Landscape analysis of environmental, social and governance (ESG) investing metrics for consumer nutrition and health in the food and beverage sector

Introduction

The private sector plays a critical role in influencing food choices and health outcomes of consumers. Among private sector actors, investors are a powerful yet underutilised stakeholder for driving scalable public health impact. There are systems to facilitate investors' involvement, notably environmental, social and governance (ESG) investing, which is well placed to include an assessment of business risks to social well-being. However, nutrition efforts within the ESG agenda (ESG-Nutrition) are nascent. We aimed to critically assess the strength of existing ESG-Nutrition metrics to advance the science of measuring business impacts on consumer nutrition and health.

Methods

ESG-Nutrition metrics were extracted from eight ESG frameworks and categorised across four domains: product portfolio healthfulness; product distribution and equity; product marketing and labelling; and nutrition-related governance. The strength of each metric was evaluated and scored 1-3 (best), independently by two researchers, based on six attributes: materiality, objectivity, alignment, activity, resolution and verifiability. The total score (range 6-18) and intercorrelation for each attribute was calculated.

Results

Across 529 metrics, most related to product marketing and labelling (n=230, 43.5%), followed by product healthfulness (n=126, 23.8%), nutrition-related governance (n=108, 20.4%) and product distribution and equity (n=65, 12.3%). Across all metrics, average total score was 10.94 (1.58), with average attribute scoring highest for verifiability (mean: 2.36 (SD: 0.57)), objectivity (2.11 (0.61)) and materiality (2.01 (0.68)) and lowest for activity (1.83 (0.74)), alignment (1.37 (0.67)) and resolution (1.26 (0.65)). Most intercorrelations were null, suggesting attributes were measuring distinct characteristics of each metric. Significant heterogeneity across domains and frameworks was also observed.

Conclusions

This research identifies a range of nutrition-related metrics used in ESG frameworks with respect to food companies, but with substantial heterogeneity in relevant nutrition domains covered and strength of each metric. Efforts are required to improve the quality of metrics across frameworks, establish standardised reporting and align these with investor priorities.

An integrative analytical framework to identify healthy, impactful, and equitable foods: a case study on 100% orange juice

To identify healthy, impactful, and equitable foods, we combined health scores from six diverse nutrient profiling systems (NPS) into a meta-framework (meta-NPS) and paired this with dietary guideline adherence assessment via multilevel regression and poststratification. In a case-study format, a commonly debated beverage formulation - 100% orange juice (OJ) - was chosen to showcase the utility and depth of our framework, systematically scoring high across multiple food systems (i.e. a Meta-Score percentile = 93rd and Stability percentile = 75th) and leading to an expected increase of US dietary fruit guideline adherence by ∼10%. Moreover, the increased adherence varies across the 300 sociodemographic strata, with the benefit patterns being sensitive to absolute or relative quantification of the difference of adherence affected by OJ. In sum, the adaptable, integrative framework we established deepens the science of nutrient profiling and dietary guideline adherence assessment while shedding light on the nuances of defining equitable health effects.

Innovative financing for nutrition

Given the constraints of both overseas development aid and domestic financing for nutrition, innovative financing is critical-yet nutrition lags behind other sectors in catalysing it. Here, we argue that the framing for nutrition must evolve and critical actions must be taken to generate more money for nutrition and more nutrition for money. Food systems hold some of the most powerful opportunities to improve human and planetary health while increasing productivity-and the private sector has a key role to play in this.

Incident type 2 diabetes attributable to suboptimal diet in 184 countries

The global burden of diet-attributable type 2 diabetes (T2D) is not well established. This risk assessment model estimated T2D incidence among adults attributable to direct and body weight-mediated effects of 11 dietary factors in 184 countries in 1990 and 2018. In 2018, suboptimal intake of these dietary factors was estimated to be attributable to 14.1 million (95% uncertainty interval (UI), 13.8-14.4 million) incident T2D cases, representing 70.3% (68.8-71.8%) of new cases globally. Largest T2D burdens were attributable to insufficient whole-grain intake (26.1% (25.0-27.1%)), excess refined rice and wheat intake (24.6% (22.3-27.2%)) and excess processed meat intake (20.3% (18.3-23.5%)). Across regions, highest proportional burdens were in central and eastern Europe and central Asia (85.6% (83.4-87.7%)) and Latin America and the Caribbean (81.8% (80.1-83.4%)); and lowest proportional burdens were in South Asia (55.4% (52.1-60.7%)). Proportions of diet-attributable T2D were generally larger in men than in women and were inversely correlated with age. Diet-attributable T2D was generally larger among urban versus rural residents and higher versus lower educated individuals, except in high-income countries, central and eastern Europe and central Asia, where burdens were larger in rural residents and in lower educated individuals. Compared with 1990, global diet-attributable T2D increased by 2.6 absolute percentage points (8.6 million more cases) in 2018, with variation in these trends by world region and dietary factor. These findings inform nutritional priorities and clinical and public health planning to improve dietary quality and reduce T2D globally.

