Christina Berg

Television Food Advertising to Children: A Global Perspective

OBJECTIVES We compared television food advertising to children in several countries. METHODS We undertook a collaboration among 13 research groups in Australia, Asia, Western Europe, and North and South America. Each group recorded programming for 2 weekdays and 2 weekend days between 6:00 and 22:00, for the 3 channels most watched by children, between October 2007 and March 2008. We classified food advertisements as core (nutrient dense, low in energy), noncore (high in undesirable nutrients or energy, as defined by dietary standards), or miscellaneous. We also categorized thematic content (promotional characters and premiums). RESULTS Food advertisements composed 11% to 29% of advertisements. Noncore foods were featured in 53% to 87% of food advertisements, and the rate of noncore food advertising was higher during childrens peak viewing times. Most food advertisements containing persuasive marketing were for noncore products. CONCLUSIONS Across all sampled countries, children were exposed to high volumes of television advertising for unhealthy foods, featuring child-oriented persuasive techniques. Because of the proven connections between food advertising, preferences, and consumption, our findings lend support to calls for regulation of food advertising during childrens peak viewing times.

Eating patterns and portion size associated with obesity in a Swedish population.

The objective of this study was to describe the association between meal pattern and obesity. The study is based on data from the INTERGENE research programme, and the study population consists of randomly selected women and men, aged 25-74, living in the Västra Götaland Region in Sweden. A total of 3610 were examined. Participants with measured BMI> or =30 were compared with others (BMI<30) with respect to questionnaire data on habitual meal patterns and intake of energy estimated from food frequencies and standard portions. Odds ratios (OR) with 95% confidence intervals were adjusted for age, sex, smoking and physical activity in logistic regression models. Being obese was significantly associated with omitting breakfast, OR 1.41 (1.05-1.90), omitting lunch OR 1.31 (1.04-1.66) and eating at night OR 1.62 (1.10-2.39). Obesity was also related to significantly larger self-reported portion sizes of main meals. No statistically significant relationship with intake of total energy was revealed. Thus, the results indicate that examination of meal patterns and portion sizes might tell us more about obesogenic food patterns than traditional nutrient analyses of food frequencies. Being obese was associated with a meal pattern shifted to later in the day and significantly larger self-reported portions of main meals.

Trends in overweight and obesity from 1985 to 2002 in Göteborg, West Sweden.

OBJECTIVE:To study secular trends in overweight and selected correlates in men and women in Göteborg, Sweden.DESIGN:Cross-sequential population-based surveys.SUBJECTS:A total of 2931 female and 2691 male subjects aged 25–64 y participated in WHO MONICA surveys (1985, 1990, 1995) and the INTERGENE study (2002).MEASUREMENTS:Body mass index (BMI), waist-to-hip ratio (WHR), prevalence of overweight (BMI≥25 kg/m2), and obesity (BMI≥30 kg/m2).RESULTS:Mean body weight increased by 3.3 kg for women and 5 kg for men, with a significant upward trend for BMI in men but not women over the 17-y observation period. The prevalence of overweight and obesity increased significantly in both sexes over the period. The largest increase was observed in men, and in women aged 25–34 y. In 2002, the prevalence of overweight was 38% in women and 58% in men, and the prevalence of obesity was 11% in women and 15% in men. No significant secular trends were observed for WHR, but there was an upward trend in prevalence of WHR>0.85 in women. A decreased prevalence of smoking in both sexes was observed together with an increase in reported leisure time physical activity. No significant secular trends were observed in rates of self-reported diabetes, although the risk of diabetes attributable to obesity was 24%.CONCLUSION:The results indicate that 25–64-y-olds in the recent survey were more overweight and obese than earlier studied MONICA participants. The increase in BMI was more pronounced in men while abdominal obesity increased principally in women. Although obesity and overweight are clearly important risk factors for type 2 diabetes, the number of diabetics remains low and any secular increase is not yet apparent.

Trends in blood lipid levels, blood pressure, alcohol and smoking habits from 1985 to 2002: results from INTERGENE and GOT-MONICA

