SSB taxes and diet quality in US preschoolers: estimated changes in the 2010 Healthy Eating Index.

BACKGROUND: Taxing sugar-sweetened beverages (SSBs) has been proposed as a strategy to combat child obesity. Yet it is unclear how a tax on SSBs might influence the overall quality of diet in preschool children. Thus, we use simulated price increases and the 2010 Healthy Eating Index (HEI-2010) to explore the relationship between SSB taxes and diet quality in preschool children. METHODS: Price and purchase data from the 2009-2012 Nielsen Homescan Panel and a two-part marginal effects model were used to estimate relative changes in purchases with a 20% increase in the price of SSBs. Demand elasticities were applied to dietary intake data for children ages 2-5 years from the National Health and Nutrition Examination Survey (2009-2010 and 2011-2012) to estimate the impact of a 20% SSB tax on dietary intake and quality (HEI-2010). RESULTS: A 20% increase in the price of SSBs was associated with lower total caloric intake (-28 kcal d-1 , p < 0.01), caloric intake from juice drinks (-20 kcal d-1 , p < 0.01), added sugars (-4.1 servings d-1 , p = 0.03), refined grains (-0.63 servings d-1 , p < 0.01) and total meat (-0.56 servings d-1 , p < 0.01). Beneficial decreases in empty calories and refined grains were offset by unfavourable changes in fatty acid profile, total protein, vegetables and fruit, such that total HEI scores (0-100 range) were not meaningfully changed with a 20% increase in SSB price (difference: -0.85, p < 0.01). CONCLUSIONS: A 20% tax on SSBs could decrease caloric intake, and intakes of added sugars and SSBs, but may not improve diet quality as an isolated intervention among US preschool children.

Sociodemographic disparity in the diet quality transition among Chinese adults from 1991 to 2011.

BACKGROUND/OBJECTIVES: This study investigates secular trends in diet quality distribution and related socioeconomic disparity from 1991 to 2011 in the Chinese adult population. SUBJECTS/METHODS: The analysis uses the 1991-2011 China Health and Nutrition Survey data on 13 853 participants (6876 men and 6977 women) aged 18-65 with 56 319 responses. Dietary assessment was carried out over a 3-day period with 24-h recalls combined with a household food inventory. We tailored Alternative Healthy Eating Index 2010 (named as tAHEI) to measure diet quality and performed quantile regression to investigate shifts in tAHEI scores at different percentiles and used mixed-effect linear regression to examine average diet quality trend and potential sociodemographic disparity. RESULTS: The energy-adjusted mean tAHEI scores increased from 36.9 (36.7-37.1) points in 1991 to 50.3 (50.1-50.5) in 2011 for men (P<0.001) and from 35.6 (35.4-35.8) to 46.9 (46.7-47.1) for women (P<0.001). The covariate-adjusted score of polyunsaturated fatty acids increased by 6.8 (6.6, 7.0) and 7.0 (6.9, 7.2), and the score of long-chain (ω-3) fats increased by 5.3 (5.2, 5.4) and 5.3 (5.2, 5.5) in men and women, respectively, whereas the cereal fiber and red meat scores decreased slightly. Increasing tAHEI score occurred across the entire distribution, and diet quality transition varied across sociodemographic groups. CONCLUSIONS: Chinese diet quality is far from optimal, with moderate improvement over a 21-year period. Findings suggest that nutritional intervention should give priority to low-income, low-urbanized communities and southern provincial adults with low diet quality in China.

The double burden of under- and overnutrition and nutrient adequacy among Chinese preschool and school-aged children in 2009-2011.

