from Chile

Objectives

Chile's 2016 on food labeling and advertising reduced household (HH) sugary drink purchases by 24%. However, it is unclear if this regulation was also associated with a subsequent increase in non-calorically sweetened (NCS) beverage purchases, nor who is most likely to be a top consumer of NCS beverages.

Methods

We used longitudinal monthly-level data from Kantar WorldPanel Chile 2015–2017 (HH = 2383) linked to yearly updated nutrition facts panel data to examine changes in NCS beverage purchases from the pre-implementation period (January 2015-June 2016) to the post-implementation period (July 2016-December 2017). Beverages were categorized into 4 mutually exclusive groups: CS: sweetened with caloric sweeteners, NCS: sweetened with non-caloric sweeteners, CS + NCS: sweetened with both sweeteners, and unsweetened. For the pre-implementation period, we used multinomial logistic regression to model HH sociodemographic predictors (head of HH educational level, HH assets, HH composition and region) of being in tertiles of NCS beverages volume purchased. We estimated the changes in beverage volume purchases between pre- and post-implementation using linear regression models adjusted for HH sociodemographic characteristics and month of data collection to account for seasonality.

Results

HH with higher education (35%) and HH assets (38%) were more likely to be high NCS beverages purchasers, while HH with lower education (37%) and HH assets (42%) were more likely to be low NCS beverages purchasers. After policy implementation, volume of purchases of NCS beverages increased by 6.2 mL/capita/day (95% CI: 4.7, 7.6), while volume of CS, CS + NCS and unsweetened beverages purchases decreased by 24.6 mL (95% CI: −27.5, −21.7), 4.3 mL (95% CI: −6.4, −2.2) and 16.4 mL (95% CI: −20.8, −12.1), respectively.

Conclusions

In Chile, people of high SES purchase more NCS beverages. After policy implementation, the volume of CS, NCS + CS and unsweetened beverages decreased while the volume of NCS sweetened beverages increased.

Funding Sources

Bloomberg Philanthropies, International Development Research Centre, and Chilean National Agency of Research and Development. This project was also supported by the Carolina Population Center.

Contribution of Major Food Companies and Their Products to Household Dietary Sodium Purchases in Australia

Objectives

To support the work of the Australian federal governments proposed sodium reformulation targets, this study sought to identify the relative contribution that different food companies and their products make to household sodium purchases in Australia. We also examined differences in household sodium purchases from packaged foods and beverages by income level.

Methods

We used one year of grocery purchase data from a nationally representative consumer panel of Australian households who reported their grocery purchases (the Nielsen Homescan panel), combined with a packaged food and beverage database (FoodSwitch) that contains brand- and product-specific sodium information. Outcome measures were sodium purchases per capita (mg/day), sodium density (mg/1000 kcal), and purchase-weighted sodium content (mg/100 g). The top food companies and food categories were ranked according to their contribution to household sodium purchases. Per capita sodium purchases was estimated in household income strata. All analyses were modeled to the Australian population in 2018 using sample weights.

Results

Sodium data were available from 7188 households who purchased 26,728 unique products and, in total, just under 7.5 million units of foods and beverages. The total sodium acquired from packaged foods and beverages was 1443 mg/day per capita. Out of 1329 food companies, the top 10 accounted for 58% of all sodium purchased from packaged foods and beverages. The top three companies were grocery food retailers each contributing 12–15% of sodium purchases from sales of their private label products, particularly processed meat, cheese and bread. Out of the 67 food categories, the top 10 accounted for 73% of sodium purchased, driven by purchases of processed meat (14%), bread (12%) and sauces (11%). Low-income Australian households purchased substantially more sodium from packaged products than high-income households per capita (220 mg/d, 95% CI: 132–307 mg/d, P &lt; 0.001).

Conclusions

A small number of food companies and food categories account for the majority of dietary sodium purchased by Australian households. There is an opportunity for governments to prioritize engagement and incentivize key companies and food categories to deliver a large reduction in sodium intake and reduce cardiovascular disease.

Funding Sources

National Health and Medical Research Council.

Arsenic in the Pathway to Cardiovascular Diseases: Arsenic May Mediate Lipid Profile in Adults

Objectives

Recent studies indicate arsenic exposure may increase the risk of cardiovascular diseases, but the mechanism of this association is still unknown. This study explores the relationship between urine arsenic levels and serum cholesterol and triglycerides. Our hypothesis is that greater arsenic levels may be associated with dyslipidemia.

Methods

We used data from a subpopulation (n = 1203, 25 – 65 years of age) of an ongoing cohort study, the China Health and Nutrition Survey, which has collected data from participants on demographics, arsenic levels, lipid profile, and many other variables. We measured arsenic levels from urine samples with inductively coupled plasma mass spectrometry and serum lipid profile with an automated analyzer. With data collected in 2015, we used logistic regressions to analyze cross-sectional associations between arsenic exposure (categorized into three tertiles) and dyslipidemia, controlling for potential confounding variables like age, gender, residence area, occupation, and education level.

