The present paper aims at describing the current status of nutrition policyin the WHO European Region and to discuss the implications for publichealth. The stages of policy development in the Region are illustrated andachievements in specific aspects of food and nutrition policy arehighlighted.

The analysis is based on a WHO survey on nutrition policies in the WHOEuropean Region in 2005 with information from forty-eight out of fifty-threecountries in the Region. Based on the findings, countries were categorizedaccording to their stage in policy development. Additionally, fifty policydocuments related to nutrition and published by a national body wereanalysed according to certain criteria of food and nutrition policy.

Most Member States (n 46) have available apolicy document related to nutrition and forty have a mechanism to implementit. Collaboration between sectors is taking place in thirty-one countries.Implementation tools, such as food-based dietary guidelines and monitoringand surveillance systems, are in place in twenty-seven countries. Theanalysis of policy documents revealed that actions addressing the individualwith information or education are well developed. Actions addressingenvironmental determinants, such as food availability, affordability andaccessibility, are indicated in only a few policies.

Food and nutrition policies appear to have developed successfully in the pastdecade. However, implementation of the policies seems to be a majorchallenge due to lack of funds, political commitment and coordination. Moresupport should be given to the implementation and evaluation of policies anda shift towards stronger environmental approaches is needed.

To identify factors influencing dietary behaviours in urban food environments in Africa and identify areas for future research.

We systematically reviewed published/grey literature (protocol CRD4201706893). Findings were compiled into a map using a socio-ecological model on four environmental levels: individual, social, physical and macro.

Urban food environments in Africa.

Studies involving adolescents and adults (11–70 years, male/female).

Thirty-nine studies were included (six adolescent, fifteen adolescent/adult combined and eighteen adult). Quantitative methods were most common (twenty-eight quantitative, nine qualitative and two mixed methods). Studies were from fifteen African countries. Seventy-seven factors influencing dietary behaviours were identified, with two-thirds at the individual level (45/77). Factors in the social (11/77), physical (12/77) and macro (9/77) environments were investigated less. Individual-level factors that specifically emerged for adolescents included self-esteem, body satisfaction, dieting, spoken language, school attendance, gender, body composition, pubertal development, BMI and fat mass. Studies involving adolescents investigated social environment-level factors more, for example, sharing food with friends. The physical food environment was more commonly explored in adults, for example, convenience/availability of food. Macro-level factors associated with dietary behaviours were food/drink advertising, religion and food prices. Factors associated with dietary behaviour were broadly similar for men and women.

The dominance of studies exploring individual-level factors suggests a need for research to explore how social, physical and macro-level environments drive dietary behaviours of adolescents and adults in urban Africa. More studies are needed for adolescents and men, and studies widening the geographical scope to encompass all African countries.

To evaluate the current status of dietary intakes in early pubertal girls with a special focus on milk products.

Cross-sectional data using 3-day food records.

Eight hundred and sixty girls, aged 10–12 years, at Tanner maturation stage I-III.

The mean consumption of milk products (620 g day−1) was similar to that of a Finnish study in the 1980s, while the consumption of non-milk drinks (403 gday−1) had increased. Twelve per cent of the girls had a dairy-restricted diet and consumed significantly less milk products than girls with a non-restricted diet (465 vs. 644 g day−1, P<0.001). Girls with low milk product consumption had the highest non-milk drinks consumption (P<0.001). The mean energy intake was 7.1 MJ day−1. No major changes were found in the sources of nutrients. The shares of energy for nutrients were close to recommendations except for saturated fat (13.9 vs. 10% of energy) and carbohydrates (51.5 vs. 55–60% of energy). The mean calcium intake (1117 mg day−1) was above the recommendation, while the vitamin D intake (3.1 μg day−1) of 88% of the girls was below the recommendation.

The diet quality of early pubertal girls is close to the recommendations and has improved with respect to fat compared with the 1980s. Consumption of milk products is high although the consumption of non-milk drinks has increased. We found a subgroup of girls who compensate their low milk product consumption with a higher consumption of non-milk drinks. Following a dairy-restricted diet is the main reason for low consumption of milk products.

