Key Considerations for Policymakers-Iodized Salt as a Vehicle for Iron Fortification: Current Evidence, Challenges, and Knowledge Gaps.

Could DFS help prevent iron deficiency and anemia? Studies in controlled settings (efficacy) demonstrate that double-fortified salt (DFS; iron added to iodized salt) reduces the prevalence of anemia and iron deficiency anemia. Studies in program settings (effectiveness) are limited and reported differing levels of DFS coverage, resulting in mixed evidence of impact on anemia. What iron formulations are available and how do they affect iodized salt? Ferrous sulfate and encapsulated ferrous fumarate (both with various enhancers and/or coating materials) are the main iron formulations currently in use for DFS. Adding iron to iodized salt may lead to adverse changes in the product, specifically discoloration and losses in iodine content. These changes are greatest when the iodized salt used in DFS production is of low quality (e.g., contain impurities, has high moisture, and is of large crystal size). DFS requires iodized salt of the highest quality and a high-quality iron formulation in order to minimize adverse sensory changes and iodine losses. Appropriate packaging of iodized salt is also important to prevent losses. What is known about the minimum requirements to manufacture DFS? DFS producers must use high-quality refined iodized salt meeting the minimum standards for DFS production (which is higher than standards for salt intended for iodization alone), and an iron formulation for which there are rigid quality-assurance measures to ensure consistent quality and blending techniques. The actual proportion of iodized salt meeting the stringent requirements necessary for DFS production is unclear, but likely to be low in many countries, especially those with fragmented salt industries and a low proportion of industrially produced salt. What are the financial implications of adding iron to iodized salt? As a result of higher input costs both for input salt and the iron compound, DFS is more expensive to produce than iodized salt and thus has a higher production cost. Various grades of iodized salt are produced and consumed in different sectors of the market. Experience in India indicates that, on average, producing DFS costs 31-40 US dollars/metric ton or 0.03-0.04 US dollars/kg more than high-quality refined iodized salt. The exact impact of this production-level cost difference on profit margins and consumer price is specific to the conditions of different salt markets. Factors such as transport costs, customary wholesale and retail mark-ups, and taxes all vary greatly and need to be assessed on a case by case basis. Is DFS in alignment with salt-reduction efforts? The WHO has long recognized that salt iodization is an important public health intervention to achieve optimal iodine nutrition and is compatible with salt-reduction goals. Fortification of salt (with any nutrient) should not be used to justify or encourage an increase in salt intake to the public. Any effort to expand salt fortification to other nutrients should be done in close consultation with WHO and those working on salt reduction. What has been the experience with DFS delivery under different platforms? To date, DFS has been introduced into the retail market and in social safety net (primarily in India) programs, but sensory changes in DFS have been raised as concerns. The higher price for DFS has limited expansion in the retail market. In social safety net programs where the cost of DFS is subsidized for beneficiaries, programs must consider long-term resourcing for sustainability. Overall: The optimal production and delivery of DFS are still under development, as many challenges need to be overcome. There is a beneficial impact on hemoglobin in efficacy trials. Thus, if those conditions can be replicated in programs or the technology can be adapted to better fit current production and delivery realities, DFS may provide an effective contribution in countries that need additional food-fortification vehicles to improve iron intake.

Nutrient density: addressing the challenge of obesity.

Obesity rates are increasing worldwide. Potential reasons include excessive consumption of sugary beverages and energy-dense foods instead of more nutrient-rich options. On a per kJ basis, energy-dense grains, added sugars and fats cost less, whereas lean meats, seafood, leafy greens and whole fruit generally cost more. Given that consumer food choices are often driven by price, the observed social inequities in diet quality and health can be explained, in part, by nutrition economics. Achieving a nutrient-rich diet at an affordable cost has become progressively more difficult within the constraints of global food supply. However, given the necessary metrics and educational tools, it may be possible to eat better for less. New metrics of nutrient density help consumers identify foods, processed and unprocessed, that are nutrient-rich, affordable and appealing. Affordability metrics, created by adding food prices to food composition data, permit calculations of both kJ and nutrients per penny, allowing for new studies on the economic drivers of food choice. Merging dietary intake data with local or national food prices permits the estimation of individual-level diet costs. New metrics of nutrient balance can help identify those food patterns that provide optimal nutritional value. Behavioural factors, including cooking at home, have been associated with nutrition resilience, defined as healthier diets at lower cost. Studies of the energy and nutrient costs of the global food supply and diverse food patterns will permit a better understanding of the socioeconomic determinants of health. Dietary advice ought to be accompanied by economic feasibility studies.

