Prevention of childhood overweight and obesity in Mongolia, the Philippines and Vietnam: identifying priority actions

Low- and middle-income countries are increasingly faced with a triple burden of malnutrition: endemic underweight, micronutrient deficiencies and rising prevalence of overweight. This study aimed to address existing knowledge gaps and to identify priority policy options in Mongolia, the Philippines and Vietnam. A landscape analysis approach was adopted using methods set out in a UNICEF global toolkit. Quantitative and qualitative data were compiled from a range of global and national sources on childhood overweight and obesity, risk factors and policy responses. Key informant interviews and validation workshops were undertaken with key food and nutrition stakeholders from government and non-government organizations to identify priority policy options for the prevention of overweight and obesity among children. Overweight and obesity among children are increasing in all three countries. Associated risk factors are related to maternal nutrition, birthweight, breastfeeding, as well as diets and physical activity shaped by increasingly obesogenic environments. Key informants identified undefined policy approaches, poor community understanding and food and beverage industry influence as barriers to addressing overweight and obesity. Key policy priorities include restricting the marketing of unhealthy food and beverages, unhealthy food and beverage taxation, introduction of front-of-pack nutrition labels and improving school nutrition environments. Mongolia, the Philippines and Vietnam are all facing an increasing burden of childhood overweight and obesity. Despite differing national contexts, similar environmental factors are driving this rise. A suite of evidence-based policies can effectively be introduced to address obesogenic environments.

The development of a method for the global health community to assess the proportion of food and beverage companies' sales that are derived from unhealthy foods

CONTEXT

Corporate engagement with food and beverage companies who produce food associated with health harms is a divisive topic in the global nutrition community, with high-profile cases of conflict of interest increasingly coming under scrutiny. There is a need for an agreed method to support health organizations in deciding whether and how to engage with large food and beverage manufacturers.

AIM

The aim of this study was to develop a method to quantify the proportion of sales from food and beverage companies that are derived from unhealthy foods to support organizations in determining which companies might be considered high-risk for engagement.

METHODS

The 2015 WHO Euro nutrient profile model was applied to 35,550 products from 1294 brands manufactured by the top 20 global food and beverage companies from seven countries (Australia, Brazil, China, India, South Africa, UK and USA). For the purpose of this study, products that met the WHO Euro criteria were classified as "healthier" and those that failed were classified as "unhealthy". Products were grouped by brand and weighted by the brand's value sales for 2020. The primary outcome was the proportion of each company's sales that were classified as unhealthy and healthier by company and category.

RESULTS

Overall, 89% of the top 20 companies' brand sales were classified as unhealthy. For every USD$10 spent on the top 20 companies' brands, only $1.10 was spent on products considered healthier. All companies saw the majority of their sales come from unhealthy foods, including soft drinks, confectionery and snacks. None of Red Bull or Ferrero's sales were classified as healthier and less than 5% of total sales were healthier for Mondelēz, Mars, and PepsiCo. Some companies had higher proportions of sales deriving from healthier products, including Grupo Bimbo (48%), Danone (34%) and Conagra (32%), although the majority of their sales were still derived from unhealthy foods.

DISCUSSION

The results presented in this study highlight the reliance the leading food and beverage companies have on sales of unhealthy products that are contributing to diet-related disease globally. The method and steps we have laid out here could be used by organizations in the global health community to identify companies that have conflicts of interest when it comes to engaging with governments, international organizations and public health bodies on issues of policy and regulation.

Investment case for the prevention and reduction of childhood and adolescent overweight and obesity in Mexico

Despite efforts to curb the rise in Mexico's child and adolescent overweight and obesity rates, prevalence in Mexico has grown by 120% since 1990 to 43.3% in 2022. This investment case identifies policies that will produce the largest returns for Mexico. The investment case model builds beyond a cost-of-illness analysis by predicting the health and societal economic impact of implementing child and adolescent overweight and obesity interventions in a cohort aged 0-19 from 2025 to 2090. The Markov model's impacts include healthcare expenditures, years of life lost, and reduced wages and productivity. We projected and compared costs in a status quo scenario to an intervention scenario to estimate cost savings and calculate return-on-investment (ROI). Total lifetime health and economic costs amount to USD 1.8 trillion-USD 30 billion on average per year. Implementing five interventions can reduce lifetime costs by approximately 7%. Each intervention has a low cost per disability-adjusted life year averted over 30-year, 50-year, and lifetime horizons. The findings demonstrate that a package of interventions mitigating child and adolescent overweight and obesity offers a strong ROI. The novel investment case methods should be applied to other countries, particularly low- and middle-income countries.

Estimating the health impacts of sugar-sweetened beverage tax for informing policy decisions about the obesity burden in Vietnam

BACKGROUND

Taxation on sugar-sweetened beverages (SSBs) has been adopted in more than 40 countries but remained under discussion in Vietnam. This study aimed to estimate the health impacts of different SSBs tax plans currently under discussion to provide an evidence base to inform decision-making about a SSBs tax policy in Vietnam.

