Population Subgroups at Risk of Unhealthy Changes in Food and Beverage Consumption During COVID-19 Lockdowns

BACKGROUND

Understanding health behaviour changes during the COVID-19 pandemic can assist in developing strategies to promote healthy lifestyles at such times. The aim of this exploratory study was to examine whether the frequency of consuming unhealthy foods and beverages changed during lockdown and whether certain population subgroups were more likely to make such changes.

METHOD

An online survey was administered to a national sample of 4022 Australian adults (51% female, mean age 48 years). Generalised linear models with generalised estimating equations were used to identify whether demographic characteristics (age, gender, education, presence of children in the household, number of people in the household) and beliefs related to COVID-19 were associated with changes in the frequency of consuming alcohol, sweet snacks, salty snacks, and sugary beverages from pre to during lockdown.

RESULTS

Overall, the frequency of consuming the four assessed unhealthy products did not change during lockdown. However, being male and having children at home were consistently associated with unhealthy changes, whereas believing that alcohol or unhealthy diets would exacerbate COVID-19 severity was linked to a decreased frequency of consuming these products respectively. Age, education, and living with more people were also associated with changes in the frequency of consuming some product categories.

CONCLUSION

During lockdown, certain population subgroups appeared to be at increased risk of more frequent consumption of unhealthy foods and beverages. Believing certain consumption habits are linked to adverse health impacts of COVID was found to reduce frequency of consumption of related products, presenting a potential focus for future public health actions.

Protocol for the implementation and evaluation of a community-based behavior change intervention to reduce dietary salt intake in India

Excess dietary salt intake is well established as a leading cause of high blood pressure and associated cardiovascular disease, yet current salt intake in India is nearly 11 g per day, more than twice World Health Organization maximum recommended intake of 5 g per day. Although dietary survey data from India indicate that the main sources of dietary salt are salt added during cooking at home, and few salt reduction efforts have focused on interventions at the household level. As a result, there is little evidence of the effectiveness of behavior change programs to reduce salt intake at the household level. The study aims to develop and implement a community based behavioral change intervention to reduce salt intake delivered by front line community-based health volunteers; and evaluate the preliminary effectiveness, acceptability, and feasibility of delivering a salt reduction behavior change program and potential to support future scale-up. The study is a pre-post intervention design, and outcomes will be evaluated from a random sample of 1500 participants from 28 villages in two primary health centers in Siddipet, Telangana. Primary outcome is change in salt-related KAB (knowledge, attitude, and behavior) score, and secondary outcomes will be changes in salt intake measured by 24 h urinary sodium excretion and change in scores using the subscales of the COM-B ("capability", "opportunity", "motivation" and "behavior") tool. Findings will be used to inform future public health policies to support implementation of scalable community-based interventions to reduce salt intake and control hypertension, the leading-cause of death in India.

Advancing Health Research Impact through a Systemic Multi-Sectoral Approach: A Protocol for Introducing Reduced-Sodium Salts and Salty Condiments in Vietnam

Better alignment between health research organisations with the needs (and interests) of key stakeholders in the health policy and research system is critical to improving research impact. The George Institute for Global Health's 'Healthier Societies' program focuses on harnessing the power of governments, markets, and communities to improve population level health equity outcomes and maximise research impact. This protocol outlines a systemic multi-sectoral approach to advance health research impact globally applied to a project to reduce population salt intake in Vietnam by introducing reduced-sodium salts and salty condiments. We defined a systemic multi-sectoral approach to be a strategy that involves engaging with government, market and communities in a deliberate and joined-up way to solve a problem in which they all have a role to play. The project objectives are to: (i) produce reduced-sodium fish sauce products and test consumer acceptability; (ii) investigate the market feasibility of introducing reduced-sodium foods (salt, bot canh and fish sauce) into the Vietnamese market; (iii) estimate the cost-effectiveness of three different government strategies to support the implementation of reduced-sodium products; and (iv) develop an advocacy roadmap to maximise potential research impact. Methods will include standard quality and safety assessments, consumer sensory testing for the locally produced reduced-sodium fish sauces, market feasibility assessment (including collating market data and semi-structured interviews with stakeholders), cost-effectiveness modelling (Markov cohort model), multi-sector stakeholder engagement, and the development of a coordinated advocacy strategy using the Kotter Plus framework. Health research organisations are increasingly seeking ways to achieve greater impact with their research. Through the application of a systemic multi-sectoral approach with governments, markets and communities, this protocol provides an example of how health research projects can achieve such impact.