The Bariatric Experience Long Term (BELONG): Factors Related to Having Bariatric Surgery in a Large Integrated Healthcare System.

PURPOSE: Bariatric surgery is the most effective treatment for severe obesity, but currently, only 1-2% of all eligible patients undergo surgery each year. This study examined which factors were associated with a patient receiving bariatric surgery after referral in a real-world healthcare setting. MATERIALS AND METHODS: The current study used the baseline survey and electronic medical record (EMR) data from the Bariatric Experience Long Term (BELONG) study (n = 1975). Predictors of who did (n = 1680) and who did not (n = 295) have surgery were analyzed using multivariate logistic regression. RESULTS: Participants (n = 1975; 42.4% response rate) were primarily women (84%) and either non-Hispanic Black or Hispanic (60%). In the fully adjusted multivariate model, the strongest predictors of having surgery were being a woman (OR = 3.17; 95% CI = 2.15, 4.68; p < .001) and losing at least 5% of their body weight in the year before surgery (OR = 3.16; 95% CI = 2.28, 4.38; p < .001). The strongest predictors of not having surgery were a ≥ BMI 50 kg/m2 (OR = .39; 95% CI = .27, .56; p < .001) and having a higher physical comorbidity burden (OR = .84; 95% CI = .75, .94; p = .004). CONCLUSIONS: Practices such as 5-10% total weight loss before surgery and selection of patients with safer operative risk profiles (younger with lower comorbidity burden) may inadvertently contribute to under-utilization of bariatric surgery among some demographic subpopulations who could most benefit from this intervention.

The Mediterranean diet: does it have to cost more?

OBJECTIVE: To test the viability of the Mediterranean diet as an affordable low-energy-density model for dietary change. DESIGN: Foods characteristic of the Mediterranean diet were identified using previously published criteria. For these foods, energy density (kJ/100 g) and nutrient density in relation to both energy ($/MJ) and nutrient cost were examined. RESULTS: Some nutrient-rich low-energy-density foods associated with the Mediterranean diet were expensive, however, others that also fit within the Mediterranean dietary pattern were not. CONCLUSIONS: The Mediterranean diet provides a socially acceptable framework for the inclusion of grains, pulses, legumes, nuts, vegetables and both fresh and dried fruit into a nutrient-rich everyday diet. The precise balance between good nutrition, affordability and acceptable social norms is an area that deserves further study. The new Mediterranean diet can be a valuable tool in helping to stem the global obesity epidemic.

Novel public-private partnerships to address the double burden of malnutrition.

Public-private partnerships are an effective way to address the global double burden of malnutrition. While public-private partnerships operate in multiple forms, their leadership usually falls to governments, public health agencies, or nongovernmental organizations, with the private sector taking a subordinate role. The rapid ascent of social media and mass communications worldwide has provided a disruptive technology for new nutrition intervention programs. A new model, provisionally called private-public engagement, takes advantage of social media, mass media, and integrated social marketing to reach parents, families, and communities directly. These new private-public engagement initiatives need to be managed in ways suggested for public-private partnerships by the World Health Organization, especially if the private sector is in the lead. Once the rationale for engagement is defined, there is a need to mobilize resources, establish in-country partnerships and codes of conduct, and provide a plan for monitoring, evaluation, and accountability. Provided here is an example consistent with the private-public engagement approach, ie, the United for Healthier Kids program, which has been aimed at families with children aged less than 12 years. Materials to inspire behavioral change and promote healthier diets and lifestyle were disseminated in a number of countries through both digital and physical channels, often in partnership with local or regional governments. A description of this program, along with strategies to promote transparency and communication among stakeholders, serves to provide guidance for the development of future effective private-public engagements.

The Impact of Crunchy Wednesdays on Happy Meal Fruit Orders: Analysis of Sales Data in France, 2009-2013.

OBJECTIVE: Beginning in September, 2010, all McDonald's restaurants in France offered free fruit with every Happy Meal sold on the first Wednesday of the month. Sales data were used to determine the impact of free fruit promotion on the proportion of regular Happy Meal fruit desserts sold. METHODS: Trend analyses examined the proportion of fruit desserts for 2009-2013. Analyses also compared fruit orders on Crunchy Wednesdays with other weekdays. RESULTS: Happy Meal fruit desserts rose from 14.5% in 2010 to 18.0% in 2011 and to 19.4% in 2013 (P < .001). More Happy Meal fruit desserts were ordered on Crunchy Wednesdays compared with other weekdays (P < .001). Orders of cherry tomato sides and water as a beverage on Crunchy Wednesdays were unaffected. CONCLUSIONS AND IMPLICATIONS: Based on sales transactions data across multiple years, this study provides evidence of the long-term effectiveness of menu promotions aimed at increasing children's consumption of vegetables and fruit.

