Diet quality and its association with type 2 diabetes and major cardiometabolic risk factors among adults in China.

AIM: We examined the association between diet quality and diabetes and major cardiometabolic risks among adults in China. METHODS AND RESULTS: We developed the China Dietary Guideline Index (CDGI) based on the 2007 Chinese dietary guidelines and tailored the Alternate Healthy Eating Index 2010 (which we call the tAHEI) to assess diet quality. Our analysis linked the dietary intake and covariates measured in 2006 with CM risk factors measured in 2009. We used diet data the longitudinal China Health and Nutrition Survey 2006 collected in 3 consecutive 24-h recalls from 4440 adults aged 18 to 65 to calculate both the tAHEI and the CDGI scores. We performed multivariable logistic regressions to analyze the association of each 2006 score with diabetes, abdominal obesity, elevated blood pressure, and lipid-related cardiometabolic risk factors in 2009. After we adjusted for potential confounders, adults in the top quintile compared with the bottom quintile of the tAHEI scores showed 36% lower odds of high low-density lipoprotein cholesterol (LDL-C) (odds ratio [OR] 0.64; 95% confidence interval [CI] 0.46, 0.90] in men and 33% lower odds (OR 0.67; 95% CI 0.49, 0.91) in women, while the CDGI scores showed 35% lower odds of high LDL-C (OR 0.65; 95% CI 0.46, 0.92) in men only. Further, the CDGI scores indicated 55% lower odds of diabetes in the top versus the bottom quintile (OR 0.45; 95% CI 0.23, 0.87) in men only, whereas a null association was observed for the tAHEI scores for both sexes. Both index scores showed null associations with other cardiometabolic risk factors. CONCLUSIONS: Chinese diets that scored high on both the CDGI and the tAHEI showed similarly negative associations with high LDL-C risk, whereas only CDGI score was negatively related to diabetes risk in men.

Changes in waist circumference relative to body mass index in Chinese adults, 1993-2009.

BACKGROUND: Although body mass index (BMI) and waist circumference (WC) are correlated, the relationship between WC and BMI may have changed over time. OBJECTIVES: To describe temporal trends in BMI and WC distributions and quantify the increase in WC at a given BMI over time. SUBJECTS/METHODS: Data on adults aged 20-59 years from two waves (1993 and 2009) of the China Health and Nutrition Survey were used in a pooled cross-sectional analysis. Quantile regression examined age-adjusted temporal trends in the distributions of BMI and WC. Linear regression examined changes in mean WC over time, adjusting for BMI, age at survey and survey year. All models were stratified by gender. RESULTS: There was a significant increase in BMI and WC over time, particularly at the 95th quantile: on average, men had 2.8 kg m(-2) (95% confidence interval (CI): 2.4, 3.3) and women 1.5 kg m(-)(2) (95% CI: 1.1, 2.0) higher BMI in 2009 compared with their counterparts in 1993. WC increased by 9.0 cm (95% CI: 7.5, 10.1) and 5.0 cm (95% CI: 3.4, 6.6) for men and women, respectively. On average, men and women had a 3.2 cm (95% CI: 2.8, 3.7) and 2.1 cm (95% CI: 1.7, 2.5) higher WC in 2009 compared with their counterparts in 1993, holding BMI and age constant. WC adjusted for BMI increased to a larger extent among obese versus lean individuals and among younger versus older women. CONCLUSIONS: For both genders, BMI and WC increased significantly over time, with particularly greatest increase in magnitude in the upper tail of the BMI and WC distributions. Furthermore, WC at equivalent BMIs was higher in 2009, compared with their counterparts in 1993. Our findings suggest that even if BMI remained constant from 1993 to 2009, adults in 2009 might be at increased cardiometabolic risk as a result of their higher WC.

Fatty and lean red meat consumption in China: differential association with Chinese abdominal obesity.

