Nurses' use of 'wellness' supplements during the COVID-19 pandemic in the United States

AIM

Quantify disparities and identify correlates and predictors of 'wellness' supplement use among nurses during the first year of the pandemic.

DESIGN

Longitudinal secondary analysis of Nurses' Health Studies 2 and 3 and Growing Up Today Study data.

METHODS

Sample included 36,518 total participants, 12,044 of which were nurses, who completed surveys during the first year of the COVID-19 pandemic (April 2020 to April 2021). Analyses were conducted in March 2023. Modified Poisson models were used to estimate disparities in 'wellness' supplement use between nurses and non-healthcare workers and, among nurses only, to quantify associations with workplace-related predictors (occupational discrimination, PPE access, workplace setting) and psychosocial predictors (depression/anxiety, county-level COVID-19 mortality). Models included race/ethnicity, gender identity, age and cohort as covariates.

RESULTS

Nurses were significantly more likely to use all types of supplements than non-healthcare workers. Lacking personal protective equipment and experiencing occupational discrimination were significantly associated with new immune supplement use. Depression increased the risk of using weight loss, energy and immune supplements.

CONCLUSION

Nurses' disproportionate use of 'wellness' supplements during the COVID-19 pandemic may be related to workplace and psychosocial stressors. Given well-documented risks of harm from the use of 'wellness' supplements, the use of these products by nurses is of concern.

IMPACT

'Wellness' supplements promoting weight loss, increased energy, boosted immunity and cleansing of organs are omnipresent in today's health-focused culture, though their use has been associated with harm. This is of added concern among nurses given their risk of COVID-19 infection at work. Our study highlighted the risk factors associated with use of these products (lacking PPE and experiencing occupational discrimination). Findings support prior research suggesting a need for greater public health policy and education around the use of 'wellness' supplements.

REPORTING METHOD

STROBE guidelines were followed throughout manuscript.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was involved.

Social media platforms generate billions of dollars in revenue from U.S. youth: Findings from a simulated revenue model

Social media platforms are suspected to derive hefty profits from youth users who may be vulnerable to negative mental health outcomes, including depression, anxiety, and eating disorders. Platforms, however, are not required to make these data publicly available, which may limit the abilities of researchers and policymakers to adequately investigate and regulate platform practices. This study aimed to estimate the number of U.S.-based child (0-12 years old) and adolescent (13-17 years old) users and the annual advertising revenue generated from youth across six major platforms. Data were drawn from public survey and market research sources conducted in 2021 and 2022. A simulation analysis was conducted to derive estimates of the number of users and the annual advertising revenue per age group and overall (ages 0-17 years) for 2022. The findings reveal that, across six major social media platforms, the 2022 annual advertising revenue from youth users ages 0-17 years is nearly $11 billion. Approximately 30-40% of the advertising revenue generated from three social media platforms is attributable to young people. Our findings highlight the need for greater transparency from social media platforms as well as regulation of potentially harmful advertising practices that may exploit vulnerable child and adolescent social media users.

Associations between weight discrimination and the use of potentially harmful dietary supplements during the COVID-19 pandemic in the United States

The dietary supplements industry disproportionately markets potentially harmful products promising weight loss, cleansing/detoxing, and boosted energy and immunity to women. The COVID-19 pandemic heightened consumer concerns around health and body weight, which may have increased women's risks of using supplements, particularly if they had a higher weight and experienced weight discrimination. This study aimed to estimate inequities in prevalence and change in use of weight-loss, cleanse/detox, immunity, and energy supplements in the first year of the pandemic and to assess the extent to which the relationship between weight and supplement use differs across discrimination experiences. We drew upon longitudinal data from cisgender women in the U.S. COVID-19 Pandemic Substudy of the Nurses' Health Study II and 3 and Growing Up Today Study cohorts, collected over 5 waves from April/May 2020 to April 2021 (N = 51,814). Modified Poisson generalized estimating equation models, adjusted for age, cohort, race/ethnicity, wave, and Census region, estimated the relative excess risk due to interaction (RERI) between weight status and weight discrimination on prevalence of supplement use. Weight status categories were derived from body mass index (BMI), and weight discrimination was assessed using the attributions item of the Everyday Discrimination Scale. Baseline prevalence of supplement use was 2.7% for weight-loss, 3.3% for cleanse/detox, 4.2% for energy, and 22.6% for immune. Respondents with BMIs of 25-29.9 kg/m2 and 30-34.9 kg/m2 who experienced weight discrimination had RERI values of 0.89 (95% CI 0.14, 1.65) and 1.00 (95% CI 0.25, 1.75) for weight-loss and 0.57 (95% CI 0.13, 1.02) and 0.60 (95% CI 0.19, 1.01) for energy supplements, respectively, indicating this group had excess risk of use compared to lower BMI respondents who experienced no weight discrimination. The findings demonstrate the disproportionate impact of weight discrimination on use of potentially harmful supplements among cisgender women with higher weights during the pandemic.

