School-based interventions and policies encourage youths to include and consume fruits and vegetables at lunchtime via school lunches, but limited research has examined how these behaviours compare when youths have home-packed lunches. The objective of the present study was to compare fruit and vegetable contents and consumption among students having school or home-packed lunches over the school week.

Participants were observed over five consecutive days at school lunchtime. Trained analysts estimated students’ lunchtime fruit and vegetable contents and consumption using digital imaging. Mixed models examined associations between fruit and vegetable dietary behaviours and lunch source (school v. home-packed), controlling for student gender, grade and school.

Three elementary schools in northern California, USA.

Fourth-, fifth- and sixth-grade students (nchildren 315; nobservations 1421).

Students were significantly less likely to have and to consume fruits and vegetables (all P<0·05) when having home-packed lunches, compared with when having school lunches. Among those who did have or did consume these foods, having a home-packed lunch was associated with consuming significantly less fruit (P<0·05) but no differences for other dietary outcomes.

The study adds to a growing body of literature indicating shortfalls in fruit and vegetable contents and consumption associated with having a home-packed lunch, relative to having a school lunch. Findings suggest that school-based interventions, particularly when targeting home-packed lunches, should focus on whether or not these foods are included and consumed, with less emphasis on quantities.

To evaluate the implementation of the Uruguayan healthy snacking initiative in primary and secondary schools in the capital, and to explore the factors underlying compliance from the perspective of school principals.

A mixed-method approach was used, which included semi-structured interviews with school principals and a survey of the foods and beverages sold and advertised in the schools.

Primary and secondary schools in Montevideo (the capital city of Uruguay).

School principals.

The great majority of the schools did not comply with the initiative. Exhibition of non-recommended products was the main cause for non-compliance, followed by advertising of non-recommended products through promotional activities of food and beverage companies. Although school principals were aware of the healthy snack initiative and showed a positive attitude towards it, the majority lacked knowledge about its specific content. Factors underlying compliance with the healthy snacking initiative were related to its characteristics, characteristics of the schools, and external factors such as family habits and advertising.

Results showed that the rationale underlying the selling of products at schools favours the availability of ultra-processed products and constitutes the main barrier for the promotion of healthy dietary habits among children and adolescents. Strategies aimed at facilitating the identification of unhealthy foods and beverages and provision of incentives to canteen managers to modify their offer are recommended.

The present longitudinal study assessed whether changes in socio-economic status (SES) from infancy to adolescence were associated with plasma lipoprotein concentrations in adolescence, of which low HDL-cholesterol (HDL-C) and high LDL-cholesterol (LDL-C), TAG and total cholesterol (TC) concentrations are associated with higher cardiovascular risk.

SES, assessed using the modified Graffar Index, was calculated at 1, 5, 10 and 16 years. Principal components factor analysis with varimax rotation extracted two orthogonal SES factors, termed ‘environmental capital’ and ‘social capital’. Generalized linear models were used to analyse associations between environmental and social capital at 1 and 16 years and outcomes (HDL-C, LDL-C, TAG, TC) at 16 years, as well as changes in environmental and social capital from 1–5, 5–10, 10–16 and 1–16 years, and outcomes at 16 years.

Santiago, Chile.

We evaluated 665 participants from the Santiago Longitudinal Study enrolled at infancy in Fe-deficiency anaemia studies and examined every 5 years to age 16 years.

Social capital in infancy was associated with higher HDL-C in adolescence. Environmental capital in adolescence was associated with higher LDL-C and TC during adolescence. Changing environmental capital from 1–16 years was associated with higher LDL-C. Changing environmental capital from 1–5 and 1–16 years was associated with higher TC.

Improvements in environmental capital throughout childhood were associated with less healthy LDL-C and TC concentrations in adolescence. We found no evidence of associations between changing environmental capital and HDL-C or TAG, or changing social capital and HDL-C, LDL-C, TAG or TC.

The study examines the impact of a front-of-pack label (Dutch Choices) on household purchase patterns.

Change in households’ volume share of products eligible for the label (treatment group) is estimated as a function of changes in the market share of products displaying the label (treatment), while controlling for other relevant factors.

Home-scan data for five food categories, subdivided into eighteen food groups, for households participating in a Dutch consumer panel. The data are from the period 2005 to 2009, which includes the date of the introduction of the Choices label.

