Can a health warning label diminish the persuasive effects of health-oriented nutrition advertising on ready-to-drink alcohol product packaging? A randomized experiment

BACKGROUND AND AIMS

A health warning label (HWL) cautioning about the link between alcohol and cancer may be able to communicate alcohol risks to consumers and potentially counter health-oriented nutrition advertising on ready-to-drink alcoholic beverages. This study aimed to examine the independent and combined effects of nutrient content claims (e.g. 0 g sugar) and a HWL on perceived product characteristics and intentions to consume, and whether these effects differed by gender and age.

DESIGN

A between-subjects randomized experiment. Participants were randomized to view one of six experimental label conditions: nutrient content claims plus nutrition declaration (NCC + ND), ND only, NCC + ND + HWL, ND + HWL, HWL only and no NCC, ND or HWL, all on a ready-to-drink (RTD) vodka-based soda container.

SETTING AND PARTICIPANTS

Alcohol consumers (n = 5063; 52% women) in Canada aged 18-64 recruited through a national online panel.

MEASUREMENTS

Participants completed ratings of perceived product characteristics, perceived product health risks, and intentions to try, buy, binge and drink the product.

FINDINGS

Compared with the reference condition NCC + ND (current policy scenario in Canada), the other five experimental label conditions were associated with lower ratings for perceiving the product as healthy. All experimental conditions with a HWL were associated with lower product appeal, higher risk perceptions and reduced intentions to try, buy and binge. The experimental condition with a HWL only was associated with intentions to consume fewer cans in the next 7 days (β = -0.72, 95% confidence interval [CI] = -1.37,-0.08) versus the reference. Few interactions were observed, suggesting that label effects on outcomes were similar by gender and age.

CONCLUSIONS

Health warning labels on alcohol packaging appear to be associated with lower product appeal, higher perceived health risks and reduced consumption intentions, even in the presence of nutrient content claims.

Trends in alcohol-attributable hospitalisations and emergency department visits by age, sex, drinking group and health condition in Ontario, Canada

INTRODUCTION

Alcohol-attributable harms are increasing in Canada. We described trends in alcohol-attributable hospitalisations and emergency department (ED) visits by age, sex, drinking group, attribution and health condition.

METHODS

Hospitalisation and ED visits for partially or wholly alcohol-attributable health conditions by age and sex were obtained from population-based health administrative data for individuals aged 15+ in Ontario, Canada. Population-level alcohol exposure was estimated using per capita alcohol sales and alcohol use data. We estimated the number and rate of alcohol-attributable hospitalisations (2008-2018) and ED visits (2008-2019) using the International Model of Alcohol Harms and Policies (InterMAHP).

RESULTS

Over the study period, the modelled rates of alcohol-attributable health-care encounters were higher in males, but increased faster in females. Specifically, rates of alcohol-attributable hospitalisations and ED visits increased by 300% (19-76 per 100,000) and 37% (774-1,064 per 100,000) in females, compared to 20% (322-386 per 100,000) and 2% (2563-2626 per 100,000) in males, respectively. Alcohol-attributable ED visit rates were highest among individuals aged 15-34, however, increased faster among individuals aged 65+ (females: 266%; males: 44%) than 15-34 years (females:+17%; males: -16%). High-volume drinkers had the highest rates of alcohol-attributable health-care encounters; yet, low-/medium-volume drinkers contributed substantial hospitalisations (11%) and ED visits (36%), with increasing rates of ED visits in females drinking low/medium volumes.

DISCUSSION AND CONCLUSIONS

Alcohol-attributable health-care encounters increased overall, and faster among females, adults aged 65+ and low-/medium-volume drinkers. Monitoring trends across subpopulations is imperative to inform equitable interventions to mitigate alcohol-attributable harms.

