Indian Academy of Pediatrics Guidelines on the Fast and Junk Foods, Sugar Sweetened Beverages, Fruit Juices, and Energy Drinks

Childhood Obesity: A Narrative Review

Obesity among children has emerged as a worldwide health issue due to childhood obesity becoming a pandemic, and it is often linked to various illnesses, fatal outcomes, and disability in adulthood. Obesity has become an epidemic issue in both developed and developing countries, particularly among youngsters. The most common factors contributing to non-communicable diseases (NCDs) are unhealthy eating habits, desk-bound games, avoidance of physical activity-requiring activities, smoking, alcohol usage, and other added items. All these factors increase NCDs, including obesity, resulting in various morbidities and early death. Additionally, childhood obesity has psychological, emotional, cognitive, societal, and communicative effects. For example, it raises the possibility of issues related to physical appearance, self-esteem, confidence level, feelings of isolation, social disengagement, stigma, depression, and a sense of inequality. Children who consume more energy-dense, high-fat, low-fiber-containing food than they need usually store the excess as body fat. Standardizing indicators and terminology for obesity-related metrics is critical for better understanding the comparability of obesity prevalence and program effectiveness within and between countries. The underlying variables must be altered to reduce or avoid harm to the target organ in children. As a result, reducing childhood obesity is a considerable public health goal for the benefit of society and the long-term well-being of individuals.

A recent update on childhood obesity: aetiology, treatment and complications

Obesity is a complex, chronic condition characterised by excess adiposity. Rates of obesity in childhood and adolescence are increasing worldwide, with a corresponding increase in adulthood. The aetiology of obesity is multifactorial and results from a combination of endocrine, genetic, environmental and societal factors. Population level approaches to reduce the prevalence of childhood obesity worldwide are urgently needed. There are wide-ranging complications from excess weight affecting every system in the body, which lead to significant morbidity and reduced life expectancy. Treatment of obesity and its complications requires a multi-faceted, biopsychosocial approach incorporating dietary, exercise and psychological treatments. Pharmacological treatments for treating childhood obesity have recently become available, and there is further development of new anti-obesity medications in the pipeline. In addition, bariatric surgery is being increasingly recognised as a treatment option for obesity in adolescence providing the potential to reverse complications related to excess weight. In this review, we present an update on the prevalence, aetiology, complications and treatment of childhood obesity.

Cardiovascular Risk Factors Among Healthcare Providers at the Bamenda Regional Hospital, Bamenda, Cameroon

Objective This study aimed to assess cardiovascular risk factors (CVRFs) among healthcare professionals (HCPs) practicing at the Bamenda Regional Hospital (BRH) in Bamenda, Cameroon. Methodology This was a hospital-based cross-sectional study involving HCPs practicing at the BRH. Data on lifestyle risk factors were collected across several units and services of the BRH by using a modified Health Improvement Card (HIC). Results A total of 237 participants were included in the final analysis; most were female (59.1%). The mean age of the sample was 30.1 ± 5.8 years. Based on the HIC, most HCPs were in the medium-risk zone (54.0%) for diet; in the high-risk zone for physical activity (68.4%); and in the low-risk zone for tobacco use and alcohol consumption (97.9% and 82.3%, respectively). The risk of developing cardiovascular diseases (CVDs) increases from a low to high-risk level. The mean HIC score was 10.3 ± 1.8 in males), and 10.2 ± 1.7 in females (p=0.781). The age group of 20-30 years had the lowest HIC score, with a mean of 9.9 ± 1.6; those over 40 years had higher HIC scores, with a mean of 11.5 ± 1.4 (p=0.000). When HIC CVRFs were quantified (higher score indicates higher risk), the HIC scores were highest in physicians (11.0 ± 1.8), followed by pharmacists (11.0 ± 1.4) and nurses (10.5 ± 1.7), and lowest in physiotherapists (8.0 ± 1.1) (p=0.000). Regarding socioeconomic status, the mean HIC scores were highest for the upper class (11.5 ± 1.3), followed by the middle (10.0 ± 1.9) and lower classes (10.0 ± 1.7) (p=0.013). Conclusions Most participants were in the low-risk zone for BMI and alcohol and tobacco use; in the moderate-risk zone for healthy diet and blood pressure; and the high-risk zone for physical activity and exercise. Physicians exhibited higher levels of CVRFs compared to other healthcare professionals. Furthermore, high socioeconomic status was associated with a high risk of CVD. Our findings identify opportunities for targeted training and effective interventions to reduce the burden of CVDs among HCPs and beyond and maximize their potential as health educators and influencers with their patients and students.