Weak regulations threaten the safety of consumers from harmful weight-loss supplements globally: results from a pilot global policy scan

OBJECTIVE

To pilot a global policy scan assessing how governments worldwide regulate weight-loss supplements (WLS).

DESIGN

Experts on WLS policies from thirty countries that varied by World Bank income classification, with five from each of the six WHO regions, completed an online survey on WLS regulation in their country. The survey covered six domains: legal frameworks; pre-market requirements; claims, labelling, and advertisements; product availability; adverse events reporting; and monitoring and enforcement. Percentages were calculated for presence or absence of a type of regulation.

SETTING

Experts were recruited through websites of regulatory bodies and professional LinkedIn networks and scientific article searches on Google Scholar.

PARTICIPANTS

Thirty experts, one from each country (i.e. researchers, regulators, other experts in food and drug regulation).

RESULTS

WLS regulations varied widely across countries, and a number of gaps were identified. One country (Nigeria) has a minimum legal age to purchase WLS. Thirteen countries reported independently evaluating the safety of a new WLS product sample. Two countries have limitations on where WLS can be sold. In eleven countries, reports on adverse events related to WLS are publicly available. In eighteen countries, safety of new WLS is to be established through scientific criteria. Penalties for WLS non-compliance with pre-market regulations exist in twelve countries and labelling requirements in sixteen countries.

CONCLUSIONS

Results of this pilot study document wide variability in national WLS regulations globally, exposing many gaps in important components of consumer protection regulatory frameworks for WLS, which likely put consumer health at risk.

Economic Value of Initial Implementation Activities for Proposed Ban on Sales of Over-The-Counter Diet Pills and Muscle-Building Supplements to Minors

Introduction

Over-the-counter diet pills, weight-loss supplements, and muscle-building supplements often contain harmful ingredients and are associated with eating disorder diagnoses and other negative health outcomes. This study estimated the value of state initial implementation activities, for example, regulation development, to implement a ban on the sale of dangerous over-the-counter diet pills and muscle-building supplements to minors.

Methods

We enumerated minimum, best, and maximum values for 22 inputs among 11 activities state employees may undertake if the legislation were signed into law. For employment costs, we estimated staff hours on the basis of data from 10 key informants and obtained salary ranges from a state government website. Data were collected and analyzed between September 2021 and January 2022. We calculated 95% CIs using 10,000 Monte Carlo simulations that varied inputs simultaneously and probabilistically. We conducted two sensitivity analyses using all minimum and all maximum salaries.

Results

The estimated value of state start-up activities was $47,536 (95% CI=$36,831-$57,381). Inputs with the largest impact on this estimate corresponded to combinations of the highest salary and greatest hours per task.

Conclusions

The state's one-time opportunity cost to initiate this age-restriction policy would be minimal considering potential health gains. Sensitivity analyses did not change the conclusion, especially if the state produces subregulations linked to existing law rather than new regulations.

Population-level policy recommendations for the prevention of disordered weight control behaviors: A scoping review

OBJECTIVE

The aim of this scoping review was to identify recommendations and gaps in knowledge surrounding the prevention of disordered weight control behaviors (DWCBs) through policy.

METHOD

A search was conducted in several databases to identify English language articles that described an active policy, recommendation, guideline, or educational curriculum that could be implemented by governments or regulatory bodies to prevent DWCBs or related constructs (e.g., weight stigma, body dissatisfaction). Two researchers independently screened articles with oversight from a third researcher. Data were extracted from the final sample (n = 65) and analyzed qualitatively across all articles and within the domains of education, public policy, public health, industry regulation, and media.

