Interventions to prevent or manage obesity in Māori and Pacific adults: a systematic review and narrative synthesis

OBJECTIVES

Obesity and its sequelae are an increasing problem, disproportionally affecting Māori and Pacific peoples, secondary to multifactorial systemic causes, including the effects of colonisation and the impact of globalisation. There is limited synthesised evidence on interventions to address obesity in these populations. The objective of this review is to identify evaluated interventions for prevention and management of obesity amongst Māori and Pacific adults, assess the effectiveness of these interventions, and identify enablers and barriers to their uptake.

DESIGN

Systematic review of databases (Medline, PubMed, EMBASE, CINAHL, Scopus, CENTRAL), key non-indexed journals, and reference lists of included articles were searched from inception to June 2021. Eligibility criteria defined using a Population, Intervention, Control, Outcome format and study/publication characteristics. Quantitative and qualitative data were extracted and analysed using narrative syntheses. Study quality was assessed using modified GRADE approach.

RESULTS

From the 8190 articles identified, 21 were included, with 18 eligible for quantitative and five for qualitative analysis. The studies were heterogenous, with most graded as low quality. Some studies reported small but statistically significant improvements in weight and body mass index. Key enablers identified were social connection, making achievable sustainable lifestyle changes, culturally-centred interventions and incentives including money and enjoyment. Barriers to intervention uptake included difficulty in maintaining adherence to a programme due to intrinsic programme factors such as lack of social support and malfunctioning or lost equipment.

CONCLUSIONS

Normal weight trajectory is progressive increase over time. Modest weight loss or no weight gain after several years may have a positive outcome in lowering progression to diabetes, or improvement of glycaemic control in people with diabetes. We recommend urgent implementation of Māori and Pacific-led, culturally-tailored weight loss programmes that promote holistic, small and sustainable lifestyle changes delivered in socially appropriate contexts.

A1 beta-casein milk protein and other environmental pre-disposing factors for type 1 diabetes

Globally type 1 diabetes incidence is increasing. It is widely accepted that the pathophysiology of type 1 diabetes is influenced by environmental factors in people with specific human leukocyte antigen haplotypes. We propose that a complex interplay between dietary triggers, permissive gut factors and potentially other influencing factors underpins disease progression. We present evidence that A1 β-casein cows’ milk protein is a primary causal trigger of type 1 diabetes in individuals with genetic risk factors. Permissive gut factors (for example, aberrant mucosal immunity), intervene by impacting the gut’s environment and the mucosal barrier. Various influencing factors (for example, breastfeeding duration, exposure to other dietary triggers and vitamin D) modify the impact of triggers and permissive gut factors on disease. The power of the dominant trigger and permissive gut factors on disease is influenced by timing, magnitude and/or duration of exposure. Within this framework, removal of a dominant dietary trigger may profoundly affect type 1 diabetes incidence. We present epidemiological, animal-based, in vitro and theoretical evidence for A1 β-casein and its β-casomorphin-7 derivative as dominant causal triggers of type 1 diabetes. The effects of ordinary milk containing A1 and A2 β-casein and milk containing only the A2 β-casein warrant comparison in prospective trials.

A parent-based intervention to promote healthy eating and active behaviours in pre-school children: evaluation of the MEND 2-4 randomized controlled trial

BACKGROUND

There is a paucity of studies evaluating targeted obesity prevention interventions in pre-school children.

OBJECTIVES

We conducted a randomized controlled trial to evaluate the efficacy of a parent-based obesity prevention intervention for pre-schoolers - MEND (Mind, Exercise, Nutrition … Do It!) 2-4 on child diet, eating habits, physical activity/sedentary behaviours, and body mass index (BMI).

METHODS

Parent-child dyads attended 10 weekly 90-min workshops relating to nutrition, physical activity and behaviours, including guided active play and healthy snack time. Assessments were conducted at baseline, immediately post-intervention, and 6 and 12 months post-intervention; child intake of vegetables, fruit, beverages, processed snack foods, fussiness, satiety responsiveness, physical activity, sedentary behaviour and neophobia were assessed via parent proxy report. Parent and child height and weight were measured.

RESULTS

Two hundred one parent-child dyads were randomized to intervention (n = 104) and control (n = 97). Baseline mean child age was 2.7 (standard deviation [SD] 0.6) years, and child BMI-for-age z-score (World Health Organization) was 0.66 (SD 0.88). We found significant positive group effects for vegetable (P = 0.01) and snack food (P = 0.03) intake, and satiety responsiveness (P = 0.047) immediately post-intervention. At 12 months follow-up, intervention children exhibited less neophobia (P = 0.03) than controls.

