Relative validity of a brief dietary survey to assess food intake and adherence to national dietary guidelines among Sri Lankan adults.

BACKGROUND: Suboptimal diet is the leading cause of global morbidity and mortality. Addressing this problem requires context-specific solutions informed by context-specific data collected by context-specific tools. This study aimed to assess the relative validity of a newly developed brief dietary survey to estimate food intake and adherence to the Food Based Dietary Guidelines for Sri Lankans. METHODS: Between December 2018 and February 2019, we interviewed 94 Sri Lankan adults living in Colombo (Western Province), Kalutara (Western Province), and Trincomalee (Eastern Province). We assessed the relative validity of the Sri Lankan Brief Dietary Survey (SLBDS) with Wilcoxon rank-sum tests, Spearman's Rho correlation coefficients, Bland-Altman plots, and Cohen's kappa tests using a 24-h Dietary Recall (24DR) as reference. RESULTS: Ninety-four adults (40.7 years ±12.6; 66% female) completed both surveys during the same interview. With the exception of 'Fish, pulses, meat and eggs' food group median intake, which was underestimated by the SLBDS compared to the 24DR, there was no strong evidence of difference between median intakes reported by the two methods. Correlation coefficients were highest for 'Milk and dairy products' (0.84) at the food group level and for 'dosa', 'hoppers', 'milk rice', and 'dried fish' (1.00) among individual food and beverages. Visual exploration of Bland-Altman plots showed acceptable agreement between the SLBDS and 24DR, with the SLBDS tending to overestimate consumption as the number of servings of 'Rice, bread, other cereals and yams' and 'Vegetables' consumed increased and slightly underestimate consumption as the number of servings of 'Fish, pulses, meat and eggs', 'Milk and dairy products', and 'Nuts' increased. Kappa values ranged from from 0.59 (95% CI: 0.32-0.86) for 'Vegetables' to 0.81 (95% CI: 0.66-0.96) for 'Fruit' indicating a moderate to strong level of agreement. CONCLUSIONS: Having been developed for and relatively validated with the study population in question, our study shows that the SLBDS can be used as a fit for purpose research tool. Additional research is needed to assess SLBDS test-retest reliability and to validate further the reporting of salt, oil, and coconut intake.

Food labour, consumption hierarchies, and diet decision-making in Sri Lankan households: a qualitative study.

BACKGROUND: Sri Lanka faces the double burden of over- and undernutrition. To tackle this dual challenge, double duty interventions that improve the quality of the Sri Lankan diet in line with national dietary guidelines have been suggested. The success of these interventions depends upon an understanding of the context-specific factors that impact their uptake within the population. The purpose of this study was threefold: explore household responsibility for food-related labour; understand food decision-making influences; and investigate consumption hierarchies that might impact the distribution of intervention benefits. METHODS: We conducted face-to-face semi-structured interviews with 93 Sri Lankan adults residing in urban Colombo (n = 56), and urban and rural sectors in Kalutara (n = 29) and Trincomalee (n = 8). Interview data were analysed thematically. RESULTS: Findings from this study suggest that women in Sri Lanka continue to shoulder the burden of food-related labour disproportionately to men but that this responsibility is not always a proxy for dietary decision-making power. While men are often absent from the kitchen, their role in food purchasing and payment is prominent in many households. Despite these observed gender differences in food labour and provisioning, "traditional" age- and gender-based consumption hierarchies with negative nutrition consequences for women and children are not common, indicating that Sri Lankan 'table culture' may be changing. CONCLUSION: Dietary interventions with the aim of influencing day-to-day practice should be developed with an awareness of who is responsible for, who is able to perform, and who influences targeted behaviours.

Reductions in sugar sales from soft drinks in the UK from 2015 to 2018.

