Ecological momentary assessment of digital food and beverage marketing exposure and impact in young adults: A feasibility study.

Unhealthy food marketing is contributing to the obesity epidemic, but real-time insights into the mechanisms of this relationship are under-studied. Digital marketing is growing and following food and beverage (F&B) brands on social media is common, but measurement of exposure and impact of such marketing presents novel challenges. Thus, this study aimed to evaluate the feasibility of collecting data on exposure and impact of digital F&B marketing (DFM) using a smartphone-based ecological momentary assessment (EMA) methodology. We hypothesized that DFM-induced food cravings would vary based on whether (or not) participants engaged with F&B brands online. Participants were Singapore residents (n = 95, 21-40 years), recruited via telephone from an existing cohort. Participants were asked to upload screenshots of all sightings of online F&B marketing messages for seven days, and answer in-app contextual questions about sightings including whether any cravings were induced. Participants provided a total of 1310 uploads (median 9 per participant, Q1-Q3: 4-21) of F&B marketing messages, 27% of which were provided on Day 1, significantly more than on other days (P < 0.001). Followers of food/beverage brands on social media encountered 25.6 percentage points (95% CI 11.4, 39.7) more marketing messages that induced cravings than participants who were not followers. University education was also associated with more (18.1 percentage points; 95% CI 3.1, 33.1) encounters with marketing messages that induced cravings. It was practical and acceptable to participants to gather insights into digital F&B marketing exposure and impact using EMA in young adults, although a shorter study period is recommended in future studies. Followers of food and beverage brands on social media appear to be more prone to experience cravings after exposure to digital F&B marketing.

Evaluation of Combinations of Nudging, Pricing, and Labeling Strategies to Improve Diet Quality: A Virtual Grocery Store Experiment Employing a Multiphase Optimization Strategy.

BACKGROUND: Several intervention strategies have been shown to improve diet quality. However, there is limited evidence on the increase in effectiveness that may be achieved through select combinations of these strategies. PURPOSE: This study aimed to identify an effective multicomponent intervention to improve diet quality of a grocery basket by applying a Multiphase Optimization Strategy framework and testing various combinations of four promising strategies using a fully functional web-based grocery store: (i) front-of-pack food labels and real-time feedback of the healthiness of the shoppers' grocery basket, (ii) a tax, (iii) ordering products by a nutritional quality score, and (iv) healthier substitute offers. METHODS: We conducted a hypothetical shopping study (N = 756) with a randomized full factorial design (16 conditions) to estimate main and interaction effects of the four interventions. RESULTS: The "food labels & real-time feedback" and "ordering" strategies had significantly positive main effects on overall diet quality of the shopping basket (both at p < .001). We found no effects on diet quality for the "tax" and "healthier substitute offers." None of the two-way interaction effects for different strategies on overall diet quality and nutrients were significant. CONCLUSIONS: Having "food labels & real-time feedback" and "ordering" simultaneously seemed to be more effective at improving diet quality, compared to having only one of these interventions. These results suggest that a combination of food labels with real-time feedback and ordering interventions can be part of a promising multicomponent strategy to improve diet quality in online shopping platforms. TRIAL REGISTRATION: ClinicalTrials.gov NCT04632212.

Ethnicity, Neighborhood and Individual Socioeconomic Status, and Obesity: The Singapore Multiethnic Cohort.

OBJECTIVE: It remains unclear whether ethnicity has an impact on obesity independent of socioeconomic status (SES) and environmental factors. Singapore provides a unique opportunity to address this issue because three major Asian ethnic groups are represented, and government policies prevent ethnic segregation. Therefore this study examined associations between ethnicity, SES, and obesity within neighborhoods in Singapore. METHODS: Cross-sectional data from 29,819 participants of the Singapore Multiethnic Cohort who were aged 21 to 75 years and of Chinese, Malay, and Indian ethnicity were used. Obesity was defined using Asian criteria. Multilevel models used obesity as the dependent variable and age, marital status, ethnicity, education level, income, and neighborhood SES as independent variables. RESULTS: Education level was more strongly inversely associated with obesity than income level or neighborhood SES. The association between ethnicity and obesity was not substantially explained by measures of individual and neighborhood SES. In females, the fully adjusted odds ratio of obesity was 5.01 for Malay ethnicity and 4.81 for Indian ethnicity as compared with Chinese ethnicity. In males, these odds ratios were 2.61 and 2.07, respectively. CONCLUSIONS: Ethnicity was strongly associated with obesity independent of SES and neighborhood environment. More research on sociocultural factors contributing to ethnic differences in obesity is warranted.