Between 831 and 7216 households from all over the Netherlands.

An increase in the market share of products displaying the label led to an increase in the volume share purchased of products eligible for the label for dairy products, yoghurts and for sauces. For some of the products, the partial effect is considerable (e.g. a 10 percentage point (pp) increase in the share of products displaying the label is associated with a 11·5 and 14·0 pp increase in the volume share of eligible products for chocolate milk and quark, respectively).

The results suggest a positive effect from the presence of the Choices label on the volume share of eligible products purchased. Provided that eligible products are healthier than non-eligible products, the Choices label is a good guide for consumers in order to help them make healthier food choices. The positive effect is found mainly in food groups with a mix of both healthy and unhealthy food products.

In the light of Chile’s comprehensive new restriction on unhealthy food marketing, we analyse food advertising on Chilean television prior to the first and final phases of implementation of the restriction.

Content analysis of marketing strategies of 6976 advertisements, based on products’ nutritional quality. Statistical analysis of total and child audience reached using television ratings data.

Advertising from television aired between 06.00 and 00.00 hours during two random composite weeks across April–May 2016 from the four broadcast and four cable channels with the largest youth audiences.

Food ads represented 16 % of all advertising; 34 % of food ads featured a product high in energy, saturated fats, sugars and/or salt (HEFSS), as defined by the initial regulation. HEFSS ads were seen by more children and contained more child-directed marketing strategies than ads without HEFSS foods. If HEFSS advertising was restricted only in programmes where 20 % are children aged 4–12 years, 31 % of children’s and 8 % of the general audience’s HEFSS advertising exposure would be reduced. The newest 06.00–22.00 hours restriction captures 80 % of all audience exposure.

HEFSS advertising was seen by a large proportion of children before Chile’s regulation. Chile’s first implementation based on audience composition should reduce a third of this exposure and its second restriction across the television day should eliminate most of the exposure. The current study is a crucial first step in evaluating how Chile’s regulation efforts will impact children’s diets and obesity prevalence.

The focus of interventions for adults living with HIV (ALH) in Nigeria has been mostly on prevention and provision of antiretroviral therapy (ART) with little consideration to nutrition-related matters. Therefore, the present study aimed to improve the quality of life (QoL) and anthropometric status of ALH in Abeokuta, Nigeria.

A quasi-experimental design where 200 conveniently selected participants were stratified by gender and duration on ART. The intervention group (n 100) received the nutrition education programme (NEP) for 12 weeks. The control group received a brochure on nutrition guidelines for ALH. Socio-biographical information, QoL and anthropometric status were assessed using previously validated questionnaires and standard techniques at baseline, week 12 and week 24. Generalised least squares (GLS) regression analysis was used for group comparisons. Anthropometric status was summarised by gender.

Two tertiary hospitals in Abeokuta, Nigeria.

ALH.

The NEP led to significant improvement in the physical functioning (week 12 and 24: P < 0·01), role limitation due to physical health (week 12: P = 0·01; week 24: P = 0·002) and pain (week 12: P = 0·01) constructs of the QoL of the intervention group compared with the control group. There was no significant difference (P = 0·07) between the mean weights of the two groups at baseline.

There was a significant improvement at week 12 and week 24 in the QoL of the intervention participants. The results indicated that a tailored NEP could make a positive contribution to the management of ALH.

The Food Standards Code regulates health claims on Australian food labels. General-level health claims highlight food–health relationships, e.g. ‘contains calcium for strong bones’. Food companies making claims must notify Food Standards Australia New Zealand (FSANZ) and certify that a systematic literature review (SLR) substantiating the food–health relationship has been conducted. There is no pre- or post-notification assessment of the SLR, potentially enabling the food industry to make claims based on poor-quality research. The present study assessed the rigour of self-substantiation.

Food–health relationships notified to FSANZ were monitored monthly between 2013 and 2017. These relationships were assessed by scoping published literature. Where evidence was equivocal/insufficient, the relevant government food regulatory agency was asked to investigate. If not investigated, or the response was unsatisfactory, the project team conducted an independent SLR which was provided to the government agency.

Australia.

Self-substantiated food–health relationships.

