To reduce children’s sugar-sweetened beverage intake, California’s Healthy-By-Default Beverage law (SB1192) mandates only unflavoured dairy/non-dairy milk or water be the default drinks with restaurant children’s meals. The objective of this study is to examine consistency with this law for meals sold through online platforms from restaurants in low-income California neighbourhoods.

This observational, cross-sectional study examines beverage availability, upcharges (additional cost) and presentation of beverage options consistent with SB1192 (using four increasingly restrictive criteria) within a random sample of quick-service restaurants (QSR) in Supplemental Nutrition Assistance Program Education eligible census tracts selling children’s meals online from November 2020 to April 2021.

Low-income California neighbourhoods (n 226 census tracts).

QSR that sold children’s meals online via a restaurant-specific platform, DoorDash, GrubHub and/or UberEats (n 631 observations from 254 QSR).

Seventy percent of observations offered water; 63 % offered unflavoured milk. Among all beverages, water was most likely to have an upcharge; among observations offering water (n 445), 41 % had an upcharge (average $0·51). Among observations offering unflavoured milk (n 396), 11 % had an upcharge (average $0·38). No observations upcharged for soda (regular or diet). Implementation consistency with SB1192 ranged from 40·5 % (using the least restrictive criteria) to 5·6 % (most restrictive) of observations.

Based on observations from restaurant websites and three of the most popular online ordering platforms, most California QSR located in low-income neighbourhoods are not offering children’s meal beverages consistent with the state’s Healthy-By-Default Beverage law. As the popularity of online ordering increases, further work to ensure restaurants offering healthy default beverages with children’s meals sold online is necessary.

There are many systematic reviews of weight management interventions delivered by healthcare professionals (HCP), but it is not clear under what circumstances interventions are effective due to differences in review methodology. This review of systematic reviews synthesises the evidence about: (a) the effectiveness of HCP-delivered weight management interventions and (b) intervention and sample characteristics related to their effectiveness.

The review of reviews involved searching six databases (inception – October 2020). Reviews were included if they were (a) systematic, (b) weight management interventions delivered, at least partially, by HCP, (c) of randomised controlled trials and (d) written in English. Data regarding weight management outcomes (e.g. weight) and moderating factors were extracted. Secondary analyses were conducted using study-level data reported in each of the reviews.

The review included studies that were delivered by HCP in any clinical or non-clinical setting.

Not applicable.

Six systematic reviews were included (forty-six unique studies). First-level synthesis showed that weight management interventions delivered by HCP are effective. The second-level synthesis found that interventions are only successful for up to 6 months, are most effective for women, non-Caucasians and adults and are most effective if they have at least six sessions.

As interventions are only successful for up to 6 months, they are not sufficient for achieving and maintaining a healthy weight.

Antenatal multiple micronutrient supplements (MMS) are a cost-effective intervention to reduce adverse pregnancy and birth outcomes. However, the current WHO recommendation on the use of antenatal MMS is conditional, partly due to concerns about the effect on neonatal mortality in a subgroup of studies comparing MMS with iron and folic acid (IFA) supplements containing 60 mg of Fe. We aimed to assess the effect of MMS v. IFA on neonatal mortality stratified by Fe dose in each supplement.

We updated the neonatal mortality analysis of the 2020 WHO guidelines using the generic inverse variance method and applied the random effects model to calculate the effect estimates of MMS v. IFA on neonatal mortality in subgroups of trials (n 13) providing the same or different amounts of Fe, that is, MMS with 60 mg of Fe v. IFA with 60 mg of Fe; MMS with 30 mg of Fe v. IFA with 30 mg of Fe; MMS with 30 mg of Fe v. IFA with 60 mg of Fe; and MMS with 20 mg of Fe v. IFA with 60 mg of Fe.

There were no statistically significant differences in neonatal mortality between MMS and IFA within any of the subgroups of trials. Analysis of MMS with 30 mg v. IFA with 60 mg of Fe (7 trials, 14 114 participants), yielded a non-significant risk ratio of 1·12 (95 % CI 0·83 to 1·50).

