Citizen Science to improve healthy and active living among adolescents in four European countries: a protocol of the cluster randomised controlled trial of the Science Engagement to Empower aDolescentS (SEEDS) project.

INTRODUCTION: Improving healthy lifestyles of adolescents is challenging. Citizen Science is a way to engage them in the design and delivery of interventions, and may also increase their interest in science, technology, engineering and mathematics (STEM). The Science Engagement to Empower aDolescentS (SEEDS) project aims to use an equity-lens, and engage and empower boys and girls from deprived areas by designing and cocreating interventions to promote healthy lifestyles, and to seed interest in STEM. METHODS AND ANALYSIS: SEEDS is a cluster randomised controlled trial in four countries (Greece, the Netherlands, Spain and the UK). Each country will recruit six to eight high schools from lower socioeconomic neighbourhoods. Adolescents aged 13-15 years are the target population. High schools will be randomised into intervention or control group. Each country will select 15 adolescents from intervention schools called ambassadors, who will be involved throughout the project.In each country, focus groups with ambassadors and stakeholders will focus on physical activity, snacking behaviour and STEM. The input from focus groups will be used to shape Makeathon events, cocreation events where adolescents and stakeholders will develop the interventions. The resultant intervention will be implemented in the intervention schools during 6 months. In total, we aim to recruit 720 adolescents who will complete questionnaires related to healthy lifestyles and STEM outcomes at baseline (November 2021) and after the 6 months (June 2022). ETHICS AND DISSEMINATION: The four countries obtained approval from their corresponding Ethics Committees (Greece: Bioethics Committee of Harokopio University; the Netherlands: The Medical Research Ethics Committee of the Erasmus Medical Center; Spain: The Drug Research Ethics Committee of the Pere Virgili Health Research Institute; UK: Sport and Health Sciences Ethics Committee of the University of Exeter). Informed consent will be collected from adolescents and their parents in line with General Data Protection Regulation legislation. The findings will be disseminated by conference presentations, publications in scientific peer-reviewed journals and during (local) stakeholders and public events. Lessons learnt and the main results will also be used to provide policy recommendations. TRIAL REGISTRATION NUMBER: NCT05002049.

Public support for smoke-free policies in outdoor areas and (semi-)private places: a systematic review and meta-analysis.

Background: Smoke-free policies are essential to protect people against tobacco smoke exposure. To successfully implement smoke-free policies that go beyond enclosed public places and workplaces, public support is important. We undertook a comprehensive systematic review of levels and determinants of public support for indoor (semi-)private and outdoor smoke-free policies. Methods: In this systematic review and meta-analysis, six electronic databases were searched for studies (published between 1 January 2004 and 19 January 2022) reporting support for (semi-)private and outdoor smoke-free policies in representative samples of at least 400 respondents aged 16 years and above. Two reviewers independently extracted data and assessed risk of bias of individual reports using the Mixed Methods Appraisal Tool. The primary outcome was proportion support for smoke-free policies, grouped according to location covered. Three-level meta-analyses, subgroup analyses and meta-regression were performed. Findings: 14,749 records were screened, of which 107 were included; 42 had low risk of bias and 65 were at moderate risk. 99 studies were included in the meta-analyses, reporting 326 measures of support from 896,016 individuals across 33 different countries. Support was pooled for indoor private areas (e.g., private cars, homes: 73%, 95% confidence interval (CI): 66-79), indoor semi-private areas (e.g., multi-unit housing: 70%, 95% CI: 48-86), outdoor hospitality areas (e.g., café and restaurant terraces: 50%, 95% CI: 43-56), outdoor non-hospitality areas (e.g., school grounds, playgrounds, parks, beaches: 69%, 95% CI: 64-73), outdoor semi-private areas (e.g., shared gardens: 67%, 95% CI: 53-79) and outdoor private areas (e.g., private balconies: 41%, 95% CI: 18-69). Subcategories showed highest support for smoke-free cars with children (86%, 95% CI: 81-89), playgrounds (80%, 95% CI: 74-86) and school grounds (76%, 95% CI: 69-83). Non-smokers and ex-smokers were more in favour of smoke-free policies compared to smokers. Support generally increased over time, and following implementation of each smoke-free policy. Interpretation: Our findings suggested that public support for novel smoke-free policies is high, especially in places frequented by children. Governments should be reassured about public support for implementation of novel smoke-free policies. Funding: Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation and Netherlands Thrombosis Foundation.