AIM: We examined the longitudinal association between red meat (RM) consumption and the risk of abdominal obesity in Chinese adults. METHODS AND RESULTS: Our data are from 16,822 adults aged 18-75 in the China Health and Nutrition Survey from 1993 to 2011. We assessed RM intake with three 24-h dietary recalls. We defined abdominal obesity as a waist circumference (WC) ≥85 centimeters (cm) for men and ≥80 cm for women. Multilevel mixed-effect regression models showed that men experienced WC increases of 0.74 cm (95% confidence interval [CI]: 0.39-1.09) from a higher total intake of fresh RM and 0.59 cm (95% CI: 0.24-0. 95) from a higher intake of fatty fresh RM but 0.14 cm (95% CI: -0.39 to 0.66) from a higher intake of lean fresh RM in the top quartile versus non-consumers when adjusted for potential confounders. In contrast, after additional adjustment for baseline WC, the odds ratios of abdominal obesity in men were attenuated for total fresh RM (1.25 [95% CI: 1.06-1.47]) and fatty fresh RM (1.22 [95% CI: 1.03-1.44]) but were still not affected by lean fresh RM (0.95 [95% CI: 0.75-1.22]). Women also showed a positive association of fatty fresh RM intake with abdominal obesity. CONCLUSION: Greater intake of fatty fresh RM was significantly associated with higher WC (men only) and abdominal obesity risk in Chinese adults. The gender-specific differential association of fatty versus lean fresh RM warrants further study.

Multilevel examination of diabetes in modernising China: what elements of urbanisation are most associated with diabetes?

AIMS/HYPOTHESIS: The purpose of this study was to examine the association between urbanisation-related factors and diabetes prevalence in China. METHODS: Anthropometry, fasting blood glucose (FBG) and community-level data were collected for 7,741 adults (18-90 years) across 217 communities and nine provinces in the 2009 China Health and Nutrition Survey to examine diabetes (FBG ≥7.0 mmol/l or doctor diagnosis). Sex-stratified multilevel models, clustered at the community and province levels and controlling for individual-level age and household income were used to examine the association between diabetes and: (1) a multicomponent urbanisation measure reflecting overall modernisation and (2) 12 separate components of urbanisation (e.g., population density, employment, markets, infrastructure and social factors). RESULTS: Prevalent diabetes was higher in more-urbanised (men 12%; women 9%) vs less-urbanised (men 6%; women 5%) areas. In sex-stratified multilevel models adjusting for residential community and province, age and household income, there was a twofold higher diabetes prevalence in urban vs rural areas (men OR 2.02, 95% CI 1.47, 2.78; women, OR 1.94, 95% CI 1.35, 2.79). All urbanisation components were positively associated with diabetes, with variation across components (e.g. men, economic and income diversity, OR 1.42, 95% CI 1.20, 1.66; women, transportation infrastructure, OR 1.18, 95% CI 1.06, 1.32). Community-level variation in diabetes was comparatively greater for women (intraclass correlation [ICC] 0.03-0.05) vs men (ICC ≤0.01); province-level variation was greater for men (men 0.03-0.04; women 0.02). CONCLUSIONS/INTERPRETATION: Diabetes prevention and treatment efforts are needed particularly in urbanised areas of China. Community economic factors, modern markets, communications and transportation infrastructure might present opportunities for such efforts.

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.

Breast-feeding patterns in low-income countries.

Breast-feeding is important to infant nutrition, morbidity, and mortality, and to postpartum amenorrhea (hence to birth intervals). Evidence on breast-feeding patterns in low-income countries from nationally representative World Fertility Surveys and secondary sources shows that in all but a few such countries most children are breast-fed for at least a few months. The limited evidence available on trends seems to indicate a decline in the duration of breast-feeding, but in most of Asia and Africa breast-feeding is almost universal during at least the first 6 months. Earlier weaning is common in Latin America.

Body mass index (BMI) dynamics in Vietnam.