METHOD & FINDINGS

Five tax scenarios were modelled, representing three levels of price increase: 5%, 11% and 19-20%. Scenarios of the highest price increase were assessed across three different tax designs: ad valorem, volume-based specific tax & sugar-based specific tax. We modelled SSBs consumption in each tax scenario; how this reduction in consumption translates to a reduction in total energy intake and how this relationship in turn translates to an average change in body weight and obesity status among adults by applying the calorie-to weight conversion factor. Changes in type 2 diabetes burden were then calculated based on the change in average BMI of the modelled cohort. A Monte Carlo simulation approach was applied on the conversion factor of weight change and diabetes risk reduction for the sensitivity analysis. We found that the taxation that involved a 5% price increase gave relatively small impacts while increasing SSBs' price up to 20% appeared to impact substantially on overweight and obesity rates (reduction of 12.7% and 12.4% respectively) saving 27 million USD for direct medical cost. The greatest reduction was observed for overweight and obesity class I. The decline in overweight and obesity rates was slightly higher for women than men.

CONCLUSION

This study supports the SSB tax policy in pursuit of public health benefits, especially where the tax increase involves around a 20% price increase. The health benefit and revenue gains were evident across all three tax designs with the specific tax based on sugar density achieving greatest effects.

Weight stigma among adolescents in three low- and middle-income countries

Background

Overweight (OW) and obesity affect millions of adolescents worldwide. Evidence from high-income countries indicates widespread weight stigma that adversely affects young people's mental and physical health. However, evidence relating to low- and middle-income countries (LMICs) is sparse. We aimed to generate insight into weight stigma prevalence and experience among adolescents in three LMICs.

Methods

We identified adolescents aged 15-19 from Brazil, South Africa, and Indonesia from families within market research databases. We adopted a mixed-methods design. The sample included equal numbers by country, sex, and age, and included urban and rural dwellers. Self-reported weight was recorded but was not a selection criterion. Consent (age >18) and assent/parental consent (<age 18) were obtained. In-depth interviews (n = 18) informed the survey design. We used a computer-assisted telephonic interviewing survey (n = 1200) to assess weight stigma prevalence and experience. We conducted a qualitative thematic data analysis and used SPSS-23 for quantitative data.

Results

Many adolescents affected by OW and some affected by underweight (UW) had experienced weight stigma and expressed negative perceptions of their weight. Negative perceptions were expressed the most by those affected by OW, followed by those affected by UW, and then those of healthy weight (HW). Weight stigma and weight dissatisfaction were highest in Brazil and South Africa, and lower in Indonesia. More young women experienced weight stigma, yet this was also common among young men. One in five of all participants reported negative impacts, predominantly on mental health, and regarding weight management and healthy behaviours. Young people recommended measures to address weight stigma, promote an inclusive model of health and body image, and better support to achieve and maintain a HW.

Conclusions

Weight stigma adversely affects sizeable numbers of adolescents in LMICs, particularly those affected by OW. Addressing this is essential to protect adolescent (and future adult) mental and physical health.

What is a "high" prevalence of obesity? Two rapid reviews and a proposed set of thresholds for classifying prevalence levels

Categories such as "low" and "high" have been used for several decades to describe the prevalence of stunting and wasting in populations of children aged under 5 years. They provide support for public health risk assessment and policy-making, including alerting health departments and aid agencies to national trends and local needs. In the light of the need for monitoring progress to meet globally agreed targets for overweight and obesity, the classification of their prevalence will be a valuable to aid in policy development, to target resources, and to promote public health interventions. This paper reviews the current use of categories to describe obesity prevalence in policy, advocacy, and research literature. Where prevalence categories have been formally proposed, this paper compares their application on large-scale datasets. The paper then develops a set of recommended threshold values to classify prevalence levels for overweight and obesity among children under age 5 years, children aged 5-19 years, and adults.

The European Food Regulatory Environment Index: a tool to monitor progress in implementing food environment policies

Background

Evidence based health policy, such as that put forward in the European Food and Nutrition Action Plan 2015–2020 and the WHO Global Action Plan on the Prevention and Control of Noncommunicable Diseases, has a role in curbing the consumption of unhealthful foods and drink. We ask how countries are performing in the adoption of these policies and how the comprehensiveness of their food environment policies explains variations in consumption of unhealthful products across Europe.

Methods

In order to assess the state of policy adoption, we developed a composite indicator—the Food Regulatory Environment Index (FREI) for which we calculated unweighted and weighted formulations according to the strength of the evidence base. We used linear regression models to explain variations in the consumption of unhealthful products as well as variations in a composite indicator of obesogenic diets.

Results

Overall, wealthier countries in the Region perform better. The weighting of the constituent policies does not affect the rankings. We find negative associations between unweighted and weighted formulations of the Index and household consumption of sugary and carbonate drinks as well as with the composite indicator for obesogenic diets.

Conclusions

The main strength of this study is the comprehensiveness and comparability of the policy data across the relatively large number of countries covered. There is a negative association that is statistically significant, between all formulations of the FREI and the household consumption of sugary and carbonated drinks. There is also a negative association between some FREI formulations and obesogenic diets.

Rising to the challenge: Introducing protocols to monitor food marketing to children from the World Health Organization Regional Office for Europe

Unhealthy marketing has been unequivocally linked to children's food preferences, requests, purchases and eating behaviors and hence to childhood obesity. Regulating children's exposure to such marketing has been identified as a key challenge to which States must rise. Regulation mandates the need for monitoring and hence for credible data that are comparable between countries, regions and across time. However, there are major challenges presented by the complexity of the digital marketing ecosystem including the personalized targeting with persuasive, exploitative advertising to which children are subject. This narrative review identifies challenges faced by researchers in the digital ecosystem; reviews recent papers attempting to address these and specifies benefits and limitations; and introduces a set of WHO protocols with templates and guidance for studies of food marketing to children.