The long-term effects of primary school-based obesity prevention interventions in children: A systematic review and meta-analysis.

INTRODUCTION: This systematic review and meta-analysis investigate the long-term effects of primary school-based obesity prevention interventions on body-mass index (and z-scores), waist circumference (and z-scores) and weight status. METHODS: Four databases were searched for studies from date of inception until June 8th, 2021. We included randomized controlled trials (RCT) and non-RCTs investigating effects ≥12 months post-intervention of primary school-based interventions with intervention duration ≥6 months and containing a diet and/or physical activity component on outcomes of interest. Articles were assessed on risk of bias and methodological quality by RoB2 and ROBINS-I. Meta-analysis was performed and results were narratively summarized. Evidence quality was assessed with GRADE. RESULTS: Nineteen studies were included, 9 were pooled in a meta-analysis. No long-term effects were found on body-mass index (+0.06 kg/m2 ; CI95% = -0.38, 0.50; I2  = 66%), body-mass index z-scores (-0.08; CI95% = -0.20, 0.04; I2  = 36%), and waist circumference (+0.57 cm; CI95% = -0.62, 1.75; I2  = 13%). Non-pooled studies reported mixed findings regarding long-term effects on body-mass index, body-mass index z-scores and weight status, and no effects on waist circumference and waist circumference z-scores. Evidence certainty was moderate to very low. DISCUSSION: No clear evidence regarding long-term effects of primary school-based interventions on obesity-related outcomes was found. Recommendations for further research and policy are discussed. Prospero registration ID: CRD42021240446.

Physical Activity Spaces Not Effective against Socioeconomic Inequalities in Myopia Incidence: The Generation R Study.

SIGNIFICANCE: Our findings show that non-Dutch background, lower maternal education, and lower net household income level may be new risk factors for myopia development in the Netherlands. Newly introduced physical activity spaces may not be effective enough in increasing outdoor exposure in children to reduce eye growth. PURPOSE: The aims of this study were to evaluate socioeconomic inequalities in myopia incidence, eye growth, outdoor exposure, and computer use and to investigate if newly introduced physical activity spaces can reduce eye growth in school-aged children. METHODS: Participants (N = 2643) from the Dutch population-based birth cohort Generation R were examined at ages 6 and 9 years. Socioeconomic inequalities in myopia incidence, eye growth, and lifestyle were determined using regression analyses. Information on physical activity spaces located in Rotterdam was obtained. Differences in eye growth between those who became exposed to new physical activity spaces (n = 230) and those nonexposed (n = 1866) were evaluated with individual-level fixed-effects models. RESULTS: Myopia prevalence was 2.2% at age 6 years and 12.2% at age 9 years. Outdoor exposure was 11.4 h/wk at age 6 years and 7.4 h/wk at age 9 years. Computer use was 2.1 h/wk at age 6 years and 5.2 h/wk at age 9 years. Myopia incidence was higher in children with non-Dutch background, and families with lower household income and lower maternal education (odds ratio [OR], 1.081 [95% confidence interval, 1.052 to 1.112]; OR, 1.035 [95% confidence interval, 1.008 to 1.063]; OR, 1.028 [95% confidence interval, 1.001 to 1.055], respectively). Children living <600 m of a physical activity space did not have increased outdoor exposure, except those from families with lower maternal education (ß = 1.33 h/wk; 95% confidence interval, 0.15 to 2.51 h/wk). Newly introduced physical activity spaces were not associated with reduction of eye growth. CONCLUSIONS: Children from socioeconomically disadvantaged families became more often myopic than those from socioeconomically advantaged families. We did not find evidence that physical activity spaces protect against myopia for the population at large, but subgroups may benefit.

