Children's everyday exposure to food marketing: an objective analysis using wearable cameras.

BACKGROUND: Over the past three decades the global prevalence of childhood overweight and obesity has increased by 47%. Marketing of energy-dense nutrient-poor foods and beverages contributes to this worldwide increase. Previous research on food marketing to children largely uses self-report, reporting by parents, or third-party observation of children's environments, with the focus mostly on single settings and/or media. This paper reports on innovative research, Kids'Cam, in which children wore cameras to examine the frequency and nature of everyday exposure to food marketing across multiple media and settings. METHODS: Kids'Cam was a cross-sectional study of 168 children (mean age 12.6 years, SD = 0.5) in Wellington, New Zealand. Each child wore a wearable camera on four consecutive days, capturing images automatically every seven seconds. Images were manually coded as either recommended (core) or not recommended (non-core) to be marketed to children by setting, marketing medium, and product category. Images in convenience stores and supermarkets were excluded as marketing examples were considered too numerous to count. RESULTS: On average, children were exposed to non-core food marketing 27.3 times a day (95% CI 24.8, 30.1) across all settings. This was more than twice their average exposure to core food marketing (12.3 per day, 95% CI 8.7, 17.4). Most non-core exposures occurred at home (33%), in public spaces (30%) and at school (19%). Food packaging was the predominant marketing medium (74% and 64% for core and non-core foods) followed by signs (21% and 28% for core and non-core). Sugary drinks, fast food, confectionary and snack foods were the most commonly encountered non-core foods marketed. Rates were calculated using Poisson regression. CONCLUSIONS: Children in this study were frequently exposed, across multiple settings, to marketing of non-core foods not recommended to be marketed to children. The study provides further evidence of the need for urgent action to reduce children's exposure to marketing of unhealthy foods, and suggests the settings and media in which to act. Such action is necessary if the Commission on Ending Childhood Obesity's vision is to be achieved.

Use of electronic sales data to tailor nutrition education resources for an ethnically diverse population.

BACKGROUND: Nutrition education may be most effective when personally tailored. Individualised electronic supermarket sales data offer opportunities to tailor nutrition education using shopper's usual food purchases. The present study aimed to use individualised electronic supermarket sales data to tailor nutrition resources for an ethnically diverse population in a large supermarket intervention trial in New Zealand. METHODS: Culturally appropriate nutrition education resources (i.e. messages and shopping lists) were developed with the target population (through two sets of focus groups) and ethnic researchers. A nutrient database of supermarket products was developed using retrospective sales data and linked to participant sales to allow tailoring by usual food purchases. Modified Heart Foundation Tick criteria were used to identify 'healthier' products in the database suitable for promotion in the resources. Rules were developed to create a monthly report listing the tailored and culturally targeted messages to be sent to each participant, and to produce automated, tailored shopping lists. RESULTS: Culturally targeted nutrition messages (n = 864) and shopping lists (n = 3 formats) were developed. The food and nutrient database (n = 3000 top-selling products) was created using 12 months of retrospective sales data, and comprised 60%'healthier' products. Three months of baseline sales data were used to determine usual food purchases. Tailored resources were successfully mailed to 123 Maori, 52 Pacific and 346 non-Maori non-Pacific participants over the 6-month trial intervention period. CONCLUSIONS: Electronic supermarket sales data can be used to tailor nutrition education resources for a large number of ethnically diverse supermarket shoppers.

Children and television watching: a qualitative study of New Zealand parents' perceptions and views.

BACKGROUND: Television (TV) viewing is one of the most pervasive sedentary pursuits among children and adolescents. Research studies have shown that higher TV viewing hours are associated with a number of negative effects such as being overweight and obese, attention and behavioural problems, and impaired academic performance. Most interventions to reduce time spent watching TV have been school-based and little is known about the strategies that families use to control TV watching time. METHODS: Six focus groups with Maori, Pacific and non-Maori non-Pacific parents were conducted to examine New Zealand parents' perceptions of their children's TV watching. Focus groups explored attitudes towards TV viewing, strategies used to reduce viewing, and opinion on two different electronic monitors that can be used to restrict TV viewing. Focus group discussions were transcribed and a content analysis was conducted. RESULTS: Parents described TV as playing a dominant role in their family's lives, and highlighted several barriers to reducing children's TV viewing, such as parents not willing to reduce their own TV watching, a lack of safe alternatives to TV and the need to use TV as a babysitting tool. Limiting access to TV, making TV viewing a reward and finding alternative activities were current strategies parents employed to limit TV viewing; however, the barriers highlighted by parents make implementing such strategies difficult. Attitudes towards electronic monitor use to reduce TV viewing were mixed, but suggest further investigation of these devices is needed. CONCLUSIONS: Electronic devices that restrict the amount and content of TV viewing have some potential to support interventions and merit further investigation. It is imperative for interventions aimed at reducing TV viewing to consider the role TV plays within a family context, ensuring parental perceptions around the benefits and barriers of reducing TV are accounted for.

