Unhealthy Food and Beverage Marketing to Children in the Digital Age: Global Research and Policy Challenges and Priorities.

Food and nonalcoholic beverage marketing is implicated in poor diet and obesity in children. The rapid growth and proliferation of digital marketing has resulted in dramatic changes to advertising practices and children's exposure. The constantly evolving and data-driven nature of digital food marketing presents substantial challenges for researchers seeking to quantify the impact on children and for policymakers tasked with designing and implementing restrictive policies. We outline the latest evidence on children's experience of the contemporary digital food marketing ecosystem, conceptual frameworks guiding digital food marketing research, the impact of digital food marketing on dietary outcomes, and the methods used to determine impact, and we consider the key research and policy challenges and priorities for the field. Recent methodological and policy developments represent opportunities to apply novel and innovative solutions to address this complex issue, which could drive meaningful improvements in children's dietary health.

Nutritional Adequacy of Essential Nutrients in Low Protein Animal-Based and Plant-Based Diets in the United States for Chronic Kidney Disease Patients.

OBJECTIVES: The nutritional adequacy of both animal-based and plant-based low protein diets (LPDs) and moderate protein diets that are recommended for patients with chronic kidney disease have not been well examined. We therefore analyzed the nutrient content of three representative LPDs and moderate protein diets (lacto-ovo vegetarian, omnivorous, and vegan) containing foods that are likely to be prescribed for nondialyzed chronic kidney disease or chronic dialysis patients in the United States to determine the nutritional adequacy at different levels of protein intake. METHODS: Theoretical 3-day menus were developed as per current renal dietary guidelines to model each diet at 7 different levels of protein intake (0.5-1.2 g/kilograms body weight/day [g/kg/d]). The diets were analyzed for their content of essential amino acids (EAAs) and other essential nutrients. RESULTS: At an a priori recognized inadequate dietary protein level of 0.5 g/kg/d, all 3 diets failed to meet the Recommended Dietary Allowances (RDAs) for the following EAAs: histidine, leucine, lysine, and threonine. The omnivorous LPD met both the RDA and Estimated Average Requirement at levels of 0.6 g protein/kg/d or more. The lacto-ovo and vegan diets at 0.6 and 0.8 g protein/kg/d, respectively, were below the RDA for lysine. The amounts of several other vitamins and minerals were not uncommonly reduced below the RDA or Adequate Intake with all 3 LPDs. CONCLUSION: In comparison to omnivorous LPDs, both vegan and lacto-ovo LPDs are more likely to be deficient in several EAAs and other essential nutrients. To provide sufficient amounts of all EAA, vegan and lacto-ovo LPDs must be carefully planned to include adequate amounts of appropriate dietary sources. Supplements of some other essential nutrients may be necessary with all three LPDs.

Identifying Challenges and Potential Solutions for Sustainable Kidney Nutrition Care Delivery in Selected Asian Countries.

BACKGROUND: Recent surveys highlight gross workforce shortage of dietitians in global kidney health and significant gaps in renal nutrition care, with disparities greater in low/low-middle income countries. OBJECTIVE: This paper narrates ground experiences gained through the Palm Tocotrienols in Chronic Hemodialysis (PaTCH) project on kidney nutrition care scenarios and some Asian low-to-middle-income countries namely Bangladesh, India, and Malaysia. METHOD: Core PaTCH investigators from 3 universities (USA and Malaysia) were supported by their postgraduate students (n = 17) with capacity skills in kidney nutrition care methodology and processes. This core team, in turn, built capacity for partnering hospitals as countries differed in their ability to deliver dietitian-related activities for dialysis patients. RESULTS: We performed a structural component analyses of PaTCH affiliated and nonaffiliated (Myanmar and Indonesia) countries to identify challenges to kidney nutrition care. Deficits in patient-centered care, empowerment processes and moderating factors to nutrition care optimization characterized country comparisons. Underscoring these factors were some countries lacked trained dietitians whilst for others generalist dietitians or nonclinical nutritionists were providing patient care. Resolution of some challenges in low-to-middle-income countries through coalition networking to facilitate interprofessional collaboration and task sharing is described. CONCLUSIONS: We perceive interprofessional collaboration is the way forward to fill gaps in essential dietitian services and regional-based institutional coalitions will facilitate culture-sensitive capacity in building skills. For the long-term an advanced renal nutrition course such as the Global Renal Internet Course for Dietitians is vital to facilitate sustainable kidney nutrition care.