BACKGROUND: The consumption of free sugars in the UK is more than double the guideline intake for adults and close to triple for children, with soft drinks representing a significant proportion. The aim of this study was to assess how individual soft drink companies and consumers have responded to calls to reduce sugar consumption, including the soft drink industry levy (SDIL), between 2015 and 2018. METHODS: This was an annual cross-sectional study using nutrient composition data of 7377 products collected online, paired with volume sales data for 195 brands offered by 57 companies. The main outcome measures were sales volume, sugar content and volume of sugars sold by company and category, expressed in total and per capita per day terms. RESULTS: Between 2015 and 2018, the volume of sugars sold per capita per day from soft drinks declined by 30%, equivalent to a reduction of 4.6 g per capita per day. The sales-weighted mean sugar content of soft drinks fell from 4.4 g/100 ml in 2015 to 2.9 g/100 ml in 2018. The total volume sales of soft drinks that are subject to the SDIL (i.e. contain more than 5 g/100 ml of sugar) fell by 50%, while volume sales of low- and zero-sugar (< 5 g/100 ml) drinks rose by 40%. CONCLUSION: Action by the soft drinks industry to reduce sugar in products and change their product portfolios, coupled with changes in consumer purchasing, has led to a significant reduction in the total volume and per capita sales of sugars sold in soft drinks in the UK. The rate of change accelerated between 2017 and 2018, which also implies that the implementation of the SDIL acted as an extra incentive for companies to reformulate above and beyond what was already being done as part of voluntary commitments to reformulation, or changes in sales driven by consumer preferences.

The nutritional quality of foods carrying health-related claims in Germany, The Netherlands, Spain, Slovenia and the United Kingdom.

Backgroung/Objectives:Compares the nutritional quality of pre-packaged foods carrying health-related claims with foods that do not carry health-related claims. SUBJECT/METHODS: Cross-sectional survey of pre-packaged foods available in Germany, The Netherlands, Spain, Slovenia and the United Kingdom in 2013. A total of 2034 foods were randomly sampled from three food store types (a supermarket, a neighbourhood store and a discounter). Nutritional information was taken from nutrient declarations present on food labels and assessed through a comparison of mean levels, regression analyses and the application of a nutrient profile model currently used to regulate health claims in Australia and New Zealand (Food Standards Australia New Zealand's Nutrient Profiling Scoring Criterion, FSANZ NPSC). RESULTS: Foods carrying health claims had, on average, lower levels, per 100 g, of the following nutrients, energy-29.3 kcal (P<0.05), protein-1.2 g (P<0.01), total sugars-3.1 g (P<0.05), saturated fat-2.4 g (P<0.001), and sodium-842 mg (P<0.001), and higher levels of fibre-0.8 g (P<0.001). A similar pattern was observed for foods carrying nutrition claims. Forty-three percent (confidence interval (CI) 41%, 45%) of foods passed the FSANZ NPSC, with foods carrying health claims more likely to pass (70%, CI 64%, 76%) than foods carrying nutrition claims (61%, CI 57%, 66%) or foods that did not carry either type of claim (36%, CI 34%, 38%). CONCLUSIONS: Foods carrying health-related claims have marginally better nutrition profiles than those that do not carry claims; these differences would be increased if the FSANZ NPSC was used to regulate health-related claims. It is unclear whether these relatively small differences have significant impacts on health.

Contribution of healthy and unhealthy primary school meals to greenhouse gas emissions in England: linking nutritional data and greenhouse gas emission data of diets.

BACKGROUND/OBJECTIVES: School meals represent the largest sector in Government food procurement in the United Kingdom. This paper aims to quantify, simultaneously, the nutritional quality and carbon footprint of meals provided by primary schools in England. SUBJECTS/METHODS: The School Food Trust conducted the 'Primary School Food Survey 2009' in a nationally representative sample of 139 primary schools in England. The survey included 6690 students who consumed school lunches and 3488 students who brought packed lunches. We estimated the total greenhouse gas emissions (GHGEs) per Kg of the food items contributing to those lunches based on the results of a systematic review of life-cycle analyses. RESULTS: In both school lunches and packed lunches, the 'meat, fish and alternatives' group contributed the largest share of GHGEs. The mean GHGE value per school lunch was estimated to be 0.72 (95% uncertainty interval 0.52-1.34) KgCO2e and per packed lunch was 0.70 (0.58-0.94) KgCO2e. The total GHGE due to primary school meals in England per year is 578.1 million KgCO2e (455-892 million). CONCLUSIONS: If all children achieved a healthy meal defined by having a low level of salt, free sugars and saturated fat, the total GHGEs from primary school meals would be 441.2 million KgCO2e (384-1192), saving 136.9 million KgCO2e compared with the current total emissions from primary school meals. This paper demonstrates that changes in the primary school food sector can have an impact on UK GHGEs.