Children's exposure to alcohol marketing within supermarkets: An objective analysis using GPS technology and wearable cameras.

BACKGROUND AND AIM: Exposure to alcohol marketing within alcohol retailers has been associated with higher rates of childhood drinking, brand recognition, and marketing recall. This study aimed to objectively measure children's everyday exposure to alcohol marketing within supermarkets. METHOD: Children aged 11-13 (n = 167) each wore a wearable camera and GPS device for four consecutive days. Micro-spatial analyses were used to examine exposures within supermarkets. RESULTS: In alcohol retailing supermarkets (n = 30), children encountered alcohol marketing on 85% of their visits (n = 78). Alcohol marketing was frequently near everyday goods (bread and milk) or entrance/exit. CONCLUSION: Alcohol sales in supermarkets should be banned in order to protect children from alcohol marketing.

Kids in space: Measuring children's residential neighborhoods and other destinations using activity space GPS and wearable camera data.

INTRODUCTION: Defining the boundary of children's 'neighborhoods' has important implications for understanding the contextual influences on child health. Additionally, insight into activities that occur outside people's neighborhoods may indicate exposures that place-based studies cannot detect. This study aimed to 1) extend current neighborhood research, using data from wearable cameras and GPS devices that were worn over several days in an urban setting; 2) define the boundary of children's neighborhoods by using leisure time activity space data; and 3) determine the destinations visited by children in their leisure time, outside their neighborhoods. METHOD: One hundred and fourteen children (mean age 12y) from Wellington, New Zealand wore wearable cameras and GPS recorders. Residential Euclidean buffers at incremental distances were paired with GPS data (thereby identifying time spent in different places) to explore alternative definitions of neighborhood boundaries. Children's neighborhood boundary was at 500 m. A newly developed software application was used to identify 'destinations' visited outside the neighborhood by specifying space-time parameters. Image data from wearable cameras were used to determine the type of destination. RESULTS: Children spent over half of their leisure time within 500 m of their homes. Children left their neighborhood predominantly to visit school (for leisure purposes), other residential locations (e.g. to visit friends) and food retail outlets (e.g. convenience stores, fast food outlets). Children spent more time at food retail outlets than at structured sport and in outdoor recreation locations combined. CONCLUSION: Person-centered neighborhood definitions may serve to better represent children's everyday experiences and neighborhood exposures than previous methods based on place-based measures. As schools and other residential locations (friends and family) are important destinations outside the neighborhood, such destinations should be taken into account. The combination of image data and activity space GPS data provides a more robust approach to understanding children's neighborhoods and activity spaces.

An evaluation of metabolic risks for coronary death in the Asia Pacific region.

AIM: To investigate the generalizability of current definitions of the metabolic syndrome in Asia-Pacific populations, and whether information on metabolic risk factors could be better used to discriminate fatal coronary heart disease (CHD) risk. METHODS AND RESULTS: Analyses were performed on individual participant data from 26 cohorts involving 329, 166 participants from the Asia Pacific region. Sensitivity and specificity estimates for CHD death associated with cut-points as defined by the U.S. National Cholesterol Education Panel (NCEP) were determined for component risk factors of a modified NCEP-defined metabolic syndrome. Five cohorts (6437 subjects, 53 CHD deaths) measuring all five risk factors at baseline were used to evaluate the association between the metabolic syndrome and CHD, and to compare risk discrimination using a definition including each risk factor as a continuous variable. Sensitivity and specificity estimates for risk factor cut-points varied considerably by region (Asia versus Australia/New Zealand) and moderately by sex. The adjusted hazard ratio for CHD death associated with the modified NCEP-defined metabolic syndrome was 2.05 (95%CI, 1.13-3.72). On receiver operator characteristic analysis, the area-under-the-curve for CHD death was 0.586 (95%CI: 0.439-0.732) for the modified NCEP-defined metabolic syndrome, and 0.733, 95%CI: 0.664-0.802) for a definition including each of the metabolic risk factors in their continuous form. CONCLUSION: Specific cut-points for metabolic risk factors are not generalizable between populations. This finding is not restricted to measures of central obesity. A multivariable definition of the metabolic syndrome including all risk factors as continuous variables improves CHD risk discrimination substantially.