Changes in Food Security, Healthfulness, and Access During the Coronavirus Disease 2019 Pandemic: Results From a National United States Survey

Background

Coronavirus disease 2019 (COVID-19) disrupted access to food and adequate nutrition and the types of foods consumed. However, little empiric data exists on the changes in American's food and nutrition habits 2 y into the pandemic.

Objectives

To assess current and altered food choices ∼2 y into the COVID-19 pandemic in the months after historic public pandemic relief.

Methods

A national sample of 1878 United States adults balanced by age, sex, race/ethnicity, and income completed a one-time, online, semi-quantitative, 44-item questionnaire in Fall 2021 asking about the demographics, COVID-19 food choice changes (including free-text), and consumer priorities. This analysis investigates COVID-19 impacts on food security, healthfulness, and access.

Results

More than 35% of respondents reported improved food security and >45% reported improved food healthfulness compared with prepandemic status. Improvement was reported in more than 30% of Black/African-American and Hispanic/Latinx adults, adults with lower annual income, and female sex, despite over 75% reporting reduced choice of where to eat or buy food. The pandemic offered occasion for many to improve diet, but a similar number expressed that the pandemic destabilized healthy habits.

Conclusions

Our novel findings suggest that by late 2021, most Americans had improved food security and food choice healthfulness, despite reduced access to food service and retail, although with worsening among a meaningful proportion of Americans as well as heterogeneity in these changes. Vigorous federal, state, city, and community responses to the pandemic may have played a role in improving the food security and food choice healthfulness during the COVID-19 pandemic. Health crises differently impact health behaviors, but when accompanied by vigorous civic and community response, food security, and food healthfulness can be fortified.

Trends and Disparities in Cardiometabolic Health Among U.S. Adults, 1999-2018

BACKGROUND

Few studies have assessed U.S. cardiometabolic health trends-optimal levels of multiple risk factors and absence of clinical cardiovascular disease (CVD)-or its impact on health disparities.

OBJECTIVES

The purpose of this study was to investigate U.S. trends in optimal cardiometabolic health from 1999 to 2018.

METHODS

We assessed proportions of adults with optimal cardiometabolic health, based on adiposity, blood glucose, blood lipids, blood pressure, and clinical CVD; and optimal, intermediate, and poor levels of each component among 55,081 U.S. adults in the National Health and Nutrition Examination Survey.

RESULTS

In 2017-2018, only 6.8% (95% CI: 5.4%-8.1%) of U.S. adults had optimal cardiometabolic health, declining from 1999-2000 (P trend = 0.02). Among components of cardiometabolic health, the largest declines were for adiposity (optimal levels: 33.8%-24.0%; poor levels: 47.7%-61.9%) and glucose (optimal levels: 59.4%-36.9%; poor levels: 8.6%-13.7%) (P trend <0.001 for each). Optimal levels of blood lipids increased from 29.9%-37.0%, whereas poor decreased from 28.3%-14.7% (P trend <0.001). Trends over time for blood pressure and CVD were smaller. Disparities by age, sex, education, and race/ethnicity were evident in all years, and generally worsened over time. By 2017-2018, prevalence of optimal cardiometabolic health was lower among Americans with lower (5.0% [95% CI: 2.8%-7.2%]) vs higher education (10.3% [95% CI: 7.6%-13.0%]); and among Mexican American (3.2% [95% CI: 1.4%-4.9%]) vs non-Hispanic White (8.4% [95% CI: 6.3%-10.4%]) adults.

CONCLUSIONS

Between 1999 and 2000 and 2017 and 2018, U.S. cardiometabolic health has been poor and worsening, with only 6.8% of adults having optimal cardiometabolic health, and disparities by age, sex, education, and race/ethnicity. These novel findings inform the need for nationwide clinical and public health interventions to improve cardiometabolic health and health equity.