Evaluation of the Dietary Habits of Polish and Greek University Students in the Context of the Health Benefits of Their Diets

Background/Objectives: Eating habits and behaviors play a central role in maintaining health and overall well-being. In the case of young students, they affect not only appearance and general mood but also cognitive ability, concentration, and broader learning ability. For this reason, it is essential for young people to have well-balanced and wholesome diets. Methods: The study included 186 Polish and 136 Greek university students majoring in sports. The research tool was the validated survey questionnaire FFQ-6, and the data collected were additionally used to calculate the healthy diet index (pHDI-10). Results: Based on the analysis of the collected data, the dietary habits of the students surveyed were assessed, taking into account, among other things, the frequency of consumption of sweets, salty snacks, processed foods, and sweetened drinks, but also healthy products, including vegetables and fruit or vegetable and fruit juices. The data collected made it possible to determine an index of the health value of the participants' diet. Conclusions: The analysis of the collected data led to the conclusion that, more often than their Greek peers, Polish university students tend to reach for sweets, salty snacks, or sweetened drinks. Greeks were more likely to choose fruit and vegetables and vegetable and fruit juices. However, among both Poles and Greeks, the index of the health-promoting value of the diet is low, indicating a high risk of diet-related diseases of lifestyle. Similar trends can be observed among students of almost all nationalities, which makes it reasonable to consider the implementation of appropriate educational programs on nutrition and healthy lifestyle principles in general.

A study of parental knowledge and intended behaviour regarding introduction of juices and sugar-sweetened beverages in early childhood

Background

Parents and families have a role to play in helping children develop healthy behaviours that will carry over into adulthood. The sugary drink and fruit juice consumption is significantly related to unhealthy weight gain in childhood. Hence, this study was planned to assess parental knowledge, attitudes, and practices about juice and sugar-sweetened beverages (SSBs) among parents of children (2-24 months) and identify factors that contribute to their early introduction.

Methods and Material

A cross-sectional study was conducted on 400 children-parent dyads (2-24 months). A questionnaire regarding the knowledge and attitudes about initiating fruit juice and SSB among children was prepared with 6 statements that were validated for contents by two subject experts. Each of the questions was designed to be answered on a Five-point Likert-type scale. STATA 14.2 version was used to analyse data.

Results

Out of 400, 14 (26.9%) and 125 (68%) parents planned to introduce SSBs and juices respectively in the first year life of their child. None of the parents had an excellent knowledge score. There was no significant difference reported between parents with less than high school and those with high school/graduation educated in their intention to introduce juice and SSBs (P = 0.68) to their babies in the first year of life and about its knowledge (P = 0.82). Most parents with lower socio-economic status (58.6%) showed less likeliness to introduce juices and SSBs to their child's diet as reflected by a statistically significant (P = 0.01) knowledge score.

Conclusion

There was a knowledge gap among parent's of children irrespective of their education level and socio-economic status.

Estimating the potential impact of a health tax on the demand for unhealthy food and beverages and on tax revenue in India

Foods high in fat, sugar or salt are important contributors to the rising burden of non-communicable diseases globally and in India. Health taxes (HTs) have been used by over 70 countries as an effective tool for reducing consumption of sugar sweetened beverages (SSBs). However, the potential impacts of HTs on consumption and on revenues have not been estimated in India. This paper aims to estimate the potential impact of health taxes on the demand for sugar, SSBs and foods high in fat, sugar or salt (HFSS) in India while exploring its impact on tax revenues. PE of sugar was estimated using Private Final Consumption Expenditure and Consumer Price Index data while price elasticities for SSBs and HFSS were obtained from literature. The reduction in demand was estimated for an additional 10-30% HT added to the current goods and services tax, for varying levels of price elasticities. The results show that for manufacturers of sweets and confectionaries who buy sugar in bulk and assuming a higher price elasticity of -0.70, 20% additional HT (total tax 48%) would result in 13-18% decrease in the demand for sugar used for confectionaries and sweets. For SSBs, HT of 10-30% would result in 7-30% decline in the demand of SSBs. For HFSS food products, 10-30% HT would result in 5-24% decline in the demand for HFSS products. These additional taxes would increase tax revenues for the government by 12-200% across different scenarios. Taxing unhealthy foods is likely to reduce demand, while increasing government revenues for reinvestment back into public health programmes and policies that may reduce obesity and the incidence of non-communicable diseases in India.