Results

Among this population, the median urine arsenic level was 19.3 µg/L (range 0 – 492.2 µg/L). The prevalence of high total cholesterol (defined as cholesterol ≥200 mg/dL) and high triglycerides (defined as total triglycerides ≥150 mg/dL) was 43.5% and 30.2%, respectively. After adjusting for potential cofounders, the odds ratio and 95% confidence interval was 1.41 (1.05, 1.88) for having high cholesterol, 1.41 (1.01, 1.97) for having high triglycerides and 1.42 (1.03, 1.97) for having low HDL level (defined as ≤40 mg/dL for men or 50 mg/dL for women), among participants in the higher arsenic exposure tertile compared to those in the lower tertile.

Conclusions

Our findings suggest that arsenic exposure, even in moderate concentrations, is positively associated with dyslipidemia. These results indicate that arsenic-mediated dyslipidemia may be a pathway to cardiovascular diseases.

Funding Sources

The Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD30880, P2C HD050924); the National Institute of Diabetes and Digestive and Kidney Diseases (R01 DK104371); the National Institutes of Health (NIH); the NIH Fogarty International Center (D43 TW009077); the National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention.

An evaluation of Chile's Law of Food Labeling and Advertising on sugar-sweetened beverage purchases from 2015 to 2017: A before-and-after study

BACKGROUND

Chile's Law of Food Labeling and Advertising, implemented in 2016, was the first national regulation to jointly mandate front-of-package warning labels, restrict child-directed marketing, and ban sales in schools of all foods and beverages containing added sugars, sodium, or saturated fats that exceed set nutrient or calorie thresholds. The objective of this study is to evaluate the impact of this package of policies on household beverage purchases.

METHOD AND FINDINGS

In this observational study, monthly longitudinal data on packaged beverage purchases were collected from urban-dwelling households (n = 2,383) participating in the Kantar WordPanel Chile Survey from January 1, 2015, to December 31, 2017. Beverage purchases were linked to nutritional information at the product level, reviewed by a team of nutritionists, and categorized as "high-in" or "not high-in" according to whether they contained high levels of nutrients of concern (i.e., sugars, sodium, saturated fat, or energy) according to Chilean nutrient thresholds and were thus subject to the law's warning label, marketing restriction, and school sales ban policies. The majority of high-in beverages were categorized as such because of high sugar content. We used fixed-effects models to compare the observed volume as well as calorie and sugar content of postregulation beverage purchases to a counterfactual based on preregulation trends, overall and by household-head educational attainment. Of households included in the study, 37% of household heads had low education (less than high school), 40% had medium education (graduated high school), and 23% had high education (graduated college), with the sample becoming more educated over the study period. Compared to the counterfactual, the volume of high-in beverage purchases decreased 22.8 mL/capita/day, postregulation (95% confidence interval [CI] -22.9 to -22.7; p < 0.001), or 23.7% (95% CI -23.8% to -23.7%). High-educated and low-educated households showed similar absolute reductions in high-in beverage purchases (approximately 27 mL/capita/day; p < 0.001), but for high-educated households this amounted to a larger relative decline (-28.7%, 95% CI -28.8% to -28.6%) compared to low-educated households (-21.5%, 95% CI -21.6% to -21.4%), likely because of the high-educated households' lower level of high-in beverage purchases in the preregulation period. Calories from high-in beverage purchases decreased 11.9 kcal/capita/day (95% CI -12.0 to -11.9; p < 0.001) or 27.5% (95% CI -27.6% to -27.5%). Calories purchased from beverages classified as "not high-in" increased 5.7 kcal/capita/day (95% CI 5.7-5.7; p < 0.001), or 10.8% (10.8%-10.8%). Calories from total beverage purchases decreased 7.4 kcal/capita/day (95% CI -7.4 to -7.3; p < 0.001), or 7.5% (95% CI -7.6% to -7.5%). A key limitation of this study is the inability to assess causality because of its observational nature. We also cannot determine whether observed changes in purchases are due to reformulation or consumer behavioral change, nor can we parse out the effects of the labeling, marketing, and school sales ban policies.

CONCLUSIONS

Purchases of high-in beverages significantly declined following implementation of Chile's Law of Food Labeling and Advertising; these reductions were larger than those observed from single, standalone policies, including sugar-sweetened-beverage taxes previously implemented in Latin America. Future research should evaluate the effects of Chile's policies on purchases of high-in foods, dietary intake, and long-term purchasing changes.

Mexican Households’ Food Store Shopping Patterns and Healthfulness of Purchases (P18-117-19)

Objectives

To determine the patterns of food shopping in Mexico by store-type, and whether these are associated with the healthfulness of food purchases.

Methods

Using data from the Nielsen Mexico Consumer Panel Survey 2012–2015 (households (HH) = 5500), in each year we performed a k-means cluster analysis using households percentage of food and beverage purchases from each store type (i.e., convenience stores, traditional shops, supermarkets, wholesalers, and others). Separate clusters were derived for foods and beverages. We present the unadjusted mean volume (per capita/day) of less healthy and healthier products purchased in each cluster.