Socioeconomic inequalities in the food environment and body composition among school-aged children: a fixed-effects analysis.

BACKGROUND: There is limited evidence regarding socioeconomic inequalities of exposure to the food environment and its contribution to childhood obesity. METHODS: We used data from 4235 children from the Generation R Study, a large birth-cohort conducted in the city of Rotterdam, The Netherlands. We included 11,277 person-observations of body mass index (BMI) and 6240 person-observations of DXA-derived fat mass index (FMI) and fat-free mass index (FFMI) when children were between 4 and 14 years. We applied linear regression models to evaluate changes in the relative and absolute exposure of fast-food outlets, and the healthiness of the food environment within 400 m from home by maternal education. Furthermore, we used individual-level fixed-effects models to study changes in the food environment to changes in BMI, FMI and FFMI. RESULTS: Children from lower educated mothers were exposed to more fast-food outlets at any time-point between the age of 4 and 14 years. Over a median period of 7.1 years, the absolute (0.6 fast-food outlet (95% CI: 0.4-0.8)) and relative (2.0%-point (95% CI: 0.7-3.4)) amount of fast-food outlets increased more for children from lower as compared to higher educated mothers. The food environment became more unhealthy over time, but no differences in trends were seen by maternal education level. Changes in the food environment were not associated with subsequent changes in BMI, FMI and FFMI. For children from lower educated mothers not exposed to fast-food at first, we found some evidence that the introduction of fast-food was associated with small increases in BMI. CONCLUSIONS: Our findings provide evidence of widening inequalities in exposure to fast-food in an already poor food environment. Access to more fast-food outlets does not seem to have an additional impact on BMI in contemporary contexts with ubiquitous fast-food outlets.

Study protocol for the evaluation of long-term effects of the school-based obesity prevention program Lekker Fit! ('enjoy being fit'): a retrospective, controlled design.

INTRODUCTION: Preventive interventions to reduce overweight and obesity in childhood and adolescence are studied on their effectiveness worldwide. A number with positive results. However, long-term effects of these interventions and their potentially wider influence on well-being and health have been less studied. This study aims to evaluate the long-term effects of a multicomponent intervention in elementary school children targeting individual behaviour as well as environment (Lekker Fit!). The primary outcomeis body mass index and the secondary outcomes are waist circumference, weight status, physical fitness, lifestyle, psychosocial health and academic performance. METHODS AND ANALYSIS: In a naturalistic effect evaluation with a retrospective, controlled design adolescents in secondary schools, from intervention and non-intervention elementary schools, will be compared on a wide set of outcome variables. Data will be collected by questionnaires and through anthropometric and fitness measurements by trained physical education teachers and research assistants. Baseline data consist of measurements from the adolescents at the age of 5 years old and are gathered from preventive youth healthcare records, from before the intervention took place. Multilevel regression models will be used and adjusted for baseline measurements and potential confounding variables on the individual and environmental level. Furthermore, propensity scores will be applied. ETHICS AND DISSEMINATION: The study has been approved by the Medical Research Ethics Committee of the Erasmus Medical Centre, Rotterdam, The Netherlands (permission ID: MEC-2020-0644). Study findings will be disseminated in peer-reviewed journals and by conference presentations. TRIAL REGISTRATION NUMBER: NL8799. Pre-results.

Effect of smoke-free policies in outdoor areas and private places on children's tobacco smoke exposure and respiratory health: a systematic review and meta-analysis.