Is malnutrition a determining factor of health-related quality of life in hemodialysis patients? A cross-sectional design examining relationships with a comprehensive assessment of nutritional status.

PURPOSE: To identify relationships between health-related quality of life (HRQOL) and nutritional status in hemodialysis (HD) patients. METHOD: Secondary data from a cross-sectional survey was utilized. HRQOL was assessed for 379 HD patients using the generic Short Form 36 (SF-36) and disease-specific Kidney-Disease Quality of Life-36 (KDQOL-36). Malnutrition was indicated by malnutrition inflammation score (MIS) ≥ 5, and presence of protein-energy wasting (PEW). The individual nutritional parameters included the domains of physical status, serum biomarkers, and dietary intake. Multivariate associations were assessed using the general linear model. RESULTS: MIS ≥ 5 was negatively associated with SF-36 scores of physical functioning (MIS < 5 = 73.4 ± 8.0 SE vs MIS ≥ 5 = 64.6 ± 7.7 SE, P < 0.001), role-limitation-physical (MIS < 5 = 65.3 ± 14.3 SE vs MIS ≥ 5 = 52.9 ± 14.0 SE, P = 0.006), general health (MIS < 5 = 53.7 ± 7.5 SE vs MIS ≥ 5 = 47.0 ± 7.1 SE, P = 0.003), and PCS-36 (MIS < 5 = 40.5 ± 3.3 SE vs MIS ≥ 5 = 35.9 ± 3.1 SE, P < 0.001); and KDQOL-36 score of symptoms/problems (MIS < 5 = 78.9 ± 5.6 SE vs MIS ≥ 5 = 74.8 ± 5.4 SE, P = 0.022), but not with PEW by any tool. Of individual nutritional parameters, underweight (68.1 ± 5.4 SE, P = 0.031), normal weight (63.8 ± 2.8 SE, P = 0.023), and overweight (64.3 ± 2.9 SE, P = 0.003) patients had significantly higher physical functioning scores compared to obese patients (44.8 ± 5.5 SE). Serum albumin levels were positively associated with physical functioning (P = 0.041) score. HGS was also positively associated with physical functioning (P = 0.036), and vitality (P = 0.041) scores. Greater dietary phosphorus intakes were significantly associated with lower scores for role limitation-physical (P = 0.008), bodily pain (P = 0.043), and PCS-36 (P = 0.024). CONCLUSION: Malnutrition diagnosis by MIS, but not PEW, indicated associations with HRQOL in HD patients. Individual nutritional parameters that related to higher HRQOL were BMI < 30 kg/m2, better dietary phosphorus control, greater muscle strength and higher visceral protein pool.

A collective call to strengthen monitoring and evaluation efforts to support healthy and sustainable food systems: 'The Accountability Pact'.

There is widespread agreement among experts that a fundamental reorientation of global, regional, national and local food systems is needed to achieve the UN Sustainable Development Goals Agenda and address the linked challenges of undernutrition, obesity and climate change described as the Global Syndemic. Recognising the urgency of this imperative, a wide range of global stakeholders - governments, civil society, academia, agri-food industry, business leaders and donors - convened at the September 2021 UN Food Systems Summit to coordinate numerous statements, commitments and declarations for action to transform food systems. As the dust settles, how will they be pieced together, how will governments and food corporations be held to account and by whom? New data, analytical methods and global coalitions have created an opportunity and a need for those working in food systems monitoring to scale up and connect their efforts in order to inform and strengthen accountability actions for food systems. To this end, we present - and encourage stakeholders to join or support - an Accountability Pact to catalyse an evidence-informed transformation of current food systems to promote human and ecological health and wellbeing, social equity and economic prosperity.

