Food choice in low income populations – A review

Unmet needs and barriers to navigating care services in the low- and middle-income families with young children in Singapore: a qualitative study

INTRODUCTION

Children's health and health behaviours primarily depend on their parental socioeconomic status backgrounds. There is limited research seeking to understand in depth the health needs and challenges of low- to middle-income families in Singapore. Understanding this can help the healthcare professional identify vulnerable families at an early stage, allowing for targeted interventions and preventive measures to address socioeconomic comorbidities and their consequences during childhood.

OBJECTIVES

To explore the health needs of the low- and middle-income families with children aged 2 months to 6 years in Singapore, and their facilitators and barriers to engagement in existing health, social and education services.

METHODS

An interpretive qualitative approach was adopted in this study. We conducted 34 semi-structured one-to-one interviews with purposively sampled low- and middle-income families with children aged 2 months to 6 years. In addition, four focus group discussions comprising 19 service providers were conducted to complement the findings. All interviews were transcribed verbatim. Thematic analysis was conducted to identify key themes and subthemes.

RESULTS

The bottom two tiers of Maslow's Hierarchy of Needs (physical, safety and security needs) constituted the larger proportion of unmet needs expressed by families. Physical needs encompassed food, exercise, sleep, screen time as well as needs related to smoking and alcohol consumption, while safety and security needs included social security needs, educational needs and physical health. Themes identified as enablers of service engagement included accessibility and convenience, financial and policy support, health awareness and engagement, trust and relationship-based engagement, interagency and technological support, and holistic family and workforce support. Conversely, themes identified as barriers to service engagement consisted of access and utilisation barriers, financial and policy inequities, challenges in information management and service coordination, and service delivery and support gaps.

CONCLUSIONS

Our analysis assembled an objective picture of challenges and strengths in relation to the health status of caregivers and their children from low- and middle-income families. Good interpersonal relationships with families, improved health literacy, readily available competent healthcare professionals, better access to social services and financial assistance, and enhanced health information technology help overcome challenges faced by low- to middle-income households.

Co-creating innovative and accepted legume-based dishes for school canteens with adolescents in a low socioeconomic area

The promotion of sustainable diets, that valorise and give stage to plant-based foods, is beneficial for both human and environmental health. Adolescence is crucial to support healthy and sustainable eating. Despite this, adolescents remain an understudied group, especially those with a lower economic status. This study aimed to develop innovative, sustainable and healthy legume-based dishes for school canteens through co-creation with adolescents in a low socioeconomic status area with high immigration rate. Nineteen adolescents and four chefs participated in iterative sessions of focus group discussions using a combination of methods (Jobs-To-Be-Done, free association tasks, SCAMPER (Substitute-Combine-Adapt-Modify-Purpose-Eliminate-Rearrange) technique) to identify ideas of new legume-based dishes. Subsequently, 91 adolescents rated their willingness-to-try 28 dish concepts based on these ideas. Six concepts were selected and translated into prototypes that underwent further evaluation by 138 adolescents who assessed their liking, sensory and emotional responses. Results showed that all dishes were well-received, with lower acceptance among high-neophobic adolescents, yet none of the selected dishes were rejected. Exploring individual differences in liking identified two clusters with different hedonic patterns. Emotional characterization of dishes showed those that elicit positive emotional responses high in arousal and novelty in all adolescents, independently from food neophobia, increasing their likelihood of acceptance. The study shows that co-creation with adolescents, in combination with understanding individual differences, are promising strategies to develop innovative, healthy and well-received legume-based dishes for school canteens.

The prevalence of abnormal semen parameters in male partners of women with anovulatory polycystic ovarian syndrome: a retrospective case-control study

PURPOSE

Polycystic ovary syndrome (PCOS) is the leading cause of anovulatory infertility, often requiring ovarian stimulation in affected women attempting to conceive. Male partner semen quality and shared lifestyle factors can significantly impact reproductive outcomes. However, current international guidelines lack evidence-based recommendations on the necessity and timing of semen analysis for the fertility management of anovulatory PCOS women.

METHODS

In a retrospective case-control study, semen analysis results of male partners of 187 anovulatory PCOS women scheduled for ovarian stimulation were analyzed and compared to a control group of 76 male partners of women with bilateral tubal occlusion.

RESULTS

The prevalence of semen analysis results with at least one parameter classified as "borderline" and "pathological" among male partners of women with PCOS eligible to undergo ovarian stimulation was 51.3% and 22.5%, compared to 44.7% and 13.2% in the control group, respectively (p = 0.027). In the PCOS group, male body mass index (odds ratio, OR 1.478, p < 0.001), and smoking status (OR 6.228, p < 0.001) were significant predictors of pathological sperm test results, while no association was observed with any female characteristics (p > 0.05).

CONCLUSION

The high frequency of pathological sperm analysis results provides lacking epidemiological data on semen quality in this population, emphasizing the critical need for early male fertility evaluation prior to ovarian stimulation in PCOS women. Moreover, our findings indicate that the risk prediction for abnormal semen quality cannot be based on the female's data.