BACKGROUND: Smoke-free policies in outdoor areas and semi-private and private places (eg, cars) might reduce the health harms caused by tobacco smoke exposure (TSE). We aimed to investigate the effect of smoke-free policies covering outdoor areas or semi-private and private places on TSE and respiratory health in children, to inform policy. METHODS: In this systematic review and meta-analysis, we searched 13 electronic databases from date of inception to Jan 29, 2021, for published studies that assessed the effects of smoke-free policies in outdoor areas or semi-private or private places on TSE, respiratory health outcomes, or both, in children. Non-randomised and randomised trials, interrupted time series, and controlled before-after studies, without restrictions to the observational period, publication date, or language, were eligible for the main analysis. Two reviewers independently extracted data, including adjusted test statistics from each study using a prespecified form, and assessed risk of bias for effect estimates from each study using the Risk of Bias in Non-Randomised Studies of Interventions tool. Primary outcomes were TSE in places covered by the policy, unplanned hospital attendance for wheezing or asthma, and unplanned hospital attendance for respiratory tract infections, in children younger than 17 years. Random-effects meta-analyses were done when at least two studies evaluated policies that regulated smoking in similar places and reported on the same outcome. This study is registered with PROSPERO, CRD42020190563. FINDINGS: We identified 5745 records and assessed 204 full-text articles for eligibility, of which 11 studies met the inclusion criteria and were included in the qualitative synthesis. Of these studies, seven fit prespecified robustness criteria as recommended by the Cochrane Effective Practice and Organization of Care group, assessing smoke-free cars (n=5), schools (n=1), and a comprehensive policy covering multiple areas (n=1). Risk of bias was low in three studies, moderate in three, and critical in one. In the meta-analysis of ten effect estimates from four studies, smoke-free car policies were associated with an immediate TSE reduction in cars (risk ratio 0·69, 95% CI 0·55-0·87; 161 466 participants); heterogeneity was substantial (I2 80·7%; p<0·0001). One additional study reported a gradual TSE decrease in cars annually. Individual studies found TSE reductions on school grounds, following a smoke-free school policy, and in hospital attendances for respiratory tract infection, following a comprehensive smoke-free policy. INTERPRETATION: Smoke-free car policies are associated with reductions in reported child TSE in cars, which could translate into respiratory health benefits. Few additional studies assessed the effect of policies regulating smoking in outdoor areas and semi-private and private places on children's TSE or health outcomes. On the basis of these findings, governments should consider including private cars in comprehensive smoke-free policies to protect child health. FUNDING: Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation, Netherlands Thrombosis Foundation, and Health Data Research UK.

A framework for exploring non-response patterns over time in health surveys.

BACKGROUND: Most health surveys have experienced a decline in response rates. A structured approach to evaluate whether a decreasing - and potentially more selective - response over time biased estimated trends in health behaviours is lacking. We developed a framework to explore the role of differential non-response over time. This framework was applied to a repeated cross-sectional survey in which the response rate gradually declined. METHODS: We used data from a survey conducted biannually between 1995 and 2017 in the city of Rotterdam, The Netherlands. Information on the sociodemographic determinants of age, sex, and ethnicity was available for respondents and non-respondents. The main outcome measures of prevalence of sport participation and watching TV were only available for respondents. The framework consisted of four steps: 1) investigating the sociodemographic determinants of responding to the survey and the difference in response over time between sociodemographic groups; 2) estimating variation in health behaviour over time; 3) comparing weighted and unweighted prevalence estimates of health behaviour over time; and 4) comparing associations between sociodemographic determinants and health behaviour over time. RESULTS: The overall response rate per survey declined from 47% in 1995 to 15% in 2017. The probability of responding was higher among older people, females, and those with a Western background. The response rate declined in all subgroups, and a faster decline was observed among younger persons and those with a non-Western ethnicity as compared to older persons and those with a Western ethnicity. Variation in health behaviours remained constant. Prevalence estimates and associations did not follow the changes in response over time. On the contrary, the difference in probability of participating in sport gradually decreased between males and females, while no differential change in the response rate was observed. CONCLUSIONS: Providing insights on non-response patterns over time is essential to understand whether declines in response rates may have influenced estimated trends in health behaviours. The framework outlined in this study can be used for this purpose. In our example, in spite of a major decline in response rate, there was no evidence that the risk of non-response bias increased over time.

