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.

Large goiters and postoperative complications: does it really matter?

INTRODUCTION: Thyroidectomy is one of the most commonly performed surgical procedures worldwide. Although the mortality rate is currently approaching 0%, the incidence of complications in such a frequent surgery is not insignificant. The most frequent are postoperative hypoparathyroidism, recurrent injury, and asphyxial hematoma. The size of the thyroid gland has traditionally been considered one of the most important risk factors, but there is currently no study that analyzes it independently. The objective of this study is to analyze whether the size of the thyroid gland is an isolated risk factor for the development of postoperative complications. PATIENTS AND METHOD: A prospective review of all patients who underwent total thyroidectomy at a third-level hospital between January 2019 and December 2021 was conducted. The thyroid volume was calculated preoperatively using ultrasound and, together with the weight of the definitive piece, was correlated with the development of postoperative complications. RESULTS: One hundred twenty-one patients were included. When analyzing the incidence of complications based on the quartiles of weight and glandular volume, there were no significant differences in the incidence of transient or permanent hypoparathyroidism in any of the groups. No differences were found in terms of recurrent paralysis. No fewer parathyroid glands were visualized intraoperatively in patients with larger thyroid glands, nor did the number of them accidentally removed during surgery increase. In fact, a certain protective trend was observed with regard to the number of glands visualized and glandular size or in the relationship between thyroid volume and accidental gland removal, with no significant differences. CONCLUSION: The size of the thyroid gland has not been shown to be a risk factor for the development of postoperative complications, contrary to what has traditionally been considered.

Association of the retail food environment, BMI, dietary patterns, and socioeconomic position in urban areas of Mexico.

The retail food environment is a key modifiable driver of food choice and the risk of non-communicable diseases (NCDs). This study aimed to assess the relationship between the density of food retailers, body mass index (BMI), dietary patterns, and socioeconomic position in Mexico. Cross-sectional dietary data, BMI and socioeconomic characteristics of adult participants came from the nationally representative 2012 National Health and Nutrition Survey in Mexico. Geographical and food outlet data were obtained from official statistics. Densities of food outlets per census tract area (CTA) were calculated. Dietary patterns were determined using exploratory factor analysis and principal component analysis. The association of food environment variables, socioeconomic position, BMI, and dietary patterns was assessed using two-level multilevel linear regression models. Three dietary patterns were identified-the healthy, the unhealthy and the carbohydrates-and-drinks dietary pattern. Lower availability of fruit and vegetable stores was associated with an unhealthier dietary pattern whilst a higher restaurant density was associated with a carbohydrates-and-drinks pattern. A graded and inverse association was observed for fruit and vegetable store density and socioeconomic position (SEP)-lower-income populations had a reduced availability of fruit and vegetable stores, compared with higher-income populations. A higher density of convenience stores was associated with a higher BMI when adjusting for unhealthy dietary patterns. Upper-income households were more likely to consume healthy dietary patterns and middle-upper-income households were less likely to consume unhealthy dietary patterns when exposed to high densities of fruit and vegetable stores. When exposed to a high concentration of convenience stores, lower and upper-lower-income households were more likely to consume unhealthy dietary patterns. Food environment and sociodemographic conditions within neighbourhoods may affect dietary behaviours. Food environment interventions and policies which improve access to healthy foods and restrict access to unhealthy foods may facilitate healthier diets and contribute to the prevention of NCDs.

Policy implementation and priorities to create healthy food environments using the Healthy Food Environment Policy Index (Food-EPI): A pooled level analysis across eleven European countries.

