Breast composition during and after puberty: the Chilean Growth and Obesity Cohort Study.

BACKGROUND: Breast density (BD) is a strong risk factor for breast cancer. Little is known about how BD develops during puberty. Understanding BD trajectories during puberty and its determinants could be crucial for promoting preventive actions against breast cancer (BC) at early ages. The objective of this research is to characterize % fibroglandular volume (%FGV), absolute fibroglandular volume (AFGV), and breast volume (BV) at different breast Tanner stages until 4-year post menarche in a Latino cohort and to assess determinants of high %FGV and AFGV during puberty and in a fully mature breast. METHODS: This is a longitudinal follow-up of 509 girls from low-middle socioeconomic status of the Southeast area of Santiago, recruited at a mean age of 3.5 years. The inclusion criteria were singleton birth born, birthweight between 2500 and 4500 g with no medical or mental disorder. A trained dietitian measured weight and height since 3.5 years old and sexual maturation from 8 years old (breast Tanner stages and age at menarche onset). Using standardized methods, BD was measured using dual-energy X-ray absorptiometry (DXA) in various developmental periods (breast Tanner stage B1 until 4 years after menarche onset). RESULTS: In the 509 girls, we collected 1,442 breast DXA scans; the mean age at Tanner B4 was 11.3 years. %FGV increased across breast Tanner stages and peaked 250 days after menarche. AFGV and BV peaked 2 years after menarche onset. Girls in the highest quartiles of %FGV, AFGV, and BV at Tanner B4 and B5 before menarche onset had the highest values thereafter until 4 years after menarche onset. The most important determinants of %FGV and AFGV variability were BMI z-score (R2 = 44%) and time since menarche (R2 = 42%), respectively. CONCLUSION: We characterize the breast development during puberty, a critical window of susceptibility. Although the onset of menarche is a key milestone for breast development, we observed that girls in the highest quartiles of %FGV and AFGV tracked in that group afterwards. Following these participants in adulthood would be of interest to understand the changes in breast composition during this period and its potential link with BC risk.

Time-specific impact of trace metals on breast density of adolescent girls in Santiago, Chile.

Whether trace metals modify breast density, the strongest predictor for breast cancer, during critical developmental stages such as puberty remains understudied. Our study prospectively evaluated the association between trace metals at Tanner breast stage B1 (n = 291) and at stages both B1 and B4 (n = 253) and breast density at 2 years post-menarche among Chilean girls from the Growth and Obesity Cohort Study. Dual-energy x-ray absorptiometry assessed the volume of dense breast tissue (absolute fibroglandular volume [FGV]) and percent breast density (%FGV). Urine trace metals included arsenic, barium, cadmium, cobalt, cesium, copper, magnesium, manganese, molybdenum, nickel, lead, antimony, selenium, tin, thallium, vanadium, and zinc. At B1, a doubling of thallium concentration resulted in 13.69 cm3 increase in absolute FGV (ß: 13.69, 95% confidence interval [CI]: 2.81, 24.52), while a doubling of lead concentration resulted in a 7.76 cm3 decrease in absolute FGV (ß: -7.76, 95%CI: -14.71, -0.73). At B4, a doubling of barium concentration was associated with a 10.06 cm3 increase (ß: 10.06, 95% CI: 1.44, 18.60), copper concentration with a 12.29 cm3 increase (ß: 12.29, 95% CI: 2.78, 21.56), lead concentration with a 9.86 cm3 increase (ß: 9.86, 95% CI: 0.73, 18.98), antimony concentration with a 12.97 cm3 increase (ß: 12.97, 95% CI: 1.98, 23.79) and vanadium concentration with a 13.14 cm3 increase in absolute FGV (ß: 13.14, 95% CI: 2.73, 23.58). Trace metals may affect pubertal breast density at varying developmental stages with implications for increased susceptibility for breast cancer.

Decreases in purchases of energy, sodium, sugar, and saturated fat 3 years after implementation of the Chilean food labeling and marketing law: An interrupted time series analysis.