OBJECTIVE: To provide an overview of dynamic shifts in body mass index (BMI) and nutritional status patterns of the Vietnamese population from 1992 to 2002. DESIGN: Nationally representative, cross-sectional surveys. SETTING AND SUBJECTS: Secondary data obtained from The Living Standard Survey in 1992 (24 068 individuals) and the National Health Survey in 2002 (158 019 individuals). METHODS: Nutrition status was defined by comparing measured BMI, grouped for under- and overweight with the Centers for Disease Control and Prevention 2000 BMI growth charts for the 2-17 year-olds and the World Health Organization 1995 cutoff points for the 18-65 year-olds. RESULTS: Over the 1992 and 2002 period, minimal changes were observed in the prevalence of overweight (from 1.4% (95% confidence interval (95% CI): 1.0-1.8) to 1.8% (1.6-2.0)) and underweight (from 32.1% (30.4-33.7) to 33.5% (32.8-34.1)) among 2-17 year-olds. In contrast, among 18-65 year-olds, the prevalence of overweight and obesity increased (from 2.0% (1.5-2.4) to 5.2% (5.0-5.4)) and underweight declined (from 32.6% (31.2-33.9) to 24.8% (24.3-25.3)). Urban residents experienced larger reductions in underweight and increases in overweight than rural residents. Analyses of BMI levels for the 15th, 50th and 85th percentiles, by age, revealed a trend of increasing BMI that was higher among adults, females and urban residents. CONCLUSION: Although underweight remains the main concern, overweight is an emerging problem in Vietnam. Early prevention is needed to prevent overweight from causing undesirable effects on health and economic in the transitional period.

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.

Longitudinal relationships between occupational and domestic physical activity patterns and body weight in China.

OBJECTIVES: To examine the longitudinal relationship between occupational and domestic sources of physical activity and body weight in a sample of Chinese adults. METHODS: Population-based longitudinal observational study of Chinese adults (4697 women and 4708 men) aged 18-55 from the 1991, 1993, 1997, and 2000 waves of the China Health and Nutrition Survey. Measured height and weight and detailed self-reported energy expenditure from multiple occupational and domestic sources were assessed over a 9-year period. Longitudinal relationships were modeled using linear random effects models. RESULTS: Increased occupational physical activity resulted in overall lower body weight for both men and women (beta-coefficients (95% confidence interval (CI)) for high levels: -0.46 (-0.76, -0.15) for men, -0.36 (-0.62, -0.10) for women, and increased domestic physical activity resulted in overall lower body weight in men (beta-coefficient (95% CI): -0.40 (-0.62, -0.18)). CONCLUSIONS: Physical activity that occurs in the occupational and domestic sectors is often overlooked; yet our research suggests they have important effects on body weight in Chinese adults. As China continues to urbanize, energy expenditure from these sources is decreasing, and our results point out the need to explore these types of physical activity more broadly across the world as potential sources of weight gain.

Obesity and the food system transformation in Latin America.

The Latin America and the Caribbean (LAC) region faces a major diet-related health problem accompanied by enormous economic and social costs. The shifts in diet are profound: major shifts in intake of less-healthful low-nutrient-density foods and sugary beverages, changes in away-from-home eating and snacking and rapid shifts towards very high levels of overweight and obesity among all ages along with, in some countries, high burdens of stunting. Diet changes have occurred in parallel to, and in two-way causality with, changes in the broad food system - the set of supply chains from farms, through midstream segments of processing, wholesale and logistics, to downstream segments of retail and food service (restaurants and fast food chains). An essential contribution of this piece is to marry and integrate the nutrition transition literature with the literature on the economics of food system transformation. These two literatures and debates have been to date largely 'two ships passing in the night'. This review documents in-depth the recent history of rapid growth and transformation of that broad food system in LAC, with the rapid rise of supermarkets, large processors, fast food chains and food logistics firms. The transformation is the story of a 'double-edged sword', showing its links to various negative diet side trends, e.g. the rise of consumption of fast food and highly processed food, as well as in parallel, to various positive trends, e.g. the reduction of the cost of food, de-seasonalization, increase of convenience of food preparation reducing women's time associated with that and increase of availability of some nutritious foods like meat and dairy. We view the transformation of the food system, as well as certain aspects of diet change linked to long-run changes in employment and demographics (e.g. the quest for convenience), as broad parameters that will endure for the next decades without truly major regulatory and fiscal changes. We then focus in on what are the steps that are being and can be taken to curb the negative effects on diet of these changes. We show that countries in LAC are already among the global leaders in initiating demand-related solutions via taxation and marketing controls. But we also show that this is only a small step forward. To shift LAC's food supply towards prices that incentivize consumption of healthier diets and demand away from the less healthy component is not simple and will not happen immediately. We must be cognizant that ultimately, food industry firms must be incentivized to market the components of healthy diets. This will primarily need to be via selective taxes and subsidies, marketing controls, as well as food quality regulations, consumer education and, in the medium term, consumers' desires to combine healthier foods with their ongoing quest for convenience in the face of busy lives. In the end, the food industry in LAC will orient itself towards profitable solutions, ie those demanded by the broad mass of consumers.

