Guidance on the use of complex systems models for economic evaluations of public health interventions.

To help health economic modelers respond to demands for greater use of complex systems models in public health. To propose identifiable features of such models and support researchers to plan public health modeling projects using these models. A working group of experts in complex systems modeling and economic evaluation was brought together to develop and jointly write guidance for the use of complex systems models for health economic analysis. The content of workshops was informed by a scoping review. A public health complex systems model for economic evaluation is defined as a quantitative, dynamic, non-linear model that incorporates feedback and interactions among model elements, in order to capture emergent outcomes and estimate health, economic and potentially other consequences to inform public policies. The guidance covers: when complex systems modeling is needed; principles for designing a complex systems model; and how to choose an appropriate modeling technique. This paper provides a definition to identify and characterize complex systems models for economic evaluations and proposes guidance on key aspects of the process for health economics analysis. This document will support the development of complex systems models, with impact on public health systems policy and decision making.

Effective policies to promote sugar reduction in soft drinks: lessons from a comparison of six European countries.

BACKGROUND: Many countries have sought to incentivise soft drinks manufacturers to reduce sugar in their products as part of efforts to address a growing prevalence of obesity. Are their policies effective? METHODS: Using a difference-in-differences design, we compared trends in the sugar content of 10 695 new sugar-sweetened beverages (SSB) launched between 2010 and 2019 in six European markets, including the UK and France (taxes designed to incentivise reformulation), the Netherlands (policy based on voluntary agreements to reduce sugar), Germany, Italy and Spain (no national policies). RESULTS: The announcement in 2016 and adoption in 2018 of the UK tax led to yearly reductions in average sugar content of 17% (95% CI: 15-19%) to 31% (13-48%) between 2016 and 2019, compared to 2015, while the 2018 French tax produced a 6% (95% CI: 5-7%) sugar reduction only in 2018, compared to 2017, shortly after it was redesigned to provide a stronger incentive for reformulation. Voluntary agreements implemented in the Netherlands in 2014 led to an 8% (95% CI: 4-13%) sugar reduction only in 2015, compared to 2013. CONCLUSION: The analysis supports the conclusions that sugar reductions in new SSBs have been greater in countries that have adopted specific policies to encourage them; a sugar-based tax design encourages more sugar reductions than a volume-based tax design; the tax rate and the amount of the tax reduction from switching to the next lower tier in a sugar-based tax design may be critical to incentivize reformulation.

Food environment and diabetes mellitus in South Asia: A geospatial analysis of health outcome data.

BACKGROUND: The global epidemic of type 2 diabetes mellitus (T2DM) renders its prevention a major public health priority. A key risk factor of diabetes is obesity and poor diets. Food environments have been found to influence people's diets and obesity, positing they may play a role in the prevalence of diabetes. Yet, there is scant evidence on the role they may play in the context of low- and middle-income countries (LMICs). We examined the associations of food environments on T2DM among adults and its heterogeneity by income and sex. METHODS AND FINDINGS: We linked individual health outcome data of 12,167 individuals from a network of health surveillance sites (the South Asia Biobank) to the density and proximity of food outlets geolocated around their homes from environment mapping survey data collected between 2018 and 2020 in Bangladesh and Sri Lanka. Density was defined as share of food outlets within 300 m from study participant's home, and proximity was defined as having at least 1 outlet within 100 m from home. The outcome variables include fasting blood glucose level, high blood glucose, and self-reported diagnosed diabetes. Control variables included demographics, socioeconomic status (SES), health status, healthcare utilization, and physical activities. Data were analyzed in ArcMap 10.3 and STATA 15.1. A higher share of fast-food restaurants (FFR) was associated with a 9.21 mg/dl blood glucose increase (95% CI: 0.17, 18.24; p < 0.05). Having at least 1 FFR in the proximity was associated with 2.14 mg/dl blood glucose increase (CI: 0.55, 3.72; p < 0.01). A 1% increase in the share of FFR near an individual's home was associated with 8% increase in the probability of being clinically diagnosed as a diabetic (average marginal effects (AMEs): 0.08; CI: 0.02, 0.14; p < 0.05). Having at least 1 FFR near home was associated with 16% (odds ratio [OR]: 1.16; CI: 1.01, 1.33; p < 0.05) and 19% (OR: 1.19; CI: 1.03, 1.38; p < 0.05) increases in the odds of higher blood glucose levels and diagnosed diabetes, respectively. The positive association between FFR density and blood glucose level was stronger among women than men, but the association between FFR proximity and blood glucose level was stronger among men as well as among those with higher incomes. One of the study's key limitations is that we measured exposure to food environments around residency geolocation; however, participants may source their meals elsewhere. CONCLUSIONS: Our results suggest that the exposure to fast-food outlets may have a detrimental impact on the risk of T2DM, especially among females and higher-income earners. Policies should target changes in the food environments to promote better diets and prevent T2DM.

