Are U.S. food and beverage companies now advertising healthy products to children on television? An evaluation of improvements in industry self-regulation, 2017-2021.

BACKGROUND: Through the Children's Food and Beverage Advertising Initiative (CFBAI), U.S. food companies pledge to only advertise healthier products in children's television (TV) programming, but previous research shows that highly advertised products do not qualify as nutritious according to independent nutrition criteria. In 2020, the CFBAI implemented stricter nutrition criteria for products that may be advertised to children, but the potential impact of these changes has not been assessed. This observational study evaluates (1) improvements in energy and individual nutrient composition of products that companies indicated may be advertised to children (i.e., CFBAI-listed products) in 2020 versus 2017, (2) amount of advertising on children's TV for CFBAI-listed versus other products in 2021, and 3) the nutrition quality of advertised versus non-advertised CFBAI-listed products. METHODS: Data include energy, saturated fat, sodium, and sugar content and overall nutrition quality (Nutrition Profile Index [NPI] scores) of CFBAI-listed products in 2017 (n = 308) and 2020 (n = 245). Nielsen data provided total ad spending and children's exposure to ads on children's TV channels for all foods and beverages in 2021. RESULTS: From 2017 to 2021, energy, saturated fat and sugar declined for CFBAI-listed products in three of six food categories (yogurt, sweet and salty snacks). Although CFBAI-listed products accounted for 79% of food ads viewed by children on children's TV channels, just 50% of CFBAI-listed food and 36% of drink brands were advertised on children's TV. Moreover, advertised products were significantly less nutritious than non-advertised CFBAI-listed products. CONCLUSION: Despite revised nutrition standards and improvements in nutrient content of some product categories, participating companies continued to primarily advertise nutritionally poor food and beverages on children's TV. CFBAI companies have not delivered on their promises to advertise healthier products to children.

Etiquetado frontal de advertencia nutricional de alimentos y bebidas pre-envasados. Postura intersectorial de expertos en Centro América y República Dominicana / Front-of-package warning labelling system for pre-packaged foods and beverages: an intersectoral position of expertsin Central American and Dominican Republic

La región latinoamericana ha sido pionera en la implementación del etiquetado frontal de advertencia nutricional (EFAN), mismo que ha demostrado su eficacia y efectividad para identificar correctamente cuando un producto contiene cantidades excesivas de nutrientes asociados a Enfermedades no transmisibles (ENT). Sin embargo, ningún país del Sistema de la Integración Centroamericana (SICA); que incluye a Belice, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panamá y República Dominicana, lo ha adoptado. Por esta razón, el Instituto de Nutrición de Centro América y Panamá, convocó a un grupo de expertos de la academia y la sociedad civil con el objetivo de establecer una postura técnica, basada en la mejor evidencia científica, en relación al etiquetado frontal para los nutrientes críticos de alimentos y bebidas pre- envasados en la región centroamericana. Se presenta evidencia específica de la región del SICA que demuestran la superioridad del EFAN frente a otros etiquetados como las Guías Diarias de Alimentación (GDA), el semáforo y el Nutriscore para seleccionar opciones más saludables. Dentro del marco de los derechos de la niñez y de los consumidores, se brindan argumentos y se hace un llamado a los gobiernos para la pronta adopción del EFAN como una política costo-efectiva para la prevención de ENT. Además, se proveen recomendaciones para su monitoreo y evaluación, así como recomendaciones de otras políticas costo-efectivas como la regulación de la publicidad de alimentos no saludables dirigido a la niñez y adolescencia, entre otros, para la prevención de las ENT y la creación de ambientes y sistemas alimentarios más saludables y sostenibles(AU)