The effects of the Danish saturated fat tax on food and nutrient intake and modelled health outcomes: an econometric and comparative risk assessment evaluation.

BACKGROUND/OBJECTIVE: The World Health Organisation recommends governments to consider the use of fiscal policies to promote healthy eating. However, there is very limited evidence of the effect of food taxation in a real-life setting, as most evidence is based on simulation studies. The objective of this study is to evaluate the effect of the Danish tax on saturated fat in terms of changes in nutritional quality of the diet, that is, changes in saturated fat consumption, as well as other non-targeted dietary measures, and to model the associated changes in mortality for different age groups and genders. SUBJECTS/METHODS: On the basis of household scanner data, we estimate the impact of the tax on consumption of saturated fat, unsaturated fat, salt, fruit, vegetables and fibre. The resultant changes in dietary quality are then used as inputs into a comparative risk assessment model (PRIME (Preventable Risk Integrated ModEl)) to estimate the effect of these changes on non-communicable diseases (NCDs) and mortality. RESULTS: The tax resulted in a 4.0% reduction in saturated fat intake. Vegetable consumption increased, and salt consumption increased for most individuals, except younger females. We find a modelled reduction in mortality with 123 lives saved annually, 76 of them below 75 years equal to 0.4% of all deaths from NCDs. CONCLUSIONS: Modelling the effect of the changes in diet on health outcomes suggests that the saturated fat tax made a positive, but minor, contribution to public health in Denmark.

Are edible insects more or less 'healthy' than commonly consumed meats? A comparison using two nutrient profiling models developed to combat over- and undernutrition.

BACKGROUND/OBJECTIVES: Insects have been the subject of recent attention as a potentially environmentally sustainable and nutritious alternative to traditional protein sources. The purpose of this paper is to test the hypothesis that insects are nutritionally preferable to meat, using two evaluative tools that are designed to combat over- and under-nutrition. SUBJECTS/METHODS: We selected 183 datalines of publicly available data on the nutrient composition of raw cuts and offal of three commonly consumed meats (beef, pork and chicken), and six commercially available insect species, for energy and 12 relevant nutrients. We applied two nutrient profiling tools to this data: The Ofcom model, which is used in the United Kingdom, and the Nutrient Value Score (NVS), which has been used in East Africa. We compared the median nutrient profile scores of different insect species and meat types using non-parametric tests and applied Bonferroni adjustments to assess for statistical significance in differences. RESULTS: Insect nutritional composition showed high diversity between species. According to the Ofcom model, no insects were significantly 'healthier' than meat products. The NVS assigned crickets, palm weevil larvae and mealworm a significantly healthier score than beef (P<0.001) and chicken (P<0.001). No insects were statistically less healthy than meat. CONCLUSIONS: Insect nutritional composition is highly diverse in comparison with commonly consumed meats. The food category 'insects' contains some foods that could potentially exacerbate diet-related public health problems related to over-nutrition, but may be effective in combating under-nutrition.

Modelling the impact of compliance with dietary recommendations on cancer and cardiovascular disease mortality in Canada.