CONCLUSION

Future research should focus on additional strategies to support parents to continue positive behaviour change. ACTRN12610000200088.

A proposed approach to systematically identify and monitor the corporate political activity of the food industry with respect to public health using publicly available information

Unhealthy diets represent one of the major risk factors for non-communicable diseases. There is currently a risk that the political influence of the food industry results in public health policies that do not adequately balance public and commercial interests. This paper aims to develop a framework for categorizing the corporate political activity of the food industry with respect to public health and proposes an approach to systematically identify and monitor it. The proposed framework includes six strategies used by the food industry to influence public health policies and outcomes: information and messaging; financial incentive; constituency building; legal; policy substitution; opposition fragmentation and destabilization. The corporate political activity of the food industry could be identified and monitored through publicly available data sourced from the industry itself, governments, the media and other sources. Steps for country-level monitoring include identification of key food industry actors and related sources of information, followed by systematic data collection and analysis of relevant documents, using the proposed framework as a basis for classification of results. The proposed monitoring approach should be pilot tested in different countries as part of efforts to increase the transparency and accountability of the food industry. This approach has the potential to help redress any imbalance of interests and thereby contribute to the prevention and control of non-communicable diseases.

Large reductions in child overweight and obesity in intervention and comparison communities 3 years after a community project

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Childhood obesity has been increasing over decades and scalable, population-wide solutions are urgently needed to reverse this trend. Evidence is emerging that community-based approaches can reduce unhealthy weight gain in children. In some countries, such as Australia, the prevalence of childhood obesity appears to be flattening, suggesting that some population-wide changes may be underway.

WHAT THIS STUDY ADDS

A community-based intervention project for obesity prevention in a rural town appears to have increasing effects 3 years after the end of the project, substantially reducing overweight and obesity by 6% points in new cohorts of children, 6 years after the original baseline. An apparent and unanticipated 'spillover' of effects into the surrounding region appeared to have occurred with 10%-point reductions in childhood overweight and obesity over the same time period. A 'viral-like' spread of obesity prevention efforts may be becoming possible and an increase in endogenous community activities appears to be surprisingly successful in reducing childhood obesity prevalence.

BACKGROUND

The long-term evaluations of community-based childhood obesity prevention interventions are needed to determine their sustainability and scalability.

OBJECTIVES

To measure the impacts of the successful Be Active Eat Well (BAEW) programme in Victoria, Australia (2003-2006), 3 years after the programme finished (2009).

METHODS

A serial cross-sectional study of children in six intervention and 10 comparison primary schools in 2003 (n = 1674, response rate 47%) and 2009 (n = 1281, response rate 37%). Height, weight, lunch box audits, self-reported behaviours and economic investment in obesity prevention were measured.

RESULTS

Compared with 2003, the 2009 prevalence of overweight/obesity (World Health Organization criteria) was significantly lower (P < 0.001) in both intervention (39.2% vs. 32.8%) and comparison (39.6% vs. 29.1%) areas, as was the mean standardized body mass index (0.79 vs. 0.65, 0.77 vs. 0.57, respectively) with no significant differences between areas. Some behaviours improved and a few deteriorated with any group differences favouring the comparison area. In 2009, the investment in obesity prevention in intervention schools was about 30 000 Australian dollars (AUD) per school per year, less than half the amount during BAEW. By contrast, the comparison schools increased from a very low base to over 66 000 AUD per school per year in 2009.

CONCLUSIONS

The 8%-point reduction in overweight/obesity in both areas over 6 years from baseline to 3 years post-intervention was substantial. While the benefits of BAEW increased in the intervention community in the long term, the surrounding communities appeared to have more than caught up in programme investments and health gains, suggesting a possible 'viral spread' of obesity prevention actions across the wider region.

When ignorance is bliss: weight perception, body mass index and quality of life in adolescents

Background/Objectives:

Body weight is negatively associated with adolescent Health-Related Quality of Life (HRQoL). Despite this well-established relationship, some adolescents with obesity do not display the expected HRQoL decreases. This study hypothesised weight perception as a moderator of the association between weight status and adolescent HRQoL.