The Latin American region has been a pioneer in the implementation of a front- of-pack warning labeling system (FOPWL), which has demonstrated its efficacy and effectiveness in correctly identifying when a product contains excessive amounts of nutrients associated with Non-Communicable Diseases (NCDs). However, countries of the Central American Integration System (SICA); which includes Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and the Dominican Republic, have no adopted it. For this reason, the Institute of Nutrition of Central America and Panama convened a group of experts from academia and civil society with the aim of establishing an evidence-based technical position, in relation to front-of-pack labelling for critical nutrients of pre-packaged foods and beverages in the Central American region. Specific evidence from the SICA region demonstrating the superiority of FOPWL over other labels such as the Guideline Daily Amount (GDA), the traffic light and Nutriscore to select healthier choices is presented. Within the framework of children's and consumer rights, arguments are provided, and a call is made to governments for the prompt adoption of FOPWL as a cost-effective policy for the prevention of NCDs. In addition, recommendations for its monitoring and evaluation are provided, as well as recommendations for other cost-effective policies such as the regulation of unhealthy food advertising aimed at children and adolescents, among others, for the prevention of NCDs and the creation ofhealthier and more sustainable environments and food systems(AU)

Unhealthy food advertising on Costa Rican and Guatemalan television: a comparative study.

This study aimed to exhaustively explore the characteristics of food advertising on TV in Guatemala and Costa Rica. The International Network for Food and Obesity Non-Communicable Diseases (NCDs) Research, Monitoring and Action Support (INFORMAS) methodology was applied. In 2016, we recorded 1440 h of video among 10 TV channels. We used the Pan American Health Organization (PAHO) Nutrient Profile (NP) Model to identify 'critical nutrients', whose excessive consumption is associated with NCDs. We created a nutritional quality score (0 if the product did not exceed any critical nutrient, 1 if the product exceeded one and 2 if it exceeded ≥2). We classified food ads as permitted (score = 0) and not-permitted (score 1 or 2) for marketing. Persuasive marketing techniques were classified as promotional characters (e.g. Batman), premium offers (e.g. toys), brand benefit claims (e.g. tasty) and health-related claims (e.g. nutritious). In Guatemala, foods that exceeded one critical nutrient were more likely to use persuasive marketing techniques, and in Costa Rica were those with an excess of ≥2 critical nutrients, compared with foods without any excess in critical nutrients [Guatemala: promotional characters (odds ratio, OR = 16.6, 95% confidence interval, CI: 5.8, 47.3), premium offers (OR = 3.4, 95% CI: 1.4, 8.2) and health-related claims (OR = 3.5, 95% CI: 2.2, 5.7); Costa Rica: health-related claims (OR = 4.2, 95% CI: 2.0, 8.5)]. In conclusion, Guatemalan and Costa Rican children are exposed to an overabundance of not-permitted food ads on TV. This justifies implementing national policies to reduce exposure to not-permitted food for marketing, including on TV and other media.

This study aimed to exhaustively explore the characteristics of food advertising on TV in Guatemala and Costa Rica. In 2016, we recorded 1440 h of video among 10 TV channels. We used the PAHO Nutrient Profile Model to identify 'critical nutrients' (e.g. sodium) whose excessive consumption is associated with Non-Communicable Chronic Diseases (e.g. hypertension). We created a nutritional quality score (0 if the product did not exceed any critical nutrient, 1 if the product exceeded one and 2 if it exceeded ≥2). We classified food ads as permitted (score = 0) and not-permitted (score 1 or 2) for marketing. Persuasive marketing techniques were classified as promotional characters, premium offers, brand benefit claims and health-related claims. In Guatemala, foods that exceeded one critical nutrient had a high probability of using promotional characters, premium offers and health-related claims than foods without any excess in critical nutrients. However, in Costa Rica health-related claims had a high probability of appearing with foods that exceeded ≥2 critical nutrients. In conclusion, Guatemalan and Costa Rican children are exposed to an overabundance of not-permitted food ads on TV. This justifies implementing national policies to reduce exposure to not-permitted food for marketing.

Caregivers' provision of sweetened fruit-flavoured drinks to young children: importance of perceived product attributes and differences by socio-demographic and behavioural characteristics.

