Sara N. Bleich

Increasing Caloric Contribution From Sugar- Sweetened Beverages and 100% Fruit Juices Among US Children and Adolescents, 1988-2004

OBJECTIVE. We sought to document increases in caloric contributions from sugar-sweetened beverages and 100% fruit juice among US youth during 1988–2004. PATIENTS AND METHODS. We analyzed 24-hour dietary recalls from children and adolescents (aged 2–19) in 2 nationally representative population surveys: National Health and Nutrition Examination Survey III (1988–1994, N = 9882) and National Health and Nutrition Examination Survey 1999–2004 (N = 10 962). We estimated trends in caloric contribution, type, and location of sugar-sweetened beverages and 100% fruit juice consumed. RESULTS. Per-capita daily caloric contribution from sugar-sweetened beverages and 100% fruit juice increased from 242 kcal/day (1 kcal = 4.2 kJ) in 1988–1994 to 270 kcal/day in 1999–2004; sugar-sweetened beverage intake increased from 204 to 224 kcal/day and 100% fruit juice increased from 38 to 48 kcal/day. The largest increases occurred among children aged 6 to 11 years (∼20% increase). There was no change in per-capita consumption among white adolescents but significant increases among black and Mexican American youths. On average, respondents aged 2 to 5, 6 to 11, and 12 to 19 years who had sugar-sweetened beverages on the surveyed day in 1999–2004 consumed 176, 229, and 356 kcal/day, respectively. Soda contributed ∼67% of all sugar-sweetened beverage calories among the adolescents, whereas fruit drinks provided more than half of the sugar-sweetened beverage calories consumed by preschool-aged children. Fruit juice drinkers consumed, on average, 148 (ages 2–5), 136 (ages 6–11), and 184 (ages 12–19) kcal/day. On a typical weekday, 55% to 70% of all sugar-sweetened beverage calories were consumed in the home environment, and 7% to 15% occurred in schools. CONCLUSIONS. Children and adolescents today derive 10% to 15% of total calories from sugar-sweetened beverages and 100% fruit juice. Our analysis indicates increasing consumption in all ages. Schools are a limited source for sugar-sweetened beverages, suggesting that initiatives to restrict sugar-sweetened beverage sales in schools may have an only marginal impact on overall consumption. Pediatricians’ awareness of these trends is critical for helping children and parents target suboptimal dietary patterns that may contribute to excess calories and obesity.

Increasing consumption of sugar-sweetened beverages among US adults: 1988–1994 to 1999—2004

BACKGROUND Consumption of sugar-sweetened beverages (SSBs) has been linked to obesity and type 2 diabetes. OBJECTIVE We examined national trends in SSB consumption among US adults by sociodemographic characteristics, body weight status, and weight-loss intention. DESIGN We analyzed 24-h dietary recall data to estimate beverage consumption among adults (aged > or = 20 y) obtained from the third National Health and Nutrition Examination Survey (NHANES III, 1988-1994; n = 15,979) and NHANES 1999-2004 (n = 13,431). RESULTS From 1988-1994 to 1999-2004 on the survey day, the percentage of adult SSB drinkers increased from 58% to 63% (P < 0.001), per capita consumption of SSB increased by 46 kcal/d (P = 0.001), and daily SSB consumption among drinkers increased by 6 oz (P < 0.001). In both survey periods, per capita SSB consumption was highest among young adults (231-289 kcal/d) and lowest among the elderly (68-83 kcal/d). Young blacks had the highest percentage of SSB drinkers and the highest per capita consumption compared with white and Mexican American adults (P < 0.05). Overweight-obese adults with weight-loss intention (compared with those without) were significantly less likely to drink SSB, but they still consumed a considerable amount in 1999-2004 (278 kcal/d). Among young adults, 20% of SSB calories were consumed at work. CONCLUSIONS Over the past decade, US adult SSB consumption has increased. SSB comprises a considerable source of total daily intake and is the largest source of beverage calories. SSB consumption is highest among subgroups also at greatest risk of obesity and type 2 diabetes.

Why is the developed world obese

Obesity has risen dramatically in the past few decades. However, the relative contribution of energy intake and energy expenditure to rising obesity is not known. Moreover, the extent to which social and economic factors tip the energy balance is not well understood. This exploratory study estimates the relative contribution of increased caloric intake and reduced physical activity to obesity in developed countries using two methods of energy accounting. Results show that rising obesity is primarily the result of consuming more calories. We estimate multivariate regression models and use simulation analysis to explore technological and sociodemographic determinants of this dietary excess. Results indicate that the increase in caloric intake is associated with technological innovations as well as changing sociodemographic factors. This review offers useful insights to future research concerned with the etiology of obesity and suggests that obesity-related policies should focus on encouraging lower caloric intake.