Subjects/Methods:

Subjects were secondary school students from an obesity prevention project in the Barwon South-West region of Victoria, Australia, entitled It's Your Move (N=3040). Measures included standardised body mass index (BMI-z; World Health Organization growth standards), weight perception and HRQoL, measured by the Paediatric Quality of Life Inventory. Linear regression and average marginal effect analyses were conducted on cross-sectional baseline data to determine the significance of any interaction between weight perception and measured weight status in shaping adolescent HRQoL.

Results:

The BMI-z/perceived weight status interaction was significantly associated with adolescent HRQoL outcomes. Adolescents with BMI z-scores in the overweight/obesity range who perceived themselves as overweight had lower HRQoL than those who perceived themselves as ‘about right.' Conversely, adolescents with BMI scores in the lower end of the normal range or in the thinness range who perceived themselves as underweight had lower HRQoL than those with ‘about right' perceptions.

Conclusions:

This was the first study to report third-variable impacts of a body-perception variable on the relationship between adolescent weight status and HRQoL. Adolescents' weight perceptions significantly moderated the relationship between overweight/obesity and reduced HRQoL. Adolescents who were outside the normal weight range and misperceived their objectively measured weight status enjoyed a higher HRQoL than adolescents whose weight perception was concordant with their actual weight status. These findings suggest that practitioners may need to exercise caution when educating adolescents about their weight status, as such ‘reality checks' may negatively impact on adolescent HRQoL. It is suggested that more research be conducted to examine this potential effect.

Associations between obesogenic risk and depressive symptomatology in Australian adolescents: a cross-sectional study

BACKGROUND

Depression and obesity are significant health concerns currently facing adolescents worldwide. This paper investigates the associations between obesity and related risk behaviours and depressive symptomatology in an Australian adolescent population.

METHODS

Data from the Australian Capital Territory It's Your Move project, an Australian community-based intervention project were used. In 2012, 800 students (440 females, 360 males) aged 11-14 years (M=13.11 years, SD=0.62 years), from 6 secondary schools were weighed and measured and completed a questionnaire which included physical activity, sedentary behaviour and dietary intake. Weight status was defined by WHO criteria. A cut-off score ≥10 on the Short Mood and Feelings Questionnaire indicated symptomatic depression. Logistic regression was used to test associations.

RESULTS

After controlling for potential confounders, results showed significantly higher odds of depressive symptomatology in males (OR=1.22, p<0.05) and females (OR=1.12, p<0.05) who exceeded guidelines for daily screen-time leisure sedentary activities. Higher odds of depressive symptoms were seen in females who consumed greater amounts of sweet drink (OR=1.18, p<0.05), compared to lower female consumers of sweet drinks, and males who were overweight/obese also had greater odds of depressive symptoms (OR=1.83, p<0.05) compared to male normal weight adolescents.

CONCLUSIONS

This study demonstrates the associations between obesogenic risks and depression in adolescents. Further research should explore the direction of these associations and identify common determinants of obesity and depression. Mental health outcomes need to be included in the rationale and evaluation for diet and activity interventions.

The utility of serving size in the measurement of soft drink consumption

BACKGROUND

Many studies examining population differences in soft drink consumption or the association it has with fatness have not included serving size in its assessment. It is not clear what effect this has on their findings and our study aimed to investigate this by comparing the relationships that days (serving size unaccounted for) and cans/day (serving size accounted for) of consumption have with ethnicity/country and fatness.

METHODS

Daily nutrient intakes were calculated from a self-administered food frequency questionnaire from a cross-sectional health screening study. Participants were Pacific (n=954) and New Zealand European (n=1745) people aged 35 to 74 years.

RESULTS

Compared to Australian youth, NZ Pacific youth consumed soft drinks more frequently but a larger difference was observed for cans/day. In a dose-dependent manner, FMI was positively associated with days (P=0.015) and cans/day (P=0.024) of consumption. However, cans/day showed a stronger relationship, with a standardised regression coefficient of 0.066, compared to 0.033 for days of consumption.

CONCLUSIONS

It is useful to include serving size in the assessment of soft drink consumption. Excluding it leads to underestimation of both ethnic/country differences in daily volume of intake and associations with fatness.

Under-reporting remains a key limitation of self-reported dietary intake: an analysis of the 2008/09 New Zealand Adult Nutrition Survey

BACKGROUND/OBJECTIVES

The most recent New Zealand Adult Nutrition Survey 2008/09 (ANS 08/9) revealed a decrease in reported energy intakes (EIs) compared with the previous 1997 National Nutrition Survey (NNS97). Conversely, measured body weights increased over the same period. We conducted an analysis on the ANS 08/9 data sets to evaluate reported EIs.