Treatment for childhood obesity is characterised by high attrition rates and failure to achieve weight maintenance. It is therefore important to develop more effective programmes. The aim of the present qualitative study was to explore the views of parents, children and health trainers to identify issues which can inform the development of more effective programmes.

A qualitative study combining in-depth interviews and focus groups. Participants were selected purposively from current and past attendees.

WATCH-IT, a UK-based community child weight management programme.

Twenty-three families who had previously attended (or were currently attending) WATCH-IT were interviewed. Focus groups with ten trainers explored their views of the intervention.

Parents and children had different goals for involvement, with parents focusing on psychological benefits, while children concentrated on goals relating to weight loss and physical fitness. Parents were found to struggle to provide consistent support to their children and this was exacerbated by family dynamics. The child's commitment to lose weight, support from their family and a good relationship between the child and their trainer were viewed as important keys to successful weight management.

The study will guide the design of existing and future programmes by providing insights into issues that challenge successful engagement. It highlights the possible value of exploring the therapeutic relationship between trainers and participants.

To investigate the prevalence of vitamin A deficiency (VAD) among pregnant women in rural Bangladesh, and examine the relationship between various factors and vitamin A status.

Community Nutrition Promoter (CNP) centres in Kapasia sub-district of Gazipur district, Bangladesh.

A cross-sectional study.

Two hundred women, aged 18–39 years, in their second or third trimester of pregnancy were selected from seventeen CNP centres in four unions of Kapasia sub-district where they usually visit for antenatal care. Various socio-economic, personal and pregnancy-related information, dietary intake of vitamin A and mid-upper arm circumference (MUAC) data were collected. Serum retinol (vitamin A) concentration was determined.

More than half (51 %) of the pregnant women had low vitamin A status (serum retinol <1·05 μmol/l) with 18·5 % having VAD (serum retinol <0·70 μmol/l). Fifty-three per cent of the women’s vitamin A intake was less than the recommended dietary allowance. By multiple regression analysis, MUAC, per-capita expenditure on food and wealth index were found to have significant independent positive relationship with serum retinol concentration, while gestational age of the pregnant women had a negative relationship. The overall F-ratio (10·3) was highly significant (P = 0·0001), the adjusted R2 was 0·18 (multiple R = 0·45).

VAD is highly prevalent among rural pregnant women in Bangladesh. Gestational age, nutritional status, per-capita expenditure on food and wealth index appear to be important in influencing the vitamin A status of these women. An appropriate intervention is warranted in order to improve the vitamin A status.

Despite a rapidly growing economy and rising income levels in India, improvements in child malnutrition have lagged. Data from the most recent National Family Health Survey reveal that the infant and young child feeding (IYCF) practices recommended by the WHO and the Indian Government, including the timely introduction of solid food, are not being followed by a majority of mothers in India. It is puzzling that even among rich households children are not being fed adequately. The present study analyses the socio-economic factors that contribute to this phenomenon, including the role of nutritional information.

IYCF practices from the latest National Family Health Survey (2005–2006) were analysed. Multivariate logistic regression analyses were performed to establish the determinants of poor feeding practices. The indicators recommended by the WHO were used to assess the IYCF practices.

India.

Children (n 9241) aged 6–18 months.

Wealth was shown to have only a small effect on feeding practices. For children aged 6–8 months, the mother's wealth status was not found to be a significant determinant of sound feeding practices. Strikingly, nutritional advice on infant feeding practices provided by health professionals (including anganwadi workers) was strongly correlated with improved practices across all age groups. Exposure to the media was also found to be a significant determinant.

Providing appropriate information may be a crucial determinant of sound feeding practices. Efforts to eradicate malnutrition should include the broader goals of improving knowledge related to childhood nutrition and IYCF practices.

To investigate the influence of a trial lifestyle intervention on participants’ preferences for a range of exercise and diet programmes and whether these differ between successful and unsuccessful participants.

Hypothetical scenarios that describe attributes of diet and exercise programmes were developed using an experimental design. Participants completed an online questionnaire at baseline, 16 weeks and 12 months where they chose their most preferred of three programmes in each of sixteen scenarios. Discrete choice modelling was used to identify which attributes participants emphasised at each time point.