BACKGROUND/OBJECTIVES: Coincident with economic development, China has experienced a marked transition from undernutrition to overweight/obesity over the last few decades. We aimed to explore the burden of under- and overnutrition and nutrient adequacy among 2-12-year-old Chinese children. SUBJECTS/METHODS: We included anthropometry, dietary intake and biomarkers from 2-12-year-olds who participated in the 2009-2011 China Health and Nutrition Survey (n=1191 in 2009; n=1648 in 2011). Dietary intakes were compared with the 2013 Chinese Dietary Recommended Intakes. RESULTS: In 2011, ~19% of 2-6-year-old children were underweight, 4% were stunted, 10% were overweight and 12% were obese. Among 7-12-year-old children, stunting was almost 0%, whereas ~21% were underweight, 13% were overweight and 6% were obese in 2011. Overweight and obesity were more prevalent among children from urban areas and higher income households. In particular, 2-6-year-old children from urban areas and higher income households experienced the highest increase in obesity from 2009 to 2011 (P<0.05). Children from urban areas and higher income households had overall higher intakes of total daily energy and most macro- and micronutrients (P<0.05). However, a significant proportion of children did not meet the recommendations for important micronutrients. CONCLUSIONS: Underweight and stunting currently coexist with overweight and obesity among Chinese children <12-year-old. We found critical disparities in the prevalence of under- and overweight/obesity, as well as in nutrient intakes and dietary adequacies between children from different incomes, revealing that the burden of childhood under- and overnutrition may constitute a public health concern in modern China.

China in the period of transition from scarcity and extensive undernutrition to emerging nutrition-related non-communicable diseases, 1949-1992.

This study uses unique official data to document nutritional changes in the 1949-1992 period. In 1949, widespread famine, high mortality and low life expectancy dominated. Economic progress was uneven; however, the longer term food supply changed greatly, and hunger was conquered. Diet composition shifted greatly over this period. Cereal consumption, already high, increased from 541.2 g d(-1) (70.0% coarse grains) in 1952 to 645.9 g d(-1) (15.9% coarse grains) in 1992. Consumption of animal-source foods, half of which were pork and pork products, tripled from 30.0 to 103.0 g d(-1). The proportion of energy intake from fat tripled from 7.6% to 22.5%, and that from carbohydrates decreased from 83.0% to 65.8% over the same period. Physical activity was high in all domains, but shifts were beginning to occur (e.g. the initial mechanization of work and the expansion of biking). Nutritional improvement was uneven, including increased undernutrition in the 1959-1962 period and a remarkable rebound and continued improvement thereafter. Overweight emerged only after 1982. Shifts in diet, activity and body composition in 1949-1992 set the stage for major shifts in nutrition in the subsequent decades.

Synthesis and implications: China's nutrition transition in the context of changes across other low- and middle-income countries.

The China Health and Nutrition Survey (CHNS) is important for its insights into current and future diet, physical activity, and obesity-related changes in China and for understanding underlying processes common across low- and middle-income countries (LMICs). While China modernized later than Latin American countries, many changes seen in China echo those in Latin America and in other LMICs. In general, changes in physical activity and diet behaviours in China have occurred at a faster pace relative to other LMICs. Modernization of the overall Chinese food system has lagged behind most other LMICs, yet the now-rapid changes in the Chinese food system are similar to what has been seen in other LMICs. Further, there is variation in these changes across social and geographic space. The incidence of obesity and non-communicable diseases has increased as the major health burden has shifted towards the poor. This paper examines changes in China and addresses the literature and issues that link these changes with those in other LMICs. In many ways, the detailed 20-year CHNS, with nine repeated measures, provides a remarkable window through which to understand nutrition-related changes in other LMICs.

Trends in intakes and sources of solid fats and added sugars among U.S. children and adolescents: 1994-2010.

BACKGROUND: There are increasing global concerns about improving the dietary intakes of children and adolescents. In the United States (U.S.), the focus is on reducing energy from foods and beverages that provide empty calories from solid fats and added sugars (SoFAS). OBJECTIVE: We examine trends in intakes and sources of solid fat and added sugars among U.S. 2-18 year olds from 1994 to 2010. METHODS: Data from five nationally representative surveys, the Continuing Survey of Food Intakes by Individuals Surveys (1994-1996) and the What We Eat In America, National Health and Nutrition Examination Surveys (2003-2004, 2005-2006, 2007-2008 and 2009-2010) were used to examine key food sources and energy from solid fats and added sugars. Sample sizes ranged from 2594 to 8259 per survey period, for a total of 17 268 observations across the five surveys. Food files were linked over time to create comparable food groups and nutrient values. Differences were examined by age, race/ethnicity and family income. RESULTS: Daily intake of energy from SoFAS among U.S. 2-18 year olds decreased from 1994 to 2010, with declines primarily detected in the recent time periods. Solid fats accounted for a greater proportion of total energy intake than did added sugars. CONCLUSIONS: Although the consumption of solid fats and added sugars among children and adolescents in the U.S. decreased between 1994-1998 and 2009-2010, mean intakes continue to exceed recommended limits.

