Tackling (Childhood) Obesity through a Voluntary Food Reformulation Policy: A Repeated Cross-Sectional Study Investigating Nutritional Changes in the Out-of-Home Sector.

The Childhood Obesity Plan aimed to reduce sugar and energy in foods through a voluntary sugar-reduction programme. Our primary objective was to determine whether this implementation strategy had been successful, focusing on the out-of-home sector. We used a repeated cross-sectional design to evaluate nutritional changes in desserts served by leading chain restaurants. We extracted nutrition information from online menus in autumn/winter 2020, for comparison with baseline (2017) and interim (2018) values extracted from third-party datasets. We assessed compliance with the 20% sugar-reduction target and category-specific energy targets by product category and for pooled desserts. Overall, sugar/portion and energy/portion decreased by 11% and 4%, respectively. Policy targets were achieved in one of five categories (ice-cream: -38% sugar, p < 0.001; -30% energy, p < 0.001). Secondary outcomes were analysed for subgroups with the necessary data. Few chains significantly reduced sugar and/or energy across their dessert range. Energy/portion was positively associated with portion weight and sugar/portion but not with sugar/100 g. More than half of adults' desserts contained excessive sugar and/or saturated fat compared with dietary guidelines. Children's desserts less frequently exceeded guidelines. These results demonstrate that voluntary measures can drive substantial change when technical, commercial, and operational barriers can be overcome.

Impact of acute consumption of beverages containing plant-based or alternative sweetener blends on postprandial appetite, food intake, metabolism, and gastro-intestinal symptoms: Results of the SWEET beverages trial.

Project SWEET examined the barriers and facilitators to the use of non-nutritive sweeteners and sweetness enhancers (hereafter "S&SE") alongside potential risks/benefits for health and sustainability. The Beverages trial was a double-blind multi-centre, randomised crossover trial within SWEET evaluating the acute impact of three S&SE blends (plant-based and alternatives) vs. a sucrose control on glycaemic response, food intake, appetite sensations and safety after a carbohydrate-rich breakfast meal. The blends were: mogroside V and stevia RebM; stevia RebA and thaumatin; and sucralose and acesulfame-potassium (ace-K). At each 4 h visit, 60 healthy volunteers (53% male; all with overweight/obesity) consumed a 330 mL beverage with either an S&SE blend (0 kJ) or 8% sucrose (26 g, 442 kJ), shortly followed by a standardised breakfast (∼2600 or 1800 kJ with 77 or 51 g carbohydrates, depending on sex). All blends reduced the 2-h incremental area-under-the-curve (iAUC) for blood insulin (p < 0.001 in mixed-effects models), while the stevia RebA and sucralose blends reduced the glucose iAUC (p < 0.05) compared with sucrose. Post-prandial levels of triglycerides plus hepatic transaminases did not differ across conditions (p > 0.05 for all). Compared with sucrose, there was a 3% increase in LDL-cholesterol after stevia RebA-thaumatin (p < 0.001 in adjusted models); and a 2% decrease in HDL-cholesterol after sucralose-ace-K (p < 0.01). There was an impact of blend on fullness and desire to eat ratings (both p < 0.05) and sucralose-acesulfame K induced higher prospective intake vs sucrose (p < 0.001 in adjusted models), but changes were of a small magnitude and did not translate into energy intake differences over the next 24 h. Gastro-intestinal symptoms for all beverages were mostly mild. In general, responses to a carbohydrate-rich meal following consumption of S&SE blends with stevia or sucralose were similar to sucrose.

Acute and repeated impact of sweeteners and sweetness enhancers in solid and semi-solid foods on appetite: protocol for a multicentre, cross-over, RCT in people with overweight/obesity - the SWEET Project.