Results

Three distinctive patterns emerged for both foods and beverages, and these were consistent over time: a cluster in which most beverages were made at traditional stores (e.g., small tiendas [“Traditional” pattern]), supermarkets (“Supermarket” pattern), or both traditional stores, supermarkets, and convenience stores (beverages only) or wholesalers (foods only) (“Mixed” pattern).

For beverages, the Traditional pattern was most prevalent (60% of HH); and households in this pattern purchased twice as many less healthy beverages as healthy beverages (710 ml vs 371 ml) overall. In the Supermarket beverage pattern (26% of HH), the relative volume of healthier and less healthy beverages was similar. In the Mixed beverage pattern (14% of HH), purchases of healthier beverages were higher than purchases of less healthy beverages (550 ml vs 364 ml) overall.

For foods, households in the Supermarket pattern (38% of HH) and in the Mixed pattern (35% of HH), purchased a similar relative volume of healthier and less healthy foods. Households in the Traditional pattern (28% of HH) however, purchased more healthier foods than less healthy foods (75 g vs 54 g) overall.

Conclusions

Mexican households mainly rely in three combinations of stores to obtain their foods and beverages, which are associated with the healthfulness of their purchases of packaged products. Understanding the shopping behavior in Mexico can provide evidence to develop interventions that improve the healthfulness of the Mexican food environment and inform current policies.

Funding Sources

Bloomberg Philanthropies and the Mexican National Council of Science and Technology Scholarship (CONACyT).

Physical Activity and Sedentary Behaviors on Risk of Overweight and Obesity in Chinese Children and Adolescents (P16-010-19)

Objectives

The prevalence of overweight among Chinese children and adolescent increased steadily in the past two decades. Few studies exist even on long-term trends in physical activity in children or adolescents and very few long-term longitudinal studies have examined the association between physical activity or sedentary activity and the risk of overweight and obesity globally.

Methods

We used longitudinal data of the China Health and Nutrition Survey from 2004 to 2015 to examine the relationship among 4520 children and adolescents aged 6–18 years old. We collected detailed seven-day data on physical activity and sedentary activity, including sports and exercise, commute mode, household chores, screen time, homework, and other activities and converted them into metabolic equivalents (MET) values. We used the hybrid approach on the random-effects models to estimate the association between physical activity, sedentary activity and the risk of overweight and obesity.

Results

The child and adolescent prevalence of overweight and obesity increased from 5.8% in 2004 to 16.5% in 2015, while physical activity decreased from 60.9 to 49.1 METs hour/week and sedentary activity increased from 26.9 to 22.9 hours/week during the same period. Controlled for age, gender, urbanization index, income, energy intake, mother's BMI and education, and survey year, the results showed that physical activity significantly decreased the risk of overweight and obesity among girls [for 6–11 years old girls, OR = 0.37(95% CI 0.20 – 0.67); for 12–18 years old girls, OR = 0.46 (95% CI: 0.25 – 0.85)]. Sedentary activity significantly increased the risk of overweight and obesity among older girls only [OR = 1.96 (95% CI: 1.09 – 3.54)]. The association was not significant among boys.

Conclusions

Low physical activity and high sedentary activity increased the risk of overweight and obesity among Chinese girls, particularly teenage girls. More studies are needed among boys.

Funding Sources

The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), NIH; The Fogarty International Center, NIH; Department of Nutrition & Carolina Population Center, The University of North Carolina at Chapel Hill; Chinese Center for Disease Control and Prevention.

Chile's 2014 sugar-sweetened beverage tax and changes in prices and purchases of sugar-sweetened beverages: An observational study in an urban environment

BACKGROUND

On October 1, 2014, the Chilean government modified its previous sugar-sweetened beverage (SSB) tax, increasing the tax rate from 13% to 18% on industrialized beverages with high levels of sugar (H-SSBs) (greater than 6.25 grams [g] sugar/100 milliliters [mL]) and decreasing the tax rate from 13% to 10% on industrialized beverages with low or no sugar (L-SSBs) (less than 6.25 g sugar/100 mL). This study examines changes in beverage prices and household beverage purchases following the implementation of the tax reform.

