Reducing Young Schoolchildren's Intake of Sugar-Rich Food and Drinks: Study Protocol and Intervention Design for "Are You Too Sweet?" A Multicomponent 3.5-Month Cluster Randomised Family-Based Intervention Study

A global survey of national oral health policies and its coverage for young children

Background

There is no accessible information on countries with oral health policies. The purpose of this study was to identify World Dental Federation (FDI) member countries with oral health policies and their scope and extent of coverage of oral health care for young children.

Methods

This international survey recruited chief dental officers, oral health advisors to national ministries of health, and other key informants of the 158 FDI member countries between December 2020 and December 2021. The survey tool was administered online to the study participants. Key questions explored the following outcome measures: countries with oral health policies; the thrusts of the oral health policies; policy thrusts targeting young children; and dental care plans as a component of a universal health care plan. Descriptive statistics were conducted to determine the number of countries with any of the study outcome measures and coverage per country.

Results

Sixty (38%) of the 158 FDI member-countries responded to the survey. Forty-eight (55.2%) of the 60 countries had a national oral health policy document or position statement on oral health; 54 (62.1%) countries had plans on universal health care, and 42 (48.3%) included dental care within their universal health care plan. The most common policy thrusts addressing the oral health needs of children were the promotion of oral hygiene (71.7%), provision of fluoride products for children (53.3%), collaboration with primary care providers (35%), and prenatal oral health education (50%). There were differences in the scope of oral health care coverage and the coverage for young children between continents as well as between countries. Europe had many countries with children-friendly oral health policy coverage.

Conclusions

About half of the surveyed countries had a national oral health policy. There were variations in the scope of oral health care coverage, particularly for young children, both between continents and among individual countries. These findings underscore the importance of understanding the landscape of oral health policies globally. Such insights can help inform targeted interventions to enhance oral health policies, thereby contributing to improved oral health outcomes on a global level.

Reduction in intake of discretionary foods and drinks among Danish schoolchildren: dietary results from the real-life cluster-randomised controlled trial 'Are You Too Sweet?'

OBJECTIVE

To evaluate the effectiveness of the multicomponent intervention trial 'Are You Too Sweet?' in reducing discretionary foods and drinks intake among young schoolchildren.

DESIGN

The study was a 3·5-month two-arm cluster-randomised controlled trial among primary schoolchildren and their families. School health nurses provided guidance to families regarding discretionary foods and drinks for the children. Moreover, families were given a variety of knowledge- and capability-building materials to utilise at home. Dietary intake was assessed using a web-based 7-d dietary record. Linear mixed regression models were used to estimate intervention effects as changes in child intake of discretionary foods and drinks and sugar between groups.

SETTING

Six schools from a Danish municipality were randomised to the intervention group (n 4) or the control group (n 2).

PARTICIPANTS

A total of 153 children aged 5-7 years.

RESULTS

No significant reduction in the children's intake of total discretionary foods and drinks or discretionary foods alone was observed between the intervention and control group, while a decreased intake of discretionary drinks of 40·9 % (P = 0·045) was observed compared with control. Secondary subgroup analysis showed that children of parents with shorter educational level significantly reduced their intake of added sugar by 2·9 E% (P = 0·002).

CONCLUSION

The results of this study indicate that multicomponent interventions involving school health nurses may have some effects in reducing, especially, discretionary drinks.

Components in downstream health promotions to reduce sugar intake among adults: a systematic review

Excessive sugar consumption is well documented as a common risk factor for many Non-Communicable Diseases (NCDs). Thus, an adequate intervention description is important to minimise research waste and improve research usability and reproducibility. A systematic review was conducted to identify components in published evidence interventions pertaining to the health promotions on reducing sugar intake among adults. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and used the Mixed Methods Appraisal Tool (MMAT) for quality appraisal. The period for the selected study was from 2000 to 2022, and articles were retrieved from Web of Science (WOS), Medline, Scopus, and PubMed. The target population was adults aged 18 years old and above who underwent intervention to assess the changes in their sugar intake. Data sources and all human epidemiologic studies were included. Out of the 9,333 papers identified, 25 were included. The overall quality of evidence of the studies was considered moderate. Apart from the characteristics of the reviewed studies, components of interventions are including the basis of theoretical or model for the intervention, which majority use Social Cognitive Theory, followed by PRECEDE-PROCEED model, socio-ecological and process-improvement theories and Transtheoretical Model; providers, who are commercial provider, qualified nutritionist, professor of nutrigenomics and nutrigenetics, doctor, dietitian nutritionist, lifestyle coaches, and junior public health nurses; duration of the intervention and follow-up time, varies from as short as one month to as long as 24 months; material provided either softcopy or hardcopy; tailoring approach, based on the individual goals, the process of change, genotype analysis, beliefs, barriers, and sociocultural norms; delivery mechanism either face-to-face or technology-mediated; and tools to measure the sugar consumption outcome mostly used Food Frequency Questionnaire (FFQ), besides 24-h dietary recalls, and food diaries. There are various components in downstream health promotion to reduce sugar intake among adults that can be adapted according to the local health promotion and intervention context. More well-designed interventions using integration components are encouraged in further studies.