OBJECTIVE: Drinks containing added sugar and/or non-nutritive sweeteners are not recommended for children under 6 years. Yet, most young children consume these products. The current study examined factors associated with caregivers' provision of sweetened drinks to their young child. DESIGN: Caregivers reported frequency of providing sweetened fruit-flavoured drinks (fruit drinks and flavoured water) and unsweetened juices (100 % juice and juice/water blends) to their 1- to 5-year-old child in the past month and perceived importance of product attributes (healthfulness, product claims and other characteristics), other drinks provided, reading the nutrition facts panel and socio-demographic characteristics. A partial proportional odds model measured the relationship between these factors and frequency of providing sweetened fruit-flavoured drinks. SETTING: Online cross-sectional survey. PARTICIPANTS: U.S. caregivers (n 1763) with a young child (ages 1-5). RESULTS: The majority (74 %) of caregivers provided sweetened fruit-flavoured drinks to their child in the past month; 26 % provided them daily. Provision frequency was positively associated with some drink attributes, including perceived healthfulness, vitamin C claims and box/pouch packaging; child requests and serving other sweetened drinks and juice/water blends. Provision frequency was negatively associated with perceived importance of 'no/less sugar' and 'all natural' claims. Reading nutrition facts panels, serving water to their child and child's age were not significant. CONCLUSION: Misunderstanding of product healthfulness and other marketing attributes contribute to frequent provision of sweetened drinks to young children. Public health efforts to address common misperceptions, including counter marketing, may raise awareness among caregivers about the harms of providing sweetened drinks to young children.

Caregivers' Understanding of Ingredients in Drinks Served to Young Children: Opportunities for Nutrition Education and Improved Labeling.

BACKGROUND: Against expert recommendations, sugar-sweetened beverages, especially fruit drinks, are consumed by young children. Misperceptions about drink ingredients and healthfulness can contribute to caregivers' provision. OBJECTIVES: To assess caregivers' reasons for serving sweetened fruit-flavored drinks and unsweetened juices to their young children (1-5 y) and perceptions of product healthfulness and drink ingredients. METHODS: A cross-sectional online survey assessed participants' (n = 1614) perceptions of sweetened fruit-flavored drinks (fruit drinks and flavored water) and unsweetened juices (100% juice and water/juice blends) provided to their child in the past month, including product healthfulness, reasons for providing, and knowledge of product ingredients [added sugar, nonnutritive sweeteners (NNSs), percentage juice]. One-factor ANOVA compared perceived healthfulness of drink categories and types of sugar and NNSs, and differences between participants who could compared with those who could not accurately identify drink ingredients. RESULTS: Participants' top reasons for providing sweetened drinks included child liking it, being inexpensive, child asking for it, and being a special treat. Participants perceived 100% juice as healthiest, followed by juice/water blends, flavored waters, and, lastly, fruit drinks (P < 0.05). Many participants inaccurately believed the fruit drink or flavored water they served their child most often did not contain NNSs (59.0% and 64.9%) and/or added sugars (20.1% and 42.2%), when in fact they did, and 81.3-91.1% overestimated the percentage juice in the drink. Perceived healthfulness of fruit drinks was associated with caregivers' belief that the drink contained added sugar (P < 0.05), but not with their belief that it contained NNS; increased accuracy was associated with decreased perceived healthfulness (P < 0.05). CONCLUSIONS: Inaccurate understanding of added sugar, NNSs, and percentage juice in drinks served to young children was common and could contribute to sugary drink provision. Public health efforts should seek to improve labeling practices and revise nutrition education messages.

Television viewing and using screens while eating: Associations with dietary intake in children and adolescents.

Screen time has been associated with overweight and obesity, as well as with poorer dietary quality. However, the reasons explaining these associations are not well understood. The objectives of this cross-sectional study were [1] to determine the extent of overall TV viewing as well as using screens while eating (e.g., watching TV or using a tablet), [2] to compare food and nutrient consumption of on-versus off-screen eating occasions, and [3] to determine whether TV viewing and using screens while eating is associated with overall dietary intake. Participants were from the Food Environment Chilean Cohort (n = 938, 4-6 y) and the Growth and Obesity Cohort Study (n = 752, 12-14 y). Dietary data was collected via one 24-h food recall. For each eating occasion, activity performed during consumption (e.g., watching TV, playing sports) was reported. Weekly TV viewing time was collected via an additional survey instrument. Analyses included multivariable linear and logistic regression. Post-hoc pairwise comparisons examined differences in outcomes by tertiles. Our sample reported a median of 9-13.5 weekly hours of TV viewing and 87.5% reported consuming at least one meal or snack per day while using screens. The median kilocalories contributed by eating during screen use was 387 kcal/d in children and 848 kcal/day in adolescents, which represents 34.7% and 42.3% of daily energy intake, respectively. There were no consistent differences when comparing eating occasions consumed on-screen versus off-screen. Higher weekly TV viewing was associated with elements of a less healthy diet including more sweets and desserts in children, and more sugar sweetened beverages in adolescents. A large percentage of Chilean children and adolescents' daily energy is consumed while using screens. In depth, longitudinal work is needed to understand how screen time eating affects diet quality and nutritional status.