RESULTS

Only a single empirical evaluation of an implemented policy to reduce DWCBs was identified. Over one-third of articles proposed recommendations relating to industry regulation and media (n = 24, 36.9%), followed by education (n = 21, 32.3%), public policy (n = 19, 29.2%), and public health (n = 10, 15.4%). Recommendations included school-based changes to curricula, staff training, and anti-bullying policies; legislation to ban weight discrimination; policies informed by strategic science; collaboration with researchers from other fields; de-emphasizing weight in health communications; diversifying body sizes and limiting modified images in media; and restricting the sale of weight-loss supplements.

DISCUSSION

The findings of this review highlight gaps in empirically evaluated policies to reduce DWCBs but also promising policy recommendations across several domains. Although some policy recommendations were supported by empirical evidence, others were primarily based on experts' knowledge, highlighting the need for greater research on population-level DWCBs prevention through policy.

PUBLIC SIGNIFICANCE

Our scoping review of the evidence on policies for the prevention of disordered weight control behaviors identified several recommendations across the domains of education, public policy, public health, and industry regulation and media. Although few empirical investigations of implemented policies have been conducted, expert recommendations for policies to prevent disordered weight control behaviors among populations are plentiful and warrant future consideration by researchers and policymakers alike.

ALGORITHMS, ADDICTION, AND ADOLESCENT MENTAL HEALTH: An Interdisciplinary Study to Inform State-level Policy Action to Protect Youth from the Dangers of Social Media

A recent Wall Street Journal investigation revealed that TikTok floods child and adolescent users with videos of rapid weight loss methods, including tips on how to consume less than 300 calories a day and promoting a "corpse bride diet," showing emaciated girls with protruding bones. The investigation involved the creation of a dozen automated accounts registered as 13-year-olds and revealed that TikTok algorithms fed adolescents tens of thousands of weight-loss videos within just a few weeks of joining the platform. Emerging research indicates that these practices extend well beyond TikTok to other social media platforms that engage millions of U.S. youth on a daily basis.Social media algorithms that push extreme content to vulnerable youth are linked to an increase in mental health problems for adolescents, including poor body image, eating disorders, and suicidality. Policy measures must be taken to curb this harmful practice. The Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED), a research program based at the Harvard T.H. Chan School of Public Health and Boston Children's Hospital, has assembled a diverse team of scholars, including experts in public health, neuroscience, health economics, and law with specialization in First Amendment law, to study the harmful effects of social media algorithms, identify the economic incentives that drive social media companies to use them, and develop strategies that can be pursued to regulate social media platforms' use of algorithms. For our study, we have examined a critical mass of public health and neuroscience research demonstrating mental health harms to youth. We have conducted a groundbreaking economic study showing nearly $11 billion in advertising revenue is generated annually by social media platforms through advertisements targeted at users 0 to 17 years old, thus incentivizing platforms to continue their harmful practices. We have also examined legal strategies to address the regulation of social media platforms by conducting reviews of federal and state legal precedent and consulting with stakeholders in business regulation, technology, and federal and state government.While nationally the issue is being scrutinized by Congress and the Federal Trade Commission, quicker and more effective legal strategies that would survive constitutional scrutiny may be implemented by states, such as the Age Appropriate Design Code Act recently adopted in California, which sets standards that online services likely to be accessed by children must follow. Another avenue for regulation may be through states mandating that social media platforms submit to algorithm risk audits conducted by independent third parties and publicly disclose the results. Furthermore, Section 230 of the federal Communications Decency Act, which has long shielded social media platforms from liability for wrongful acts, may be circumvented if it is proven that social media companies share advertising revenues with content providers posting illegal or harmful content.Our research team's public health and economic findings combined with our legal analysis and resulting recommendations, provide innovative and viable policy actions that state lawmakers and attorneys general can take to protect youth from the harms of dangerous social media algorithms.

Financial precarity, food insecurity, and psychological distress prospectively linked with use of potentially dangerous dietary supplements during the pandemic in the US

Introduction

Supplements sold with claims to promote weight loss, cleansing/detoxing, increased energy, or boosted immunity can be dangerous, and consumers experiencing extreme stressors may be especially vulnerable to deceptive claims. The purpose of our study was to investigate associations of financial strain and psychological distress during the COVID-19 pandemic with use of supplements sold for weight loss, cleanse/detox, energy, or immunity.