Dietary under-reporting: what foods and which meals are typically under-reported?

Little objective information exists regarding which foods and meals are typically under-reported during retrospective self-reported dietary assessments. Automated wearable cameras record dietary behaviours in free-living settings and allow the context of under-reporting to be explored. As part of a study to validate image-assisted dietary assessment, 40 participants wore a wearable camera on days before three image-assisted 24-h dietary recalls. The foods and meals were typically under-reported, and the environmental and social contexts of under-reporting were assessed. Under-reporting occurred most frequently during afternoon snacks (75/265 foods), dinner (54/265 foods) and breakfast (44/265 foods). Snack foods were most frequently unreported during afternoon snacks, and condiments were most frequently under-reported at breakfasts. No clear pattern of social or environmental contexts for under-reporting was observed. Wearable cameras can identify when specific foods are likely to be under-reported during retrospective dietary assessments. Problematic foods and meals identified could be given additional attention during dietary assessments.

Chitosan for overweight or obesity.

BACKGROUND: Chitosan, a deacetylated chitin, is a dietary supplement reported to decrease body weight. It is widely available over the counter worldwide and although evaluated in a number of trials its efficacy remains in dispute. OBJECTIVES: To assess the effects of chitosan as a treatment for overweight and obesity. SEARCH STRATEGY: We searched electronic databases (MEDLINE, EMBASE, BIOSIS, CINAHL, The Cochrane Library), specialised web sites (Controlled Trials, IBIDS, SIGLE, Reuter's Health Service, Natural Alternatives International, Pharmanutrients), bibliographies of relevant journal articles, and contacted relevant authors and manufacturers. Last searches were completed in March 2004. SELECTION CRITERIA: Trials were included in the review if they were randomised controlled trials of chitosan a minimum of four weeks duration in adults who were overweight or obese. Authors of included studies were contacted for additional information where appropriate. DATA COLLECTION AND ANALYSIS: Details from eligible trials were extracted independently by two reviewers using a standardised data extraction form. Differences in data extraction were resolved by consensus. Continuous data were expressed as weighted mean differences and standard deviations. The pooled effect size was computed by using the inverse variance weighted method. MAIN RESULTS: Fourteen trials including a total of 1131 participants met the inclusion criteria. No trial to date has measured the effect of chitosan on mortality or morbidity. Analyses including all trials indicated that chitosan preparations result in a significantly greater weight loss (weighted mean difference -1.7 kg; 95% confidence interval (CI) -2.1 to -1.3 kg; P < 0.00001), decrease in total cholesterol (-0.2 mmol/L; 95% CI -0.3 to -0.1; P < 0.00001), decrease in systolic (-5.9 mmHg; 95% CI -7.3 to -4.6; P < 0.0001) and diastolic (-3.4 mmHg; 95% CI -4.4 to -2.4; P < 0.00001) blood pressure compared with placebo. There were no clear differences between intervention and control groups in terms of frequency of adverse events or in faecal fat excretion. However, the quality of many studies was sub-optimal and analyses restricted to studies that met allocation concealment criteria, were larger, or of longer duration showed that such trials produced substantially smaller decreases in weight and total cholesterol. AUTHORS' CONCLUSIONS: There is some evidence that chitosan is more effective than placebo in the short-term treatment of overweight and obesity. However, many trials to date have been of poor quality and results have been variable. Results obtained from high quality trials indicate that the effect of chitosan on body weight is minimal and unlikely to be of clinical significance.

Body mass index and cardiovascular disease in the Asia-Pacific Region: an overview of 33 cohorts involving 310 000 participants.

