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Breastmilk confers empirical benefits for preterm infants, however direct breastfeeding rates in this population remain low. For preterm infants, it may be useful to assess the volume of breastmilk transferred from mother to baby when breastfeeding, particularly during transition to oral feeding when breastfeeding attrition is high. Establishing breastfeeding in preterm infants is complex and without knowledge of milk intake during breastfeeds there is risk of inaccurate feed supplementation with subsequent effects on growth and nutrition. Here we review the evidence for clinical assessments of breastfeeding in preterm infants including test weighing, use of isotope labelled water and clinical observation tools designed to estimate adequacy of breastfeeds. Test weighing is a validated measurement, however requires rigorous protocols and further investigation in small infants. Use of isotope labelled water is a validated technique but, due to sampling requirements, reflects intake over days and weeks instead of individual feeds. Clinical observation tools assessed in preterm infants, have not been shown to reflect volumes of breastmilk intake. While current methods have limitations, the goal is to identify measurement tools to be used as temporary aids to facilitate transition to direct breastfeeding while minimising risk of inaccurate supplementation.
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BACKGROUND: The UK soft drinks industry levy (SDIL) was announced in March 2016 and implemented in April 2018, encouraging manufacturers to reduce the sugar content of soft drinks. This is the first study to investigate changes in individual-level consumption of free sugars in relation to the SDIL. METHODS: We used controlled interrupted time series (2011-2019) to explore changes in the consumption of free sugars in the whole diet and from soft drinks alone 11 months after SDIL implementation in a nationally representative sample of adults (>18 years; n=7999) and children (1.5-19 years; n=7656) drawn from the UK National Diet and Nutrition Survey. Estimates were based on differences between observed data and a counterfactual scenario of no SDIL announcement/implementation. Models included protein consumption (control) and accounted for autocorrelation. RESULTS: Accounting for trends prior to the SDIL announcement, there were absolute reductions in the daily consumption of free sugars from the whole diet in children and adults of 4.8 g (95% CI 0.6 to 9.1) and 10.9 g (95% CI 7.8 to 13.9), respectively. Comparable reductions in free sugar consumption from drinks alone were 3.0 g (95% CI 0.1 to 5.8) and 5.2 g (95% CI 4.2 to 6.1). The percentage of total dietary energy from free sugars declined over the study period but was not significantly different from the counterfactual. CONCLUSION: The SDIL led to significant reductions in dietary free sugar consumption in children and adults. Energy from free sugar as a percentage of total energy did not change relative to the counterfactual, which could be due to simultaneous reductions in total energy intake associated with reductions in dietary free sugar.
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Bebidas Gaseificadas , Análise de Séries Temporais Interrompida , Inquéritos Nutricionais , Humanos , Reino Unido , Bebidas Gaseificadas/estatística & dados numéricos , Criança , Feminino , Masculino , Adolescente , Adulto , Pré-Escolar , Açúcares da Dieta , Adulto Jovem , Lactente , Indústria Alimentícia , Pessoa de Meia-Idade , DietaRESUMO