37 year snacking trends for US children 1977-2014.

BACKGROUND: Previous studies have indicated that snacking is contributing to increased calorie intake of American children and that the energy density of snacks in US diets has increased in recent decades. OBJECTIVE: Examine short-term and long-term trends in the energy density and food sources of snacks for US children from 1977 to 2014, and examine whether trends differ between socio-demographic groups. METHODS: We used data collected from eight nationally representative surveys of food intake in 49,952 US children age 2-18 years, between 1977 and 2014. Overall patterns of snacking, trends in energy intake from snacking, trends in food and beverage sources and energy density of snacks across race-ethnic, age, gender, education and income groups were examined. RESULTS: In all socio-demographic groups, there was a significant increase in per capita energy intake deriving from snacks from 1977 to 2014 (P < 0.01). Salty snack intake doubled over the study period, and sugar-sweetened beverage intake decreased overall from 1977 to 2014 but increased in Non-Hispanic Blacks. Non-Hispanic Blacks had the largest increase in per capita intake from foods as a snack from 1977 to 2014. Children in the lowest poverty level and household education groups had more than 100% increase in calorie intake from snacks from 1977 to 2014. CONCLUSIONS: We found that snacking behaviour in the USA differs between race-ethnic, household education, gender and income groups, yet snacking remains a significant component of children's diets and the foods consumed at these snacks are not the types of foods recommended by the US dietary guidelines.

The altered fluid distribution in obesity may reflect plasma hypertonicity.

OBJECTIVE: This study explored whether the increased extracellular relative to intracellular fluid (ECF/ICF) ratio in obesity might reflect osmotic effects of elevated plasma solute concentrations. DESIGN: Cross-sectional, epidemiological survey. SETTING AND SUBJECTS: The present analysis used nationally representative data from the Third National Health and Nutrition Examination Survey on community-dwelling adults (aged 40-59 years) in the US without evidence of glucose dysregulation or chronic disease (n=1285). INTERVENTION: Body mass index (BMI) was estimated from measured height and weight. Total body reactance, an index of body fluid distribution, was determined by bioelectrical impedance analysis. Plasma tonicity (the cumulative index of osmotically effective plasma solute) was estimated from plasma glucose, sodium and potassium. Sex-specific relative odds of lower reactance (or=295 mmol/l) associated with overweight (25or=30) were estimated using logistic regression models that controlled for sociodemographic variables, smoking, leisure-time physical activity, total energy intake, serum creatinine, plasma insulin and glucose. Multinomial logistic regression models tested for associations between weight status and specific serum solute. RESULTS: Independent of covariates, in men and women, overweight and obesity were associated with increased odds of lower reactance and hypertonicity. Overweight and obese individuals with lower reactance had significantly higher serum sodium than normal weight individuals. CONCLUSIONS: Elevated plasma solute concentrations are associated with obesity in free-living adults. Physicians and researchers should be alert to a possible link between hypertonicity and obesity. SPONSORSHIP: Grants from the NIH, Nestle Waters.

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.

Concordance of haemoglobin A1c, blood pressure and C-reactive protein between children and their parents in Chinese households.

BACKGROUND: China has the world's highest diabetes prevalence, which along with hypertension and inflammation continues to grow particularly among children. Little is known about the strength of the association of these cardiometabolic risk factors between parents and their children; thus, the potential of household-based strategies to reduce risk is unknown. OBJECTIVES: The objective of the study is to examine the parent-child association for haemoglobin A1c (HbA1c), blood pressure (BP) and C-reactive protein (CRP) in a large, geographically diverse Chinese sample. METHODS: In 940 parent-child pairs (children aged 7-17 years) who participated in the 2009 China Health and Nutrition Survey, we measured each individual's HbA1c and CRP using fasting blood and BP. We used sex-specific random-effects linear regression to examine the parent-child association for these risk factors, accounting for within-family clustering. RESULTS: Child's HbA1c was positively associated with parental HbA1c. Beta coefficients ranged from 0.06 (95% CI 0.03-0.12) for father-daughter to 0.43 (95% CI 0.28-0.58) for mother-son pairs. We also detected a positive mother-daughter association for BP and positive father-child associations for CRP. CONCLUSION: The statistically significant parent-child association for HbA1c, BP and CRP in Chinese families suggests that household-based interventions could be useful for confronting the high rates of diabetes, hypertension and inflammation in China.

