Unhealthy snack foods, diets, and nutritional status ... · 239 unique snack foods or beverages...
Transcript of Unhealthy snack foods, diets, and nutritional status ... · 239 unique snack foods or beverages...
Alissa Pries, Senior Research Advisor, ARCH Project
Helen Keller International
October 30, 2019
Unhealthy snack foods, diets, and nutritional status
during the complementary feeding period: a study
among young children in Kathmandu Valley, Nepal
CHANGING FOOD ENVIRONMENTS AND
DIETS
• Rapid growth in availability of processed foods worldwide with ‘nutrition transitions’ occurring in many LMIC1,2
• Shift in diet patterns increases risk of overweight/obesity in countries with concurrent high rates of undernutrition3
• Increased consumption of snack foods and sugar-sweetened beverages (SSB) among adults and children
EVOLVING FOOD SYSTEMS:TREND FROM GLOBAL NUTRITION REPORT
PREVALENCE OF SUGARY SNACK
CONSUMPTION AMONG CHILDREN 6-23
MONTHS IN LMIC4
0 20 40 60 80 100
Zimbabwe
Uganda
Zambia
Tanzania
Sierra Leone
Madagascar
Cameroon
Swaziland
Nigeria
Liberia
Ghana
Timor-Leste
Namibia
Malawi
Maldives
Cambodia
Nepal
Philippines
% of children 12-23 months
26.4
7.6
57.7
38.4
74.7
31.3
82.7
63.1
0
20
40
60
80
100
Dakar Dar es Salaam Kathmandu Phnom Penh
% o
f ch
ildre
n
6-11 mths
12-23 mths
PROPORTION OF CHILDREN CONSUMING ANY COMMERCIAL SNACK FOOD IN THE LAST 24 HRS5
SNACKS DURING THE COMPLEMENTARY
FEEDING PERIOD: A CONCERN?
• Snacks not necessarily negative; but, snack foods are often energy-dense,
high in trans fats/added sugar/salt
• Overconsumption of unhealthy foods could displace consumption of other
important micronutrients
– Could be a particular concern in LMIC
• Excessive energy intakes; impact on food preferences potential
pathway to obesity and NCDs later in life
• No prior research in LMIC among childern below 2 years...
STUDY OBJECTIVES
1. To describe reasons for use and perceptions of commercial snack foods
and beverages
2. To assess the nutrient profiles and describe the consumption patterns
of unhealthy snack foods/beverages (USFB) consumed
3. To investigate the socio-economic characteristics associated with high
consumption of USFB
4. To describe children’s dietary outcomes (nutrient intakes and dietary
adequacy) and nutritional status (anthropometric and iron status)
5. To assess associations between high consumption of USFB and these
nutritional outcomes
STUDY POPULATION & SAMPLING
DESIGN
Children 12-23 months and their primary
caregivers living in Kathmandu Valley
Two-stage cluster sampling procedure:
1. 78 clusters randomly assigned to municipality
wards based on probability-proportional-to-
size
2. In each cluster, 12 caregivers/children
recruited 2-3 days in advance of data
collection
– 9-10 caregivers/children randomly sampled from
this list for interview
SAMPLE SIZE
Outcomes Measurement Power
Difference
between low/high
USFB consumers
Sample required1
Iron status Hemoglobin 90% 1.0 g/dl516
(n=172 per tercile)
Linear growth LAZ 80% 0.5 LAZ666
(n=222 per tercile)
Ponderal growth WLZ 80% 0.5 WLZ666
(n=222 per tercile)
Dietary adequacy Mean nutrient intake 90% 0.3 SD702
(n=234 per tercile)
1α = 0.05 for all calculations; assumed design effect = 2