The cost-effectiveness of government actions to reduce sodium intake through salt substitutes in Vietnam

Background

Dietary sodium reduction is recommended to reduce the burden of cardiovascular disease. In Vietnam food products including salt, fish sauce and bot canh contribute to ~ 70% of dietary sodium intake. Reduced sodium versions of these products can be produced by replacing some of the sodium chloride with potassium chloride. We aimed to assess the cost-effectiveness of three alternative approaches to introducing reduced sodium products onto the market with a view to lowering population sodium intake in Vietnam.

Methods

The three salt substitution strategies included voluntary, subsidised and regulatory approaches targeting salt, fish sauce and bot canh products. Costs were modelled using the WHO-CHOICE methodology. A Markov cohort model was developed to evaluate the cost-effectiveness of each strategy versus no intervention from the government perspective. The model linked each intervention strategy to assumed changes in levels of sodium intake and then to systolic blood pressure. Changes in SBP were linked to a probability of ischaemic heart disease or stroke. The model followed people over their lifetime to assess average costs and quality adjusted life years (QALYs) gained for each strategy.

Results

The voluntary salt substitution strategy was assumed to require no investment by government. Following ramp up (years 6+), the average annual costs for the subsidised and regulatory strategies were 21,808,968,902 ₫ (US$ 977,354) and 12,949,953,247 ₫ (US$ 580,410) respectively. Relative to no intervention, all three salt substitution strategies were found to be cost-effective. Cost savings were driven by reductions in strokes (32,595; 768,384; 2,366,480) and ischaemic heart disease (IHD) events (22,830; 537,157; 1,648,590) for the voluntary, subsidised & regulatory strategies, respectively. The voluntary strategy was least cost-effective (− 3445 ₫ US$ -0.15; 0.009 QALYs gained) followed by the subsidised strategy (− 43,189 ₫ US$ -1.86; 0.022 QALYs gained) and the regulatory strategy delivered the highest cost savings and health gains (− 243,530 ₫ US$ -10.49; 0.074 QALYs gained).

Conclusion

This research shows that all three modelled salt substitution strategies would be good value for money relative to no intervention in Vietnam. The subsidised alternative would require the highest level of government investment; however the implementation costs will be exceeded by healthcare savings assuming a reasonable time horizon is considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-021-00540-4.

Towards a multi-level framework of household food waste and consumer behaviour: Untangling spaghetti soup

Changing the everyday food-related behaviours of consumers is a critical part of tackling the global food waste challenge. Comprehensive frameworks of household food waste and consumer behavior are needed to guide the development of targeted interventions and future research agendas. This study systematically reviews food waste and behaviour studies from developed nations to provide an overview of the current research field. It uses a multi-level perspective to organise the various factors influencing food-related behaviour and proposes a new, multi-level, framework of consumer behaviour and household food waste. A novel addition to the field, the framework gathers factors at micro (individual), meso (household), and macro (external to the household) levels and argues that behaviour and food waste emerge from their interactions. Our review also reveals a research domain with disciplinary and methodological ‘bald spots’ and an over-emphasis on individual level factors. A multi-level research agenda focusing on under-explored factors and interactions between factors across levels is presented, and consideration given to multi-level interventions that support consumer behaviour change to reduce household food waste.

Monitoring and implementation of salt reduction initiatives in Africa: A systematic review

This systematic review aims to document salt consumption patterns and the implementation status and potential impact of salt reduction initiatives in Africa, from studies published between January 2009 and November 2019. Studies were sourced using MEDLINE, Embase, Cochrane Library electronic databases, and gray literature. Of the 887 records retrieved, 38 studies conducted in 18 African countries were included. Twelve studies measured population salt intake, 11 examined salt level in foods, 11 assessed consumer knowledge, attitudes, and behaviors, 1 study evaluated a behavior change intervention, and 3 studies modeled potential health gains and cost savings of salt reduction interventions. The population salt intake studies determined by 24‐hour urine collections showed that the mean (SD) salt intake in African adults ranged from 6.8 (2.2) g to 11.3 (5.4) g/d. Salt levels in foods were generally high, and consumer knowledge was fairly high but did not seem to translate into salt lowering behaviors. Modeling studies showed that interventions for reducing dietary sodium would generate large health gains and cost savings for the health system. Despite this evidence, adoption of population salt reduction strategies in Africa has been slow, and dietary consumption of sodium remains high. Only South Africa adopted legislation in 2016 to reduce population salt intake, but success of this intervention has not yet been fully evaluated. Thus, rigorous evaluation of the salt reduction legislation in South Africa and initiation of salt reduction programs in other African countries will be vital to achieving the targeted 30% reduction in salt intake by 2025.