Solidarity through food: Coping with food insecurity among adolescent migrants in transit through Mexico and Central America

BACKGROUND

The food choices of migrants are frequently limited by lack of access to sufficient and adequate food. Food insecurity (FI) during adolescence has potential negative health consequences, however the experiences of FI of adolescent in-transit migrants have seldom been reported.

OBJECTIVE

To explore the experiences of FI of adolescent in-transit migrants and their ways of coping with it.

METHODS

Qualitative study, with 19 semi-structured interviews with adolescents (ages 13-19 years), in shelters for migrants in Mexico in 2022-2023. We followed a reflexive thematic analysis strategy.

RESULTS

Most participants had experienced FI during the journey, and responded by limiting intake, choosing food according to price, seeking temporary work or asking for food or money in the streets. We defined "solidarity through food" as a central theme that summarized participants' experiences of sharing food with other migrants, as givers or recipients. Solidarity through food was a response to FI, benefitting the more disadvantaged (e.g. young children, those who had been robbed). Despite their young age, interviewees took part in this, giving their food to others and restricting their intake to prioritize younger siblings.

DISCUSSION/CONCLUSIONS

Solidarity through food was a form of generalized reciprocity, enacted not only among family members or friends, but extended to other migrants sharing the route. In further studies, it will be important to explore the role and nuances of food sharing as a practice of social exchange of responsibility and care, on adolescent migrants' health, and in their psychological and relational development into adulthood.

Engaging with 'less affluent' communities for food system transformation: a community food researcher model (FoodSEqual project)

The UK food system is distorted by inequalities in access, failing the people most in need, yet it should provide access to safe, nutritious affordable food for all citizens. Dietary patterns are associated with socio-demographic characteristics, with high levels of diet-related disease mortality attributed to poor dietary habits. Disadvantaged UK communities face urgent public health challenges, yet are often treated as powerless recipients of dietary and health initiatives. The need for food system transformation has been illustrated within recent UK government policy drivers and research funding. The Food Systems Equality project is a research consortium that aims to 'co-produce healthy and sustainable food systems for disadvantaged communities'. The project focusses on innovating food products, supply chains and policies, placing communities at the centre of the change. Tackling the above issues requires new ways of working. Creative approaches in food research are known to empower a wider range of individuals to share their 'lived food experience' narratives, building relationships and corroborating co-production philosophies, thus promoting social justice, and challenging more traditional positivist/reductionist 'biomedical' approaches for nutrition and food studies. This review paper critiques the use of community-centric approaches for food system transformation, focusing on one, a community food researcher model() as an exemplar, to highlight their utility in advocating with rather than for less affluent communities. The potential for creative methods to lead to more equitable and lasting solutions for food system transformation is appraised, consolidating the need for community-driven systemic change to foster more progressive and inclusive approaches to strengthen social capital. The paper closes with practice insights and critical considerations offering recommendations for readers, researchers, and practitioners, enabling them to better understand and apply similar approaches.

Decreases in purchases of energy, sodium, sugar, and saturated fat 3 years after implementation of the Chilean food labeling and marketing law: An interrupted time series analysis

BACKGROUND

In 2016, Chile implemented a multiphase set of policies that mandated warning labels, restricted food marketing to children, and banned school sales of foods and beverages high in nutrients of concern ("high-in" foods). Chile's law, particularly the warning label component, set the precedent for a rapid global proliferation of similar policies. While our initial evaluation showed policy-linked decreases in purchases of high-in, a longer-term evaluation is needed, particularly as later phases of Chile's law included stricter nutrient thresholds and introduced a daytime ban on advertising of high-in foods for all audiences. The objective is to evaluate changes in purchases of energy, sugar, sodium, and saturated fat purchased after Phase 2 implementation of the Chilean policies.

METHODS AND FINDINGS

This interrupted time series study used longitudinal data on monthly food and beverage purchases from 2,844 Chilean households (138,391 household-months) from July 1, 2013 until June 25, 2019. Nutrition facts panel data from food and beverage packages were linked at the product level and reviewed by nutritionists. Products were considered "high-in" if they contained added sugar, sodium, or saturated fat and exceeded nutrient or calorie thresholds. Using correlated random-effects models and an interrupted time series design, we estimated the nutrient content of food and beverage purchases associated with Phase 1 and Phase 2 compared to a counterfactual scenario based on trends during a 36-month pre-policy timeframe. Compared to the counterfactual, we observed significant decreases in high-in purchases of foods and beverages during Phase 2, including a relative 36.8% reduction in sugar (-30.4 calories/capita/day, 95% CI -34.5, -26.3), a 23.0% relative reduction in energy (-51.6 calories/capita/day, 95% CI -60.7, -42.6), a 21.9% relative reduction in sodium (-85.8 mg/capita/day, 95% CI -105.0, -66.7), and a 15.7% relative reduction in saturated fat (-6.4 calories/capita/day, 95% CI -8.4, -4.3), while purchases of not-high-in foods and drinks increased. Reductions in sugar and energy purchases were driven by beverage purchases, whereas reductions in sodium and saturated fat were driven by foods. Compared to the counterfactual, changes in both high-in purchases and not high-in purchases observed in Phase 2 tended to be larger than changes observed in Phase 1. The pattern of changes in purchases was similar for households of lower versus higher socioeconomic status. A limitation of this study is that some results were sensitive to the use of shorter pre-policy time frames.