Benchmarking Diet Quality to Assess Nutritional Risk in Hemodialysis Patients: Applying Adequacy and Moderation Metrics of the Hemodialysis-Healthy Eating Index.

OBJECTIVES: This study modified Healthy Eating Index (HEI) based on hemodialysis (HD)-specific nutritional guidelines and investigated associations between the diet quality (DQ) and nutritional risk in HD patients. METHODS: The HD-HEI tool adapted the Malaysian Dietary Guidelines 2010 framework according to HD-specific nutrition guidelines. This HD-HEI was applied to 3-day dietary records of 382 HD patients. Relationships between HD-HEI scores and nutritional parameters were tested by partial correlations. Binary logistic regression models adjusted with confounders were used to determine adjusted odds ratio (adjOR) with 95% confidence interval (CI) for nutritional risk based on HD-HEI scores categorization. RESULTS: The total HD-HEI score (51.3 ± 10.2) for this HD patient population was affected by ethnicity (Ptrend < .001) and sex (P = .003). No patient achieved "good" DQ (score: 81-100), while DQ of 54.5% patients were classified as "needs improvement" (score: 51-80) and remaining as "poor" (score: 0-51). Total HD-HEI scores were positively associated with dietary energy intake (DEI), dietary protein intake (DPI), dry weight, and handgrip strength, but inversely associated with Dietary Monotony Index (DMI) (all P < .05). Individually, scores for refined grain, total protein, and animal protein were positively associated with DEI (all P < .05), while total, animal, fish, and vegetable proteins indicated positive associations with DPI (all P < .05). Moderating metrics for convenience meals, saturated fats, sodium, and fluid negatively correlated toward DEI with similar trends for DPI excepting convenience meals and fluids. "Poor" DQ was associated with DMI ≥ 29.2 (adjOR 18.83, 95% CI 9.36-37.86, P < .001), Malnutrition Inflammation Score ≥ 5 (adjOR 1.78, 95% CI 1.01-3.15, P = .045), and protein energy wasting (adjOR 1.96, 95% CI 1.14-3.34, P = .031), but became nullified with covariate adjustments. "Poor" DQ was also associated with low lean tissue mass (<32.6 kg) in men (adjOR 2.38, 95% CI 1.01-5.58, P = .046) but not women. CONCLUSION: "Poor" DQ was associated with poor nutritional status in Malaysian HD patients, who should be targeted for nutritional counseling.

Exploring the experiences and perceptions of haemodialysis patients observing Ramadan fasting: a qualitative study.

BACKGROUND: The festival of Ramadan is a month of spiritual reflection for Muslims worldwide. During Ramadan, Muslims are required to refrain from eating and drinking during daylight hours. Although exempted from fasting, many patients undergoing maintenance haemodialysis (HD) opt to participate in this religious practice. Many studies have explored the effects of Ramadan on health outcomes, however, the exploration from patients' own point of view pertaining to this religious practice is lacking. Thus, we aimed to explore the experiences and perceptions of Muslim HD patients observing Ramadan fasting from three HD centres in Klang Valley, Malaysia. METHOD: An exploratory phenomenology qualitative study was conducted whereby subjects were purposively selected based on previous experience in observing Ramadan fasting. Face-to-face in-depth interviews were conducted, and study data were analyzed thematically and iteratively coded using a constant comparison method. RESULTS: Four major themes emerged from the data, namely: (i) "fasting experiences", (ii) "perceived side effects of fasting", (iii) "health-seeking behavior" and, (iv) "education and awareness needs". Patients expressed the significance of Ramadan fasting as well as the perceived impact of fasting on their health. Additionally, there is lack of health-seeking behaviour observed among patients thus, raising needs for awareness and education related to Ramadan fasting. CONCLUSIONS: Findings of this study shed light on patients' experiences and perceptions regarding Ramadan fasting which warrants the needs for an effective communication between patients and health care practitioners through a structured-Ramadan specific education program.