Attitudes and beliefs regarding food in a multi-ethnic Asian population and their association with socio-demographic variables and healthy eating intentions.

BACKGROUND: Attitudes and beliefs regarding food are known to influence dietary behaviours and may reflect cultural traditions. Therefore, understanding the food culture in the population is important to inform culturally relevant and acceptable public health interventions. OBJECTIVE: (1) To evaluate attitudes towards pleasure and health with regard to eating and its association with healthy eating intentions. (2) To assess traditional beliefs about 'hot-cold balance' and its influence on food choice. METHODS: We conducted a cross-sectional study using an online research panel comprising of 787 male and female adults of Chinese, Malay and Indian ethnicity recruited from population-based cohorts and public housing estates in Singapore. A self-administered questionnaire was used to assess beliefs and attitudes towards food. To evaluate the association of beliefs and attitudes with socio-demographic determinants and potential consequences for healthy eating intentions, multivariable logistic regression was used with adjustment for age, gender and ethnicity. RESULTS: Beliefs about the importance of considering hot-cold balance for food choice were common among all three Asian ethnic groups and most prominent among the Chinese ethnic group (56.3% Malay, 64.5% Indian and 72.4% Chinese). The majority of participants (73.8%) often consider the effects of diet on health, but also value eating pleasure greatly (84.9%). Older age was associated with a shift in attitudes from valuing eating pleasure towards health. Valuing the importance of food for health was associated with a wide range of healthy eating intentions, whereas highly valuing eating pleasure was associated with a lower intention to reduce salt intake. CONCLUSION: In a cosmopolitan Asian population, both eating for health and eating for pleasure were valued highly and traditional beliefs regarding the hot-cold balance were held by the majority.

Impact of tax and subsidy framed messages on high- and lower-sugar beverages sold in vending machines: a randomized crossover trial.

OBJECTIVE: Framing of fiscal incentives has been suggested to be important in influencing purchase decisions. We aimed to examine the effect of framing a modest price difference between high- and lower-sugar beverages as a tax or a subsidy respectively, using messages placed on vending machines to influence beverage purchases. DESIGN/SETTING: This is an 11-week randomized crossover trial conducted between August and November 2015, with a two-week run-in period before intervention, targeted at students, staff and faculty of a university campus in Singapore. Twenty-one beverage vending machines were used to implement the intervention involving 'tax message', 'subsidy message' and 'no message (control)'. The former two messages suggest 'a tax for high sugar beverages' or 'a subsidy for lower sugar beverages' respectively. Prices of the beverages offered were fixed at baseline and remained the same in all three experimental conditions: lower-sugar beverage options were priced ~ 10% lower than the corresponding high-sugar option. The machines were randomized to one of the 6 sequences of intervention. Each message intervention period was 3 weeks. The effect of messages was assessed by comparing average weekly units of beverages sold between interventions using mixed effects model. RESULTS: The average weekly units of high and lower-sugar beverages sold per vending machine were 115 and 98 respectively in the control condition. The percentage of high-sugar beverages sold was 54% in the control, 53% in the tax, and 54% in the subsidy message condition. There was no difference in the weekly units of high-sugar beverages sold for the tax message (- 2, 95% CI -8 to 5, p = 0.61) or the subsidy message (0, 95% CI -10 to 10, p = 0.96) conditions as compared with the control condition. Similarly, there was no difference in the weekly units of lower-sugar beverages sold for the tax message (4, 95% CI -4 to 13, p = 0.32) or the subsidy message (7, 95% CI -4 to 18, p = 0.18) conditions as compared with the control condition. CONCLUSIONS: The use of tax and subsidy messages to highlight modest price differences did not substantially reduce high-sugar beverage sales in vending machines on an Asian university campus.

