Knowledge of gendered needs among the planners and policy makers for prevention of NCDs in Bangladesh: a qualitative exploration.

BACKGROUND: Globally, non-communicable diseases (NCDs) are increasingly the primary cause of mortality and morbidity among women. Like many developing countries, Bangladesh also faces a growing burden of NCDs. The "Multisectoral Action Plan for Prevention and Control of Non-communicable Diseases, 2018-2025" signifies Bangladesh's commitment to comprehensively combating the rising burden of NCDs. This study investigates the perceptions of those involved in developing the action plan and if/how a gender lens was incorporated into its implementation. METHODS: In-depth interviews were conducted with 25 key individuals involved in a high-level committee to develop and implement Bangladesh's multisectoral action plan to address the burden of NCDs. Data were collected between July and November 2021, and thematic analysis was conducted. RESULTS: The findings revealed that interviewees believed the multisectoral action plan adopted a population-wide approach without considering gender-specific needs. This study presents the explanations for this inattention under five themes: (1) A population-level approach to NCD prevention; (2) Understanding women's health beyond reproductive health; (3) Absence of gender-specific programs; (4) Lack of consideration of gender constraints on physical activity; and (5) Lack of collaborative efforts to address NCDs beyond the health ministry. CONCLUSION: In conclusion, governments in countries like Bangladesh can develop more effective strategies to reduce the disease burden of NCDs among women by recognizing and addressing the gendered nature of preventive health. This can be achieved by promoting gender-responsive research, programs, and policy initiatives that consider women's specific health concerns, ultimately leading to better health outcomes for all.

The association between body weight indices, behavioral factors, and type 2 diabetes mellitus in Africa: A systematic review and meta-analysis of population-based epidemiological studies.

BACKGROUND AND AIM: Type 2 diabetes mellitus (T2DM) is a significant public health concern in Africa. While the associations between modifiable risk factors and T2DM are likely to be Africa-specific, their overall estimations have not been published. This study aimed to use systematic and meta-analytic methods to examine the strength of associations between modifiable risk factors and T2DM in Africa. METHODS AND RESULTS: A systematic search of literature published between January 2000 to March 2022 was conducted. The review included only population-based studies and data extracted from 57 studies. Of these, unadjusted data from 50 studies were included in meta-analysis. With considerable heterogeneity between studies, random-effect models were calculated to ascertain the odds ratios (OR) and 95% confidence intervals (CI) for the associations between obesity (OB) and overweight (OV), defined by BMI; central obesity (waist circumference (OB-WC), waist-to-hip-ratio (OB-WHR)), alcohol, fruit and vegetable consumption, smoking, physical activity (PA) and T2DM. Moderator effects of age, African regions, and urban/rural location were assessed. Risk factors associated with T2DM include BMI-OB [OR = 3.05, 95% CI: (2.58, 3.61)], BMI-OV [OR = 2.38, 95% CI: (1.51, 3.75)], and BMI-OV/OB [OR = 2.07, 95% CI: (1.82, 2.34)]; OB-WC [OR = 2.58, 95% CI: (2.09, 3.18)] and OB-WHR [OR = 2.22, 95% CI: (1.69, 2.92)]; PA [OR = 1.85, 95% CI: (1.50, 2.30)]. Significant moderator effects were not observed. CONCLUSION: Obesity defined by BMI and central obesity, but not behavioral risk factors were most strongly associated with T2DM in African populations, emphasizing the need for obesity prevention to limit the rise of T2DM. REGISTRATION: The PROSPERO registration number is CRD42016043027.

'Healthier options tend to get lost in the noise of online' - Australian shoppers' experiences with online grocery platforms.