Benchmarking the transparency, comprehensiveness and specificity of population nutrition commitments of major food companies in Malaysia.

BACKGROUND: The aim of this study was to assess the commitments of food companies in Malaysia to improving population nutrition using the Business Impact Assessment on population nutrition and obesity (BIA-Obesity) tool and process, and proposing recommendations for industry action in line with government priorities and international norms. METHODS: BIA-Obesity good practice indicators for food industry commitments across a range of domains (n = 6) were adapted to the Malaysian context. Euromonitor market share data was used to identify major food and non-alcoholic beverage manufacturers (n = 22), quick service restaurants (5), and retailers (6) for inclusion in the assessment. Evidence of commitments, including from national and international entities, were compiled from publicly available information for each company published between 2014 and 2017. Companies were invited to review their gathered evidence and provide further information wherever available. A qualified Expert Panel (≥5 members for each domain) assessed commitments and disclosures collected against the BIA-Obesity scoring criteria. Weighted scores across domains were added and the derived percentage was used to rank companies. A Review Panel, comprising of the Expert Panel and additional government officials (n = 13), then formulated recommendations. RESULTS: Of the 33 selected companies, 6 participating companies agreed to provide more information. The median overall BIA-Obesity score was 11% across food industry sectors with only 8/33 companies achieving a score of > 25%. Participating (p < 0.001) and global (p = 0.036) companies achieved significantly higher scores than non-participating, and national or regional companies, respectively. Corporate strategy related to population nutrition (median score of 28%) was the highest scoring domain, while product formulation, accessibility, and promotion domains scored the lowest (median scores < 10%). Recommendations included the establishment of clear targets for product formulation, and strong commitments to reduce the exposure of children to promotion of unhealthy foods. CONCLUSIONS: This is the first BIA-Obesity study to benchmark the population nutrition commitments of major food companies in Asia. Commitments of companies were generally vague and non-specific. In the absence of strong government regulation, an accountability framework, such as provided by the BIA-Obesity, is essential to monitor and benchmark company action to improve population nutrition.

Investigating Physical and Nutritional Changes During Prolonged Intermittent Fasting in Hemodialysis Patients: A Prospective Cohort Study.

OBJECTIVE: Studies investigating the health effects of prolonged intermittent fasting during Ramadan among Muslim patients on hemodialysis (HD) are limited and reported heterogeneous findings. This study aimed to evaluate the effects of intermittent fasting during Ramadan on nutritional and functional status of patients on maintenance HD. DESIGN AND METHODS: This was a 12-week, multicenter, prospective observational study. The study setting included three HD centers. Adult Muslim patients, who were undergoing HD session thrice weekly and planned to fast during Ramadan, were screened for eligibility and recruited. Nutritional and functional status assessments were carried out 2 weeks before (V0), at the fourth week of Ramadan (V1), and 4 weeks after Ramadan (V2). Nutritional status parameters included anthropometry (body mass index, interdialytic weight gain, waist circumference), body composition (mid-arm circumference, triceps skinfold, body fat percentage), blood biochemistry (albumin, renal profile, lipid profile, and inflammatory markers), blood pressure, dietary intake, and handgrip strength. Changes in nutritional and functional status parameters across study timepoints were analyzed using repeated-measures analysis of variance. RESULTS: A total of 87 patients completed the study, with 68 patients (78.2%) reporting fasting ≥20 days. Ramadan fasting led to significant reductions (all P < .05) in body mass index, interdialytic weight gain, waist circumference, mid-arm circumference, fat tissue mass, and body fat percentage, but these were not accompanied by any significant change in lean tissue mass (P > .05). Significant improvement was observed in serum phosphate levels, but serum albumin, urea, and creatinine were also reduced significantly during Ramadan (P < .05). There were no significant changes in lipid profile and inflammatory markers. Interestingly, energy and protein intakes remain unchanged during Ramadan. Handgrip strength improved significantly during Ramadan and further improved after Ramadan. CONCLUSION: Intermittent Ramadan fasting leads to temporary changes in nutritional status parameters and poses nondetrimental nutritional risk for patients on maintenance HD.