BACKGROUND: In April 2018, the UK government implemented a levy on soft drinks importers and manufacturers, tiered according to the amount of sugar in drinks. The stated aim was to encourage manufacturers to reduce sugar and portion sizes. Previous evidence suggests that the policy has been successful in reducing sugar in drinks in the short-term since implementation, but their sustained effects have not been explored. This study aimed to assess the impact of the soft drink industry levy (SDIL) on sugar levels, price, portion size and use of non-sugar sweeteners in the medium-term. METHODS AND FINDINGS: Product data from 30 November 2017 to 14 March 2020 from one major UK retail supermarket were analysed (112,452 observations, 126 weekly time points). We used interrupted time series analysis, to assess the impact of the soft-drink industry levy (SDIL) on levy-eligible soft drinks, with exempt drinks (i.e. 100% fruit juices, milks, flavoured milks) acting as a comparator series. At the point of implementation of the SDIL (April 2018) there was a step change in the proportion of eligible drinks with sugar content below the SDIL levy threshold (5g per 100ml) (+0.08, 95%CI: +0.04, +0.12), with a similar sized decrease in the proportion in the highest levy category (> = 8g sugar per 100ml) (-0.06, 95%CI: -0.10, -0.03). Between April 2018 and March 2020, the proportion of eligible drinks below the SDIL levy threshold continued to gradually increase (p = 0.003), while those in the highest levy category decreased (p = 0.007). There was a step change in price of eligible drinks in the higher levy category at the point of implementation of +£0.049 (95%CI: +£0.034, +£0.065) per 100mL (for comparison, the levy is set at £0.024 per 100mL for this group). Trends in price for the high levy category were not altered by the SDIL. In the no levy category, there was a step change in price at the implementation (+£0.012 per 100mL, 95%CI: +£0.008, +£0.023), followed by a second step change in October 2018 (-£0.018p per 100mL, 95%CI: -£0.033, -£0.001p). The volume of products in the higher levy group decreased at the time of the implementation (-305mL on average including multipacks, 95%CI: -511, -99). The change in trend for the product volume of drinks in the higher levy group between April 2018 and March 2020 was in the increasing direction (+704mL per year, 95%CI: -95, 1504), but it did not meet our threshold for statistical significance (p = 0.084). There were no changes observed in the volume of lower levy drinks or no levy drinks. There was a step change in the proportion of drinks with non-sugar sweeteners at the implementation of the SDIL (+0.04, 95%CI: +0.02, +0.06). CONCLUSION: These results suggest that the SDIL was successful in [1] producing reductions in sugar levels that were maintained over the medium term up to March 2020 and [2] a reduction in product volume for higher tier drinks that may be diminishing over time. Our results also show that the SDIL was associated with a maintained price differential between high and low sugar drinks.
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Bebidas Gaseificadas , Análise de Séries Temporais Interrompida , Bebidas Gaseificadas/economia , Reino Unido , Humanos , Comércio , Indústria Alimentícia/tendênciasRESUMO
Sugar sweetened beverage consumption has been suggested as a risk factor for childhood asthma symptoms. We examined whether the UK Soft Drinks Industry Levy (SDIL), announced in March 2016 and implemented in April 2018, was associated with changes in National Health Service hospital admission rates for asthma in children, 22 months post-implementation of SDIL. We conducted interrupted time series analyses (2012-2020) to measure changes in monthly incidence rates of hospital admissions. Sub-analysis was by age-group (5-9,10-14,15-18 years) and neighbourhood deprivation quintiles. Changes were relative to counterfactual scenarios where the SDIL wasn't announced, or implemented. Overall, incidence rates reduced by 20.9% (95%CI: 29.6-12.2). Reductions were similar across age-groups and deprivation quintiles. These findings give support to the idea that implementation of a UK tax intended to reduce childhood obesity may have contributed to a significant unexpected and additional public health benefit in the form of reduced hospital admissions for childhood asthma.