METHODS AND FINDINGS

We used longitudinal data collected between January 1, 2013, and December 31, 2015, from 2,000 households. We defined the pretax period as January 1, 2013, to September 30, 2014, and the posttax period as October 1, 2014, to December 31, 2015. We conducted a pre-post analysis for changes in prices and purchases, with the latter examined by volume and calories. We compared posttax changes in prices and purchases to a counterfactual, defined as what would have been expected in the posttax period based on pretax trends. All results are stated as comparisons to this counterfactual. We linked beverages at the bar code level to nutrition facts panel data collected by a team of Chilean nutritionists who categorized them by taxation level and beverage subcategory, which included carbonated and noncarbonated H-SSBs and concentrated, ready-to-drink L-SSBs and untaxed beverages. We reconstituted concentrated beverages and analyzed all beverages using as-consumed volumes and calories. Posttax monthly prices of H-SSBs increased, but these changes were small. Prices of carbonated H-SSBs increased by 2.0% (95% confidence interval [CI] 1.0%-3.0%), while those of noncarbonated H-SSBs increased by 3.9% (95% CI 1.6%-6.2%). Prices of L-SSB concentrates decreased after the tax by 6.7% (95% CI -8.2%--4.6%), and prices of ready-to-drink L-SSBs increased by 1.5% (95% CI 0.3%-2.7%). Households decreased monthly per capita purchases of H-SSBs by 3.4% by volume (95% CI -5.9%--0.9%) and 4.0% by calories (95% CI -6.3%--1.9%), and this change was greater among high socioeconomic status (SES) households. The volume of household purchases of L-SSBs increased 10.7% (95% CI 7.5%-13.9%), while that of untaxed beverage purchases decreased by 3.1% (95% CI -5.1%--1.1%). The main limitation of this study was that there was no control group, so we were unable to assess the causal impact of the tax.

CONCLUSIONS

The modifications of Chile's SSB tax were small, and observed changes in prices and purchases of beverages after the tax were also small. Our results are consistent with previous evidence indicating that small increases in SSB taxes are unlikely to promote large enough changes in SSB purchases to reduce obesity and noncommunicable diseases (NCDs).

37 year snacking trends for US children 1977-2014

BACKGROUND

Previous studies have indicated that snacking is contributing to increased calorie intake of American children and that the energy density of snacks in US diets has increased in recent decades.

OBJECTIVE

Examine short-term and long-term trends in the energy density and food sources of snacks for US children from 1977 to 2014, and examine whether trends differ between socio-demographic groups.

METHODS

We used data collected from eight nationally representative surveys of food intake in 49,952 US children age 2-18 years, between 1977 and 2014. Overall patterns of snacking, trends in energy intake from snacking, trends in food and beverage sources and energy density of snacks across race-ethnic, age, gender, education and income groups were examined.

RESULTS

In all socio-demographic groups, there was a significant increase in per capita energy intake deriving from snacks from 1977 to 2014 (P < 0.01). Salty snack intake doubled over the study period, and sugar-sweetened beverage intake decreased overall from 1977 to 2014 but increased in Non-Hispanic Blacks. Non-Hispanic Blacks had the largest increase in per capita intake from foods as a snack from 1977 to 2014. Children in the lowest poverty level and household education groups had more than 100% increase in calorie intake from snacks from 1977 to 2014.

CONCLUSIONS

We found that snacking behaviour in the USA differs between race-ethnic, household education, gender and income groups, yet snacking remains a significant component of children's diets and the foods consumed at these snacks are not the types of foods recommended by the US dietary guidelines.

Pitfalls of the self-regulation of advertisements directed at children on Mexican television

BACKGROUND

There are no academic studies that characterize advertisements directed at children from the companies that signed the self-regulation.

OBJECTIVE

The aim of this paper was to assess the extent and nature of food advertisements and the persuasive techniques used to market unhealthy food and beverages (UFB) to children, by signatory companies of self-regulation.

METHODS

From December 2012 to April 2013, 600 h of programming were recorded on the four broadcast public television channels in Mexico with the highest rating nationwide. Marketing aimed at children directly (broadcast on children's programmes or advertisements with a specific appeal to children) or indirectly (aimed at other target audiences with messages or scenes that link children to the product) were considered.

RESULTS

About 74.9% (2148) of the total food and beverage advertisements tried to influence children directly and indirectly. Companies, which had signed the self-regulation, focused 92.7% of their advertisements on UFB. Of the total number, 23.9% were aimed at children, 7.1% at adolescents, 12.5% at parents and 56.2% at the general public. Most of these advertisements were broadcast on movies (29.8%), cartoons (18%), soap operas (17.6%), entertainment shows (17.2%) and sports programs (6.4%).

CONCLUSION

Despite the self-regulation of television marketing, children were surrounded by UFB advertisements. Signatory companies influence children indirectly by targeting other audiences and by marketing during family television programs, which are also watched by children.

Designing a food tax to impact food-related non-communicable diseases: the case of Chile