Assessing public support for extending smoke-free policies beyond enclosed public places and workplaces: protocol for a systematic review and meta-analysis.

INTRODUCTION: Smoke-free enclosed public environments are effective in reducing exposure to secondhand smoke and yield major public health benefits. Building on this, many countries are now implementing smoke-free policies regulating smoking beyond enclosed public places and workplaces. In order to successfully implement such 'novel smoke-free policies', public support is essential. We aim to provide the first comprehensive systematic review and meta-analysis assessing levels and determinants of public support for novel smoke-free policies. METHODS AND ANALYSIS: The primary objective of this review is to summarise the level of public support for novel smoke-free policies. Eight online databases (Embase.com, Medline ALL Ovid, Web of Science Core Collection, WHO Library Database, Latin American and Caribbean Health Sciences Literature, Scientific Online Library Online, PsychINFO and Google Scholar) will be searched from 1 January 2004 by two independent researchers with no language restrictions. The initial search was performed on 15 April 2020 and will be updated prior to finalisation of the report. Studies are eligible if assessing support for novel smoke-free policies in the general population (age ≥16 years) and have a sample size of n≥400. Studies funded by the tobacco industry or evaluating support among groups with vested interest are excluded. The primary outcome is proportion of public support for smoke-free policies, subdivided according to the spaces covered: (1) indoor private spaces (eg, cars) (2) indoor semiprivate spaces (eg, multi-unit housing) (3) outdoor (semi)private spaces (eg, courtyards) (4) non-hospitality outdoor public spaces (eg, parks, hospital grounds, playgrounds) and (5) hospitality outdoor public spaces (eg, restaurant terraces). The secondary objective is to identify determinants associated with public support on three levels: (1) within-study determinants (eg, smoking status) (2) between-study determinants (eg, survey year) and (3) context-specific determinants (eg, social norms). Risk of bias will be assessed using the Mixed Methods Appraisal Tool and a sensitivity analysis will be performed excluding studies at high risk of bias. ETHICS AND DISSEMINATION: No formal ethical approval is required. Findings will be disseminated to academics, policymakers and the general public.

Impact of expanding smoke-free policies beyond enclosed public places and workplaces on children's tobacco smoke exposure and respiratory health: protocol for a systematic review and meta-analysis.

INTRODUCTION: Tobacco smoke exposure (TSE) has considerable adverse respiratory health impact among children. Smoke-free policies covering enclosed public places are known to reduce child TSE and benefit child health. An increasing number of jurisdictions are now expanding smoke-free policies to also cover outdoor areas and/or (semi)private spaces (indoor and/or outdoor). We aim to systematically review the evidence on the impact of these 'novel smoke-free policies' on children's TSE and respiratory health. METHODS AND ANALYSIS: 13 electronic databases will be searched by two independent reviewers for eligible studies. We will consult experts from the field and hand-search references and citations to identify additional published and unpublished studies. Study designs recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group are eligible, without restrictions on the observational period, publication date or language. Our primary outcomes are: self-reported or parental-reported TSE in places covered by the policy; unplanned hospital attendance for wheezing/asthma and unplanned hospital attendance for respiratory infections. We will assess risk of bias of individual studies following the EPOC or Risk Of Bias In Non-randomised Studies of Interventions tool, as appropriate. We will conduct separate random effects meta-analyses for smoke-free policies covering (1) indoor private places, (2) indoor semiprivate places, (3) outdoor (semi)private places and (4) outdoor public places. We will assess whether the policies were associated with changes in TSE in other locations (eg, displacement). Subgroup analyses will be conducted based on country income classification (ie, high, middle or low income) and by socioeconomic status. Sensitivity analyses will be undertaken via broadening our study design eligibility criteria (ie, including non-EPOC designs) or via excluding studies with a high risk of bias. This review will inform policymakers regarding the implementation of extended smoke-free policies to safeguard children's health. ETHICS AND DISSEMINATION: Ethical approval is not required. Findings will be disseminated to academics and the general public. PROSPERO REGISTRATION NUMBER: CRD42020190563.