OBJECTIVES: Despite strong evidence indicating that unbalanced diets relate to chronic diseases and mortality, most adults do not comply with dietary recommendations. To help determine which recommendations could yield the most benefits, the number of deaths attributable to cardiovascular diseases and cancer that could be delayed or averted in Canada if adults changed their diet to adhere to recommendations were estimated. STUDY DESIGN: Macrosimulation based on national population-based survey and vital statistics data. METHODS: A macrosimulation model was used to draw age- and sex-specific changes in relative risks based on the results of meta-analyses of relationship between food components and risk of cardiovascular disease and diet-related cancers. Inputs in the model included Canadian recommendations (fruit and vegetable, fibre, salt, and total-, monounsaturated-, polyunsaturated-, saturated-, and trans-fats), average dietary intake (from 35,107 participants with 24-h recall), and mortality from specific causes (from Canadian Vital Statistics). Monte Carlo analyses were used to compute 95% credible intervals (CI). RESULTS: The estimates of this study suggest that 30,540 deaths (95% CI: 24,953, 34,989) per year could be averted or delayed if Canadians adhered to their dietary recommendations. By itself, the recommendation for fruit and vegetable intake could save as many as 72% (55-87%) of these deaths. It is followed by recommendations for fibres (29%, 13-43%) and salt (10%, 9-12%). CONCLUSIONS: A considerable number of lives could be saved if Canadians adhered to the national dietary intake recommendations. Given the scarce resources available to promote guideline adhesion, priority should be given to recommendations for fruit and vegetable intake.

A systematic review of the influence of the retail food environment around schools on obesity-related outcomes.

The high prevalence of childhood obesity has led to questions about the influence of 'obesogenic' environments on children's health. Public health interventions targeting the retail food environment around schools have been proposed, but it is unclear if they are evidence based. This systematic review investigates associations between food outlets near schools and children's food purchases, consumption and body weight. We conducted a keyword search in 10 databases. Inclusion criteria required papers to be peer reviewed, to measure retailing around schools and to measure obesity-related outcomes among schoolchildren. Thirty papers were included. This review found very little evidence for an effect of the retail food environment surrounding schools on food purchases and consumption, but some evidence of an effect on body weight. Given the general lack of evidence for association with the mediating variables of food purchases and consumption, and the observational nature of the included studies, it is possible that the effect on body weight is a result of residual confounding. Most of the included studies did not consider individual children's journeys through the food environment, suggesting that predominant exposure measures may not account for what individual children actually experience. These findings suggest that future interventions targeting the food environment around schools need careful evaluation.

How important is the choice of the nutrient profile model used to regulate broadcast advertising of foods to children? A comparison using a targeted data set.

BACKGROUND/OBJECTIVE: The World Health Assembly recommends that children's exposure to marketing of unhealthy foods should be reduced. Nutrient profile models have been developed that define 'unhealthy' to support regulation of broadcast advertising of foods to children. The level of agreement between these models is not clear. The objective of this study was to measure the agreement between eight nutrient profile models that have been proposed for the regulation of marketing to children over (a) how many and (b) what kind of foods should be permitted to be advertised during television viewed by children. SUBJECTS/METHODS: A representative data set of commercials for foods broadcast during television viewed by children in the UK was collected in 2008. The data set consisted of 11,763 commercials for 336 different products or brands. This data set was supplemented with nutrition data from company web sites, food packaging and a food composition table, and the nutrient profile models were applied. RESULTS: The percentage of commercials that would be permitted by the different nutrient profile models ranged from 2.1% (0.4%, 3.7%) to 47.4% (42.1%, 52.6%). Half of the pairwise comparisons between models yielded kappa statistics less than 0.2, indicating that there was little agreement between models. CONCLUSIONS: Policy makers considering the regulation of broadcast advertising to children should carefully consider the choice of nutrient profile model to support the regulation, as this choice will have considerable influence on the outcome of the regulation.

Modelling the health impact of environmentally sustainable dietary scenarios in the UK.