High sugar content of European commercial baby foods and proposed updates to existing recommendations

The aim was to determine whether commercial baby foods marketed within Europe (up to 36 months of age) have inappropriate formulation and high sugar content and to provide suggestions to update European regulations and recommendations as part of a nutrient profile model developed for this age group. The latter was produced following recommended World Health Organization (WHO) steps, including undertaking a rapid literature review. Packaging information from countries across the WHO European region was used to determine mean energy from total sugar by food category. The percentage of products containing added sugar and the percentage of savoury meal‐type products containing pureed fruit were also calculated. A total of 2,634 baby foods from 10 countries were summarised: 768 sold in the United Kingdom, over 200 each from Denmark (319), Spain (241), Italy (430) and Malta (243) and between 99–200 from Hungary, Norway, Portugal, Estonia and Slovenia. On average, approximately a third of energy in baby foods in these European countries came from total sugar, and for most food categories, energy from sugar was higher than 10%. Use of added sugars was widespread across product categories, with concentrated fruit juice most commonly used. Savoury meal‐type purees did not contain added sugars except in United Kingdom and Malta; however, fruit as an ingredient was found in 7% of savoury meals, most frequently seen in UK products. Clear proposals for reducing the high sugar content seen in commercial baby foods were produced. These suggestions, relating to both content and labelling, should be used to update regulations and promote product reformulation.

Inequalities in education and national income are associated with poorer diet: Pooled analysis of individual participant data across 12 European countries

Background

Malnutrition linked to noncommunicable diseases presents major health problems across Europe. The World Health Organisation encourages countries to conduct national dietary surveys to obtain data to inform public health policies designed to prevent noncommunicable diseases.

Methods

Data on 27334 participants aged 19-64y were harmonised and pooled across national dietary survey datasets from 12 countries across the WHO European Region. Weighted mean nutrient intakes were age-standardised using the Eurostat 2013 European Standard Population. Associations between country-level Gross Domestic Product (GDP) and key nutrients and nutrient densities were investigated using linear regression. The potential mitigating influence of participant-level educational status was explored.

Findings

Higher GDP was positively associated with total sugar intake (5·0% energy for each 10% increase in GDP, 95% CI 0·6, 9·3). Scandinavian countries had the highest vitamin D intakes. Participants with higher educational status had better nutritional intakes, particularly within lower GDP countries. A 10% higher GDP was associated with lower total fat intakes (-0·2% energy, 95% CI -0·3, -0·1) and higher daily total folate intakes (14μg, 95% CI 12, 16) in higher educated individuals.

Interpretation

Lower income countries and lower education groups had poorer diet, particularly for micronutrients. We demonstrate for the first time that higher educational status appeared to have a mitigating effect on poorer diet in lower income countries. It illustrates the feasibility and value of harmonising national dietary survey data to inform European policy regarding access to healthy diets, particularly in disadvantaged groups. It specifically highlights the need for strong policies supporting nutritional intakes, prioritising lower education groups and lower income countries.

Assessing diet in European populations using national dietary surveys

The WHO encourages countries to conduct national dietary surveys (NDS) to inform preventative policies targeting malnutrition and noncommunicable diseases. Previous reviews have found inadequate nutrient intakes and survey provision across Europe. This research is the first to provide an updated review of NDS provision within the whole WHO European Region, across the lifecourse, with reference to disadvantaged groups, obesity and nutrients of concern. Over a third of WHO European countries, mainly Central and Eastern European countries (CEEC), had no identifiable NDS. Where countries reported nutrient intakes, poor WHO recommended nutrient intake attainment was Europe-wide across the lifecourse, particularly in CEEC. Lower educated individuals had poorer diet quality. However, heterogeneity in age group sampled, dietary assessment method, nutrient composition database and under-reporting hindered inter-country comparisons. Average population trans fatty acid intakes below WHO recommended limits may hide inequalities in disadvantaged groups; legislative bans may help alleviate this. There were few associations between NDS-derived consumed food portion size (FPS) and BMI. However, consumed FPS was greater than on-pack serving-size in the majority of foods studied. This review illustrates how NDS can generate information on diet, nutrient intakes and the food environment. However, to enable valid inter-country comparisons, countries should be encouraged to conduct and report harmonised NDS, particularly in the age groups sampled, dietary assessment methodology, nutrient range, underpinning food composition database and treatment of under-reporters. This will aid effective, coordinated policy development that can have a real impact on dietary improvement, on a population and subgroup level, throughout Europe.

A multicentre study of street foods purchased in urban areas of Central Asia: the FEEDCities Project

Background

Street food (SF) is a strong tradition in Central Asia, where urbanization and westernization of food habits is occurring. Research on SF consumption is scarce, and crucial to understand its implications for public health. This study aims to describe the SF purchases in urban areas of Tajikistan, Kyrgyzstan, Turkmenistan and Kazakhstan.

Methods

A cross-sectional study was conducted in Dushanbe, Bishkek, Ashgabat and Almaty in 2016/2017. SF markets (n = 34) and vending sites (n = 270) were selected by random and systematic sampling. Data on customers’ characteristics and food items purchased was collected by direct observation. Nutritional composition of the food items (n = 852) was obtained by laboratorial analysis (n = 582) or food composition tables and labels (n = 270).