Conclusions of the II International and IV Spanish Hydration Congress. Toledo, Spain, 2nd-4th December, 2015.

Water is the major component of our organism representing about 60% of total body weight in adults and has to be obtained through the consumption of different foods and beverages as part of our diet. Water is an essential nutrient performing important functions, including transport of other nutrients, elimination of waste products, temperature regulation, lubrication and structural support. In this context, hydration through water has an essential role in health and wellness, which has been highly acknowledged in recent years among the health community experts such as nutritionists, dietitians, general practitioners, pharmacists, educators, as well as by physical activity and sport sciences experts and the general population.

The economics of obesity: dietary energy density and energy cost.

Highest rates of obesity and diabetes in the United States are found among the lower-income groups. The observed links between obesity and socioeconomic position may be related to dietary energy density and energy cost. Refined grains, added sugars, and added fats are among the lowest-cost sources of dietary energy. They are inexpensive, good tasting, and convenient. In contrast, the more nutrient-dense lean meats, fish, fresh vegetables, and fruit generally cost more. An inverse relationship between energy density of foods (kilojoules per gram) and their energy cost (dollars per megajoule) means that the more energy-dense diets are associated with lower daily food consumption costs and may be an effective way to save money. However, economic decisions affecting food choice may have physiologic consequences. Laboratory studies suggest that energy-dense foods and energy-dense diets have a lower satiating power and may result in passive overeating and therefore weight gain. Epidemiologic analyses suggest that the low-cost energy-dense diets also tend to be nutrient poor. If the rise in obesity rates is related to the growing price disparity between healthy and unhealthy foods, then the current strategies for obesity prevention may need to be revised. Encouraging low-income families to consume healthier but more costly foods to prevent future disease can be construed as an elitist approach to public health. Limiting access to inexpensive foods through taxes on frowned upon fats and sweets is a regressive measure. The broader problem may lie with growing disparities in incomes and wealth, declining value of the minimum wage, food imports, tariffs, and trade. Evidence is emerging that obesity in America is a largely economic issue.

The feasibility of meeting the WHO guidelines for sodium and potassium: a cross-national comparison study.

OBJECTIVE: To determine joint compliance with the WHO sodium-potassium goals in four different countries, using data from nationally representative dietary surveys. SETTING: Compared to national and international recommendations and guidelines, the world's population consumes too much sodium and inadequate amounts of potassium. The WHO recommends consuming less than 2000 mg sodium (86 mmol) and at least 3510 mg potassium (90 mmol) per person per day. PARTICIPANTS: Dietary surveillance data were obtained from the National Health and Nutrition Examination Survey (NHANES 2007-2010) for the USA; the Encuesta Nacional de Salud y Nutrición 2012 for Mexico; the Individual and National Study on Food Consumption (INCA2) for France; and the National Diet and Nutrition Survey (NDNS) for the UK. PRIMARY OUTCOME MEASURES: We estimated the proportion of adults meeting the joint WHO sodium-potassium goals in the USA, the UK, France and Mexico. RESULTS: The upper bounds of joint compliance with the WHO sodium-potassium goals were estimated at 0.3% in the USA, 0.15% in Mexico, 0.5% in France and 0.1% in the UK. CONCLUSIONS: Given prevailing food consumption patterns and the current food supply, implementing WHO guidelines will be an enormous challenge for global public health.

Comparing the nutrient rich foods index with "Go," "Slow," and "Whoa," foods.

The US National Heart, Lung, and Blood Institute has grouped foods and beverages into three classes: "Go," "Slow," and "Whoa," as part of a children's guide to eating right. Using nutrient composition data in the 2004 Food and Nutrient Database for Dietary Studies, this descriptive study compared the Go, Slow, and Whoa food classes to tertiles of food rankings generated by the Nutrient Rich Foods Index. A total of 1,045 foods and beverages were first assigned into Go, Slow, and Whoa classes and then ranked by the Nutrient Rich Foods Index nutrient profile model. The Nutrient Rich Foods Index model was based on nine nutrients to encourage: protein, fiber, vitamins A, C, and E, calcium, iron, magnesium, and potassium; and on three nutrients to limit: saturated fat, added sugar, and sodium, all calculated per 100 calories. Both the Go, Slow, and Whoa and the Nutrient Rich Foods Index models readily distinguished between energy-dense and nutrient-rich beverages and foods, and the three Go, Slow, and Whoa classes closely corresponded to tertiles of Nutrient Rich Foods Index scores. There were some disagreements in the class assignment of fortified cereals, some dairy products, and diet beverages. Unlike the Go, Slow, and Whoa model, the Nutrient Rich Foods Index model produced continuous scores that could be used to rank foods within a given class. The study provides an illustration of how diverse nutrient profiling systems can be used to identify healthful foods and beverages.