Emerging disparities in overweight by educational attainment in Chinese adults (1989-2006).

OBJECTIVE: To test whether a disparity in overweight by socioeconomic status (SES; represented by educational attainment) has emerged among men or women during a recent 17-year period in China. METHODS: Data from the China Health and Nutrition Survey (CHNS), a panel study including 7314 women and 6492 men, are used to longitudinally track the body mass index (BMI) and odds of overweight by educational attainment among Chinese adults (baseline age 18-50) from 1989 to 2006 to determine whether individuals of low (secondary school) educational attainment experienced a disproportionately faster increase in BMI or odds of overweight (BMI≥25) over time. The unadjusted mean BMI and prevalence of overweight by education are presented. Sex-stratified, random-effects models are used to estimate the associations, and interactions by birth cohort are included. FINDINGS: Overweight prevalence doubled for women and tripled for men. In 1989, among women, the odds of overweight were not different for those of high versus those of low educational attainment; however, by 2006, the odds of overweight were significantly lower for those with the highest education in both the younger (odds ratio (OR) 0.22 (CI 0.11, 0.42)) and the older (OR 0.27 (CI 0.10, 0.72)) birth cohorts. The reverse trend is seen for men, who also begin with no difference in odds of overweight by SES, but by 2006, the OR for the highest versus the lowest education group was 3.4 (CI 1.82, 6.18). CONCLUSIONS: Over 17 years, low SES has become associated with higher BMI and odds of overweight among Chinese women, whereas high SES remains a risk factor for overweight among Chinese men.

Is the burden of overweight shifting to the poor across the globe? Time trends among women in 39 low- and middle-income countries (1991-2008).

BACKGROUND: Overweight prevalence has increased globally; however, current time trends of overweight prevalence by social class in lower income countries have not been fully explored. METHODS: We used repeated cross-sectional, nationally representative data from the Demographic and Health Surveys on women aged 18-49 years with young children (n=421,689) in 39 lower-income countries. We present overweight (body mass index ≥ 25 kg m⁻²) prevalence at each survey wave, prevalence difference and prevalence growth rate for each country over time, separately by wealth quintile and educational attainment. We present the correlation between nation wealth and differential overweight prevalence growth by wealth and education. RESULTS: In the majority of countries, the highest wealth and education groups still have the highest prevalence of overweight and obesity. However, in a substantial number of countries (14% when wealth is used as the indicator of socioeconomic status and 28% for education) the estimated increases in overweight prevalence over time have been greater in the lowest- compared with the highest-wealth and -education groups. Gross domestic product per capita was associated with a higher overweight prevalence growth rate for the lowest-wealth group compared with the highest (Pearson's correlation coefficient: 0.45). CONCLUSIONS: Higher (vs lower) wealth and education groups had higher overweight prevalence across most developing countries. However, some countries show a faster growth rate in overweight in the lowest- (vs highest-) wealth and -education groups, which is indicative of an increasing burden of overweight among lower wealth and education groups in the lower-income countries.

Obesity, race/ethnicity and life course socioeconomic status across the transition from adolescence to adulthood.

BACKGROUND: Differences in the association of socioeconomic status (SES) with obesity may underlie the racial/ethnic disparities in obesity that increase dramatically across the transition to adulthood in the United States. The aim of this study was to examine racial/ethnic differences in the influence of life course SES on longitudinal obesity patterns from adolescence to adulthood. METHODS: Latent class analysis was used on a nationally representative, diverse sample of 12 940 adolescents followed into young adulthood (mean age = 21.7 years) to identify life course SES group profiles based on SES data in adolescence and young adulthood. Gender-stratified multinomial logistic regression models estimated the association of SES groups with obesity incidence and persistence versus staying non-obese. RESULTS: No significant interactions with race/ethnicity were observed, although racial/ethnic minorities had the highest obesity risk across SES groups. Racial/ethnic-pooled associations between disadvantaged SES exposure and higher obesity risk were strong but differed by gender. Males with a disadvantaged background who experienced early transitions into the labour force, marriage and residential independence had the highest risk of obesity incidence (relative risk ratio (RRR) = 1.64; 95% confidence interval (CI) 1.12 to 2.40), while females exposed to persistent adversity were at highest risk (RRR = 3.01, 95% CI 1.95 to 4.66). In general, SES group membership had a stronger relationship with obesity persistence than incidence. CONCLUSIONS: The relationship between SES and obesity patterns is similar across race/ethnicity and differs by gender during the transition to adulthood. However, stronger associations with obesity persistence and enduring racial/ethnic disparities in obesity risk across SES groups suggest that these social factors play a larger role in disparities earlier in the life course.