SUBJECTS/METHODS

Analysis was conducted on data from 3919 (1715 men and 2204 women aged > or = 15 years) survey participants who completed the 24-h dietary recall in the ANS 08/9. Under-reporting was assessed using the ratio of reported EI to estimated resting metabolic rate (EI:RMRest), and a cutoff limit of <0.9 (EI:RMRest) was used to identify low energy reporters (LERs). Results were examined by gender, body size, age and ethnicity.

RESULTS

The mean EI:RMRest (s.e.m.) was 1.34 (0.02) for men, and 1.23 (0.02) for women. Overall, 21% of men and 25% of women were classified as LERs. There was a greater prevalence of LERs among people with overweight (25%), or obesity (30%) than people with normal body weight (16%, P<0.001). The oldest age group (> or =65 years) had a greater prevalence of LERs (33%) compared with all other age groups (19-24%, P<0.001). Pacific people had a greater prevalence of LERs (33%) compared with Maori (26%, P=0.007) and European (23%, P<0.001). Compared with the NNS97, a substantial increase in the prevalence of LERs was evident in most subgroups.

CONCLUSIONS

Under-reporting of EI will continue to be a major limitation of nutrition surveys without technological innovation. Care should be taken when interpreting EI data.

Relationship between overweight and health-related quality of life in secondary school children in Fiji: results from a cross-sectional population-based study

OBJECTIVE

To investigate the relationship between excess weight (overweight and obesity) and health-related quality of life (HRQoL) in a sample of secondary school children in Fiji, by gender, age and ethnicity.

METHODS

The study comprised 8947 children from forms 3-6 (age 12-18 years) in 18 secondary schools on Viti Levu, the main island of Fiji. Body mass index (BMI) was calculated from measured height and weight, and weight status was classified according to the International Obesity Task Force recommendations. HRQoL was measured by the self-report version of the Pediatric Quality of Life Inventory 4.0.

RESULTS

HRQoL was similar in children with obesity and normal weight. Generally, this was replicated when analyzed separately by gender and ethnicity, but age stratification revealed disparities. In 12-14-year-old children, obesity was associated with better HRQoL, owing to better social and school functioning and well-being, and in 15-18-year olds with poorer HRQoL, owing to worse physical, emotional and social functioning and well-being (Cohen's d 0.2-0.3). Children with a BMI in the overweight range also reported a slightly lower HRQoL than children with a BMI in the normal weight range, but although statistically significant, the size of this difference was trivial (Cohen's d <0.2).

DISCUSSION

The results suggest that, overall there is no meaningful negative association between excess weight and HRQoL in secondary school children in Fiji. This is in contradiction to the negative relationship between excess weight and HRQoL shown in studies from other countries and cultures. The assumption that a large body size is associated with a lower quality of life cannot be held universally. Although a generally low HRQoL among children in Fiji may be masking or overriding the potential effect of excess weight on HRQoL, socio-economic and/or socio-cultural factors, may help to explain these relationships.

Progress on obesity prevention over 20 years in Australia and New Zealand

The lessons learned from over 20 years of obesity prevention efforts in Australia and New Zealand are presented. The obesity epidemic started in the 1980s but poor monitoring systems meant the rise in obesity prevalence initially went undetected. In the 1990 s, experts started advocating for government action; however, it was the rapid increase in media reports on obesity in the early 2000s which created the pressure for action. Several, comprehensive reports produced some programme investment but no regulatory policies were implemented. The powerful food industry lobby ensured this lack of policies on front-of-pack food labelling, restrictions on unhealthy food marketing to children, or taxes on unhealthy foods. The New Zealand government even backpedalled by rescinding healthy school food guidelines and withdrawing funding for the comprehensive national obesity strategy. In 2007, Australian Governments started a major long term-investment in preventive health in order to improve economic productivity. Other positive initiatives, especially in Australia, were: the establishment of several advocacy organizations; successful, long-term, whole-of-community projects reducing childhood obesity; a national knowledge exchange system for practitioners; and some innovative programmes and social marketing. However, despite multiple reports and strong advocacy, key recommended regulatory policies remain unimplemented, largely due to the private sector interests dominating public policy development.