There were sixty-seven relationships notified by thirty-eight food companies. Of these, thirty-three relationships (52 %) from twenty companies were deemed to have sufficient published evidence. Four were excluded as they originated in New Zealand. Three relationships were removed before investigations were initiated. The project initiated twenty-seven food–health relationship investigations. Another six relationships were withdrawn, and three relationships were awaiting government assessment.

To ensure that SLR underpinning food–health relationships are rigorous and reduce regulatory enforcement burden, pre-market approval of food–health relationships should be introduced. This will increase consumer and public health confidence in the regulatory process and prevent potentially misleading general-level health claims on food labels.

To examine the frequency of television (TV) food and beverage advertisements (F&B ads) to which children (4–11 years) are likely exposed and the nutrient profile of products advertised.

TV broadcasting between September and November 2016 was recorded (288 h of children’s programming; 288 h of family programming) resulting in 8980 advertisements, of which 1862 were F&B ads. Of those, 1473 could be classified into one of the seventeen food groups, and into permitted/non-permitted according to the WHO-EU nutrient profile model. Persuasive marketing techniques used were also identified.

TV programming was recorded for four weekdays and four weekend days, between 06.00 and 00.00 hours (576 total hours), for four channels (two national and two cable), in Costa Rica.

Mean (sd) number of F&B ads/h was greater in cable than national channels (3·7 (0·4) v. 2·8 (0·4), P < 0·05) and during children’s peak viewing hours (4·4 (0·4) v. 2·9 (0·3)). Of F&B ads classified with WHO-EU nutrient profile model (n 1473, 71·1 %), 91·1 % were non-permitted to be marketed to children. Categories most frequently advertised were ready-made/convenience foods (16 %), chocolates/confectionery/desserts (15 %), breakfast cereals (14 %), beverages (15 %), edible ices (9 %) and salty snacks (8 %). Non-permitted F&B ads were more likely to use promotional characters, brand benefit claims, and nutrition and health claims than permitted F&B ads.

Children watching popular TV channels in Costa Rica are exposed to a high number of unhealthy F&B ads daily. Our findings help justify the need for regulatory actions by national authorities.

In resource-constrained facilities or during resuscitation, immediate paediatric weight estimation remains a fundamental challenge. We aimed to develop and validate weight estimation models based on ulna length and forearm width and circumference measured by simple and portable tools; and to compare them against previous methods (advanced paediatric life support (APLS), Theron and Traub–Johnson formulas).

Cross-sectional analysis of anthropometric measurements. Four ulna- and forearm-based weight estimation models were developed in the training set (n 1016). Assessment of bias, precision and accuracy was examined in the validation set (n 457).

National Children’s Study-Formative Research in Anthropometry (2011–2012).

Multi-racial/ethnic infants and children aged <6 years (n 1473).

Developed Models 1–4 had high predictive precision (R2=0·91–0·97). Mean percentage errors between predicted and measured weight were significantly smaller across the developed models (0·1–0·7 %) v. the APLS, Theron and Traub–Johnson formulas (−1·7, 9·2 and −4·9 %, respectively). Root-mean-squared percentage error was overall smaller among Models 1–4 v. the three existing methods (range=7·5–8·7 v. 9·8–13·3 %). Further, Models 1–4 were within 10 and 20 % of actual weight in 72–87 and 95–99 % of the weight estimations, respectively, which outperformed any of the three existing methods.

Ulna length, forearm width and forearm circumference by simple and portable tools could serve as valid and reliable surrogate measures of weight among infants and children aged <6 years with improved precision over the existing age- or length-based methods. Further validation of these models in physically impaired or non-ambulatory children is warranted.

Research has begun to take a more ecological view of eating behaviour, examining multiple levels of influence: personal, social and environmental. The food environment is a major influence on eating behaviour, attracting the attention of researchers who have measured it in a number of ways. The present paper examines the short-form version, in comparison to the long-form version, of the Nutrition Environment Measures Survey (NEMS) – an observational food outlet audit tool.

Both the short-form and long-form were examined to qualitatively appraise the dimensions of the food environment assessed by each measure. Data from 135 food outlets in Australia were then used to compare results obtained using the short-form with the results from the long-form method, to consider the utility of the short-form measure.

The retail food environment in Australia.