Methods

We used repeated-measures data gathered over five survey waves from April/May 2020-April 2021 from the COVID-19 Substudy (N = 54,951), within three prospective US national cohorts (Nurses' Health Study 2, Nurses' Health Study 3, and Growing Up Today Study), to investigate longitudinal associations between financial strain and psychological distress and risk of use of potentially dangerous types of supplements. Surveys assessed use of supplements prior to and during the first year of the pandemic, as well as financial precarity, food insecurity, depressive and anxiety symptoms, perceived stress, and daily hassles. We fit sociodemographic-adjusted modified Poisson GEE models to estimate risk ratios (RRs) and 95% confidence intervals (CIs) for associations between baseline or lagged time-varying predictors and prevalent or incident (i.e., new-onset) use of each supplement type.

Results

At baseline in April/May 2020, soon after pandemic onset, current use of supplement types was: weight loss 2.7%; cleanse/detox 3.2%; energy 4.4%; immune 22.6%. By the end of the study period, cumulative incidence was: weight loss 3.5%; cleanse/detox 3.7%; energy 4.5%; immune 21.3%. In prevalent-use analyses, financial precarity, food insecurity, and psychological distress were associated with up to 2.4 times the risk of use of these types of supplements across the study period. Similarly, in incident-use analyses, financial precarity and psychological distress were associated with up to 2.1 times the risk of initiating use; whereas, high food insecurity was associated with nearly 1.8 times higher risk of onset of weight-loss supplements use but was not associated with onset of use of other types of supplements.

Discussion

We found consistent evidence that during the first year of the pandemic, participants experiencing elevated financial strain and psychological distress were at heightened risk of initiating use of potentially dangerous types of supplements. Our findings raise concerns about deceptive claims about the safety and product effectiveness by manufacturers of these supplements to profit from vulnerable consumers during the pandemic.

Acceptability of an Online Module Addressing Weight Bias: Perspectives and Attitudes of Undergraduate Health Students and Instructors

Weight bias and discrimination are highly pervasive and harmful to Canadians with higher weights. Researchers and practitioners who deliver, evaluate, and advise on dietary and weight-related interventions may inadvertently perpetuate weight bias through their work; however, trainees in these fields rarely have access to weight bias education within their applied health programs. This study evaluated the acceptability of an online educational weight bias module developed for undergraduate students enrolled in health courses. The intervention included a pre-recorded 20-minute online module with prompts for reflection or discussion, a self-assessment quiz, as well as a separate module and range of resources for instructors. Overall, 211 students from applied health courses and 4 instructors completed an online survey querying the module's delivery, impact, and relevance. Students agreed that the module provided useful information (82%), was easy to understand (97%), and was the right length (75%), but reported wanting more interactivity and engagement with the content. Instructors found the module engaging and useful and expressed interest in additional resources and support for weight bias education. Future research should explore the impact of weight bias education on students' weight-related attitudes and perceptions as well as feasibility and relevance of online features such as multimedia tools.

Evaluation of a one-hour asynchronous video training for eating disorder screening and referral in U.S. Pediatric Primary Care: A pilot study

OBJECTIVE

Develop and pilot-test the efficacy of an online training in improving comfort, knowledge, and behaviors related to eating disorders (EDs) screening among U.S.-based pediatric primary care providers (PCPs).

METHODS

PCPs (N = 84) completed a baseline survey assessing comfort, knowledge, and behaviors regarding ED screening and referral, then watched a 1-h training video followed by a post-video survey. Half of the participants were randomly assigned to complete spaced-education questions in the following 2 months. All participants completed a 2-month follow-up survey. We used McNemar's and McNemar-Bowker tests to assess differences from baseline to post-video and post-video to follow-up, and logistic models to assess differences by spaced-education condition.

RESULTS

From baseline to post-video, there were significant improvements in PCPs' knowledge about and comfort in screening and making referrals for EDs (p < .05). There were no differences between spaced-education conditions in knowledge and behaviors from baseline or post-video to follow-up, but spaced-education participants reported significantly greater comfort in screening for BN (p < .01) and BED (p < .01) compared to non-spaced-education participants.