OBJECTIVE: We aimed to understand what influences parents' purchasing behaviours when shopping for groceries online and potential ways to improve the healthiness of online grocery platforms. DESIGN: We conducted semi-structured interviews, guided by the Marketing Mix framework. Reflexive thematic analysis was used to analyse data. SETTING: Online interviews were conducted with primary grocery shoppers. PARTICIPANTS: Parents (n 14) or caregivers (n 2) using online grocery platforms at least every 2 weeks. RESULTS: Most participants perceived purchasing healthy food when shopping for groceries online to be more challenging compared to in physical stores. They expressed concerns about the prominence of online marketing for unhealthy food. Participants from lower socio-economic backgrounds often depended on online supermarket catalogues to find price promotions, but healthy options at discounted prices were limited. Across socio-economic groups, fresh items like meat and fruit were preferred to be purchased instore due to concerns about online food quality.Participants believed online grocery platforms should make healthy foods more affordable and supported regulations on supermarket retailers to promote healthy options and limit unhealthy food promotion online. CONCLUSIONS: Participants had varied experiences with online grocery shopping, with both positive and negative aspects. Efforts to improve population diets need to include mechanisms to create health-enabling online grocery retail platforms. Government interventions to restrict marketing of unhealthy foods and promote marketing of healthy options on these platforms warrant investigation.

A systems framework for implementing healthy food retail in grocery settings.

BACKGROUND: Food retailers can be reluctant to initiate healthy food retail activities in the face of a complex set of interrelated drivers that impact the retail environment. The Systems Thinking Approach for Retail Transformation (START) is a determinants framework created using qualitative systems modelling to guide healthy food retail interventions in community-based, health-promoting settings. We aimed to test the applicability of the START map to a suite of distinct healthy food marketing and promotion activities that formed an intervention in a grocery setting in regional Victoria, Australia. METHODS: A secondary analysis was undertaken of 16 previously completed semi-structured interviews with independent grocery retailers and stakeholders. Interviews were deductively coded against the existing START framework, whilst allowing for new grocery-setting specific factors to be identified. New factors and relationships were used to build causal loop diagrams and extend the original START systems map using Vensim. RESULTS: A version of the START map including aspects relevant to the grocery setting was developed ("START-G"). In both health-promoting and grocery settings, it was important for retailers to 'Get Started' with healthy food retail interventions that were supported by a proof-of-concept and 'Focus on the customer' response (with grocery-settings focused on monitoring sales data). New factors and relationships described perceived difficulties associated with disrupting a grocery-setting 'Supply-side status quo' that promotes less healthy food and beverage options. Yet, most grocery retailers discussed relationships that highlighted the potential for 'Healthy food as innovation' and 'Supporting cultural change through corporate social responsibility and leadership'. CONCLUSIONS: Several differences were found when implementing healthy food retail in grocery compared to health promotion settings. The START-G map offers preliminary guidance for identifying and addressing commercial interests in grocery settings that currently promote less healthy foods and beverages, including by starting to address business outcomes and supplier relationships.

Understanding parents' perceptions of children's exposure to unhealthy food marketing in digital and retail environments.

Unhealthy food and non-alcoholic beverage marketing (UFM) adversely impacts children's selection and intake of foods and beverages, undermining parents' efforts to promote healthy eating. Parents' support for restrictions on children's exposure to food marketing can catalyse government action, yet research describing parent concerns is limited for media other than television. We examined parents' perceptions of UFM and their views on potential policies to address UFM in supermarkets and on digital devices - two settings where children are highly exposed to UFM and where little recent research exists. We conducted in-depth interviews with sixteen parents of children aged 7-12 from Victoria, Australia, analysing the data thematically. Parents perceived UFM as ubiquitous and viewed exposure as having an immediate but temporary impact on children's food desires and pestering behaviours. Parents were concerned about UFM in supermarkets as they viewed it as leading their children to pester them to buy marketed products, undermining their efforts to instil healthy eating behaviours. Parents generally accepted UFM as an aspect of contemporary parenting. Concern for digital UFM was lower compared to supermarkets as it was not directly linked to pestering and parents had limited awareness of what their children saw online. Nevertheless, parents felt strongly that companies should not be allowed to target their children with UFM online and supported government intervention to protect their children. While parents supported government policy actions for healthier supermarket environments, their views towards restricting UFM in supermarkets varied as some parents felt it was their responsibility to mitigate supermarket marketing. These findings could be used to advocate for policy action in this area.

A multi-country comparison of jurisdictions with and without mandatory nutrition labelling policies in restaurants: analysis of behaviours associated with menu labelling in the 2019 International Food Policy Study.