Background: Food environments have been recognised as highly influential on population diets. Government policies have great potential to create healthy food environments to promote healthy diets. This study aimed to evaluate food environment policy implementation in European countries and identify priority actions for governments to create healthy food environments. Methods: The Healthy Food Environment Policy Index (Food-EPI) was used to evaluate the level of food environment policy and infrastructure support implementation in Estonia, Finland, Germany, Ireland, Italy, the Netherlands, Norway, Poland, Portugal, Slovenia, and Spain in 2019-2021. Evidence of implementation of food environment policies was compiled in each country and validated by government officials. National experts evaluated the implementation of policies and identified priority recommendations. Findings: Finland had the highest proportion (32%, n = 7/22) of policies shaping food environments with a "high" level of implementation. Slovenia and Poland had the highest proportion of policies rated at very low implementation (42%, n = 10/24 and 36%, n = 9/25 respectively). Policies regarding food provision, promotion, retail, funding, monitoring, and health in all policies were identified as the most important gaps across the European countries. Experts recommended immediate action on setting standards for nutrients of concern in processed foods, improvement of school food environments, fruit and vegetable subsidies, unhealthy food and beverage taxation, and restrictions on unhealthy food marketing to children. Interpretation: Immediate implementation of policies and infrastructure support that prioritize action towards healthy food environments is urgently required to tackle the burden of obesity and diet-related non-communicable diseases in Europe. Funding: This project has received funding from the European Union's Horizon 2020 research and innovation programme under grant agreement No 774548 and from the Joint Programming Initiative "A Healthy Diet for a Healthy Life".

Dietary patterns, cooking methods and breast cancer risk in Mexico: An exploratory case-control study.

Background: Nutrition has an important influence on the risk of developing breast cancer (BC). Dietary patterns can capture the complex interplay of nutrients and cooking methods can contribute to the presence of heterocyclic amines, which are potent mammary carcinogens. Research on dietary patterns, cooking methods, and their association with BC in Mexican women is scarce. Aim: To evaluate the association of dietary patterns and cooking methods with BC risk among women from the Northwest region of Mexico. Methods: This case-control study included 120 women. Eligible cases (n = 60) were diagnosed and biopsy-confirmed in the past 2 years. Control subjects (n = 60) were hospital and population-based. Dietary intake and cooking methods were respectively assessed through a food frequency questionnaire (FFQ) and the National Cancer Institute survey. We obtained dietary patterns from a K-means cluster analysis (CA), and multivariate logistic regression tested the association of dietary patterns and cooking methods with BC risk. Results: Prudent and caloric dietary patterns were identified. The caloric pattern was associated with BC risk (Model 1: ORadj: 5.07, 95%CI:1.44-17.84, p = 0.011; Model 2: ORadj: 4.99 (95%CI:1.39-17.92, p = 0.014). Intense frying, meat grilling and poultry resulted in a significant BC risk (Model 1: ORadj: 5.54,95%CI: 2.13-14.41), p < 0.001; Model 2: ORadj: 5.12, 95%CI: 1.83-14.31, p = 0.002). At Oestrogen exposure of <32 years, there was an association between dietary patterns and BC risk (ORadj: 4.69, 95%CI: 1.01-21.92, p = 0.049). The relationship between BC risk and cooking intensity was found in both strata of exposure to oestrogens: <32 years (ORadj: 3.72, 95%CI:1.04-13.33, p = 0.044), and ≥32 years (ORadj: 6.06, 95%CI:1.34-27.42, p = 0.019). Conclusions: A caloric dietary pattern rich in refined carbohydrates and saturated fat, and intense meat product cooking may increase the risk of BC in Mexican women.

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.

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.

Food environments and obesity: A geospatial analysis of the South Asia Biobank, income and sex inequalities.