A systematic review of the effect of infrastructural interventions to promote cycling: strengthening causal inference from observational data.

BACKGROUND: Previous reviews have suggested that infrastructural interventions can be effective in promoting cycling. Given inherent methodological complexities in the evaluation of such changes, it is important to understand whether study results obtained depend on the study design and methods used, and to describe the implications of the methods used for causality. The aims of this systematic review were to summarize the effects obtained in studies that used a wide range of study designs to assess the effects of infrastructural interventions on cycling and physical activity, and whether the effects varied by study design, data collection methods, or statistical approaches. METHODS: Six databases were searched for studies that evaluated infrastructural interventions to promote cycling in adult populations, such as the opening of cycling lanes, or the expansion of a city-wide cycling network. Controlled and uncontrolled studies that presented data before and after the intervention were included. No language or date restrictions were applied. Data was extracted for any outcome presented (e.g. bikes counted on the new infrastructure, making a bike trip, cycling frequency, cycling duration), and for any purpose of cycling (e.g. total cycling, recreational cycling, cycling for commuting). Data for physical activity outcomes and equity effects was extracted, and quality assessment was conducted following previous methodologies and the UK Medical Research Council guidance on natural experiments. The PROGRESS-Plus framework was used to describe the impact on subgroups of the population. Studies were categorized by outcome, i.e. changes in cycling behavior, or usage of the cycling infrastructure. The relative change was calculated to derive a common outcome across various metrics and cycling purposes. The median relative change was presented to evaluate whether effects differed by methodological aspects. RESULTS: The review included 31 studies and all were conducted within urban areas in high-income countries. Most of the evaluations found changes in favor of the intervention, showing that the number of cyclists using the facilities increased (median relative change compared to baseline: 62%; range: 4 to 438%), and to a lesser extent that cycling behavior increased (median relative change compared to baseline: 22%; range: - 21 to 262%). Studies that tested for statistical significance and studies that used subjective measurement methods (such as surveys and direct observations of cyclists) found larger changes than those that did not perform statistical tests, and those that used objective measurement methods (such as GPS and accelerometers, and automatic counting stations). Seven studies provided information on changes of physical activity behaviors, and findings were mixed. Three studies tested for equity effects following the opening of cycling infrastructure. CONCLUSIONS: Study findings of natural experiments evaluating infrastructural interventions to promote cycling depended on the methods used and the approach to analysis. Studies measuring cycling behavior were more likely to assess actual behavioral change that is most relevant for population health, as compared to studies that measured the use of cycling infrastructure. Triangulation of methods is warranted to overcome potential issues that one may encounter when evaluating environmental changes within the built environment. TRIAL REGISTRATION: The protocol of this study was registered at PROSPERO (CRD42018091079).

New physical activity spaces in deprived neighborhoods: Does it change outdoor play and sedentary behavior? A natural experiment.

BACKGROUND: We used the introduction of dedicated physical activity (PA) spaces in Rotterdam, the Netherlands, to study the impact of reducing distance to dedicated PA spaces on outdoor play and sedentary behavior, and to evaluate if these effects were similar between population subgroups. METHODS: We included 1841 Dutch children from the Generation R Study who participated at two subsequent measurement waves when the children were, on average, 6.0 and 9.7 years old. None of these children lived within 600 m of a dedicated PA space at baseline, and during follow-up 171 children became exposed to 13 new PA spaces within 600 m from home. Individual-level fixed-effects models were used to evaluate changes in distances (determined by Geographical Information Systems (GIS)) from home to the nearest new dedicated PA space, to parent-reported outdoor play and sedentary behavior. RESULTS: The introduction of a dedicated PA space within 600 m from home, and the reduction of the distance per 100 m, did not affect outdoor play or sedentary behaviors. At p < 0.1, significant interaction terms were found between the introduction of the PA spaces and indicators of family socioeconomic position. Although not statistically significant, stratified analyses showed a consistent pattern, suggesting that reducing the distance to the nearest PA space increased outdoor play for children from parents with lower levels of education. However, they also showed a non-significant increase in sedentary behaviors for children from families with net household income below average Dutch income, and for children from a non-Dutch ethnicity. CONCLUSIONS: Introducing dedicated PA spaces may be a promising approach to increase outdoor play for children from more socioeconomically disadvantaged families, but larger studies are needed to contribute to the evidence.