OBJECTIVE: To examine differences in noticing and use of nutrition information comparing jurisdictions with and without mandatory menu labelling policies and examine differences among sociodemographic groups. DESIGN: Cross-sectional data from the International Food Policy Study (IFPS) online survey. SETTING: IFPS participants from Australia, Canada, Mexico, United Kingdom and USA in 2019. PARTICIPANTS: Adults aged 18-99; n 19 393. RESULTS: Participants in jurisdictions with mandatory policies were significantly more likely to notice and use nutrition information, order something different, eat less of their order and change restaurants compared to jurisdictions without policies. For noticed nutrition information, the differences between policy groups were greatest comparing older to younger age groups and comparing high education (difference of 10·7 %, 95 % CI 8·9, 12·6) to low education (difference of 4·1 %, 95 % CI 1·8, 6·3). For used nutrition information, differences were greatest comparing high education (difference of 4·9 %, 95 % CI 3·5, 6·4) to low education (difference of 1·8 %, 95 % CI 0·2, 3·5). Mandatory labelling was associated with an increase in ordering something different among the majority ethnicity group and a decrease among the minority ethnicity group. For changed restaurant visited, differences were greater for medium and high education compared to low education, and differences were greater for higher compared to lower income adequacy. CONCLUSIONS: Participants living in jurisdictions with mandatory nutrition information in restaurants were more likely to report noticing and using nutrition information, as well as greater efforts to modify their consumption. However, the magnitudes of these differences were relatively small.

Awareness, use and understanding of nutrition labels among adults from five countries: Findings from the 2018-2020 International Food Policy Study.

Few studies have compared the effects of different front-of-package label (FOPL) systems in the 'real world'. This study assessed adults' awareness, use and understanding of nutrition facts labels (NFLs) and nationally implemented FOPLs such as Health Star Ratings (HSR), Traffic lights, and Guideline Daily Amounts (GDAs) in five countries, including before and after implementation of Mexico's warning FOPLs in 2020. Data were from the International Food Policy Study, an annual repeat cross-sectional study conducted in 2018-2020 among adults (N=64,032) in Australia, Canada, Mexico, the UK and the US. Self-reported awareness, use, and understanding of NFLs (in all five countries) and FOPLs (in Australia, Mexico, and UK) were assessed over time, between countries, and between NFLs and FOPLs. Most respondents in all countries reported seeing their country's NFLs (awareness) 'often' or 'all the time' across all three years, with one third to half of respondents using NFLs 'often' or 'all the time' (Australia: 43-45%; Canada: 47-50%; Mexico: 36-39%; UK: 32-34%; US: 47-49%), and approximately one half to two thirds finding NFLs 'easy' or 'very easy to understand' (56-57%; 67-69%; 51-54%; 48-51%; 70-71%). In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were highest among all countries with a FOPL (p<0.001), whereas awareness and use were lowest for Australia's HSR (p<0.001). In countries with FOPLs, self-reported understanding was higher for FOPLs than NFLs, except for the GDA FOPL in Mexico. Only modest changes were observed over time. Warning FOPLs were associated with greater levels of self-reported awareness, use and understanding among adults compared to NFLs and GDA-based FOPLs. FOPLs implemented on a voluntary basis, such as Australia's HSR, may be less likely to be seen and used.

Protocol for a novel sodium and blood pressure reduction intervention targeting online grocery shoppers with hypertension - the SaltSwitch Online Grocery Shopping randomized trial.

BACKGROUND: High dietary sodium intake is a leading cause of hypertension. A major source of dietary sodium is salt added to processed food products available in retail food environments. The fast-growing online grocery shopping setting provides new opportunities for salt reduction interventions that support consumers in choosing healthier options. METHODS: The SaltSwitch Online Grocery Shopping randomized controlled trial is investigating the feasibility, acceptability, and effectiveness of a novel intervention for lowering salt consumption and blood pressure amongst people with hypertension who shop for groceries online. The intervention is based on a bespoke web browser extension that interfaces with a major retailer's online store to highlight and interpret product sodium content and suggest similar but lower-sodium alternatives. The primary outcome of interest is change in mean systolic blood pressure between individuals randomized (1:1) to the intervention and control (usual online shopping) arms at 12 weeks. Secondary outcomes are diastolic blood pressure, spot urinary sodium and sodium:potassium ratio, sodium purchases, and dietary intake. Intervention implementation and lessons for future uptake will be assessed using a mixed methods process evaluation. Participants with hypertension who shop online for groceries and exhibit high sodium purchasing behavior are being recruited across Australia. A target sample size of 1,966 provides 80% power (2-sided alpha = 0.05) to detect a 2 mm Hg difference in systolic blood pressure between groups, assuming a 15 mm Hg standard deviation, after allowing for a 10% dropout rate. DISCUSSION: This trial will provide evidence on an innovative intervention to potentially reduce salt intake and blood pressure in people with hypertension. The intervention caters to individual preferences by encouraging sustainable switches to similar but lower-salt products. If effective, the intervention will be readily scalable at low cost by interfacing with existing online retail environments.

