Numerous localities have mandated that chain restaurants post nutrition information at the point of purchase. However, some studies suggest that consumers are not highly responsive to menu labelling. The present qualitative study explored influences on full-service restaurant customers’ noticing and using menu labelling.

Five focus groups were conducted with thirty-six consumers. A semi-structured script elicited barriers and facilitators to using nutrition information by showing excerpts of real menus from full-service chain restaurants.

Participants were recruited from a full-service restaurant chain in Philadelphia, Pennsylvania, USA, in September 2011.

Focus group participants were mostly female, African American, with incomes <$US 60 000, mean age 36 years and education 14·5 years. At recruitment, 33 % (n 12) reported changing their order after seeing nutrition information on the menu.

Three themes characterized influences on label use in restaurants: nutrition knowledge, menu design and display, and normative attitudes and behaviours. Barriers to using labels were low prior knowledge of nutrition; displaying nutrition information using codes; low expectations of the nutritional quality of restaurant food; and restaurant discounts, promotions and social influences that overwhelmed interest in nutrition and reinforced disinterest in nutrition. Facilitators were higher prior knowledge of recommended daily intake; spending time reading the menu; having strong prior interest in nutrition/healthy eating; and being with people who reinforced dietary priorities.

Menu labelling use may increase if consumers learn a few key recommended dietary reference values, understand basic energy intake/expenditure scenarios and if chain restaurants present nutrition information in a user-friendly way and promote healthier items.

To evaluate the ratio of reported energy intake to basal metabolic rate (EI/BMR) among pregnant Indonesian women, as well as identifying risk factors for being an underreporter.

Longitudinal study of dietary intake, using six repeated 24-hour diet recalls each trimester. Basal metabolic rate was estimated from body weight and physical activity from occupation. The lower 95% confidence interval for plausible EI/BMR was calculated and the proportion of underreporters estimated. Risk factors for being an underreporter were assessed in multivariate logistic regression analyses.

Purworejo District, central Java, Indonesia.

Pregnant women (n = 490).

For the three trimesters, EI/BMR ratio was 1.33±0.48, 1.53±0.43 and 1.52±0.40 (mean±standard deviation), respectively. The proportion of underreporters was 29.7%, 16.2% and 17.6%. Characteristics significantly associated with underreporting in at least one trimester included high body mass index and low education.

Levels of underreporting were low among the pregnant Indonesian women during the second and third trimesters. The low EI/BMR ratio during the first trimester likely reflects a true low intake due to nausea, rather than underreporting. Risk factors for being an underreporter included those known from developed countries, i.e. obesity and low education.

The proportion of the Latin American population aged >60 years is expected to double during the next few decades. Metabolic syndrome (MetS) is associated with high morbidity and mortality worldwide. However, little is known about MetS in Latin America in general, and in Ecuador in particular. The present study aimed to examine the prevalence of MetS and its association with blood micronutrient, homocysteine (Hcy) and C-reactive protein (CRP) concentrations in the elderly living in a low-income urban area.

We performed a cross-sectional study. MetS, using the International Diabetes Federation definition, dietary intake and plasma micronutrient, CRP and Hcy concentrations were assessed.

A total of 352 elderly (≥65 years) Ecuadorians.

Quito, Ecuador.

MetS was prevalent (40 %) – considerably more so among women (81 %) than men (19 %; χ2 = 32·6, P < 0·0001). Further, 53 % of those without MetS exhibited two or more of its components. Micronutrient deficiencies were prevalent, including those of vitamin C, zinc, vitamin B12 and folate. Vitamin C and E concentrations were inversely (OR = 0·78, 95 % CI 0·71, 0·86; OR = 0·16, 95 % CI 0·03, 0·81, respectively) and CRP (OR = 1·79, 95 % CI 1·04, 3·06) was positively associated with MetS.

The coexistence of MetS with micronutrient deficiencies suggests that elderly Ecuadorians suffer from the double burden of diseases that are increasingly being observed in less developed countries. More research is needed to determine the causal factors, but results presented suggest that these older adults would benefit from interventions to reduce the risk factors for MetS, in particular higher consumption of micronutrient-rich foods.

To provide an independent monitoring report examining the ongoing impact of Australian self-regulatory pledges on food and drink advertising to children on commercial television.