CONCLUSIONS

Compared to a counterfactual based on a 36-month pre-policy timeframe, Chilean policies on food labeling, marketing, and school food sales led to declines in nutrients of concern during Phase 2 of implementation, particularly from foods and drinks high in nutrients of concern. These declines were sustained or even increased over phases of policy implementation.

Exploring Children's Knowledge of Healthy Eating, Digital Media Use, and Caregivers' Perspectives to Inform Design and Contextual Considerations for Game-Based Interventions in Schools for Low-Income Families in Lima, Peru: Survey Study

BACKGROUND

The prevalence of overweight and obesity in schoolchildren is increasing in Peru. Given the increased use of digital media, there is potential to develop effective digital health interventions to promote healthy eating practices at schools. This study investigates the needs of schoolchildren in relation to healthy eating and the potential role of digital media to inform the design of game-based nutritional interventions.

OBJECTIVE

This study aims to explore schoolchildren's knowledge about healthy eating and use of and preferences for digital media to inform the future development of a serious game to promote healthy eating.

METHODS

A survey was conducted in 17 schools in metropolitan Lima, Peru. The information was collected virtually with specific questions for the schoolchild and their caregiver during October 2021 and November 2021 and following the COVID-19 public health restrictions. Questions on nutritional knowledge and preferences for and use of digital media were included. In the descriptive analysis, the percentages of the variables of interest were calculated.

RESULTS

We received 3937 validated responses from caregivers and schoolchildren. The schoolchildren were aged between 8 years and 15 years (2030/3937, 55.8% girls). Of the caregivers, 83% (3267/3937) were mothers, and 56.5% (2223/3937) had a secondary education. Only 5.2% (203/3937) of schoolchildren's homes did not have internet access; such access was through WiFi (2151/3937, 54.6%) and mobile internet (1314/3937, 33.4%). In addition, 95.3% (3753/3937) of schoolchildren's homes had a mobile phone; 31.3% (1233/3937) had computers. In relation to children's knowledge on healthy eating, 42.2% (1663/3937) of schoolchildren did not know the recommendation to consume at least 5 servings of fruits and vegetables daily, 46.7% (1837/3937) of schoolchildren did not identify front-of-package warning labels (FOPWLs), and 63.9% (2514/3937) did not relate the presence of an FOPWL with dietary risk. Most schoolchildren (3100/3937, 78.7%) preferred to use a mobile phone. Only 38.3% (1509/3937) indicated they preferred a computer. In addition, 47.9% (1885/3937) of caregivers considered that the internet helps in the education of schoolchildren, 82.7% (3254/3937) of caregivers gave permission for schoolchildren to play games with digital devices, and 38% (1495/3937) of caregivers considered that traditional digital games for children are inadequate.

CONCLUSIONS

The results suggest that knowledge about nutrition in Peruvian schoolchildren has limitations. Most schoolchildren have access to the internet, with mobile phones being the device type with the greatest availability and preference for use. Caregivers' perspectives on games and schoolchildren, including a greater interest in using digital games, provide opportunities for the design and development of serious games to improve schoolchildren's nutritional knowledge in Peru. Future research is needed to explore the potential of serious games that are tailored to the needs and preferences of both schoolchildren and their caregivers in Peru in order to promote healthy eating.

Dietary patterns and associations with metabolic risk factors for non-communicable disease

Unhealthy dietary habit is a major contributor to the burden of non-communicable diseases such as cardiovascular diseases, diabetes, and hypertension, especially the increased burden in low- and middle-income countries. Evidence of the association between specific dietary patterns and health outcomes is scarce in sub-Saharan African countries. This study aimed to identify principal dietary patterns and evaluate associations with metabolic risk factors including hypertension, overweight/obesity, and abdominal obesity in Northwest Ethiopia. A community-based cross-sectional survey was conducted among adults in Bahir Dar, Northwest Ethiopia, from 10 May 2021 to 20 June 2021. Dietary intake was collected using a validated food frequency questionnaire. Anthropometric (weight, height, hip/waist circumference) and blood pressure measurements were performed using standardized tools. Principal component analysis was conducted to derive dietary patterns. Chi-square and logistic regression analyses were used to examine the association between dietary patterns and metabolic risk factors and with sociodemographic and individual risk factors. This study derives two types of dietary patterns: 'westernized' dietary pattern, which is positively correlated with consumption of meat, dairy, fast foods, alcohol, fish, sweet/sugary foods, and fruits, and 'traditional' dietary pattern, which is positively correlated with intake of cereals, vegetables, legumes, roots/tubers, coffee, and oils. The prevalence of hypertension was significantly lower in adults with higher quantiles of westernized dietary pattern (AOR = 0.28, 95% CI 0.13 to 0.60; p < 0.01; quantile three); and (AOR = 0.35, 95% CI 0.17, 0.75; p < 0.01; quantile four). Younger, married, and middle-income adults were associated with the highest quantile of the westernized pattern. Being females and having middle income associated with the highest quantile of traditional dietary patterns (p < 0.05). This study suggested two types of dietary patterns, westernized and traditional, among adults in Northwest Ethiopia and revealed a significant association with metabolic risk factors like hypertension. Identifying the main dietary patterns in the population could be informative to consider local-based dietary recommendations and interventions to reduce metabolic risk factors.