US Food and Nutrition Security During COVID-19 in Late 2021

Objectives

To assess current and altered food habits about two years into the COVID-19 pandemic.

Methods

We recruited a national sample of 1,878 adults balanced by age (18–34 years, 35–49, 50–64, 65+); sex (male, female); race/ethnicity (Non-Hispanic White, Hispanic/Latinx, Non-Hispanic Black/African-American, Asian/Other); and income (&lt;25k/year, 25k-&lt;50k, 50-&lt;100k, &gt;100k). In fall 2021, participants completed a 44-item survey asking about demographics, priorities for food businesses and products, and a 5-item section on food habit changes due to COVID-19.1420 participants added free-text to explain changes in food habits which were evaluated for themes.

Results

12% of respondents (n = 223) reported worsened food security, 49% (n = 914) reported about same, and 39% (n = 722) reported improved food security compared to pre-pandemic. 11% (n = 200) reported worsened, 42% (n = 784) reported the same, and 47% (n = 878) reported improved healthfulness of food choices. Changes in food security explained 27% of the variance in changes in healthfulness of food choice (p &lt; 0.05). 20% of respondents (n = 370) reported having less ability to choose where they eat. Nearly twice as many (39%, n = 737) reported that it stayed the same or improved (40%, n = 747). 12% (n = 229) reported less ability to choose where to buy food, 48% reported the same (n = 904), and 39% (n = 731) reported improved ability. Changes did not differ dramatically by age, sex, race/ethnicity, or income. Six common themes of pandemic changes in food habits were reduced restaurant dining, increased food delivery, reduced soft drink consumption, more eating at home, taking the opportunity to eat healthy, and more bulk and discount shopping online.

Conclusions

As Americans adapt to the pandemic, these novel data identify perceived effects on food and nutrition security. These data illustrate relative resiliency in both food security and the healthfulness of food choices, and pandemic-related opportunities to increase healthfulness of dietary choices, in a diverse national sample.

Funding Sources

Vail Innovative Global Research & NIFA National Needs Fellowship.

How Americans Define Health for Food and Beverages

Objectives

To assess how American adults consider and define healthfulness of food and beverages.

Methods

In Fall 2021, a national sample of 1,878 adults balanced by age (18–34 years, 35–49, 50–64, 65+), sex, race/ethnicity (Non-Hispanic White, Hispanic/Latinx, Non-Hispanic Black, Asian/other), and annual income, completed an online survey asking about demographics and priorities for food businesses and product purchases, including select-all and agreement rated items on definitions of healthfulness for food and beverages. Pearson's r and Jaccard Index were used to assess correlation (PCC) and choice similarity, respectively.

Results

Among 12 definitions of healthfulness, respondents most commonly chose nutritionally balanced (67%); all natural (56%); supports health outcomes (55%); and full of vitamins and minerals (52%); followed by organic (41%); safe to eat (41%); specific nutrient profile (38%); locally grown/culturally relevant (27%); supports weight loss (25%); non-GMO (23%); aids athletic/physical performance (16%); popular diet (13%). These perceptions varied by race/ethnicity and age. Nutritionally balanced was selected by 78% of Asian/other adults and 82% of 65 + y adults, vs. White (69%), Black (64%), or Hispanic/Latinx (61%) adults; or 50–65 y (75%), 35–49 y (59%), 18–34 y (57%). Findings were more similar by income. PCC was highest for nutritionally balanced and: full of vitamins (0.81); supports health outcomes (0.80); and all natural (0.76). Jaccard similarity was < 0.55 for all definition pairs except organic and safe to eat (0.99).

Conclusions

In a large, diverse national sample of US adults, consumers most defined healthfulness of food and beverages as nutritionally balanced, all natural, or supports health outcomes. Organic, supports weight loss, and non-GMO were much less reported as definitions of product healthfulness. No single definition was selected by >2/3of US adults; and combined with low Jaccard values, suggests a lack of consensus on simple definitions of healthfulness. Concepts were prioritized differently by age and race/ethnicity, but much less by income. These novel findings have implications for health communications, education, and guidance aimed at reducing consumer confusion about healthier food and beverage choices.

Funding Sources

Vail Innovative Global Research; NIFA National Needs Fellowship.