Consumption Frequency and Purchase Locations of Foods Prepared Outside the Home in Australia: 2018 International Food Policy Study.

BACKGROUND: Foods prepared outside the home (e.g., fast-food chains, restaurants) represent increasing proportions of diets worldwide, and have been associated with higher energy intakes and BMIs. To improve the healthiness of population diets, it is important to understand patterns of consumption of these foods, and whether related policy measures are effective. OBJECTIVES: This study aimed to identify the frequency and sources of consumption of foods prepared outside the home in Australia, and to understand the impact of nutrition information in restaurants on related food choices. METHODS: Data were from a web-based survey (the International Food Policy Study) completed in 2018 by Australian adults aged ≥18 years (n = 4103). The number of meals prepared outside the home, their purchase locations, and the extent to which nutrition information was noticed and influenced purchasing decisions were each analyzed by sociodemographic characteristics and BMI, with linear models also adjusted for sex, age group, education, ethnicity, and BMI. RESULTS: An average of 2.73 (95% CI, 2.61-2.86) meals per week were prepared outside the home, with higher frequencies among men, younger ages, and more highly educated participants. A wide variety of sources for these foods was observed, with fast-food outlets being most common. Around one-quarter of all foods prepared outside the home were delivered. A small percentage (14.9%; 95% CI, 13.3%-16.7%) of participants reported noticing nutrition information, but among those who did, around half reported that it influenced their behavior. CONCLUSIONS: Foods prepared outside the home are commonly purchased in Australia, particularly by young adults, from a variety of outlet types. While current menu energy labeling regulations may provide some population health benefit, a broader policy focus on foods prepared outside the home is needed as part of efforts to improve population diets.

Self-Reported Impacts of the COVID-19 Pandemic on Diet-Related Behaviors and Food Security in 5 Countries: Results from the International Food Policy Study 2020.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of daily life, including dietary intake; however, few studies have reported its impacts on dietary behaviors and food security across multiple countries. OBJECTIVES: We examined self-reported impacts of COVID-19 on food behaviors, food security, and overall diet healthfulness in 5 countries. METHODS: Adults aged 18-100 years (n = 20,554) in Australia, Canada, Mexico, the United Kingdom, and the United States completed an online survey in November and December 2020 as part of the International Food Policy Study, an annual, repeat cross-sectional survey. Survey measures assessed perceived impacts of the COVID-19 pandemic on eating food prepared away from home, having food delivered from a restaurant, and buying groceries online, as well as perceived food security and overall diet healthfulness. Regression models examined associations between each outcome and sociodemographic correlates. RESULTS: Across all countries, 62% of respondents reported eating less food prepared away from home due to the pandemic, while 11% reported eating more. Some participants reported having less food delivered from a restaurant (35%) and buying fewer groceries online (17%), while other respondents reported more of each (19% and 25%, respectively). An average of 39% reported impacts on their food security, and 27% reported healthful changes to their overall diet. The largest changes for all outcomes were observed in Mexico. Participants who were younger, ethnic minorities, or had lower income adequacy tended to be more likely to report food-related changes in either direction; however, these relationships were often less pronounced among respondents in Mexico. CONCLUSIONS: Respondents reported important changes in how they sourced their food during the pandemic, with trends suggesting shifts towards less food prepared away from home and more healthful diets overall. However, changes in diet and food behaviors occurred in both healthful and less healthful directions, suggesting that dietary responses to the pandemic were highly variable.

The Conceptual Framework for the International Food Policy Study: Evaluating the Population-Level Impact of Food Policy.