Creating "Plates" to Evaluate Canadians' Dietary Intake in Relation to the 2019 Canada's Food Guide

Purpose: Explore Canadians' dietary intake in relation to the 2019 Canada's Food Guide (CFG) Plate using novel volume-based food analyses, by age and meal occasion.Methods: Foods reported in 24-hour recalls by 20,456 Canadians in the 2015 Canadian Community Health Survey - Nutrition were classified as: Vegetables and Fruits, Whole Grain Foods, Protein Foods, Non-Whole Grain Foods or Other Foods (high in fat, sugar, sodium). Food volumes were used to calculate percent contributions of each grouping to total intake, stratified by age (1-6; 7-12; 13-17; 18-64; 65+years) and meal (breakfast, lunch, supper, snack), applying sample survey weights and bootstrapping.Results: By volume, the Canadian population diet included: 29% Vegetables and Fruits, 22% Protein Foods, 7% Whole Grains, 24% Non-Whole Grain Foods, and 18% Other Foods. Intakes of Protein Foods (1-6 years) and Other Foods (7-12; 13-17 years) were higher in children than adults by volume, relative to total intake. Whole Grains intake was highest at breakfast. Other Foods intake was highest at snack.Conclusions: The volume-based population diet of Canadians reported on a single day includes a substantial proportion of non-recommended foods. There are opportunities to design interventions that target specific foods, ages, and meals to align intake with recommendations.

Is neighbourhood walkability related to body mass index among different age groups? A cross-sectional study of Canadian urban areas

BACKGROUND

Studies of neighbourhood walkability and body mass index (BMI) have shown mixed results, possibly due to biases from self-reported outcomes or differential effects across age groups. Our objective was to examine relationships between walkability and objectively measured BMI in various age groups, in a nationally representative population.

METHODS

The study population came from the 2007-2011 Canadian Health Measures Survey, a cross-sectional survey of a nationally representative Canadian population. In our covariate-adjusted analyses, we included survey respondents aged 6-79 who were not pregnant, did not live in rural areas, were not missing data and were not thin/underweight. We used objectively measured height and weight to calculate BMI among adults aged 18-79 and zBMI among children aged 6-17. We categorised respondents into walkability quintiles based on their residential Street Smart Walk Score values. We performed linear regression to estimate differences between walkability quintiles in BMI and zBMI. We analysed adults and children overall; age subgroups 6-11, 12-17, 18-29, 30-44, 45-64 and 65-79; and sex subgroups.

RESULTS

The covariate-adjusted models included 9265 respondents overall. After adjustment, differences between walkability quintiles in BMI and zBMI were small and not statistically significant, except for males aged 6-17 in the second-highest walkability quintile who had significantly lower zBMIs than those in the lowest quintile.

CONCLUSION

After accounting for confounding factors, we did not find evidence of a relationship between walkability and BMI in children or adults overall, or in any age subgroup with sexes combined. However, post hoc analysis by sex suggested males aged 6-17 in more walkable areas may have lower zBMIs.

Prevalence of age-specific and sex-specific overweight and obesity in Ontario and Quebec, Canada: a cross-sectional study using direct measures of height and weight

OBJECTIVE

To evaluate whether combining three cycles of the Canadian Health Measures Survey (CHMS) produces provincially representative and valid estimates of overweight and obesity in Ontario and Quebec.

SETTING

An ongoing, nationally representative health survey in Canada, with data released every 2 years. Objective measures of height and weight were taken at mobile examination centres located within 100 km of participants' residences. To increase sample size, we combined three cycles completed during 2007-2013.

PARTICIPANTS

5740 Ontario residents and 3980 Quebec residents aged 6-79, with birth dates and directly measured height and weight recorded in the CHMS. Pregnant females were excluded. Sociodemographic characteristics of the Ontario and Quebec portions of the CHMS appeared similar to characteristics from the 2006 Canada Census.

PRIMARY OUTCOME MEASURES

Objectively measured overweight and obesity prevalence overall and among males and females in the following age groups: 6-11, 12-19, 20-39, 40-59 and 60-79. We compared these with provincially representative and objectively measured estimates from the 2015 Canadian Community Health Survey (CCHS)-Nutrition.

RESULTS

57.1% (95% CI 52.8% to 61.4%) of Ontarians were classified overweight or obese and 24.0% (95% CI 20.3% to 27.6%) obese, while Quebec's corresponding percentages were 56.2% (95% CI 51.3% to 61.1%) and 24.4% (95% CI 20.6% to 28.3%). Generally, overweight and obesity combined was higher in older age groups and males. Comparisons with the CCHS-Nutrition did not yield unexplainable differences between surveys.