Overview: Bellagio Conference on Program and Policy Options for Preventing Obesity in the Low- and Middle-Income Countries

The Bellagio 'Conference on Program and Policy Options for Preventing Obesity in the Low- and Middle-Income Countries' (LMICs) was organized to pull together the current. We need not reiterate the importance of this topic or the speed of change in eating, drinking and moving facing us across the globe. The conference emerges from need to significantly step up the policies and programs to reduce obesity by learning from some current examples of best practice and strengthening the role of the academic and civil society players in translating global evidence and experience into action at the national level. There is also a need to empower the younger generation of scholars and activists in these countries to carry on this effort. The meeting was also timely because a number of funding agencies in the United States, Canada and the UK, at least, are beginning to focus attention on this topic. This set of papers provides not only examples of existing best practice but also a road map ahead for LMICs in the various areas of action needed to reduce obesity across LMICs. The meeting highlighted critical barriers to implementation that have blocked many initiatives.

Monitoring policy and actions on food environments: rationale and outline of the INFORMAS policy engagement and communication strategies

The International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support (INFORMAS) proposes to collect performance indicators on food policies, actions and environments related to obesity and non-communicable diseases. This paper reviews existing communications strategies used for performance indicators and proposes the approach to be taken for INFORMAS. Twenty-seven scoring and rating tools were identified in various fields of public health including alcohol, tobacco, physical activity, infant feeding and food environments. These were compared based on the types of indicators used and how they were quantified, scoring methods, presentation and the communication and reporting strategies used. There are several implications of these analyses for INFORMAS: the ratings/benchmarking approach is very commonly used, presumably because it is an effective way to communicate progress and stimulate action, although this has not been formally evaluated; the tools used must be trustworthy, pragmatic and policy-relevant; multiple channels of communication will be needed; communications need to be tailored and targeted to decision-makers; data and methods should be freely accessible. The proposed communications strategy for INFORMAS has been built around these lessons to ensure that INFORMAS's outputs have the greatest chance of being used to improve food environments.

Monitoring the health-related labelling of foods and non-alcoholic beverages in retail settings

Food labelling on food packaging has the potential to have both positive and negative effects on diets. Monitoring different aspects of food labelling would help to identify priority policy options to help people make healthier food choices. A taxonomy of the elements of health-related food labelling is proposed. A systematic review of studies that assessed the nature and extent of health-related food labelling has been conducted to identify approaches to monitoring food labelling. A step-wise approach has been developed for independently assessing the nature and extent of health-related food labelling in different countries and over time. Procedures for sampling the food supply, and collecting and analysing data are proposed, as well as quantifiable measurement indicators and benchmarks for health-related food labelling.

Monitoring food and non-alcoholic beverage promotions to children

Food and non-alcoholic beverage marketing is recognized as an important factor influencing food choices related to non-communicable diseases. The monitoring of populations' exposure to food and non-alcoholic beverage promotions, and the content of these promotions, is necessary to generate evidence to understand the extent of the problem, and to determine appropriate and effective policy responses. A review of studies measuring the nature and extent of exposure to food promotions was conducted to identify approaches to monitoring food promotions via dominant media platforms. A step-wise approach, comprising 'minimal', 'expanded' and 'optimal' monitoring activities, was designed. This approach can be used to assess the frequency and level of exposure of population groups (especially children) to food promotions, the persuasive power of techniques used in promotional communications (power of promotions) and the nutritional composition of promoted food products. Detailed procedures for data sampling, data collection and data analysis for a range of media types are presented, as well as quantifiable measurement indicators for assessing exposure to and power of food and non-alcoholic beverage promotions. The proposed framework supports the development of a consistent system for monitoring food and non-alcoholic beverage promotions for comparison between countries and over time.

Monitoring the levels of important nutrients in the food supply

A food supply that delivers energy-dense products with high levels of salt, saturated fats and trans fats, in large portion sizes, is a major cause of non-communicable diseases (NCDs). The highly processed foods produced by large food corporations are primary drivers of increases in consumption of these adverse nutrients. The objective of this paper is to present an approach to monitoring food composition that can both document the extent of the problem and underpin novel actions to address it. The monitoring approach seeks to systematically collect information on high-level contextual factors influencing food composition and assess the energy density, salt, saturated fat, trans fats and portion sizes of highly processed foods for sale in retail outlets (with a focus on supermarkets and quick-service restaurants). Regular surveys of food composition are proposed across geographies and over time using a pragmatic, standardized methodology. Surveys have already been undertaken in several high- and middle-income countries, and the trends have been valuable in informing policy approaches. The purpose of collecting data is not to exhaustively document the composition of all foods in the food supply in each country, but rather to provide information to support governments, industry and communities to develop and enact strategies to curb food-related NCDs.