BACKGROUND: In 2016, Chile implemented a multiphase set of policies that mandated warning labels, restricted food marketing to children, and banned school sales of foods and beverages high in nutrients of concern ("high-in" foods). Chile's law, particularly the warning label component, set the precedent for a rapid global proliferation of similar policies. While our initial evaluation showed policy-linked decreases in purchases of high-in, a longer-term evaluation is needed, particularly as later phases of Chile's law included stricter nutrient thresholds and introduced a daytime ban on advertising of high-in foods for all audiences. The objective is to evaluate changes in purchases of energy, sugar, sodium, and saturated fat purchased after Phase 2 implementation of the Chilean policies. METHODS AND FINDINGS: This interrupted time series study used longitudinal data on monthly food and beverage purchases from 2,844 Chilean households (138,391 household-months) from July 1, 2013 until June 25, 2019. Nutrition facts panel data from food and beverage packages were linked at the product level and reviewed by nutritionists. Products were considered "high-in" if they contained added sugar, sodium, or saturated fat and exceeded nutrient or calorie thresholds. Using correlated random-effects models and an interrupted time series design, we estimated the nutrient content of food and beverage purchases associated with Phase 1 and Phase 2 compared to a counterfactual scenario based on trends during a 36-month pre-policy timeframe. Compared to the counterfactual, we observed significant decreases in high-in purchases of foods and beverages during Phase 2, including a relative 36.8% reduction in sugar (-30.4 calories/capita/day, 95% CI -34.5, -26.3), a 23.0% relative reduction in energy (-51.6 calories/capita/day, 95% CI -60.7, -42.6), a 21.9% relative reduction in sodium (-85.8 mg/capita/day, 95% CI -105.0, -66.7), and a 15.7% relative reduction in saturated fat (-6.4 calories/capita/day, 95% CI -8.4, -4.3), while purchases of not-high-in foods and drinks increased. Reductions in sugar and energy purchases were driven by beverage purchases, whereas reductions in sodium and saturated fat were driven by foods. Compared to the counterfactual, changes in both high-in purchases and not high-in purchases observed in Phase 2 tended to be larger than changes observed in Phase 1. The pattern of changes in purchases was similar for households of lower versus higher socioeconomic status. A limitation of this study is that some results were sensitive to the use of shorter pre-policy time frames. CONCLUSIONS: Compared to a counterfactual based on a 36-month pre-policy timeframe, Chilean policies on food labeling, marketing, and school food sales led to declines in nutrients of concern during Phase 2 of implementation, particularly from foods and drinks high in nutrients of concern. These declines were sustained or even increased over phases of policy implementation.

The consumption of ultra-processed foods was associated with adiposity, but not with metabolic indicators in a prospective cohort study of Chilean preschool children.

BACKGROUND: Increasing consumption of ultra-processed foods (UPF) has been identified as a risk factor for obesity and various diseases, primarily in adults. Nonetheless, research in children is limited, especially regarding longitudinal studies with metabolic outcomes. We aimed to evaluate the longitudinal association between consumption of UPF, adiposity, and metabolic indicators in Chilean preschool children. METHODS: We conducted a prospective analysis of 962 children enrolled in the Food and Environment Chilean Cohort (FECHIC). Dietary data were collected in 2016 at age 4 years with 24-h recalls. All reported foods and beverages were classified according to the NOVA food classification, and the usual consumption of UPF in calories and grams was estimated using the Multiple Source Method. Adiposity (z-score of body mass index [BMI z-score], waist circumference [WC], and fat mass [in kg and percentage]) and metabolic indicators (fasting glucose, insulin, HOMA-IR, triglycerides, total cholesterol, and cholesterol fractions) were measured in 2018, at the age of 6 years. Linear regression models ((0) crude, (1) adjusted for covariables, and (2) adjusted for covariables plus total caloric intake) were used to evaluate the association between UPF and outcomes. All models included inverse probability weights to account for the loss to the follow-up. RESULTS: At 4 years, usual consumption of UPF represented 48% of the total calories and 39% of the total food and beverages grams. In models adjusted for covariables plus caloric intake, we found a positive association between UPF and BMI z-score (for 100 kcal and 100 g, respectively: b = 0.24 [95%CI 0.16-0.33]; b = 0.21 [95%CI 0.10-0.31]), WC in cm (b = 0.89 [95%CI 0.41-1.37]; b = 0.86 [95%CI 0.32-1.40]), log-fat mass in kg b = 0.06 [95%CI 0.03-0.09]; b = 0.04 [95%CI 0.01-0.07]), and log-percentage fat mass (b = 0.03 [95%CI 0.01-0.04]; b = 0.02 [95%CI 0.003-0.04]), but no association with metabolic indicators. CONCLUSIONS: In this sample of Chilean preschoolers, we observed that higher consumption of UPF was associated with adiposity indicators 2 years later, but not with metabolic outcomes. Longer follow-up might help clarify the natural history of UPF consumption and metabolic risks in children.