Results

A total of 714 customers were identified. The most commonly purchased foods and beverages were savoury pastries/snacks (23.2%), main dishes (19.0%), sweet pastries/confectionery (17.9%), tea/coffee (11.3%) and soft drinks/juices (9.8%). Fruit was the least frequently purchased food (1.1%). Nearly one-third of customers purchased industrial food items; this proportion was significantly higher in Kazakhstan (43.2%) and Turkmenistan (32.3%). The median energy content of a SF purchase ranged between 352kcal (Tajikistan) and 568kcal (Turkmenistan). The median saturated (SFA) and trans fat contents were 4.74g and 0.36g, respectively; the highest values were 9.01g for SFA (Turkmenistan) and 0.60g for trans fat (Kazakhstan), accounting for 40.6% and 27.3% of the maximum daily recommendations, respectively. Sodium-potassium ratio was far above recommended, reaching the highest values of 6.57 and 5.17 in Tajikistan and Kyrgyzstan.

Conclusions

Frequent purchase of industrial food reflects a shift to a westernized dietary pattern. Public health policies in these settings should aim to increase fruit availability and to improve SF nutritional composition, namely its lipid profile and sodium content.

Key messages

A relevant proportion of customers bought industrial foods, while fruit was rarely purchased, reflecting the nutrition transition process that is occurring in developing countries. Street food meals showed concerning levels of saturated fat, trans-fat and sodium, which must be considered when designing strategies targeted to improve the urban food environment in these settings.

Impact of Austria's 2009 trans fatty acids regulation on all-cause, cardiovascular and coronary heart disease mortality

Background

Unhealthy diet, especially consumption of trans fatty acids (TFAs), is a known risk factor for cardiovascular disease (CVD), a leading cause of death in Austria. In 2009, Austria introduced a law regulating the content of TFAs in foods. The aim of this study was to assess the impact of the TFA regulation on CVD-related outcomes.

Methods

The study evaluated the TFA regulation as an intervention in a natural experiment. Two study periods were assessed: pre-intervention (1995-2009) and post-intervention (2010-14). The study compared the age-standardized death rates per 100 000 population for CVD outcomes with those of a 'synthetic' international comparator population, created from data of OECD countries where TFA regulation has not been implemented, but where the population is otherwise comparable.

Results

There was a continuous decrease in CVD-related mortality throughout the study period in both the synthetic international comparator population, as well as in the adult Austrian population, with no significant change in this trend observed as an effect of TFA regulation.

Conclusions

Whilst the results are counterintuitive, given the established link between TFA consumption and an increased risk of CVD, there are many possible explanations: high prevalence of tobacco smoking, changes in TFA content in foods due to international guidance as opposed to formal regulation and a beneficial impact of TFA regulation on sub-groups of the population that might not be detected with nationally aggregated data. However, reduction in TFAs should still be considered an important part of risk factor reduction for CVD and other non-communicable diseases.

Sodium and Potassium Intake, Knowledge Attitudes and Behaviour Towards Salt Consumption Amongst Adults in Podgorica, Montenegro

Excess salt and inadequate potassium intakes are associated with high cardiovascular disease (CVD). In Montenegro, CVD is the leading cause of death and disability. There is no survey that has directly measured salt and potassium consumption in Montenegro. The aim is to estimate population salt and potassium intakes and explore knowledge, attitudes and behaviour (KAB), amongst the adult population of Podgorica. Random samples of adults were obtained from primary care centres. Participants attended a screening including demographic, anthropometric and physical measurements. Dietary salt and potassium intakes were assessed by 24 h urinary sodium (UNa) and potassium (UK) excretions. Creatinine was measured. KAB was collected by questionnaire. Six hundred and thirty-nine (285 men, 25–65 years) were included in the analysis (response rate 63%). Mean UNa was 186.5 (SD 90.3) mmoL/day, equivalent to 11.6 g of salt/day and potassium excretion 62.5 (26.2) mmoL/day, equivalent to 3.2 g/day. Only 7% of them had a salt intake below the World Health Organization (WHO) recommended target of 5 g/day and 13% ate enough potassium (>90 mmoL/day). The majority (86%) knew that high salt causes ill-health. However, only 44% thought it would be useful to reduce consumption. Salt consumption is high and potassium consumption is low, in men and women living in Podgorica.

Overweight and Obesity in the Russian Population: Prevalence in Adults and Association with Socioeconomic Parameters and Cardiovascular Risk Factors

OBJECTIVE

To evaluate the prevalence and geographic distribution of overweight and obesity in Russian adults aged 25-64 years as well as the association between chronic risk factors and obesity.

METHODS

Data were obtained from the survey "Epidemiology of Cardiovascular Diseases and Its Risk Factors in Some Regions of the Russian Federation" (ESSE-RF). This is a large cross-sectional multicenter population-based study that included interviews and medical examination (anthropometry, blood pressure [BP] measurement, and laboratory analysis) applied in 2012-2014.

RESULTS

The sample included 20,190 adults (response rate 79.4%) aged 25-64 years. Approximately one third of participants (30.3%) had obesity and another third (34.3%) were classified as overweight. BMI increased with age in both sexes. The prevalence of obesity between regions ranged from 24.4 to 35.5%. Overweight and obesity levels decreased with higher education (men only). Overall obesity rates were higher in rural than urban populations, but rates of overweight were similar in rural and urban populations. Participants with obesity were more likely to have BP > 160/100 mm Hg (odds ratio > 2.0) and also > 140/90 mm Hg, raised blood glucose, and high triglycerides.