One hundred and thirty-five food outlets in Australia.

Results indicate that the short-form predominantly assessed availability of healthful foods (one aspect of the food environment). Several critical dimensions of the food environment known to influence eating behaviour were not assessed. For this data set, the short-form produced scores inconsistent with the longer version of the measure, delivering inflated estimates for stores and deflated estimates for restaurants.

Scores between the long-form and short-form versions were not comparable in this Australian study. Further development of food environment measures is recommended and must balance instrument brevity with the need to accurately capture important aspects of the food environment known to influence eating behaviour.

To examine the pattern and correlates of public support for twelve public health interventions aimed at reducing sugar-sweetened beverage (SSB) consumption.

Cross-sectional population-based survey. Respondents were recruited using a random digit dialling procedure (landline telephone) and a random selection of telephone numbers (mobile telephone). Sampling quotas were applied for age, and the sample was stratified according to administrative regions.

The province of Québec, Canada.

One thousand adults aged between 18 and 64 years and able to answer the survey questionnaire in French or English.

Support was observed for a number of public health interventions, but the more intrusive approaches were less supported. Support for taxation as well as for sale and access restriction was positively associated with the perceived relevance of the government intervention, perceived effectiveness, and perceived associations between SSB consumption and chronic diseases. Believing that SSB consumption is a personal choice and daily consumption were generally negatively associated with strong support and positively associated with strong opposition. Sparse associations between sociodemographic and socio-economic characteristics were observed, with the exception of sex and age: women were generally more likely to support the examined public health strategies, while younger respondents were less likely to express support.

Increasing perceived effectiveness and government responsibility for addressing the issue of SSB consumption could lead to increased support for SSB interventions. Increasing the belief that SSB consumption could be associated with chronic diseases would increase support, but SSB consumers and younger individuals are expected to be resistant.

To test the effect of a behavioural economics intervention in two food pantries on the nutritional quality of foods available at the pantries and the foods selected by adults visiting food pantries.

An intervention (SuperShelf) was implemented in two food pantries (Sites A and B), with two other pantries (Sites C and D) serving as a control for pantry outcomes. The intervention aimed to increase the amount and variety of healthy foods (supply), as well as the appeal of healthy foods (demand) using behavioural economics strategies. Assessments included baseline and 4-month follow-up client surveys, client cart inventories, pantry inventories and environmental assessments. A fidelity score (range 0–100) was assigned to each intervention pantry to measure the degree of implementation. A Healthy Eating Index-2010 (HEI-2010) score (range 0–100) was generated for each client cart and pantry.

Four Minnesota food pantries, USA.

Clients visiting intervention pantries before (n 71) and after (n 70) the intervention.

Fidelity scores differed by intervention site (Site A=82, Site B=51). At Site A, in adjusted models, client cart HEI-2010 scores increased on average by 11·8 points (P<0·0001), whereas there was no change at Site B. HEI-2010 pantry environment scores increased in intervention pantries (Site A=8 points, Site B=19 points) and decreased slightly in control pantries (Site C=−4 points, Site D=−3 points).

When implemented as intended, SuperShelf has the potential to improve the nutritional quality of foods available to and selected by pantry clients.

The present study aimed to: (i) evaluate changes in Canadian children’s dietary quality during school hours and on school days between 2004 and 2015; and (ii) explore whether changes in dietary quality over time were moderated by sociodemographic characteristics.

Nationally representative 24 h dietary recall data were obtained from the 2004 (n 4827) and 2015 (n 2447) Canadian Community Health Surveys. Dietary quality was measured using the Canadian Healthy Eating Index (C-HEI) which evaluates respondents’ compliance with 2007 national dietary recommendations, and the school-HEI which assesses respondents’ dietary quality during school hours. Multivariable regression models compared differences in dietary quality between 2004 and 2015. Interaction effects were used to test whether changes over time were moderated by sociodemographic characteristics (sex, age group, ethnicity, residential location, province of residence, parental education, food security status).

Canada.

Children aged 6–17 years.