Food Industry Compliance With the Display of Front-of-Package Warning Labels at the Final Phase (2020) of Chile's Labeling and Advertising Law.

Objectives. To investigate food industry compliance with the display of front-of-package warning labels (FOPLs) on products that exceed regulatory thresholds for being high in calories, added sugars, sodium, or saturated fats after full implementation of Chile's Food Labeling and Advertising Law. Methods. In 2020, trained dietitians took pictures of nutritional information and FOPLs on packaged products in supermarkets. We categorized foods and beverages as requiring FOPLs (or not) using their nutritional composition and ingredients as set out in government guidelines. We compared these classifications with the actual display of FOPLs. Results. About 62.5% of packaged foods and beverages displayed any FOPL. The most frequent label was for energy (38.7%), followed by sugars (35.2%), saturated fats (26.2%), and sodium (22.6%). Compliance with FOPL display was high (93.6% for any "high-in" designation). Lower compliance was observed in nonsausage meat products (83.5%) and soups (84.5%). Candies and sweet confectionery and sausages contributed most to noncompliance with any "high-in" designation. Conclusions. Following the law's full implementation, the food industry complied with the display of FOPLs. Mandatory policies with clear guidelines and monitoring systems can contribute to ensuring and sustaining high compliance. (Am J Public Health. Published online ahead of print September 26, 2024:e1-e8. https://doi.org/10.2105/AJPH.2024.307843).

Effectiveness of alcohol warning labels for at-risk groups and the general public: A policy-informing randomized experiment in Chile.

OBJECTIVE: The World Health Organization recommends using health-risk warnings on alcoholic beverages. This study examines the impact of separate or combined warning labels for at-risk groups and the general population on alcohol purchase decisions. METHODS: In 2022, 7758 adults who consumed alcohol or were pregnant/lactating women (54.0 % female, mean age = 40.6 years) were presented with an online store's beverage section and randomly assigned to one of six warning labels in a between-subjects experimental design: no-warning, pregnant/lactating, drinking-driving, general cancer risk, combined warnings, and assorted warnings across bottles. The main outcome, the intention to purchase an alcoholic vs. non-alcoholic beverage, was examined with adjusted risk differences using logistic regressions. RESULTS: Participants exposed to the general cancer risk warning decreased their alcoholic choices by 10.4 percentage points (pp.) (95 % CI [-0.139, -0.069], p < 0.001, OR = 0.561), while those in the pregnancy/lactation warning condition did it by 3.8 pp. (95 % CI [-0.071, -0.005], p = 0.025, OR = 0.806). The driving-drinking warning had no significant effect. Participants exposed to the combined warnings label, or the assorted warnings reduced alcohol purchase decisions by 6.1 pp. (95 % CI [-0.095, -0.028], p < 0.001, OR = 0.708) and 4.3 pp. (95 % CI [-0.076, -0.010], p = 0.011, OR = 0.782), respectively. Cancer warning outperformed other labels and was effective for subgroups such as pregnant/lactating women, young adults, and low-income individuals. CONCLUSIONS: General cancer risk warnings are more effective at reducing alcohol purchase decisions compared to warning labels for specific groups or labels using multiple warnings. In addition to warning labels, other policies should be considered for addressing well-known alcohol-related risks (e.g., drinking and driving).

Chilean children's adherence to sustainable healthy diets and its associations with sociodemographic and anthropometric factors: a cross-sectional study.

PURPOSE: To describe adherence to sustainable healthy diets among a sample of 958 Chilean pre-schoolers (3-6 years) and explore associations between adherence and child and maternal sociodemographic and anthropometric characteristics. METHODS: Children's adherence to sustainable healthy diets was calculated from single multiple-pass 24-h dietary recalls using the Planetary Health Diet Index for children and adolescents (PHDI-C). Higher PHDI-C scores (max score = 150 points) represent greater adherence. Adjusted linear regression models were fitted to explore associations between PHDI-C scores and child and maternal characteristics. RESULTS: Children obtained low total PHDI-C scores (median 50.0 [IQR 39.5-59.8] points). This resulted from low consumption of nuts & peanuts, legumes, vegetables, whole cereals, and vegetable oils; a lack of balance between dark green and red & orange vegetables, inadequate consumption of tubers & potatoes and eggs & white meats, and excess consumption of dairy products, palm oil, red meats, and added sugars. Mean PHDI-C total score was significantly higher (50.6 [95%CI 49.6, 51.7] vs 47.3 [95%CI 45.0, 49.5]) among children whose mothers were ≥ 25 years compared to those with younger mothers. Positive associations were observed between scores for fruits and maternal education, vegetables and maternal age, added sugars and child weight status, while negative associations were observed between fruits and child age, and vegetable oils and maternal education. Scores for dairy products PHDI-C component were lower among girls. CONCLUSION: Adherence to sustainable healthy diets was low among this sample of Chilean children and was significantly associated with maternal age, being lower among children whose mothers were younger.