CONCLUSION

The prevalence of overweight and obesity in Russian adults aged 25-64 years is not evenly distributed geographically, but it is comparable to that of other European countries. Individuals with obesity were also more likely to have indicators of poor cardiovascular and metabolic health.

Portion Size of Energy-Dense Foods among French and UK Adults by BMI Status

Evidence links consumed food portion size (FPS) and excess weight via increased energy intake. Policies to regulate on-pack serving sizes may be needed; determining consumed FPS of popular energy-dense foods for normal weight and overweight or obese (OWOB) adults, as reported here, may provide evidence to assist this. Data were analysed from national cross-sectional surveys, the French Étude Individuelle Nationale des Consommations Alimentaires2 2005⁻2007 (n = 2117), and UK National Diet and Nutrition Survey 2008⁻2014 (n = 3413). The impact of body mass index (BMI) on FPS is also investigated, adjusting for age, sex and under-reporting. Effects of under-reporting on relationships between FPS and BMI; and BMI on consumption frequency (UK only) were explored. OWOB reported larger FPS than normal-weight individuals in many, but not all food subgroups; however, there were only two significant FPS differences. In adjusted analyses, French individuals consumed 1.0 g (99% CI 0.01⁻2.1 p = 0.01) greater FPS in cakes for 1 point difference in BMI. 'Other cakes' and 'dark chocolate' were also significantly positively associated with BMI. High-fat bar snacks, but no UK main food groups, were positively associated with BMI. There was limited evidence of links between FPS and BMI in UK and French national cross-sectional data, possibly due to data limitations such as under-reporting. Future work should explore this and relationships between consumed FPS and on-pack suggested serving sizes to provide evidence to assist obesity-prevention policies.

Forecasting Future Trends in Obesity across Europe: The Value of Improving Surveillance

OBJECTIVE

To project the prevalence of obesity across the WHO European region and examine whether the WHO target of halting obesity at 2010 levels by 2025 is achievable.

METHODS

BMI data were collected from online databases and the literature. Past and present BMI trends were extrapolated to 2025 using a non-linear categorical regression model fitted to nationally representative survey data. Where only 1 year of data was available, a flat trend was assumed. Where no data were available, proxy country data was used adjusted for demographics.

RESULTS

By 2025, obesity is projected to increase in 44 countries. If present trends continue, 33 of the 53 countries are projected to have an obesity prevalence of 20% or more. The highest prevalence is projected for Ireland (43%, 95% confidence interval (CI): 28-58%). Lithuania, Finland, and the Netherlands were each estimated to have an absolute increase of 2 percentage points in the prevalence of obesity between 2015 and 2025.

DISCUSSION

The quality of BMI data across Europe is highly variable, with fewer than 50% of the 53 countries having measured nationally representative data and often not enough data to interpret projections meaningfully. Nevertheless, the prevalence of obesity in the European Region appears to be increasing in most countries and, with it, the health and economic burden of its associated diseases. This paints a concerning picture of the future burden of obesity-related noncommunicable diseases across the region. Greater and continued effort for the implementation of effective preventive policies and interventions is required from governments.

Impact of Front-of-Pack Nutrition Labels on Portion Size Selection: An Experimental Study in a French Cohort

In the European Union (EU) three coloured graded Front-of-Pack labels (FoPLs), two endorsed by governments (Nutri-Score and Multiple Traffic Lights (MTL)) and one designed by industry (Evolved Nutrition Label (ENL)) are currently being discussed. This study aimed to investigate the impact of these FoPLs on portion size selection, specifically for less healthy products. In 2018, participants from the French NutriNet-Santé cohort study (N = 25,772) were exposed through a web-based self-administered questionnaire to products from three food categories (sweet biscuits, cheeses, and sweet spreads), with or without FoPLs, and were invited to select the portion they would consume (in size and number). Kruskall-Wallis tests, and mixed ordinal logistic regression models, were used to investigate the effects of FoPLs on portion size selection. Compared to no label, Nutri-Score consistently lowered portion sizes (OR = 0.76 (0.74⁻0.76)), followed by MTL (OR = 0.83 (0.82⁻0.84)). For ENL, the effects differed depending on the food group: It lowered portion size selection for cheeses (OR = 0.84 (0.83⁻0.87)), and increased it for spreads (OR = 1.19 (1.15⁻1.22)). Nutri-Score followed by MTL appear efficient tools to encourage consumers to decrease their portion size for less healthy products, while ENL appears to have inconsistent effects depending on the food category.

The Importance of the World Health Organization Sugar Guidelines for Dental Health and Obesity Prevention

The World Health Organization (WHO) recommends a reduced intake of free sugars throughout the life course (strong recommendation) with a reduction of free sugars intake to less than 10% of the total energy intake (strong recommendation) and preferably below 5% of the total energy intake (conditional recommendation) in both adults and children. Available data clearly show that people already consume significantly more sugar than they should, increasing the risk for dental caries, overweight and obesity. The WHO recommendations are intended for use by the policy makers as a benchmark for assessing intake of sugars by populations and as a driving force for policy change. To create a favorable environment, enabling the overall amount of free sugar intake to be as low as possible and to reduce the frequency of consumption of sugar-rich foods, a range of public health interventions is advised.

National nutrition surveys in Europe: a review on the current status in the 53 countries of the WHO European region

OBJECTIVES

The objectives of this study were (1) to determine the coverage of national nutrition surveys in the 53 countries monitored by the World Health Organization (WHO) Regional Office for Europe and identify gaps in provision, (2) to describe relevant survey attributes and (3) to check whether energy and nutrients are reported with a view to providing information for evidence-based nutrition policy planning.