CONCLUSIONS

Combining three CHMS cycles can produce estimates of overweight and obesity in populations representative of Ontario and Quebec. As new CHMS data are collected, these estimates can be updated and used to evaluate trends.

Residents of highly walkable neighbourhoods in Canadian urban areas do substantially more physical activity: a cross-sectional analysis

BACKGROUND

Research has shown that neighbourhood walkability is associated with small differences in physical activity; however, the health impacts of these small differences have been questioned. We examined the size of the association of walkability with accelerometer-measured physical activity in a large, national-level Canadian population, and compared results to physical activity levels recommended in international guidelines. Our primary objective was to investigate the direction and size of the differences in physical activity that were related to walkability, and whether these differences depended on age.

METHODS

Participants were included from among respondents to the 2007-2011 Canadian Health Measures Surveys who lived in urban areas and were aged 6-79 years. The Canadian Health Measures Surveys are ongoing cross-sectional surveys of a Canada-wide population. Respondents were divided into quintiles based on Street Smart Walk Score® values of their census dissemination areas. For all respondents and age subgroups, we used covariate-adjusted generalized linear models to estimate differences between quintiles in accelerometer-measured moderate-to-vigorous physical activity (MVPA) and sedentary time.

RESULTS

We included 7180 respondents. Differences in participant MVPA between highest and lowest Street Smart Walk Score quintiles were 3.2 (95% confidence interval [CI] -3.2 to 9.6) minutes/day for ages 6-11 years, 11.4 (95% CI 5.3 to 17.4) minutes/day for ages 12-17 years, 9.9 (95% CI 2.4 to 17.4) minutes/day for ages 18-29 years, 14.9 (95% CI 10.2 to 19.6) minutes/day for ages 30-44 years, 11.5 (95% CI 6.7 to 16.3) minutes/day for ages 45-64 years and 6.9 (95% CI 3.1 to 10.8) minutes/day for ages 65-79 years. There were no significant differences in sedentary time in any age group.

INTERPRETATION

In all groups except the youngest, participants in the most walkable areas did significantly more MVPA than those in the least walkable areas. For several age groups, this difference was approximately one-half to two-thirds of the amount recommended in guidelines for physical activity. Substantially higher MVPA levels suggest that residents of highly walkable areas may have greater health benefits.

Neighborhood walkability: Differential associations with self-reported transport walking and leisure-time physical activity in Canadian towns and cities of all sizes

OBJECTIVE

To estimate associations between walkability and physical activity during transportation and leisure in a national-level population.

METHODS

Walkability was measured by Walk Score® (2012-2014) and physical activity by the Canadian Community Health Survey (2007-2012) for urban participants who worked or attended school. Multiple linear regression was done on the total study population, four age subgroups (12-17, 18-29, 30-64, 65+) and three population center subgroups (1000-29,999, 30,000-99,999, 100,000+).

RESULTS

151,318 respondents were examined. Comparing highest to lowest Walk Score® quintiles, covariate-adjusted energy expenditure on transport walking [95% confidence interval] was 0.17 [0.15, 0.18] kcal/kg/day higher in the total study population, and significantly higher in all age and population center subgroups. Leisure physical activity was lower in the age 18-29 subgroup (-0.28 [-0.43, -0.12]) and population centers 100,000+ subgroup (-0.10 [-0.18, -0.03]), but higher in the population centers 1000-29,999 subgroup (0.30 [0.12, 0.48]). Total physical activity was higher in the following subgroups: age 30-64 (0.19 [0.12, 0.26]), population centers 100,000+ (0.12 [0.04, 0.19]) and population centers 1000-29,999 (0.40 [0.20, 0.59]).

CONCLUSIONS

Walkability is associated with transport walking in all age groups and towns and cities of all sizes. Walkability's inverse associations with leisure physical activity among young adults and in large population centers may offset energy expenditure gains, while positive associations with leisure physical activity in small centers may add to energy expenditure.

Relation of completeness of reporting of health research to journals' endorsement of reporting guidelines: systematic review

OBJECTIVE

To assess whether the completeness of reporting of health research is related to journals' endorsement of reporting guidelines.

DESIGN

Systematic review.