Prevalence of inadequate intake of folate in the post-fortification era: data from the Brazilian National Dietary Surveys 2008-2009 and 2017-2018

The objectives were to compare the evolution of dietary folate intake, to estimate the prevalence of folate inadequacy (POFI) and the contribution of food groups to folate intake (dietary folate plus folic acid from fortified foods) in two post-fortification periods in the Brazilian population, according to life stages, geographic regions and per capita income. Population-based study including representative data from the National Dietary Survey - Brazilian Household Budget Surveys (NDS-HBS) 2008-2009 and 2017-2018, with a total of 32 749 (2008-2009) and 44 744 (2017-2018) individuals aged ≥ 10 years old, excluding pregnant and lactating women. The National Cancer Institute method was used to estimate the distributions of usual dietary folate intake. POFI was estimated according to estimated average requirement cut-off point method. After 10 years of the first NDS-HBS, POFI has increased in all sex-age groups, except for 10-13 years. POFI among women of reproductive age was around 30 and 40 % in 2008-2009 and 2017-2018. Higher POFI was observed in the North region. The top five food groups contributors to folate intake in Brazil were beans, breads, pasta and pizza, cakes and cookies and non-alcoholic beverages groups in both periods, differing in the rank order of the last two groups. Although being a country that has adopted mandatory folic acid flour fortification for almost two decades, increased POFI was observed in 2017-2018. This study brings significant scientific information, which can help understand folate dietary data in different contexts and consequently guide the approach for public health fortification strategies.

Traditional Knowledge and Modern Motivations for Consuming Seaweed (Limu) in Samoa

Seaweeds are a traditional food throughout the Pacific. In Samoa, the edible seaweeds limu fuafua (sea grapes, Caulerpa racemosa and C. chemnitzia) and limu a’au (red seaweed, Halymenia durvillei and Halymenia sp.) are hand-harvested and consumed fresh or cooked, respectively. However, there is limited scientific or traditional documentation of these commodities. Here, we assess the traditional use and cultural value of edible seaweeds and explore modern consumer preferences and perceived nutritional benefits. Structured enumerator-administered questionnaires were used to examine the relationship between consumption and demographics and subsequently to assess the key motivators for consumption, including perceived nutritional benefits. A total of 320 participants were surveyed across 20 village communities, with 95% reporting consumption of Caulerpa and 40% of Halymenia. Consumption was primarily on a weekly to monthly basis, and even once a day. Motivators and barriers for consumption were then assessed in 320 village participants with an additional 203 intercept interviews at fish markets. A content analysis of the open-ended questions revealed the key motivators for eating limu were health and taste (positive), whereas the key barriers were taste (negative) and availability. We identify opportunities to develop a nutrient evidence base for Samoan seaweeds to aid in marketing, especially for youth.

The effect of personal relative deprivation on food choice: An experimental approach

Growing evidence suggests that relative disadvantage is more relevant than absolute socioeconomic factors in explaining disparities in healthfulness of diet. In a series of pre-registered experiments, we tested whether personal relative deprivation (PRD), i.e. the sense that one is unfairly deprived of a deserved outcome relative to others, results in choosing more palatable, rewarding foods. Study 1 (N = 102) demonstrated the feasibility and effectiveness of a game for inducing real-time experiences of PRD. Study 2 (N = 287) showed no main effect of PRD condition on hypothetical food choices, but an interaction between chronic PRD and condition revealed that those in the PRD condition chose more rewarding foods when feeling chronically deprived. In Study 3 (N = 260) the hypothesized main effect was found on real, non-hypothetical food choices: those in the PRD condition chose more rewarding foods, controlling for sensitivity to palatable food. Our results provide preliminary indications that the experience of being relatively deprived, rather than the objective amount or resources, may result in a higher preference for high-caloric and palatable foods. It may be suggested that efforts to reduce societal disparities in healthfulness of diet may need to focus on perceptions of injustice beyond objective inequalities.

Towards Sustainable Shifts to Healthy Diets and Food Security in Sub-Saharan Africa with Climate-Resilient Crops in Bread-Type Products: A Food System Analysis

Massive urbanization and increasing disposable incomes favor a rapid transition in diets and lifestyle in sub-Saharan Africa (SSA). As a result, the SSA population is becoming increasingly vulnerable to the double burden of malnutrition and obesity. This, combined with the increasing pressure to produce sufficient food and provide employment for this growing population together with the threat of climate change-induced declining crop yields, requires urgent sustainable solutions. Can an increase in the cultivation of climate-resilient crops (CRCs) and their utilization to produce attractive, convenient and nutritious bread products contribute to climate change adaptation and healthy and sustainable diets? A food system analysis of the bread food value chain in SSA indicates that replacement of refined, mostly imported, wheat in attractive bread products could (1) improve food and nutrition security, (2) bring about a shift to more nutritionally balanced diets, (3) increase economic inclusiveness and equitable benefits, and (4) improve sustainability and resilience of the food system. The food system analysis also provided systematic insight into the challenges and hurdles that need to be overcome to increase the availability, affordability and uptake of CRCs. Proposed interventions include improving the agronomic yield of CRCs, food product technology, raising consumer awareness and directing policies. Overall, integrated programs involving all stakeholders in the food system are needed.