A comprehensive overview and qualitative analysis of government-led nutrition policies in Australian institutions

Background

Institutions are a recommended setting for dietary interventions and nutrition policies as these provide an opportunity to improve health by creating healthy food environments. In Australia, state and territory governments encourage or mandate institutions in their jurisdiction to adopt nutrition policies. However, no work has analysed the policy design across settings and jurisdictions. This study aimed to compare the design and components of government-led institutional nutrition policies between Australian states and territories, determine gaps in existing policies, and assess the potential for developing stronger, more comprehensive policies.

Methods

Government-led institutional nutrition policies, in schools, workplaces, health facilities and other public settings, were identified by searching health and education department websites for each Australian state and territory government. This was supplemented by data from other relevant stakeholder websites and from the Food Policy Index Australia website. A framework for monitoring and evaluating nutrition policies in publicly-funded institutions was used to extract data and a qualitative analysis of the design and content of institutional nutrition policies was performed. Comparative analyses between the jurisdictions and institution types were conducted, and policies were assessed for comprehensiveness.

Results

Twenty-seven institutional nutrition policies were identified across eight states and territories in Australia. Most policies in health facilities and public schools were mandatory, though most workplace policies were voluntary. Twenty-four included nutrient criteria, and 22 included guidelines for catering/fundraising/advertising. While most included implementation guides or tools and additional supporting resources, less than half included tools/timelines for monitoring and evaluation. The policy design, components and nutrient criteria varied between jurisdictions and institution types, though all were based on the Australian Dietary Guidelines.

Conclusions

Nutrition policies in institutions present an opportunity to create healthy eating environments and improve population health in Australia. However, the design of these policies, including lack of key components such as accountability mechanisms, and jurisdictional differences, may be a barrier to implementation and prevent the policies having their intended impact.

A level-of-analysis issue in resource consumption and environmental behavior research: A theoretical and empirical contradiction

Behavioral theories have much to offer researchers and policy makers who seek sustainable resource management within households. However, much research on household resource consumption applies theories of the individual to understand the behavioral patterns of what are very often groups of people cohabiting in a particular dwelling. This misalignment of levels of analysis leads to erroneous empirical results and conclusions, and thereby less effective policy and management actions. We address this issue by first detailing the nature of the problem; illustrating its pervasiveness in research on resource consumption behaviors; offering some ways forward by drawing on research on group dynamics; and exploring new ways of thinking about some existing concepts in resource consumption and conservation with the goal of developing insights from a household-level perspective. We suggest that researchers seek a multi-level understanding of consumption and conservation in future research, as this could lead to theories and evidence to support group-level interventions that target behaviors in a household setting, which is likely to be more effective than existing individualistic approaches.

Adolescents' Responses to a School-Based Prevention Program Promoting Healthy Eating at School

Background

To improve the effectiveness of school-based programs that aim to promote adolescents' healthy food choices, it is essential to understand the views and behaviors of the target group. This study aimed to get a better understanding of adolescents' food and health perceptions and their willingness to be involved in a specific school-based prevention program, i.e., the Dutch "Healthy School Canteen Program."

Methods

This study used a mixed-methods research design. First, seven semi-structured focus groups were conducted using a selective sample of 42 Dutch adolescents (25 girls, 17 boys, aged 13-16 years). Second, an online survey among 133 adolescent respondents (72 girls, 61 boys, aged 12-19 years) using snowball sampling was conducted. Content analysis was performed to make inferences about the focus group discussions, whereas statistical analyses were conducted to analyze the survey data.