How does satisfaction with the health-care system relate to patient experience?

OBJECTIVE To explore what determines peoples satisfaction with the health-care system above and beyond their experience as patients. METHODS Data on health system responsiveness, which refers to the manner and environment in which people are treated when they seek health care, provides a unique opportunity to better understand the determinants of peoples satisfaction with the health-care system and how strongly this is influenced by an individuals experience as a patient. The data were obtained from 21 European Union countries in the World Health Survey for 2003. Additive ordinary least-squares regression models were used to assess the extent to which variables commonly associated with satisfaction with the health-care system, as recorded in the literature, explain the variation around the concept of satisfaction. A residual analysis was used to identify other predictors of satisfaction with the health-care system. FINDINGS Patient experience was significantly associated with satisfaction with the health-care system and explained 10.4% of the variation around the concept of satisfaction. Other factors such as patient expectations, health status, type of care, and immunization coverage were also significant predictors of health system satisfaction; although together they explained only 17.5% of the observed variation, while broader societal factors may largely account for the unexplained portion of satisfaction with the health-care system. CONCLUSION Contrary to published reports, peoples satisfaction with the health-care system depends more on factors external to the health system than on the experience of care as a patient. Thus, measuring the latter may be of limited use as a basis for quality improvement and health system reform.

Systematic review of community-based childhood obesity prevention studies

OBJECTIVE: This study systematically reviewed community-based childhood obesity prevention programs in the United States and high-income countries. METHODS: We searched Medline, Embase, PsychInfo, CINAHL, clinicaltrials.gov, and the Cochrane Library for relevant English-language studies. Studies were eligible if the intervention was primarily implemented in the community setting; had at least 1 year of follow-up after baseline; and compared results from an intervention to a comparison group. Two independent reviewers conducted title scans and abstract reviews and reviewed the full articles to assess eligibility. Each article received a double review for data abstraction. The second reviewer confirmed the first reviewer’s data abstraction for completeness and accuracy. RESULTS: Nine community-based studies were included; 5 randomized controlled trials and 4 non–randomized controlled trials. One study was conducted only in the community setting, 3 were conducted in the community and school setting, and 5 were conducted in the community setting in combination with at least 1 other setting such as the home. Desirable changes in BMI or BMI z-score were found in 4 of the 9 studies. Two studies reported significant improvements in behavioral outcomes (1 in physical activity and 1 in vegetable intake). CONCLUSIONS: The strength of evidence is moderate that a combined diet and physical activity intervention conducted in the community with a school component is more effective at preventing obesity or overweight. More research and consistent methods are needed to understand the comparative effectiveness of childhood obesity prevention programs in the community setting.

What childhood obesity prevention programmes work? A systematic review and meta-analysis

Previous reviews of childhood obesity prevention have focused largely on schools and findings have been inconsistent. Funded by the US Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health, we systematically evaluated the effectiveness of childhood obesity prevention programmes conducted in high‐income countries and implemented in various settings. We searched MEDLINE®, Embase, PsycINFO, CINAHL®, ClinicalTrials.gov and the Cochrane Library from inception through 22 April 2013 for relevant studies, including randomized controlled trials, quasi‐experimental studies and natural experiments, targeting diet, physical activity or both, and conducted in children aged 2–18 in high‐income countries. Two reviewers independently abstracted the data. The strength of evidence (SOE) supporting interventions was graded for each study setting (e.g. home, school). Meta‐analyses were performed on studies judged sufficiently similar and appropriate to pool using random effect models. This paper reported our findings on various adiposity‐related outcomes. We identified 147 articles (139 intervention studies) of which 115 studies were primarily school based, although other settings could have been involved. Most were conducted in the United States and within the past decade. SOE was high for physical activity‐only interventions delivered in schools with home involvement or combined diet–physical activity interventions delivered in schools with both home and community components. SOE was moderate for school‐based interventions targeting either diet or physical activity, combined interventions delivered in schools with home or community components or combined interventions delivered in the community with a school component. SOE was low for combined interventions in childcare or home settings. Evidence was insufficient for other interventions. In conclusion, at least moderately strong evidence supports the effectiveness of school‐based interventions for preventing childhood obesity. More research is needed to evaluate programmes in other settings or of other design types, especially environmental, policy and consumer health informatics‐oriented interventions.