An unhealthy diet is among the leading global causes of death and disability. Globally, a range of policies are being implemented to support healthy food choices at a population level, including novel polices in the areas of food marketing, nutrition labeling, and taxation of less healthy foods. There is a need to evaluate and inform the implementation of these policies, including their impacts on marginalized population subgroups. The International Food Policy Study (IFPS) consists of repeated cross-sectional surveys conducted in 5 high- and upper-middle-income countries: Australia, Canada, Mexico, the United Kingdom, and the United States. In each country, approximately 4000 adults and 1200 children and youth (aged 10-17) were recruited from a global commercial panel to complete an online survey using consistent measures and methodologies across countries. The first annual IFPS surveys were conducted in 2017 with adults; annual surveys for young people aged 10-17 were launched in 2019 in the same countries, as well as in Chile. The design of the IFPS surveys creates a framework for evaluating "natural experiments" in food policies, including comparisons over time within countries implementing the policy and comparisons with countries in which the policy was not implemented. IFPS surveys have 3 primary areas of focus: 1) knowledge, attitudes, and beliefs associated with specific policies; 2) diet-related behaviors; and 3) dietary intake, including 24-hour dietary recalls for adults in 4 of the 5 countries. Surveys also assess food insecurity, income adequacy, sex and gender, race/ethnicity, and a range of other measures to assess trends among priority subgroups. Overall, the IFPS project has the potential to address important gaps in national monitoring surveys for dietary patterns, and to evaluate the impacts of novel food policies implemented in any of the 5 countries over the study period.

Evidence Gaps in Assessments of the Healthiness of Online Supermarkets Highlight the Need for New Monitoring Tools: a Systematic Review.

PURPOSE OF REVIEW: Online grocery shopping is increasingly popular, but the extent to which these food environments encourage healthy or unhealthy purchases is unclear. This review identifies studies assessing the healthiness of real-world online supermarkets and frameworks to support future efforts. RECENT FINDINGS: A total of 18 studies were included and 17 assessed aspects of online supermarkets. Pricing and promotional strategies were commonly applied to unhealthy products, while nutrition labelling may not meet regulated requirements or support consumer decision-making. Few studies investigated the different and specific ways online supermarkets can influence consumers. One framework for comprehensively capturing the healthiness of online supermarkets was identified, particularly highlighting the various ways retailers can tailor the environment to target individuals. Comprehensive assessments of online supermarkets can identify the potential to support or undermine healthy choices and dietary patterns. Common, validated instruments to facilitate consistent analysis and comparison are needed, particularly to investigate the new opportunities the online setting offers to influence consumers.

Price promotions offered by quick service restaurants in Australia: analysis from an obesity prevention perspective.

OBJECTIVE: To assess the price promotions offered by major quick service restaurant (QSR) chains in Australia from an obesity prevention perspective. DESIGN: Cross-sectional audit of ten of the largest QSR chains in Australia. We collected information regarding temporary price promotions and 'combination deals' offered by each chain over thirteen consecutive weeks in 2019-2020. We assessed the type of promotions, the magnitude of discount, and the energy content and healthiness of items promoted (based on Victorian Government criteria). SETTING: Melbourne, Australia. PARTICIPANTS: Ten major QSR chains. RESULTS: Temporary price promotions (n 196) and combination deals (n 537 on regular menus, n 36 on children's menus) were observed across the ten selected QSR chains. In relation to temporary price promotions, the mean magnitude of discount for main menu items (n 75) was 41·7 %. The price reductions and energy content of combination deals varied substantially the by chain, the meal size and the sides/drinks selected as part of the 'deal'. When the lowest-energy options (e.g. small chips, small sugar-free drink) were included as part of each combination deal, the mean energy content was 2935 kJ, compared to 5764 kJ when the highest-energy options (e.g. large fries, large sugar-sweetened drink) were included. Almost all available products were classified as unhealthy. CONCLUSION: Price promotions are ubiquitous in major QSR chains in Australia and provide incentives to consume high levels of energy. The action to restrict price promotions on unhealthy foods and ensure lower-energy default items as part of combination deals should be included as part of efforts to improve population diets and address obesity in Australia.

Food industry perspectives on potential policies targeting unhealthy food and beverage price promotions in Australian supermarkets.