Results

Findings from the group discussions indicated that healthy eating was only an issue of importance when adolescents perceived negative physical changes (e.g., with regard to looks or physical performance). Adolescents also indicated that they clearly wanted to make their own food and beverage choices at school. The quantitative data indicated that taste, price, and variety were seen as the most important aspects of a healthy food assortment (mean scores 8.1, 7.8, and 7.7 on a 10-point scale, respectively). In general, a majority of the adolescents (64%) expressed that students should be involved in the organization of a healthy food environment in schools. At the same time, however, adolescents were not willing to participate themselves. This was mostly because they were skeptical about their ideas being heard and put into action by their schools.

Conclusion

School-based prevention programs, such as the Healthy School Program, should take into account that adolescents have a low risk perception of unhealthy eating and are seeking food choice autonomy. In addition, schools should not lose sight of product price, taste, and variety to make their food assortment attractive to students. If schools aim to involve adolescents in prevention programs that promote healthy eating, it is essential that they have a formal student involvement process that ensures that adolescents' suggestions are valued.

Shrinking the food-print: A qualitative study into consumer perceptions, experiences and attitudes towards healthy and environmentally friendly food behaviours

Internationally, there is increasing recognition of the importance of multilevel policies and actions that address healthy and environmentally friendly food behaviours. However it is not yet clear which actions are most suitable to support consumers to adopt both behaviours concurrently. To this end, we undertook a qualitative study to assess consumer perceptions, experiences and attitudes towards healthy and environmentally friendly foods and four target behaviours: reducing overconsumption of food beyond energy needs, reducing consumption of low-nutrient energy dense foods, eating less animal- and more plant-derived foods, and reducing food waste. Online in-depth interviews were held with 29 Australian food shoppers representing different levels of involvement with health and environment in daily food choices. The results indicate that compared to health, the relationship between food and the environment is rarely considered by consumers. The four target food behaviours were primarily associated and motivated by an impact on health, except for not wasting foods. Participants had the most positive attitude and highest motivation for eating less processed and packaged foods, mostly to avoid excessive packaging and 'chemicals' in foods. This was followed by the behaviours reducing food waste and overconsumption. Conversely, there was a predominantly negative attitude towards, and low motivation for, eating less animal-derived products and more plant based foods. Overall, consumers found a joined concept of healthy and environmentally friendly foods an acceptable idea. We recommend that health should remain the overarching principle for policies and actions concerned with shifting consumer behaviours, as this personal benefit appears to have a greater potential to support behaviour change. Future consumer focused work could pay attention to framing behavioural messages, providing intermediate behavioural goals, and a multiple target approach to change habitual behaviours.

Food-related lifestyle and health attitudes of Dutch vegetarians, non-vegetarian consumers of meat substitutes, and meat consumers

The aim was to investigate socio-demographic characteristics, and attitudes to food and health of vegetarians, non-vegetarian consumers of meat substitutes, and meat consumers in The Netherlands. The sample used for this study (participants > or =18 years) was taken from the Dutch National Food Consumption Survey, 1997/1998. Vegetarians (n = 63) and consumers of meat substitutes (n = 39) had similar socio-demographic profiles: higher education levels, higher social economic status, smaller households, and more urbanised residential areas, compared to meat consumers (n = 4313). Attitudes to food were assessed by the food-related lifestyle instrument. We found that vegetarians (n = 32) had more positive attitudes towards importance of product information, speciality shops, health, novelty, ecological products, social event, and social relationships than meat consumers (n = 1638). The health consciousness scale, which was used to assess attitudes to health, supported earlier findings that vegetarians are more occupied by health. Food-related lifestyle and health attitudes of meat substitute consumers (n = 17) were predominantly in-between those from vegetarians and meat consumers. The outcome of this study suggests that in strategies to promote meat substitutes for non-vegetarian consumers, the focus should not only be on health and ecological aspects of foods.

An improved NMR method for the quantification of alpha-acids in hops and hop products

A new and independent method for the quantification of alpha-acids in hops and hop products has been developed. NMR was used as a qualitative method for the complete assignment of all 1H- and 13C-NMR signals of the three main alpha-acids, cohumulone (1), humulone (2) and adhumulone (3). In a 13C two-dimensional INADEQUATE experiment, the 13C-NMR spectrum of 1 was unambiguously assigned via the carbon-carbon connectivities. Use of NMR as a quantitative method allowed quantification of the pure and individual alpha-acids 1 and 2, and the determination of the absolute concentration of solutions of these compounds. Quantification of alpha-acids by NMR is less complicated and more reliable than the methods used until now.