Cord blood metabolites and rapid postnatal growth as multiple mediators in the prenatal propensity to childhood overweight.

BACKGROUND: The mechanisms underlying childhood overweight and obesity are poorly known. Here, we investigated the direct and indirect effects of different prenatal exposures on offspring rapid postnatal growth and overweight in childhood, mediated through cord blood metabolites. Additionally, rapid postnatal growth was considered a potential mediator on childhood overweight, alone and sequentially to each metabolite. METHODS: Within four European birth-cohorts (N = 375 mother-child dyads), information on seven prenatal exposures (maternal education, pre-pregnancy BMI, weight gain and tobacco smoke during pregnancy, age at delivery, parity, and child gestational age), selected as obesogenic according to a-priori knowledge, was collected. Cord blood levels of 31 metabolites, associated with rapid postnatal growth and/or childhood overweight in a previous study, were measured via liquid-chromatography-quadrupole-time-of-flight-mass-spectrometry. Rapid growth at 12 months and childhood overweight (including obesity) between four and eight years were defined with reference to WHO growth charts. Single mediation analysis was performed using the imputation approach and multiple mediation analysis using the extended-imputation approach. RESULTS: Single mediation suggested that the effect of maternal education, pregnancy weight gain, parity, and gestational age on rapid postnatal growth but not on childhood overweight was partly mediated by seven metabolites, including cholestenone, decenoylcarnitine(C10:1), phosphatidylcholine(C34:3), progesterone and three unidentified metabolites; and the effect of gestational age on childhood overweight was mainly mediated by rapid postnatal growth. Multiple mediation suggested that the effect of gestational age on childhood overweight was mainly mediated by rapid postnatal growth and that the mediating role of the metabolites was marginal. CONCLUSION: Our findings provide evidence of the involvement of in utero metabolism in the propensity to rapid postnatal growth and of rapid postnatal growth in the propensity to childhood overweight. We did not find evidence supporting a mediating role of the studied metabolites alone between the studied prenatal exposures and the propensity to childhood overweight.

The benefits and challenges of taxing sugar in a small island state: an interrupted time series analysis.

BACKGROUND: Beverage and food taxes have become a popular 'best buy' public health intervention in the global battle to tackle noncommunicable diseases. Though many countries have introduced taxes, mainly targeting products containing sugar, there is great heterogeneity in tax design. For taxes levied as import tariffs, there is limited evidence of effectiveness in changing the price and sale of taxed products, while the evidence base is stronger for excise taxes levied as a fixed amount per quantity of product. This paper examines the effect of the Bermuda Discretionary Foods Tax, which was based on import tariff changes, on retail prices and sales of sugar-sweetened beverages (SSBs), and on selected fruits and vegetables that benefited from a tariff reduction. METHODS: We used weekly electronic point-of-sale data from a major food retailer in Bermuda. We assessed historical weekly sales and price data using an interrupted time series design on 2,703 unique products between the dates of January 2018 through January 2020, covering 103 weeks. RESULTS: By January 2020, the average price per ounce of SSBs increased by 26.0%, while the price of untaxed beverages (including waters and non-added sugar drinks) remained constant. The increasing price of SSBs was the sole observable structural driver of SSB market share, responsible for a decrease in the market share by nearly eight percentage points by the end of the study period. The subsidy on fruits and vegetables was ineffective in changing prices and sales, due to the relatively small 5% import tax decrease. CONCLUSIONS: The tax was largely passed through to consumers. However, several factors mitigated the impact of the tax on the prices paid for SSBs by consumers, including the specific design of the tax, price promotions and consumer responses. The experience of Bermuda provides important lessons for the planning of similar taxes in the future.