INTRODUCTION: In low-middle income countries (LMICs) the role of food environments on obesity has been understudied. We address this gap by 1) examining the effect of food environments on adults' body size (BMI, waist circumference) and obesity; 2) measuring the heterogeneity of such effects by income and sex. METHODS: This cross-sectional study analysed South Asia Biobank surveillance and environment mapping data for 12,167 adults collected between 2018 and 2020 from 33 surveillance sites in Bangladesh and Sri Lanka. Individual-level data (demographic, socio-economic, and health characteristics) were combined with exposure to healthy and unhealthy food environments measured with geolocations of food outlets (obtained through ground-truth surveys) within 300 m buffer zones around participants' homes. Multivariate regression models were used to assess association of exposure to healthy and unhealthy food environments on waist circumference, BMI, and probability of obesity for the total sample and stratified by sex and income. FINDINGS: The presence of a higher share of supermarkets in the neighbourhood was associated with a reduction in body size (BMI, ß = - 3∙23; p < 0∙0001, and waist circumference, ß = -5∙99; p = 0∙0212) and obesity (Average Marginal Effect (AME): -0∙18; p = 0∙0009). High share of fast-food restaurants in the neighbourhood was not significantly associated with body size, but it significantly increased the probability of obesity measured by BMI (AME: 0∙09; p = 0∙0234) and waist circumference (AME: 0∙21; p = 0∙0021). These effects were stronger among females and low-income individuals. INTERPRETATION: The results suggest the availability of fast-food outlets influences obesity, especially among female and lower-income groups. The availability of supermarkets is associated with reduced body size and obesity, but their effects do not outweigh the role of fast-food outlets. Policies should target food environments to promote better diets and reduce obesity.

The impact of the consumer and neighbourhood food environment on dietary intake and obesity-related outcomes: A systematic review of causal impact studies.

BACKGROUND: The food environment has been found to impact population dietary behaviour. Our study aimed to systematically review the impact of different elements of the food environment on dietary intake and obesity. METHODS: We searched MEDLINE, Embase, PsychInfo, EconLit databases to identify literature that assessed the relationship between the built food environments (intervention) and dietary intake and obesity (outcomes), published between database inception to March 26, 2020. All human studies were eligible except for those on clinical sub-groups. Only studies with causal inference methods were assessed. Studies focusing on the food environment inside homes, workplaces and schools were excluded. A risk of bias assessment was conducted using the CASP appraisal checklist. Findings were summarized using a narrative synthesis approach. FINDINGS: 58 papers were included, 55 of which were conducted in high-income countries. 70% of papers focused on the consumer food environments and found that in-kind/financial incentives, healthy food saliency, and health primes, but not calorie menu labelling significantly improved dietary quality of children and adults, while BMI results were null. 30% of the papers focused on the neighbourhood food environments and found that the number of and distance to unhealthy food outlets increased the likelihood of fast-food consumption and higher BMI for children of any SES; among adults only selected groups were impacted - females, black, and Hispanics living in low and medium density areas. The availability and distance to healthy food outlets significantly improved children's dietary intake and BMI but null results were found for adults. INTERPRETATION: Evidence suggests certain elements of the consumer and neighbourhood food environments could improve populations dietary intake, while effect on BMI was observed among children and selected adult populations. Underprivileged groups are most likely to experience and impact on BMI. Future research should investigate whether findings translate in other countries.

The built environment as determinant of childhood obesity: A systematic literature review.

We evaluated the epidemiological evidence on the built environment and its link to childhood obesity, focusing on environmental factors such as traffic noise and air pollution, as well as physical factors potentially driving obesity-related behaviors, such as neighborhood walkability and availability and accessibility of parks and playgrounds. Eligible studies were (i) conducted on human children below the age of 18 years, (ii) focused on body size measurements in childhood, (iii) examined at least one built environment characteristic, (iv) reported effect sizes and associated confidence intervals, and (v) were published in English language. A z test, as alternative to the meta-analysis, was used to quantify associations due to heterogeneity in exposure and outcome definition. We found strong evidence for an association of traffic-related air pollution (nitrogen dioxide and nitrogen oxides exposure, p < 0.001) and built environment characteristics supportive of walking (street intersection density, p < 0.01 and access to parks, p < 0.001) with childhood obesity. We identified a lack of studies that account for interactions between different built environment exposures or verify the role and mechanism of important effect modifiers such as age.

The retail food environment and its association with body mass index in Mexico.