Monitoring foods and beverages provided and sold in public sector settings

This paper outlines a step-wise framework for monitoring foods and beverages provided or sold in publicly funded institutions. The focus is on foods in schools, but the framework can also be applied to foods provided or sold in other publicly funded institutions. Data collection and evaluation within this monitoring framework will consist of two components. In component I, information on existing food or nutrition policies and/or programmes within settings would be compiled. Currently, nutrition standards and voluntary guidelines associated with such policies/programmes vary widely globally. This paper, which provides a comprehensive review of such standards and guidelines, will facilitate institutional learnings for those jurisdictions that have not yet established them or are undergoing review of existing ones. In component II, the quality of foods provided or sold in public sector settings is evaluated relative to existing national or sub-national nutrition standards or voluntary guidelines. Where there are no (or only poor) standards or guidelines available, the nutritional quality of foods can be evaluated relative to standards of a similar jurisdiction or other appropriate standards. Measurement indicators are proposed (within 'minimal', 'expanded' and 'optimal' approaches) that can be used to monitor progress over time in meeting policy objectives, and facilitate comparisons between countries.

Monitoring the impacts of trade agreements on food environments

The liberalization of international trade and foreign direct investment through multilateral, regional and bilateral agreements has had profound implications for the structure and nature of food systems, and therefore, for the availability, nutritional quality, accessibility, price and promotion of foods in different locations. Public health attention has only relatively recently turned to the links between trade and investment agreements, diets and health, and there is currently no systematic monitoring of this area. This paper reviews the available evidence on the links between trade agreements, food environments and diets from an obesity and non-communicable disease (NCD) perspective. Based on the key issues identified through the review, the paper outlines an approach for monitoring the potential impact of trade agreements on food environments and obesity/NCD risks. The proposed monitoring approach encompasses a set of guiding principles, recommended procedures for data collection and analysis, and quantifiable 'minimal', 'expanded' and 'optimal' measurement indicators to be tailored to national priorities, capacity and resources. Formal risk assessment processes of existing and evolving trade and investment agreements, which focus on their impacts on food environments will help inform the development of healthy trade policy, strengthen domestic nutrition and health policy space and ultimately protect population nutrition.

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): overview and key principles

Non-communicable diseases (NCDs) dominate disease burdens globally and poor nutrition increasingly contributes to this global burden. Comprehensive monitoring of food environments, and evaluation of the impact of public and private sector policies on food environments is needed to strengthen accountability systems to reduce NCDs. The International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) is a global network of public-interest organizations and researchers that aims to monitor, benchmark and support public and private sector actions to create healthy food environments and reduce obesity, NCDs and their related inequalities. The INFORMAS framework includes two 'process' modules, that monitor the policies and actions of the public and private sectors, seven 'impact' modules that monitor the key characteristics of food environments and three 'outcome' modules that monitor dietary quality, risk factors and NCD morbidity and mortality. Monitoring frameworks and indicators have been developed for 10 modules to provide consistency, but allowing for stepwise approaches ('minimal', 'expanded', 'optimal') to data collection and analysis. INFORMAS data will enable benchmarking of food environments between countries, and monitoring of progress over time within countries. Through monitoring and benchmarking, INFORMAS will strengthen the accountability systems needed to help reduce the burden of obesity, NCDs and their related inequalities.

Monitoring and benchmarking population diet quality globally: a step-wise approach

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support) aims to monitor and benchmark the healthiness of food environments globally. In order to assess the impact of food environments on population diets, it is necessary to monitor population diet quality between countries and over time. This paper reviews existing data sources suitable for monitoring population diet quality, and assesses their strengths and limitations. A step-wise framework is then proposed for monitoring population diet quality. Food balance sheets (FBaS), household budget and expenditure surveys (HBES) and food intake surveys are all suitable methods for assessing population diet quality. In the proposed 'minimal' approach, national trends of food and energy availability can be explored using FBaS. In the 'expanded' and 'optimal' approaches, the dietary share of ultra-processed products is measured as an indicator of energy-dense, nutrient-poor diets using HBES and food intake surveys, respectively. In addition, it is proposed that pre-defined diet quality indices are used to score diets, and some of those have been designed for application within all three monitoring approaches. However, in order to enhance the value of global efforts to monitor diet quality, data collection methods and diet quality indicators need further development work.