Analysis of food advertisements across comparable sample time periods in April/May 2006, 2007, 2009, 2010 and 2011. The main outcome measure comprised change in the mean rate of non-core food advertisements from 2006 to 2011.

Sydney free-to-air television channels.

Televised food advertisements.

In 2011 the rate of non-core food advertisements was not significantly different from that in 2006 or 2010 (3·2/h v. 4·1/h and 3·1/h), although there were variations across the intervening years. The rate of fast-food advertising in 2010 was significantly higher than in 2006 (1·8/h v. 1·1/h, P < 0·001), but the same as that in 2011 (1·5/h).

The frequency of non-core food advertising on Sydney television has remained essentially unchanged between 2006 and 2011, despite the implementation of two industry self-regulatory pledges. The current study illustrates the value of independent monitoring as a basic requirement of any responsive regulatory approach.

To determine the relationship between BMI and risk of CVD mortality and all-cause mortality among Malaysian adults.

Population-based, retrospective cohort study. Participants were followed up for 5 years from 2006 to 2010. Mortality data were obtained via record linkages with the Malaysian National Registration Department. Multiple Cox regression was applied to compare risk of CVD and all-cause mortality between BMI categories adjusting for age, gender and ethnicity. Models were generated for all participants, all participants the first 2 years of follow-up, healthy participants, healthy never smokers, never smokers, current smokers and former smokers.

All fourteen states in Malaysia.

Malaysian adults (n 32 839) aged 18 years or above from the third National Health and Morbidity Survey.

Total follow-up time was 153 814 person-years with 1035 deaths from all causes and 225 deaths from CVD. Underweight (BMI<18·5 kg/m2) was associated with a significantly increased risk of all-cause mortality, while obesity (BMI ≥30·0 kg/m2) was associated with a heightened risk of CVD mortality. Overweight (BMI=25·0–29·9 kg/m2) was inversely associated with risk of all-cause mortality. Underweight was significantly associated with all-cause mortality in all models except for current smokers. Overweight was inversely associated with all-cause mortality in all participants. Although a positive trend was observed between BMI and CVD mortality in all participants, a significant association was observed only for severe obesity (BMI≥35·0 kg/m2).

Underweight was associated with increased risk of all-cause mortality and obesity with increased risk of CVD mortality. Therefore, maintaining a normal BMI through leading an active lifestyle and healthy dietary habits should continue to be promoted.

Childhood stunting remains a major public health concern in Bangladesh. To accelerate the reduction rate of stunting, special focus is required during the first 23 months of a child’s life when the bulk of growth takes place. Therefore the present study explored individual-, maternal- and household-level factors associated with stunting among children under 2 years of age in Bangladesh.

Data were collected through a nationwide cross-sectional survey conducted between October 2015 and January 2016. A two-stage cluster random sampling procedure was applied to select 11 428 households. In the first stage, 210 enumerations areas (EA) were selected with probability proportional to EA size (180 EA from rural areas, thirty EA from urban slums). In the second stage, an average of fifty-four households were selected from each EA through systematic random sampling.

Rural areas and urban slums of Bangladesh.

A total of 6539 children aged 0–23 months.

Overall, 29·9 % of the children were stunted. After adjusting for all potential confounders in the modified Poisson regression model, child’s gender, birth weight (individual level), maternal education, age at first pregnancy, nutrition (maternal level), administrative division, place of residence, socio-economic status, food security status, access to sanitary latrine and toilet hygiene condition (household level) were significantly associated with stunting.

The study identified a number of potentially addressable multilevel risk factors for stunting among young children in Bangladesh that should be addressed through comprehensive multicomponent interventions.

The present study investigated whether parent/child pairs would select more healthful foods when: (i) products were labelled with front-of-package (FOP) nutrition labels relative to packages without labels; (ii) products were labelled with colour-coded Multiple Traffic Light (MTL) FOP labels relative to monochromatic Facts up Front (FuF) FOP labels; and (iii) FOP labels were explained via in-aisle signage v. unexplained.