BACKGROUND/OBJECTIVES: Food is responsible for around one-fifth of all greenhouse gas (GHG) emissions from products consumed in the UK, the largest contributor of which is meat and dairy. The Committee on Climate Change have modelled the impact on GHG emissions of three dietary scenarios for food consumption in the UK. This paper models the impact of the three scenarios on mortality from cardiovascular disease and cancer. SUBJECTS/METHODS: A previously published model (DIETRON) was used. The three scenarios were parameterised by fruit and vegetables, fibre, total fat, saturated fat, monounsaturated fatty acids, polyunsaturated fatty acids, cholesterol and salt using the 2008 Family Food Survey. A Monte Carlo simulation generated 95% credible intervals. RESULTS: Scenario 1 (50% reduction in meat and dairy replaced by fruit, vegetables and cereals: 19% reduction in GHG emissions) resulted in 36,910 (30,192 to 43,592) deaths delayed or averted per year. Scenario 2 (75% reduction in cow and sheep meat replaced by pigs and poultry: 9% reduction in GHG emissions) resulted in 1999 (1739 to 2389) deaths delayed or averted. Scenario 3 (50% reduction in pigs and poultry replaced with fruit, vegetables and cereals: 3% reduction in GHG emissions) resulted in 9297 (7288 to 11,301) deaths delayed or averted. CONCLUSION: Modelled results suggest that public health and climate change dietary goals are in broad alignment with the largest results in both domains occurring when consumption of all meat and dairy products are reduced. Further work in real-life settings is needed to confirm these results.

What can phylogeographic breaks in the livebearer Poeciliopsis turrubarensis tell about fish community boundaries in western Costa Rica?

This study asks if the geographic boundary delineating two fish communities in western Costa Rica is congruent with a phylogeographic break in a single widespread fish species Poeciliopsis turrubarensis (Poeciliidae) that spans this area. Such congruence would suggest that a common historical event (e.g. geological or climatic) could be responsible for both patterns. It was found that there was a shared break across a region in central Costa Rica suggesting a common cause may be responsible for both the abrupt shift in fish community composition and the genetic break in P. turrubarensis.

Ethnic inequalities in obesity among children and adults in the UK: a systematic review of the literature.

Ethnic minority groups are growing as a proportion of the British population. Although disparate, literature suggests inequalities in obesity risk within and among ethnic minority groups relative to Caucasians in the UK. We summarize and appraise the existing peer-reviewed literature about the prevalence and determinants of obesity among ethnic minority groups relative to Caucasians among children and adults in the UK. There was no consensus about obesity prevalence relative to Caucasians among South Asian or Black children or among South Asian adults relative to Caucasians. Black adults generally had higher risk for obesity than Caucasians. Both Chinese children and adults had lower risk for obesity than Caucasians. Few studies have considered differences in the aetiology of obesity by ethnicity. The lack of consensus regarding obesity risk among large ethnic minority groups relative to Caucasians in the UK, and the paucity of studies concerned with differences in obesity aetiology by ethnicity warrant further research in this area. Certain obesity metrics may bias obesity prevalence among particular ethnic groups relative to Caucasians. We summarize key methodological limitations to the current literature and suggest avenues for future research.

Applications of nutrient profiling: potential role in diet-related chronic disease prevention and the feasibility of a core nutrient-profiling system.

BACKGROUND/OBJECTIVES: A number of different nutrient-profiling models have been proposed and several applications of nutrient profiling have been identified. This paper outlines the potential role of nutrient-profiling applications in the prevention of diet-related chronic disease (DRCD), and considers the feasibility of a core nutrient-profiling system, which could be modified for purpose, to underpin the multiple potential applications in a particular country. METHODS: The 'Four 'P's of Marketing' (Product, Promotion, Place and Price) are used as a framework for identifying and for classifying potential applications of nutrient profiling. A logic pathway is then presented that can be used to gauge the potential impact of nutrient-profiling interventions on changes in behaviour, changes in diet and, ultimately, changes in DRCD outcomes. The feasibility of a core nutrient-profiling system is assessed by examining the implications of different model design decisions and their suitability to different purposes. RESULTS AND CONCLUSIONS: There is substantial scope to use nutrient profiling as part of the policies for the prevention of DRCD. A core nutrient-profiling system underpinning the various applications is likely to reduce discrepancies and minimise the confusion for regulators, manufacturers and consumers. It seems feasible that common elements, such as a standard scoring method, a core set of nutrients and food components, and defined food categories, could be incorporated as part of a core system, with additional application-specific criteria applying. However, in developing and in implementing such a system, several country-specific contextual and technical factors would need to be balanced.