INTRODUCTION: Intake of free sugars in European countries is high and attempts to reduce sugar intake have been mostly ineffective. Non-nutritive sweeteners and sweetness enhancers (S&SEs) can maintain sweet taste in the absence of energy, but little is known about the impact of acute and repeated consumption of S&SE in foods on appetite. This study aims to evaluate the effect of acute and repeated consumption of two individual S&SEs and two S&SE blends in semisolid and solid foods on appetite and related behavioural, metabolic and health outcomes. METHODS AND ANALYSIS: A work package of the SWEET Project; this study consists of five double-blind randomised cross-over trials which will be carried out at five sites across four European countries, aiming to have n=213. Five food matrices will be tested across three formulations (sucrose-sweetened control vs two reformulated products with S&SE blends and no added sugar). Participants (body mass index 25-35 kg/m2; aged 18-60 years) will consume each formulation for 14 days. The primary endpoint is composite appetite score (hunger, inverse of fullness, desire to eat and prospective food consumption) over a 3-hour postprandial incremental area under the curve during clinical investigation days on days 1 and 14. ETHICS AND DISSEMINATION: The trial has been approved by national ethical committees and will be conducted in accordance with the Declaration of Helsinki. Results will be published in international peer-reviewed open-access scientific journals. Research data from the trial will be deposited in an open-access online research data archive. TRIAL REGISTRATION NUMBER: NCT04633681.

Protocol for a multicentre, parallel, randomised, controlled trial on the effect of sweeteners and sweetness enhancers on health, obesity and safety in overweight adults and children: the SWEET project.

INTRODUCTION: The aim of this randomised controlled trial (RCT) is to investigate whether prolonged consumption of sweeteners and sweetness enhancers (S&SEs) within a healthy diet will improve weight loss maintenance and obesity-related risk factors and affect safety markers compared with sugar. METHODS AND ANALYSIS: SWEET (S&SEs: prolonged effects on health, obesity and safety) is a 1-year multicentre RCT including at least 330 adults with overweight (18-65 years, body mass index (BMI) >25 kg/m2) and 40 children (6-12 years, BMI-for-age >85th percentile). In an initial 2-month period, adults will consume a low-energy diet with the aim to achieve ≥5% weight loss. Children are advised to consume a generally healthy diet to maintain body weight, thus reducing their BMI-for-age z-score. In the following 10 months, participants will be randomised to follow a healthy ad libitum diet with or without S&SE products. Clinical investigations are scheduled at baseline, after 2, 6 and 12 months. The primary outcomes are body weight for efficacy and gut microbiota composition (in relation to metabolic health) for safety, both in adults. Secondary outcomes include anthropometry, risk markers for type-2 diabetes and cardiovascular diseases, questionnaires including, for example, food preferences, craving and appetite and tests for allergenicity. ETHICS AND DISSEMINATION: The trial protocol has been approved by the following national ethical committees; The research ethics committees of the capital region (Denmark), approval code: H-19040679, The medical ethics committee of the University Hospital Maastricht and Maastricht University (the Netherlands), approval code: NL70977.068.19/METC19-056s, Research Ethics Committee of the University of Navarra (Spain), approval code: 2019.146 mod1, Research Ethics Committee of Harokopio University (Greece), approval code: 1810/18-06-2019. The trial will be conducted in accordance with the Declaration of Helsinki. Results will be published in international peer-reviewed scientific journals regardless of whether the findings are positive, negative or inconclusive. TRIAL REGISTRATION NUMBER: NCT04226911 (Clinicaltrials.gov).

Disease knowledge and functional disability of a cohort of rheumatoid arthritis in a tertiary government hospital in Manila, Philippines

Background@#Rheumatoid arthritis (RA) is a chronic and progressive disease resulting in disability and poor quality of life. Patients’ knowledge (PxK) of disease can contribute to better disease control, reduced disability, and improved quality of life. @*Objective@#The objective of this study was to determine the disease knowledge and functional disability of a cohort of patients with RA. @*Methods@#We conducted a cross-sectional study among patients with RA at the University of the Philippines - Philippine General Hospital Arthritis Clinic. The subjects were recruited using convenience sampling over three months in 2019. We obtained demographic and disease characteristics, clinic attendance, patient knowledge, and functional status through chart review, a questionnaire, and a disability index. Descriptive statistics, 2-sample T-test, Pearson’s correlation, analysis of variance (ANOVA), and multiple linear regression analysis were used for data analysis. Informed consent was obtained before participation in the study. @*Results@#Eighty percent (57/71) of recruited patients participated in the study. All were female, and the mean age was 51.6 years (±12.9). Most participants completed secondary education, were employed, had an average duration of RA of 8 (±6.8) years, had been consulting at the Arthritis Clinic for an average of 4.8 years (±3.8), and had moderate disease activity (49.1%). Most patients had American College of Rheumatology (ACR) class I or II functional status (50/57, 88%). The usual source of the patients' knowledge about RA was their physician. The mean knowledge score was 5.10 (±0.93) out of a perfect score of 9. Most patients were aware of their disease diagnosis and the non-communicable nature of RA. There was low awareness of the need for self-monitoring for disease flares or treatment adverse events and the extra-articular involvement in RA. The mean functional disability score was 6.65 ± 5.33, and the mean functional disability index (FDI) was 0.83 (±0.66). These correspond to mild functional disability (FD). There was no significant relationship between the total knowledge score and age, duration of disease, number of consultations in the past year, level of education, employment status, perceived level of disease knowledge, or the practice of asking their physician about illness. Perception of overall health status was associated with functional disability (p=0.001). @*Conclusion@#Most of the patients in our cohort of RA patients had a mild functional disability and low knowledge scores. The study identified the gaps in our patients’ knowledge of disease and its management. A re-evaluation of existing educational and treatment strategies will be beneficial to enhance disease knowledge and improve health outcomes.