Participants were randomly assigned to one of five conditions: (i) FuF labels with in-aisle signs explaining the labels; (ii) FuF labels, no signage; (iii) MTL labels with in-aisle signage; (iv) MTL labels, no signage; (v) control group, no labels/signage. Saturated fat, sodium, sugar and energy (calorie) content were compared across conditions.

The study took place in a laboratory grocery aisle.

Parent/child pairs (n 153) completed the study.

Results did not support the hypothesis that MTL labels would lead to more healthful choices than FuF labels. The presence of FOP labels did little to improve the healthfulness of selected foods, with few exceptions (participants with v. without access to FOP labels selected lower-calorie cereals, participants with access to both FOP labels and in-aisle explanatory signage selected products with less saturated fat v. participants without explanatory signage).

Neither MTL nor FuF FOP labels led to food choices with significantly lower saturated fat, sodium or sugar. In-aisle signs explaining the FOP labels were somewhat helpful to consumers in making more healthful dietary decisions. New FOP labelling programmes could benefit from campaigns to increase consumer awareness and understanding of the labels.

The current paper aims to describe the characteristics of mothers failing to initiate breast-feeding, provide information on the factors contributing to longer duration of breast-feeding and identify the association of maternal obesity with both initiation and duration of breast-feeding in the Greek population.

Data from the cross-sectional GENESIS (Growth, Exercise and Nutrition Epidemiological Study In preSchoolers) study were used. Mothers were categorized by their pre-pregnancy BMI and their gestational weight gain according to guidelines from the Institute of Medicine.

Preschool children aged 1–5 years in five counties in Greece.

Preschoolers (n 2374) with full maternal anthropometric data before and during pregnancy and breast-feeding data.

A higher percentage of mothers with increased pre-pregnancy BMI or high gestational weight gain failed to initiate breast-feeding compared with their normal-weight counterparts. Obese mothers were 2·86 times more likely to fail in initiating breast-feeding in a multiple logistic regression model. Multiple linear regression analysis showed that among women initiating breast-feeding, those who were either underweight before pregnancy or smoked at the third trimester of pregnancy breast-fed their children for about 1·5 weeks less than their normal-weight or non-smoking counterparts, respectively. Similarly, multiparous women breast-fed their children for about 7 weeks less than uniparous women. In women who initiated breast-feeding, no significant differences in breast-feeding duration were found between women of different gestational weight gains.

Mothers with high pre-pregnancy BMI are less likely to initiate breast-feeding while high gestational weight gain has no effect on either the initiation or duration of breast-feeding in Greece.

To examine the impact of a 6-month participatory and empowerment-based intervention study on employees’ dietary habits and on changes in the canteen nutrition environment.

Worksites were stratified by company type and by the presence or absence of an in-house canteen, and randomly allocated to either an intervention group (five worksites) or a minimum intervention control group (three worksites). The study was carried out in partnership with a trade union and guided by an ecological framework targeting both individual and environment levels. Outcome measures included: (i) changes in employees’ dietary habits derived from 4 d pre-coded food diaries of a group of employees at the worksites (paired-data structure); and (ii) the canteen nutrition environment as identified by aggregating chemical nutritional analysis of individual canteen lunches (different participants at baseline and at endpoint).

Eight blue-collar worksites (five of these with canteens).

Employees.

In the intervention group (n 102), several significant positive nutritional effects were observed among employees, including a median daily decrease in intake of fat (−2·2 %E, P = 0·002) and cake and sweets (−18 g/10 MJ, P = 0·002) and a median increase in intake of dietary fibre (3 g/10 MJ, P < 0·001) and fruit (55 g/d, P = 0·007 and 74 g/10 MJ, P = 0·009). With regard to the canteen nutrition environment, a significant reduction in the percentage of energy obtained from fat was found in the intervention group (median difference 11 %E, P < 0·001, n 144).

The present study shows that moderate positive changes in dietary patterns can be achieved among employees in blue-collar worksites.

The objectives of this paper are to (1) introduce the concept of upstream and downstream public health approaches and discuss diet assessment issues in that context, and (2) provide examples of diet assessment methods and challenges in assessing environmental factors influencing eating patterns.