Ursodeoxycholic acid therapy for primary sclerosing cholangitis: results of a 2-year randomized controlled trial to evaluate single versus multiple daily doses

BACKGROUND/AIMS

Ursodeoxycholic acid has been reported to be of potential benefit for primary sclerosing cholangitis but little is known about the long-term biochemical, histological and radiological efficacy or the optimum frequency of ursodeoxycholic acid administration.

METHODS

A 2-year multicentre randomised controlled trial was initiated to assess the effects of ursodeoxycholic acid (10 mg kg(-1).d(-1), given in either single or multiple daily doses, on symptoms, serum liver tests, cholangiographic and histological findings and the occurrence of treatment failure. Liver biopsies were taken and endoscopic retrograde cholangiography was performed at entry and after 2 years; follow-up examinations were at 3-month intervals. Treatment failure was defined as death, liver transplantation, 4-fold increase in serum bilirubin, variceal bleeding, de novo ascites or cholangitis. Actuarial survival was compared with predicted survival using the revised Mayo natural history model for primary sclerosing cholangitis.

RESULTS

Forty-eight patients were enrolled. In one case, ursodeoxycholic acid had to be discontinued because of gastro-intestinal complaints. No other side-effects were observed. After 2 years of follow-up, treatment was not associated with a beneficial effect on either symptoms or liver histology. Serum liver tests (alkaline phosphatase, y-glutamyl transferase, aspartate aminotransferase) improved significantly in both groups, while serum bilirubin (which was near normal at entry) and IgG remained stable. No major changes in radiographic bile duct appearance seemed to be present. After 2 years, actuarial survival was 91% (95 CI 83%-99%), which is comparable to the predicted 97% survival rate. Treatment failure occurred in 15% of cases. No significant differences in any of the study endpoints (symptoms, serum liver tests, cholangiographic findings, histology, disease progression) were found between the two groups.

CONCLUSIONS

Ursodeoxycholic acid is well tolerated in primary sclerosing cholangitis. Significant effects on biochemical parameters were found and symptoms, bilirubin and histology did not deteriorate. No advantage of a multiple daily dose over a single dose was observed.

Lack of effect of dietary minerals on liver cholesterol concentrations in rats

Female rats were fed cholesterol-free, purified diets with different concentrations of calcium (0.13-0.75%, w/w), magnesium (0.02 or 0.04%) or phosphorus (0.2-0.8%) as the only dietary variable. After 28 days, no effects of the minerals were found on liver cholesterol concentrations and rates of fecal excretion of bile acids.

Influence of dietary calcium:phosphorus ratio on mineral excretion and nephrocalcinosis in female rats

The effects of dietary calcium (Ca) concentration and calcium: phosphorus (Ca:P) ratio on mineral balance and nephrocalcinosis were studied in female rats. In the first experiment there were two dietary Ca concentrations (0.25 and 0.50%, wt/wt) at two different Ca:P ratios (0.6 and 1.3). In the second experiment the diets were formulated to contain 0.40% P and either 0.13, 0.25, 0.50 or 0.75% Ca. The diets contained 0.03% magnesium (Mg). The fecal outputs of Ca, P and Mg were lower (P less than 0.01) after feeding low Ca diets than after feeding high Ca diets. Urinary excretion of P decreased with increasing dietary Ca and increased with increasing P intake. In rats fed the 0.25% Ca diets whole-body retentions of Ca and P were lower than in the rats fed 0.50% Ca. Both increases in dietary Ca from 0.13 to 0.50% and P from 0.20 to 0.40% elevated Ca and P content of kidneys as well as the degree of nephrocalcinosis. However, after feeding the highest Ca concentration (0.75%) nephrocalcinosis was essentially absent while kidney concentrations of Ca and P were relatively low. When compared with 0.50% Ca in the diet, 0.75% Ca increased group mean whole-body retention of Ca but lowered that of P. In individual rats the degree of nephrocalcinosis and the concentrations of minerals in kidney were positively correlated.

Elevated lesions in the duodenal bulb caused by heterotopic gastric mucosa

Heterotopic gastric mucosa in the duodenal bulb is sometimes seen as elevated lesions. Radiological and endoscopic findings in 22 patients are reported, and the characteristic appearance on each study is described. Glucagon-induced hypotonia of the duodenal bulb facilitates the diagnosis.