Potential actions for preventing high consumption of Non-Nutritive Sweeteners among Chilean children and adolescents: recommendations from a panel of relevant actors.

OBJECTIVE: To provide local policymakers with a guideline of potential actions to prevent the high consumption of Non-Nutritive Sweeteners (NNS) among children and adolescents observed in Chile, given the potential health problems related to NNS intake. DESIGN: The Delphi method was used for the evaluation of twenty-one recommendations to decrease the intake of NNS in paediatric population, with the participation of a panel of relevant actors. SETTING: The proposed recommendations were developed by the research team using the NOURISHING framework; potential actions were based on the increase in the use and intake of NNS by Chilean children, current local food regulations, recommendations of health organisations and foreign policy experiences. PARTICIPANTS: Twenty-five relevant actors related to NNS, nutrition, food technology and paediatrics (out of thirty-nine invitations made to scholars, professional institutions and civil society's organisations) participated in the Delphi study. RESULTS: A consensus was reached on nine recommendations regarding relevance and feasibility to be part of the guideline. Recommendations involved measures mostly related to improving the delivery of information (food content and potential health effects of NNS), supporting the generation of more evidence of NNS health effects and substitutes, and marketing restrictions when targeted to children. CONCLUSIONS: The process produced a nine-action guideline to reduce the excessive NNS consumption among Chilean children and adolescents. Developed through a consensus-driven approach among key stakeholders, this guideline provides policymakers with a framework to adopt a precautionary stance, particularly concerning vulnerable populations, given the currently inconclusive evidence on the long-term health effects of NNS consumption.

Sociodemographic differences in nutrition labels effect on Chilean and Mexican youth.

Objective: To examine sociodemographic differences in the awareness, understanding, use and effect of nutrition labels among Mexican and Chilean youth. Methods: Online surveys among youth (10-17 years) were obtained in 2019 (n=2631). Participants reported their awareness, understanding, and use of their country-specific nutrition facts tables (NFT) and front-of-pack labels (FOPL) (Chile: warning labels [WLs]; Mexico: guideline daily amounts [GDA]). Additionally, participants reported their perceived healthfulness of a sweetened fruit drink after viewing one of six versions of it with different FOPL (no-label control, Health Star Rating, WLs, GDAs, Traffic Light, or Nutri-Score) during an experimental task. Results: Higher self-reported nutrition knowledge was associated with higher NFT and FOPL awareness, understanding, and use, except for WL use. WLs were the most effective FOPL in decreasing the perceived healthfulness of the sweetened fruit drink compared to a no-label condition and other FOP labels. In Chile, the effect of GDA differed by income adequacy, while in Mexico Nutri-Score differed by age. Conclusions: Results suggest that nutrition label awareness, use, understanding, and impact differ across demographics, favoring higher income and nutrition knowledge. Despite this, WLs are likely to have a positive impact on nutrition-related knowledge and behaviors among Mexican and Chilean youth, independently of their socio-demographic groups.

Dietary Iron Intake in Relation to Age at Menarche: A Prospective Cohort Study in Chilean Girls.

BACKGROUND: Early onset of menarche is considered an important risk factor for a number of diseases in adulthood. Iron intake may be related to pubertal timing because of its role in childhood growth and reproductive function. OBJECTIVE: We investigated the relation between dietary iron intake and age at menarche in a prospective cohort of Chilean girls. METHODS: Overall, 602 Chilean girls were included in the Growth and Obesity Cohort Study, a longitudinal study that began in 2006 when the girls were 3-4 y old. Starting in 2013, diet was assessed every 6 mo through 24-h recall. The date of menarche was reported every 6 mo. Our analysis included 435 girls with prospective data on diet and age at menarche. We used a multivariable Cox proportional hazards regression model with restricted cubic splines to estimate HRs and 95% CIs for the association between cumulative mean iron intake and age at menarche. RESULTS: Most girls (99.5%) attained menarche with a mean (standard deviation) age at menarche of 12.2 (0.9) y. The mean dietary iron intake was 13.5 (range: 4.0-30.6) mg/d. Only 3.7% of girls consumed below 8 mg/d, the RDA. After multivariable adjustment, cumulative mean iron intake had a nonlinear association with menarche (P-for-nonlinearity: 0.02). Iron intakes above the RDA, between 8 and 15 mg/d, were associated with progressively lower probability of earlier menarche. Above 15 mg/d, the HRs were imprecise but tended to approach the null as iron intake increased. This association was attenuated after adjusting for girls' BMI and height before menarche (P-for-nonlinearity: 0.11). CONCLUSION: In Chilean girls, iron intake during late childhood, independent of body weight, was not an important determinant of menarche timing.