Dietary assessment of environmental factors is discussed as they relate to nutrition interventions for school-aged children, although the issues transcend population characteristics. Examples of assessment challenges in measuring ‘dietary environments’ are drawn from the Child and Adolescent Trial for Cardiovascular Health (CATCH), Teens Eating for Energy and Nutrition at School (TEENS) and Trying Alternative Cafeteria Options in Schools (TACOS) studies.

The healthfulness of our ‘dietary environments’ (which may include food availability, social norms around food choice and the effect of pricing, policy and promotion on food choice) may be more important in determining what people consume than their individual decision-making about food choice. There is a dearth of published information to inform us on how to assess these ‘dietary environments’.

The present study aimed to derive food purchase patterns considering the convenience level of foods. Associations between identified patterns and dietary quality were analysed, as well as household characteristics associated with the dietary patterns.

A Convenience Food Classification Scheme (CFCS) was developed. After classifying basic food groups into the CFCS, the formed groups were used to apply a factor analysis to identify convenience-based food purchase patterns. For these patterns nutrient and energy densities were examined. Using regression analysis, associations between the adherence to the patterns and household characteristic and attitude variables were analysed.

The study used representative German food purchase data from 2011. Approximately 12 million purchases of 13 131 households were recorded in these data.

Three convenience-based patterns were identified: a low-convenience, a semi-convenience and a ready-to-eat food pattern. Tighter adherence to the semi-convenience pattern was shown to result in the lowest nutrient and highest energy densities. Important factors influencing adherence to the patterns were household size, presence of children and attitudes. Working full-time was negatively associated with adherence to the low-convenience pattern and positively with the ready-to-eat pattern.

Convenience foods were an important part of households’ food baskets which in some cases led to lower nutritional quality. Therefore, it is important to offer convenience foods higher in nutrient density and lower in energy density. Interventions targeted on enhancing cooking skills could be an effective strategy to increase purchases of unprocessed foods, which, in turn, could also contribute to an improved diet quality.

To determine whether maternal anthropometry predicted birth weight, and if so, to identify which cut-offs provided the best prediction of low birth weight (LBW) in a field situation.

Community-based longitudinal study.

A rural union of Bhaluka Upazila, Mymensingh, located 110 km north-west of Dhaka, the capital of Bangladesh.

A total of 1104 normotensive, non-smoking pregnant women who attended community nutrition centres were studied from first presentation at the centre until delivery of their child.

Most of the pregnant mothers were between 20 and 34 years of age. Over one-third of the women were nulliparous, while 12.8% were multiparous (parity ≥ 4). Most (93%) mothers registered between the 3rd and 5th month of pregnancy. The frequency of LBW ( < 2500 g) was 17%. Polynomial regression analyses showed that the best predictors of birth weight (based on adjusted R2 values) were in general weight at registration and weight at month 9, with adjusted R2 ranging from 2.5% to nearly 20%. Sequential regression analyses with height and weight showed that there was a significant effect of height after removing the weight variables, and adjusted R2 increased in all analyses. Weight and height at registration month continued to be the best predictors of LBW. Sensitivity and specificity curves were drawn for each registration month, body mass index and different weight gain groups, and using different weight and height combinations. The results showed that, for registration month 3–5, a combination of weight ( ≤ 45 kg) and height ( ≤ 150 cm) gave the highest sensitivity, which was 50%. However, maternal weight ≤ 43 kg in pregnancy month 3–5 alone gave the highest sensitivity of 80%.

The best predictor of birth weight as a continuous variable was maternal weight at registration, each 1 kg increase in weight at registration being associated with an increase in birth weight of about 260 g. Maternal weight ≤ 43 kg in pregnancy month 3–5 alone gave the highest sensitivity of 80%. A combination of initial weight and height of the mother was not as good a predictor of LBW as weight alone.

It is generally thought that causes of undernutrition are multifactorial, butthere are limited quantitative studies performed. We therefore examined awide range of potential factors associated with undernutrition incommunity-dwelling older adults.

Cross-sectional study.

Community-dwelling older adults (≥65 years) receiving home care in theNetherlands.

Data on potential factors associated with (risk of) undernutrition werecollected among 300 older adults. Nutritional status was assessed by theSNAQ65+ instrument. Undernutrition was defined asmid-upper arm circumference <25 cm or unintentional weight loss of≥4 kg in 6 months. Being at risk of undernutrition was defined ashaving poor appetite and inability to walk up and down stairs of fifteensteps, without resting.