Economic Evaluation of Nutrition-Sensitive Agricultural Interventions to Increase Maternal and Child Dietary Diversity and Nutritional Status in Rural Odisha, India

BACKGROUND

Economic evaluations of nutrition-sensitive agriculture (NSA) interventions are scarce, limiting assessment of their potential affordability and scalability.

OBJECTIVES

We conducted cost-consequence analyses of 3 participatory video-based interventions of fortnightly women's group meetings using the following platforms: 1) NSA videos; 2) NSA and nutrition-specific videos; or 3) NSA videos with a nutrition-specific participatory learning and action (PLA) cycle.

METHODS

Interventions were tested in a 32-mo, 4-arm cluster-randomized controlled trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) in the Keonjhar district, Odisha, India. Impacts were evaluated in children aged 0-23 mo and their mothers. We estimated program costs using data collected prospectively from expenditure records of implementing and technical partners and societal costs using expenditure assessment data collected from households with a child aged 0-23 mo and key informant interviews. Costs were adjusted for inflation, discounted, and converted to 2019 US$.

RESULTS

Total program costs of each intervention ranged from US$272,121 to US$386,907. Program costs per pregnant woman or mother of a child aged 0-23 mo were US$62 for NSA videos, US$84 for NSA and nutrition-specific videos, and US$78 for NSA videos with PLA (societal costs: US$125, US$143, and US$122, respectively). Substantial shares of total costs were attributable to development and delivery of the videos and PLA (52-69%) and quality assurance (25-41%). Relative to control, minimum dietary diversity was higher in the children who underwent the interventions incorporating nutrition-specific videos and PLA (adjusted RRs: 1.19 and 1.27; 95% CIs: 1.03-1.37 and 1.11, 1.46, respectively). Relative to control, minimum dietary diversity in mothers was higher in those who underwent NSA video (1.21 [1.01, 1.45]) and NSA with PLA (1.30 [1.10, 1.53]) interventions.

CONCLUSION

NSA videos with PLA can increase both maternal and child dietary diversity and have the lowest cost per unit increase in diet diversity. Building on investments made in developing UPAVAN, cost-efficiency at scale could be increased with less intensive monitoring, reduced startup costs, and integration within existing government programs. This trial was registered at clinicaltrials.gov as ISRCTN65922679.

Food Compass is a nutrient profiling system using expanded characteristics for assessing healthfulness of foods

Nutrient profiling systems (NPS) aim to discriminate the healthfulness of foods for front-of-package labelling, warning labels, taxation, company ratings and more. Existing NPS often assess relatively few nutrients and ingredients, use inconsistent criteria across food categories and have not incorporated the newest science. Here, we developed and validated an NPS, the Food Compass, to incorporate a broader range of food characteristics, attributes and uniform scoring principles. We scored 54 attributes across 9 health-relevant domains: nutrient ratios, vitamins, minerals, food ingredients, additives, processing, specific lipids, fibre and protein, and phytochemicals. The domain scores were summed into a final Food Compass Score (FCS) ranging from 1 (least healthy) to 100 (most healthy) for all foods and beverages. Content validity was confirmed by assessing nutrients, food ingredients and other characteristics of public health concern; face validity was confirmed by assessing the FCS for 8,032 foods and beverages reported in NHANES/FNDDS 2015-16; and convergent and discriminant validity was confirmed from comparisons with the NOVA food processing classification, the Health Star Rating and the Nutri-Score. The FCS differentiated food categories and food items well, with mean ± s.d. ranging from 17.1 ± 17.2 for savoury snacks and sweet desserts to 81.6 ± 16.0 for legumes, nuts and seeds. In many food categories, the FCS provided important discrimination of specific foods and beverages as compared with NOVA, the Health Star Rating or the Nutri-Score. On the basis of demonstrated content, convergent and discriminant validity, the Food Compass provides an NPS scoring a broader range of attributes and domains than previous systems with uniform and transparent principles. This publicly available tool will help guide consumer choice, research, food policy, industry reformulations and mission-focused investment decisions.