Nutrition status of children in Latin America.

The prevalence of overweight and obesity is rapidly increasing among Latin American children, posing challenges for current healthcare systems and increasing the risk for a wide range of diseases. To understand the factors contributing to childhood obesity in Latin America, this paper reviews the current nutrition status and physical activity situation, the disparities between and within countries and the potential challenges for ensuring adequate nutrition and physical activity. Across the region, children face a dual burden of undernutrition and excess weight. While efforts to address undernutrition have made marked improvements, childhood obesity is on the rise as a result of diets that favour energy-dense, nutrient-poor foods and the adoption of a sedentary lifestyle. Over the last decade, changes in socioeconomic conditions, urbanization, retail foods and public transportation have all contributed to childhood obesity in the region. Additional research and research capacity are needed to address this growing epidemic, particularly with respect to designing, implementing and evaluating the impact of evidence-based obesity prevention interventions.

A research agenda to guide progress on childhood obesity prevention in Latin America.

Childhood obesity rates in Latin America are among the highest in the world. This paper examines and evaluates the many efforts underway in the region to reduce and prevent further increases in obesity, identifies and discusses unique research challenges and opportunities in Latin America, and proposes a research agenda in Latin America for the prevention of childhood obesity and concomitant non-communicable diseases. Identified research gaps include biological challenges to healthy growth across the life cycle, diet and physical activity dynamics, community interventions promoting healthy child growth, and rigorous evaluation of national food and activity programs and regulatory actions. Addressing these research gaps is critical to advance the evidence-based policy and practice in childhood obesity tailored to the Latin American context that will be effective in addressing obesity.

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.

Ten-year beverage intake trends among US preschool children: rapid declines between 2003 and 2010 but stagnancy in recent years.

BACKGROUND: It has been previously reported that total energy intake among US preschool children (ages 2-5 years) decreased between 2003-2004 and 2009-2010. However, little is known about how intakes of beverages among US preschoolers (ages 2-5 years) changed from 2003-2004 to 2011-2012. OBJECTIVES: This paper examines changes in intakes of key beverages during this period, as well as how eating location (at home or away from home) and source (store vs. others) may have contributed to these changes. METHODS: Cross-sectional day one dietary data among children ages 2-5 years from the National Health and Nutrition Examination Survey 2003-2004, 2005-2006, 2007-2008, 2009-2010 and 2011-2012 were used. Survey-weighted mean intakes by survey year, eating location and source were computed for total sugar-sweetened beverages (SSBs), milks, 100% juice, low/no-calorie beverages, 10 key beverages, total beverages and total foods. Means were compared using two-tailed z-tests with Bonferroni corrections (α < 0.05). RESULTS: Between 2003-2004 and 2011-2012, among 2-5 year olds, total caloric intake fell by 132 kcal d(-1) , with intakes of beverages falling by 55 kcal d(-1) . Decreases in intakes of total SSBs (-57 kcal d(-1) ), fruit-flavoured or juice drinks containing <100% juice (juice drinks) (-37 kcal d(-1) ), caloric soft drinks (-13 kcal d(-1) ) and >1% fat, low-sugar milk (-42 kcal d(-1) ) were among the major changes. By eating location, total beverage intake at home fell by 73 kcal d(-1) . By source, total beverage intake from stores fell by 106 kcal d(-1) . Changes in intakes occurred primarily between 2003-2004 and 2009-2010, as there were no significant differences in beverage intakes between 2009-2010 and 2011-2012. Intakes of total calories (+49 kcal d(-1) ) and calories from foods (+53 kcal d(-1) ) trended upward between 2009-2010 and 2011-2012, but changes were not significant. CONCLUSIONS: These findings suggest improvements in the diets of preschoolers between 2003-2004 and 2009-2010, of which stores were a major contributor.