Unhealthy Foods and Sugar-Sweetened Beverages Consumption Among Bangladeshi Adolescents and Their Sociodemographic Determinants: Findings From a Nationally Representative Cross-Sectional Study

BACKGROUND

Consumption of savory crispy or fried snacks (SCFS), sugary snacks (SS), and sugar-sweetened beverages (SSB) is associated with an increased prevalence of obesity and noncommunicable diseases. We aimed to estimate the consumption of SCFS, SS, and SSB among adolescent males and females in Bangladesh and to report the factors associated with their consumption using data from a nationwide cross-sectional survey.

METHODS

We interviewed 4,907 adolescent males and 4,865 females for the seven-day recall on intake of SCFS, SS, and SSB from 82 randomly selected clusters from rural, non-slum urban, and slum areas. Sociodemographic and anthropometry data were also collected.

RESULTS

Consumption of SCFS, SS, and SSB for ≥7 times per week was reported by 11.6%, 28.9%, and 25.6% of the males and 4.9%, 24.8%, and 20.7% of the females, respectively. The weekly mean frequency of SCFS, SS, and SSB intake increased after adjustment for potential confounders among females with higher maternal education and for SCFS and SSB among males with the highest level of father's education. Increased intake of SS and SSB for both males and females was associated with dwelling in a female-headed household. SCFS intake was higher among both males and females from the richest households. Nutritional status, both overweight and obesity, and underweight, was not associated with a more frequent intake of SCFS and SS among males and females; however, a lower frequency of intake of SSB was observed among overweight and obese males. Screen time (television viewing: none, up to 1 hour, and more than 1 hour) was not associated with consumption of SCFS and SSB among both males and females.

CONCLUSION

Consumption of unhealthy snacks and drinks is high among adolescents in Bangladesh and needs to be addressed through policy and program measures to abate the epidemic of obesity and associated NCD.

Knowledge, practices and influencing factors defining unhealthy food behavior among adolescents in India: a scoping review

Unhealthy food behaviors are the major contributing factors to the rising burden of non-communicable diseases (NCDs) among adolescents in India. Knowledge and practices related to unhealthy eating are significant factors influencing adolescents' food behavior. In this scoping review, we aim to map evidence and identify gaps on knowledge, practices, and the influencing factors associated with unhealthy food behavior among Indian adolescents by examining the existing literature. Arksey and O'Malley's scoping review framework and the Joanna Briggs Institute Reviewers' manual were used for this review. After the screening, 33 articles were identified according to the inclusion criteria. Data extraction was performed according to the study objectives, followed by narrative summarization. The studies included a total of 20,566 adolescents. Most studies reported insufficient knowledge about healthy food choices among adolescents. Diet intake patterns among the adolescents showed a lower amount of fruits and vegetables and an increase in fried items, sugar-sweetened beverages, packaged food, and fast food in both sexes, with a broader association with peer influence (21.2%), parental unhealthy food behavior (15.1%), place of residence (6.06%), emotional status (6.06%), and mass media exposure (18.1%). The scoping review highlights the need for targeted interventions aimed at improving the knowledge and practices of Indian adolescents by promoting healthy food choices and sensitizing them about the risk of non-communicable diseases. The analysis of evidence around adolescent dietary behavior in India shows a monotonous, limited, and narrow range in scope, indicating the extended need for research.