Monitoring and benchmarking government policies and actions to improve the healthiness of food environments: a proposed Government Healthy Food Environment Policy Index

Government action is essential to increase the healthiness of food environments and reduce obesity, diet-related non-communicable diseases (NCDs), and their related inequalities. This paper proposes a monitoring framework to assess government policies and actions for creating healthy food environments. Recommendations from relevant authoritative organizations and expert advisory groups for reducing obesity and NCDs were examined, and pertinent components were incorporated into a comprehensive framework for monitoring government policies and actions. A Government Healthy Food Environment Policy Index (Food-EPI) was developed, which comprises a 'policy' component with seven domains on specific aspects of food environments, and an 'infrastructure support' component with seven domains to strengthen systems to prevent obesity and NCDs. These were revised through a week-long consultation process with international experts. Examples of good practice statements are proposed within each domain, and these will evolve into benchmarks established by governments at the forefront of creating and implementing food policies for good health. A rating process is proposed to assess a government's level of policy implementation towards good practice. The Food-EPI will be pre-tested and piloted in countries of varying size and income levels. The benchmarking of government policy implementation has the potential to catalyse greater action to reduce obesity and NCDs.

Monitoring the availability of healthy and unhealthy foods and non-alcoholic beverages in community and consumer retail food environments globally

Retail food environments are increasingly considered influential in determining dietary behaviours and health outcomes. We reviewed the available evidence on associations between community (type, availability and accessibility of food outlets) and consumer (product availability, prices, promotions and nutritional quality within stores) food environments and dietary outcomes in order to develop an evidence-based framework for monitoring the availability of healthy and unhealthy foods and non-alcoholic beverages in retail food environments. Current evidence is suggestive of an association between community and consumer food environments and dietary outcomes; however, substantial heterogeneity in study designs, methods and measurement tools makes it difficult to draw firm conclusions. The use of standardized tools to monitor local food environments within and across countries may help to validate this relationship. We propose a step-wise framework to monitor and benchmark community and consumer retail food environments that can be used to assess density of healthy and unhealthy food outlets; measure proximity of healthy and unhealthy food outlets to homes/schools; evaluate availability of healthy and unhealthy foods in-store; compare food environments over time and between regions and countries; evaluate compliance with local policies, guidelines or voluntary codes of practice; and determine the impact of changes to retail food environments on health outcomes, such as obesity.

A proposed approach to monitor private-sector policies and practices related to food environments, obesity and non-communicable disease prevention

Private-sector organizations play a critical role in shaping the food environments of individuals and populations. However, there is currently very limited independent monitoring of private-sector actions related to food environments. This paper reviews previous efforts to monitor the private sector in this area, and outlines a proposed approach to monitor private-sector policies and practices related to food environments, and their influence on obesity and non-communicable disease (NCD) prevention. A step-wise approach to data collection is recommended, in which the first ('minimal') step is the collation of publicly available food and nutrition-related policies of selected private-sector organizations. The second ('expanded') step assesses the nutritional composition of each organization's products, their promotions to children, their labelling practices, and the accessibility, availability and affordability of their products. The third ('optimal') step includes data on other commercial activities that may influence food environments, such as political lobbying and corporate philanthropy. The proposed approach will be further developed and piloted in countries of varying size and income levels. There is potential for this approach to enable national and international benchmarking of private-sector policies and practices, and to inform efforts to hold the private sector to account for their role in obesity and NCD prevention.

Monitoring the price and affordability of foods and diets globally

Food prices and food affordability are important determinants of food choices, obesity and non-communicable diseases. As governments around the world consider policies to promote the consumption of healthier foods, data on the relative price and affordability of foods, with a particular focus on the difference between 'less healthy' and 'healthy' foods and diets, are urgently needed. This paper briefly reviews past and current approaches to monitoring food prices, and identifies key issues affecting the development of practical tools and methods for food price data collection, analysis and reporting. A step-wise monitoring framework, including measurement indicators, is proposed. 'Minimal' data collection will assess the differential price of 'healthy' and 'less healthy' foods; 'expanded' monitoring will assess the differential price of 'healthy' and 'less healthy' diets; and the 'optimal' approach will also monitor food affordability, by taking into account household income. The monitoring of the price and affordability of 'healthy' and 'less healthy' foods and diets globally will provide robust data and benchmarks to inform economic and fiscal policy responses. Given the range of methodological, cultural and logistical challenges in this area, it is imperative that all aspects of the proposed monitoring framework are tested rigorously before implementation.