The global shift towards diets high in sugar-sweetened beverages (SSBs) and energy dense ultra-processed foods is linked to higher prevalence of obesity, diabetes and most other noncommunicable diseases (NCDs), causing significant health costs. Chile has the highest SSB consumption in the world, very high junk food intake and very rapid increases in these poor components of the diet plus obesity prevalence. This study's purpose is to compare the effect of different tax schemes for SSBs and ultra-processed foods on nutrient availability, utilizing price-elasticities, which are estimated from a Quadratic Almost Ideal Demand System model, using the 2011-2012 Income and Expenditure survey. We take into account the high proportion of households not purchasing various food and beverage groups (censored nature of data). The food groups considered were: sweets and desserts; salty snacks and chips; meat products and fats; fruits, vegetables and seafood; cereals and cereal products; SSB ready-to-drink; SSB from concentrate; plain water, coffee and tea; and milk, which together represent 90% of food expenditures. The simulated taxes were: (1) 40% price tax on SSBs(22% above the current tax level); (2) a 5 cents per gram of sugar tax on products with added sugar; and (3) 30% price tax on all foods(27% above current tax levels) and beverages (12% above the current tax level) exceeding thresholds on sodium, saturated fat, and added sugar and for which marketing is restricted (based on a Chilean law, effective June 16 2016). Unhealthy foods are price-elastic (-1.99 for salty snacks and chips, -1.06 for SSBs ready-to-drink, and -1.27 for SSBs from concentrate), meaning that the change in consumption is proportionally larger with respect to a change in price. Results are robust to different model specification, and consistent among different socioeconomic sub-populations. Overall, the tax on marketing controlled foods and beverages is associated with the largest reduction in household purchases of sodium, added sugar, saturated fat and calorie purchases. Chile is unique in currently having instituted a small current SSB tax as well as marketing controls and front-of-package labeling of unhealthy foods and beverages. The design of a larger, more comprehensive tax to enhance the overall effect of these policies on healthier diets is a next critical step. This study shows that a large tax on the same foods and beverages already delineated as unhealthy by the marketing controls and front-of-pack labeling should prove to be more effective for promoting a healthier diet.

Tasting profile affects adoption of caloric beverage reduction in a randomized weight loss intervention

Objective

The aim of this study was to examine differences in rates of non‐caloric beverage adoption by participants classified as sweet likers (SLs) or sweet dislikers (measured using a behavioural tasting task).

Methods

Data are a sub‐study from a 6‐month, three‐group, randomized weight loss trial (CHOICE) (body mass index 36.3 ± 5.8 kg m⁻², 84% female, aged 42.2 ± 10.9 years, 53% African‐American) comparing the replacement of caloric beverages with either non‐caloric sweetened beverages (diet) or water (water) compared with a control group. This sub‐study, which included participants within the water (n = 106) and diet (n = 103) groups only, examined whether SLs (n = 33 water; n = 37 diet) varied in their adherence to caloric beverage recommendations compared with sweet dislikers (n = 73 water; n = 76 diet) over the 6‐month study.

Results

Diet intake and sweet‐liking data collected on 190 (3 months) and 169 participants (6 months) were used for analysis. The interaction between SL status and beverage group (diet vs. water) approached significance (P = 0.06) at 3 months but not 6 months. Caloric beverage intake (% energy) at 3 months was significantly higher in SLs within the water group (9.7 ± 1.4%) compared with SLs in the diet group (5.4 ± 1.0%, P = 0.03).

Conclusions

Results suggest that SL status may affect the rate in reduction of caloric beverages when water is the recommended substitution. Future studies should explore tailoring beverage recommendations to tasting profile.

Weight Gain Trajectories Associated With Elevated C-Reactive Protein Levels in Chinese Adults

BACKGROUND

Recent longitudinal work suggests that weight change is an important risk factor for inflammation across the full range of BMI. However, few studies have examined whether the risk of inflammation differs by patterns of weight gain over time. Using latent class trajectory analysis, we test whether patterns of weight gain are associated with elevated high-sensitivity C-reactive protein (hs-CRP 2-10 mg/L).

METHODS AND RESULTS

Data come from China Health and Nutrition Survey (CHNS) participants (n=5536), aged 18 at baseline to 66 years in 2009, with measured weight over 18 years. Latent class trajectory analysis was used to identify weight-change trajectories in 6 age and sex strata. Multivariable general linear mixed-effects models fit with a logit link were used to assess the risk of elevated hs-CRP across weight trajectory classes. Models were fit within age and sex strata, controlling for baseline weight, adult height, and smoking, and included random intercepts to account for community-level correlation. Steeper weight-gain trajectories were associated with greater risk of elevated hs-CRP compared to more moderate weight-gain trajectories in men and women. Initially high weight gain followed by weight loss was associated with lower risk of elevated hs-CRP in women aged 18 to 40.

CONCLUSIONS

Latent class trajectory analysis identified heterogeneity in adult weight change associated with differential risk of inflammation independently of baseline weight and smoking. These results suggest that trajectories of weight gain are an important clinical concern and may identify those at risk for inflammation and the development of cardiometabolic disease.

Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels: findings from the Prospective Urban Rural Epidemiology (PURE) study

BACKGROUND

Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day, but their intake is thought to be low worldwide. We aimed to determine the extent to which such low intake is related to availability and affordability.

METHODS

We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random effects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost.

FINDINGS

Of 143 305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66-3·86) per day. Mean daily consumption was 2·14 servings (1·93-2·36) in low-income countries (LICs), 3·17 servings (2·99-3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09-4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13-5·71) in high-income countries (HICs). In 130 402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06-57·88) of household income in LICs, 18·10% (14·53-21·68) in LMICs, 15·87% (11·51-20·23) in UMICs, and 1·85% (-3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p<0·0001 for each pairwise comparison). Fruit and vegetable consumption among individuals decreased as the relative cost increased (ptrend=0·00040).