DESIGN

Dietary survey information was gathered using three methods: (1) direct email to survey authors and other relevant contacts, (2) systematic review of literature databases and (3) general web-based searches. Survey characteristics relating to time frame, sampling and dietary methodology and nutrients reported were tabled from all relevant surveys found since 1990.

SETTING

Fifty-three countries of the WHO Regional Office for Europe, which have need for an overview of dietary surveys across the life course.

SUBJECTS

European individuals (adults and children) in national diet surveys.

RESULTS

A total of 109 nationally representative dietary surveys undertaken post-1990 were found across 34 countries. Of these, 78 surveys from 33 countries were found post-2000, and of these, 48 surveys from 27 countries included children and 60 surveys from 30 countries included adults. No nationally representative surveys were found for 19 of 53 countries, mainly from Central and Eastern Europe. Multiple 24hr recall and food diaries were the most common dietary assessment methods. Only 22 countries reported energy and nutrient intakes from post-2000 surveys; macronutrients were more widely reported than micronutrients.

CONCLUSIONS

Less than two-thirds of WHO Europe countries have nationally representative diet surveys, mainly collected post-2000. The main availability gaps lie in Central and Eastern European countries, where nutrition policies may therefore lack an appropriate evidence base. Dietary methodological differences may limit the scope for inter-country comparisons.

The Sodium and Potassium Content of the Most Commonly Available Street Foods in Tajikistan and Kyrgyzstan in the Context of the FEEDCities Project

This cross-sectional study is aimed at assessing sodium (Na) and potassium (K) content and the molar Na:K ratios of the most commonly available ready-to-eat street foods in Tajikistan and Kyrgyzstan. Four different samples of each of these foods were collected and 62 food categories were evaluated through bromatological analysis. Flame photometry was used to quantify sodium and potassium concentrations. The results show that home-made foods can be important sources of sodium. In particular, main dishes and sandwiches, respectively, contain more than 1400 and nearly 1000 mg Na in an average serving and provide approximately 70% and 50% of the maximum daily recommended values. Wide ranges of sodium content were found between individual samples of the same home-made food collected from different vending sites from both countries. In industrial foods, sodium contents ranged from 1 to 1511 mg/serving in Tajikistan, and from 19 to 658 mg/serving in Kyrgyzstan. Most Na:K ratios exceeded the recommended level of 1.0 and the highest ratios were found in home-made snacks (21.2) from Tajikistan and industrial beverages (16.4) from Kyrgyzstan. These findings not only improve data on the nutritional composition of foods in these countries, but may also serve as baseline information for future policies and interventions.

An exploration of socio-economic and food characteristics of high trans fatty acid consumers in the Dutch and UK national surveys after voluntary product reformulation

Trans fatty acids (TFA) increase the risk of mortality and chronic diseases. TFA intakes have fallen since reformulation, but may still be high in certain, vulnerable, groups. This paper investigates socio-economic and food consumption characteristics of high TFA consumers after voluntary reformulation in the Netherlands and UK. Post-reformulation data of adults aged 19-64 was analysed in two national surveys: the Dutch National Food Consumption Survey (DNFCS) collected 2007-2010 using 2*24hr recalls (N = 1933) and the UK National Diet and Nutrition Survey (NDNS) years 3&4 collected 2010/11 and 2011/12 using 4-day food diaries (N = 848). The socio-economic and food consumption characteristics of the top 10% and remaining 90% TFA consumers were compared. Means of continuous data were compared using t-tests and categorical data means using chi-squared tests. Multivariate logistic regression models indicated which socio-demographic variables were associated with high TFA consumption. In the Dutch analyses, women and those born outside the Netherlands were more likely to be top 10% TFA consumers than men and Dutch-born. In the UK unadjusted analyses there was no significant trend in socio-economic characteristics between high and lower TFA consumers, but there were regional differences in the multivariate logistic regression analyses. In the Netherlands, high TFA consumers were more likely to be consumers of cakes, buns & pastries; cream; and fried potato than the remaining 90%. Whereas in the UK, high TFA consumers were more likely to be consumers of lamb; cheese; and dairy desserts and lower crisps and savoury snack consumers. Some socio-demographic differences between high and lower TFA consumers were evident post-reformulation. High TFA consumers in the Dutch 2007-10 survey appeared more likely to obtain TFA from artificial sources than those in the UK survey. Further analyses using more up-to-date food composition databases may be needed.

Overweight and Obesity in Children under 5 Years: Surveillance Opportunities and Challenges for the WHO European Region

Background

Many children who have overweight or obesity before puberty can develop obesity in early adulthood, which is associated with increased morbidity and mortality. The preschool years (ages 0–5) represents a point of opportunity for children to be active, develop healthy eating habits, and maintain healthy growth. Surveillance of childhood overweight and obesity in this age group can help inform future policies and interventions.

Objective

To review and report available prevalence data in WHO European Region Member States and determine how many countries can accurately report on rates of overweight and obesity in children under 5 years.

Methods

We conducted a rapid review of studies reporting on overweight and obesity prevalence in children ages 0–5 in the WHO European region member states from 1998 to 2015.

Results

Currently, 35 of the 53 member states have data providing prevalence rates for overweight and obesity for children under 5 years. There was little consistency in study methods, impacting comparability across countries. The prevalence of overweight and obesity in children under 5 years ranges from 1 to 28.6% across member states.