Responsible Governance for a Food and Nutrition E-Infrastructure: Case Study of the Determinants and Intake Data Platform.

The focus of the current paper is on a design of responsible governance of food consumer science e-infrastructure using the case study Determinants and Intake Data Platform (DI Data Platform). One of the key challenges for implementation of the DI Data Platform is how to develop responsible governance that observes the ethical and legal frameworks of big data research and innovation, whilst simultaneously capitalizing on huge opportunities offered by open science and the use of big data in food consumer science research. We address this challenge with a specific focus on four key governance considerations: data type and technology; data ownership and intellectual property; data privacy and security; and institutional arrangements for ethical governance. The paper concludes with a set of responsible research governance principles that can inform the implementation of DI Data Platform, and in particular: consider both individual and group privacy; monitor the power and control (e.g., between the scientist and the research participant) in the process of research; question the veracity of new knowledge based on big data analytics; understand the diverse interpretations of scientists' responsibility across different jurisdictions.

Understanding How Consumers Categorise Health Related Claims on Foods: A Consumer-Derived Typology of Health-Related Claims.

The Nutrition and Health Claims Regulation (NHCR) EC No 1924/2006 aims to provide an appropriate level of consumer protection whilst supporting future innovation and fair competition within the EU food industry. However, consumers' interpretation of health claims is less well understood. There is a lack of evidence on the extent to which consumers are able to understand claims defined by this regulatory framework. Utilising the Multiple Sort Procedure (MSP), a study was performed (N = 100 participants across five countries: Germany, the Netherlands, Slovenia, Spain and the United Kingdom) to facilitate development of a framework of health-related claims encompassing dimensions derived from consumers. Our results provide useful insight into how consumers make sense of these claims and how claims may be optimised to enhance appropriate consumer understanding. They suggest consumers may not consciously differentiate between a nutrition claim and a health claim in the way that regulatory experts do and provide insight into where this might occur. A consumer-derived typology of health-related claims based on three key dimensions is proposed: (1) Familiarity with the nutrient, substance or food stated in the claim; (2) statement type in terms of simplicity/complexity; (3) relevance of the claim, either personally or for a stated population group.

The role of causal models and beliefs in interpreting health claims.

OBJECTIVE: Health claims on food packaging are regulated to inform and protect consumers; however, many consumers do not accurately interpret the meaning of the claims. Whilst research has shown different types of misinterpretation, it is not clear how those interpretations are formed. The aim of this study was to elicit the causal beliefs and causal models about food and health held by consumers, that is their understanding of the causal relationships between nutrients, health outcomes, and the causal pathways connecting them, and investigate how well this knowledge explains the variation in inferences they draw about health benefits from health claims. METHOD: A total of 400 participants from Germany, the Netherlands, Spain, Slovenia, and the United Kingdom were presented with seven authorized health claims and drew inferences about the health benefits of consuming nutrients specified in the claim. Then, their personal causal models of health were elicited along with their belief in the truth and familiarity with the claims. RESULTS: The strength of inferences about health benefits that participants drew from the claims was predicted independently by the strength of the relevant causal pathways within the causal model, and belief in the truth of the claim, but not familiarity with the claim. Participants drew inferences about overall health benefits of the nutrients by extrapolating from their causal models of health. CONCLUSION: Consumers' interpretation of claims is associated with their belief in the claim and their causal models of health. This prior knowledge is used to interpret the claim and draw inferences about overall health benefits that go beyond the information in the claim. Therefore, efforts to improve consumers' understanding and interpretation of health claims must address both their wider causal models of health and their knowledge of specific claims. Statement of Contribution What is already known on this subject? Health claims influence the likelihood of buying a product. But consumers do not accurately understand or interpret health claims. What does this study add? Consumers' interpretation of health claims is mediated by their personal causal model of health. Consumers draw inferences that go beyond what is claimed by extrapolating from their personal causal model of health. Consumers are also influenced directly by their belief in the claim, but not frequency of exposure to it.