Mean school-HEI score rose from 51.3 to 58.0 points (maximum = 100) from 2004 to 2015 (P < 0.001). School-HEI sub-scores for total vegetables and fruit, whole fruit, dark green and orange vegetables, milk and alternatives, and meat and alternatives improved over time, but remained well below recommendations. Decreased energy from minimally nutritious foods accounted for 39 % of the improvement in mean school-HEI scores. Mean whole day C-HEI scores also improved (60.8 to 66.4 points, P < 0.001). There was no evidence of a moderating effect for any of the sociodemographic variables examined.

Mean dietary quality of Canadian children during school hours and on school days improved modestly for all age and sex groups but remained below 2007 national dietary recommendations.

The present commentary introduces a Health Evidence Network (HEN) report that synthesises evidence of front-of-pack food labelling (FOPL) policy development and implementation across the European Region.

Countries were identified as having policies on interpretive FOPL from the WHO databases of Member State policies and online repositories of global food policies. For each identified country, evidence published from 1 January 1980 to 31 March 2018 was retrieved from peer-reviewed and grey literature. Extracted data were cross-checked with in-country representatives to ensure completeness and accuracy.

WHO European Region, spanning fifty-three countries.

Fifteen countries had a government-endorsed policy on interpretive FOPL. Thirteen of these countries had introduced endorsement logos, while only three labelling systems provided an indicator for unhealthfulness. Common steps were identified in FOPL policy development, including: establishing FOPL as a nutrition policy priority; engaging stakeholders and the public; and collecting formative evidence on which to base the labelling system. Few countries had outlined formal provisions for evaluation of FOPL systems. The HEN report describes seven considerations for the adoption/review of FOPL policies to ensure these achieve the population nutrition aims of FOPL. These considerations relate to supporting consumer use and understanding of the labelling, policy feasibility and credibility, and ensuring policy implementation and accountability.

The HEN report encourages countries to consider FOPL policy that is applied widely across all products and provides negative evaluative judgements, possibly combined with positive indicators. Implementation provisions should drive widespread uptake of the system and allow for formal evaluation of impact.

Pacific Island countries are experiencing a high burden of diet-related non-communicable diseases; and consumption of fat, sugar and salt are important modifiable risk factors contributing to this. The present study systematically reviewed and summarized available literature on dietary intakes of fat, sugar and salt in the Pacific Islands.

Electronic databases (PubMed, Scopus, ScienceDirect and GlobalHealth) were searched from 2005 to January 2018. Grey literature was also searched and key stakeholders were consulted for additional information. Study eligibility was assessed by two authors and quality was evaluated using a modified tool for assessing dietary intake studies.

Thirty-one studies were included, twenty-two contained information on fat, seventeen on sugar and fourteen on salt. Dietary assessment methods varied widely and six different outcome measures for fat, sugar and salt intake – absolute intake, household expenditure, percentage contribution to energy intake, sources, availability and dietary behaviours – were used. Absolute intake of fat ranged from 25·4 g/d in Solomon Islands to 98·9 g/d in Guam, while salt intake ranged from 5·6 g/d in Kiribati to 10·3 g/d in Fiji. Only Guam reported on absolute sugar intake (47·3 g/d). Peer-reviewed research studies used higher-quality dietary assessment methods, while reports from national surveys had better participation rates but mostly utilized indirect methods to quantify intake.

Despite the established and growing crisis of diet-related diseases in the Pacific, there is inadequate evidence about what Pacific Islanders are eating. Pacific Island countries need nutrition monitoring systems to fully understand the changing diets of Pacific Islanders and inform effective policy interventions.

To assess and compare the favourability of healthy public policy options to promote healthy eating from the perspective of members of the general public and policy influencers in two Canadian provinces.

The Chronic Disease Prevention Survey, administered in 2016, required participants to rank their level of support for different evidence-based policy options to promote healthy eating at the population level. Pearson’s χ2 significance testing was used to compare support between groups for each policy option and results were interpreted using the Nuffield Council on Bioethics’ intervention ladder framework.

Alberta and Québec, Canada.

Members of the general public (n 2400) and policy influencers (n 302) in Alberta and Québec.

General public and policy influencer survey respondents were more supportive of healthy eating policies if they were less intrusive on individual autonomy. However, in comparing levels of support between groups, we found policy influencers indicated significantly stronger support overall for healthy eating policy options. We also found that policy influencers in Québec tended to show more support for more restrictive policy options than their counterparts from Alberta.