DISCUSSION

Findings suggest that a 1-h asynchronous training can improve PCP comfort, knowledge, and behavior in screening for EDs; spaced-education may provide slight additional benefits in PCP comfort.

PUBLIC SIGNIFICANCE

The delivery of an 1-h asynchronous online video training helped to improve PCPs' comfort, knowledge, and behavior in screening and referral for EDs among pediatric populations. This has implications for future evaluations of brief trainings among this provider population, which could ultimately help to improve early identification of EDs and referrals to appropriate treatment.

Binge-eating behaviors in adolescents and young adults during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic and subsequent public health measures have resulted in a worsening of eating disorder symptoms and an increase in psychological distress. The present study examined symptoms and behaviors in adolescents and young adults with emotional eating, bingeing behaviors and binge eating disorder during the pandemic. Additionally, the study explored if individuals who experienced pandemic-related food availability and food affordability issues experienced increased binge-eating symptoms and negative feelings.

METHOD

Participants (n = 39) were a convenience sample who participated between November 2020 and January 2021 in a weight and lifestyle management program at an urban New England pediatric hospital. Participants completed online surveys that assessed (1) participant's exposure to COVID-19 related stress and binge-eating behaviors using the COVID-19 Exposure and Family Impact Survey-Adolescent and Young Adult Version (CEFIS-AYA) and the Binge Eating Scale (BES) respectively, (2) participants' and their families' ability to attain and afford food and its association with bingeing behaviors, and (3) the relationship between food availability and affordability and negative emotions.

RESULTS

Nearly half of all participants (48.7%) reported moderate to severe bingeing during the COVID-19 pandemic; those who experienced greater COVID-related stress reported more binge-eating behaviors (p = 0.03). There were no associations between indicators of food availability and affordability and binge eating or between food availability and affordability and negative feelings.

CONCLUSIONS

Higher pandemic-related stress was associated with more binge-eating behaviors among adolescents and young adults. These results underscore the need to monitor symptoms and provide treatment for these patients despite barriers to care imposed by the COVID-19 pandemic. Research and clinical care for adolescents and young adults with EDs must recognize and respond to pandemic effects across the weight and disordered eating spectrum.

"Maybe a little bit of guilt isn't so bad for the overall health of an individual": a mixed-methods exploration of young adults' experiences with calorie labelling

Background

Menu labelling, and more specifically calorie labelling, has been posited as an intervention to improve nutrition literacy and the healthfulness of consumers’ food purchases. However, there is some concern calorie labelling may unintentionally trigger or exacerbate disordered eating among vulnerable persons. The purpose of this research was to explore young adults’ experiences with labelling, with a focus on its implications for their relationships with food.

Methods

Individual semi-structured interviews were conducted with participants from a campus-based menu labelling study. Interview data were inductively coded using thematic analysis and supported by survey data assessing disordered eating, body esteem, and related constructs.

Results

The sample consisted of 13 participants (10 women, 3 men), most of whom perceived themselves as “about the right weight” (62%). Four key themes included: (1) participants’ support of and skepticism about labelling interventions, (2) the identification of knowledge and autonomy as mechanisms of labelling interventions, (3) the role of the individual’s and others’ relationships with food in experiences with labelling, and (4) disordered eating and dieting as lenses that shape experiences with interventions. Participants’ perceptions of and experiences with calorie labels were shaped by gender, body esteem, and disordered eating risk.

Conclusions

The results provide insight into the complexity of young adults’ interactions with labelling interventions and context for future research exploring the unintended consequences of public health nutrition interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13364-w.

Dietary Supplements for Weight Loss: Legal Basis for Excise Tax and Other Government Action to Protect Consumers from a Public Health Menace

PURPOSE

Dietary supplements sold for weight loss pose a risk to public health due to deceptive claims and unscrupulous manufacturing practices in the context of weak federal regulation. Efforts to strengthen U.S. federal oversight have not been successful, thus action at the state and local levels should be explored. This study investigates proposed action to impose excise taxes on weight-loss supplements.

METHODS

We reviewed U.S. federal law on taxation at federal, state, and local levels and precedent for taxation of harmful consumer products to promote public health. We assessed the rationale, legal viability, and potential effectiveness of proposed excise taxes on weight loss supplements.