When is an image a health claim? A false-recollection method to detect implicit inferences about products' health benefits.

OBJECTIVE: Images on food and dietary supplement packaging might lead people to infer (appropriately or inappropriately) certain health benefits of those products. Research on this issue largely involves direct questions, which could (a) elicit inferences that would not be made unprompted, and (b) fail to capture inferences made implicitly. Using a novel memory-based method, in the present research, we explored whether packaging imagery elicits health inferences without prompting, and the extent to which these inferences are made implicitly. METHOD: In 3 experiments, participants saw fictional product packages accompanied by written claims. Some packages contained an image that implied a health-related function (e.g., a brain), and some contained no image. Participants studied these packages and claims, and subsequently their memory for seen and unseen claims were tested. RESULTS: When a health image was featured on a package, participants often subsequently recognized health claims that-despite being implied by the image-were not truly presented. In Experiment 2, these recognition errors persisted despite an explicit warning against treating the images as informative. In Experiment 3, these findings were replicated in a large consumer sample from 5 European countries, and with a cued-recall test. CONCLUSION: These findings confirm that images can act as health claims, by leading people to infer health benefits without prompting. These inferences appear often to be implicit, and could therefore be highly pervasive. The data underscore the importance of regulating imagery on product packaging; memory-based methods represent innovative ways to measure how leading (or misleading) specific images can be. (PsycINFO Database Record

Guiding healthier food choice: systematic comparison of four front-of-pack labelling systems and their effect on judgements of product healthiness.

Different front-of-pack (FOP) labelling systems have been developed in Europe by industry and organisations concerned with health promotion. A study (n 2068) was performed to establish the extent to which inclusion of the most prevalent FOP systems--guideline daily amounts (GDA), traffic lights (TL), GDA+TL hybrid (HYB) and health logos (HL)--impact consumer perceptions of healthiness over and above the provision of a FOP basic label (BL) containing numerical nutritional information alone. The design included within- and between-subjects factors. The within-subjects factors were: food (pizzas, yogurts and biscuits), healthiness of the food (high health, medium health and low health) and the repeated measurements under BL and test FOP label conditions. The between-subjects factors were: the system (GDA, TL, GDA+TL hybrid, HL), portion size (typical portion size and a 50% reduction of a typical portion) and country (the UK, Germany, Poland and Turkey). Although the FOP systems tested did result in small improvements for objective understanding under some conditions, there was little difference between the provision of an FOP label containing basic numerical nutritional information alone or between the various systems. Thus, any structured and legible presentation of key nutrient and energy information on the FOP label is sufficient to enable consumers to detect a healthier alternative within a food category when provided with foods that have distinctly different levels of healthiness. Future research should focus on developing greater understanding of the psychological and contextual factors that impact motivation and the opportunity to use the various FOP systems in real-world shopping settings.

Are bedside features of shock reproducible between different observers?

Shock is often under-reported in children attending hospitals in developing countries. Readily obtainable features of shock (capillary refill time, temperature gradient, pulse volume, and signs of dehydration) are widely used to help prioritise management in the emergency assessment of critically ill or injured children. However, data are lacking on their validity, including, importantly, reproducibility between observers. Agreement of these signs was examined in 100 consecutive children admitted to a paediatric ward on the coast of Kenya. After an initial training of clinical sign recognition, there was moderate agreement for most features of cardiovascular compromise (delayed capillary refill > or =4 s, kappa = 0.49; and weak pulse volume, kappa = 0.4) and only substantial agreement for temperature gradient (kappa = 0.62). For hydration status, only in the assessment of skin turgor was there a moderate level of agreement (kappa = 0.55). Capillary refill times and assessment of pulse volume recommended by the recent American consensus guidelines achieved only a "low" moderate to poor interrater agreement, questioning the reliability of such parameters.