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Asma , Bebidas Gaseificadas , Hospitalização , Humanos , Asma/epidemiologia , Asma/etiologia , Criança , Adolescente , Pré-Escolar , Inglaterra/epidemiologia , Hospitalização/estatística & dados numéricos , Bebidas Gaseificadas/economia , Bebidas Gaseificadas/efeitos adversos , Bebidas Gaseificadas/estatística & dados numéricos , Masculino , Feminino , Análise de Séries Temporais Interrompida , Impostos/economia , Incidência , Obesidade Infantil/epidemiologia , Fatores de Risco , Bebidas Adoçadas com Açúcar/efeitos adversos , Bebidas Adoçadas com Açúcar/estatística & dados numéricos , Bebidas Adoçadas com Açúcar/economiaRESUMO
By the end of 2017, 35 local authorities (LAs) across England had adopted takeaway management zones (or "exclusion zones") around schools as a means to curb proliferation of new takeaways. In this nationwide, natural experimental study, we evaluated the impact of management zones on takeaway retail, including unintended displacement of takeaways to areas immediately beyond management zones, and impacts on chain fast-food outlets. We used uncontrolled interrupted time series analyses to estimate changes from up to six years pre- and post-adoption of takeaway management zones around schools. We evaluated three outcomes: mean number of new takeaways within management zones (and by three identified sub-types: full management, town centre exempt and time management zones); mean number on the periphery of management zones (i.e. within an additional 100 m of the edge of zones); and presence of new chain fast-food outlets within management zones. For 26 LAs, we observed an overall decrease in the number of new takeaways opening within management zones. Six years post-intervention, we observed 0.83 (95% CI -0.30, -1.03) fewer new outlets opening per LA than would have been expected in absence of the intervention, equivalent to an 81.0% (95% CI -29.1, -100) reduction in the number of new outlets. Cumulatively, 12 (54%) fewer new takeaways opened than would have been expected over the six-year post-intervention period. When stratified by policy type, effects were most prominent for full management zones and town centre exempt zones. Estimates of intervention effects on numbers of new takeaways on the periphery of management zones, and on the presence of new chain fast-food outlets within management zones, did not meet statistical significance. Our findings suggest that management zone policies were able to demonstrably curb the proliferation of new takeaways. Modelling studies are required to measure the possible population health impacts associated with this change.
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BACKGROUND AND OBJECTIVES: On 6 April 2022, the UK government implemented mandatory kilocalorie (kcal) labelling regulations for food and drink products sold in the out-of-home food sector (OHFS) in England. Previous assessments of kcal labelling practices in the UK OHFS found a low prevalence of voluntary implementation and poor compliance with labelling recommendations. This study aimed to examine changes in labelling practices preimplementation versus post implementation of mandatory labelling regulations in 2022. METHODS: In August-December 2021 (preimplementation) and August-November 2022 (post implementation), large OHFS businesses (250 or more employees) subject to labelling regulations were visited. At two time points, a researcher visited the same 117 food outlets (belonging to 90 unique businesses) across four local authorities in England. Outlets were rated for compliance with government regulations for whether kcal labelling was provided at any or all point of choice, provided for all eligible food and drink items, provided per portion for sharing items, if labelling was clear and legible and if kcal reference information was displayed. RESULTS: There was a significant increase (21% preimplementation vs 80% post implementation, OR=40.98 (95% CI 8.08 to 207.74), p<0.001) in the proportion of outlets providing any kcal labelling at point-of-choice post implementation. Only 15% of outlets met all labelling compliance criteria post implementation, with a minority of outlets not presenting labelling in a clear (33%) or legible (29%) way. CONCLUSION: The number of large businesses in the OHFS providing kcal labelling increased following the implementation of mandatory labelling regulations. However, around one-fifth of eligible outlets sampled were not providing kcal labelling 4-8 months after the regulations came into force, and the majority of businesses only partially complied with government guidance. More effective enforcement may be required to further improve kcal labelling practices in the OHFS in England. PREREGISTRATION: Study protocol and analysis strategy preregistered on Open Science Framework (https://osf.io/pfnm6/).
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Alimentos , Restaurantes , Humanos , Comércio , Ingestão de Energia , InglaterraRESUMO
Physical exposure to takeaway food outlets ("takeaways") is associated with poor diet and excess weight, which are leading causes of excess morbidity and mortality. At the end of 2017, 35 local authorities (LAs) in England had adopted takeaway management zones (or "exclusion zones"), which is an urban planning intervention designed to reduce physical exposure to takeaways around schools. In this nationwide, natural experimental study, we used interrupted time series analyses to estimate the impact of this intervention on changes in the total number of takeaway planning applications received by LAs and the percentage rejected, at both first decision and after any appeal, within management zones, per quarter of calendar year. Changes in these proximal process measures would precede downstream retail and health impacts. We observed an overall decrease in the number of applications received by intervention LAs at 12 months post-intervention (6.3 fewer, 95% CI -0.1, -12.5), and an increase in the percentage of applications that were rejected at first (additional 18.8%, 95% CI 3.7, 33.9) and final (additional 19.6%, 95% CI 4.7, 34.6) decision, the latter taking into account any appeal outcomes. This effect size for the number of planning applications was maintained at 24 months, although it was not statistically significant. We also identified three distinct sub-types of management zone regulations (full, town centre exempt, and time management zones). The changes observed in rejections were most prominent for full management zones (where the regulations are applied irrespective of overlap with town centres), where the percentage of applications rejected was increased by an additional 46.1% at 24 months. Our findings suggest that takeaway management zone policies may have the potential to curb the proliferation of new takeaways near schools and subsequently impact on population health.