Adapting the Planetary Health Diet Index for children and adolescents.

BACKGROUND: Tools for measuring adherence to sustainable healthy diets among children and adolescents are lacking. OBJECTIVE: To advance methods for measuring adherence to sustainable healthy diets among children and adolescents by adapting an existing index, compare scores obtained using the original and adapted versions of the index in a sample of Chilean children, and describe the adapted index association with diet characteristics. METHODS: The Planetary Health Diet Index (PHDI) was adapted to better reflect children's and adolescents' nutritional requirements. The adapted index (PHDI-C) comprises 16 components with a maximum score of 150 points. PHDI-C was piloted among a sample of 958 Chilean children (3-6 years) using dietary data collected in 2016 through single 24-h recalls. A decision tree and food disaggregation methodology were developed to guide the calculation of scores. Scores obtained using the original and adapted versions of the index were compared. Linear regression models adjusted by child's gender and age were fitted to explore associations between total PHDI-C score, dietary recall characteristics and nutritional composition of children's diets. RESULTS: PHDI accounted for 75.7% of children's total caloric intake, whereas PHDI-C accounted for 99.6%. PHDI & PHCI-C scores were low among this sample of children; however, mean total score was lower when using PHDI compared to PHDI-C [40.7(12.1) vs 50.1(14.6)]. Children's scores were very low for nuts & peanuts, legumes, dark green vegetables, whole cereals, tubers & potatoes, and added sugars components across both indices, but were higher for dairy products and eggs & white meats components when using the PHDI-C due to adjustments made to ensure nutritional adequacy. Mean total PHDI-C score was significantly lower on weekends and special occasions, and significantly higher when children reported having a special diet (e.g., vegetarian). Total PHDI-C score was negatively associated with total sugars, saturated fats, trans fats, and animal-based protein intake, and positively associated with total protein, plant-based protein, total carbohydrates, and total fibre intake. CONCLUSIONS: This study provides a replicable method for measuring adherence to sustainable healthy diets among children and adolescents that can be used to monitor trends and measure the effectiveness of actions targeting improving children's diets.

Restricting child-directed ads is effective, but adding a time-based ban is better: evaluating a multi-phase regulation to protect children from unhealthy food marketing on television.

BACKGROUND: As childhood obesity rates continue to rise, health organizations have called for regulations that protect children from exposure to unhealthy food marketing. In this study, we evaluate the impact of child-based versus time-based restrictions of "high-in" food and beverage advertising in Chile, which first restricted the placement of "high-in" advertisements (ads) in television attracting children and the use of child-directed content in high-in ads and, second, banned high-in ads from 6am-10pm. "High-in" refers to products above regulation-defined thresholds in energy, saturated fats, sugars, and/or sodium. High-in advertising prevalence and children's exposure to high-in advertising are assessed. METHODS: We analyzed a random stratified sample of advertising from two constructed weeks of television at pre-regulation (2016), after Phase 1 child-based advertising restrictions (2017, 2018), and after the Phase 2 addition of a 6am-10pm high-in advertising ban (2019). High-in ad prevalence in post-regulation years were compared to prior years to assess changes in prevalence. We also analyzed television ratings data for the 4-12 year-old child audience to estimate children's ad exposure. RESULTS: Compared to pre-regulation, high-in ads decreased after Phase 1 (2017) by 42% across television (41% between 6am-10pm, 44% from 10pm-12am) and 29% in programs attracting children (P < 0.01). High-in ads further decreased after Phase 2, reaching a 64% drop from pre-regulation across television (66% between 6am-10pm, 56% from 10pm-12am) and a 77% drop in programs attracting children (P < 0.01). High-in ads with child-directed ad content also dropped across television in Phase 1 (by 41%) and Phase 2 (by 67%), compared to pre-regulation (P < 0.01). Except for high-in ads from 10pm-12am, decreases in high-in ads between Phase 1 (2018) and Phase 2 were significant (P < 0.01). Children's high-in ad exposure decreased by 57% after Phase 1 and by 73% after Phase 2 (P < 0.001), compared to pre-regulation. CONCLUSIONS: Chile's regulation most effectively reduced children's exposure to unhealthy food marketing with combined child-based and time-based restrictions. Challenges remain with compliance and limits in the regulation, as high-in ads were not eliminated from television. Yet, having a 6am-10pm ban is clearly critical for maximizing the design and implementation of policies that protect children from unhealthy food marketing.