Habitual Dietary Patterns of Patients on Hemodialysis Indicate Nutritional Risk.

OBJECTIVE: This study aimed to (i) determine habitual dietary patterns of Malaysian patients on hemodialysis (HD) and (ii) examine their association with nutritional status. METHODS: An à posteriori approach examined 3-day dietary recalls of 382 multiethnic Malaysian patients on HD, leading to short-listing of 31 food groups. Dietary patterns were derived through principal component analysis. Sociodemographic and lifestyle characteristics together with nutritional parameters were examined for associations with specific dietary patterns. RESULTS: Four dietary patterns emerged, namely, "Home Food," "Eating Out (EO)-Rice," "EO-Sugar sweetened beverages," and "EO-Noodle." Younger patients, male gender, Malay, and patients with working status were more likely to follow "EO-Rice" and "EO-Sugar sweetened beverages" patterns, while Chinese patients were more likely to consume "EO-Noodle" pattern (all P values < .05). The EO frequency was directly associated with "EO-Rice" (P = .030), "EO-Sugar sweetened beverages" (P = .040), and "EO-Noodle" (P = .001) patterns. The highest tertile of the "Home Food" pattern related to higher handgrip strength (T3 = 21.3 ± 0.74 vs. 18.0 ± 0.73 kg, P = .006), higher serum albumin (T3 = 3.99 ± 0.04 vs. T1 = 3.84 ± 0.04 g/dL, P = .027), and lower Malnutrition-Inflammation Score (T3 = 4.9 ± 0.36 vs. T1 = 6.4 ± 0.34, P = .010), along with lower Diet Monotony Index (T3 = 29.0 ± 1.1 vs. T1 = 33.0 ± 1.0, P = .030). while "EO-Rice" and "EO-Sugar sweetened beverage" patterns were associated only with higher energy intake (all P values < .001). CONCLUSIONS: These results indicated that a home-based diet inclusive of healthy food choices was associated with better nutritional status in this HD population.

Extent of implementation of food environment policies by the Malaysian Government: gaps and priority recommendations.

OBJECTIVE: To determine the degree of food environment policies that have been implemented and supported by the Malaysian Government, in comparison to international best practice, and to establish prioritised recommendations for the government based on the identified implementation gaps. DESIGN: The Healthy Food-Environment Policy Index (Food-EPI) comprises forty-seven indicators of government policy practice. Local evidence of each indicator was compiled from government institutions and verified by related government stakeholders. The extent of implementation of the policies was rated by experts against international best practices. Rating results were used to identify and propose policy actions which were subsequently prioritised by the experts based on 'importance' and 'achievability' criteria. The policy actions with relatively higher 'achievability' and 'importance' were set as priority recommendations for government action. SETTING: Malaysia. SUBJECTS: Twenty-six local experts. RESULTS: Majority (62 %) of indicators was rated 'low' implementation with no indicator rated as either 'high' or 'very little, if any' in terms of implementation. The top five recommendations were (i) restrict unhealthy food marketing in children's settings and (ii) on broadcast media; (iii) mandatory nutrition labelling for added sugars; (iv) designation of priority research areas related to obesity prevention and diet-related non-communicable diseases; and (v) introduce energy labelling on menu boards for fast-food outlets. CONCLUSIONS: This first policy study conducted in Malaysia identified a number of gaps in implementation of key policies to promote healthy food environments, compared with international best practices. Study findings could strengthen civil society advocacies for government accountability to create a healthier food environment.

The state of nutrition care in outpatient hemodialysis settings in Malaysia: a nationwide survey.