The 'sugar tax' in Bermuda: a mixed methods study of general population and key stakeholder perceptions.

BACKGROUND: Taxes on discretionary foods and sugar-sweetened beverages have emerged as a strategy for health promotion. Between 2018-2019, the Bermuda government introduced a phased tax on imported sugar-sweetened beverages, confectionery, products containing cocoa and pure sugar, and eliminated import duties on select healthy food items. The aim of this study was to conduct an mixed methods evaluation of perceptions of the tax among the general population and key stakeholders. METHODS: We conducted a survey of the general population (N = 400), and semi-structured interviews with key informants (N = 14) from the government, food and beverage, and health sectors to understand awareness, acceptability, and perceived impact of the tax after implementation. Survey data was analysed using thematic analysis, summary statistics, and Chi-squared tests. Key informant interviews were analysed using the framework method. RESULTS: General population respondents had high awareness of the sugar tax (94%) but low awareness of the healthy food subsidy (32%). Most respondents (67%) felt the tax was not an appropriate way to motivate healthier consumption due to beliefs the tax would not be effective (44%), and because of the high price of healthy food (20%). However, nearly half (48%) reported consuming fewer taxed products, primarily for health reasons but also motivated by price increases. Key informants indicated there was high awareness but limited understanding of the tax policy. Informants expressed support for taxation as a health promotion strategy, conditional on policy implementation. The lack of clear price differentiation between taxed and un-taxed products and the absence of accompanying health education were key factors believed to affect the impact of the tax. No informants were aware of use of tax revenues for health purposes and tax revenue was reportedly re-directed to other priorities after implementation. CONCLUSIONS: There was high awareness, but limited acceptability of the Bermuda sugar tax as implemented. Clarity in the tax policy, appropriateness of the tax mechanism, and use of revenue in alignment with the tax aim are critical components for acceptance. The absence of complementary education and health promotion affected acceptance and may limit potential health impacts. The lessons learned in Bermuda can inform similar policies in other settings.

Estimating the impact of nutrition and physical activity policies with quasi-experimental methods and simulation modelling: an integrative review of methods, challenges and synergies.

BACKGROUND: The promotion of healthy lifestyles has high priority on the global public health agenda. Evidence on the real-world (cost-)effectiveness of policies addressing nutrition and physical activity is needed. To estimate short-term policy impacts, quasi-experimental methods using observational data are useful, while simulation models can estimate long-term impacts. We review the methods, challenges and potential synergies of both approaches for the evaluation of nutrition and physical activity policies. METHODS: We performed an integrative review applying purposive literature sampling techniques to synthesize original articles, systematic reviews and lessons learned from public international workshops conducted within the European Union Policy Evaluation Network. RESULTS: We highlight data requirements for policy evaluations, discuss the distinct assumptions of instrumental variable, difference-in-difference, and regression discontinuity designs and describe the necessary robustness and falsification analyses to test them. Further, we summarize the specific assumptions of comparative risk assessment and Markov state-transition simulation models, including their extension to microsimulation. We describe the advantages and limitations of these modelling approaches and discuss future directions, such as the adequate consideration of heterogeneous policy responses. Finally, we highlight how quasi-experimental and simulation modelling methods can be integrated into an evidence cycle for policy evaluation. CONCLUSIONS: Assumptions of quasi-experimental and simulation modelling methods in policy evaluations should be credible, rigorously tested and transparently communicated. Both approaches can be applied synergistically within a coherent framework to compare policy implementation scenarios and improve the estimation of nutrition and physical activity policy impacts, including their distribution across population sub-groups.

Cord blood metabolic signatures predictive of childhood overweight and rapid growth.