Fifty-five individuals who exhibited symptoms of metabolic syndrome and who participated in a 16-week trial lifestyle intervention.

There was a clear shift in programme preferences from structure to flexibility over the intervention. At baseline, emphasis was on individually designed and supervised exercise, structured diets and high levels of support, with Gainers focusing almost exclusively on support and supervision. Losers tended to consider a wider range of programme attributes. After 16 weeks preferences shifted towards self-directed rather than organised/supervised exercise and support was less important (this depended on the type of participant and whether they were in the follow-up group). Cost became significant for Gainers following the end of the primary intervention.

The stated preference method could be a useful tool in identifying potential for success and specific needs. Gainers’ relinquishment of responsibility for lifestyle change to programme staff may be a factor in their failure and in their greater cost sensitivity, since they focus on external rather than internal resources.

To review the psycho-social research with respect to relevance for the development of nutritional education strategies.

The eating behaviour of the newborn baby is controlled by innate preferences and dislikes, and by biological self-regulation. These innate control-systems are modified by learning processes, most importantly by the mere exposure to unknown food, by social influences, and by associating the physiological consequences of food intake with taste cues. The last decades have witnessed a change of the social meaning of food and eating, and the social context of eating is subject to dramatic changes. While on the one hand, prevalence of overweight and obesity is increasing, even young children deliberately practise weight control measures ranging from selective food choice to self-induced vomiting thus including behaviours which are clearly symptomatic of eating disorders. Such behaviour is motivated by unrealistic conceptions of a healthy body weight and shape. Children are interested in a range of nutrition topics. However, these topics have to be related to direct perceivable benefits from nutrition.

Educational strategies should: firstly, focus on providing a variety of foods, including a range of nutrient-dense ‘healthy’ food and encouraging children to taste it; secondly, provide a stable and predictive pattern of social eating occasions to promote the social meaning and importance of eating and to enable social learning of food preferences; and finally, encourage a positive body image by providing advice and reassurance regarding the range of healthy and acceptable body weights and shapes.

To examine the availability of nutritional support services in HIV care and treatment sites across sub-Saharan Africa.

In 2008, we conducted a cross-sectional survey of sites providing antiretroviral therapy (ART) in nine sub-Saharan African countries. Outcomes included availability of: (i) nutritional counselling; (ii) micronutrient supplementation; (iii) treatment for severe malnutrition; and (iv) food rations. Associations with health system indicators were explored using bivariate and multivariate methods.

President's Emergency Plan for AIDS Relief-supported HIV treatment and care sites across nine sub-Saharan African countries.

A total of 336 HIV care and treatment sites, serving 467 175 enrolled patients.

Of the sites under study, 303 (90 %) offered some form of nutritional support service. Nutritional counselling, micronutrient supplementation, treatment for severe acute malnutrition and food rations were available at 98 %, 64 %, 36 % and 31 % of sites, respectively. In multivariate analysis, secondary or tertiary care sites were more likely to offer nutritional counselling (adjusted OR (AOR): 2·2, 95 % CI 1·1, 4·5). Rural sites (AOR: 2·3, 95 % CI 1·4, 3·8) had increased odds of micronutrient supplementation availability. Sites providing ART for >2 years had higher odds of availability of treatment for severe malnutrition (AOR: 2·4, 95 % CI 1·4, 4·1). Sites providing ART for >2 years (AOR: 1·6, 95 % CI 1·3, 1·9) and rural sites (AOR: 2·4, 95 % CI 1·4, 4·4) had greater odds of food ration availability.

Availability of nutritional support services was high in this large sample of HIV care and treatment sites in sub-Saharan Africa. Further efforts are needed to determine the uptake, quality and effectiveness of these services and their impact on patient and programme outcomes.

To analyse the effect of community-based counselling on feeding patterns during the first 12 weeks after birth, and to study whether the effect differs by maternal HIV status, educational level or household wealth.

Cluster-randomized trial with fifteen clusters in each arm to evaluate an integrated package providing two pregnancy and five postnatal home visits delivered by community health workers. Infant feeding data were collected using 24 h recall of nineteen food and fluid items.