Implementation of a regulatory food policy to reduce availability of energy-dense foods in Costa Rican high schools.

OBJECTIVE: To assess the extent to which mandatory Guidelines to improve the school food environment were being implemented in Costa Rican high schools and to explore the perspectives of key policy actors towards the Guidelines. DESIGN: Semi-structured interviews and site observations. Interviews were recorded, transcribed verbatim and imported to NVivo 12 for analysis. Inductive and deductive themes were identified, and elements of the RE-AIM framework and the social process framework were used when classifying these themes. SETTING: Sixteen public high schools in San José, Costa Rica. PARTICIPANTS: High school principal and kiosk concessionaires. RESULTS: Products that did not adhere to the Guidelines were still widely available in schools, and amongst the most prevalent challenges to implementation that emerged from our interviews, were a lack of understanding of the policy content, a lack of monitoring and accountability, and competing values amongst actors which affected their views on the role that the school must have in offering a healthy food environment. CONCLUSION: Most products offered in high schools did not meet the criteria required by the mandatory Guidelines, and several contextual factors were found to influence implementation. Strengthening the implementation of the Costa Rican Guidelines will require further actions at the governmental and school levels.

TV advertising and dietary intake in adolescents: a pre- and post- study of Chile's Food Marketing Policy.

BACKGROUND: The first phase of a comprehensive marketing policy was implemented in Chile in 2016. The policy restricted child-directed marketing of foods and beverages considered high in energy, total sugars, sodium or saturated fat ("high-in"). The objective of this study was to examine the role of high-in TV food advertising as a mediator in the association between policy implementation and consumption of high-in foods and beverages between 2016 and 2017. METHODS: Dietary data were from 24-hour diet recalls collected in 2016 and 2017 in a cohort of 12-14 y children (n = 721). Television use was assessed concurrently and linked to analyses of food advertisements on broadcast and paid television to derive individual-level estimates of exposure to high-in food advertising. A multilevel mediation analysis examined direct and indirect effects of the policy through advertising exposure. RESULTS: Following the policy implementation, high-in advertising exposure was significantly reduced (p < 0.01). High-in food intake decreased in adolescents with lower levels, but not higher levels, of high-in advertising at baseline. We did not find evidence of mediation by changes in high-in ad exposure. CONCLUSIONS: Adolescents' exposure to high-in TV advertising decreased after the 2016 implementation of the Chilean Food Labeling and Marketing Law. However, evidence that changes in advertisement mediated dietary changes was not found. Further research is needed to understand how marketing changes will relate to dietary changes after full implementation of the law and in the long term.

Examining Chile's unique food marketing policy: TV advertising and dietary intake in preschool children, a pre- and post- policy study.

BACKGROUND: The Chilean government implemented the first phase of a comprehensive marketing policy in 2016, restricting child-directed marketing of products high in energy, total sugars, sodium or saturated fat (hereafter "high-in"). OBJECTIVES: To examine the role that high-in TV food advertising had in the effect of the policy on consumption of high-in products between 2016 and 2017. METHODS: Dietary data were obtained from 24-hour diet recall measured in 2016 (n = 940) and 2017 (n = 853), pre- and post-policy, from a cohort of 4 to 6 years children. Television use was linked to analyses of food advertisements to derive individual-level estimates of exposure to advertising. A multilevel mediation analysis examined direct and indirect effects of the policy through advertising exposure. RESULTS: Children's high-in food consumption and advertising exposure declined significantly from 2016 to 2017 (P < .01). Consumption changes were not significantly mediated by changes in advertising exposure, which might suggest other elements of the Chilean Law potentially driving decreases in consumption to a greater extent than TV ads. CONCLUSIONS: Preschoolers' exposure to high-in advertising and consumption of high-in products decreased post-policy. Further research is needed to understand how marketing changes will relate to dietary changes after full implementation of the law and in the long term.