Stepping volume and intensity patterns in a multi-ethnic urban Asian population.

BACKGROUND: Accelerometer measured physical activity (PA) studies particularly in non-western populations are lacking. Therefore, this study investigated stepping activity in a multi-ethnic urban Asian population. METHODS: Adult participants from the Singapore Health Study 2 consented to accelerometer activity monitoring for 7-consecutive days. Mean daily step count, peak stepping intensity (i.e. cadence) over 1-min, 30-min and 60-min and time spent in each cadence band: 0 (non-movement), 1-19, 20-39, 40-59, 60-79, 80-99 and ≥ 100 steps/minute (moderate to vigorous PA) were calculated. RESULTS: A total of 713 participants (42% male, mean age 47.8 years) were included. Overall, the mean daily step count was 7549. Mean daily step count was significantly lower in Indians (7083 adjusted p = 0.02) but not Malays 7140 (adjusted p = 0.052) compared to Chinese (7745 steps). The proportion of Malays, Indians, and Chinese achieving < 5000 daily steps was 26%, 23% and 14%, respectively (p < 0.01). Regardless of ethnicity, approximately half of the recorded time was spent undertaking 0-steps/minute (7.9 h). CONCLUSIONS: Greater promotion of brisk walking is required in light of the low step volume and pace observed in this multi-ethnic Asian population. Ethnic differences in stepping activity were also identified which indicates a need for targeted ethnic specific health promotion interventions.

Direct vs. Expressed Breast Milk Feeding: Relation to Duration of Breastfeeding.

BACKGROUND: Studies examining direct vs. expressed breast milk feeding are scarce. We explored the predictors of mode of breastfeeding and its association with breastfeeding duration in a multi-ethnic Asian population. METHODS: We included 541 breastfeeding mother-infant pairs from the Growing Up in Singapore Toward healthy Outcomes cohort. Mode of breastfeeding (feeding directly at the breast, expressed breast milk (EBM) feeding only, or mixed feeding (a combination of the former 2 modes)) was ascertained at three months postpartum. Ordinal logistic regression analyses identified predictors of breast milk expression. Cox regression models examined the association between mode of breastfeeding and duration of any and of full breastfeeding. RESULTS: Maternal factors independently associated with a greater likelihood of breast milk expression instead of direct breastfeeding were Chinese (vs. Indian) ethnicity, (adjusted odds ratio, 95% CI; 3.41, 1.97-5.91), tertiary education (vs. secondary education or lower) (2.22, 1.22-4.04), primiparity (1.54, 1.04-2.26) and employment during pregnancy (2.53, 1.60-4.02). Relative to those who fed their infants directly at the breast, mothers who fed their infants EBM only had a higher likelihood of early weaning among all mothers who were breastfeeding (adjusted hazard ratio, 95% CI; 2.20, 1.61-3.02), and among those who were fully breastfeeding (2.39, 1.05-5.41). Mothers who practiced mixed feeding, however, were not at higher risk of earlier termination of any or of full breastfeeding. CONCLUSIONS: Mothers who fed their infants EBM exclusively, but not those who practiced mixed feeding, were at a higher risk of terminating breastfeeding earlier than those who fed their infants directly at the breast. More education and support are required for women who feed their infants EBM only.

Determinants of Breastfeeding Practices and Success in a Multi-Ethnic Asian Population.