Conclusion

Although measuring overweight and obesity in this age group may be challenging, there is an opportunity to leverage existing surveillance resources in the WHO European Region.

Smart food policies for obesity prevention

Prevention of obesity requires policies that work. In this Series paper, we propose a new way to understand how food policies could be made to work more effectively for obesity prevention. Our approach draws on evidence from a range of disciplines (psychology, economics, and public health nutrition) to develop a theory of change to understand how food policies work. We focus on one of the key determinants of obesity: diet. The evidence we review suggests that the interaction between human food preferences and the environment in which those preferences are learned, expressed, and reassessed has a central role. We identify four mechanisms through which food policies can affect diet: providing an enabling environment for learning of healthy preferences, overcoming barriers to the expression of healthy preferences, encouraging people to reassess existing unhealthy preferences at the point-of-purchase, and stimulating a food-systems response. We explore how actions in three specific policy areas (school settings, economic instruments, and nutrition labelling) work through these mechanisms, and draw implications for more effective policy design. We find that effective food-policy actions are those that lead to positive changes to food, social, and information environments and the systems that underpin them. Effective food-policy actions are tailored to the preference, behavioural, socioeconomic, and demographic characteristics of the people they seek to support, are designed to work through the mechanisms through which they have greatest effect, and are implemented as part of a combination of mutually reinforcing actions. Moving forward, priorities should include comprehensive policy actions that create an enabling environment for infants and children to learn healthy food preferences and targeted actions that enable disadvantaged populations to overcome barriers to meeting healthy preferences. Policy assessments should be carefully designed on the basis of a theory of change, using indicators of progress along the various pathways towards the long-term goal of reducing obesity rates.

Joint analysis of BICEP2/keck array and Planck Data

We report the results of a joint analysis of data from BICEP2/Keck Array and Planck. BICEP2 and Keck Array have observed the same approximately 400  deg^{2} patch of sky centered on RA 0 h, Dec. -57.5°. The combined maps reach a depth of 57 nK deg in Stokes Q and U in a band centered at 150 GHz. Planck has observed the full sky in polarization at seven frequencies from 30 to 353 GHz, but much less deeply in any given region (1.2  μK deg in Q and U at 143 GHz). We detect 150×353 cross-correlation in B modes at high significance. We fit the single- and cross-frequency power spectra at frequencies ≥150  GHz to a lensed-ΛCDM model that includes dust and a possible contribution from inflationary gravitational waves (as parametrized by the tensor-to-scalar ratio r), using a prior on the frequency spectral behavior of polarized dust emission from previous Planck analysis of other regions of the sky. We find strong evidence for dust and no statistically significant evidence for tensor modes. We probe various model variations and extensions, including adding a synchrotron component in combination with lower frequency data, and find that these make little difference to the r constraint. Finally, we present an alternative analysis which is similar to a map-based cleaning of the dust contribution, and show that this gives similar constraints. The final result is expressed as a likelihood curve for r, and yields an upper limit r_{0.05}<0.12 at 95% confidence. Marginalizing over dust and r, lensing B modes are detected at 7.0σ significance.

Energy drink consumption in europe: a review of the risks, adverse health effects, and policy options to respond

With the worldwide consumption of energy drinks increasing in recent years, concerns have been raised both in the scientific community and among the general public about the health effects of these products. Recent studies provide data on consumption patterns in Europe; however, more research is needed to determine the potential for adverse health effects related to the increasing consumption of energy drinks, particularly among young people. A review of the literature was conducted to identify published articles that examined the health risks, consequences, and policies related to energy drink consumption. The health risks associated with energy drink consumption are primarily related to their caffeine content, but more research is needed that evaluates the long-term effects of consuming common energy drink ingredients. The evidence indicating adverse health effects due to the consumption of energy drinks with alcohol is growing. The risks of heavy consumption of energy drinks among young people have largely gone unaddressed and are poised to become a significant public health problem in the future.

A food policy package for healthy diets and the prevention of obesity and diet-related non-communicable diseases: the NOURISHING framework

This paper presents the NOURISHING framework of food policies to promote healthy diets, and uses the framework to summarize the policy actions taken by the Bellagio meeting countries. NOURISHING was developed by WCRF International to formalize a comprehensive policy package that brings together the key domains of action and policy areas. It aims to provide global level recommendations for a comprehensive response, within which policymakers have the flexibility to select specific policy options suitable for their national/local contexts and target populations. It also aims to provide a framework for reporting, categorizing and monitoring policy actions taken around the world, and for systematically categorizing, updating, interpreting and communicating the evidence for policy to policymakers. In this paper we explain the structure for NOURISHING and the rationale behind it. We also use the framework to report on and categorize the policy actions implemented in the Bellagio countries.

Trends in European liver death rates: implications for alcohol policy

Changing alcohol consumption has led to a three- to fivefold increase in liver deaths in the UK and Finland, and a three- to fivefold decrease in France and Italy. Increasing consumption from a low baseline has been driven by fiscal, marketing and commercial factors--some of which have occurred as a result of countries joining the EU. In contrast consumption has fallen from previously very high levels as a result of shifting social and cultural factors; a move from rural to urban lifestyles and increased health consciousness. The marketing drive in these countries has had to shift from a model based on quantity to one based on quality, which means that health gains have occurred alongside a steady improvement in the overall value of the wine industry. Fiscal incentives--minimum pricing, restricting cross border trade and more volumetric taxation could aid this shift. A healthier population and a healthy drinks industry are not incompatible.