How to design a complex behaviour change intervention: experiences from a nutrition-sensitive agriculture trial in rural India

Many public health interventions aim to promote healthful behaviours, with varying degrees of success. With a lack of existing empirical evidence on the optimal number or combination of behaviours to promote to achieve a given health outcome, a key challenge in intervention design lies in deciding what behaviours to prioritise, and how best to promote them. We describe how key behaviours were selected and promoted within a multisectoral nutrition-sensitive agriculture intervention that aimed to address maternal and child undernutrition in rural India. First, we formulated a Theory of Change, which outlined our hypothesised impact pathways. To do this, we used the following inputs: existing conceptual frameworks, published empirical evidence, a feasibility study, formative research and the intervention team’s local knowledge. Then, we selected specific behaviours to address within each impact pathway, based on our formative research, behaviour change models, local knowledge and community feedback. As the intervention progressed, we mapped each of the behaviours against our impact pathways and the transtheoretical model of behaviour change, to monitor the balance of behaviours across pathways and along stages of behaviour change. By collectively agreeing on definitions of complex concepts and hypothesised impact pathways, implementing partners were able to communicate clearly between each other and with intervention participants. Our intervention was iteratively informed by continuous review, by monitoring implementation against targets and by integrating community feedback. Impact and process evaluations will reveal whether these approaches are effective for improving maternal and child nutrition, and what the effects are on each hypothesised impact pathway.

Effect of nutrition-sensitive agriculture interventions with participatory videos and women's group meetings on maternal and child nutritional outcomes in rural Odisha, India (UPAVAN trial): a four-arm, observer-blind, cluster-randomised controlled trial

BACKGROUND

Almost a quarter of the world's undernourished people live in India. We tested the effects of three nutrition-sensitive agriculture (NSA) interventions on maternal and child nutrition in India.

METHODS

We did a parallel, four-arm, observer-blind, cluster-randomised trial in Keonjhar district, Odisha, India. A cluster was one or more villages with a combined minimum population of 800 residents. The clusters were allocated 1:1:1:1 to a control group or an intervention group of fortnightly women's groups meetings and household visits over 32 months using: NSA videos (AGRI group); NSA and nutrition-specific videos (AGRI-NUT group); or NSA videos and a nutrition-specific participatory learning and action (PLA) cycle meetings and videos (AGRI-NUT+PLA group). Primary outcomes were the proportion of children aged 6-23 months consuming at least four of seven food groups the previous day and mean maternal body-mass index (BMI). Secondary outcomes were proportion of mothers consuming at least five of ten food groups and child wasting (proportion of children with weight-for-height Z score SD <-2). Outcomes were assessed in children and mothers through cross-sectional surveys at baseline and at endline, 36 months later. Analyses were by intention to treat. Participants and intervention facilitators were not blinded to allocation; the research team were. This trial is registered at ISRCTN, ISRCTN65922679.

FINDINGS

148 of 162 clusters assessed for eligibility were enrolled and randomly allocated to trial groups (37 clusters per group). Baseline surveys took place from Nov 24, 2016, to Jan 24, 2017; clusters were randomised from December, 2016, to January, 2017; and interventions were implemented from March 20, 2017, to Oct 31, 2019, and endline surveys done from Nov 19, 2019, to Jan 12, 2020, in an average of 32 households per cluster. All clusters were included in the analyses. There was an increase in the proportion of children consuming at least four of seven food groups in the AGRI-NUT (adjusted relative risk [RR] 1·19, 95% CI 1·03 to 1·37, p=0·02) and AGRI-NUT+PLA (1·27, 1·11 to 1·46, p=0·001) groups, but not AGRI (1·06, 0·91 to 1·23, p=0·44), compared with the control group. We found no effects on mean maternal BMI (adjusted mean differences vs control, AGRI -0·05, -0·34 to 0·24; AGRI-NUT 0·04, -0·26 to 0·33; AGRI-NUT+PLA -0·03, -0·3 to 0·23). An increase in the proportion of mothers consuming at least five of ten food groups was seen in the AGRI (adjusted RR 1·21, 1·01 to 1·45) and AGRI-NUT+PLA (1·30, 1·10 to 1·53) groups compared with the control group, but not in AGRI-NUT (1·16, 0·98 to 1·38). We found no effects on child wasting (adjusted RR vs control, AGRI 0·95, 0·73 to 1·24; AGRI-NUT 0·96, 0·72 to 1·29; AGRI-NUT+PLA 0·96, 0·73 to 1·26).

INTERPRETATION

Women's groups using combinations of NSA videos, nutrition-specific videos, and PLA cycle meetings improved maternal and child diet quality in rural Odisha, India. These components have been implemented separately in several low-income settings; effects could be increased by scaling up together.