RESULTS

Taxation of tobacco and sweetened beverages is effective in reducing consumer use. Imposition of excise taxes on weight-loss supplements is within the authority of federal, state, and local governments, though is least politically feasible at the federal level. State or local taxation of these products has clear rationale, legal viability, and likelihood of effectiveness in reducing the public health burden posed by these products.

CONCLUSIONS

Excise taxation is an effective policy intervention to reduce consumer use, particularly among youth, and is a promising public health strategy to decrease consumer exposure to noxious weight-loss supplements.

Integrating Health at Every Size principles into adolescent care

PURPOSE OF REVIEW

Weight trends continue to increase in adolescents, but current weight-focused interventions have not demonstrated any lasting impact on overall health. Among adolescents, experiencing weight bias increases risks of harmful weight-related behaviors and decreases engagement in health-promoting behaviors, thus leading to worsened health outcomes. The Health at Every Size (HAES) approach may be an avenue to promote health holistically among adolescents without eliciting harmful weight-related behavior and improving provider-patient rapport. The purpose of this review is to summarize the literature on integrating HAES principles into healthcare and to generate recommendations for healthcare providers.

RECENT FINDINGS

Research among adults shows that HAES-informed care can improve some physical health measures and generates improvements in behavioral and psychological outcomes, as well as promotion of social justice and equity. HAES-informed recommendations for adolescent care de-emphasize weight loss and focus on removing barriers to engaging in health-promoting behaviors at the point of assessment, in the diagnosis and management of medical complications, and in treatment.

SUMMARY

HAES principles can be an invaluable tool for providers who aim to improve overall health whilst avoiding a focus on weight among their clients.

Weight Management Efforts, But Not Weight Perceptions, Are Associated with Dietary Quality among Youth and Young Adults in Canada

BACKGROUND

Efforts to lose, gain, or maintain weight are prevalent among youth and young adults, but little is known about the relationship between weight management efforts and dietary quality. Attempts to manage weight are typically driven by weight perceptions, which may also uniquely affect overall diet.

OBJECTIVE

The objective was to explore sex-stratified associations between weight management efforts and perceptions with dietary quality among youth and young adults.

DESIGN

Cross-sectional online survey data were drawn from Wave 1 (2016) of the Canada Food Study.

PARTICIPANTS/SETTING

Youth and young adults (n = 3,000), aged 16 to 30 years, were recruited from community settings in five Canadian cities and completed the online survey. The analytic sample consisted of 2,040 participants.

MAIN OUTCOME MEASURES

The Healthy Eating Index-2015 (HEI-2015) was used to characterize dietary quality among participants who completed a 24-hour recall. Respondents reported their weight change efforts over the past year and their weight perception.

STATISTICAL ANALYSES PERFORMED

Sex-stratified multiple linear regression analyses were conducted to investigate relationships between each of weight management efforts and perceptions, separately, and dietary quality, controlling for known covariates.

RESULTS

The HEI-2015 mean score was 52 of 100 possible points. Nearly one quarter of male and female respondents reported not trying to do anything about their weight, whereas 16% reported trying to maintain, 28% and 5% trying to gain, and 33% and 55% trying to lose weight, respectively. Most respondents (63% of males and 66% of females) perceived their weight as just about right. Among males, trying to gain or maintain weight were each significantly associated with higher HEI-2015 mean scores compared with not trying to manage weight (P < .01 and <.001, respectively), whereas this relationship existed only for weight maintenance among female respondents (P < .01). Weight perceptions and HEI-2015 mean scores were not significantly related.

CONCLUSIONS

Efforts to manage weight, which are commonplace among youth and young adults, are associated with dietary quality. Future behavioral research may provide insights into strategies used by youth to manage weight, guiding interventions that recognize links among weight-related behaviors, dietary quality, and other determinants of health.

School-Age Children Can Recall Some Foods and Beverages Consumed the Prior Day Using the Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24) without Assistance

BACKGROUND

Technological innovations allow for collection of 24-h recalls (24HRs) in a broader range of studies than previously possible. The web-based Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24) has been shown to be feasible and to perform well in capturing true intake among adults. However, data to inform use with children are limited.