The Nutrient Rich Foods Index helps to identify healthy, affordable foods.

BACKGROUND: The Nutrient Rich Foods (NRF) Index is a formal scoring system that ranks foods on the basis of their nutrient content. When used in conjunction with a food prices database, it can help identify foods that are both nutritious and affordable. OBJECTIVE: Our aim was to identify healthy, affordable foods and food groups by using the NRF index and US Department of Agriculture (USDA) nutrient composition and food prices data sets. DESIGN: Foods in the USDA Food and Nutrition Database for Dietary Studies 1.0 were scored by using the NRF index. This NRF algorithm was represented by the sum of the percentage of the daily values of 9 nutrients to encourage (protein, fiber, vitamin A, vitamin C, vitamin E, calcium, iron, magnesium, and potassium) minus the sum of the percentage of the maximum recommended values for 3 nutrients to limit (saturated fat, added sugar, and sodium). NRF scores and mean national food prices were calculated per calorie and per US Food and Drug Administration-defined serving. RESULTS: Each of the 9 USDA food groups offered foods of diverse nutritive value and cost. Eggs, dry beans and legumes, and meat and milk products were the lowest-cost sources of protein. Milk and milk products were the lowest-cost sources of calcium, whereas vegetables and fruit were the lowest-cost sources of vitamin C. Milk, potatoes, citrus juices, cereals, and beans had more favorable overall nutrient-to-price ratios than did many vegetables and fruit. Energy-dense grains, sweets, and fats provided most of the calories but fewer nutrients per dollar. CONCLUSION: One important application of nutrient profile models is to help consumers identify foods that provide optimal nutrition at an affordable cost.

Does social class predict diet quality?

A large body of epidemiologic data show that diet quality follows a socioeconomic gradient. Whereas higher-quality diets are associated with greater affluence, energy-dense diets that are nutrient-poor are preferentially consumed by persons of lower socioeconomic status (SES) and of more limited economic means. As this review demonstrates, whole grains, lean meats, fish, low-fat dairy products, and fresh vegetables and fruit are more likely to be consumed by groups of higher SES. In contrast, the consumption of refined grains and added fats has been associated with lower SES. Although micronutrient intake and, hence, diet quality are affected by SES, little evidence indicates that SES affects either total energy intakes or the macronutrient composition of the diet. The observed associations between SES variables and diet-quality measures can be explained by a variety of potentially causal mechanisms. The disparity in energy costs ($/MJ) between energy-dense and nutrient-dense foods is one such mechanism; easy physical access to low-cost energy-dense foods is another. If higher SES is a causal determinant of diet quality, then the reported associations between diet quality and better health, found in so many epidemiologic studies, may have been confounded by unobserved indexes of social class. Conversely, if limited economic resources are causally linked to low-quality diets, some current strategies for health promotion, based on recommending high-cost foods to low-income people, may prove to be wholly ineffective. Exploring the possible causal relations between SES and diet quality is the purpose of this review.

Symposium on understanding and influencing consumer food behaviours for health: executive summary report.

Food consumption patterns in Asia are rapidly changing. Urbanization and changing lifestyles have diminished the consumption of traditional meals based on cereals, vegetables and root crops. These changes are accompa-nied by an increasing prevalence of chronic diseases among Asian populations. ILSI Southeast Asia and CSIRO, Australia jointly organized the Symposium on Understanding and Influencing Food Behaviours for Health, focusing on the use of consumer science to improve food behaviour. The goals of the Symposium were to present an understanding of Asian consumers and their food choices, examine the use of consumer research to modify food choices towards better health, illustrate how health programs and food regulations can be utilized effectively to promote healthier choices, and identify knowledge gaps regarding the promotion of healthy food behaviour in Asian populations. There is no difference in taste perception among Asians, and Asian preference for certain tastes is determined by exposure and familiarity largely dictated by culture and its underlying values and beliefs. Cross-cultural validity of consumer science theories and tools derived from western populations need to be tested in Asia. Information on consumption levels and substitution behaviours for foods and food products, obtained using consumer research methods, can guide the development of food regulations and programs that will enable individuals to make healthier choices. Existing knowledge gaps include consumer research techniques appropriate for use in Asian settings, diet-health relationships from consumption of traditional Asian diets, and methods to address the increasing prevalence of over- and undernutrition within the same households in Asia.