Dietary fatty acid intake after myocardial infarction: a theoretical substitution analysis of the Alpha Omega Cohort.

BACKGROUND: Replacement of saturated fatty acids (SFAs) with unsaturated fatty acids (UFAs), especially polyunsaturated fatty acids (PUFAs), has been associated with a lower risk of ischemic heart disease (IHD). Whether this replacement is beneficial for drug-treated patients with cardiac disease is not yet clear. OBJECTIVE: In a prospective study of Dutch patients with cardiac disease (Alpha Omega Cohort), we examined the risk of cardiovascular disease (CVD) and IHD mortality when the sum of SFAs and trans fatty acids (TFAs) was theoretically replaced by total UFAs, PUFAs, or cis monounsaturated fatty acids (MUFAs). DESIGN: We included 4146 state-of-the-art drug-treated patients aged 60-80 y with a history of myocardial infarction (79% male patients) and reliable dietary data at baseline (2002-2006). Cause-specific mortality was monitored until 1 January 2013. HRs for CVD mortality and IHD mortality for theoretical, isocaloric replacement of dietary fatty acids (FAs) in quintiles (1-5) and continuously (per 5% of energy) were obtained from Cox regression models, adjusting for demographic factors, medication use, and lifestyle and dietary factors. RESULTS: Patients consumed, on average, 17.5% of energy of total UFAs, 13.0% of energy of SFAs, and <1% of energy of TFAs. During ∼7 y of follow-up, 372 CVD deaths and 249 IHD deaths occurred. Substitution modeling yielded significantly lower risks of CVD mortality when replacing SFAs plus TFAs with total UFAs [HR in quintile 5 compared with quintile 1: 0.45 (95% CI: 0.28, 0.72)] or PUFAs [HR: 0.66 (95% CI: 0.44, 0.98)], whereas HRs in cis MUFA quintiles were nonsignificant. HRs were similar for IHD mortality. In continuous analyses, replacement of SFAs plus TFAs with total UFAs, PUFAs, or cis MUFAs (per 5% of energy) was associated with significantly lower risks of CVD mortality (HRs between 0.68 and 0.75) and IHD mortality (HRs between 0.55 and 0.70). CONCLUSION: Shifting the FA composition of the diet toward a higher proportion of UFAs may lower CVD mortality risk in drug-treated patients with cardiac disease. This study was registered at clinicaltrials.gov as NCT03192410.

Coffee consumption after myocardial infarction and risk of cardiovascular mortality: a prospective analysis in the Alpha Omega Cohort.