Changes in children's and adolescents' dietary intake after the implementation of Chile's law of food labeling, advertising and sales in schools: a longitudinal study.

BACKGROUND: In June 2016, a comprehensive food policy was implemented in Chile that included front-of-package warning labels on key nutrients of concern (total sugars, added saturated fats, sodium, and calories), child-directed food advertisement bans, and school regulations. The policy was implemented in 3 phases from 2016 to 2019 and the primary objective was to improve children's food environments. This study's objective was to assess changes in child and adolescent intake of key nutrients of concern (total sugars, saturated fats, and sodium) at school after the initial implementation of Chile's Law of Food Labeling and Advertisement. METHODS: Longitudinal study of 349 children from the Food Environment Chilean Cohort (FECHIC) and 294 adolescents from the Growth and Obesity Cohort Study (GOCS). Data were from single 24-hour dietary recalls collected from 2016 to 2019. Fixed-effects models stratified by school, home, and other locations compared nutrient consumption in each year to consumption at the pre-policy 2016 baseline. Nutrient intakes are expressed as percent of total energy. RESULTS: Compared to 2016 (pre-policy), total sugars consumed by children at school decreased 4.5 [-8.0, -0.9] percentage points (pp) and 11.8 [-15.4, -8.3] pp in 2018 and 2019 respectively. In 2019, children's saturated fats and sodium intake at school also decreased (1.1 [-1.9, -0.2] pp and 10.3 [-18.1, -2.5] mg/100 kcal respectively). Likewise, in adolescents, total sugars and saturated fats consumed at school decreased in 2018 (5.3 [-8.4, -2.2] pp and 1.5 [-2.7, -0.3] pp respectively). However, consumption of key nutrients of concern at other locations increased after implementation of the policy. CONCLUSIONS: After initial implementation of Chile's Labeling Law, intake of most key nutrients of concern significantly declined at school. However, we found evidence of compensatory behavior in out-of-school settings. Further research is needed to evaluate what other actions are needed to impact overall diets in the long term both at schools and out of school.

Ultra-processed food consumption is associated with variations in daily routines in elementary schoolchildren during the COVID-19 pandemic in Chile.

OBJECTIVE: To assess the association between child ultra-processed food (UPF) consumption and home-school learning environment characteristics during school closures due to the COVID-19 pandemic in schoolchildren with low- and middle income in Chile. DESIGN: Cross-sectional. UPF consumption was collected using the Nova screener. We apply the structured days hypothesis (SDH) to assess home-school learning environment characteristics with three constructs that summarised school preparedness for online teaching and learning, school closure difficulties for caregivers and child routine. We explored associations between child UPF consumption and home-school environment characteristics using multivariate linear regression analyses after controlling for child demographic and school characteristics. SETTING: Low- and middle-income neighbourhoods in southeastern Santiago, Chile. PARTICIPANTS: Children from the Food Environment Chilean Cohort (n 428, 8-10 years old). RESULTS: Based on the Nova score, child mean consumption of UPF was 4·3 (sd 1·9) groups. We found a statistically significant negative association between child routine for eating, play and study and child UPF consumption when we adjusted for child sociodemographic (model 1: ß = -0·19, (95 % CI -0·40, 0·02)) and school characteristics (model 2: ß = -0·20, (95 % CI -0·41, 0·00)). Associations between school preparedness for online teaching or school closure difficulties and UPF were not statistically significant. CONCLUSIONS: Variations in child routines during the COVID-19 pandemic were negatively associated with UPF intake in schoolchildren with low- and middle income. Our findings are consistent with the SDH, suggesting the school environment helps regulate eating behaviours. Future research should evaluate what happens when children return to in-person classes at school.

Sugar-sweetened beverage consumption and breast composition in a longitudinal study of Chilean girls.