INTERPRETATION

The consumption of fruit and vegetables is low worldwide, particularly in LICs, and this is associated with low affordability. Policies worldwide should enhance the availability and affordability of fruits and vegetables.

FUNDING

Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.

Comparing a 7-day diary vs. 24 h-recall for estimating fluid consumption in overweight and obese Mexican women

BACKGROUND

High intake of sugar-sweetened beverages (SSB) is linked to increased weight, energy intake, and diabetes. Even though the increasing interest on beverages and water intake, there are few dietary tools carefully validated. The purpose of this paper is to compare a fluid intake 7-day diary against a 24-h recall questionnaire to estimate the fluid consumption in overweight and obese women participating in a randomized controlled trial in Mexico.

METHODS

This cross-sectional study explored the correlation of reported fluid consumption between two methods: 3-day 24-hr recalls and 7-day diary beverage registry in overweight and obese Mexican women aged 18-45 y (n = 190).

RESULTS

There was no difference on median estimated volume (mL/d), nor the median estimated energy (kcal/d) from total beverage consumption registered by the two dietary tools. The crude and rank correlation among the two dietary instruments was high for total fluid consumption in mL/d r = 0.7, p < 0.001 (crude and rank correlation) and for fluid consumption measured as energy intake: r = 0.7; p < 0.001 crude, and r = 0.5; p < 0.001 rank correlation. By type of beverage, the more meaningful rank correlations were for fluid intake in: mL/d, water, alcohol beverages, and SSB; and in kcal/d, alcohol beverages and SSBs (rank correlation ≥ 0.6).

CONCLUSIONS

Overall, the 7-day diary showed high and strong rank correlations with that reported in the 24-h recall, suggesting that the diary method is a valid dietary tool to evaluate total fluid, water and SSB intake in this population.

Environmental, Dietary, and Behavioral Factors Distinguish Chinese Adults with High Waist-to-Height Ratio with and without Inflammation

BACKGROUND

The environmental and behavioral risk factors associated with central obesity and/or inflammation in populations exposed to both obesogenic and pathogenic environments remain unclear.

OBJECTIVES

We tested which of the characteristics distinguished 3 risk groups--high waist-to-height ratio (WHtR; >0.5) without inflammation [high-sensitivity C-reactive protein (hs-CRP) <3 mg/L], normal WHtR (≤ 0.5) with inflammation (hs-CRP: 3-10 mg/L), and high WHtR with inflammation--from the referent group with normal WHtR without inflammation and, secondarily, which factors differed between the groups with high WHtR with and without inflammation.

METHODS

The analytic sample included 8068 adults participating in the China Health and Nutrition Survey in 2009. Adjusted multinomial and logistic regression models were used to assess the risk of being in one of the "unhealthy" groups compared with the referent group.

RESULTS

Men with high WHtR with and without inflammation were more likely to live at higher urbanicity (57-63%) and have higher incomes (26-42%) and household sanitation (26-67%) and were >40% less likely to have high physical activity than the healthy referent group. Men with high WHtR with inflammation had higher odds of infectious symptoms than those with high WHtR without inflammation (OR: 1.73; 95% CI: 1.15, 2.61). Women with high WHtR without inflammation were less likely to have high household sanitation (44%) or perform high levels of physical activity (24%) and were 34% more likely to consume more fiber than the healthy referent group. Women with high WHtR and inflammation were more likely than those with high WHtR without inflammation to have infectious symptoms (OR: 1.45; 95% CI: 1.01, 2.07) and less likely to have higher fiber intake (OR: 0.77; 95% CI: 0.60,1.00) or physical activity (OR: 0.55; 95% CI: 0.41, 0.73).

CONCLUSION

These results document different underlying pathogenic and obesogenic risk factors for visceral adiposity with and without inflammation in Chinese adults, suggesting that context-specific approaches may be needed to prevent and treat inflammation.

Monitoring changes in the nutritional content of ready-to-eat grain-based dessert products manufactured and purchased between 2005 and 2012

BACKGROUND

Monitoring changes in the nutritional content of food/beverage products and shifts in consumer purchasing behaviors is needed to measure the effectiveness of efforts by both food manufacturers and policy makers to improve dietary quality in the United States.

OBJECTIVE

To examine changes in the nutritional content (eg, energy, saturated fat, and sugar density) of ready-to-eat (RTE) grain-based dessert (GBD) products manufactured and purchased between 2005 and 2012.

DESIGN

Nutrition Facts panel information from commercial databases was linked to RTE GBD products purchased by households (N=134,128) in the Nielsen Homescan longitudinal dataset 2005-2012.

STATISTICAL ANALYSIS

Linear regression models were used to examine changes in the energy, saturated fat, and sugar density of RTE GBD products manufactured in each year between 2005 and 2012. Random effects models controlling for demographics, household composition/size, and geographic location were used to examine changes in household purchases of RTE GBD products (in grams) and the average energy, saturated fat, and sugar density of RTE GBD products purchased.