Current supermarket price promotions are likely to encourage unhealthy diets, leading some governments to recently endorse restrictions on price promotions for unhealthy food and beverages. However, little is known about the likely industry response to policy action in this area. The aim of this study was to understand how potential government policies targeting food and beverage price promotions in supermarkets are perceived by food industry stakeholders in Australia. Twelve semi-structured in-depth interviews were conducted with current and former employees of major food manufacturers and food retailers as well as other industry experts with experience related to price promotion practices in the Australian supermarket setting. Data were analysed deductively based on Lewin's organisational change theories and inductively to highlight forces that might drive or restrain change.From an industry perspective, forces likely to create industry opposition to implementation of price promotion policy included: fear of losing competitive advantage; potential financial loss for food retailers and their suppliers; a perception that restrictions on price promotions for unhealthy products will not impact health; and a perception of increased financial cost to consumers. Forces perceived to drive implementation of a policy that would benefit public health included: mandatory regulation; extensive compliance monitoring; support for promoting healthy products; consumer education; and sufficient lead time and support from retailers for implementation. These forces, and the way in which they interact, need to be actively considered as part of efforts to change the healthiness of food and beverage price promotions in supermarkets.

Effect of age and sex on the associations between potential modifiable risk factors and both type 2 diabetes and impaired fasting glycaemia among West African adults.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is becoming one of the leading causes of morbidity and mortality worldwide, including among Africans. Knowledge of the association between traditional risk factors and both diabetes and pre-diabetes, and whether these differ by age and sex, is important for designing targeted interventions. However, little is known about these associations for African populations. METHODS: The study used data from WHO STEPS surveys, comprising 15,520 participants (6,774 men and 8,746 women) aged 25-64 years, from 5 different West African countries, namely Burkina Faso (4,711), Benin (3,816), Mali (1,772), Liberia (2,594), and Ghana (2,662). T-test and chi-square tests were used to compare differences in the prevalence of traditional risk factors for both sexes. Multinomial logistic regression was conducted to ascertain the relative risks (RR) and 95% confidence intervals (CI) for both T2DM and impaired fasting glucose (IFG) relating to each risk factor, including obesity [defined by BMI, waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR)], high blood pressure (HBP), fruit and vegetable consumption, physical inactivity, alcohol consumption, and smoking. Models for each of these traditional risk factors and interactions with age and sex were fitted. RESULTS: Factors associated with T2DM and IFG were age, obesity [defined by BMI, WC, WHtR, and WHR], HBP, smoking, physical inactivity, and fruit and vegetable consumption (p < 0.05). Analysis of interaction effects showed few significant differences in associations between risk factors and T2DM according to age or sex. Significant interaction with age was observed for HBP*age and T2DM [RR; 1.20, 95% CI: (1.01, 1.42)) (p = 0.04)], WHtR*age and T2DM [RR; 1.23, 95% CI: (1.06, 1.44) (p = 0.007)] and WHR*age and IFG [RR: 0.79, 95% CI: (0.67, 0.94) (p = 0.006)]. Some interactions with age and sex were observed for the association of alcohol consumption and both IFG and T2DM, but no clear patterns were observed. CONCLUSION: The study found that with very few exceptions, associations between traditional risk factors examined and both IFG and T2DM did not vary by age or sex among the West African population. Policies and public health intervention strategies for the prevention of T2DM and IFG should target adults of any age or sex in West Africa.

Public support for healthy supermarket initiatives focused on product placement: a multi-country cross-sectional analysis of the 2018 International Food Policy Study.