BACKGROUND: Few prospective data from the Asia-Pacific region are available relating body mass index (BMI) to the risks of stroke and ischaemic heart disease (IHD). Our objective was to assess the age-, sex-, and region-specific associations of BMI with cardiovascular disease using individual participant data from prospective studies in the Asia-Pacific region. METHODS: Studies were identified from literature searches, proceedings of meetings, and personal communication. All studies had at least 5000 person-years of follow-up. Hazard ratios were calculated from Cox models, stratified by sex and cohort, and adjusted for age at risk and smoking. The first 3 years of follow-up were excluded in order to reduce confounding due to disease at baseline. RESULTS: A total of 33 cohort studies, including 310 283 participants, contributed 2 148 354 person-years of follow-up, during which 3332 stroke and 2073 IHD events were observed. There were continuous positive associations between baseline BMI and the risks of ischaemic stroke, haemorrhagic stroke, and IHD, with each 2 kg/m(2) lower BMI associated a 12% (95% CI: 9, 15%) lower risk of ischaemic stroke, 8% (95% CI: 4, 12%) lower risk in haemorrhagic stroke, and 11% (95% CI: 9, 13%) lower risk of IHD. The strengths of all associations were strongly age dependent, and there was no significant difference between Asian and Australasian cohorts. CONCLUSIONS: This overview provides the most reliable estimates to date of the associations between BMI and cardiovascular disease in the Asia-Pacific region, and the first direct comparisons within the region. Continuous relationships of approximately equal strength are evident in both Asian and Australasian populations. These results indicate considerable potential for cardiovascular disease reduction with population-wide lowering of BMI.

Applying the stages-of-change model to dietary change.

The transtheoretical model of behavior change ("Stages of Change") was first proposed by Prochaska and DiClemente 14 years ago. It was originally developed by observing smokers who were planning or attempting to give up smoking. It has since been applied to behaviors other than smoking, and several recently published papers have examined its application in the area of dietary change. The complexity of dietary change, however, has made it more difficult to apply the model in this area. Studies applying the model to diet have differed in terms of the aspect of diet being examined, as well as the staging algorithms and dietary assessment methodology used. Such differences in methodology have led to variable results and have made it difficult to interpret results obtained. This review summarizes the studies in this area and makes recommendations for future research.

Sweetened and unsweetened non-alcoholic beverages in New Zealand: assessment of relative availability, price, serve size, and sugar content.

BACKGROUND: Sweetened beverages are a major contributor to sugar intakes in New Zealand, yet little information exists regarding the retail environment and the characteristics of sweetened and unsweetened beverages available for purchase. AIM: Our aim was to assess the availability, price, serve size and sugar content of sweetened and unsweetened non-alcoholic beverages available for purchase in New Zealand supermarkets. We also review and summarise the evidence for policy options relating to beverage availability, price, serve size and sugar content. METHODS: Data on all non-alcoholic beverages available for purchase in two large Auckland supermarkets were sourced from Nutritrack, a brand- specific packaged food composition database. RESULTS: Of 680 beverages available for sale in 2012, less than one in five (17%) was low-energy or unsweetened. However, low-energy options were cheaper, on average, than their sugar-sweetened counterparts (by approximately one third). The sugar content of beverages available ranged from zero to 23 g/100 mL. Some beverages contained more than 80 g of sugar (16 teaspoons) per single serve. National and international evidence suggests that increasing prices of fizzy drinks could reduce consumption, but long-term impacts on obesity and population health are unknown. Little evidence exists regarding other strategies to create healthier retail food environments. CONCLUSION: The vast majority of beverages available for purchase in New Zealand supermarkets are either sugar-sweetened or contain naturally occurring sugars. Options to decrease availability and reduce consumption of sweetened beverages should be urgently explored.

Kelston Beverages Pilot Study: Rationale, design and implementation of a community and school based intervention to reduce sugary drink consumption among children and youth.

The Kelston Beverages Study was designed to increase awareness of the sugar content of sugary drinks, the poor health consequences that high intake of these drinks have, and inform on ways to reduce intake of students. The aims of this pilot study were to refine interventions and processes designed to raise awareness of the harms that sugar sweetened beverages (SSBs) have on health, and to reduce their consumption among the youth of a small West Auckland suburb. There were three arms to this interventional study, one in schools, another in community organisations (churches, sports clubs and community groups), and the final arm is in the local retail sector. The school arm was the most extensive component and initially involved a survey of children's knowledge and consumption of sugar sweetened beverages (SSBs) using a brief questionnaire. The study evaluated any SSB policies in schools and for schools that did not have policies, opportunities were scoped to develop and implement them; a canteen AUDIT focussed particularly on beverages was carried out; and finally a student partnered social marketing exercise was undertaken that comprised 2 competitions, one to design a poster, and another to write and perform a rap. Children were re-surveyed at the completion of the intervention (7 months later) to determine change in knowledge and self-reported consumption of SSBs. Both the community organisations and retail arms of this study focussed on raising awareness into the harmful effects of SSBs and establishing healthy beverage policy in the respective organisations. Promising results with regards to acceptability, feasibility, and recruitment as well as valuable learnings with regard to process support the development of a proposal to conduct a cluster randomised trial of the interventions successfully tested in this pilot study.