Under- and overnutrition dynamics in Chinese children and adults (1991-2004).

OBJECTIVE: To examine trends in under- and overweight prevalence from 1991 to 2004 among adults and children in China by income and residence differentials. METHODS/SUBJECTS: Prevalence, average annual changes and annual relative changes in under- and overweight were determined. In 1991, 2848 children and 6806 adults were surveyed. The 2004 survey included 1566 children and 6172 adults. RESULTS: Higher average annual reductions in underweight prevalence were found among children, particularly rural children, when compared with adults. With respect to income, low-income children and adults experienced the greatest average annual reductions in underweight prevalence. The trend for increased overweight was more pronounced than the trend for decreased underweight. Intensified trends were found among adults (versus children) and males (versus females). Relative to baseline prevalence, overweight increased fastest among adults in low-income and rural populations. CONCLUSIONS: Rapid increases in the overweight prevalence, particularly as found among low-income and rural Chinese adults, will likely lead to a shift in the burden of obesity-related chronic diseases toward the poor. Associated economic and health implications will further challenge the country's health care system, restrain economic development and widen existing disparities between the rural and urban as well as between the rich and poor populations of China.

Measuring the full economic costs of diet, physical activity and obesity-related chronic diseases.

Most studies that have focused on the costs of obesity have ignored the direct effects of obesity-related patterns of diet and physical activity. This study reviews the full effects of each component--poor dietary and physical activity patterns and obesity--on morbidity, mortality and productivity. The direct healthcare costs are based on a review of the effects of these factors on key diseases and the related medical care costs of each disease. The indirect costs on reduced disability, mortality and sickness during the period of active labour force participation prior to retirement are also examined. A case study is prepared for China to provide some guidance in the utilization of this review for economic analysis of obesity. The case study shows that the indirect costs are often far more important than the direct medical care costs. The Chinese case study found that the indirect effects of obesity and obesity-related dietary and physical activity patterns range between 3.58% and 8.73% of gross national product (GNP) in 2000 and 2025 respectively.

Trends in eating behaviours among Chinese children (1991 -1997).

This study examined the trends in snacking behaviours and eating food-prepared-outside-the-home (FPOH) by Chinese children and adolescents using data from the China Health and Nutrition Survey. The sample consisted of 3223 subjects aged 6-18 in 1991 and 2836 in 1997. Three days of 24hr recall dietary data and per capita income (deflated to 1989) was used. The percentage of Chinese children having snacking behaviours was significantly differentiated according to the income level while percentage of eating FPOH increased in middle and high income groups. Snacking contributed about 8% of the energy intake (EI) for snackers, compared with over 15% from FPOH for those who ate FPOH. Fruit was a major component of snacking: snacks based on fruit intake almost doubled over the study period as did snacks based on soft drink consumption. Animal source food consumption was a key component of FPOH and its intake also increased.

Obesity and inequities in health in the developing world.

OBJECTIVE: To update the social distribution of women's obesity in the developing world and, in particular, to identify the specific level of economic development at which, if any, women's obesity in the developing world starts to fuel inequities in health. DESIGN: Multilevel logistic regression analyses applied to anthropometric and socioeconomic data collected by nationally representative cross-sectional surveys conducted from 1992 to 2000 in 37 developing countries within a wide range of world regions and stages of economic development (gross national product (GNP) from 190 to 4440 US dollars per capita). SUBJECTS: : In total, 148 579 nonpregnant women aged 20-49 y. MEASUREMENTS: Body mass index to assess obesity status; quartiles of years of education to assess woman's socioeconomic status (SES), and GNP per capita to assess country's stage of economic development. RESULTS: Belonging to the lower SES group confers strong protection against obesity in low-income economies, but it is a systematic risk factor for the disease in upper-middle income developing economies. A multilevel logistic model-including an interaction term between the country's GNP and each woman's SES-indicates that obesity starts to fuel health inequities in the developing world when the GNP reaches a value of about 2500 US dollars per capita. CONCLUSIONS: For most upper-middle income economies and part of the lower-middle income economies, obesity among adult women is already a relevant booster of health inequities and, in the absence of concerted national public actions to prevent obesity, economic growth will greatly expand the list of developing countries where this situation occurs.