A Qualitative Evaluation of Social Aspects of Sugar-Rich Food and Drink Intake and Parental Strategies for Reductions

Danish children have a much larger intake of sugar-rich foods and drinks than recommended. This study aimed to (1) explore social aspects and practices of pre-school children's intake of sugar-rich foods and drinks and (2) evaluate barriers and parental strategies to reduce their children's intake of sugar-rich foods and drinks employed in connection with the 3.5-month family-centred intervention trial 'Are you too sweet?'. Intervention components included communication of the recommended maximum intake and reduction strategies, supported by resources encouraging and facilitating behavioural changes. A random sample of families (n = 24) from intervention schools participated in post-intervention semi-structured interviews. A thematic content analysis was conducted, revealing three main domains of social practices: (1) 'family treats', including the weekly Danish concept 'Friday sweets', (2) 'everyday treats', such as sweet snacks in lunch packs, between-meals snacks and soft drink habits and (3) 'socialized treats', including treats at special occasions. Parents employed several strategies, most often substitution and portion-size reduction, but also limiting home availability. Families most frequently made changes that were easily adoptable and close to existing routines at home. In conclusion, the intervention components provided families with knowledge and strategies that facilitated behavioural changes towards reducing the intake of sugar-rich foods and drinks.

The Importance of Addressing Multilevel Transactional Influences of Childhood Obesity to Inform Future Health Behavior Interventions

We provide a transactional model of health for understanding the early risk of obesity in youth. This model argues that positive health is construed through the choices and actions that youth take within the range of resources and constraints of their biological and contextual situations across time. Social, cognitive, affective, and behavioral regulatory/motivational processes within the child mediate the relation between life experiences and health outcomes and obesity pathways are influenced by cumulative risk or protective processes for health promotion/compromising behaviors influencing health. We provide evidence-based examples of multilevel approaches to obesity prevention and treatment and highlight recommendations for future health behavior interventions.

Evaluation of Parental Acceptability and Use of Intervention Components to Reduce Pre-School Children's Intake of Sugar-Rich Food and Drinks

Knowledge is needed about effective tools that reach public health objectives focused on reducing the intake of sugar-rich foods and drinks. The purpose of this study was to assess the parental acceptability, use and motivational potential of intervention components developed in the randomized family-based trial ‘Are you too sweet?’ aimed at reducing the intake of sugar-rich foods and drinks among children (5–7 y). Intervention components included guidance on sugar-rich foods and drinks at a school health nurse consultation, a box with home-use materials and a digital platform. The methods used were a questionnaire among intervention families (n = 83) and semi-structured interviews with parents in selected intervention families (n = 24). Results showed the good acceptability and usefulness of the components, with reported frequencies of use of materials ranging from 48% to 94% and a high satisfaction rate with the school health nurse consultation. Personalized feedback and guidance from the school health nurse seemed to be a motivational trigger, and components that were compatible with existing practices were most frequently used. However, the components were not considered engaging by all families. Overall, intervention components were well received and hold the potential for enhancing parental knowledge and parenting practices regarding limiting the intake of sugar-rich foods and drinks.

Comparison of Discretionary Food and Drink Intake Based on a Short Web-Based Sugar-Rich Food Screener and a Validated Web-Based 7-Day Dietary Record

A high consumption of discretionary foods and drinks has been associated with increased risk of multiple adverse health outcomes, including risk of overweight and dental caries. The family-based cluster randomized intervention study “Are you too sweet?” aimed at reducing the intake of discretionary foods and drinks in a population of children starting pre-school. As part of the intervention a new short web-based sugar-rich food screener (SRFS), was developed to make the parents and the school health nurses aware of the children’s intake of discretionary foods and drinks. In addition to the short assessment tool the parents also completed a validated web-based 7-day dietary record for the children. In the present study, estimates for intake of discretionary foods and drinks from the two assessment tools were compared (n = 80). There was significant correlation between estimates from the two assessment tools, but the SRFS provided lower estimates for intake of discretionary foods and drinks compared to the 7-day dietary record. The correlation coefficient between the two assessment tools was 0.49 (p < 0.001) and Kappa coefficient was 0.33. It is concluded that the SRFS can provide a fairly ranking of participants according to their intake of discretionary foods and drinks when compared to a validated 7-day dietary record. The screener may be a useful tool in practical settings, such as school health nurse consultations, in order to gain insight into the child’s sweet intake habits.

Development of a Food Frequency Questionnaire for Assessing Habitual Intake of Free Sugar Among Children in Saudi Arabia

The World Health Organization emphasizes the urgency to assess and limit the intake of free sugar (FS) among individuals in order to prevent several non-communicable diseases. However, data regarding intake of FS are lacking in Saudi Arabia and in the Middle East. A reliable valid tool is needed to assess children's habitual intake of FS. Thus, we aimed to develop and validate a food frequency questionnaire (FFQ) that assesses children's habitual intake of FS in Saudi Arabia. In this cross-sectional study, 424 healthy Saudi children ages 6–12 years were included using river sampling method. Sociodemographic data and contact information were collected from mothers using an online survey. Dietary data were collected using 24-h dietary recalls (reference method) and a semi-quantitative FFQ through phone interviews. Items and food groups included in the initial draft of the FFQ were adopted from previous work. Content validity was done to the FFQ with total of 12 food groups and 41 food items. Next, a pilot study was conducted to estimate the sample size needed for the study and to ensure that all items reported in the 24-h dietary recalls were included in the final draft of the FFQ. Finally, data were collected to assess the validity and reliability of the FFQ at the population level. Mean intake of FS assessed by the FFQ was significantly higher than that assessed by the 24-h dietary recalls. Spearman's correlation between total FS assessed by the FFQ and 24-h dietary recall was positively low (rs = 0.30, p &lt; 0.001). The coefficient alpha indicated an acceptable level of internal consistency (α = 0.74, p &lt; 0.001). Test-retest reliability for total FS intake assessed by the FFQ was positively high (rs = 0.82). A slight agreement between FS intake assessed by the FFQ and the 24-h dietary recall was seen among the study sample (κ = 0.21, p &lt; 0.001). The newly developed FFQ was found to be reasonably valid in assessing children's habitual intake of FS in Saudi Arabia. Validating the instrument among older population in Saudi Arabia is warranted.