Use of the Spectroscopy-Based Veggie Meter® to Objectively Assess Fruit and Vegetable Intake in Low-Income Adults

Reflection spectroscopy is an emerging approach for noninvasively assessing dermal carotenoids as a biomarker of fruit and vegetable (FV) intake. This study sought to profile and identify determinants of scores from a reflection spectroscopy device (the Veggie Meter (VM)®) among 297 urban, primarily Hispanic low-income adults served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The repeatability of the scores and bi- and multivariate relationships between VM scores, self-reported FV intake measured by a brief screener, and participant characteristics were examined. The mean VM score was 270 (range 0-695); 3- and 6-month test-retest correlations were positive and strong (r = 0.79 and 0.55, respectively). VM scores were negatively associated with body mass index (BMI; r = -0.22) and were higher among participants of Ecuadorian, Dominican, and Mexican Hispanic origin relative to those of Puerto Rican origin; foreign- vs. US-born participants, breastfeeding vs. non-breastfeeding participants, nonsmokers vs. smokers, and participants who consumed three or more cups of FV/day relative to those who consumed less than three cups of FV/day. Foreign-born nativity, consumption of three or more cups of FV/day, and smaller body size were determinants of increased VM scores. Although replication studies are needed to confirm these findings, investigators working with similar populations are encouraged to use the VM to longitudinally track FV intake and to target determinants of the scores in observational and intervention studies of FV intake as measured by the VM.

Role of Seaweed in Diets of Samoa and Kiribati: Exploring Key Motivators for Consumption

Edible seaweeds have significant potential to contribute to sustainable diets that promote health of Pacific Islanders in ecologically, economically, and socially acceptable ways. No studies to date have investigated motivators for and the consumption of edible green seaweed from the genus Caulerpa (sea grapes) in Samoa and Kiribati. An observational, cross-sectional study utilized an interviewer-administered questionnaire to explore consumption behaviors and the role of sea grapes in the current diets of individuals in Samoa and Kiribati. Of the total 145 participants (n = 79, 54.5% Samoa; n = 66, 45.5% Kiribati), half (n = 76, 52%) reported consuming sea grapes. A significantly greater proportion of Samoans (n = 56, 70.9%) reported consumption than I-Kiribati participants (n = 20, 30.3%). A greater proportion of consumers were male (n = 47, 61.8%). Samoan consumers reported consumption of sea grapes with a higher diversity of foods and being related to traditional events or ceremonies. Motivators for consumption varied between countries, with Samoan consumers reporting strong agreement for taste and value for money, and identified sea grapes as nutritious food, as influences on consumption. Easy access was a motivator in Kiribati only. The findings of this study are underpinned by the degree of food security and differences in culture in Samoa and Kiribati. Future public health efforts to integrate traditional fresh food into local food systems will need to work within the existing social parameters in each respective country.

Nutrition label processing in the past 10 years: Contributions from eye tracking approach

Healthy eating plays a critical role in preventing diet-related chronic diseases. To promote healthy eating, nutrition labels have been mandated to certain foods in many countries. To test how different designs of nutrition labels affect consumer behavior, eye tracking technique has been increasingly used to overcome the limitations of subjective report which are susceptible to different biases and a poor indicator of nutrition label use in reality. In this review, we reviewed 45 eye-tracking studies on nutrition label processing. Besides a summary of eye tracking methodology, we found three emerged topics from these studies: attention capture, nutrition label comprehension and food choice. Overall, updated designs of nutrition labels improve attention capture and nutrition label comprehension, but it does not necessarily lead to healthier food choices. The discrepancy between attention capture and food choice also indicate potential limitation in promoting healthy food choice via the indirect attention route (exposure - attention - nutrition label processing - food choice). Instead, actual food choice may be a consequence of a direct heuristic route and modulated by person-, product- and context-related factors. These findings can not only guide future studies, but also have implications on making nutrition label policy and improving human health in eastern developing countries.

Dataset on The Cultural Dimension of Urban Society Food Consumption in Indonesia

This article introduces a dataset that presents the cultural values and practices of food consumption patterns in major urban communities in Indonesian cities. The data illustrate the cultural characteristics of urban residents’ food consumption patterns based on social class categories. Data collection was conducted in five major Indonesian cities through face-to-face interviews with 710 respondents identified using a stratified random sampling technique. The data show that culture has a dominant influence on the pattern of food consumption of urban communities in Indonesia in comparison with economic and health dimensions. Although the value and practice sub-dimensions are conceptually related, the cultural dimension of food consumption patterns in the five urban communities is more dominated by religious value than other cultural practices. Regarding food consumption patterns, urban upper classes are more dominantly influenced by economic dimensions and modern healthy lifestyles than cultural dimensions.