BACKGROUND: This study aimed to assess the situational capacity for nutrition care delivery in the outpatient hemodialysis (HD) setting in Malaysia by evaluating dietitian accessibility, nutrition practices and patients' outcomes. METHODS: A 17-item questionnaire was developed to assess nutrition practices and administered to dialysis managers of 150 HD centers, identified through the National Renal Registry. Nutritional outcomes of 4362 patients enabled crosscutting comparisons as per dietitian accessibility and center sector. RESULTS: Dedicated dietitian (18%) and visiting/shared dietitian (14.7%) service availability was limited, with greatest accessibility at government centers (82.4%) > non-governmental organization (NGO) centers (26.7%) > private centers (15.1%). Nutritional monitoring varied across HD centers as per albumin (100%) > normalized protein catabolic rate (32.7%) > body mass index (BMI, 30.7%) > dietary intake (6.0%). Both sector and dietitian accessibility was not associated with achieving albumin ≥40 g/L. However, NGO centers were 36% more likely (p = 0.030) to achieve pre-dialysis serum creatinine ≥884 µmol/L compared to government centers, whilst centers with dedicated dietitian service were 29% less likely (p = 0.017) to achieve pre-dialysis serum creatinine ≥884 µmol/L. In terms of BMI, private centers were 32% more likely (p = 0.022) to achieve BMI ≥ 25.0 kg/m2 compared to government centers. Private centers were 62% less likely (p <  0.001) while NGO centers were 56% less likely (p <  0.001) to achieve serum phosphorus control compared to government centers. Patients from centers with a shared/visiting dietitian had 35% lower probability (p <  0.001) to achieve serum phosphorus levels below 1.78 mmol/L compared to centers without access to a dietitian. CONCLUSIONS: There were clear discrepancies in nutritional care in Malaysian HD centers. Changes in stakeholder policy are required to ensure that dietitian service is available in Malaysian HD centers.

Global Prevalence of Protein-Energy Wasting in Kidney Disease: A Meta-analysis of Contemporary Observational Studies From the International Society of Renal Nutrition and Metabolism.

OBJECTIVE: To better define the prevalence of protein-energy wasting (PEW) in kidney disease is poorly defined. METHODS: We performed a meta-analysis of PEW prevalence from contemporary studies including more than 50 subjects with kidney disease, published during 2000-2014 and reporting on PEW prevalence by subjective global assessment or malnutrition-inflammation score. Data were reviewed throughout different strata: (1) acute kidney injury (AKI), (2) pediatric chronic kidney disease (CKD), (3) nondialyzed CKD 3-5, (4) maintenance dialysis, and (5) subjects undergoing kidney transplantation (Tx). Sample size, period of publication, reporting quality, methods, dialysis technique, country, geographical region, and gross national income were a priori considered factors influencing between-study variability. RESULTS: Two studies including 189 AKI patients reported a PEW prevalence of 60% and 82%. Five studies including 1776 patients with CKD stages 3-5 reported PEW prevalence ranging from 11% to 54%. Finally, 90 studies from 34 countries including 16,434 patients on maintenance dialysis were identified. The 25th-75th percentiles range in PEW prevalence among dialysis studies was 28-54%. Large variation in PEW prevalence across studies remained even when accounting for moderators. Mixed-effects meta-regression identified geographical region as the only significant moderator explaining 23% of the observed data heterogeneity. Finally, two studies including 1067 Tx patients reported a PEW prevalence of 28% and 52%, and no studies recruiting pediatric CKD patients were identified. CONCLUSION: By providing evidence-based ranges of PEW prevalence, we conclude that PEW is a common phenomenon across the spectrum of AKI and CKD. This, together with the well-documented impact of PEW on patient outcomes, justifies the need for increased medical attention.

Comparing effects of soybean oil- and palm olein-based mayonnaise consumption on the plasma lipid and lipoprotein profiles in human subjects: a double-blind randomized controlled trial with cross-over design.