These results suggest that additional knowledge brokering may be required to increase support for more intrusive yet impactful evidence-based policy interventions; and that the overall lower levels of support among members of the public may impede policy influencers from taking action on policies to promote healthy eating.

To explore people’s perceptions of, and responses to, obesity and tobacco policies with a particular focus on motivation; and to compare and contrast responses to explore the potential for translating learning across domains.

A theoretically informed comparative qualitative study involving semi-structured interviews with two groups of participants (smokers and ex-smokers; those who have previously or are currently attempting to lose weight). Data were analysed inductively using thematic analysis and interpreted through the lens of Self-Determination Theory.

Community-based.

Interviews were conducted with five smokers and four ex-smokers around tobacco policy, and seventeen people acting to control their weight around obesity policy.

Three primary themes were identified. (i) Participants believed social norms to be crucial to supporting health behaviour change and responses to policy; not smoking was perceived as socially normal, whereas being physically active and eating healthily were perceived to go against social norms. (ii) Policies influencing the physical environment were perceived to support stopping smoking (e.g. smoke-free laws, advertising bans), but to undermine attempts to lose or control weight (e.g. high visibility, availability and low cost of energy-dense foods). (iii) While policies for both domains were considered necessary and legitimate, both groups found policy interventions neither motivating nor undermining of their sense of autonomy.

The results suggest those trying to lose weight respond similarly to obesity-related policy as smokers do to tobacco policy. Environmental interventions are perceived to be more helpful than appealing to people’s motivation to change for their own sake.

Food environments may be contributing to the rapid increase in obesity occurring in most Latin American (LA) countries. The present study reviews literature from LA that (i) describes the food environment and policies targeting the food environment (FEP); and (ii) analytic studies that investigate associations between the FEP and dietary behaviours, overweight/obesity and obesity related chronic diseases. We focus on six dimensions of the FEP: food retail, provision, labelling, marketing, price and composition.

Systematic literature review. Three databases (Web of Science, SciELO, LILACS) were searched, from 1 January 1999 up to July 2017. Two authors independently selected the studies. A narrative synthesis was used to summarize, integrate and interpret findings.

Studies conducted in LA countries.

The search yielded 2695 articles of which eighty-four met inclusion criteria.

Most studies were descriptive and came from Brazil (61 %), followed by Mexico (18 %) and Guatemala (6 %). Studies were focused primarily on retail/provision (n 27), marketing (n 16) and labelling (n 15). Consistent associations between availability of fruit and vegetable markets and higher consumption of fruits and vegetables were found in cross-sectional studies. Health claims in food packaging were prevalent and mostly misleading. There was widespread use of marketing strategies for unhealthy foods aimed at children. Food prices were lower for processed relative to fresh foods. Some studies documented high sodium in industrially processed foods.

Gaps in knowledge remain regarding policy evaluations, longitudinal food retail studies, impacts of food price on diet and effects of digital marketing on diet/health.

To assess knowledge of osteoporosis and its risk factors and to explore associations between knowledge and various sociodemographic factors in Indian adults.

Cross-sectional study. The Revised Osteoporosis Knowledge Test (OKT) was used to assess knowledge of osteoporosis. Four scores (OKT-total, range 0–32; OKT-exercise, range 0–20; OKT-nutrition, range 0–26; OKT-risk factors, range 0–14) were generated by giving 1 point to every correct answer and 0 points for incorrect or ‘not known’ answers.

Tertiary-care hospital in Pune city, India.

Adults aged 40–75 years (n 477; 234 males) enrolled through voluntary routine health checks and health camps.

Mean age of the study population was 54·6 (sd 9·5) years. Half the participants were aware of osteoporosis and could correctly define it. Women showed significantly higher median OKT-total and OKT-nutrition scores than men (P<0·05). Those with higher education and higher socio-economic status had significantly higher scores in both men and women (P<0·05). All four scores were significantly higher in both men and women who could correctly define osteoporosis (P<0·05). All four scores were significantly higher in women with a family history of osteoporosis (P<0·05) but not in men (P>0·1).

Understanding about osteoporosis and its risk factors is low in the present cohort of Indian men and women. There is need to create awareness programmes aimed at both men and women especially targeting those with lower education, lower socio-economic status and no previous exposure to osteoporosis.