Inconsistent associations between sweet drink intake and 2-year change in BMI among Victorian children and adolescents

OBJECTIVE

The aim of this study was to examine whether baseline (T1) or 2-year change in sweet drink intake in children and adolescents was associated with age- and gender-standardized body mass index (BMIz) at time two (T2), 2 years later.

METHODS

Data on 1465 children and adolescents from the comparison groups of two quasi-experimental intervention studies from Victoria, Australia were analysed. At two time points between 2003 and 2008 (mean interval: 2.2 years) height and weight were measured and sweet drink consumption (soft drink and fruit juice/cordial) was assessed.

RESULTS

No association was observed between T1 sweet drink intake and BMIz at T2 among children or adolescents. Children from higher socioeconomic status families who reported an increased intake of sweet drinks at T2 compared with T1 had higher mean BMIz at T2 (β: 0.13, P = 0.05). There was no evidence of a dose-response relationship between sweet drink intake and BMIz. In supplementary analyses, we observed that more frequent usual consumption of fruit juice/cordial was associated with a higher BMIz at T2 among children.

CONCLUSION

This study showed limited evidence of an association between sweet drink intake and BMIz. However, the association is complex and may be confounded by both dietary and activity behaviours.

The appropriateness of opt-out consent for monitoring childhood obesity in Australia

Childhood obesity monitoring is a fundamental component of obesity prevention but is poorly done in Australia. Monitoring obesity prevalence in children provides important population health data that can be used to track trends over time, identify areas at greatest risk of obesity, determine the effectiveness of interventions and policies, raise awareness and stimulate action. High participation rates are essential for effective monitoring because these provide more representative data. Passive ('opt-out') consent has been shown to provide high participation rates in international childhood obesity monitoring programs and in a recent Australian federal initiative monitoring early child development. A federal initiative structured like existing child development monitoring programs, but with the authority to collect height and weight measurements using opt-out consent, is recommended to monitor rates of childhood obesity in Australia.

EPODE approach for childhood obesity prevention: methods, progress and international development

Childhood obesity is a complex issue and needs multi-stakeholder involvement at all levels to foster healthier lifestyles in a sustainable way. 'Ensemble Prévenons l'Obésité Des Enfants' (EPODE, Together Let's Prevent Childhood Obesity) is a large-scale, coordinated, capacity-building approach for communities to implement effective and sustainable strategies to prevent childhood obesity. This paper describes EPODE methodology and its objective of preventing childhood obesity. At a central level, a coordination team, using social marketing and organizational techniques, trains and coaches a local project manager nominated in each EPODE community by the local authorities. The local project manager is also provided with tools to mobilize local stakeholders through a local steering committee and local networks. The added value of the methodology is to mobilize stakeholders at all levels across the public and the private sectors. Its critical components include political commitment, sustainable resources, support services and a strong scientific input--drawing on the evidence-base--together with evaluation of the programme. Since 2004, EPODE methodology has been implemented in more than 500 communities in six countries. Community-based interventions are integral to childhood obesity prevention. EPODE provides a valuable model to address this challenge.

Government regulation to promote healthy food environments--a view from inside state governments

Food policy interventions are an important component of obesity-prevention strategies and can potentially drive positive changes in obesogenic environments. This study sought to identify regulatory interventions targeting the food environment, and barriers/facilitators to their implementation at the Australian state government level. In-depth interviews were conducted with senior representatives from state/territory governments, statutory authorities and non-government organizations (n =45) to examine participants' (i) suggestions for regulatory interventions for healthier food environments and (ii) support for pre-selected regulatory interventions derived from a literature review. Data were analysed using thematic and constant comparative analyses. Interventions commonly suggested by participants were regulating unhealthy food marketing; limiting the density of fast food outlets; pricing reforms to decrease fruit/vegetable prices and increase unhealthy food prices; and improved food labelling. The most commonly supported pre-selected interventions were related to food marketing and service. Primary production and retail sector interventions were least supported. The dominant themes were the need for whole-of-government and collaborative approaches; the influence of the food industry; conflicting policies/agenda; regulatory challenges; the need for evidence of effectiveness; and economic disincentives. While interventions such as public sector healthy food service policies were supported by participants, marketing restrictions and fiscal interventions face substantial barriers including a push for deregulation and private sector opposition.