BACKGROUND: Food retail environments have an influential role in shaping purchasing behavior and could contribute to improving dietary patterns at a population level. However, little is known about the level of public support for different types of initiatives to encourage healthy food choices in supermarkets, and whether this varies across countries or context. The current study aimed to explore the level of support for three potential supermarket initiatives focused on product placement across five countries, and factors that may influence this support. METHODS: A total of 22,264 adults from Australia, Canada, Mexico, the United Kingdom and the United States (US) provided information on support for three supermarket initiatives related to product placement (targeting product positioning: 'checkouts with only healthy products', 'fewer end-of-aisle displays containing unhealthy foods or soft drinks' or availability: 'more shelf space for fresh and healthier foods') as part of the online 2018 International Food Policy Study. The proportion of respondents that supported each initiative was assessed across countries, and multivariable logistic regression analyses were conducted to evaluate the influence of sociodemographic factors on support. RESULTS: The initiative that received the highest support was 'more shelf space for fresh and healthier foods': 72.0% [95% CI 71.3-72.7], whereas 'checkouts with only healthy products' received the lowest support: 48.6% [95% CI 47.8-49.4]. The level of support differed between countries (p < 0.001 for all initiatives), with the US generally showing the lowest support and Mexico the highest. Noteworthy, in the overall sample, there was not much opposition to any of the initiatives (2.5-14.2%), whereas there was a large proportion of neutral responses (25.5-37.2%). Respondents who were older, female, highly educated, and those who reported having more nutrition knowledge tended to be more supportive, with several differences between countries and initiatives. CONCLUSIONS: Most people in the assessed five countries showed a generally high level of support for three placement initiatives in supermarkets to encourage healthy food choices. Support varied by type of initiative (i.e., product positioning or availability) and was influenced by several factors related to country context and sociodemographic characteristics. This evidence could prompt and guide retailers and policy makers to take stronger action to promote healthy food choices in stores.

The 'Eat Well @ IGA' healthy supermarket randomised controlled trial: process evaluation.

BACKGROUND: Successful implementation and long-term maintenance of healthy supermarkets initiatives are crucial to achieving potential population health benefits. Understanding barriers and enablers of implementation of real-world trials will enhance wide-scale implementation. This process evaluation of a healthy supermarket intervention sought to describe (i) customer, retailer and stakeholder perspectives on the intervention; (ii) intervention implementation; and (iii) implementation barriers and enablers. METHODS: Eat Well @ IGA was a 12-month randomised controlled trial conducted in 11 Independent Grocers of Australia (IGA) chain supermarkets in regional Victoria, Australia (5 intervention and 6 wait-listed control stores). Intervention components included trolley and basket signage, local area and in-store promotion, and shelf tags highlighting the healthiest packaged foods. A sequential mixed-methods process evaluation was undertaken. Customer exit surveys investigated demographics, and intervention recall and perceptions. Logistic mixed-models estimated associations between customer responses and demographics, with store as random effect. Supermarket staff surveys investigated staff demographics, interactions with customers, and intervention component feedback. Semi-structured stakeholder interviews with local government, retail and academic partners explored intervention perceptions, and factors which enabled or inhibited implementation, maintenance and scalability. Interviews were inductively coded to identify key themes. RESULTS: Of 500 customers surveyed, 33%[95%CI:23,44] recalled the Eat Well @ IGA brand and 97%[95%CI:93,99] agreed that IGA should continue its efforts to encourage healthy eating. The 82 staff surveyed demonstrated very favourable intervention perceptions. Themes from 19 interviews included that business models favour sales of unhealthy foods, and that stakeholder collaboration was crucial to intervention design and implementation. Staff surveys and interviews highlighted the need to minimise staff time for project maintenance and to regularly refresh intervention materials to increase and maintain salience among customers. CONCLUSIONS: This process evaluation found that interventions to promote healthy diets in supermarkets can be perceived as beneficial by retailers, customers, and government partners provided that barriers including staff time and intervention salience are addressed. Collaborative partnerships in intervention design and implementation, including retailers, governments, and academics, show potential for encouraging long-term sustainability of interventions. TRIAL REGISTRATION: ISRCTN, ISRCTN37395231 Registered 4 May 2017.

Associations between obesity indices and both type 2 diabetes and impaired fasting glucose among West African adults: Results from WHO STEPS surveys.

BACKGROUND AND AIM: Various obesity indices such as BMI, waist circumference (WC), waist-hip ratio, (WHR) and waist-to-height ratio (WHtR) are associated with the risk of type 2 Diabetes Mellitus (T2DM). Given few studies examining the strength of the association in this population, we aimed to identify which obesity indices are most strongly associated with T2DM and impaired fasting glucose (IFG) among adults from five West African countries. METHODS AND RESULTS: Data from 15,520 participants from the World Health Organisation (WHO) STEPs surveys in Burkina Faso, Benin, Mali, Liberia, and Ghana were included in analyses. Multinomial logistic regression was used to calculate the relative risk (RR) per standard deviation (SD) of each anthropometric measure, modelled as both continuous variables and as categorical variables based on established cut-points. In the analyses with continuous variables, the unadjusted RRs for T2DM per SD were 1.30 (1.23, 1.37) for body mass index (BMI); 1.56 (1.46, 1.67) for WC; 2.57 (2.15, 3.09) for WHtR and 1.16 (1.03, 1.31) for WHR. WHtR showed the strongest association with T2DM in all adjusted analyses. For models using categorical variables based on established cut-points, obesity defined using waist circumference (OB-WC) and OB-BMI showed the strongest associations with T2DM, and OB-WHR, the weakest association in all adjusted analyses. CONCLUSION: WHtR and WC appear to be the indices most strongly associated with T2DM and IFG respectively. Given its simplicity, WC may be the metric that most usefully conveys risk for T2DM in West African adults.