Health Inequalities: Trends, Progress, and Policy

Health inequalities, which have been well documented for decades, have more recently become policy targets in developed countries. This review describes time trends in health inequalities (by sex, race/ethnicity, and socioeconomic status), commitments to reduce health inequalities, and progress made to eliminate health inequalities in the United States, United Kingdom, and other OECD countries. Time-trend data in the United States indicate a narrowing of the gap between the best- and worst-off groups in some health indicators, such as life expectancy, but a widening of the gap in others, such as diabetes prevalence. Similarly, time-trend data in the United Kingdom indicate a narrowing of the gap between the best- and worst-off groups in some indicators, such as hypertension prevalence, whereas the gap between social classes has increased for life expectancy. More research and better methods are needed to measure precisely the relationships between stated policy goals and observed trends in health inequalities.

Physician Practice Patterns of Obesity Diagnosis and Weight-Related Counseling

METHODS we analyzed cross-sectional clinical encounter data. Obese adults were obtained from the 2005 National Ambulatory Medical Care Survey (N=2458). RESULTS a third of obese adults received an obesity diagnosis (28.9%) and approximately a fifth received counseling for weight reduction (17.6%), diet (25.2%), or exercise (20.5%). Women (OR=1.54; 95% CI: 1.14, 2.09), young adults ages 18-29 (OR=2.61; 95% CI: 1.37, 4.97), and severely/morbidly obese individuals (class II: OR 2.08; 95% CI: 1.53, 2.83; class III: OR 4.36; 95% CI: 3.09, 6.16) were significantly more likely to receive an obesity diagnosis. One of the biggest predictors of weight-related counseling was an obesity diagnosis (weight reduction: OR=5.72; 95% CI: 4.01, 8.17; diet: OR=2.89; 95% CI: 2.05, 4.06; exercise: OR=2.54; 95% CI: 1.67, 3.85). Other predictors of weight-related counseling included seeing a cardiologist/other internal medicine specialist, a preventive visit, or spending more time with the doctor (p<0.05). CONCLUSIONS most obese patients do not receive an obesity diagnosis or weight-related counseling. PRACTICE IMPLICATIONS preventive visits may provide a key opportunity for obese patients to receive weight-related counseling from their physician.

Reduction in Purchases of Sugar-Sweetened Beverages Among Low-Income Black Adolescents After Exposure to Caloric Information

OBJECTIVES We examined the effect of an intervention to provide caloric information about sugar-sweetened beverages (SSBs) on the number of SSB purchases. METHODS We used a case-crossover design with 4 corner stores located in low-income, predominately Black neighborhoods in Baltimore, Maryland. The intervention randomly posted 1 of 3 signs with the following caloric information: (1) absolute caloric count, (2) percentage of total recommended daily intake, and (3) physical activity equivalent. We collected data for 1600 beverage sales by Black adolescents, aged 12-18 years, including 400 during a baseline period and 400 for each of the 3 caloric condition interventions. RESULTS Providing Black adolescents with any caloric information significantly reduced the odds of SSB purchases relative to the baseline (odds ratio [OR] = 0.56; 95% confidence interval [CI] = 0.36, 0.89). When examining the 3 caloric conditions separately, the significant effect was observed when caloric information was provided as a physical activity equivalent (OR = 0.51; 95% CI = 0.31, 0.85). CONCLUSIONS Providing easily understandable caloric information--particularly a physical activity equivalent--may reduce calorie intake from SSBs among low-income, Black adolescents.

A systematic review of home-based childhood obesity prevention studies

BACKGROUND AND OBJECTIVES: Childhood obesity is a global epidemic. Despite emerging research about the role of the family and home on obesity risk behaviors, the evidence base for the effectiveness of home-based interventions on obesity prevention remains uncertain. The objective was to systematically review the effectiveness of home-based interventions on weight, intermediate (eg, diet and physical activity [PA]), and clinical outcomes. METHODS: We searched Medline, Embase, PsychInfo, CINAHL, clinicaltrials.gov, and the Cochrane Library from inception through August 11, 2012. We included experimental and natural experimental studies with ≥1-year follow-up reporting weight-related outcomes and targeting children at home. Two independent reviewers screened studies and extracted data. We graded the strength of the evidence supporting interventions targeting diet, PA, or both for obesity prevention. RESULTS: We identified 6 studies; 3 tested combined interventions (diet and PA), 1 used diet intervention, 1 combined intervention with primary care and consumer health informatics components, and 1 combined intervention with school and community components. Select combined interventions had beneficial effects on fruit/vegetable intake and sedentary behaviors. However, none of the 6 studies reported a significant effect on weight outcomes. Overall, the strength of evidence is low that combined home-based interventions effectively prevent obesity. The evidence is insufficient for conclusions about home-based diet interventions or interventions implemented at home in association with other settings. CONCLUSIONS: The strength of evidence is low to support the effectiveness of home-based child obesity prevention programs. Additional research is needed to test interventions in the home setting, particularly those incorporating parenting strategies and addressing environmental influences.