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Fast Foods , Análise de Séries Temporais Interrompida , Instituições Acadêmicas , Humanos , Inglaterra , Fast Foods/provisão & distribuição , Restaurantes/estatística & dados numéricos , Planejamento de Cidades , ComércioRESUMO
The UK Medical Research Council's widely used guidance for developing and evaluating complex interventions has been replaced by a new framework, commissioned jointly by the Medical Research Council and the National Institute for Health Research, which takes account of recent developments in theory and methods and the need to maximise the efficiency, use, and impact of research.
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Guias como Assunto , Reino Unido , Humanos , Pesquisa BiomédicaRESUMO
The objective of this study was to report outcomes of early cleft palate repair in infants born with Robin sequence (RS). A retrospective case series in a tertiary referral paediatric hospital was carried out, examining a consecutive series of 69 infants born with RS and cleft palate. A minimally invasive approach was taken to upper airway obstruction, with liberal nasopharyngeal airway (NPA) and non-invasive ventilation (NIV) use, guided by sleep studies. The palate was repaired between 6 and 9 months with a modified Malek technique. The most frequently used airway adjunct (59.4% of patients) was an NPA and the median duration of use was 5.6 months. All patients underwent a modified Malek cleft palate repair at a median of 7 months of age. Overnight oximetry demonstrated higher mean oxygen saturation (SpO2) across the group from initial neonatal admission to discharge (median 96.5% (interquartile range [IQR] 95-98%) vs 97.45% (IQR 96.5-98%) (P = 0.2, N = 34). Of those with a cardiorespiratory polysomnogram, the obstructive apnoea-hypopnea index (OAHI) was significantly lower postoperatively (5.9 vs 2.8, P = 0.028). This study supports the use of non-surgical airway strategies and early cleft palate repair in infants born with RS and cleft palate.
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Obstrução das Vias Respiratórias , Fissura Palatina , Síndrome de Pierre Robin , Lactente , Recém-Nascido , Humanos , Criança , Fissura Palatina/cirurgia , Síndrome de Pierre Robin/cirurgia , Estudos Retrospectivos , Manuseio das Vias Aéreas , Nasofaringe , Obstrução das Vias Respiratórias/cirurgiaRESUMO
BACKGROUND: The soft drinks industry levy (SDIL) in the United Kingdom has led to a significant reduction in household purchasing of sugar in drinks. In this study, we examined the potential medium- and long-term implications for health and health inequalities among children and adolescents in England. METHODS AND FINDINGS: We conducted a controlled interrupted time series analysis to measure the effects of the SDIL on the amount of sugar per household per week from soft drinks purchased, 19 months post implementation and by index of multiple deprivation (IMD) quintile in England. We modelled the effect of observed sugar reduction on body mass index (BMI), dental caries, and quality-adjusted life years (QALYs) in children and adolescents (0 to 17 years) by IMD quintile over the first 10 years following announcement (March 2016) and implementation (April 2018) of the SDIL. Using a lifetable model, we simulated the potential long-term impact of these changes on life expectancy for the current birth cohort and, using regression models with results from the IMD-specific lifetable models, we calculated the impact of the SDIL on the slope index of inequality (SII) in life expectancy. The SDIL was found to have reduced sugar from purchased drinks in England by 15 g/household/week (95% confidence interval: -10.3 to -19.7). The model predicts these reductions in sugar will lead to 3,600 (95% uncertainty interval: 946 to 6,330) fewer dental caries and 64,100 (54,400 to 73,400) fewer children and adolescents classified as overweight or obese, in the first 10 years after implementation. The changes in sugar purchasing and predicted impacts on health are largest for children and adolescents in the most deprived areas (Q1: 11,000 QALYs [8,370 to 14,100] and Q2: 7,760 QALYs [5,730 to 9,970]), while children and adolescents in less deprived areas will likely experience much smaller simulated effects (Q3: -1,830 QALYs [-3,260 to -501], Q4: 652 QALYs [-336 to 1,680], Q5: 1,860 QALYs [929 to 2,890]). If the simulated effects of the SDIL are sustained over the life course, it is predicted there will be a small but significant reduction in slope index of inequality: 0.76% (95% uncertainty interval: -0.9 to -0.62) for females and 0.94% (-1.1 to -0.76) for males. CONCLUSIONS: We predict that the SDIL will lead to medium-term reductions in dental caries and overweight/obesity, and long-term improvements in life expectancy, with the greatest benefits projected for children and adolescents from more deprived areas. This study provides evidence that the SDIL could narrow health inequalities for children and adolescents in England.