Neonatal mortality did not differ between MMS and IFA regardless of Fe dose in either supplement.

To examine associations among neighbourhood food environments (NFE), household food insecurity (HFI) and child’s weight-related outcomes in a racially/ethnically diverse sample of US-born and immigrant/refugee families.

This cross-sectional, observational study involving individual and geographic-level data used multilevel models to estimate associations between neighbourhood food environment and child outcomes. Interactions between HFI and NFE were employed to determine whether HFI moderated the association between NFE and child outcomes and whether the associations differed for US-born v. immigrant/refugee groups.

The sample resided in 367 census tracts in the Minneapolis/St. Paul, MN metropolitan area, and the data were collected in 2016–2019.

The sample was from the Family Matters study of families (n 1296) with children from six racial/ethnic and immigrant/refugee groups (African American, Latino, Hmong, Native American, Somali/Ethiopian and White).

Living in a neighbourhood with low perceived access to affordable fresh fruits and vegetables was found to be associated with lower food security (P < 0·01), poorer child diet quality (P < 0·01) and reduced availability of a variety of fruits (P < 0·01), vegetables (P < 0·05) and whole grains in the home (P < 0·01). Moreover, residing in a food desert was found to be associated with a higher child BMI percentile if the child’s household was food insecure (P < 0·05). No differences in associations were found for immigrant/refugee groups.

Poor NFE were associated with worse weight-related outcomes for children; the association with weight was more pronounced among children with HFI. Interventions aiming to improve child weight-related outcomes should consider both NFE and HFI.

This study evaluated the impact of the Addis Ababa School Feeding Program (SFP) on educational outcomes.

Single-group repeated measurement/longitudinal study design and multistage stratified sampling design were followed. Effect sizes estimates, repeated measures ANOVA, Chi-square, Generalised Additive Mixed Model and mixed effects negative binomial regression were used. Academic scores, attendance and dropout and height and weight of schoolchildren were collected.

School Feeding Programs in Addis Ababa, Ethiopia.

Schoolchildren in primary schools and school directors and teachers in fifteen randomly selected schools for Key Informant Interview (KII).

Anthropometric measurements of 4500 schoolchildren were taken from 50 schools. Academic scores of 3924 schoolchildren from 46 schools, class attendance records of 1584 schoolchildren from 18 schools and annual enrolment records of 50 schools were gathered. School meals achieved a minimum to large scale effects on educational outcomes with effect sizes (η 2) of academic scores (boys = 0·023, girls = 0·04), enrolment (girls = 0·001, boys = 0·05) and attendance (Cramer’s V = 0·2). The average scores of girls were significantly higher than that of boys (P < 0·0001). Height-for-age in all schoolchildren (P < 0·01) and BMI-for-age Z-scores in adolescent girls of 15–19 years (P < 0·0001) never had a significant positive relationship with average scores. Significant relation was observed between nutritional status and attendance (P = 0·021). KII showed that SFP created convenient teaching–learning environment and reduced hunger in schools, while boosting enrolment, attendance and academic performance among the schoolchildren.

The Addis Ababa SFP has positively contributed to educational outcomes. Strengthening the program would enhance nutritional outcomes and diminish educational inequalities.

Despite broad agreement on the need for comprehensive policy action to improve the healthiness of food environments, implementation of recommended policies has been slow and fragmented. Benchmarking is increasingly being used to strengthen accountability for action. However, there have been few evaluations of benchmarking and accountability initiatives to understand their contribution to policy change. This study aimed to evaluate the impact of the Healthy Food Environment Policy Index (Food-EPI) Australia initiative (2016–2020) that assessed Australian governments on their progress in implementing recommended policies for improving food environments.

A convergent mixed methods approach was employed incorporating data from online surveys (conducted in 2017 and 2020) and in-depth semi-structured interviews (conducted in 2020). Data were analysed against a pre-defined logic model.

Australia.

Interviews: twenty stakeholders (sixteen government, four non-government). Online surveys: fifty-three non-government stakeholders (52 % response rate) in 2017; thirty-four non-government stakeholders (36 % response rate) in 2020.