BACKGROUND: Frequent sugar-sweetened beverage (SSB) intake has been associated with indirect markers of breast cancer risk, such as weight gain in adolescents and early menarche. How SSB intake relates to breast composition in adolescent girls has not been explored. METHODS: We evaluated the association between prospective intake of SSB and breast density in a cohort of 374 adolescent girls participating in the Growth and Obesity Cohort Study in Santiago, Chile. Multivariable linear regression models were used to analyze the association between average daily SSB intake quartiles and breast composition (absolute fibroglandular volume [aFGV], percent fibroglandular volume [%FGV], total breast volume [tBV]). Models were adjusted for potential confounding by BMI Z-score, age, daily energy intake (g/day), maternal education, hours of daily television watching after school, dairy intake (g/day), meat intake (g/day), waist circumference, and menarche. To examine the sensitivity of the association to the number of dietary recalls for each girl, analyses were further stratified by girls with one dietary recall and girls with > one dietary recall. RESULTS: A total of 881 dietary recalls were available for 374 girls prior to the breast density assessment. More than 60% of the cohort had > one dietary recall available. In multivariable analyses, we found no association between SSB intake quartile and aFGV (Q2 vs Q1 ß: - 5.4, 95% CI - 15.1, 4.4; Q3 vs Q1 ß: 1.3, 95% CI - 8.6, 11.3; Q4 vs Q1 ß: 3.0, 95% CI - 7.1, 13). No associations were noted for %FGV and tBV. Among girls with at least one dietary recall, we found no significant associations between SSB intake quartiles and %FGV, aFGV, or tBV. CONCLUSION: Overall, we observed no evidence that SSB intake was associated with breast density in adolescent Chilean girls.

High DHEAS in girls and metabolic features throughout pubertal maturation.

CONTEXT: An association between premature adrenarche and metabolic syndrome at presentation has been described. Our aim was to assess whether the presence of high dehydroepiandrosterone sulphate (DHEAS [HD]) at the adrenarche determines the risk of metabolic syndrome during puberty, taking into account body mass index (BMI) and birth weight. DESIGN: Prospective observational. PATIENTS: Five hundred four girls from the Growth and Obesity Chilean Cohort Study were followed from birth through puberty. At age ~7, subjects were classified by DHEAS concentrations into the HD (>75th percentile) or normal DHEAS (ND, ≤75th percentile) subgroups. MEASUREMENTS: Anthropometrics, semiannual clinical pubertal staging and hormonal and metabolic levels. The relationships among DHEAS at age ~7, metabolic syndrome, and each of its components independently, were analyzed by linear and logistic regression models during puberty and 1-year postmenarche, adjusted by confounders. RESULTS: Girls with HD at 7 years exhibited higher BMI, more central fat and higher serum androgen and insulin like growth factor (IGF)-I levels throughout puberty. Also, girls with HD had a greater prevalence of hyperglycemia at B2 and B4 breast stages, and of low HDL at B4. At 1 year after menarche, HD girls had a higher prevalence of metabolic syndrome, and those with BMI > 1 SD score had a higher metabolic score and insulin levels than ND girls with similar BMI. CONCLUSIONS: Our observations suggest that girls with HD at the age of adrenarche may be at greater risk for metabolic syndrome at adolescence, especially in those who are overweight or obese. Our results emphasize the importance of lifestyle interventions for childhood overweight and obesity among girls with HD.

Awareness of and Participation in School Food Programs in Youth from Six Countries.

BACKGROUND: School-based meal programs can promote healthy dietary intake in youth. However, limited data exist regarding the impact of income-targeted school meal programs across countries, particularly among food-insecure youth. OBJECTIVES: We examined self-reported awareness of and participation in free school meal programs, and associations with dietary intake in youth from 6 countries with differing national school meal policies. METHODS: Data were collected through the 2019 International Food Policy Study Youth Survey, a cross-sectional survey of 10,565 youth aged 10-17 y from Australia, Canada, Chile, Mexico, the United Kingdom, and the United States. Regression models examined: 1) country differences in awareness of and participation in breakfast and lunch programs; and 2) associations between lunch program participation and intake of fruit and vegetables, and "less healthy" foods during the previous school lunch day. RESULTS: Awareness of and participation in free breakfast and lunch programs varied across countries. Approximately half of USA and Chilean students participated in school lunch programs-the countries with the most comprehensive national policies-compared with one-fifth of students in the United Kingdom, and ∼5% in Australia, Canada, and Mexico (P < 0.001 for all contrasts). In the United States and Chile, more than two-thirds of youth with the highest level of food insecurity participated in lunch programs, compared with 45% in the United Kingdom, 27% in Canada, and ≤20% in Australia and Mexico. In all countries, youth reporting school lunch program participation were more likely to report fruit and vegetable intake during their previous school lunch (P < 0.001), and higher intake of "less healthy" food in all countries except the United States and Chile. CONCLUSIONS: More comprehensive national policies were associated with greater participation in school meal programs, particularly among youth at greatest risk of food insecurity, as well as healthier dietary intake from school lunches.