Background Favourable trends in cardiovascular disease have been observed in Sweden. The aim of this study was to study secular trends in a variety of cardiovascular risk factors. Methods Total-, low-density (LDL) and high-density lipoprotein (HDL) serum cholesterol; serum triglycerides; systolic and diastolic blood pressure; self-reported smoking and alcohol consumption were studied in repeated cross-sectional surveys. Data from four population-based samples in Göteborg, Sweden were used—WHO MONICA project 1985, 1990 and 1995, and INTERGENE 2002. A total of 2931 females and 2691 males aged 25–64 consisting of 1021–1624 randomly selected subjects at each survey period participated. Results Serum cholesterol levels showed downward trends but the decline in both total- and LDL-cholesterol seems to be levelling off from 1995 and onwards. No significant changes were observed in serum triglyceride, HDL-serum cholesterol or blood pressure levels. The majority of the participants had higher total- and LDL-serum cholesterol levels than currently recommended. Antihypertensive medical treatment increased in women and the oldest men. The prevalence of smoking decreased from 39 to 25% in women and 35 to 20% in men respectively from 1985–2002. In contrast, the prevalence of subjects consuming strong beer and wine, respectively, at least once a week almost doubled from 1990–2002. Conclusions Cardiovascular risk factor patterns change continuously and need to be monitored. The favourable trends in LDL-serum cholesterol and smoking in the Göteborg surveys were paralleled by less favourable trends in being overweight and alcohol consumption.

Selection bias in a population survey with registry linkage: potential effect on socioeconomic gradient in cardiovascular risk.

Non-participation in population studies is likely to be a source of bias in many types of epidemiologic studies, including those describing social disparities in health. The objective of this paper is to present a non-attendance analysis evaluating the possible impact of selection bias, when investigating the association between education level and cardiovascular risk factors. Data from the INTERGENE research programme including 3,610 randomly selected individuals aged 25–74 (1,908 women and 1,702 men), in West Sweden were used. Only 42% of the invited population participated. Non-attendance analyses were done by comparing data from official registries (Statistics Sweden) covering the entire invited study population. This analysis revealed that participants were more likely to be women, have university education, high income, be married and of Nordic origin compared to non-participants. Among participants, all health behaviours studied were significantly related to education. Physical activity, alcohol use and breakfast consumption were higher in the more educated group, while there were more smokers in the less educated group. Central obesity, obesity and hypertension were also significantly associated with lower education level. Weaker associations were observed for blood lipids, diabetes, high plasma glucose level and perceived stress. The socio-demographic differences between participants and non-participants indicated by the register analysis imply potential biases in epidemiological research. For instance, the positive association between education level and frequent alcohol consumption, may, in part be explained by participation bias. For other risk factors studied, an underestimation of the importance of low socioeconomic status may be more likely.

Strengthening the Reporting of Observational Studies in Epidemiology - nutritional epidemiology (STROBE-nut): An extension of the STROBE statement.

Background Concerns have been raised about the quality of reporting in nutritional epidemiology. Research reporting guidelines such as the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement can improve quality of reporting in observational studies. Herein, we propose recommendations for reporting nutritional epidemiology and dietary assessment research by extending the STROBE statement into Strengthening the Reporting of Observational Studies in Epidemiology—Nutritional Epidemiology (STROBE-nut). Methods and Findings Recommendations for the reporting of nutritional epidemiology and dietary assessment research were developed following a systematic and consultative process, coordinated by a multidisciplinary group of 21 experts. Consensus on reporting guidelines was reached through a three-round Delphi consultation process with 53 external experts. In total, 24 recommendations for nutritional epidemiology were added to the STROBE checklist. Conclusion When used appropriately, reporting guidelines for nutritional epidemiology can contribute to improve reporting of observational studies with a focus on diet and health.

Young children’s screen activities, sweet drink consumption and anthropometry: results from a prospective European study

Background/Objectives:This longitudinal study describes the relationship between young children’s screen time, dietary habits and anthropometric measures. The hypothesis was that television viewing and other screen activities at baseline result in increased consumption of sugar-sweetened beverages (SSB) and increased BMI, BMI z-score and waist to height ratio (WHtR) two years later. A second hypothesis was that SSB consumption mediates the association between the screen activities and changes in the anthropometric measures.Subjects/Methods:The study is a part of the prospective cohort study IDEFICS (“Identification and prevention of dietary and lifestyle-induced health effects in children and infants”), investigating diet, lifestyle and social determinants of obesity in 2 to 9-year-olds in eight European countries (baseline n=16 225, two-year follow-up; n=11 038). Anthropometry was objectively measured, and behaviours were parent-reported.Results:The main hypothesis was supported, but the second hypothesis was not confirmed. The odds ratio of being in the highest quintile of % change in WHtR was 1.26 (95% CI: 1.17–1.36) and in BMI 1.22 (95% CI: 1.13–1.31), for each hour per day watching television. The odds ratio of having increased SSB consumption was 1.19 (95% CI: 1.09–1.29) for each hour per day watching TV. The associations for total screen time were slightly weaker.Conclusions:The results indicate substantial effects of TV viewing and other screen activities for young children, both on their consumption of sugary drinks and on an increase in BMI and central obesity. Our findings suggest that television viewing seems to have a stronger effect on food habits and anthropometry than other screen activities in this age group.