BACKGROUND: Mayonnaise is used widely in contemporary human diet with widespread use as a salad dressing or spread on breads. Vegetable oils used in its formulation may be a rich source of ω-6 PUFAs and the higher-PUFA content of mayonnaise may be beneficial in mediating a hypocholesterolemic effect. This study, therefore, evaluated the functionality of mayonnaise on cardiometabolic risk within a regular human consumption scenario. METHODS: Subjects underwent a randomized double-blind crossover trial, consuming diets supplemented with 20 g/day of either soybean oil-based mayonnaise (SB-mayo) or palm olein-based mayonnaise (PO-mayo) for 4 weeks each with a 2-week wash-out period. The magnitude of changes for metabolic outcomes between dietary treatments was compared with PO-mayo serving as the control. The data was analyzed by ANCOVA using the GLM model. Analysis was adjusted for weight changes. RESULTS: Treatments resulted in significant reductions in TC (diff = -0.25 mmol/L; P = 0.001), LDL-C (diff = -0.17 mmol/L; P = 0.016) and HDL-C (diff = -0.12 mmol/L; P < 0.001) in SB-mayo compared to PO-mayo without affecting LDL-C:HDL-C ratio (P > 0.05). Lipoprotein particle change was significant with large LDL particles increasing after PO-mayo (diff = +63.2 nmol/L; P = 0.007) compared to SB-mayo but small LDL particles remained unaffected. Plasma glucose, apolipoproteins and oxidative stress markers remained unchanged. CONCLUSIONS: Daily use with 20 g of linoleic acid-rich SB-mayo elicited reductions in TC and LDL-C concentrations without significantly changing LDL-C:HDL-C ratio or small LDL particle distributions compared to the PO-mayo diet. TRIAL REGISTRATION: This clinical trial was retrospectively registered with the National Medical Research Register, National Institute of Health, Ministry of Health Malaysia, (NMRR-15-40-24035; registered on 29/01/2015; https://www.nmrr.gov.my/fwbPage.jsp?fwbPageId=ResearchISRForm&fwbAction=Update&fwbStep=10&pk.researchID=24035&fwbVMenu=3&fwbResearchAction=Update ). Ethical approval was obtained from the National University of Malaysia's Medical Ethics Committee (UKM 1.5.3.5/244/SPP/NN-054-2011, approved on 25/05/2011).

Children's exposure to food advertising on free-to-air television: an Asia-Pacific perspective.

There is an established link between food promotions and children's food purchase and consumption. Children in developing countries may be more vulnerable to food promotions given the relative novelty of advertising in these markets. This study aimed to determine the scope of television food advertising to children across the Asia-Pacific to inform policies to restrict this marketing. Six sites were sampled, including from China, Indonesia, Malaysia and South Korea. At each site, 192 h of television were recorded (4 days, 16 h/day, three channels) from May to October 2012. Advertised foods were categorized as core/healthy, non-core/unhealthy or miscellaneous, and by product type. Twenty-seven percent of advertisements were for food/beverages, and the most frequently advertised product was sugar-sweetened drinks. Rates of non-core food advertising were highest during viewing times most popular with children, when between 3 (South Korea) and 15 (Indonesia) non-core food advertisements were broadcast each hour. Children in the Asia-Pacific are exposed to high volumes of unhealthy food/beverage television advertising. Different policy arrangements for food advertising are likely to contribute to regional variations in advertising patterns. Cities with the lowest advertising rates can be identified as exemplars of good policy practice.

Assessing protein energy wasting in a Malaysian haemodialysis population using self-reported appetite rating: a cross-sectional study.