The Food-EPI process involved extensive engagement with government officials and the broader public health community across Australia. Food-EPI Australia was found to support policy processes, including as a tool to increase knowledge of good practice, as a process for collaboration and as an authoritative reference to support policy decisions and advocacy strategies.

Key stakeholders involved in the Food-EPI Australia process viewed it as a valuable initiative that should be repeated to maximise its value as an accountability mechanism. The highly collaborative nature of the initiative was seen as a key strength that could inform design of other benchmarking processes.

To evaluate the effectiveness of a nutritional intervention to promote fruit and vegetable (FV) intake.

A randomised controlled community trial was conducted to evaluate the effectiveness of a 7-month nutritional intervention and to promote FV intake, separately and together. All participants attended physical exercise sessions. The intervention was based on the transtheoretical model and Paulo Freire’s pedagogy. The interventions included group educational sessions, motivational cards and informational materials. The primary outcome was a change in FV intake (g/d), and secondary outcomes included stages of change, self-efficacy, decisional balance and knowledge on FV. All data were collected face-to-face; and FV intake was assessed using a validated brief questionnaire.

Health promotion services of Brazilian Primary Health Care.

3414 users of Brazilian Primary Health Care (1931 in the control group and 1483 in the intervention group (IG)).

At baseline, the average daily FV intake was 370·4 g/d (95 % CI 364·2, 376·6). The increase in FV intake (23·4 g/d; 95 % CI 6·7, 40·0) and fruit intake (+17·3 g/d; 95 % CI 5·1, 29·4; P = 0·01) was greater in the IG among participants in the lowest baseline intake. Participants in the IG also showed progression in the stages of change (P < 0·001), increased self-efficacy (P < 0·001) and improved knowledge of FV crops (P < 0·001).

The nutritional intervention was effective in increasing FV intake and fruits intake among individuals with a lower intake at baseline and in maintaining FV intake among those who reported consuming FV as recommended (400 g/d).

The objective was to examine risk and protective factors associated with pre- to early-pandemic changes in risk of household food insecurity (FI).

We re-enrolled families from two statewide studies (2017–2020) in an observational cohort (May–August 2020). Caregivers reported on risk of household FI, demographics, pandemic-related hardships, and participation in safety net programmes (e.g. Coronavirus Aid, Relief, and Economic Security (CARES) stimulus payment, school meals).

Maryland, USA.

Economically, geographically and racially/ethnically diverse families with preschool to adolescent-age children. Eligibility included reported receipt or expected receipt of the CARES stimulus payment or a pandemic-related economic hardship (n 496).

Prevalence of risk of FI was unchanged (pre-pandemic: 22 %, early-pandemic: 25 %, p = 0·27). Risk of early-pandemic FI was elevated for non-Hispanic Black (adjusted relative risk (aRR) = 2·1 (95 % CI 1·1, 4·0)) and Other families (aRR = 2·6 (1·3, 5·4)) and families earning ≤ 300 % federal poverty level. Among pre-pandemic food secure families, decreased income, job loss and reduced hours were associated with increased early-pandemic FI risk (aRR = 2·1 (1·2, 3·6) to 2·5 (1·5, 4·1)); CARES stimulus payment (aRR = 0·5 (0·3, 0·9)) and continued school meal participation (aRR = 0·2 (0·1, 0·9)) were associated with decreased risk. Among families at risk of FI pre-pandemic, safety net programme participation was not associated with early-pandemic FI risk.

The CARES stimulus payment and continued school meal participation protected pre-pandemic food secure families from early-pandemic FI risk but did not protect families who were at risk of FI pre-pandemic. Mitigating pre-pandemic FI risk and providing stimulus payments and school meals may support children’s health and reduce disparities in response to pandemics.

This qualitative study aimed to explore young Australians’ perspectives, motivators and current practices in achieving a sustainable and healthy diet.

Semi-structured online interviews were conducted with young Australians. Interviews were audio-recorded using the online Zoom platform, transcribed and analysed using a deductive analysis method by applying the Theoretical Domains Framework and inductive thematic data analysis.