FUNDING

Bill & Melinda Gates Foundation, UK AID from the UK Government, and US Agency for International Development.

Coronavirus Disease 2019 Hospitalizations Attributable to Cardiometabolic Conditions in the United States: A Comparative Risk Assessment Analysis

BACKGROUND Risk of coronavirus disease 2019 (COVID-19) hospitalization is robustly linked to cardiometabolic health. We estimated the absolute and proportional COVID-19 hospitalizations in US adults attributable to 4 major US cardiometabolic conditions, separately and jointly, and by race/ethnicity, age, and sex. METHODS AND RESULTS We used the best available estimates of independent associations of cardiometabolic conditions with a risk of COVID-19 hospitalization; nationally representative data on cardiometabolic conditions from the National Health and Nutrition Examination Survey 2015 to 2018; and US COVID-19 hospitalizations stratified by age, sex, and race/ethnicity from the Centers for Disease Control and Prevention's Coronavirus Disease 2019-Associated Hospitalization Surveillance Network database and from the COVID Tracking Project to estimate the numbers and proportions of COVID-19 hospitalizations attributable to diabetes mellitus, obesity, hypertension, and heart failure. Inputs were combined in a comparative risk assessment framework, with probabilistic sensitivity analyses and 1000 Monte Carlo simulations to jointly incorporate stratum-specific uncertainties in data inputs. As of November 18, 2020, an estimated 906 849 COVID-19 hospitalizations occurred in US adults. Of these, an estimated 20.5% (95% uncertainty interval [UIs], 18.9-22.1) of COVID-19 hospitalizations were attributable to diabetes mellitus, 30.2% (UI, 28.2-32.3) to total obesity (body mass index ≥30 kg/m²), 26.2% (UI, 24.3-28.3) to hypertension, and 11.7% (UI, 9.5-14.1) to heart failure. Considered jointly, 63.5% (UI, 61.6-65.4) or 575 419 (UI, 559 072-593 412) of COVID-19 hospitalizations were attributable to these 4 conditions. Large differences were seen in proportions of cardiometabolic risk-attributable COVID-19 hospitalizations by age and race/ethnicity, with smaller differences by sex. CONCLUSIONS A substantial proportion of US COVID-19 hospitalizations appear attributable to major cardiometabolic conditions. These results can help inform public health prevention strategies to reduce COVID-19 healthcare burdens.

The Impact of Suboptimal Diet on Type 2 Diabetes at Global, Regional, National, and Sub-National Levels: A Comparative Risk Assessment Analysis

Objectives

To prioritize dietary factors for reducing the growing burden of type 2 diabetes (T2D) worldwide, we estimated the impact of suboptimal diet on T2D incidence at global, regional, national, and subnational levels between 1990 and 2015.

Methods

A comparative risk assessment framework estimated T2D incidence attributable to suboptimal diet in strata jointly stratified by year, nation, age, and sex, across 185 countries. We estimated direct (dietary composition) etiologic effects of 8 factors including nuts/seeds, whole grains, yogurt, processed meats, unprocessed red meats, glycemic load (estimated from refined grains), sugar-sweetened beverages (SSBs) and potatoes. Population demographics were from the United Nations; stratum-specific mean dietary intakes and distributions from Global Dietary Database (GDD), diet-T2D etiologic effects from meta-analyses of prospective cohort studies; and T2D incidence from the Global Burden of Disease study. These inputs and their uncertainties were used to calculate the stratum-specific population attributable fraction (PAF) and then absolute attributable cases, with joint effects estimated using multiplicative PAFs.

Results

In 2015, suboptimal intakes of these 8 factors were jointly estimated to cause 10.9 million T2D cases (95% UI 7.2–15.3), representing 59.6% of all cases (39.3–83.3%) among adults age 25 + y globally. Low intake of whole grains (3.6 million cases (3.4–3.8)) followed by high intake of SSBs (2.7 million cases (2.5–2.9)) had the largest estimated attributable burdens. Across 7 world regions, highest diet-attributable burdens of T2D were in High Income Countries (2516 cases per million (2115, 2870)) and Former Soviet Union (2341 cases per million (1465, 2970)); and lowest in Sub-Saharan Africa (797 cases per million (333, 1435)). The proportion of T2D attributable to suboptimal diet was generally greater in males vs. females and in younger vs. older age groups. Results for specific countries, trends over time, and further sensitivity analyses will be presented.