DATA SOURCES

Reporting guidelines from a published systematic review and the EQUATOR Network (October 2011). Studies assessing the completeness of reporting by using an included reporting guideline (termed "evaluations") (1990 to October 2011; addendum searches in January 2012) from searches of either Medline, Embase, and the Cochrane Methodology Register or Scopus, depending on reporting guideline name.

STUDY SELECTION

English language reporting guidelines that provided explicit guidance for reporting, described the guidance development process, and indicated use of a consensus development process were included. The CONSORT statement was excluded, as evaluations of adherence to CONSORT had previously been reviewed. English or French language evaluations of included reporting guidelines were eligible if they assessed the completeness of reporting of studies as a primary intent and those included studies enabled the comparisons of interest (that is, after versus before journal endorsement and/or endorsing versus non-endorsing journals).

DATA EXTRACTION

Potentially eligible evaluations of included guidelines were screened initially by title and abstract and then as full text reports. If eligibility was unclear, authors of evaluations were contacted; journals' websites were consulted for endorsement information where needed. The completeness of reporting of reporting guidelines was analyzed in relation to endorsement by item and, where consistent with the authors' analysis, a mean summed score.

RESULTS

101 reporting guidelines were included. Of 15,249 records retrieved from the search for evaluations, 26 evaluations that assessed completeness of reporting in relation to endorsement for nine reporting guidelines were identified. Of those, 13 evaluations assessing seven reporting guidelines (BMJ economic checklist, CONSORT for harms, PRISMA, QUOROM, STARD, STRICTA, and STROBE) could be analyzed. Reporting guideline items were assessed by few evaluations.

CONCLUSIONS

The completeness of reporting of only nine of 101 health research reporting guidelines (excluding CONSORT) has been evaluated in relation to journals' endorsement. Items from seven reporting guidelines were quantitatively analyzed, by few evaluations each. Insufficient evidence exists to determine the relation between journals' endorsement of reporting guidelines and the completeness of reporting of published health research reports. Journal editors and researchers should consider collaborative prospectively designed, controlled studies to provide more robust evidence.

SYSTEMATIC REVIEW REGISTRATION

Not registered; no known register currently accepts protocols for methodology systematic reviews.

Comparative effectiveness of monotherapies and combination therapies for patients with hypertension: protocol for a systematic review with network meta-analyses

BACKGROUND

Hypertension has been cited as the most common attributable risk factor for death worldwide, and in Canada more than one of every five adults had this diagnosis in 2007. In addition to different lifestyle modifications, such as diet and exercise, there exist many pharmaco-therapies from different drug classes which can be used to lower blood pressure, thereby reducing the risk of serious clinical outcomes. In moderate and severe cases, more than one agent may be used. The optimal mono- and combination therapies for mild hypertension and moderate/severe hypertension are unclear, and clinical guidelines provide different recommendations for first line therapy. The objective of this review is to explore the relative benefits and safety of different pharmacotherapies for management of non-diabetic patients with hypertension, whether of a mild or moderate to severe nature.

METHODS/DESIGN

Searches involving MEDLINE and the Cochrane Database of Systematic Reviews will be used to identify related systematic reviews and relevant randomized trials. The outcomes of interest include myocardial infarction, stroke, incident diabetes, heart failure, overall and cardiovascular related death, and important side effects (cancers, depression, syncopal episodes/falls and sexual dysfunction). Randomized controlled trials will be sought. Two reviewers will independently screen relevant reviews, titles and abstracts resulting from the literature search, and also potentially relevant full-text articles in duplicate. Data will be abstracted and quality will be appraised by two team members independently. Conflicts at all levels of screening and abstraction will be resolved through team discussion. Random effect pairwise meta-analyses and network meta-analyses will be conducted where deemed appropriate. Analyses will be geared toward studying treatment of mild hypertension and moderate/severe hypertension separately.

DISCUSSION

Our systematic review results will assess the extent of currently available evidence for single agent and multi-agent pharmacotherapies in patients with mild, moderate and severe hypertension, and will provide a rigorous and updated synthesis of a range of important clinical outcomes for clinicians, decision makers and patients.

TRIAL REGISTRATION

PROSPERO Registration Number: CRD42013004459.