Young Australians recruited via social media platforms, noticeboard announcements and flyers.

Twenty-two Australians aged 18 to 25 years.

The majority of participants were aware of some aspects of a sustainable and healthy diet and indicated the need to reduce meat intake, increase intake of plant-based foods, reduce food wastage and packaging and reduce food miles. Young adults were motivated to adopt more sustainable dietary practices but reported that individual and environmental factors such as low food literacy, limited food preparation and cooking skills, lack of availability and accessibility of environmentally friendly food options and costs associated with sustainable and healthy diets hindered their ability to do so.

Given the barriers faced by many of our participants, there is a need for interventions aimed at improving food literacy and food preparation and cooking skills as well as those that create food environments that make it easy to select sustainable and healthy diets. Future research is needed for longitudinal larger scale quantitative studies to confirm our qualitative findings. In addition, the development and evaluation of individual and micro-environmental-based interventions promote sustainable and healthy diets more comprehensively.

To evaluate the impact of the 2017 update to the voluntary Advertising Standards Authority (ASA) code for advertising food on children and young people’s exposure to unhealthy food advertisements on New Zealand television.

Audience ratings data were analysed for New Zealand children and young people’s television viewing for eight random days prior to (June to August 2015) and following (October to December 2018) the code update, from 06.00 to midnight (864 h). Food advertisements were coded using three nutrient profiling models. The number of children and young people watching television each year was compared.

Three free-to-air New Zealand television channels.

New Zealand children aged 5–18 years.

Television viewer numbers decreased over the 3 years (P < 0·0001). The mean rate of unhealthy food advertising on weekdays was 10·4 advertisements/h (2015) and 9·5 advertisements/h (2018). Corresponding rates for weekend days were 8·1 and 7·3 advertisements/h, respectively. The percentage of food advertisements which were for unhealthy foods remained high (63·7 % on weekdays and 65·9 % on weekends) in 2018. The ASA definition of children’s ‘peak viewing time’ (when 25 % of the audience are children) did not correspond to any broadcast times across weekdays and weekend days.

Between 2015 and 2018, children and young people’s television exposure to unhealthy food advertising decreased. However, almost two-thirds of all food advertisements were still unhealthy, and the updated ASA code excluded the times when the greatest number of children was watching television. Consequently, government regulation and regular monitoring should reflect the evolving food marketing environment.

Are diets with a greater environmental impact less healthy? This is a key question for nutrition policy, but previous research does not provide a clear answer. To address this, our objective here was to test whether American diets with the highest carbon footprints predicted greater population-level mortality from diet-related chronic disease than those with the lowest.

Baseline dietary recall data were combined with a database of greenhouse gases emitted in the production of foods to estimate a carbon footprint for each diet. Diets were ranked on their carbon footprints and those in the highest and lowest quintiles were studied here. Preventable Risk Integrated Model (PRIME), an epidemiological modelling software, was used to assess CVD and cancer mortality for a simulated dietary change from the highest to the lowest impact diets. The diet–mortality relationships used by PRIME came from published meta-analyses of randomised controlled trials and prospective cohort studies.

USA.

Baseline diets came from adults (n 12 865) in the nationally representative 2005–2010 National Health and Nutrition Examination Survey.

A simulated change at the population level from the highest to the lowest carbon footprint diets resulted in 23 739 (95 % CI 20 349, 27 065) fewer annual deaths from CVD and cancer. This represents a 1·83 % (95 % CI 1·57 %, 2·08 %) decrease in total deaths. About 95 % of deaths averted were from CVD.

Diets with the highest carbon footprints were associated with a greater risk of mortality than the lowest, suggesting that dietary guidance could incorporate sustainability information to reinforce health messaging.

To develop a simulation framework for assessing how combinations of taxes, nutrition warning labels and advertising levels could affect purchasing of ultra-processed foods (UPF) in Latin American countries and to understand whether policies reinforce or reduce pre-existing social disparities in UPF consumption.

We developed an agent-based simulation model using international evidence regarding the effect of price, nutrition warning labels and advertising on UPF purchasing.