OBJECTIVE

This observational feeding study was conducted to evaluate children's ability to accurately report a lunchtime meal using ASA24 without assistance.

METHODS

The study was conducted among children (n = 100) aged 10-13 y within a school setting. Students were served an individual cheese pizza, baby carrots, ranch dip, yogurt, a cookie, and 1 choice of water, juice, or milk. Plate waste was collected and weighed. The next day, participants completed ASA24 and a sociodemographic questionnaire. Descriptive statistics were generated to determine match rates by food item and age, and linear regression analyses were conducted to examine associations between sociodemographic characteristics and accuracy of reported energy and nutrient intake. Associations between true and reported energy and nutrient intakes and portion sizes were assessed with use of t tests.

RESULTS

Just under half (49%) of children fully completed ASA24 (median time, 41 min). Children reported an exact, close, or far match for 58% of all foods and beverages consumed, ranging from 29% for dip to 76% for pizza, but also reported some items not consumed as part of the study meal. Older children completed the recall in a shorter time than younger children (mean 31 among 13 y compared with 52 min among 10 y). Intakes of energy (39%), protein (33%), and sodium (78%) were significantly overestimated, whereas portion sizes for cookies (53%) and juice (69%) were underestimated.

CONCLUSIONS

Children can report some foods and drinks consumed using ASA24, but our findings suggest challenges with independent completion, necessitating research to examine strategies, such as training and resources, to support data quality.

Top dietary sources of energy, sodium, sugars, and saturated fats among Canadians: insights from the 2015 Canadian Community Health Survey

Dietary factors are major contributors to morbidity and mortality, and significant attention is being paid to interventions to support healthy eating, including through the creation of a healthier food supply. The objective of this study was to inform interventions to support healthy eating by examining the top dietary sources of calories, sodium, sugars, and saturated fats among Canadians in relation to sex, age, and income. We drew upon data from the 2015 Canadian Community Health Survey, which collected interviewer-administered 24-h dietary recalls from Canadians who were 1 year of age and older (n = 20 176), residing in the 10 provinces. Foods and beverages were grouped into 91 mutually exclusive categories (e.g., 100% fruit juice, fruit drinks). On the basis of the average proportion contributed, the top 20 sources of each dietary component were identified for all individuals and by sex–age and income groups. The mean amount of each dietary component contributed by each category (per capita and per consumer) and the proportions of persons consuming items in each category were also examined. Top sources included commonly consumed items (e.g., breads and flatbreads as sources of sodium), as well as those high in a given dietary component (e.g., soda as a source of sugars). Several food and beverage categories were top contributors to more than one dietary component examined, suggesting possible priorities for intervention and future analyses. The identification of major sources of calories and nutrients of concern can inform population health efforts, such as reformulation, to improve the health of Canadians.

Gaps in the Evidence on Population Interventions to Reduce Consumption of Sugars: A Review of Reviews

There is currently considerable attention directed to identifying promising interventions to reduce consumption of sugars among populations around the world. A review of systematic reviews was conducted to identify gaps in the evidence on such interventions. Medline, EMBASE CINAHL, and the Cochrane Database of Systematic Reviews were searched to identify systematic reviews published in English from January 2005 to May 2017 and considering research on interventions to reduce sugar intake. Twelve systematic reviews that considered price changes, interventions to alter the food available within specific environments, and health promotion and education programs were examined. Each of the identified reviews focused on sugar-sweetened beverages (SSBs). The existing literature provides some promising indications in terms of the potential of interventions to reduce SSB consumption among populations. However, a common thread is the limited scope of available evidence, combined with the heterogeneity of methods and measures used in existing studies, which limits conclusions that can be reached regarding the effectiveness of interventions. Reviewed studies typically had limited follow-up periods, making it difficult to assess the sustainability of effects. Further, there is a lack of studies that address the complex context within which interventions are implemented and evaluated, and little is known about the cost-effectiveness of interventions. Identified gaps speak to the need for a more holistic approach to sources of sugars beyond SSBs, consensus on measures and methods, attention to the implementation of interventions in relation to context, and careful monitoring to identify intended and unintended consequences.

Correlates of Weight-Loss Methods Among Young Adults in Canada

OBJECTIVE

The aim of this study was to examine the prevalence of various weight-loss behaviors among young adults in Canada and differences in the use of these methods by demographic characteristics, health literacy, and perceived body size.