Background: Consumption of coffee, one of the most popular beverages around the world, has been associated with a lower risk of cardiovascular and all-cause mortality in population-based studies. However, little is known about these associations in patient populations.Objective: This prospective study aimed to examine the consumption of caffeinated and decaffeinated coffee in relation to cardiovascular disease (CVD) mortality, ischemic heart disease (IHD) mortality, and all-cause mortality in patients with a prior myocardial infarction (MI).Design: We included 4365 Dutch patients from the Alpha Omega Cohort who were aged 60-80 y (21% female) and had experienced an MI <10 y before study enrollment. At baseline (2002-2006), dietary data including coffee consumption over the past month was collected with a 203-item validated food-frequency questionnaire. Causes of death were monitored until 1 January 2013. HRs for mortality in categories of coffee consumption were obtained from multivariable Cox proportional hazard models, adjusting for lifestyle and dietary factors.Results: Most patients (96%) drank coffee, and the median total coffee intake was 375 mL/d (∼3 cups/d). During a median follow-up of 7.1 y, a total of 945 deaths occurred, including 396 CVD-related and 266 IHD-related deaths. Coffee consumption was inversely associated with CVD mortality, with HRs of 0.69 (95% CI: 0.54, 0.89) for >2-4 cups/d and 0.72 (0.55, 0.95) for >4 cups/d, compared with 0-2 cups/d. Corresponding HRs were 0.77 (95% CI: 0.57, 1.05) and 0.68 (95% CI: 0.48, 0.95) for IHD mortality and 0.84 (95% CI: 0.71, 1.00) and 0.82 (95% CI: 0.68, 0.98) for all-cause mortality, respectively. Similar associations were found for decaffeinated coffee and for coffee with additives.Conclusion: Drinking coffee, either caffeinated or decaffeinated, may lower the risk of CVD and IHD mortality in patients with a prior MI. This study was registered at clinicaltrials.gov as NCT03192410.

Testing the Capacity of a Multi-Nutrient Profiling System to Guide Food and Beverage Reformulation: Results from Five National Food Composition Databases.

Nutrient profiling ranks foods based on their nutrient composition, with applications in multiple aspects of food policy. We tested the capacity of a category-specific model developed for product reformulation to improve the average nutrient content of foods, using five national food composition datasets (UK, US, China, Brazil, France). Products (n = 7183) were split into 35 categories based on the Nestlé Nutritional Profiling Systems (NNPS) and were then classified as NNPS 'Pass' if all nutrient targets were met (energy (E), total fat (TF), saturated fat (SFA), sodium (Na), added sugars (AS), protein, calcium). In a modelling scenario, all NNPS Fail products were 'reformulated' to meet NNPS standards. Overall, a third (36%) of all products achieved the NNPS standard/pass (inter-country and inter-category range: 32%-40%; 5%-72%, respectively), with most products requiring reformulation in two or more nutrients. The most common nutrients to require reformulation were SFA (22%-44%) and TF (23%-42%). Modelled compliance with NNPS standards could reduce the average content of SFA, Na and AS (10%, 8% and 6%, respectively) at the food supply level. Despite the good potential to stimulate reformulation across the five countries, the study highlights the need for better data quality and granularity of food composition databases.

Modeled Dietary Impact of Pizza Reformulations in US Children and Adolescents.

BACKGROUND AND OBJECTIVE: Approximately 20% of US children and adolescents consume pizza on any given day; and pizza intake is associated with higher intakes of energy, sodium, and saturated fat. The reformulation of pizza products has yet to be evaluated as a viable option to improve diets of the US youth. This study modeled the effect on nutrient intakes of two potential pizza reformulation strategies based on the standards established by the Nestlé Nutritional Profiling System (NNPS). METHODS: Dietary intakes were retrieved from the first 24hr-recall of the National Health and Nutrition Examination Survey (NHANES) 2011-12, for 2655 participants aged 4-19 years. The composition of pizzas in the NHANES food database (n = 69) were compared against the NNPS standards for energy, total fat, saturated fat, sodium, added sugars, and protein. In a reformulation scenario, the nutrient content of pizzas was adjusted to the NNPS standards if these were not met. In a substitution scenario, pizzas that did not meet the standards were replaced by the closest pizza, based on nutrient content, that met all of the NNPS standards. RESULTS: Pizzas consistent with all the NNPS standards (29% of all pizzas) were significantly lower in energy, saturated fat and sodium than pizzas that were not. Among pizza consumers, modeled intakes in the reformulation and substitution scenarios were lower in energy (-14 and -45kcal, respectively), saturated fat (-1.2 and -2.7g), and sodium (-143 and -153mg) compared to baseline. CONCLUSIONS: Potential industry wide reformulation of a single food category or intra-category food substitutions may positively impact dietary intakes of US children and adolescents. Further promotion and support of these complimentary strategies may facilitate the adoption and implementation of reformulation standards.