RESULTS

The saturated fat density (grams/100 g) of RTE GBD products increased significantly from 6.5±0.2 in 2005 to 7.3±0.2 and 7.9±0.2 for pre-existing and newly introduced products in 2012, respectively. Between 2005 and 2012, the energy density (kilocalories/100 g) of RTE GBD products purchased decreased significantly from 433±0.2 to 422±0.2, the saturated fat density (grams/100 g) of products purchased increased significantly from 6.3±0.01 to 6.6±0.01, the sugar density (grams/100 g) of products purchased decreased significantly from 32.4±0.03 to 31.3±0.02, and household purchases of RTE GBD products (in grams) decreased by 24.1%±0.4%.

CONCLUSIONS

These results highlight an opportunity for both food manufacturers and public health officials to develop new strategies to shift consumer purchases toward products with lower energy, saturated fat, and sugar densities in addition to decreasing overall purchases of RTE GBDs.

Substituting water for sugar-sweetened beverages reduces circulating triglycerides and the prevalence of metabolic syndrome in obese but not in overweight Mexican women in a randomized controlled trial

BACKGROUND

Mexico's sugar-sweetened beverage (SSB) intake is among the highest globally. Although evidence shows that increases in SSB intake are linked with increased energy intake, weight gain, and cardiometabolic risks, few randomized clinical trials have been conducted in adults.

OBJECTIVE

The aim of this study was to determine if replacing SSBs with water affects plasma triglycerides (TGs) (primary outcome), weight, and other cardiometabolic factors.

METHODS

We selected overweight/obese (BMI ≥ 25 and <39 kg/m(2)) women (18-45 y old) reporting an SSB intake of at least 250 kcal/d living in Cuernavaca, Mexico. Women were randomly allocated to the water and education provision (WEP) group (n = 120) or the education provision (EP)-only group (n = 120). The WEP group received biweekly water deliveries, and both groups received equal monthly nutrition counseling. During nutrition counseling, the WEP group sessions included activities to encourage increased water intake, reduced SSB intake, and substitution of water for SSBs. Repeated 24-h dietary recalls, anthropometric measurements, and fasting blood samples were collected at baseline and at 3, 6, and 9 mo. The Markov-Monte Carlo method was used for multiple imputation; separate mixed-effects models tested each outcome.

RESULTS

An intent-to-treat (ITT) analysis indicated that the WEP group increased water intake and decreased SSB intake significantly over time, but there were no differences in plasma TG concentrations between groups at the end of the intervention (WEP at baseline: 155 ± 2.10 mg/dL; WEP at 9 mo: 149 ± 2.80 mg/dL; EP at baseline: 150 ± 1.90 mg/dL; EP at 9 mo: 161 ± 2.70 mg/dL; P for mean comparisons at 9 mo = 0.10). Secondary analyses showed significant effects on plasma TGs (change from baseline to 9 mo: WEP, -28.9 ± 7.7 mg/dL; EP, 8.5 ± 10.9 mg/dL; P = 0.03) and metabolic syndrome (MetS) prevalence at 9 mo (WEP: 18.1%; EP: 37.7%; P = 0.02) among obese participants.

CONCLUSIONS

Providing water and nutritional counseling was effective in increasing water intake and in partially decreasing SSB intake. We found no effect on plasma TGs, weight, and other cardiometabolic risks in the ITT analysis, although the intervention lowered plasma TGs and MetS prevalence among obese participants. Further studies are warranted. This trial was registered at http://www.clinicaltrials.gov as NCT01245010.

Dietary pattern trajectories during 15 years of follow-up and HbA1c, insulin resistance and diabetes prevalence among Chinese adults

BACKGROUND

Most research on dietary patterns and health outcomes does not include longitudinal exposure data. We used an innovative technique to capture dietary pattern trajectories and their association with haemoglobin A1c (HbA1c), homeostasis model of insulin resistance (HOMA-IR) and prevalence of newly diagnosed diabetes.

METHODS

We included 4096 adults with 3-6 waves of diet data (1991-2006) and biomarkers measured in 2009 from the China Health and Nutrition Survey. Diet was assessed with three 24-h recalls and a household food inventory. We used a dietary pattern previously identified with reduced rank regression that positively predicted diabetes in 2006 (high in wheat products and soy milk and low in rice, legumes, poultry, eggs and fish). We estimated a score for this dietary pattern for each subject at each wave. Using latent class trajectory analysis, we grouped subjects with similar dietary pattern score trajectories over time into five classes.

RESULTS

Three trajectory classes were stable over time, and in two classes the diet became unhealthier over time (upward trend in dietary pattern score). Among two classes with similar scores in 2006, the one with the lower (healthier) initial score had an HbA1c 1.64% lower (-1.64 (95% CI -3.17 to -0.11)) and non-significantly a HOMA-IR 6.47% lower (-6.47 (-17.37 to 4.42)) and lower odds of diabetes (0.86 (0.44 to 1.67)).