METHODS

Data from the 2016 wave of the Canada Food Study were used, which collected self-reported information from 3,000 young adults in five cities. Linear regression models were conducted to investigate correlates of the number and type of weight-loss methods used across the following four categories: dietary changes, physical activity, assisted weight-loss methods, and unhealthy behaviors.

RESULTS

In the past 12 months, more than half of respondents reported a weight-loss attempt, and nearly one-fifth engaged in an unhealthy weight-loss method. The risk of engaging in a greater number of weight-loss behaviors across categories was higher for women, nonbinary-gendered individuals, and individuals who perceived themselves as having overweight or obesity. Respondents with lower health literacy engaged in a significantly greater number of unhealthy methods.

CONCLUSIONS

Many young adults use healthier weight-loss strategies, but a concerning number use multiple and/or unhealthy weight-loss methods as well. Furthermore, there are subgroup differences in weight-loss method engagement, which holds significance for public health efforts aiming to improve weight-related behaviors.

Dieting predicts engagement in multiple risky behaviours among adolescent Canadian girls: a longitudinal analysis

OBJECTIVES

We investigated associations between dieting and other health-compromising behaviours among adolescent girls, both cross-sectionally and longitudinally. The behaviours considered included smoking, binge drinking, and breakfast-skipping, and clusters of these.

METHODS

Data for 3386 adolescent Ontario girls were drawn from COMPASS, a school-based study, which collects self-reported measures of weight, dieting, and other health-related factors. Multilevel logistic regression models were used to investigate relationships between dieting at baseline and smoking, binge drinking, and breakfast-skipping, as well as clusters of these behaviours at baseline and 2 years later.

RESULTS

Baseline dieters were at an elevated risk of smoking and binge drinking (RR = 1.8 and 1.5, respectively) by follow-up compared to non-dieters. Further, dieting was associated with combinations of these behaviours, with the highest risks for smoking/breakfast-skipping (RR = 1.64) and smoking/binge drinking (RR = 1.55). Over one in two (58%) girls reported dieting at baseline and four in five baseline dieters reported dieting 2 years later. Seven in ten girls were dieting at one or both time points. Baseline dieters were more likely to engage in a greater number of risky behaviours, regardless of what the actual behaviours were.

CONCLUSION

Dieting is longitudinally associated with engagement in other risky behaviours among adolescent girls. These findings suggest that dieting may be an early risk factor for engagement in other risky behaviours and highlight the need for comprehensive prevention strategies to target shared underlying drivers. In addition, attention is needed to the potential for well-meaning weight-related initiatives to promote dieting.

Self-Report Dietary Assessment Tools Used in Canadian Research: A Scoping Review

Choosing the most appropriate dietary assessment tool for a study can be a challenge. Through a scoping review, we characterized self-report tools used to assess diet in Canada to identify patterns in tool use and to inform strategies to strengthen nutrition research. The research databases Medline, PubMed, PsycINFO, and CINAHL were used to identify Canadian studies published from 2009 to 2014 that included a self-report assessment of dietary intake. The search elicited 2358 records that were screened to identify those that reported on self-report dietary intake among nonclinical, non-Aboriginal adult populations. A pool of 189 articles (reflecting 92 studies) was examined in-depth to assess the dietary assessment tools used. Food-frequency questionnaires (FFQs) and screeners were used in 64% of studies, whereas food records and 24-h recalls were used in 18% and 14% of studies, respectively. Three studies (3%) used a single question to assess diet, and for 3 studies the tool used was not clear. A variety of distinct FFQs and screeners, including those developed and/or adapted for use in Canada and those developed elsewhere, were used. Some tools were reported to have been evaluated previously in terms of validity or reliability, but details of psychometric testing were often lacking. Energy and fat were the most commonly studied, reported by 42% and 39% of studies, respectively. For ∼20% of studies, dietary data were used to assess dietary quality or patterns, whereas close to half assessed ≤5 dietary components. A variety of dietary assessment tools are used in Canadian research. Strategies to improve the application of current evidence on best practices in dietary assessment have the potential to support a stronger and more cohesive literature on diet and health. Such strategies could benefit from national and global collaboration.