Patterns of food consumption in Vietnam: effects on socioeconomic groups during an era of economic growth.

OBJECTIVE: To identify if the nutritional status and improvements in Vietnam during the 1990s applied equally to the key vulnerable population groups (poor, rural, and ethnic minority) as it did to the nonpoor-largely in the urban areas. DESIGN: This study used cross-sectional analyses in the context of inequalities occurring in the diets of the poor and nonpoor that accompanied economic improvements during the Vietnam Doi Moi period. SETTING: During the Doi Moi period in Vietnam. SUBJECTS: A cross-sectional analysis was conducted on data using 23,839 individuals (4800 households) from the Vietnam Living Standard Survey (VLSS) in 1992-1993 and 28,509 individuals (6,002 households) from the Vietnam Living Standard Survey in 1997-1998. Analysis for changes in food consumption was conducted on 17,763 individuals (4,305 households) that were included in both surveys. INTERVENTION: None. RESULTS: After initiation of Doi Moi in 1986, the average Vietnamese person reached the dietary adequacy of 2,100 kcal per day per capita in the early 1990s, but this did not improve during the next decade. The structure of diet shifted to less starchy staples while proteins and lipids (meat, fish, other protein-rich higher fat foods) increased significantly. Although the gap in nutrient intake between the poor and the nonpoor decreased, the proportion of calories from protein- and lipid-rich food for the poor is lower than for the nonpoor. The VLSS data showed that the increase of protein and lipid foods in total energy structure over the 5 y between the VLSS studies for poor households was 0.43% (CI=0.33, 0.53) and 0.47% (CI=0.41, 0.54) lower, respectively, than for nonpoor households (P<0.0001). Inequalities compared to the nonpoor were also found in both quantity and quality of food consumption. For example, poor households consumed (quantity) 127 kcal/day (CI=119, 135) less from meat, and 32 kcal/day (CI=27, 38) less from fats than nonpoor households (P<0.0001), and the proportion of calories consumed (quality) by poor households was 5.8% (CI=5.4, 6.1) less from meat and 0.96% (CI=1.2, 0.7) less from fats than by nonpoor households (P<0.0001). CONCLUSIONS: Although the key vulnerable groups-rural, poor, and minority populations-showed improvements in diet, there still remains an inequity between these groups and the nonpoor of the population. In particular, the vulnerable groups consumed less of their daily consumption from the desirable high-quality proteins of animal foods and fats, and more from cereals and other starches-lagging the better-off populations in desired composition.

Obesity, diet, and poverty: trends in the Russian transition to market economy.

OBJECTIVE: To examine trends in macronutrient intake, overweight, and obesity. DESIGN: Cross-sectional samples-collected nine times between 1992 and 2000-from the Russian Longitudinal Monitoring Survey provide interviewer-administered 24-h diet recalls and measured height and weight, together with detailed information regarding income and expenditures. SETTING: The Russian Federation. SUBJECTS: Women and men, aged 19-55 y. INTERVENTIONS: None. METHODS: A nationally representative sample of working-age Russian adults was stratified by gender and income (per cent of regional poverty level). Secular trends in mean energy and macronutrient intake, as well as prevalence of overweight and obesity in the population are described over the first 8 y of the Russian Federation. RESULTS: Overall, energy intake increased slightly. Fat, as a percentage of energy (E%), decreased from 39.6 to 31.6% and protein, as a per cent of energy, decreased from 14.3 to 12.5%. Overweight (determined by body mass index (BMI) >/=25 kg/m(2)) prevalence remained relatively stable at about 50% and obesity (BMI >/=30 kg/m(2)) prevalence increased from 13.3 to 16.0% of the adult population. Women consumed less energy than men and displayed higher prevalences of overweight and obesity in all time periods. There was an income effect among men in all time periods, with higher-income men consuming more calories, fat, and protein than lower-income men; this effect was not apparent in women except in the proportion of fat and protein intake. CONCLUSIONS: The adult Russian population appears to have escaped macronutrient privation during economic reform and has experienced increasing rates of obesity.