INTRODUCTION: Metabolomics may identify biological pathways predisposing children to the risk of overweight and obesity. In this study, we have investigated the cord blood metabolic signatures of rapid growth in infancy and overweight in early childhood in four European birth cohorts. METHODS: Untargeted liquid chromatography-mass spectrometry metabolomic profiles were measured in cord blood from 399 newborns from four European cohorts (ENVIRONAGE, Rhea, INMA and Piccolipiu). Rapid growth in the first year of life and overweight in childhood was defined with reference to WHO growth charts. Metabolome-wide association scans for rapid growth and overweight on over 4500 metabolic features were performed using multiple adjusted logistic mixed-effect models and controlling the false discovery rate (FDR) at 5%. In addition, we performed a look-up analysis of 43 pre-annotated metabolites, previously associated with birthweight or rapid growth. RESULTS: In the Metabolome-Wide Association Study analysis, we identified three and eight metabolites associated with rapid growth and overweight, respectively, after FDR correction. Higher levels of cholestenone, a cholesterol derivative produced by microbial catabolism, were predictive of rapid growth (p = 1.6 × 10-3). Lower levels of the branched-chain amino acid (BCAA) valine (p = 8.6 × 10-6) were predictive of overweight in childhood. The area under the receiver operator curve for multivariate prediction models including these metabolites and traditional risk factors was 0.77 for rapid growth and 0.82 for overweight, compared with 0.69 and 0.69, respectively, for models using traditional risk factors alone. Among the 43 pre-annotated metabolites, seven and five metabolites were nominally associated (P < 0.05) with rapid growth and overweight, respectively. The BCAA leucine, remained associated (1.6 × 10-3) with overweight after FDR correction. CONCLUSION: The metabolites identified here may assist in the identification of children at risk of developing obesity and improve understanding of mechanisms involved in postnatal growth. Cholestenone and BCAAs are suggestive of a role of the gut microbiome and nutrient signalling respectively in child growth trajectories.

Investing in non-communicable disease prevention and management to advance the Sustainable Development Goals.

Reduction of the non-communicable disease (NCD) burden is a global development imperative. Sustainable Development Goal (SDG) 3 includes target 3·4 to reduce premature NCD mortality by a third by 2030. Progress on SDG target 3·4 will have a central role in determining the success of at least nine SDGs. A strengthened effort across multiple sectors with effective economic tools, such as price policies and insurance, is necessary. NCDs are heavily clustered in people with low socioeconomic status and are an important cause of medical impoverishment. They thereby exacerbate economic inequities within societies. As such, NCDs are a barrier to achieving SDG 1, SDG 2, SDG 4, SDG 5, and SDG 10. Productivity gains from preventing and managing NCDs will contribute to SDG 8. SDG 11 and SDG 12 offer clear opportunities to reduce the NCD burden and to create sustainable and healthy cities.

Equity impacts of price policies to promote healthy behaviours.

Governments can use fiscal policies to regulate the prices and consumption of potentially unhealthy products. However, policies aimed at reducing consumption by increasing prices, for example by taxation, might impose an unfair financial burden on low-income households. We used data from household expenditure surveys to estimate patterns of expenditure on potentially unhealthy products by socioeconomic status, with a primary focus on low-income and middle-income countries. Price policies affect the consumption and expenditure of a larger number of high-income households than low-income households, and any resulting price increases tend to be financed disproportionately by high-income households. As a share of all household consumption, however, price increases are often a larger financial burden for low-income households than for high-income households, most consistently in the case of tobacco, depending on how much consumption decreases in response to increased prices. Large health benefits often accrue to individual low-income consumers because of their strong response to price changes. The potentially larger financial burden on low-income households created by taxation could be mitigated by a pro-poor use of the generated tax revenues.

Estimating the costs of air pollution to the National Health Service and social care: An assessment and forecast up to 2035.