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Cárie Dentária , Sobrepeso , Feminino , Criança , Masculino , Humanos , Adolescente , Análise de Séries Temporais Interrompida , Cárie Dentária/epidemiologia , Cárie Dentária/prevenção & controle , Inglaterra/epidemiologia , Bebidas Gaseificadas , Reino Unido/epidemiologia , Obesidade , Açúcares , Desigualdades de SaúdeRESUMO
The classical phenomenon of crossover interference is a one-dimensional spatial patterning process that produces evenly spaced crossovers during meiosis. Quantitative analysis of diagnostic molecules along budding yeast chromosomes reveals that this process also sets up a second, interdigitated pattern of related but longer periodicity, in a "two-tiered" patterning process. The second tier corresponds to a previously mysterious minority set of crossovers. Thus, in toto, the two tiers account for all detected crossover events. Both tiers of patterning set up spatially clustered assemblies of three types of molecules ("triads") representing the three major components of meiotic chromosomes (crossover recombination complexes and chromosome axis and synaptonemal complex components), and give focal and domainal signals, respectively. Roles are suggested. All observed effects are economically and synthetically explained if crossover patterning is mediated by mechanical forces along prophase chromosomes. Intensity levels of domainal triad components are further modulated, dynamically, by the conserved protein remodeler Pch2/TRIP13.
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OBJECTIVE: The UK Soft Drinks Industry Levy (SDIL) (announced in March 2016; implemented in April 2018) aims to incentivise reformulation of soft drinks to reduce added sugar levels. The SDIL has been applauded as a policy success, and it has survived calls from parliamentarians for it to be repealed. We aimed to explore parliamentary reaction to the SDIL following its announcement until two years post-implementation in order to understand how health policy can become established and resilient to opposition. DESIGN: Searches of Hansard for parliamentary debate transcripts that discussed the SDIL retrieved 186 transcripts, with 160 included after screening. Five stages of Applied Thematic Analysis were conducted: familiarisation and creation of initial codebooks; independent second coding; codebook finalisation through team consensus; final coding of the dataset to the complete codebook; and theme finalisation through team consensus. SETTING: The United Kingdom Parliament. PARTICIPANTS: N/A. RESULTS: Between the announcement (16/03/2016) - royal assent (26/04/2017), two themes were identified 1: SDIL welcomed cross-party 2: SDIL a good start but not enough. Between royal assent - implementation (5/04/2018), one theme was identified 3: The SDIL worked - what next? The final theme identified from implementation until 16/03/2020 was 4: Moving on from the SDIL. CONCLUSIONS: After the announcement, the SDIL had cross-party support and was recognised to have encouraged reformulation prior to implementation. Lessons for governments indicate that the combination of cross-party support and a policy's documented success in achieving its aim can help cement the resilience of it to opposition and threats of repeal.