A township near Durban, South Africa.

Pregnant women (1894 intervention and 2243 control) aged 17 years or more.

Twelve weeks after birth, 1629 (intervention) and 1865 (control) mother–infant pairs were available for analysis. Socio-economic conditions differed slightly across intervention groups, which were considered in the analyses. There was no effect on early initiation of breast-feeding. At 12 weeks of age the intervention doubled exclusive breast-feeding (OR=2·29; 95 % CI 1·80, 2·92), increased exclusive formula-feeding (OR=1·70; 95 % CI 1·28, 2·27), increased predominant breast-feeding (OR=1·71; 95 % CI 1·34, 2·19), decreased mixed formula-feeding (OR=0·68; 95 % CI 0·55, 0·83) and decreased mixed breast-feeding (OR=0·54; 95 % CI 0·44, 0·67). The effect on exclusive breast-feeding at 12 weeks was stronger among HIV-negative mothers than HIV-positive mothers (P=0·01), while the effect on mixed formula-feeding was significant only among HIV-positive mothers (P=0·03). The effect on exclusive feeding was not different by household wealth or maternal education levels.

A perinatal intervention package delivered by community health workers was effective in increasing exclusive breast-feeding, exclusive formula-feeding and decreasing mixed feeding.

To evaluate the level of compliance with the PAOS Code (Publicidad, Actividad, Obesidad y Salud), which establishes standards for the self-regulation of food marketing aimed at minors, in television advertising by food and beverage companies that have agreed to abide by the Code.

The study sample consisted of food and beverage advertisements targeting children during 80 h of programming by four Spanish television networks. The level of compliance with each standard of the PAOS Code was classified into three categories: ‘compliance’, ‘non-compliance’ and ‘uncertain compliance’. Overall, an advertisement was considered compliant with the PAOS Code if it met all the standards; non-compliant if it contravened one or more standards; and uncertain in all other cases.

Of a total of 203 television advertisements from companies that agreed to the PAOS Code, the overall prevalence of non-compliance was 49·3 % (v. 50·8 % among those that did not agree to the code), with 20·7 % of advertisements considered of uncertain compliance. Non-compliance was more frequent on Saturdays, in longer advertisements, in advertisements containing promotions or dairy products, and for advertisements from companies of French or US origin.

Non-compliance with the PAOS Code was very high and was similar for companies that did and did not agree to the Code, casting doubt on the Code’s effectiveness and oversight system. It seems the time has come to commit to statutory regulations that reduce the negative impact of advertising on children’s diets, as demanded by public health experts and consumer associations.

Nutritional warnings have recently been suggested as a simplified front-of-pack nutrition labelling scheme to facilitate citizens’ ability to identify unhealthful products and discourage their consumption. However, citizens’ perspective on this policy is still under-researched. The objective of the present work was to study how citizens perceive nutritional warnings and to evaluate public support of this policy, with the goal of deriving recommendations for the design of policy measures accompanying the introduction of nutritional warnings.

An online survey with 1416 Uruguayan citizens, aged 18–75 years, 61 % female, was conducted. Participants had to answer a series of questions (open-ended and multiple-choice) related to their perception of warnings as a front-of-package nutrition labelling scheme.

Participants showed a positive attitude towards nutritional warnings, which were regarded as easy to understand and to identify on food packages. The majority of respondents emphasized that they would take nutritional warnings into account when making their food choices, stating that they would allow them to make informed choices and, consequently, to increase the quality of their diet and their health status. Health motivation appeared as a crucial driver for taking nutritional warnings into consideration.

A high level of public support for nutritional warnings was observed. Responses can be used to derive a range of recommendations for a policy mix that should synergistically support the introduction of nutritional warnings and encourage citizens to take them into account when making their food purchases.

The present study tested the combination of an established and a validated food-choice research method (the ‘fake food buffet’) with a new food-matching technology to automate the data collection and analysis.