Cambios antropométricos y satisfacción personal con una intervención educativa que incluyó el uso de una aplicación móvil, para personas con sobrepeso u obesidad / Use of a Mobile Application in a Weight Loss Education Intervention: Anthropometric Changes and Personal Satisfaction

Antecedentes: las tecnologías móviles pueden coadyuvar en el cambio de comportamientos alimentarios en personas con exceso de peso. Sin embargo, la evidencia con aplicaciones móviles adaptadas en el contexto latinoamericano es limitada. Objetivo: evaluar cambios antropométricos y satisfacción personal en una intervención educativa para personas con exceso de peso, la cual incluyó el uso de una aplicación móvil (NutriMetas). Materiales y métodos: estudio experimental clásico con diseño de pre-post prueba en personas con exceso de peso (IMC >25,0 y ≤34,9 kg/m2). Los participantes asistieron a sesiones de educación nutricional y registraron sus metas en la aplicación NutriMetas (grupo experimental, n=26) o en papel (grupo control, n=26). Se utilizaron modelos de regresión mixto multinivel para evaluar diferencias antropométricas (peso, IMC, circunferencia de cintura y porcentaje de grasa) entre los grupos. Resultados: el grupo experimental obtuvo una pérdida de peso promedio de 2,1±2,6 kg, en comparación con 0,7±1,6 kg para el grupo control (p=0,08). La interacción entre grupo y tiempo mostró una tendencia a la significancia en el IMC (p=0,064) y en la pérdida de peso (p=0,082), que podría ser de importancia desde el punto de vista clínico. Los atributos de apariencia, efectividad, eficiencia y facilidad de aprendizaje de NutriMetas fueron valorados favorablemente por la mayoría de los participantes. Conclusiones: el uso de NutriMetas como parte de una intervención educativa resultó ser una herramienta efectiva para los pacientes.

Background: Mobile technologies can enhance dietary changes in patients affected by overweight and obesity. Evidence of mobile applications designed and adapted to the Latin American context is, however, limited. Objective: To evaluate the use of the mobile app NutriMetas as part of a group nutrition education intervention, including anthropometric changes, and satisfaction with the mobile application. Materials and Methods: Randomized controlled study, in which all participants attended group nutrition education sessions, and recorded their goal progress with NutriMetas (experimental group, n=26) or on paper (control group, n=26). Multilevel mixed models were used to assess anthropometric changes (weight, BMI, body fat percentage and waist circumference between groups). Results: The experimental group had a mean weight-loss of 2.1±2.6 kg in comparison to 0.7±1.6 kg for the control group (p=0.08). Attributes of appearance, effectiveness, efficiency, and ease of use of NutriMetas were rated favorably by a majority of program participants. Conclusions: NutriMetas mobile application was an effective tool when used as part of the group weight loss nutrition intervention.

Television food and beverage marketing to children in Costa Rica: current state and policy implications.

OBJECTIVE: To examine the frequency of television (TV) food and beverage advertisements (F&B ads) to which children (4-11 years) are likely exposed and the nutrient profile of products advertised. DESIGN: TV broadcasting between September and November 2016 was recorded (288 h of children's programming; 288 h of family programming) resulting in 8980 advertisements, of which 1862 were F&B ads. Of those, 1473 could be classified into one of the seventeen food groups, and into permitted/non-permitted according to the WHO-EU nutrient profile model. Persuasive marketing techniques used were also identified. SETTING: TV programming was recorded for four weekdays and four weekend days, between 06.00 and 00.00 hours (576 total hours), for four channels (two national and two cable), in Costa Rica. RESULTS: Mean (sd) number of F&B ads/h was greater in cable than national channels (3·7 (0·4) v. 2·8 (0·4), P < 0·05) and during children's peak viewing hours (4·4 (0·4) v. 2·9 (0·3)). Of F&B ads classified with WHO-EU nutrient profile model (n 1473, 71·1 %), 91·1 % were non-permitted to be marketed to children. Categories most frequently advertised were ready-made/convenience foods (16 %), chocolates/confectionery/desserts (15 %), breakfast cereals (14 %), beverages (15 %), edible ices (9 %) and salty snacks (8 %). Non-permitted F&B ads were more likely to use promotional characters, brand benefit claims, and nutrition and health claims than permitted F&B ads. CONCLUSIONS: Children watching popular TV channels in Costa Rica are exposed to a high number of unhealthy F&B ads daily. Our findings help justify the need for regulatory actions by national authorities.