CONCLUSIONS

Our findings suggest that dietary pattern trajectories with healthier scores longitudinally had a lower HbA1c compared with those with unhealthier scores, even when the trajectories had similar scores in the end point.

Multilevel examination of the association of urbanization with inflammation in Chinese adults

We examine the associations between overall urbanicity and specific physical and social components of community-level urbanization with C-reactive protein (CRP) in adults participating in the China Health and Nutrition Study. Higher overall urbanicity and environment-related urbanicity component scores, including education, housing quality, and access to markets, were associated with elevated CRP in multilevel models controlling for clustering by community. These associations differed by age and gender and persisted after controlling for individual-level anthropometric, diet, and pathogenic risk factors. These results highlight the importance of place in relation to inflammation across the spectrum of rural and urban environments.

Averting obesity and type 2 diabetes in India through sugar-sweetened beverage taxation: an economic-epidemiologic modeling study

BACKGROUND

Taxing sugar-sweetened beverages (SSBs) has been proposed in high-income countries to reduce obesity and type 2 diabetes. We sought to estimate the potential health effects of such a fiscal strategy in the middle-income country of India, where there is heterogeneity in SSB consumption, patterns of substitution between SSBs and other beverages after tax increases, and vast differences in chronic disease risk within the population.

METHODS AND FINDINGS

Using consumption and price variations data from a nationally representative survey of 100,855 Indian households, we first calculated how changes in SSB price alter per capita consumption of SSBs and substitution with other beverages. We then incorporated SSB sales trends, body mass index (BMI), and diabetes incidence data stratified by age, sex, income, and urban/rural residence into a validated microsimulation of caloric consumption, glycemic load, overweight/obesity prevalence, and type 2 diabetes incidence among Indian subpopulations facing a 20% SSB excise tax. The 20% SSB tax was anticipated to reduce overweight and obesity prevalence by 3.0% (95% CI 1.6%-5.9%) and type 2 diabetes incidence by 1.6% (95% CI 1.2%-1.9%) among various Indian subpopulations over the period 2014-2023, if SSB consumption continued to increase linearly in accordance with secular trends. However, acceleration in SSB consumption trends consistent with industry marketing models would be expected to increase the impact efficacy of taxation, averting 4.2% of prevalent overweight/obesity (95% CI 2.5-10.0%) and 2.5% (95% CI 1.0-2.8%) of incident type 2 diabetes from 2014-2023. Given current consumption and BMI distributions, our results suggest the largest relative effect would be expected among young rural men, refuting our a priori hypothesis that urban populations would be isolated beneficiaries of SSB taxation. Key limitations of this estimation approach include the assumption that consumer expenditure behavior from prior years, captured in price elasticities, will reflect future behavior among consumers, and potential underreporting of consumption in dietary recall data used to inform our calculations.

CONCLUSION

Sustained SSB taxation at a high tax rate could mitigate rising obesity and type 2 diabetes in India among both urban and rural subpopulations.

Ultra-processed products are becoming dominant in the global food system

The relationship between the global food system and the worldwide rapid increase of obesity and related diseases is not yet well understood. A reason is that the full impact of industrialized food processing on dietary patterns, including the environments of eating and drinking, remains overlooked and underestimated. Many forms of food processing are beneficial. But what is identified and defined here as ultra-processing, a type of process that has become increasingly dominant, at first in high-income countries, and now in middle-income countries, creates attractive, hyper-palatable, cheap, ready-to-consume food products that are characteristically energy-dense, fatty, sugary or salty and generally obesogenic. In this study, the scale of change in purchase and sales of ultra-processed products is examined and the context and implications are discussed. Data come from 79 high- and middle-income countries, with special attention to Canada and Brazil. Results show that ultra-processed products dominate the food supplies of high-income countries, and that their consumption is now rapidly increasing in middle-income countries. It is proposed here that the main driving force now shaping the global food system is transnational food manufacturing, retailing and fast food service corporations whose businesses are based on very profitable, heavily promoted ultra-processed products, many in snack form.

Overview: Bellagio Conference on Program and Policy Options for Preventing Obesity in the Low- and Middle-Income Countries

The Bellagio 'Conference on Program and Policy Options for Preventing Obesity in the Low- and Middle-Income Countries' (LMICs) was organized to pull together the current. We need not reiterate the importance of this topic or the speed of change in eating, drinking and moving facing us across the globe. The conference emerges from need to significantly step up the policies and programs to reduce obesity by learning from some current examples of best practice and strengthening the role of the academic and civil society players in translating global evidence and experience into action at the national level. There is also a need to empower the younger generation of scholars and activists in these countries to carry on this effort. The meeting was also timely because a number of funding agencies in the United States, Canada and the UK, at least, are beginning to focus attention on this topic. This set of papers provides not only examples of existing best practice but also a road map ahead for LMICs in the various areas of action needed to reduce obesity across LMICs. The meeting highlighted critical barriers to implementation that have blocked many initiatives.