The methodology combines fake-food image recognition using deep learning and food matching and standardization based on natural language processing. The former is specific because it uses a single deep learning network to perform both the segmentation and the classification at the pixel level of the image. To assess its performance, measures based on the standard pixel accuracy and Intersection over Union were applied. Food matching firstly describes each of the recognized food items in the image and then matches the food items with their compositional data, considering both their food names and their descriptors.

The final accuracy of the deep learning model trained on fake-food images acquired by 124 study participants and providing fifty-five food classes was 92·18 %, while the food matching was performed with a classification accuracy of 93 %.

The present findings are a step towards automating dietary assessment and food-choice research. The methodology outperforms other approaches in pixel accuracy, and since it is the first automatic solution for recognizing the images of fake foods, the results could be used as a baseline for possible future studies. As the approach enables a semi-automatic description of recognized food items (e.g. with respect to FoodEx2), these can be linked to any food composition database that applies the same classification and description system.

The present paper investigated the impact of the 2008 financial crisis on food security in Mexico and how it disproportionally affected vulnerable households.

A generalized ordered logistic regression was estimated to assess the impact of the crisis on households’ food security status. An ordinary least squares and a quantile regression were estimated to evaluate the effect of the financial crisis on a continuous proxy measure of food security defined as the share of a household’s current income devoted to food expenditures.

Both analyses were performed using pooled cross-sectional data from the Mexican National Household Income and Expenditure Survey 2008 and 2010.

The analytical sample included 29 468 households in 2008 and 27 654 in 2010.

The generalized ordered logistic model showed that the financial crisis significantly (P<0·05) decreased the probability of being food secure, mildly or moderately food insecure, compared with being severely food insecure (OR=0·74). A similar but smaller effect was found when comparing severely and moderately food-insecure households with mildly food-insecure and food-secure households (OR=0·81). The ordinary least squares model showed that the crisis significantly (P<0·05) increased the share of total income spent on food (β coefficient of 0·02). The quantile regression confirmed the findings suggested by the generalized ordered logistic model, showing that the effects of the crisis were more profound among poorer households.

The results suggest that households that were more vulnerable before the financial crisis saw a worsened effect in terms of food insecurity with the crisis. Findings were consistent with both measures of food security – one based on self-reported experience and the other based on food spending.

To assess the validity of food photographs in portion size estimation among adolescent girls in Mozambique. The study was carried out in preparation for the larger ZANE study, which used the 24 h dietary recall method.

Life-sized photographs of three portion sizes of two staple foods and three sauces were produced. Participants ate weighed portions of one staple food and one sauce. After the meal, they were asked to estimate the amount of food with the aid of the food photographs.

Zambezia Province, Mozambique.

Ninety-nine girls aged 13–18 years.

The mean differences between estimated and actual portion sizes relative to the actual portion size ranged from −19 % to 8 % for different foods. The respective mean difference for all foods combined was −5 % (95 % CI −12, 2 %). Especially larger portions of the staple foods were often underestimated. For the staple foods, between 62 % and 64 % of the participants were classified into the same thirds of the distribution of estimated and actual food consumption and for sauces, the percentages ranged from 38 % to 63 %. Bland–Altman plots showed wide limits of agreement.

Using life-sized food photographs among adolescent Mozambican girls resulted in a rather large variation in the accuracy of individuals’ estimates. The ability to rank individuals according to their consumption was, however, satisfactory for most foods. There seems to be a need to further develop and test food photographs used in different populations in Sub-Saharan Africa to improve the accuracy of portion size estimates.

To determine perceptions, beliefs and experiences affecting breast-feeding in Marshallese mothers residing in Northwest Arkansas, USA.

A qualitative, exploratory study using a brief survey and focus groups. Marshallese women, 18 years or older who had a child under 7 years of age, were included in the study.

Community-based organization in Northwest Arkansas.

The majority of mothers viewed breast milk as superior to formula, but had concerns about adequate milk supply and the nutritional value of their milk. The primary barriers to exclusive breast-feeding in the USA included public shaming (both verbal and non-verbal), perceived milk production and quality, and maternal employment. These barriers are not reported in the Marshall Islands and are encountered only after moving to the USA. Breast-feeding mothers rely heavily on familial support, especially the eldest female, who may not reside in the USA. The influence of institutions, including the Special Supplemental Nutrition Program for Women, Infants, and Children, is strong and may negatively affect breast-feeding.