BACKGROUND: Poor appetite could be indicative of protein energy wasting (PEW) and experts recommend assessing appetite in dialysis patients. Our study aims to determine the relationship between PEW and appetite in haemodialysis (HD) patients. METHODS: HD patients (n=205) self-rated their appetite on a scale of 1 to 5 as very good (1), good (2), fair (3), poor (4) or very poor (5). Nutritional markers were compared against appetite ratings. Using logistic regression analysis associations between dichotomized appetite with PEW diagnosis were determined as per the International Society of Renal Nutrition and Metabolism (ISRNM) criteria and alternate objective measures. Data was adjusted for socioeconomic and demographic characteristics. RESULTS: Poorer appetite ratings were significantly associated with lower income (P = 0.021), lower measurements (P < 0.05) for mid-arm muscle circumference, mid-arm muscle area and lean tissue mass (LTM), serum urea (P = 0.007) and creatinine (P = 0.005). The highest hsCRP (P = 0.016) levels occurred in patients reporting the poorest appetite. Serum albumin did not differ significantly across appetite ratings. Poor oral intake represented by underreporting (EI/BMR < 1.2) was evident for all appetite ratings. PEW was prevalent irrespective of appetite ratings (very good: 17.6 %, good: 40.2 %, fair: 42.3 % and poor: 83.3 %). After dichotomizing appetite ratings into normal and diminished categories, there was a marginal positive association between diminished appetite and overall PEW diagnosis (OR adj: 1.71; 95 % CI: 0.94-3.10, P = 0.079). Amongst individual ISRNM criteria, only BMI < 23 kg/m2 was positively associated with diminished appetite (OR adj: 2.17; 95 % CI: 1.18-3.99). However, patients reporting diminished appetite were more likely to have lower LTM (OR adj: 2.86; 95 % CI: 1.31-6.24) and fat mass (OR adj: 1.91; 95 % CI: 1.03-3.53), lower levels of serum urea (OR adj: 2.74; 95 % CI: 1.49-5.06) and creatinine (OR adj: 1.99; 95 % CI: 1.01-3.92), higher Dialysis Malnutrition Score (OR adj: 2.75; 95 % CI: 1.50-5.03), Malnutrition Inflammation Score (OR adj: 2.15; 95 % CI: 1.17-3.94), and poorer physical (OR adj: 3.49; 95 % CI: 1.89-6.47) and mental (OR adj: 5.75; 95 % CI: 3.02-10.95) scores. CONCLUSIONS: A graded but non-significant increase in the proportion of PEW patients occurred as appetite became poorer. However, after dichotomization, a positive but marginally significant association was observed between diminished appetite and PEW diagnosis.

Reading the mind of children in response to food advertising: a cross-sectional study of Malaysian schoolchildren's attitudes towards food and beverages advertising on television.

BACKGROUND: Television food advertising (TVFA) is the most dominant medium in the obesogenic environment promoting unhealthy food choices in children. METHODS: This cross-sectional study investigated children's attitudes towards TVFA by examining four well-cited induction factors namely advertisement recognition, favourite advertisement, purchase request, and product preference. Malaysian urban schoolchildren (7 to 12 years) of equal ethnic distribution were voluntarily recruited (n = 402). Questionnaire administration was facilitated using a food album of 24 advertised food products. RESULTS: Majority of children were older (66.2 %), girls (56.7 %) with one-third either overweight or obese. TV viewing time for weekend was greater than weekdays (4.77 ± 2.60 vs 2.35 ± 1.40 h/day) and Malay children spent more time watching TV compared to Chinese (p < 0.001) and Indian (p < 0.05) children. Chinese children spent significantly more time surfing the internet compared to either Malay or Indian (p < 0.01). Median score trend was advertisement recognition > favourite advertisement and product preference > purchase request, and significantly greater (p < 0.001) for non-core than core food advertisements. TV viewing time and ethnicity significantly influenced all induction factors for non-core foods. After correcting for all influencing factors, 'favourite advertisement' (IRRfinal adj: 1.06; 95 % CI: 1.04 to 1.08), 'purchase request' (IRRfinal adj: 1.06; 95 % CI: 1.04 to 1.08) and 'product preference' (IRRfinal adj: 1.04; 95 % CI: 1.02 to 1.07) still were significantly associated with TV viewing time. For every additional hour of TV viewing, the incidence rates increased significantly by 1.04 to 1.06 for 'favourite advertisement', 'purchase request' and 'product preference' related to non-core foods amongst Malay and Indian children. However, Chinese children only demonstrated a significant association between TV viewing time and 'favourite advertisement' (IRRadj: 1.06; 95 % CI: 1.01 to 1.10). CONCLUSION: This study highlights TVFA as a powerful medium predisposing the mind of children to non-core foods through appealing TV commercials, promoting purchase request and generating unhealthy food preferences in early childhood.

TEMPORARY REMOVAL: Monitoring commercially available complementary foods for the infant and young child in Southeast Asia: Accountability and the way forward.

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