Decreased Fraction of Exhaled Nitric Oxide in Obese Subjects With Asthma Symptoms: Data From the Population Study INTERGENE/ADONIX

BACKGROUND Several studies have demonstrated an association between obesity and asthma. However, it is uncertain if fraction of exhaled nitric oxide (Feno), which is used as a marker of airway inflammation, and atopy are associated with BMI. The aim of this study was to examine if obese subjects with asthma symptoms have a different phenotype of asthma than nonobese subjects as indicated by Feno. METHODS The subjects (N = 2,187) consisted of women and men, aged 25 to 74, living in Gothenburg, Sweden, who participated in the randomly selected INTERGENE study cohort. Measurements included anthropometric measures, bioelectric impedance, Feno, pulmonary function, and blood samples for IgE; questionnaires included items on respiratory symptoms. Obesity was defined as BMI ≥ 30 kg/m(2). In this cross-sectional analysis, general linear models were used to analyze how Feno was associated with anthropometry, body composition, wheezing, and atopy. RESULTS In nonobese subjects, wheezing was associated with raised Feno and atopy, whereas in contrast, obese subjects who reported wheezing had lower Feno than obese subjects without wheezing (16.1 vs 19.1 parts per billion, P < .01). The prevalence of atopy was similar in both of those subgroups (25.0% vs 20.7%, P = .4). Similarly, in 395 subjects (19%) who reported wheezing, Feno was negatively associated with BMI, waist-to-hip ratio, and percentage of body fat, whereas no significant relationships were observed in those without respiratory symptoms. CONCLUSIONS Wheezing was significantly associated with reduced Feno in obese subjects, whereas there was a positive association between wheezing and Feno among the nonobese subjects, indicating a possible difference in asthma phenotype, based on body weight.

Sources of bias in a dietary survey of children

Objective: To compare non-responders and responders to a dietary survey with respect to demographic variables and intention to choose selected breakfast foods, and to examine if there was any systematic change in number of food items reported during a 7 d recording period.Design: Cross-sectional survey.Setting: Mölndal, Sweden.Subjects: All pupils in 5th, 7th and 9th grades in the municipality were asked to complete a questionnaire during school hours. All those present (n=1584, 92% of total) answered questions about lifestyle factors and about intentions, attitudes and beliefs concerning high-fibre bread and milk with varying fat content. All subjects in the initial sample were asked to fill in a 7 d record of food consumed. Acceptable food records were completed by 69% of the initial participants.Results: Subjects not completing the food record differed significantly from participants with respect to demographic, lifestyle and dietary factors. Dropout was more common among those who reported not usually eating breakfast and among those intending to drink whole milk for breakfast. A decline in reported food items during the recording period was also observed.Conclusions: Two sources of bias were observed here, one indicating significant differences between non-participants and participants, the other suggesting the presence of a time-dependent trend in number of recorded foods. It is likely such biases are present in other dietary surveys involving schoolchildren, and should be taken into consideration in the design, analysis and interpretation of such studies.Sponsorship: The Swedish Council for Forestry and Agricultural Research and the National Institute for Public Health.

The association between plasma homocysteine and coronary heart disease is modified by the MTHFR 677C>T polymorphism

Objective An elevated level of total plasma homocysteine (tHcy) has been associated with risk of coronary heart disease (CHD). The level of tHcy is affected by lifestyle, in addition to genetic predisposition. The methylene tetrahydrofolate reductase (MTHFR) 677C>T polymorphism (rs1801133) is among the strongest genetic predictors of tHcy. We examined whether the association between tHcy and CHD is modified by the MTHFR 677C>T polymorphism. Design and setting Data from two case-control studies of first-time myocardial infarction (MI), Stockholm Heart Epidemiology Programme (SHEEP), and for MI and unstable angina, INTERGENE, were analysed in parallel. Patients THcy was determined in a total of 1150 cases and 1753 controls. Interventions None. Main outcome measures The outcome comprised first-time MI and unstable angina, subsumed as CHD. Logistic regression was used to investigate the association between tHcy and CHD, and its modification by genotype. Results High tHcy was confirmed to be a risk factor for CHD in both studies. In SHEEP, the association between tHcy and MI was observed in MTHFR 677 C-homozygotes (OR=1.4, 95% CI 1.2 to 1.6, for a difference by 1 SD of log tHcy) and in heterozygotes (OR=1.3, 95% CI 1.1 to 1.6) but not in T-homozygotes, independent of smoking, physical activity and obesity. An effect modification of similar magnitude was observed but not statistically significant in the smaller INTERGENE study, and confirmed in a meta-analysis of both studies. Conclusions Two Swedish case-control studies showed that the association between elevated tHcy and CHD was confined to carriers of the MTHFR 677 C-allele, which could have implications for the efficiency of tHcy-lowering treatment.