BACKGROUND: Many countries in Asia report low breastfeeding rates and the risk factors for early weaning are not well studied. We assessed the prevalence, duration, and mode of breastfeeding (direct or expressed) among mothers of three Asian ethnic groups. METHODS: Participants were 1,030 Singaporean women recruited during early pregnancy. Data collected included early breastfeeding experiences, breastfeeding duration, and mode of breastfeeding. Full breastfeeding was defined as the intake of breast milk, with or without water. Cox regression models were used to identify factors associated with discontinuation of any and full breastfeeding. Logistic regression analyses assessed the association of ethnicity with mode of breastfeeding. RESULTS: At 6 months postpartum, the prevalence of any breastfeeding was 46 percent for Chinese mothers, 22 percent for Malay mothers, and 41 percent for Indian mothers; prevalence of full breastfeeding was 11, 2, and 5 percent, respectively. More Chinese mothers fed their infants expressed breast milk, instead of directly breastfeeding them, compared with the other two ethnic groups. Duration of any and full breastfeeding were positively associated with breastfeeding a few hours after birth, higher maternal age and education, and negatively associated with irregular breastfeeding frequency and being shown how to breastfeed. Adjusting for maternal education, breastfeeding duration was similar in the three ethnic groups, but ethnicity remained a significant predictor of mode of breastfeeding. CONCLUSIONS: The low rates and duration of breastfeeding in this population may be improved with breastfeeding education and support, especially in mothers with lower education. Further work is needed to understand the cultural differences in mode of feeding and its implications for maternal and infant health.

Comparable Dietary Patterns Describe Dietary Behavior across Ethnic Groups in the Netherlands, but Different Elements in the Diet Are Associated with Glycated Hemoglobin and Fasting Glucose Concentrations.

BACKGROUND: Ethnic minority populations in Western societies suffer from a disproportionate burden of type 2 diabetes (T2D). Insight into the role of dietary patterns in T2D may assist public health nutrition efforts in addressing these health disparities. OBJECTIVE: We explored the association between dietary patterns and biomarkers of T2D in 5 ethnic groups living in Amsterdam, Netherlands. METHODS: A total of 3776 men and women aged 18-70 y of Dutch, South Asian Surinamese, African-Surinamese, Turkish, and Moroccan origin from the HELIUS (HEalthy LIfe in an Urban Setting) study were included. Diet was assessed by using a food-frequency questionnaire, and dietary patterns were derived separately per ethnic group. First, food group-based dietary patterns were derived by using principal components analysis and the association with glycated hemoglobin (HbA1c) and plasma fasting glucose was assessed by using multivariable linear regression. Second, biomarker-driven dietary patterns based on HbA1c and fasting glucose concentrations were derived by applying reduced rank regression. RESULTS: Two comparable food group-based dietary patterns were identified in each ethnic group: a "meat and snack" pattern and a "vegetable" pattern. The meat-and-snack pattern derived within the Dutch origin population was significantly associated with HbA1c (ß = 0.09; 95% CI: 0.00, 0.19) and fasting glucose (ß = 0.18; 95% CI: 0.09, 0.26) concentrations. A biomarker-derived pattern characterized by red and processed meat was observed among Dutch-origin participants; however, among ethnic minority groups, this pattern was characterized by other foods including ethnicity-specific foods (e.g., roti, couscous). CONCLUSIONS: Although similar food group dietary patterns were derived within 5 ethnic groups, the association of the meat-and-snack pattern with fasting glucose concentrations differed by ethnicity. Taken together with the finding of ethnic differences in biomarker-driven dietary patterns, our results imply that addressing T2D risk in multiethnic populations requires ethnicity-specific approaches.

Socio-economic status and ethnicity are independently associated with dietary patterns: the HELIUS-Dietary Patterns study.