Food insecurity is associated with compromised dietary intake and quality among Lebanese mothers: findings from a national cross-sectional study

OBJECTIVE

Examine the associations between household food insecurity (HFI) with sociodemographic, anthropometric and dietary intakes of mothers.

DESIGN

Cross-sectional survey (2014-2015). In addition to a sociodemographic questionnaire, data collection included the validated Arabic version of the Household Food Insecurity Access Scale, which was used to evaluate HFI. Dietary intake was assessed using 24-h dietary recall of a single habitual day, and maternal BMI was calculated based on weight and height measurements. Associations between HFI and maternal dietary intake (food groups, energy and macronutrients' intake) were examined. Simple and multiple logistic regression analyses were conducted to explore the associations between HFI status with odds of maternal overweight and measures of diet quality and diversity (Healthy Eating Index (HEI) and Minimum Dietary Diversity for Women of Reproductive Age (MDD-W)).

SETTING

Lebanon.

PARTICIPANTS

Mothers, nationally representative sample of Lebanese households with children (n 1204).

RESULTS

HFI was experienced among almost half of the study sample. Correlates of HFI were low educational attainment, unemployment and crowding. Significant inverse associations were observed between HFI and dietary HEI (OR 0·64, 95 % CI 0·46, 0·90, P = 0·011) and MDD-W (OR 0·6, 95 % CI 0·42, 0·85, P = 0·004), even after adjusting for socioeconomic correlates. No significant association was observed between HFI and odds of maternal overweight status.

CONCLUSIONS

HFI was associated with compromised maternal dietary quality and diversity. Findings highlight the need for social welfare programmes and public health interventions to alleviate HFI and promote overall health and wellbeing of mothers.

Barriers to Preparing and Cooking Vegetables Are Associated with Decreased Home Availability of Vegetables in Low-Income Households

Knowing which barriers to buying and preparing/cooking vegetables at home are linked with the home availability of vegetables and how food-security status impacts this relationship will facilitate the tailoring of future public health interventions. Baseline data were used from an elementary-school-based intervention. Data on household food-security status, availability of vegetables at home, and barriers to buying and preparing/cooking vegetables were collected from 1942 parents. Differences between food-secure and food-insecure households were examined for barriers to buying and preparing/cooking vegetables. Mixed-effects linear regression was used to estimate the associations between barriers to buying and preparing/cooking vegetables and food-security status on the home availability of vegetables. Food insecurity was reported in 27% of households. Food-insecure households were significantly more likely to report barriers to buying and preparing/cooking vegetables. The barriers to purchasing/cooking vegetables score was associated with a decrease in the home availability of vegetables score (β = −0.77; 95% CI: −0.88, −0.65; p < 0.001). Compared to food-secure households, food-insecure households were 15% less likely to have home vegetable availability (β = −1.18; 95% CI: −1.45, −0.92; p < 0.001). Although home availability of vegetables does not guarantee consumption, this study identified specific barriers that were associated with availability that can be targeted in future interventions seeking to improve vegetable consumption in the homes of low-income families.

Changing food preferences among a former hunter-gatherer group in Namibia

The purpose of this study was to identify, describe and conceptualize the present drivers of food choices and preferences of the Khwe San indigenous peoples by considering influences of their historical and cultural contexts. Data were collected in Eastern Bwabwata National Park in Namibia using a range of qualitative methods: semi-structured and structured interviews and free listing. The various drivers of food choices have been clustered into four levels of the ecological conceptual framework. Key factors, found to be driving participants' food choices, were the following: taste, hunger, health, familiarity and body satisfaction at the individual level; culture and food taboos at the social level; access to food and food storage at the physical level, and; cost and seasonality at the macro level. Many of these factors are directly related to food insecurity and previous experiences of hunger. Current preferences towards traditional foods existed but were not prevailing among all the participants. Interviews with the elderly revealed the historical context of the increasing exposure to modern foods and a contested access to traditional foods and traditional knowledge transmission. Our findings exposed some substantial gaps in the nutritional knowledge of the Khwe that need consideration by future health promotion strategies along with the current perceptions of local food choices. Ensuring access and promoting sustainable management of traditional foods would not only contribute to the health of the Khwe people but also help to maintain a nutritional safety net in their current situation of extreme poverty.

The Effectiveness of the Good Affordable Food Intervention for Adults with Low Socioeconomic Status and Small Incomes

Good Affordable Food (GAF) is a small-group nutrition education intervention for adults with low socioeconomic status and small incomes. It aims to empower participants to save money on groceries and consume healthier diets. This paper reports the short-term and longer-term effects on behavioural determinants and self-reported behavioural changes. A quasi-experimental control group design was applied with a baseline measurement, a post-test immediately after the intervention, and a follow-up measurement after six months. The study included 237 participants (intervention group: n = 131; control group: n = 106) at baseline, 197 at post-test, and 152 at follow-up. Data were collected by telephone, mostly using closed interview questions. Positive short-term and longer-term effects were found for attitude towards the costs of healthy foods, food label use, and the use of liquid butter or oil to prepare hot meals. Short-term intervention effects related to knowledge towards saving money on groceries, self-efficacy towards healthy eating, portion size awareness, and mindful eating. GAF was effective in changing some determinants and behaviours related to cost and food consumption, however, mostly in the short term. Thereby, it is an example of combining pricing and health information in nutrition education that developers of effective nutrition education for low-income groups can build on.