Snacking patterns among Chilean children and adolescents: is there potential for improvement?

OBJECTIVE: To examine snacking patterns, food sources and nutrient profiles of snacks in low- and middle-income Chilean children and adolescents. DESIGN: Cross-sectional. Dietary data were collected via 24 h food recalls. We determined the proportion of snackers, snacks per day and energy from top food and beverage groups consumed. We compared the nutrient profile (energy, sodium, total sugars and saturated fat) of snacks v. meals. SETTING: South-east region of Chile. PARTICIPANTS: Children and adolescents from two cohorts: the Food Environment Chilean Cohort (n 958, 4-6 years old) and the Growth and Obesity Cohort Study (n 752, 12-14 years old). RESULTS: With a mean of 2·30 (se 0·03) snacks consumed daily, 95·2 % of children and 89·9 % of adolescents reported at least one snacking event. Snacks contributed on average 1506 kJ/d (360 kcal/d) in snacking children and 2218 kJ/d (530 kcal/d) in snacking adolescents (29·0 and 27·4 % daily energy contribution, respectively). Grain-based desserts, salty snacks, other sweets and desserts, dairy foods and cereal-based foods contributed the most energy from snacks in the overall sample. For meals, cereal-based foods, dairy beverages, meat and meat substitutes, oils and fats, and fruits and vegetables were the top energy contributors. CONCLUSIONS: Widespread snacking among Chilean youth provides over a quarter of their daily energy and includes foods generally considered high in energy, saturated fat, sodium and/or total sugars. Future research should explore whether snacking behaviours change as the result of Chile's national regulations on food marketing, labelling and school environments.

Global benchmarking of children's exposure to television advertising of unhealthy foods and beverages across 22 countries.

Restricting children's exposures to marketing of unhealthy foods and beverages is a global obesity prevention priority. Monitoring marketing exposures supports informed policymaking. This study presents a global overview of children's television advertising exposure to healthy and unhealthy products. Twenty-two countries contributed data, captured between 2008 and 2017. Advertisements were coded for the nature of foods and beverages, using the 2015 World Health Organization (WHO) Europe Nutrient Profile Model (should be permitted/not-permitted to be advertised). Peak viewing times were defined as the top five hour timeslots for children. On average, there were four times more advertisements for foods/beverages that should not be permitted than for permitted foods/beverages. The frequency of food/beverages advertisements that should not be permitted per hour was higher during peak viewing times compared with other times (P < 0.001). During peak viewing times, food and beverage advertisements that should not be permitted were higher in countries with industry self-regulatory programmes for responsible advertising compared with countries with no policies. Globally, children are exposed to a large volume of television advertisements for unhealthy foods and beverages, despite the implementation of food industry programmes. Governments should enact regulation to protect children from television advertising of unhealthy products that undermine their health.