A critical comparison of the Indian school food and nutrition guidelines with the WHO-nutrition friendly school initiative and the review of existing implementation scenario

Background: The school-based food and nutrition guidelines approach has the potential to combat undernutrition, overnutrition and micronutrient deficiencies among children and adolescents and set the foundation for a healthy adult lifestyle. Aim: To critically compare the Nutrition Friendly School Initiative (NFSI) of the World Health Organization (WHO) with the Food Safety and Standards Authority of India (FSSAI) and the Indian Academy of Pediatrics (IAP) guidelines to gauge the strengths and limitations. Additionally, to summarize the existing studies on implementing school food and nutrition guidelines. Methods: Policy documents of the above guidelines were critically evaluated, and narrative analysis was conducted. An electronic search was conducted for full-text research articles published in the English language between January 2007 to September 2021 in Science Direct, PubMed, Web of Science, and SCOPUS databases. Results: Upon critical comparison of the three guidelines, it was found that the NFSI and FSSAI guidelines shared similarities in many components and the FSSAI guidelines, if implemented adequately, could improve the school food environment and combat the triple malnutrition burden in India. After screening the articles based on the eligibility criteria, 11 studies were included in the preparation of the review. Studies reported partial or inadequate implementation and poor compliance with the guidelines or approach. A few studies identified barriers to guideline implementation. Conclusion: Implementation of school food and nutrition guidelines could improve the nutritional outcomes in children and adolescents. To sustain the effective implementation, adequate resources and preparedness are essential in low-and middle-income countries, including India.

Obesity, Diabetes Mellitus, and Vascular Impediment as Consequences of Excess Processed Food Consumption

Regular intake of ready-to-eat meals is related to obesity and several noninfectious illnesses, such as cardiovascular diseases, hypertension, diabetes mellitus (DM), and tumors. Processed foods contain high calories and are often enhanced with excess refined sugar, saturated and trans fat, Na⁺ andphosphate-containing taste enhancers, and preservatives. Studies showed that monosodium glutamate (MSG) induces raised echelons of oxidative stress, and excessive hepatic lipogenesis is concomitant to obesity and type 2 diabetes mellitus (T2DM). Likewise, more than standard salt intake adversely affects the cardiovascular system, renal system, and central nervous system (CNS), especially the brain. Globally, excessive utilization of phosphate-containing preservatives and additives contributes unswervingly to excessive phosphate intake through food. In addition, communities and even health experts, including medical doctors, are not well-informed about the adverse effects of phosphate preservatives on human health. Dietary phosphate excess often leads to phosphate toxicity, ultimately potentiating kidney disease development. The mechanisms involved in phosphate-related adverse effects are not explainable. Study reports suggested that high blood level of phosphate causes vascular ossification through the deposition of Ca²⁺ and substantially alters fibroblast growth factor-23 (FGF23) and calcitriol.

Excessive Gaming and Online Energy-Drink Marketing Exposure Associated with Energy-Drink Consumption among Adolescents

In this study, we examined excessive online gaming by adolescents and the resultant effects of their exposure to the online marketing of energy drinks and alcohol, and whether marketing literacy could serve as a mitigating factor. This cross-sectional study was conducted in 2020. Data were obtained from a sample of 2613 seventh-grade students from 30 middle schools in Taiwan. A self-administered questionnaire was conducted. The results showed that nearly 18% of the adolescent respondents had used energy drinks, while 75% reported seeing energy-drink advertisements on the internet in the past year. Multiple regression results indicated that factors such as being male, reporting excessive gaming, being exposed to higher levels of online energy-drink marketing, and reporting alcohol use were positively associated with energy-drink consumption. A higher level of online energy-drink marketing-affective literacy, however, was negatively associated with energy-drink consumption. In conclusion, factors that predicted energy-drink consumption among adolescents included excessive gaming and exposure to online energy-drink marketing, but marketing-affective literacy tended to lessen the impact of such advertising.

Degree of food processing and association with overweight and abdominal obesity in adolescents

OBJECTIVE

To evaluate the association between the degree of food processing, overweight, and abdominal obesity in adolescents.

METHODS

This is a cross-sectional study, with 576 adolescents aged 10 to 17 years, of both sexes. Food consumption was collected using the Food Frequency Questionnaire and foods classified as in natura or minimally processed, processed foods associated with culinary ingredients, and ultraprocessed foods. Sociodemographic data, body mass index, waist circumference and waist-to-height ratio were collected. The analysis was evaluated by the Mann-Whitney test and prevalence ratio with 95% confidence interval, considering p<0.05.