An index of unhealthy lifestyle is associated with coronary heart disease mortality rates for small areas in England after adjustment for deprivation.

Indices of socio-economic deprivation are often used as a proxy for differences in the health behaviours of populations within small areas, but these indices are a measure of the economic environment rather than the health environment. Sets of synthetic estimates of the ward-level prevalence of low fruit and vegetable consumption, obesity, raised blood pressure, raised cholesterol and smoking were combined to develop an index of unhealthy lifestyle. Multi-level regression models showed that this index described about 50% of the large-scale geographic variation in CHD mortality rates in England, and substantially adds to the ability of an index of deprivation to explain geographic variations in CHD mortality rates.

Should nutrient profile models be 'category specific' or 'across-the-board'? A comparison of the two systems using diets of British adults.

BACKGROUND/OBJECTIVES: Nutrient profile models have the potential to help promote healthier diets. Some models treat all foods equally (across-the-board), some consider different categories of foods separately (category specific). This paper assesses whether across-the-board or category-specific nutrient profile models are more appropriate tools for improving diets. SUBJECTS/METHODS: Adult respondents to a British dietary survey were split into four groups using a diet quality index. Fifteen food categories were identified. A nutrient profile model provided a measure of the healthiness of all foods consumed. The four diet quality groups were compared for differences in (a) the calories consumed from each food category and (b) the healthiness of foods consumed in each category. Evidence of healthier diet quality groups consuming more of healthy food categories than unhealthy diet quality groups supported the adoption of across-the-board nutrient profile models. Evidence of healthier diet quality groups consuming healthier versions of foods within food categories supported adoption of category-specific nutrient profile models. RESULTS: A significantly greater percentage of the healthiest diet quality group's diet consisted of fruit and vegetables (21 vs 16%), fish (3 vs 2%) and breakfast cereals (7 vs 2%), and significantly less meat and meat products (7 vs 14%) than the least healthy diet quality group. The foods from the meat, dairy and cereals categories consumed by the healthy diet quality groups were healthier versions than those consumed by the unhealthy diet quality groups. CONCLUSIONS: All other things being equal, nutrient profile models designed to promote an achievable healthy diet should be category specific but with a limited number of categories. However models which use a large number of categories are unhelpful for promoting a healthy diet.

The burden of smoking-related ill health in the UK.

BACKGROUND: Smoking is one of the biggest avoidable causes of morbidity and mortality in the United Kingdom. This paper quantifies the current health and economic burden of smoking in the UK. It provides comparisons with previous studies of the burden of smoking in the UK and with the costs for other chronic disease risk factors. METHODS: A systematic literature review to identify previous estimates of National Health Service costs attributable to smoking was undertaken. Information from the World Health Organization's Global Burden of Disease Project and routinely collected mortality data were used to calculate mortality due to smoking in the UK. Population-attributable fractions for smoking-related diseases from the Global Burden of Disease Project were applied to NHS cost data to estimate direct financial costs. RESULTS: Previous studies estimated that smoking costs the NHS about 1.4 billion to 1.7 billion pound in 1991 and has been responsible for about 100,000 deaths per annum over the past 10 years. This paper estimates that the number of deaths attributable to smoking in 2005 was 109,164 (19% of all deaths, 27% deaths in men and 11% of deaths in women). Smoking was directly responsible for 12% of disability adjusted life years lost in 2002 (15.4% in men; 8.5% in women) and the direct cost to the NHS was 5.2 billion pound in 2005-6. CONCLUSION: Smoking is still a considerable public health burden in the UK. Accurately establishing the burden in terms of death, disability and financial costs is important for informing national public health policy.