Of all participants, ninety-two (31·7 %) were undernourishedand twenty-four (8·0 %) were at risk of undernutrition. Basedon multivariate logistic regression analyses, the statistically significantfactors associated with (risk of) undernutrition(P<0·05) were: unable to go outside(OR=5·39), intestinal problems (OR=2·88),smoking (OR=2·56), osteoporosis (OR=2·46),eating fewer than three snacks daily (OR=2·61), dependency inactivities of daily living (OR=1·21), physical inactivity(OR=2·01), nausea (OR=2·50) and cancer(OR=2·84); a borderline significant factor was depressionsymptoms (OR=1·83,P=0·053).

The study suggests that (risk of) undernutrition is a multifactorial problemand that associated factors can be found in several domains. These findingsmay support the development of intervention trials for the prevention andtreatment of undernutrition in community-dwelling older adults.

To evaluate the association of the consumption of foods of the ultra-processed group (UPF) with inflammatory markers in the adolescent population in Northeastern Brazil.

A cross-sectional population-based study. Food consumption was evaluated using two 24-h dietary recalls using the NOVA classification for food processing levels. The following inflammatory markers were evaluated: adiponectin, IL-6, IL-8, C-reactive protein (CRP) and TNF-α. Multivariate linear regression was used to investigate the association between the percentage of UPF energy contribution and inflammatory markers.

São Luís, Maranhão, Brazil.

The sample consisted of 391 male and female adolescents, aged from 17 to 18 years.

The average daily energy consumption by adolescents was 8032·9 kJ/d, of which 26·1 % originated from UPF. The upper tertile (T3) of UPF consumption presented higher intake of simple carbohydrates, lipids, saturated fat, and Na and lower protein intake. Individuals in T3 presented higher serum leptin and CRP levels (P < 0·05). Adolescents with UPF energy consumption ≥30·0 % (tertile 3 of UPF) had a 79 % (exp (0·58) = 1·79) increase in IL-8 levels when compared with adolescents in tertile 1 of UPF (P = 0·013).

The association between the consumption of UPF, poor quality diet and pro-inflammatory markers have important harmful effects that can be observed as early as in adolescence.

To investigate demographic and lifestyle factors associated with adherence to the Mediterranean diet (MD) in Israeli adolescents.

Cross-sectional.

School-based.

Schoolchildren (n 5268) aged 11–19 years answered self-administered questionnaires on food consumption, eating habits and lifestyle; a subset (n 578) also completed 24 h food recalls.

Using a modified KIDMED index, 25·5 % of the students had poor, 55·2 % had average and 19·3 % had good MD adherence. Jewish middle-school children had the highest proportion (28·2 %) of poor MD adherence. Olive oil usage, derived from 24 h food recalls, was 18·1 % in Jewish families v. 71·1 % in Arab homes. In Jewish boys, the odds (OR; 95 % CI) of having poor MD adherence was higher in those who watched television/videos/listened to music for ≥2 h/d (1·25; 0·98, 1·58) and those who sometimes/don’t read food labels (1·69; 1·31, 2·18). In Jewish girls, the odds for having poor MD adherence was significantly higher in those whose mother’s schooling was <12 years (2·06; 1·41, 3·00) and those who sometimes/don’t read food labels (1·35; 1·08, 1·69). In Arab boys, watching television/videos/listening to music for ≥2 h/d was significantly associated with poor MD adherence (1·89; 1·16, 3·07). In Arab girls, no aerobic activity or ball games weekly was associated with poor MD adherence (1·38; 0·91, 2·09).

Israeli adolescents had overall a high rate of poor MD adherence. Jewish middle-school children were at the highest risk. Interventions aimed at increasing physical activity, reducing sedentary time, improving mother’s education and promoting reading of food labels are recommended.

To determine the nutritional status of a cohort of 11–12 year olds and ascertain social and demographic factors associated with under- and overweight in early adolescence.

Cross-sectional.

Subgroup (n=1698) of the birth cohort (September–October 1986) of the Jamaican Perinatal Survey enrolled in schools in the Kingston Metropolitan area. One thousand and sixty-three parents or caregivers provided social and demographic information.