BACKGROUND: Differences in dietary patterns between ethnic groups have often been observed. These differences may partially be a reflection of differences in socio-economic status (SES) or may be the result of differences in the direction and strength of the association between SES and diet. OBJECTIVE: We aimed to examine ethnic differences in dietary patterns and the role of socio-economic indicators on dietary patterns within a multi-ethnic population. DESIGN: Cross-sectional multi-ethnic population-based study. SETTING: Amsterdam, the Netherlands. SUBJECTS: Principal component analysis was used to identify dietary patterns among Dutch (n=1,254), South Asian Surinamese (n=425), and African Surinamese (n=784) participants. Levels of education and occupation were used to indicate SES. Linear regression analysis was used to examine the association between ethnicity and dietary pattern scores first and then between socio-economic indicators and dietary patterns within and between ethnic groups. RESULTS: 'Noodle/rice dishes and white meat', 'red meat, snacks, and sweets' and 'vegetables, fruit and nuts' patterns were identified. Compared to the Dutch origin participants, Surinamese more closely adhered to the 'noodle/rice dishes and white meat' pattern which was characterized by foods consumed in a 'traditional Surinamese diet'. Closer adherence to the other two patterns was observed among Dutch compared to Surinamese origin participants. Ethnic differences in dietary patterns persisted within strata of education and occupation. Surinamese showed greater adherence to a 'traditional' pattern independent of SES. Among Dutch participants, a clear socio-economic gradient in all dietary patterns was observed. Such a gradient was only present among Surinamese dietary oatterns to the 'vegetables, fruit and nuts' pattern. CONCLUSIONS: We found a selective change in the adherence to dietary patterns among Surinamese origin participants, presumably a move towards more vegetables and fruits with higher SES but continued fidelity to the traditional diet.

The role of women in food provision and food choice decision-making in Singapore: a case study.

As countries develop economically and increasing numbers of women enter the workforce, children are partly being cared for by someone other than their mother. Little is known about the impact of this shift in child-care provider on children's nutrition. This study presents findings from a case study of Singapore, a small country that has experienced phenomenal economic growth. Focus groups were conducted with 130 women of varying educational levels and ethnicities to learn about food decisions in their families. The findings showed that Singaporean working women cook infrequently, families eat out frequently, and children exert considerable influence on food choices. Implications for work-family policies and child health are discussed.

Income inequality and health: the role of population size, inequality threshold, period effects and lag effects.

BACKGROUND: Income inequality has been associated with worse health outcomes in several but not all studies. The heterogeneity across studies may be explained by the variations in the size of area or population over which income inequality was evaluated. Moreover, the studies above a certain inequality threshold, conducted more recently, and incorporating a time lag may have stronger associations between income inequality and health. The authors investigated if the strength of the association between income inequality and health was altered by these factors. METHODS: The authors conducted a multivariate meta-regression analysis using nine multilevel cohort studies on income inequality and mortality and 14 multilevel cross-sectional studies on income inequality and self-rated health. RESULTS: Among cross-sectional studies, studies evaluating country-level inequality (average population>24 million) were more likely to show a stronger association between income inequality and poor health compared with those evaluating income inequality within small average populations (<820 000). There were no significant differences in the effect size of inequality-health association relating to the differences in the population size within a country across which income inequality was evaluated in both cross-sectional and cohort studies. The authors found that the threshold effects, period effects and lag effects were independent of the population size. CONCLUSIONS: Income inequality at the country level may have stronger adverse contextual effects on health than inequality in smaller areas, perhaps by best reflecting social stratification in a society. Furthermore, we found that threshold, period and lag effects were independent of area unit for evaluating inequality, which may have important policy implications.

Patterns of physical activity in different domains and implications for intervention in a multi-ethnic Asian population: a cross-sectional study.

BACKGROUND: The benefits of regular physical activity for quality of life and disease prevention have been well documented. Identification of low activity groups would facilitate interventional programs. Many studies have focussed on leisure time activity, which may not capture the spectrum of physical activity relevant to disease prevention. Furthermore, few studies have been conducted in urban Asian settings. METHODS: We evaluated physical activity in different domains (leisure time, occupational, household and transportation) and its sociodemographic determinants in 4750 adult Chinese, Malay, and Asian Indian Singaporeans. Physical activity was assessed using locally validated questionnaires. RESULTS: Occupational and household activity contributed substantially more to total physical activity than leisure time or transportation activity. However, when only activity of at least moderate intensity was considered leisure time activity contributed most to total physical activity. Higher socio-economic status was associated with more leisure time activity, but less total physical activity due to reduced activity in the other domains. Chinese ethnicity was also associated with less total physical activity as a result of less activity in non-leisure time domains. CONCLUSIONS: In assessing levels of physical activity and recommending changes, it is important to consider physical activity in different domains. Focus on leisure-time physical activity alone could identify the wrong groups for intervention and miss opportunities for increasing physical activity in populations.