RESULTS

An intake above the third quartile of processed foods associated with culinary ingredients (prevalence ratio of 1.64; 95%CI: 1.12-2.42) and ultraprocessed (prevalence ratio of 1.58; 95%CI: 1.07-2.34) was associated with a higher prevalence of overweight. Consumption above the third quartile of ultraprocessed foods was associated with a higher prevalence of abdominal obesity, assessed by waist circumference (prevalence ratio of 2.48; 95%CI: 1.41-4.36), and waist-height ratio (prevalence ratio of 2.09; 95%CI: 1.11-3.92).

CONCLUSION

A higher consumption of processed foods associated with culinary ingredients was related to being overweight, and ultraprocessed foods with overweight and abdominal obesity.

The Escalating Health Threats from Ultra-processed and High Fat, Salt, and Sugar Foods: Urgent Need for Tailoring Policy

With its colonial past, and a glaring problem of poverty and hunger, India oft fails to acknowledge a new, rapidly growing problem of overnutrition. With the economic boost and entry of various foreign players from the food industry, Indian citizens have been increasingly exposed to ultra-processed, high in sugar, salt and fat foods (HFSS foods). The last decade or so has seen an exponential rise in the consumption of such foods, leading to increasing prevalence of overweight- and obesity-related illnesses like diabetes, hypertension, etc. In this scenario, examining the efficacy of policy-related measures in reducing consumption of these harmful foods and preventing the associated health issues is paramount. Across the globe, several countries have explored options from taxation on HFSS foods to restricting marketing to children, as well as different practices for front of the pack labeling. In the context of India and its increasing burden of preventable, diet-related illnesses, the urgent need of instituting these preventive policies at national scale cannot be neglected.

A Fit-for-Purpose Nutrient Profiling Model to Underpin Food and Nutrition Policies in South Africa

South Africa (SA) is facing a rising prevalence of obesity and diet-related chronic diseases. The government is seeking to develop effective, evidence-based policy measures to address this. A well-designed, fit-for-purpose nutrient profiling model (NPM) can aid policy development. The aim of this study was to develop a fit-for-purpose NPM in SA. Steps included: (1) determining the purpose and target population; (2) selecting appropriate nutrients and other food components to include; (3) selecting a suitable NPM type, criteria and base; and (4) selecting appropriate numbers and thresholds. As part of the evaluation, the nutritional composition of packaged foods containing nutritional information (n = 6747) in the SA food supply chain was analyzed, a literature review was undertaken and various NPMs were evaluated. Our findings indicated that it is most appropriate to adapt an NPM and underpin regulation with a restrictive NPM that limits unhealthy food components. The Chile 2019 NPM was identified as suitable to adapt, and total sugar, saturated fat, sodium and non-sugar sweetener were identified as appropriate to restrict. This NPM has the potential to underpin restrictive policies, such as front-of-package labelling and child-directed marketing regulations in SA. These policies will support the fight against obesity and NCDs in the country.

What are the new guidelines and position papers in pediatric nutrition: A 2015-2020 overview

BACKGROUND

Nutrition related publications in pediatric population cover wide range of topics and therefore it is usually difficult for clinicians to get an overview of recent nutrition related guidelines or recommendations.

METHODS

The Special Interest Group (SIG) of Pediatrics of European Society for Clinical Nutrition and Metabolism (ESPEN) performed a literature search to capture publications in the last five years aiming to provide the latest information concerning nutritional issues in children in general and in specific diseases and to discuss progression in the field of pediatric nutrition evidence-based practice.

RESULTS

Eight major topics were identified as the most frequently reported including allergy, critical illness, neonatal nutrition, parenteral and enteral nutrition, micronutrients, probiotics and malnutrition. Furthermore, it was noted that many reports were disease focused or included micronutrients and were, therefore, represented as tables.

CONCLUSION

Overall, it has been shown that most reports on nutrition topics in pediatrics were systematic reviews or guidelines/position papers of relevant societies, but many of them basing the conclusion on a limited number of high-quality randomized controlled trials or large observational cohort studies.

Amidst the COVID-19 pandemic childhood obesity is still an epidemic-spotlight on obesity's multifactorial determinants

PURPOSE

Childhood obesity is a global epidemic and a chronic disease. Multifactorial determinants have long been linked with childhood obesity. These have been challenged with the onset of COVID-19 and the associated mitigation measures. The study aimed to re-highlight these determinants while exploring the effects of the ongoing COVID-19 pandemic on these pre-existing childhood obesity determinants, while providing evidence that may be beneficial for the post-COVID-19 recovery plan.