Undernutrition and overnutrition are of public health significance among adolescent Jamaican children. Ten per cent of 11–12 year olds had body mass index (BMI) values below the 5th percentile (boys, 10.6%; girls, 7.1%) but this prevalence is relatively low compared with other developing countries. The prevalence of stunting was low (3%). The prevalence of overweight (BMI≥85th percentile) (19.3%) was approaching prevalence rates found in the USA. Similar social and demographic variables were associated with thinness and fatness in males. Birth weight predicted overweight in girls.

Under- and overnutrition in early adolescence are important problems in Jamaica. There is a need to address both under- and overnutrition in adolescence in preventive and rehabilitative intervention programmes.

A national survey was developed in order to assess the difficulties and the potential benefits that the adult Spanish population perceive when they try to eat a healthier diet and also to help nutrition educators to develop relevant and specific strategies to promote healthy eating.

The study survey was carried out according to an established protocol on a representative sample of 1009 Spanish subjects over 15 years of age selected by a multi-stage procedure. This study belongs to a partnership in a pan-European survey about food, nutrition and health. The analysis was focused on the evaluation of the seven most frequently chosen barriers and benefits.

There was a trend to select as the main barriers: ‘irregular work hours’ (29.7%), ‘willpower’ (29.7%) and ‘unappealing food’ (21.3%), while ‘prevent disease’ (73.6%) was the most frequently selected benefit to healthy eating. About 20% of the subjects said they did not have any difficulty eating healthier and most people believed that healthy eating was associated with at least one benefit.

In Spain, nutrition educators should be aware that an irregular and busy lifestyle, willpower and food-related factors (such as price and unappealing foods) are the main perceived barriers to healthy eating. Conversely, the prevention and health promotion aspects are the main perceived benefits.

To examine the potential public health impact on CHD and stroke mortality of replacing one ‘unhealthy’ snack with one ‘healthy’ snack per person, per day, across the UK population.

Nutritional information was obtained for different ‘unhealthy’ (such as crisps, chocolate bars, cakes and pastries) and ‘healthy’ snack products (such as fresh fruit, dried fruit, unsalted nuts or seeds). Expected changes in dietary intake were calculated. The mean change in total blood cholesterol levels was estimated using the Keys equation. The effect of changing cholesterol and salt levels on CHD deaths and on stroke deaths was calculated using the appropriate equations from the Law and He meta-analyses. The estimated reductions in cardiovascular deaths were then tested in a sensitivity analysis.

Substituting one ‘healthy’ snack would reduce saturated fat intake by approximately 4·4 g per person per day, resulting in approximately 2400 fewer CHD deaths and 425 fewer stroke deaths per year. The associated 500 mg decrease in salt intake would result in approximately 1790 fewer CHD deaths and 1330 fewer stroke deaths.

Simply replacing one unhealthy snack with one healthy snack per day might prevent approximately 6000 cardiovascular deaths every year in the UK.

To identify determinants of fruit and vegetable (F&V) consumption among school-aged children.

A survey study was conducted in October 2010. The questionnaire contained questions concerning social and demographic data, lifestyle and dietary habits, particularly the frequency of F&V consumption, availability of F&V and knowledge about recommended amounts of F&V intake.

Polish primary schools.

Children (n 1255) aged 9 years from randomly selected primary schools and their parents.

The children’s consumption of fruit and of vegetables was influenced by the fruit consumption and vegetable consumption of their parents (r=0·333 and r=0·273, respectively; P=0·001), parents encouraging their children to eat F&V (r=0·259 and r=0·271, respectively; P=0·001), giving children F&V to take to school (r=0·338 and r=0·321, respectively; P=0·001) and the availability of F&V at home (r=0·200 and r=0·296, respectively; P=0·001). Parental education influenced only the frequency of fruit consumption (r=0·074; P=0·01). A correlation between parents’ knowledge of the recommended intakes and the frequency of vegetable and fruit consumption by children was noticed (r=0·258 and r=0·192, respectively, P=0·001).

Factors within the family environment such as parents’ dietary habits and F&V availability had the greatest influence on the F&V consumption by children. Educational activities aimed at parents are crucial to increase the consumption of F&V among children.