Role changes experienced by clinical staff in relation to clients' recovery from psychosis

This study investigates the subjective experiences of staff from many interdisciplinary teams working with clients in the recovery process from psychosis. The clinical staff interviewed in this study included: staff nurses, clinical nurse specialists, occupational therapists, psychologists, social workers, rehabilitation workers, recreation therapists, music therapists, psychiatrists, and lodging home operators. The purpose of this study was to examine the clinical staff's changing roles and relationships with clients recovering from psychosis. The investigation used a naturalistic qualitative design with an ethnographic method of data analysis. The participants were clinical staff working with clients about to commence treatment with clozapine or risperidone. The settings used were a tertiary-care psychiatric hospital and a general hospital. The clinical staff members who participated in the study were interviewed every 3 months. In the initial interview, members of the clinical staff were asked about their knowledge regarding the new medication and their role in the decision to try the new medication. In all the interviews, clinical staff members were asked about how the recovery process was progressing with the client. Data regarding clinical staff fears related to the client's situation, changes in their relationships with the client and the client's family, and what they perceived to be current rehabilitation implications, were collected. Some of the clinical staff roles that evolved during the recovery process were: health teacher; advocate; counsellor; and support person.

From hospital to community: bridging therapeutic relationships

The 'Bridge to Discharge' project evolved from a participatory research project. The team included public health nurses, in-patient schizophrenia program nurses and mental health consumers. The project focused on therapeutic relationships and used Peplau's theory of Interpersonal Relations. A broad perspective of therapeutic relationships was used that explicitly included both peer and professional support. The theoretical approach is described and illustrated with a case study.

Bridging the discharge process

Current mental health initiatives are decreasing the number of psychiatric beds and thus increasing the number of clients with serious mental illness who are being served in the community. Such changes have implications for clients' quality of life and health care economics. To implement the changes while addressing the unique needs of psychiatric clients, appropriate models of discharge planning and community integration are critical.

Automated measurement of motor activity in human subjects: effects of repeated testing and d-amphetamine

Repeated exposure to a test setting decreases, and amphetamine increases, motor activity in animals. To evaluate whether these effects also occur in human subjects, we recorded motor activity levels from 12 subjects during a double-blind oral drug discrimination (placebo vs. 75 mg tripelennamine) study. Before each 4-h session, activity monitors were attached to the subject's wrist and ankle. During each session, subjects rated their drug effects hourly (task periods), and could freely choose among leisure activities during intertask intervals (recreational periods). Habituation was evaluated by comparing activity response during initial (training phase) vs. later (discrimination phase) placebo sessions. During later sessions the two training drugs, as well as diazepam (2.5, 5 mg P.O.) and d-amphetamine (5, 10 mg P.O.) were administered. Consistent with animal studies, repeated exposure to the test environment significantly decreased, and d-amphetamine significantly and selectively increased, wrist motor activity. These data indicate that human motor activity is sensitive to environmental factors (task, time), drug class, and d-amphetamine dose. Activity measures may, therefore, be useful in evaluating environment/psychostimulant interactions in humans.

Evaluation of Bridging Institution and Housing-A Joint Consumer-Care Provider Initiative

1. The most common alternative housing choice in the community for individuals with serious mental illness was a boarding home. 2. Community consumers noted that being with other people was the most important benefit of the teaching apartment, followed by eating, learning new skills, and entertainment. 3. Although they reported negative aspects about the homes, most consumers did not want to change anything about their boarding home.

Efficient insertion of odd-numbered transmembrane segments of the tetracycline resistance protein requires even-numbered segments

Functional membrane insertion elements in the pBR322 tetracycline resistance protein were identified by comparing the ability of odd-numbered transmembrane segments and their attached periplasmic loops to insert into the membrane individually or when combined with the next even-numbered segment in the tetracycline resistance protein sequence. The efficiency with which individual odd-numbered segments and periplasmic loops inserted was probed by treating proteins truncated at the distal ends of periplasmic loops P2-P6 with carboxypeptidases and endoproteases in inside-out membrane vesicles. Insertion of odd-numbered segments and attached loops is inefficient when they occupy a C-terminal position in the protein. The C-terminal odd-numbered segment and loop sequences of 34-54% of the molecules of periplasmic loop truncation mutants could be removed by carboxypeptidase Y. In contrast, odd-numbered segments and loops insert efficiently if the next even-numbered segment in the sequence is present. In such cytoplasmic loop truncation mutants, only the cytoplasmic tail sequences of the proteins could be removed by carboxypeptidases. Remarkably, insertion of individual odd-numbered segments and loops is inefficient even though free energies for insertion of these sequences are highly favorable. The results indicate that pairs of adjacent segments, possibly "helical hairpins," are necessary for efficient membrane insertion of the tetracycline resistance protein.

A simple method of securing a dressing on scalp wounds

A method of securing a dressing on scalp wounds, using silastic foam, is described. This method has the advantage of leaving the rest of the scalp uncovered and is particularly effective in the unco-operative patient.

MMPI scales for DSM-III personality disorders: a preliminary validation study

A preliminary investigation of the external validity of MMPI scales designed to measure certain DSM-III Personality disorders (N = 108) is reported. Results indicate that many of these scales are effective for discriminating clinically diagnosed personality disorders from control subjects (N = 640).