BACKGROUND: Air pollution damages health by promoting the onset of some non-communicable diseases (NCDs), putting additional strain on the National Health Service (NHS) and social care. This study quantifies the total health and related NHS and social care cost burden due to fine particulate matter (PM2.5) and nitrogen dioxide (NO2) in England. METHOD AND FINDINGS: Air pollutant concentration surfaces from land use regression models and cost data from hospital admissions data and a literature review were fed into a microsimulation model, that was run from 2015 to 2035. Different scenarios were modelled: (1) baseline 'no change' scenario; (2) individuals' pollutant exposure is reduced to natural (non-anthropogenic) levels to compute the disease cases attributable to PM2.5 and NO2; (3) PM2.5 and NO2 concentrations reduced by 1 µg/m3; and (4) NO2 annual European Union limit values reached (40 µg/m3). For the 18 years after baseline, the total cumulative cost to the NHS and social care is estimated at £5.37 billion for PM2.5 and NO2 combined, rising to £18.57 billion when costs for diseases for which there is less robust evidence are included. These costs are due to the cumulative incidence of air-pollution-related NCDs, such as 348,878 coronary heart disease cases estimated to be attributable to PM2.5 and 573,363 diabetes cases estimated to be attributable to NO2 by 2035. Findings from modelling studies are limited by the conceptual model, assumptions, and the availability and quality of input data. CONCLUSIONS: Approximately 2.5 million cases of NCDs attributable to air pollution are predicted by 2035 if PM2.5 and NO2 stay at current levels, making air pollution an important public health priority. In future work, the modelling framework should be updated to include multi-pollutant exposure-response functions, as well as to disaggregate results by socioeconomic status.

PRIORITIES FOR HEALTH ECONOMIC METHODOLOGICAL RESEARCH: RESULTS OF AN EXPERT CONSULTATION.

BACKGROUND: The importance of economic evaluation in decision making is growing with increasing budgetary pressures on health systems. Diverse economic evidence is available for a range of interventions across national contexts within Europe, but little attention has been given to identifying evidence gaps that, if filled, could contribute to more efficient allocation of resources. One objective of the Research Agenda for Health Economic Evaluation project is to determine the most important methodological evidence gaps for the ten highest burden conditions in the European Union (EU), and to suggest ways of filling these gaps. METHODS: The highest burden conditions in the EU by Disability Adjusted Life Years were determined using the Global Burden of Disease study. Clinical interventions were identified for each condition based on published guidelines, and economic evaluations indexed in MEDLINE were mapped to each intervention. A panel of public health and health economics experts discussed the evidence during a workshop and identified evidence gaps. RESULTS: The literature analysis contributed to identifying cross-cutting methodological and technical issues, which were considered by the expert panel to derive methodological research priorities. CONCLUSIONS: The panel suggests a research agenda for health economics which incorporates the use of real-world evidence in the assessment of new and existing interventions; increased understanding of cost-effectiveness according to patient characteristics beyond the "-omics" approach to inform both investment and disinvestment decisions; methods for assessment of complex interventions; improved cross-talk between economic evaluations from health and other sectors; early health technology assessment; and standardized, transferable approaches to economic modeling.

Social disparities in hazardous alcohol use: self-report bias may lead to incorrect estimates.

BACKGROUND: Self-report bias in surveys of alcohol consumption is widely documented; however, less is known about the distribution of such bias by socioeconomic status (SES) and about the possible impact on social disparities. This study aims to assess social disparities in hazardous drinking (HD) and to analyze how correcting alcohol consumption data for self-report bias may affect estimates of disparities. METHODS: National survey data from 13 countries, Canada, England, Finland, France, Germany, Hungary, Ireland, Japan, Korea, New Zealand, Spain, Switzerland and USA, are used to examine social disparities in HD by SES and education level. Defining HD as drinking above 3 drinks/day for men and 2 for women, social disparities were assessed by calculating country-level concentration indexes. Aggregate consumption data were used to correct survey-based estimates for self-report bias. RESULTS: Survey data show that more-educated women are more likely than less-educated women to engage in HD, while the opposite is observed in men in most countries. Large discrepancies in alcohol consumption between survey-based and aggregate estimates were found. Correcting for self-report bias increased estimates of social disparities in women, and decreased them in men, to the point that gradients were reversed in several countries (from higher rates in low education/SES men to an opposite pattern). CONCLUSION: This study provides evidence of a likely misestimation of social disparities in HD, in both men and women, due to self-report bias in alcohol consumption surveys. This study contributes to a better knowledge of the social dimensions of HD and to the targeting of alcohol policies.