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Bebidas Gaseificadas , Impostos , Humanos , Reino Unido , Política de Saúde , AçúcaresRESUMO
BACKGROUND: Online grocery delivery services (OGDSs) are a popular way of acquiring food. However, it is unclear whether OGDS use is associated with the healthiness of purchases and whether there are sociodemographic differences in OGDS use. If so, the increased prevalence of OGDS use may have implications for population diet, and differential OGDS use could contribute to diet inequalities. OBJECTIVE: This study aimed to examine whether OGDS use varies by sociodemographic characteristics and is associated with the amount and types of groceries purchased. METHODS: Item-level take-home food and drink purchase data (n=3,233,920 items) from households in London and the North of England were available from the 2019 UK Kantar fast-moving consumer goods panel (N=1911). Purchases were categorized as being bought online or in-store. We used logistic regression to estimate the likelihood of an above-median frequency of OGDS use by sociodemographic characteristics. We used Poisson regression to estimate the differences in energy and nutrients purchased by households that had above- and below-median OGDS use and the proportion of energy purchased from products high in fat, salt, and sugar (HFSS) online versus in-store among households that used both shopping methods (n=665). RESULTS: In total, 668 (35%) households used OGDSs at least once in 2019. Of the households that used OGDSs, the median use was 5 occasions in 2019. Households were more likely to have above-median use in London versus in the North of England (odds ratio 1.29, 95% CI 1.01-1.65) and if they had a higher annual household income (odds ratio 1.56, 95% CI 1.02-2.38 for ≥£50,000 [US $64,000] vs <£20,000 [$25,600]). Households with above-median OGDS use had a higher weekly mean purchase of energy by 1461 (95% CI 1448-1474) kcal per person compared with households with below-median OGDS use. For households that used a combination of in-store and online shopping, HFSS products made up a lower proportion (-10.1%, 95% CI -12% to -8.1%) of energy purchased online compared to in-store. CONCLUSIONS: Differences in grocery purchases between households with above- and below-median OGDS use could have positive or negative consequences. The extra energy purchased among households with above-median OGDS use could lead to overconsumption or food waste, which has negative consequences for population and environmental health. Alternatively, this extra energy may be replacing out-of-home purchasing, which tends to be less healthy, and may be beneficial for the population diet. Households made fewer HFSS purchases when shopping online compared to in-store, which may be due to differences in the shopping environment or experience, such as fewer promotions and advertisements when shopping online or not having to transport and carry purchases home. As higher-income households used OGDS more frequently, the implications of this sociodemographic pattern on dietary inequalities must be explored.
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Alimentos , Eliminação de Resíduos , Humanos , Estudos Transversais , Dieta , InglaterraRESUMO
Introduction: Tooth extraction due to dental caries is associated with socioeconomic deprivation and is a major reason for elective childhood hospital admissions in England. Consumption of sugar-sweetened beverages is a risk factor for dental caries. We examined whether the soft drinks industry levy (SDIL), announced in March 2016 and implemented in April 2018, was associated with changes in incidence rates of hospital admissions for carious tooth extraction in children, 22 months post-SDIL implementation. Methods: Changes in incidence rates of monthly National Health Service hospital admissions for extraction of teeth due to a primary diagnosis of dental caries (International Classification of Diseases; ICD-10 code: K02) in England, between January 2012 and February 2020, were estimated using interrupted time series and compared with a counterfactual scenario where SDIL was not announced or implemented. Periodical changes in admissions, autocorrelation and population structure were accounted for. Estimates were calculated overall, by Index of Multiple Deprivation (IMD) fifths and by age group (0-4 years, 5-9 years, 10-14 years, 15-18 years). Results: Compared with the counterfactual scenario, there was a relative reduction of 12.1% (95% CI 17.0% to 7.2%) in hospital admissions for carious tooth extractions in all children (0-18 years). Children aged 0-4 years and 5-9 years had relative reductions of 28.6% (95% CI 35.6% to 21.5%) and 5.5% (95% CI 10.5% to 0.5%), respectively; no change was observed for older children. Reductions were observed in children living in most IMD areas regardless of deprivation. Conclusion: The UK SDIL was associated with reductions in incidence rates of childhood hospital admissions for carious tooth extractions, across most areas regardless of deprivation status and especially in younger children. Trial registration number: ISRCTN18042742.