Conclusions

These novel findings provide the most updated estimates of diet-attributable T2D globally, helping to inform priorities for targeted healthcare system, policy, industry and public health interventions to reduce T2D.

Funding Sources

Gates Foundation.

The State of Diet Quality Globally: A Systematic Assessment of Worldwide Dietary Patterns Using the Global Dietary Database (P10-045-19)

Objectives

Healthy diet patterns are a global priority to reduce undernutrition and chronic disease. Prior work suggests that healthy and unhealthy diet patterns are distributed and changing independently across the world. Our objective was to characterize current healthy and unhealthy diet patterns by age, sex, education, residence and country using the 2015 Global Dietary Database (GDD).

Methods

The GDD 2015 evaluates dietary intake based on 1137 surveys-years of systematically identified national and subnational individual-level diet surveys worldwide from 185 countries (97.5% of the global population). Dietary intake estimates and their uncertainty were generated for 15 dietary factors using a Bayesian hierarchical model including the individual-level data, country-level food availability data, and other covariates. Two types of diet patterns were assessed: one reflecting greater intake of 11 healthy dietary items; and the other, lower intake of 4 unhealthy dietary items. Mean intake of each dietary factor was divided into quintiles. Quintiles were assigned an ordinal score and scores were summed to generate each pattern, scaled from 0–100. Higher scores correspond to healthier diets for each age-sex-country-year-education-residence stratum.

Results

In 2015, the global mean score was 48 [95% UI: 39–58] for the healthy diet pattern (Fig 1) and 51 [32–69] for the unhealthy diet pattern (Fig 2). Healthy vs unhealthy diet pattern scores across the 41,040 global strata annually were not strongly interrelated (r < -0.4). Western (54 [45–63]) and Latin American (63 [53–72]) regions had highest scores for the healthy diet pattern but lowest for the unhealthy diet pattern (37 [19, 54]; 27 [13, 42], respectively). Asia (57 [40–76]) and Sub-Saharan Africa (57 [34–76]) had the highest unhealthy diet pattern scores but lowest healthy diet pattern scores (42 [33, 52]; 41 [30, 53], respectively). Healthy diet pattern scores were generally higher in urban areas and among more educated strata, while unhealthy diet pattern scores were higher in rural areas and in less educated strata.

Conclusions

These novel data provide quantitative estimates of the specific heterogeneity in diet patterns across the world, providing the best estimates to date to inform policies and priorities for reducing the health and economic burdens of poor diet quality.

Funding Sources

Gates Foundation.

Supporting Tables, Images and/or Graphs

Protocol for the cost-consequence and equity impact analyses of a cluster randomised controlled trial comparing three variants of a nutrition-sensitive agricultural extension intervention to improve maternal and child dietary diversity and nutritional status in rural Odisha, India (UPAVAN trial)

Background

Undernutrition causes around 3.1 million child deaths annually, around 45% of all child deaths. India has one of the highest proportions of maternal and child undernutrition globally. To accelerate reductions in undernutrition, nutrition-specific interventions need to be coupled with nutrition-sensitive programmes that tackle the underlying causes of undernutrition. This paper describes the planned economic evaluation of the UPAVAN trial, a four-arm, cluster randomised controlled trial that tests the nutritional and agricultural impacts of an innovative agriculture extension platform of women’s groups viewing videos on nutrition-sensitive agriculture practices, coupled with a nutrition-specific behaviour-change intervention of videos on nutrition, and a participatory learning and action approach.

Methods

The economic evaluation of the UPAVAN interventions will be conducted from a societal perspective, taking into account all costs incurred by the implementing agency (programme costs), community and health care providers, and participants and their households, and all measurable outcomes associated with the interventions. All direct and indirect costs, including time costs and donated goods, will be estimated. The economic evaluation will take the form of a cost-consequence analysis, comparing incremental costs and incremental changes in the outcomes of the interventions, compared with the status quo. Robustness of the results will be assessed through a series of sensitivity analyses. In addition, an analysis of the equity impact of the interventions will be conducted.

Discussion

Evidence on the cost and cost-effectiveness of nutrition-sensitive agriculture interventions is scarce. This limits understanding of the costs of rolling out or scaling up programs. The findings of this economic evaluation will provide useful information for different multisectoral stakeholders involved in the planning and implementation of nutrition-sensitive agriculture programmes.

Trial registration

ISRCTN65922679. Registered on 21 December 2016

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3388-2) contains supplementary material, which is available to authorized users.