Aspectos importantes a incorporar en una aplicación móvil para la adherencia al tratamiento de la diabetes mellitus tipo 2 en Costa Rica según pacientes y profesionales de salud / Considerations for a Mobile Application to Support Type 2 Diabetes Mellitus Care in Costa Rica According to Patients and Healthcare Professionals

Resumen Antecedentes: la diabetes mellitus (DM) afecta al 12,8 % de los costarricenses. Recientemente, se ha presentado en Costa Rica un auge en el uso de tecnología móvil que permite innovar en el campo de aplicaciones móviles para la diabétes mellitus tipo 2 (DM2). Objetivo: explorar las perspectivas de pacientes y profesionales de la salud sobre los aspectos que podría contener una aplicación móvil para apoyar la adherencia del tratamiento en pacientes con DM2 en Costa Rica. Materiales y métodos: se utilizó un enfoque cualitativo para explorar la perspectiva de los participantes respecto al diseño de una aplicación móvil para DM2. Se aplicaron entrevistas semiestructuradas y grupos focales a 16 pacientes con DM2; y entrevistas semiestructuradas a 12 profesionales en salud (nutricionistas, enfermeras y médicos endocrinólogos). Resultados: solo dos pacientes habían utilizado una aplicación móvil para la DM2, y dos profesionales han recomendado su uso. Ambos grupos tienen intención de utilizar esta herramienta. La función de común interés es el registro de glucemia, aunque también se mencionaron otras. Los profesionales recomiendan supervisión continua en el uso de estas aplicaciones móviles. Conclusiones: los posibles usuarios brindan información valiosa con respecto a sus necesidades y expectativas de una aplicación móvil para DM2 para Costa Rica. La sencillez y el hecho de ser una aplicación móvil adaptada a Costa Rica son las características deseables más mencionadas.

Abstract Background: Diabetes mellitus (DM) affects 12.8% of the population in Costa Rica. Mobile technology use has increased in Costa Rica, potentially allowing for innovations in T2DM care. Objective: This study aimed to explore participants' perspectives related to the design of a mobile application to support T2DM care in Costa Rica. Materials and Methods: A qualitative design was used to explore participants' perspectives. Focus groups and semi-structured interviews were conducted with 16 T2DM patients, and semi-structured interviews were held with 12 healthcare professionals (nutritionists, nurses and medical doctors). Results: Only two patients had ever used an app for T2DM care, and only two professionals had previously recommended the use of these mobile applications. Both groups were willing to use these mobile applications. The most common function for which both groups showed interest was the record of blood glucose, but other functions were also mentioned. Healthcare professionals recommended continuous professional supervision in the use of these mobile applications. Conclusions: Potential mobile application users provide valuable insight regarding their needs and expectations for a T2DM care mobile application. Simplicity and being culturally adapted to Costa Rica are the most desirable mobile application features mentioned by the sample.

Participating in a Food-Assisted Maternal and Child Nutrition and Health Program in Rural Guatemala Alters Household Dietary Choices.

BACKGROUND: Food assistance programs may alter food choices, but factors determining households' decisions regarding food acquisition, preparation, and consumption in the context of food aid are not well understood. OBJECTIVE: This study aimed to understand how the Programa Comunitario Materno Infantil de Diversificación Alimentaria (Mother-Child Community Food Diversification Program; PROCOMIDA), a food-assisted maternal and child health and nutrition program in rural Alta Verapaz, Guatemala, altered household food choices. METHODS: We conducted semistructured interviews and focus groups with 63 households in 3 participating (n = 32 households) and 3 control (n = 31) villages. A last-day food recall (without estimating quantities) and food-frequency questionnaire that used food cards assessed dietary choices. Qualitative analysis used thematic a priori and emergent coding; food group consumption frequencies were analyzed by using 2-level, logistic, mixed modeling, and chi-square testing while accounting for community clustering. RESULTS: Compared with control households, PROCOMIDA changed household food choices through a combination of providing food resources (with monthly food rations) and new knowledge and skills related to health and food (in the program's behavior change communication component) while reinforcing existing knowledge and beliefs. PROCOMIDA families consumed rice, red beans, and oil more frequently than did control families (differences of 2.20 (P < 0.001), 2.68 (P < 0.001), and 1.64 (P = 0.038) times/wk, respectively); these foods were in the rations. PROCOMIDA families also ate chicken, local plants, and some vegetables more frequently. The importance of these foods was emphasized in the behavioral change communication component; these foods may have been more accessible because provision of food rations freed resources. CONCLUSION: Our findings suggest that if a program provides food free of cost to rural indigenous families in the context of a maternal and child nutrition and health program, it may be important to include a well-designed behavioral change communication component to improve household food choices.