Access to a Nutritious Diet in Samoa: Local Insights

The adult obesity prevalence in Samoa is the third highest globally, and diet is a significant contributor. Our study aimed to explore the behavioral and demographic factors which influence diets in Samoa. The most important findings for strategic policy design were: i) cost was the most important reason for food choice, ii) participants reported high rates of consumption of sugary and fatty energy foods - along with high rates of food insecurity, and iii) the food frequency questionnaire findings from our small sample are in line with the existing evidence that the nutrition transition is underway in Samoa.

Perceptions about home cooking: an integrative review of qualitative studies

This study aimed to review qualitative studies on perceptions of home cooking. A systematic search was conducted in Scopus and SciELO databases using English and Portuguese terms related to home cooking, without date or language restrictions. Twenty-six articles, published between 2004 and 2017, investigated, whether as a primary objective or as a secondary finding, the perceptions of individuals on home cooking. More than half of the studies were conducted in English-speaking countries. Study participants included women and men, adults and seniors as well as residents of urban and rural areas, Eastern and Western countries, and developing and developed nations. Thematic analysis showed that home cooking has different interpretations and meanings in diverse contexts and revealed differences in how individuals plan and cook their meals at home. Cognitive, practical, affective, and emotional factors are the major motivators to home meal preparation. Having a cooking role model in the family, cooking confidence and skills, and living alone were reported as facilitators of home cooking. A better understanding of the heterogeneity of perceptions and meanings of home cooking can contribute to the development of effective and culturally appropriate interventions for stimulating healthy cooking habits.

How food insecurity could lead to obesity in LMICs: When not enough is too much: a realist review of how food insecurity could lead to obesity in low- and middle-income countries

While food insecurity is a well-known cause of under-nutrition and stunting, in recent decades it has also been linked with obesity. Understanding and thus minimising the risk factors for obesity in low- and middle-income country contexts, which often lack the health system capacity to treat the consequent obesity-related illnesses, is crucial. This study adopted realist review methodology because it enabled us to analyse and organise the evidence from low- and middle-income countries into a coherent scheme. By comparing this evidence to existing theory on food security and nutrition, we aimed to provide a richer understanding of the nuances and the socio-demographic nature of the food insecurity-obesity relationship. The review generated 13 peer-reviewed articles which studied the relationship between food insecurity and overweight/obesity in low- and middle-income countries. Affordability of high-energy, processed foods was identified as a main mechanism, which determined whether or not food insecurity leads to obesity in low- and middle-income countries. Other mechanisms identified were: quantity and diversity of food consumed; spatial-temporal access to nutritious food; inter-personal food choice and distribution; and non-dietary behaviours. Despite the limited empirical evidence available, our review presents meaningful and policy-relevant insights into the food insecurity-obesity relationship in from low- and middle-income countries. Interventions to address the food insecurity-obesity link need to address diet quality, and demand a broad understanding across a variety of experiences.

Can front-of-pack nutrition labeling influence children's emotional associations with unhealthy food products? An experiment using emoji

Food products targeted at children are usually marketed using persuasive elements aimed at creating positive hedonic and emotional associations. For this reason, changes in children's emotional associations with unhealthy food products can discourage their consumption. In this context, the aim of the present study was to compare children's emotional associations with food products featuring different front-of-pack (FOP) nutrition labelling schemes. A total of 492 children (6-12 years old) were randomly divided into three groups, each of which evaluated a series of packages featuring different FOP nutrition labelling schemes: guidelines daily amount (GDA), traffic light system (TLS) and nutritional warnings. For each of the six packages and three unpackaged products, children were asked to select all the emoji from a list that described how they would feel eating the product. Data were analyzed using generalized linear models. FOP nutrition labelling significantly influenced the frequency of use five of the 16 emoji. In general, children who evaluated packages with directive and semi-directive schemes used emoji associated with positive emotions less frequently than those who evaluated packages with the GDA system. The effect of FOP nutrition labelling scheme on emotional associations was moderated by age and type of school. The effect of directive and semi-directive FOP nutritional schemes, in special nutritional warnings, tended to be higher for younger children and children from public schools. These results suggest that FOP nutrition labelling may contribute to discouraging consumption of products with high content of nutrients associated with non-communicable diseases among children.

A citizen perspective on nutritional warnings as front-of-pack labels: insights for the design of accompanying policy measures

Objective

Nutritional warnings have recently been suggested as a simplified front-of-pack nutrition labelling scheme to facilitate citizens’ ability to identify unhealthful products and discourage their consumption. However, citizens’ perspective on this policy is still under-researched. The objective of the present work was to study how citizens perceive nutritional warnings and to evaluate public support of this policy, with the goal of deriving recommendations for the design of policy measures accompanying the introduction of nutritional warnings.