The effects of enfuvirtide therapy on body composition and metabolic parameters over 48 weeks in the TORO body imaging substudy

OBJECTIVE

The aim of the study was to compare the metabolic and morphological effects of enfuvirtide plus an optimized background (OB) regimen vs. OB alone (control group) in treatment-experienced patients in the T-20 vs. Optimized Regimen Only (TORO) studies.

METHODS

Body composition and metabolic changes were investigated in patients over 48 weeks, based on fasting chemistries, body weight, and other anthropometric measurements. Dual-energy X-ray absorptiometry (DEXA) and computed tomography (CT) scans were performed in a patient subgroup (n=155) at baseline and at weeks 24 and 48.

RESULTS

At week 48, mean changes from baseline were similar between treatment groups for glucose, insulin, C-peptide, total cholesterol, low-density lipoprotein (LDL) cholesterol, very low density lipoprotein (VLDL) cholesterol, high-density lipoprotein (HDL) cholesterol and triglyceride levels. The enfuvirtide group experienced a significant increase in body weight [mean change from baseline +0.99 kg; 95% confidence interval (CI) +0.54, +1.44] and, in those who had body scans, there was a significant increase in truncal fat (by DEXA: median change +419.4 g; 95% CI+71.3, +767.5) and total fat [visceral adipose tissue (VAT)+subcutaneous adipose tissue (SAT) by single-slice abdominal CT scan: median change +25.5 cm(2) ; 95% CI+8.9, +42.0] over 48 weeks; significant increases in these parameters were not seen in the control group. There was no significant change in truncal:peripheral fat ratio in either the enfuvirtide or the control group.

CONCLUSION

The addition of enfuvirtide to an OB regimen does not appear to have unfavourable effects on fat distribution or metabolic parameters.

Inhibition of murine suppressor cell function by progesterone

The effects of progesterone on murine suppressor cell function generated in allogeneic MLCs were investigated. BALB/c splenic lymphocytes stimulated in vitro with C3H/He cells significantly suppressed the proliferative response of BALB/c lymphocytes in a secondary MLC. This suppression was highly specific for the sensitizing alloantigens since the suppressor cells had no effect on the proliferative response of BALB/c lymphocytes to third-party alloantigens. In addition, BALB/c lymphocytes stimulated with syngeneic cells were observed to nonspecifically suppress the MLC response to a lesser extent. One to 10 micrograms/ml progesterone added at initiation to suppressor cell generating cultures diminished the ability of both alloantigen specific and nonspecific suppressor cell populations to suppress the proliferative response of homologous lymphocytes to alloantigens. Experiments with pyrilamine, an antihistamine, which blocks cytotoxic T lymphocyte (CTL) generation, suggests that progesterone has a direct inhibitory effect on suppressor cell function independent of its ability to block CTL induction. The effects of progesterone on suppressor cells were not due to shifts in peak response time in MLC or induction of radiosensitive cells in progesterone-treated cultures. Estradiol at doses between 5 and 10 micrograms/ml, and cortisol at dose of 1 microgram/ml, also significantly inhibited suppressor cell function. These results suggest that the steroid hormone milieu within the placenta may effect the activity of allogeneic or nonspecific suppressor cell activity.

Pregnancy-induced alterations in graft-versus-host responsiveness of uterine-draining and peripheral lymph node cells toward fetal alloantigens

The popliteal lymph node assay was used to assess the effects of allogeneic pregnancy on the graft-versus-host (GVH) responsiveness of maternal uterine-draining and peripheral lymph node cells toward fetal alloantigens. These two cell populations were obtained from three groups of female mice: BALB/c virgins, BALB/c females 13 days pregnant by C3H males, and BALB/c females 13 days pregnant by BALB/c males. Recipients of the donor cells were (BALB/c x C3H)F1 and (BALB/c x C57)F1 hybrids. Uterine-draining lymph node (UDLN) cells at day 13 of an allogeneic pregnancy were specifically hyporesponsive toward fetal alloantigens compared to peripheral lymph node cells from the same donors. There was no difference in responsiveness between uterine-draining and peripheral lymph node cells in virgin or syngeneically pregnant mice. Therefore, the local nodes draining the uteri of primigravid mice carrying allogeneic fetuses, but not syngeneic fetuses, showed a specific decrease in GVH activity toward fetal alloantigens.