Feasibility of a SenseCam-assisted 24-h recall to reduce under-reporting of energy intake.

BACKGROUND/OBJECTIVES: The SenseCam is a camera worn on a lanyard around the neck that automatically captures point-of-view images in response to movement, heat and light (every 20-30 s). This device may enhance the accuracy of self-reported dietary intake by assisting participants' recall of food and beverage consumption. It was the objective of this study to evaluate if the wearable camera, SenseCam, can enhance the 24-h dietary recall by providing visual prompts to improve recall of food and beverage consumption. SUBJECT/METHODS: Thirteen volunteer adults in Oxford, United Kingdom, were recruited. Participants wore the SenseCam for 2 days while continuing their usual daily activities. On day 3, participants' diets were assessed using an interviewer-administered 24-h recall. SenseCam images were then shown to the participants and any additional dietary information that participants provided after viewing the images was recorded. Energy and macronutrient intakes were compared between the 24-h recall and 24-h recall+SenseCam. RESULTS: Data from 10 participants were included in the final analysis (8 males and 2 females), mean age 33 ± 11 years, mean BMI 25.9 ± 5.1 kg/m(2). Viewing the SenseCam images increased self-reported energy intake by approximately 1432 ± 1564 kJ or 12.5% compared with the 24-h recall alone (P=0.02). The increase was predominantly due to reporting of 41 additional foods (241 vs 282 total foods) across a range of food groups. Eight changes in portion size were made, which resulted in a negligible change to energy intake. CONCLUSIONS: Wearable cameras are promising method to enhance the accuracy of self-reported dietary assessment methods.

Monitoring the availability of healthy and unhealthy foods and non-alcoholic beverages in community and consumer retail food environments globally.

Retail food environments are increasingly considered influential in determining dietary behaviours and health outcomes. We reviewed the available evidence on associations between community (type, availability and accessibility of food outlets) and consumer (product availability, prices, promotions and nutritional quality within stores) food environments and dietary outcomes in order to develop an evidence-based framework for monitoring the availability of healthy and unhealthy foods and non-alcoholic beverages in retail food environments. Current evidence is suggestive of an association between community and consumer food environments and dietary outcomes; however, substantial heterogeneity in study designs, methods and measurement tools makes it difficult to draw firm conclusions. The use of standardized tools to monitor local food environments within and across countries may help to validate this relationship. We propose a step-wise framework to monitor and benchmark community and consumer retail food environments that can be used to assess density of healthy and unhealthy food outlets; measure proximity of healthy and unhealthy food outlets to homes/schools; evaluate availability of healthy and unhealthy foods in-store; compare food environments over time and between regions and countries; evaluate compliance with local policies, guidelines or voluntary codes of practice; and determine the impact of changes to retail food environments on health outcomes, such as obesity.

The associations of diastolic blood pressure with the risk of stroke in Western and Eastern populations.

This paper reviews evidence from two overviews of prospective, observational studies of the association of diastolic blood pressure (DBP) with the risk of stroke in populations from the US and Europe and populations from China and Japan. The Western overview included seven studies involving a total of 405,511 individuals. During a mean follow-up period of 11 years, 843 strokes were observed. The Eastern overview included 18 cohorts involving a total of 124,774 participants. During a mean follow-up duration of 9 years, 1,798 strokes were observed. The shape of the association between usual DBP and the risk of stroke was similar in Western and Eastern populations, but in Eastern populations the size of the association was about 50% steeper than that in Western populations. This may be due, at least in part, to cerebral haemorrhage comprising a greater proportion of total stroke in Eastern populations. This finding, together with the high stroke rates in many Eastern Asian populations, suggests that the potential benefits of blood pressure lowering may be greater in Eastern Asia.

1999 World Health Organization-International Society of Hypertension Guidelines for the management of hypertension. Guidelines sub-committee of the World Health Organization.

The present Guidelines were prepared by the Guidelines Sub-Committee of the World Health Organization-International Society of Hypertension (WHO-ISH) Mild Hypertension Liaison Committee, the members of which are listed at the end of the text. These guidelines represent the fourth revision of the WHO-ISH Guidelines and were finalised after presentation and discussion at the 7th WHO-ISH Meeting on Hypertension, Fukuoka, Japan, 29th Sept-1st Oct, 1998. Previous versions of the Guidelines were published in Bull WHO 1993, 71:503-517 and J Hypertens 1993, 11:905-918.