Despite the belief that breast milk is the healthiest option, breast-feeding among Marshallese mothers is challenged by numerous barriers they encounter as they assimilate to US cultural norms. The barriers and challenges, along with the strong desire to assimilate to US culture, impact Marshallese mothers’ perceptions, beliefs and experiences with breast-feeding.

To examine the cross-sectional and inter-temporal validity of the Household Food Insecurity Access Scale (HFIAS) for rural households in Burundi.

Longitudinal survey about food security and agricultural production, individually administered by trained interviewers in June 2007 and 2012.

Ngozi, north of Burundi.

Three hundred and fourteen household heads were interviewed.

Tobit models showed that the HFIAS was significantly correlated with objective measures of food security, in this case total annual food production (P<0·01), livestock keeping (P<0·01) and coffee production (P<0·01) in both 2007 and 2012. This confirms that the HFIAS is cross-sectionally valid and corroborates the findings of previous studies. However, while total food production decreased by more than 25 % in terms of energy between 2007 and 2012, households reported an improvement in their perceived food security over the same period, with the HFIAS decreasing from 13·9 to 10·8 (P<0·001). This finding questions the inter-temporal validity of the HFIAS. It may be partly explained through response shifts, in which households assess their own food security status in comparison to that of their peers.

The evidence from our study suggests that the HFIAS is cross-sectionally valid, but may not be inter-temporally valid, and should not be used as a single indicator to study temporal trends in food security.

To explore the use of references to the COVID-19 pandemic as part of the marketing strategies used on Facebook to promote ultra-processed products.

A search for Facebook accounts of ultra-processed products was performed using a master list of products commercialised in two online supermarkets in Uruguay. For each of the identified Facebook accounts, all the content posted from the confirmation of the first cases of COVID-19 in Uruguay, on 14 March 2020, until 1 July 2020 was recorded. Posts including mentions to COVID-19, social distancing measures or their consequences were identified and analysed using content analysis.

Uruguay, Latin America.

A total of 135 Facebook accounts were identified, which generated a total of 1749 posts related to ultra-processed products, from which 35 % included references to COVID-19. The majority of the posts included references to prevention measures. Approximately one-third of the posts included proposals of activities to do at home, most of which were linked to a healthy lifestyle. Tips for coping with quarantine and descriptions of the charitable work undertaken by brands were also identified.

Results from the present work provide evidence that industries of ultra-processed products have taken advantage of the COVID-19 pandemic to promote their products, create positive associations with the brands and improve their image as part of their digital marketing strategies.

Food insecurity is associated with numerous adverse health outcomes. The US Veterans Health Administration (VHA) began universal food insecurity screening in 2017. This study examined prevalence and correlates of food insecurity among Veterans screened.

Retrospective cross-sectional study using VHA administrative data. Multivariable logistic regression models were estimated to identify sociodemographic and medical characteristics associated with a positive food insecurity screen.

All US Veterans Administration (VA) medical centres (n 161).

All Veterans were screened for food insecurity since screening initiation (July 2017–December 2018).

Of 3 304 702 Veterans screened for food insecurity, 44 298 were positive on their initial screen (1·3 % of men; 2·0 % of women). Food insecurity was associated with identifying as non-Hispanic Black or Hispanic. Veterans who were non-married/partnered, low-income Veterans without VA disability-related compensation and those with housing instability had higher odds of food insecurity, as did Veterans with a BMI < 18·5, diabetes, depression and post-traumatic stress disorder. Prior military sexual trauma (MST) was associated with food insecurity among both men and women. Women screening positive, however, were eight times more likely than men to have experienced MST (48·9 % v. 5·9 %).

Food insecurity was associated with medical and trauma-related comorbidities as well as unmet social needs including housing instability. Additionally, Veterans of colour and women were at higher risk for food insecurity. Findings can inform development of tailored interventions to address food insecurity such as more frequent screening among high-risk populations, onsite support applying for federal food assistance programs and formal partnerships with community-based resources.