Omission of active commuting to school and the prevalence of children's health-related physical activity levels: the Russian Longitudinal Monitoring Study.

BACKGROUND: Active commuting to school by walking or bicycle is a potential source of continuous moderate activity for children that has been largely ignored in surveys of physical activity. The purpose of this study was to evaluate the analytical impact of omitting active commuting to school (walking or bicycling) on conclusions about children's physical activity levels. METHODS: The Russian Longitudinal Monitoring Study (RLMS) is the first nationally representative household survey in the Russian Federation. More than 6400 households from all regions of Russia were surveyed eight times between 1992 and 1998. Analysis was conducted using physical activity data (school physical education classes, out-of-school active pursuits and active commuting to school) obtained by parent-proxy on 1094 (572 boys, 522 girls) school-aged Russian children (mean age 10.2 +/- 1.9 years) participating in the November 1998 round of the RLMS. Data were examined according to prevalence of achievement of health-related physical activity guidelines, active commuting to school behaviours included then omitted. RESULTS: Omitting active commuting to school resulted in a statistically significant decrease in the prevalence of achievement of health-related guidelines from 12% to 20%, similar for both genders. Likewise, the prevalence of sedentarism (defined as not meeting any of the guidelines) was increased by 17-22%. CONCLUSIONS: The present findings suggest that, in order to avoid misclassification bias of children's physical activity levels, it is necessary to include questions about mode of commuting to school. The findings also carry practice implications: the commonplace need to get to and from school may be a missed opportunity for children's health-related physical activity in motorized societies.

The increasing prevalence of snacking among US children from 1977 to 1996.

OBJECTIVES: To determine snacking trends and changes in nutrient contribution of snacking over time. STUDY DESIGN: Nationally representative data from the 1977-78 Nationwide Food Consumption Survey (NFCS77), 1989-91 Continuing Survey of Food Intake by Individuals (CSFII89), and 1994-96 (CSFII96) were used. The sample consisted of 21,236 individuals aged 2 to 18 years. METHODS: For each survey year, mean numbers of snacks consumed, mean grams consumed per snack, and mean energy intake from snacks were computed, as was contribution of snacking to total energy intake and fat intake. Snacking was self-defined, and a snacking occasion consisted of all snack foods consumed during a 15-minute period. Differences in means between age groups and across survey years were compared. RESULTS: The prevalence of snacking increased in all age groups. The average size of snacks and energy per snack remained relatively constant; however, the number of snacking occasions increased significantly, therefore increasing the average daily energy from snacks. Compared with non-snack eating occasions, the nutrient contribution of snacks decreased in calcium density and increased in energy density and proportion of energy from fat. CONCLUSION: Snacking is extremely prevalent in our society. Healthy snack food choices should be emphasized over high-energy density convenience snacks for children.

Independent effects of income and education on the risk of obesity in the Brazilian adult population.

With a view to assess the independent effects of income and education on the risk of obesity we studied cross-sectional randomly selected samples of the adult population (20 y and over) living in 1996/97 in the less (northeastern) and the more (southeastern) developed region of Brazil (1971 and 2588 northeastern and 2289 and 2549 southeastern men and women, respectively). Independent effects of income and education on obesity (BMI > or = 30 kg/m(2)) were assessed through logistic regression analyses that controlled for age, ethnicity, household setting (urban or rural) and either education or income. The risk of obesity in men strongly increased with income in the two regions. The level of education did not influence the risk of male obesity in the less developed region but, in the more developed one, better-educated men had slightly less chance to be obese. In the less developed region obesity in women was strongly associated with both income (direct association) and education (inverse association). In the more developed region only the women's education influenced the risk of obesity, and the association between the two variables was inverse and strong as in the less developed region. Findings from this study reveal a scenario that is far from what has been generally admitted for the social distribution of obesity in the developing countries. They indicate that in transition societies income tends to be a risk factor for obesity, whereas education tends to be protective and that both gender and level of economic development are relevant modifiers of the influence exerted by these variables.