Income inequality, mortality, and self rated health: meta-analysis of multilevel studies.

OBJECTIVE: To provide quantitative evaluations on the association between income inequality and health. DESIGN: Random effects meta-analyses, calculating the overall relative risk for subsequent mortality among prospective cohort studies and the overall odds ratio for poor self rated health among cross sectional studies. DATA SOURCES: PubMed, the ISI Web of Science, and the National Bureau for Economic Research database. Review methods Peer reviewed papers with multilevel data. Results The meta-analysis included 59 509 857 subjects in nine cohort studies and 1 280 211 subjects in 19 cross sectional studies. The overall cohort relative risk and cross sectional odds ratio (95% confidence intervals) per 0.05 unit increase in Gini coefficient, a measure of income inequality, was 1.08 (1.06 to 1.10) and 1.04 (1.02 to 1.06), respectively. Meta-regressions showed stronger associations between income inequality and the health outcomes among studies with higher Gini (>or=0.3), conducted with data after 1990, with longer duration of follow-up (>7 years), and incorporating time lags between income inequality and outcomes. By contrast, analyses accounting for unmeasured regional characteristics showed a weaker association between income inequality and health. Conclusions The results suggest a modest adverse effect of income inequality on health, although the population impact might be larger if the association is truly causal. The results also support the threshold effect hypothesis, which posits the existence of a threshold of income inequality beyond which adverse impacts on health begin to emerge. The findings need to be interpreted with caution given the heterogeneity between studies, as well as the attenuation of the risk estimates in analyses that attempted to control for the unmeasured characteristics of areas with high levels of income inequality.

Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data.

BACKGROUND: Hyperglycemia is associated with increased mortality in critically ill patients. Randomized trials of intensive insulin therapy have reported inconsistent effects on mortality and increased rates of severe hypoglycemia. We conducted a meta-analysis to update the totality of evidence regarding the influence of intensive insulin therapy compared with conventional insulin therapy on mortality and severe hypoglycemia in the intensive care unit (ICU). METHODS: We conducted searches of electronic databases, abstracts from scientific conferences and bibliographies of relevant articles. We included published randomized controlled trials conducted in the ICU that directly compared intensive insulin therapy with conventional glucose management and that documented mortality. We included in our meta-analysis the data from the recent NICE-SUGAR (Normoglycemia in Intensive Care Evaluation - Survival Using Glucose Algorithm Regulation) study. RESULTS: We included 26 trials involving a total of 13 567 patients in our meta-analysis. Among the 26 trials that reported mortality, the pooled relative risk (RR) of death with intensive insulin therapy compared with conventional therapy was 0.93 (95% confidence interval [CI] 0.83-1.04). Among the 14 trials that reported hypoglycemia, the pooled RR with intensive insulin therapy was 6.0 (95% CI 4.5-8.0). The ICU setting was a contributing factor, with patients in surgical ICUs appearing to benefit from intensive insulin therapy (RR 0.63, 95% CI 0.44-0.91); patients in the other ICU settings did not (medical ICU: RR 1.0, 95% CI 0.78-1.28; mixed ICU: RR 0.99, 95% CI 0.86-1.12). The different targets of intensive insulin therapy (glucose level < or = 6.1 mmol/L v. < or = 8.3 mmol/L) did not influence either mortality or risk of hypoglycemia. INTERPRETATION: Intensive insulin therapy significantly increased the risk of hypoglycemia and conferred no overall mortality benefit among critically ill patients. However, this therapy may be beneficial to patients admitted to a surgical ICU.