Design

An online survey with 1416 Uruguayan citizens, aged 18–75 years, 61 % female, was conducted. Participants had to answer a series of questions (open-ended and multiple-choice) related to their perception of warnings as a front-of-package nutrition labelling scheme.

Results

Participants showed a positive attitude towards nutritional warnings, which were regarded as easy to understand and to identify on food packages. The majority of respondents emphasized that they would take nutritional warnings into account when making their food choices, stating that they would allow them to make informed choices and, consequently, to increase the quality of their diet and their health status. Health motivation appeared as a crucial driver for taking nutritional warnings into consideration.

Conclusions

A high level of public support for nutritional warnings was observed. Responses can be used to derive a range of recommendations for a policy mix that should synergistically support the introduction of nutritional warnings and encourage citizens to take them into account when making their food purchases.

Consumer Perception of the Healthfulness of Ultra-processed Products Featuring Different Front-of-Pack Nutrition Labeling Schemes

OBJECTIVE

To examine the influence of front-of-pack nutrition information on the perception of healthfulness of ultra-processed products across 2 income levels.

DESIGN

A between-participants design was used to compare healthfulness perception of ultra-processed products featuring different front-of-pack nutrition information schemes (guideline daily amount system, traffic light system, and monochromatic traffic light system).

PARTICIPANTS

A total of 300 people (aged 18-70 years, 75% female) from Montevideo, Uruguay, participated in the study; half were middle- or high-income people and the other half were low-income people.

MAIN OUTCOME MEASURES

Participants were shown the labels of each product and asked to rate their perceived healthfulness and the frequency with which each product should be consumed.

ANALYSIS

Results were analyzed using analysis of variance for statistical significance (P < .05).

RESULTS

Low-income participants perceived ultra-processed products to be significantly (P < .05) more healthful than did middle- and high-income participants. The lowest perceived healthfulness scores for low-income participants were obtained for products featuring the colored and monochromatic traffic light system whereas no significant differences (P > .05) among schemes were found for middle- and high-income participants.

CONCLUSIONS AND IMPLICATIONS

Nutrition education programs aimed at increasing low-income people's knowledge of the nutritional composition of these products and their potential negative effects on health seem to be necessary. Although the inclusion of semidirective front-of-pack nutrition information decreased the perceived healthfulness of low-income people, it seemed unlikely to influence how they perceive these products.

Influence of Label Design on Children's Perception of 2 Snack Foods

OBJECTIVE

To evaluate the influence of label design on children's perception of 2 popular snack foods across 3 income levels.

DESIGN

Labels of 2 snack products (yogurt and sponge cake) were designed using a fractional factorial design with 3 2-level variables: cartoon character, nutrition claims, and front-of-package nutritional information.

PARTICIPANTS

A total of 221 children (aged 9-13 years) from Montevideo, Uruguay, with different income levels, participated in the study.

MAIN OUTCOME MEASURES

Children's attitude toward and liking of 2 food products.

RESULTS

Low-income children showed a more positive attitude toward the products than did middle- and high-income children. The inclusion of a cartoon character in sponge cake labels significantly affected hedonic expectations regardless of income. Middle- and high-income children tended to use the term funny more frequently and the term boring less frequently to describe labels that included the cartoon character, compared with those that did not.

CONCLUSIONS AND IMPLICATIONS

Results showed that the inclusion of cartoon characters on food labels is associated with fun. Low-income children seem more susceptible to the marketing strategies of food companies than do middle- and high-income children.

Comparison of motives underlying food choice and barriers to healthy eating among low medium income consumers in Uruguay

Abstract: Interventions aimed at changing dietary patterns should be designed based on the main motives underlying the food choices of specific target populations. The aim of the present study was to identify motives underlying food choice and barriers to healthy eating among consumers in two socioeconomic levels in Uruguay. Eleven focus groups were carried out with a total of 76 participants. Six of the groups involved low income participants and the others were conducted with middle income participants. Discussions were held around frequently consumed products, motives underlying food choices and barriers to healthy eating. Results confirmed the strong influence of income level on motives underlying food choice and barriers to the adoption of healthy eating. Low income participants described their choices as mainly driven by economic factors and satiety, whereas convenience was the main determinant of food selection for middle income participants. Implications for the design of public policies targeted at each group are discussed.

Overweight and Obesity: Prevalence, Consequences, and Causes of a Growing Public Health Problem

This review considers a variety of perspectives on overweight and obesity (OW/obesity), including measurement and classification; prevalence and changes in prevalence in recent years; genetic, biological, medical, individual, and social correlates of OW/obesity; and treatment approaches. Despite increased attention, OW/obesity is escalating in prevalence worldwide, and the causes are exceedingly complex. A range of innovative studies, including basic research on gut microflora, dietary composition, pharmacologic interventions, and surgical procedures, is generating findings with potential for future prevention and treatment of OW/obesity. Social system changes such as school programs and the awareness of the roles of personal, family, health provider, and cultural experiences related to OW/obesity have also gained traction for vital prevention and treatment efforts over the past decade.