Health-care expenditure and health policy in the USA versus other high-spending OECD countries.

The USA has exceptional levels of health-care expenditure, but growth has slowed dramatically in recent years, amidst major efforts to close the coverage gap with other countries of the Organisation for Economic Co-operation and Development (OECD). We reviewed expenditure trends and key policies since 2000 in the USA and five other high-spending OECD countries. Higher health-sector prices explain much of the difference between the USA and other high-spending countries, and price dynamics are largely responsible for the slowdown in expenditure growth. Other high-spending countries did not face the same coverage challenges, and could draw from a broader set of policies to keep expenditure under control, but expenditure growth was similar to the USA. Tightening Medicare and Medicaid price controls on plans and providers, and leveraging the scale of the public programmes to increase efficiency in financing and care delivery, might prevent a future economic recovery from offsetting the slowdown in health sector prices and expenditure growth.

The impact of level of education on adherence to breast and cervical cancer screening: Evidence from a systematic review and meta-analysis.

OBJECTIVE: To assess the inequalities in adherence to breast and cervical cancer screening according to educational level. METHODS: A systematic review was carried out between 2000 and 2013 by querying an electronic database using specific keywords. Studies published in English reporting an estimation of the association between level of education and adherence to breast and/or cervical cancer screening were included in the study. Two different meta-analyses were carried out for adherence to breast and cervical cancer screening, respectively: women with the highest level of education and women with the lowest level of education were compared. The level of heterogeneity was investigated and subgroup analyses were carried out. RESULTS: Of 1231 identified articles, 10 cross-sectional studies were included in the analysis. The meta-analyses showed that women with the highest level of education were more likely to have both screenings with an overall OR=1.61 (95% CI 1.36-1.91; I(2)=71%) for mammography and OR=1.96 (95% CI 1.79-2.16; I(2)=0%) for Pap test, respectively. Stratified meta-analysis for breast cancer screening included only studies that reported guidelines with target age of population ≥50 years and showed a reduction in the level of heterogeneity and an increase of 36% in the adherence (95% CI 1.19-1.55; I(2)=0%). CONCLUSIONS: This study confirms and reinforces evidence of inequalities in breast and cervical cancer screening adherence according to educational level.

Fiscal incentives, behavior change and health promotion: what place in the health-in-all-policies toolkit?

Taxes, subsidies and welfare benefits may provide financial incentives to encourage healthy behaviors or discourage less healthy ones. Historically, taxes have been used in many countries to deter behaviors like tobacco smoking or harmful alcohol use. More recently, an increasing number of governments have sought to expand the scope for the use of fiscal measures in health promotion to foods and beverages high in fat, salt or sugar. A strong public health rationale, supported by a growing body of evidence of the health impacts of taxes and other fiscal measures, adds to the more traditional rationale for the use of commodity taxes, which hinges on their revenue-generating potential and their ability to address the costs imposed by consumers of health-related commodities on other individuals. Despite limitations in the existing evidence base, reviewed in this paper, taxes have been shown to generate significant health gains when applied to tobacco products and alcoholic beverages. In the case of foods and non-alcoholic beverages, the effects tend to build up over time and are stronger in people with lower socio-economic status. However, a number of potentially undesirable effects suggest that governments should exercise caution in planning and implementing taxes on health-related commodities. In particular, commodity taxes are generally regressive, and this is especially the case for taxes on tobacco, foods and non-alcoholic beverages, although the actual size of the tax burden involved is relatively modest. In addition, taxes may negatively impact on economic efficiency and social welfare, and may incentivize illicit activities.

Lessons on food security from the COVID-19 pandemic in Bermuda.