Maternal knowledge explains screen time differences 2 and 3.5 years post-intervention in INFANT.

Very few early childhood interventions have observed sustained effects regarding television viewing and none have examined the mechanisms behind sustained intervention effects at long-term follow-ups. Thus, the aim of this study was to investigate potential mechanisms relating to the maintained intervention effect on television viewing at two long-term follow-ups in the Melbourne Infant Feeding Activity and Nutrition Trial (INFANT). INFANT was a cluster-randomised controlled trial. At the 2- and 3.5-year follow-ups, a total of 262 infant/mother pairs had complete information. Television viewing was assessed via a questionnaire at both follow-ups and six potential mediators were measured post-intervention (i.e. 15 months after baseline). Causal mediation analysis was conducted. At the 2- and 3.5-year follow-ups, the positive impacts of INFANT on maternal television viewing knowledge were maintained (B = 0.34 units; 95% confidence interval (CI95): 0.21, 0.48). An indirect effect of the intervention on reducing children's television viewing time was observed at the 2- and 3.5-year follow-ups (B = -11.73 min/day; CI95: -22.26, -3.28 and B = -4.78 min/day; CI95: -9.48, -0.99, respectively) via improved maternal television viewing knowledge.Conclusion: The positive impacts of INFANT on maternal television viewing knowledge were maintained at both follow-ups, with better maternal knowledge associated with less television viewing time in their children. These results have implications for paediatricians and healthcare professionals as educating new parents early on regarding screen time may lead to the development of healthier screen time habits that are sustained through to the pre-school years. What is Known: • Lifestyle behaviours inclusive of screen time have been found to be established before the pre-school years and track. • Few trials have evaluated the long-term mechanisms related to maintained intervention effectiveness. What is New: • This study shows the positive impacts of a low-dose intervention on maternal television viewing knowledge at two long-term follow-ups. • Better maternal television viewing knowledge was associated with less television viewing time in their children.

Variation in outcomes of the Melbourne Infant, Feeding, Activity and Nutrition Trial (INFANT) according to maternal education and age 2 and 3·5 years post-intervention.

OBJECTIVE: This study aimed to assess whether the long-term effectiveness of the Melbourne Infant, Feeding, Activity and Nutrition Trial (INFANT) at 2 and 3·5 years post-intervention varied according to maternal education and age. DESIGN: Two and 3·5 years post-intervention follow-up of the INFANT cluster-randomised controlled trial. Outcomes at both follow-ups included children's BMI z-scores, physical activity (ActiGraph), television viewing (parental report) and dietary intake (3 × 24-h dietary recalls). Dichotomous moderator variables included maternal education (university v. no university) and age (< 32 v. ≥ 32 years). SETTING: Population based. PARTICIPANTS: Families completing the 15-month programme (n 492) were invited to participate in the follow-ups when their child was 3·6 and 5 years old. RESULTS: At the 2-year follow-up, the intervention effects on vegetable (positive) and sweet snack (negative) intake were greater in children with higher educated mothers, whereas water consumption (positive) was greater in children with lower educated mothers. At the 2-year follow-up, the intervention was more effective in increasing water consumption in children with younger mothers and decreasing sweet snack intake in children with older mothers (opposite result observed at the 3·5-year follow-up). At the 3·5-year follow-up, children with younger and older mothers increased and decreased their consumption of savoury snacks, respectively. CONCLUSIONS: Moderation by maternal education and age were observed for some outcomes; however, clear patterns were not evident at both follow-ups, with little consistency across outcomes. This indicates that INFANT was more-or-less equally effective in children irrespective of their mother's education level or age, which is important in community-based interventions.