BACKGROUND/OBJECTIVE: Mexico has one of the highest rates of obesity and overweight worldwide, affecting 75% of the population. The country has experienced a dietary and food retail transition involving increased availability of high-calorie-dense foods and beverages. This study aimed to assess the relationship between the retail food environment and body mass index (BMI) in Mexico. SUBJECTS/METHODS: Geographical and food outlet data were obtained from official statistics; anthropometric measurements and socioeconomic characteristics of adult participants (N = 22,219) came from the nationally representative 2012 National Health and Nutrition Survey (ENSANUT). Densities (store count/census tract area (CTA)) of convenience stores, restaurants, fast-food restaurants, supermarkets and fruit and vegetable stores were calculated. The association of retail food environment variables, sociodemographic data and BMI was tested using multilevel linear regression models. RESULTS: Convenience store density was high (mean (SD) = 50.0 (36.9)/CTA) compared with other food outlets in Mexico. A unit increase in density of convenience stores was associated with a 0.003 kg/m2 (95% CI: 0.0006, 0.005, p = 0.011) increase in BMI, equivalent to 0.34 kg extra weight for an adult 1.60 m tall for every additional 10% store density increase (number of convenience stores per CTA (km2)). Metropolitan areas showed the highest density of food outlet concentration and the highest associations with BMI (ß = 0.01, 95% CI: 0.004-0.01, p < 0.001). A 10% store density increase in these areas would represent a 1 kg increase in weight for an adult 1.60 m tall. CONCLUSIONS: Convenience store density was associated with higher mean BMI in Mexican adults. An excessive convenience store availability, that offers unhealthy food options, coupled with low access to healthy food resources or stores retailing healthy food, including fruits and vegetables, may increase the risk of higher BMI. This is the first study to assess the association of the retail food environment and BMI at a national level in Mexico.

Improving the school food environment for the prevention of childhood obesity: What works and what doesn't.

The food environment has a significant influence on dietary choices, and interventions designed to modify the food environment could contribute to the prevention of childhood obesity. Many interventions have been implemented at the school level, but effectiveness in addressing childhood obesity remains unclear. We undertook a systematic review, a meta-analysis, and meta-regression analyses to assess the effectiveness of interventions on the food environment within and around schools to improve dietary intake and prevent childhood obesity. Estimates were pooled in a random-effects meta-analysis with stratification by anthropometric or dietary intake outcome. Risk of bias was formally assessed. One hundred papers were included. Interventions had a significant and meaningful effect on adiposity (body mass index [BMI] z score, standard mean difference: -0.12, 95% confidence interval: 0.15, 0.10) and fruit consumption (portions per day, standard mean difference: +0.19, 95% confidence interval: 0.16, 0.22) but not on vegetable intake. Risk of bias assessment indicated that n = 43 (81%) of non-randomized controlled studies presented a high risk of bias in the study design by not accounting for a control. Attrition bias (n = 34, 79%) and low protection of potential contamination (n = 41, 95%) presented the highest risk of bias for randomized controlled trials. Changes in the school food environment could improve children's dietary behavior and BMI, but policy actions are needed to improve surrounding school food environments to sustain healthy dietary intake and BMI.

Forecasting Future Trends in Obesity across Europe: The Value of Improving Surveillance.

OBJECTIVE: To project the prevalence of obesity across the WHO European region and examine whether the WHO target of halting obesity at 2010 levels by 2025 is achievable. METHODS: BMI data were collected from online databases and the literature. Past and present BMI trends were extrapolated to 2025 using a non-linear categorical regression model fitted to nationally representative survey data. Where only 1 year of data was available, a flat trend was assumed. Where no data were available, proxy country data was used adjusted for demographics. RESULTS: By 2025, obesity is projected to increase in 44 countries. If present trends continue, 33 of the 53 countries are projected to have an obesity prevalence of 20% or more. The highest prevalence is projected for Ireland (43%, 95% confidence interval (CI): 28-58%). Lithuania, Finland, and the Netherlands were each estimated to have an absolute increase of 2 percentage points in the prevalence of obesity between 2015 and 2025. DISCUSSION: The quality of BMI data across Europe is highly variable, with fewer than 50% of the 53 countries having measured nationally representative data and often not enough data to interpret projections meaningfully. Nevertheless, the prevalence of obesity in the European Region appears to be increasing in most countries and, with it, the health and economic burden of its associated diseases. This paints a concerning picture of the future burden of obesity-related noncommunicable diseases across the region. Greater and continued effort for the implementation of effective preventive policies and interventions is required from governments.