Television viewing and using screens while eating: Associations with dietary intake in children and adolescents.

Screen time has been associated with overweight and obesity, as well as with poorer dietary quality. However, the reasons explaining these associations are not well understood. The objectives of this cross-sectional study were [1] to determine the extent of overall TV viewing as well as using screens while eating (e.g., watching TV or using a tablet), [2] to compare food and nutrient consumption of on-versus off-screen eating occasions, and [3] to determine whether TV viewing and using screens while eating is associated with overall dietary intake. Participants were from the Food Environment Chilean Cohort (n = 938, 4-6 y) and the Growth and Obesity Cohort Study (n = 752, 12-14 y). Dietary data was collected via one 24-h food recall. For each eating occasion, activity performed during consumption (e.g., watching TV, playing sports) was reported. Weekly TV viewing time was collected via an additional survey instrument. Analyses included multivariable linear and logistic regression. Post-hoc pairwise comparisons examined differences in outcomes by tertiles. Our sample reported a median of 9-13.5 weekly hours of TV viewing and 87.5% reported consuming at least one meal or snack per day while using screens. The median kilocalories contributed by eating during screen use was 387 kcal/d in children and 848 kcal/day in adolescents, which represents 34.7% and 42.3% of daily energy intake, respectively. There were no consistent differences when comparing eating occasions consumed on-screen versus off-screen. Higher weekly TV viewing was associated with elements of a less healthy diet including more sweets and desserts in children, and more sugar sweetened beverages in adolescents. A large percentage of Chilean children and adolescents' daily energy is consumed while using screens. In depth, longitudinal work is needed to understand how screen time eating affects diet quality and nutritional status.

Dynamics of the double burden of malnutrition and the changing nutrition reality.

The double burden of malnutrition (DBM), defined as the simultaneous manifestation of both undernutrition and overweight and obesity, affects most low-income and middle-income countries (LMICs). This Series paper describes the dynamics of the DBM in LMICs and how it differs by socioeconomic level. This Series paper shows that the DBM has increased in the poorest LMICs, mainly due to overweight and obesity increases. Indonesia is the largest country with a severe DBM, but many other Asian and sub-Saharan African countries also face this problem. We also discuss that overweight increases are mainly due to very rapid changes in the food system, particularly the availability of cheap ultra-processed food and beverages in LMICs, and major reductions in physical activity at work, transportation, home, and even leisure due to introductions of activity-saving technologies. Understanding that the lowest income LMICs face severe levels of the DBM and that the major direct cause is rapid increases in overweight allows identifying selected crucial drivers and possible options for addressing the DBM at all levels.

TV advertising and dietary intake in adolescents: a pre- and post- study of Chile's Food Marketing Policy.

BACKGROUND: The first phase of a comprehensive marketing policy was implemented in Chile in 2016. The policy restricted child-directed marketing of foods and beverages considered high in energy, total sugars, sodium or saturated fat ("high-in"). The objective of this study was to examine the role of high-in TV food advertising as a mediator in the association between policy implementation and consumption of high-in foods and beverages between 2016 and 2017. METHODS: Dietary data were from 24-hour diet recalls collected in 2016 and 2017 in a cohort of 12-14 y children (n = 721). Television use was assessed concurrently and linked to analyses of food advertisements on broadcast and paid television to derive individual-level estimates of exposure to high-in food advertising. A multilevel mediation analysis examined direct and indirect effects of the policy through advertising exposure. RESULTS: Following the policy implementation, high-in advertising exposure was significantly reduced (p < 0.01). High-in food intake decreased in adolescents with lower levels, but not higher levels, of high-in advertising at baseline. We did not find evidence of mediation by changes in high-in ad exposure. CONCLUSIONS: Adolescents' exposure to high-in TV advertising decreased after the 2016 implementation of the Chilean Food Labeling and Marketing Law. However, evidence that changes in advertisement mediated dietary changes was not found. Further research is needed to understand how marketing changes will relate to dietary changes after full implementation of the law and in the long term.