METHODS

A PubMed literature search (2016-2021) using the keywords, "childhood obesity", "gender", "sex", "obesity in youth", "obesity in adolescents", "COVID-19″ and "SARS-CoV2" was performed.

RESULTS

Genetic predisposition, biologically low leptin levels, certain cultural beliefs and socio-economic statuses, as well as exposure to an "obesogenic" environment were found to have a positive association with childhood obesity. Additionally, the onset of COVID-19 further aggravates the childhood obesity epidemic, increasing childrens' susceptibility to obesity and all associated consequential diseases.

DISCUSSION

A possible key to the control and prevention of the burden of childhood obesity, lies in dealing with its precursors and risk factors. Certain factors, including socio-cultural norms, cultural beliefs and geographical factors are amenable. COVID-19 further challenged these and it is evident that the childhood obesity epidemic is still a critical one. Encouraging preventative interventions, such as screening programs, public awareness and policies targeting the environment, amongst others, are recommended.

Differences in the sugar content of fast-food products across three countries

OBJECTIVE

To compare the sugar content of items at four multinational fast-food chains, across three countries.

DESIGN

Total sugar (g)/per serving was extracted from online nutrition information, and sugar/100 g serving was calculated. Foods were categorised as: breakfast sandwiches, burgers, sandwiches, desserts and condiments. Beverages were categorised as fountain, frozen or pre-packaged. Sugar (g) was compared across countries using linear mixed-effects models. Pairwise comparisons were performed with Tukey-Kramer adjustments.

SETTING

USA, Germany and Australia.

PARTICIPANTS

Burger King™ (Hungry Jack's™), Kentucky Fried Chicken™, McDonald's™ and Subway™.

RESULTS

Differences in total sugar/100 g or ml were observed across countries for burgers (n 104), desserts (n 110), sandwiches (n 178), pre-packaged beverages (n 36) and frozen beverages (n 72). Comparing identical items across countries (e.g. BigMacTM from McDonalds in USA, Germany and Australia), burgers (n 10 available in all three countries) had lower sugar content in Australia (3·4 g/100 g) compared with the USA (4·7 g/100 g, P = 0·02) or Germany (4·6 g/100 g, P = 0·04), yet no differences were observed in other food categories. Comparing the same beverages across countries (e.g. chocolate shake from Burger King), frozen beverages (n 4 available in all three countries) had lower sugar content in Australia (14·2 g/100 ml), compared with the USA (20·3 g/100 ml, P = 0·0005) or Germany (17·8 g/100 ml, P = 0·0148), yet no differences were observed in other beverage categories.

CONCLUSIONS

Heterogeneity in fast-food sugar content across countries suggests that reductions are possible and should be implemented to reduce health risks associated with excess added sugar intake.

Association between the Degree of Processing of Consumed Foods and Sleep Quality in Adolescents

The aim of this study was to evaluate the association between food consumption by the degree of processing and sleep quality in adolescents from São Luís, Maranhão, Brazil. A cross-sectional study with 2499 adolescents (aged 18 to 19 years) was developed. Exposure variables included energy contributions of food groups stratified by the NOVA classification: fresh or minimally processed foods (FMPF), processed foods (PF), and ultra-processed foods (UPF), categorized into quartiles. The outcome variable was sleep quality assessed with the Pittsburgh Sleep Quality Index. Associations between these variables were estimated by Poisson regression, with robust estimation of variance. Most of the adolescents had poor sleep quality (57.1%). There were associations between FMPF in the third (57.1%-66.0% of total calories; prevalence ratio PR = 0.88; 95% CI: 0.80, 0.97) and fourth quartile (66.1%-95.8% of total calories; PR = 0.87; 95% CI: 0.78, 0.96) and lower prevalence of poor sleep quality. The fourth quartile of UPF (44.3%-81.8% of total calories; PR = 1.14; 95% CI: 1.03, 1.27) was associated with a higher prevalence of poor sleep quality. Higher intake of FMPF is a protective factor for poor sleep quality, whereas higher UPF consumption is a risk factor for poor sleep quality.