We estimated policy effects in scenarios representing two stages of the ‘social transition’ in UPF purchasing: (1) a pre-transition scenario, where UPF purchasing is higher among high-income households, similar to patterns in Mexico; and (2) a post-transition scenario where UPF purchasing is highest among low-income households, similar to patterns in Chile.

A population of 1000 individual agents with levels of age, income, educational attainment and UPF purchasing similar to adult women in Mexico.

A 20 % tax would decrease purchasing by 24 % relative to baseline in both the pre- and post-transition scenarios, an effect that is similar in magnitude to that of a nutrition warning label policy. A 50 % advertising increase or decrease had a comparatively small effect. Nutrition warning labels were most effective among those with higher levels of educational attainment. Labelling reduced inequities in the pre-transition scenario (i.e. highest UPF purchasing among the highest socio-economic group) but widened inequities in the post-transition scenario.

Effective policy levers are available to reduce UPF purchasing, but policymakers should anticipate that equity impacts will differ depending on existing social patterns in UPF purchasing.

Schools can be an effective arena for food education. The Tasty School is a tailored teacher-driven food education model that provides tools for implementing food education in primary schools. This study aimed to investigate the effects of the Tasty School model on pupils’ eating patterns and experiences. We also aimed to assess the implementation strength of the Tasty School.

A quasi-experimental study was conducted during one school year 2019–2020 in fifteen intervention and ten control schools. The intervention schools implemented the Tasty School food education model. The pupils completed web-based baseline and follow-up questionnaires in class during a school day. The principals were interviewed after the intervention. The data were analysed using a mixed-effects model for repeated measures, accounting for the implementation strength and selected standardisation effects.

A total of twenty-five general Finnish primary schools.

1480 pupils from grades 3−6 (age 8–12 years) from five municipalities in Finland.

Percentages of pupils eating a balanced school meal increased in schools where food education was actively implemented (P = 0·027). In addition, pupils’ experience of social participation in school dining strengthened in schools where the Tasty School model was implemented (5-point scale mean from 2·41 to 2·61; P = 0·017).

Healthy eating patterns can be promoted by the active implementation of food education in primary schools. The Tasty School model offers a promising tool for developing healthy eating patterns and increasing social participation among pupils not only in Finland, but also potentially in other countries as well.

To identify the regulatory governance factors that lead to food policies achieving improvements in food environment, consumer behaviour and diet-related health outcomes.

Qualitative comparative analysis (QCA) was used to investigate the relationship between regulatory governance conditions and population nutrition outcomes. The regulatory governance conditions examined entailed: high industry involvement in the policy process, regulatory design, policy instrument design, policy monitoring and enforcement.

n 29 policy cases in the policy areas of food reformulation, nutrition labelling, food taxation and food marketing.

Policies implemented in thirteen countries.

Comprehensive monitoring was identified as a necessary regulatory governance condition for food policies to have an impact and was present in 94 % of policy cases that had a positive impact on nutrition outcomes. We identified two sufficient combinations of regulatory governance conditions. The first sufficient combination of conditions comprised an absence of high industry involvement in the policy process, combined with the presence of strict regulatory design, best-practice instrument design, and comprehensive monitoring and enforcement. Ninety-six percent of policy cases with positive impacts on nutrition outcomes displayed this combination. The second sufficient combination of conditions comprised an absensce of high industry involvement in the policy process, best practice instrument design and comprehensive monitoring. Eighty-two percent of policy cases with positive impacts on nutrition outcomes displayed this combination.

These findings show the importance of regulatory governance on policy outcomes. They suggest a need for more government-led nutrition policy processes and transparent monitoring systems that are independent from industry.

A core function of the public health nutrition workforce is advocacy. Little is known of the nutritionists’ role in policymaking from a policy process theory perspective. The current study analyses the nutritionists’ role in advocating for a six-year governmental plan on obesity prevention in Quebec, Canada.