Compared with other OECD countries, Bermuda ranks third globally in terms of income inequality globally. During the COVID-19 pandemic, anecdotal evidence suggested, significant fluctuations in the food demand and supply. We aimed to examine the impact of the COVID-19 pandemic on food insecurity, with a focus on the availability and affordability of various foods in Bermuda. We utilized a cross-sectional study design to investigate potential drivers of food insecurity within the local population. To gauge the level of household food insecurity we relied on the Bermuda Omnibus survey (N = 400) undertaken by Total Research Associates Ltd via telephone. To assess changes in food availability and affordability we conducted semi-structured interviews with key stakeholders who played pivotal roles in shaping food accessibility availability and affordability of food in Bermuda. These interviews were systematically analysed using the framework method. We performed analyses of food retail and import data to evaluate fluctuations in food prices and their impact on food availability and affordability. We found statistically significant associations between changes in food consumption, household income, and government aid. Food aid beneficiaries ate fewer fruits and vegetables by 50% [95% CI:17%-83%] and less fresh meat and fish by 39% [95 CI:3%-75%] compared with residents who did not receive any aid during the COVID-19 period from March 2020 to March 2021. Although we did not identify statistically significant food price increases feeding programmes played a pivotal role in preventing food insecurity during the pandemic in Bermuda. However, a lack of monitoring regarding the nutritional quality within the programmes, allowed a wide availability of foods high in sugar, salts, and fats, disproportionately affected low-income populations. In conclusion, food availability in Bermuda remained largely unaffected during the pandemic. Nevertheless, the surge in demand for feeding programs underscores underlying food security challenges in Bermuda and warrants further attention.

Social inequalities in obesity and overweight in 11 OECD countries.

BACKGROUND: Evidence of inequalities in obesity and overweight is available mostly from national studies. This article provides a broad international comparison of inequalities by education level and socio-economic status, in men and women and over time. METHODS: Data from national health surveys of 11 OECD countries were used. The size of inequalities was assessed on the basis of absolute and relative inequality indexes. A regression-analysis approach was used to assess differences between social groups in trends over time. RESULTS: Of the countries examined, USA and England had the highest rates of obesity and overweight. Large social inequalities were consistently detected in all countries, especially in women. Absolute inequalities were largest in Hungary and Spain with a difference of 11.6 and 10% in obesity rates in men, and 18.3 and 18.9% in women, respectively, across the education spectrum. Relative inequalities were largest in France and Sweden with poorly educated men 3.2 and 2.8 times as likely to be obese as men with the highest education (18 and 17 times for women in Spain and Korea, respectively). Pro-poor inequalities in overweight were observed for men in USA, Canada, Korea, Hungary, Australia and England. Inequalities remained virtually stable during the last 15 years, with only small variations in England, Korea, Italy and France. CONCLUSION: Large and persistent social inequalities in obesity and overweight by education level and socio-economic status exist in OECD countries. These are consistently larger in women than in men.

The contribution to policies of an exposome-based approach to childhood obesity.

Childhood obesity is an increasingly severe public health problem, with a prospective impact on health. We propose an exposome approach to identify actionable risk factors for this condition. Our assumption is that relationships between external exposures and outcomes such as rapid growth, overweight, or obesity in children can be better understood through a "meet-in-the-middle" model. This is based on a combination of external and internal exposome-based approaches, that is, the study of multiple exposures (in our case, dietary patterns) and molecular pathways (metabolomics and epigenetics). This may strengthen causal reasoning by identifying intermediate markers that are associated with both exposures and outcomes. Our biomarker-based studies in the STOP consortium suggest (in several ways, including mediation analysis) that branched-chain amino acids (BCAAs) could be mediators of the effect of dietary risk factors on childhood overweight/obesity. This is consistent with intervention and animal studies showing that higher intake of BCAAs has a positive impact on body composition, glycemia, and satiety. Concerning food, of particular concern is the trend of increasing intake of ultra-processed food (UPF), including among children. Several mechanisms have been proposed to explain the impact of UPF on obesity and overweight, including nutrient intake (particularly proteins), changes in appetite, or the role of additives. Research from the Avon Longitudinal Study of Parents and Children cohort has shown a relationship between UPF intake and trajectories in childhood adiposity, while UPF was related to lower blood levels of BCAAs. We suggest that an exposome-based approach can help strengthening causal reasoning and support policies. Intake of UPF in children should be restricted to prevent obesity.