We conducted qualitative research using Quebec’s obesity policy as a case study to understand the role of nutritionists in advocating for obesity prevention policies. A conceptual framework combining the Advocacy Coalition Framework with a political analysis model based on the Theory of the Strategic Actor was developed to analyse the beliefs, interests and strategies of policy actors including nutritionists. Data sources comprised semi-structured open-ended interviews with key policy actors (n 25), including eight nutritionists (32 %) and policy-related documents (n 267). Data analysis involved thematic coding and analysis using NVivo 11 Pro.

Quebec, Canada.

Key policy actors including nutritionists.

Nutritionists formed the core of the dominant public health coalition. They advocated for an inter-sectoral governmental plan to prevent obesity through enabling environments. Their advocacy, developed through an iterative process, comprised creating a think tank and reinforcing partnerships with key policy actors, conducting research and developing evidence, communicating policy positions and advocacy materials, participating in deliberative forums and negotiating an agreement with other coalitions in the policy subsystem.

Nutritionists’ advocacy influenced agenda setting and policy formulation. This research may contribute to empowering the public health nutrition workforce and strengthening its advocacy practices. It informs practitioners and researchers concerned with obesity policy and workforce development.

In 2019, California and Wilmington, Delaware‘ implemented policies requiring healthier default beverages with restaurant kids’ meals. The current study assessed restaurant beverage offerings and manager perceptions.

Pre-post menu observations were conducted in California and Wilmington. Observations of cashiers/servers during orders were conducted pre-post implementation in California and post-implementation in Wilmington. Changes in California were compared using multilevel logistic regression and paired t tests. Post-implementation, managers were interviewed.

Inside and drive-through ordering venues in a sample of quick-service restaurants in low-income California communities and all restaurants in Wilmington subject to the policy, the month before and 7–12 months after policy implementation.

Restaurant observations (California n 110; Wilmington n 14); managers (California n 75; Wilmington n 15).

Pre-implementation, the most common kids’ meal beverages on California menus were unflavoured milk and water (78·8 %, 52·0 %); in Wilmington, juice, milk and sugar-sweetened beverages were most common (81·8 %, 66·7 % and 46·2 %). Post-implementation, menus including only policy-consistent beverages significantly increased in California (9·7 % to 66·1 %, P < 0·0001), but remained constant in Wilmington (30·8 %). During orders, cashiers/servers offering only policy-consistent beverages significantly decreased post-implementation in California (5·0 % to 1·0 %, P = 0·002). Few managers (California 29·3 %; Wilmington 0 %) reported policy knowledge, although most expressed support. Most managers wanted additional information for customers and staff.

While the proportion of menus offering only policy-consistent kids’ meal default beverages increased in California, offerings did not change in Wilmington. In both jurisdictions, managers lacked policy knowledge, and few cashiers/servers offered only policy-consistent beverages. Additional efforts are needed to strengthen implementation of kids’ meal beverage policies.

To assess in 2021 the acceptance and perception of the French tax on sweetened beverages, following its revision in 2018, and factors associated with a higher level of acceptance.

A cross-sectional survey within the NutriNet-Santé cohort study. Participants were invited to complete a self-reported questionnaire in March 2021. Weighting was applied to the sample to allow inferences on the French population. Individual characteristics associated with support for the tax were investigated using logistic regression modelling.

NutriNet-Santé prospective cohort study.

Adults engaged in the NutriNet-Santé cohort, aged 18 years or older (n 28 344), living in mainland France.

Almost two-thirds (63·4 %) of the participants were aware of the existence of a tax on sweetened beverages, although less than a quarter had specific knowledge regarding its design and the 2018 revision. In turn, 64·7 % of participants expressed a favourable opinion towards the taxation scheme. This proportion was higher if tax revenues were used to finance health-related measures (respectively 68·8 % of favourable opinion if used to finance a reduction in prices of healthy products and 76·4 % if used to finance the healthcare system). Multivariable analyses showed that support towards the tax varied among subgroups of the population. Groups who tended to be less financially affected by the measure and those who perceived sugar-sweetened beverages as having detrimental effects were more likely to support the tax.

The revised French sugar-sweetened beverage tax appeared to be favourably received and perceived by the public.