Households approached
n=18,300
Household with child 12-23 mths
n=1,129
No child 12-23 mths
n=17,171
Caregiver refused
n=114
Caregiver not resident of
Kathmandu Valley
n=111
Child sick on day of interview
n=47
Eligible children 12-23 mths
n=1,018
Recruited children 12-23 mths
n=904
Completed interviews among children
12-23 mths
n=745
Child not sampled for interview
n=82
Caregiver not available on day of
interview
n=30Children 12-23 mths available on day
of interview
n=827
QUANTITATIVE SURVEY METHODS
Gathered quantitative data through:
1. Structured interview with caregivers
2. Dietary assessment
3. Anthropometric measurements
4. Capillary blood sample
CAREGIVER QUESTIONNAIRE
• Interviewer-administered; ~ 1 hour per interview
• Electronic data collection on tablets
• Survey modules gathered data on:
– Caregiver/child demographic and socio-economic characteristics
– Secondary caregivers and their involvement in child care
DIETARY ASSESSMENT
• 4-pass 24 hour dietary recalls with caregiver of
all food/beverages consumed by child
– Weighed measurement with scales of estimated
portion sizes of all foods/beverages consumed
• Used this data to calculate energy and
nutrient intakes for each child
– Food composition table compiled specifically for this
study
– Label information used for commercial products
• Repeat 24HR for 10% of sample on non-
consecutive day
ANTHROPOMETRIC MEASUREMENTS
• Length (cm) and weight (kg)
measurements for children
– Height and weight also measured for primary
caregivers who were mothers of the child
• 2 repeated measures were taken in serial
BIOCHEMICAL MEASUREMENTS
• 150 μL capillary blood samples taken
• HemoCue use for on-site haemoglobin measurements
• Iron status was assessed through – haemoglobin, serum ferritin
and transferrin receptor
• Two markers of inflammation (AGP and CRP)
EXPOSURE OF INTEREST
High consumption of unhealthy snack foods or beverages (USFB)
Snack foods/beverages: focus on food types, not the act/behaviour of
snacking
• Foods: biscuits, chips/cheeseballs, instant noodles, fruit, jaulo, lito
• Beverages: soft drinks, commercial fruit drinks, and chocolate/malt-based
drinks, milk
Unhealthy: nutrient profiling (United Kingdom FSA model)
High consumption: terciles of USFB consumption based on % of TEI
• low consumers
• moderate consumers
• high consumers
PRIMARY OUTCOMES (LOW VERSUS
HIGH USFB CONSUMERS)
Dietary: total median nutrient intakes; prevalence of risk of inadequate
nutrient intakes
• Ca, Fe, Zn, vitamins – A, C, thiamin, riboflavin, niacin, B6, B12,
folate
Anthropometrics: length-for-age z-scores (LAZ); weight-for-length (WLZ)
Biochemical: iron deficiency anemia
• Low hemoglobin (Hb<11.0 g/dL) and low serum ferritin (<12.0
μg/L)/high transferrin receptor (>8.3 mg/L)
• Adjustment for elevation and presence of infection
RESULTS: USFB CONSUMPTION
239 unique snack foods or beverages
consumed75.3% (n=180) of these were profiled as
‘unhealthy’
87.8% (n=158) of these unhealthy foods were
commercially packaged and branded
USFB contributed one-quarter (24.5%) TEI
Comparable to rates among school-age children in places like the
US or UK
Contribution by consumption tercile:
• Low consumers: 5.2% TEI
• Moderate consumers: 21.5% TEI
• High consumers: 46.9% TEI
RESULTS: CONSUMPTION OF USFB AND
CONTRIBUTION TO TOTAL ENERGY INTAKE
FOOD CATEGORIES % TEI
USFB 24.5 ± 0.7
FOODS 22.5 ± 0.7
Biscuits 10.8 ± 0.5
Candy/chocolates 3.5 ± 0.2
Savory snacks 3.4 ± 0.3
Instant noodles 2.2 ± 0.2
Sweet bread/bakery 2.0 ± 0.2
Traditional savory snacks 0.2 ± 0.04
Processed dairy 0.2 ± 0.09
Sugary breakfast cereal 0.1 ± 0.03
Traditional sweet snacks 0.1 ± 0.04
BEVERAGES 2.0 ± 0.2
Sweetened tea/water 0.8 ± 0.08
Fruit juice drinks 1.0 ± 0.1
Soft drinks 0.1 ± 0.04
Chocolate-powder drinks 0.1 ± 0.04
RESULTS: MEDIAN NUTRIENT INTAKES
Low
(n=249)
Moderate
(n=248)
High
(n=248)P
Energy, kcal/d 666 (459 – 875) 613 (462 – 802) 594 (385 – 833) 0.10
Total fat, g/d 20.8 (13.3 – 33.0) 20.0 (12.6 – 31.6) 19.3 (11.8 – 32.2) 0.98
Protein, g/d 23.5 (15.6 – 33.5)a 18.9 (13.0 – 27.8)b 15.7 (10.2 – 23.2)c <0.001
Calcium, mg/d 353 (184 – 566)a 252 (112 – 455)b 161 (67 – 314)c <0.001
Iron, mg/d 4.0 (2.6 – 6.6)a 3.3 (2.3 – 5.0)b 3.0 (1.7 – 5.0)b <0.001
Zinc, mg/d 3.3 (2.2 – 5.0)a 2.5 (1.7 – 4.0)b 1.8 (1.2 – 3.1)c <0.001
Vitamin C, mg/d 17.1 (6.3 – 34.6)a 15.1 (5.6 – 34.3)a,b 9.5 (3.4 – 25.6)b 0.004
Vitamin A (RAE), μg/d 170 (88 – 301)a 116 (54 – 226)b 81 (31 – 171)c <0.001
Thiamin, mg/d 0.4 (0.3 – 0.7)a 0.3 (0.2 – 0.5)b 0.3 (0.2 – 0.5)b 0.054
Riboflavin, mg/d 0.8 (0.4 – 1.3)a 0.6 (0.3 – 1.1)b 0.5 (0.2 – 0.8)b <0.001
Niacin, mg/d 4.8 (2.9 – 7.4)a 4.2 (2.5 – 6.7)b 3.4 (2.1 – 5.8)b 0.005
Vitamin B-6, mg/d 0.4 (0.3 – 0.7)a 0.4 (0.3 – 0.6)a 0.3 (0.2 – 0.5)b <0.001
Vitamin B-12, μg/d 0.9 (0.5 – 1.5)a 0.7 (0.3 – 1.3)b 0.6 (0.2 – 1.0)b <0.001
Folate, μg/d 72.0 (43.3 – 120.9)a 57.4 (34.1 – 90.6)b 47.6 (25.2 – 71.2)c <0.0011ANOVA of log transformed data with cluster adjustment used and Bonferroni post-hoc tests conducted to compare between groups;
labeled medians in a row without a common letter differ, P<0.05
RESULTS: % AT RISK OF INADEQUATE NUTRIENT
INTAKES
5.7
49.1
97.2
15.7
3.012.1
39.8
14.7
51.2
39.1
21.6
70.5
10.2
78.8
100.0
39.1
4.9
21.3
50.4
28.9
58.2 56.8
30.3
89.1
0
20
40
60
80
100
% o
f chi
ldre
n
Low USF/SSB consumers (n=249) High USF/SSB consumers (n=248)
– High USFB consumer LAZ: -1.12 ± 1.06
– Moderate USFB consumer LAZ: -0.93 ± 1.04
– Low USFB consumer LAZ: -0.75 ± 1.15
Mean length-for-age z-scores (LAZ) was 0.3 SD lower among high snack food consumers,
as compared to low consumers
ASSOCIATION WITH GROWTH
Unadjusted1 Adjusted2
n β
(95% CI) p n
β (95% CI)
p
Length-for-age z-score (LAZ) 733 -0.37
(-0.56 – -0.18) <0.001 684
-0.29
(-0.49 – -0.10) 0.003
Weight-for-length z-score (WLZ)7 732 0.03
(-0.15 – 0.21) 0.77 683
-0.09
(-0.28 – 0.10) 0.37
n OR
(95% CI) p n
OR
(95% CI) p
Stunting (LAZ < -2) 733 1.51
(0.95 – 2.39) 0.08 684
1.25
(0.70 – 2.24) 0.45
Wasting5 (WLZ < -2) 732 0.65
(0.29 – 1.48) 0.31 683
1.11
(0.40 – 3.04) 0.84
1Comparisons between high and low snack consumers made using random-effects linear and logistic regression with cluster adjustment 2Adjusted for: child age, sex, morbidity, deworming, immunization status, vitamin A supplementation, birthweight, breastfeeding status,
caste/ethnicity, caregiver education, household food security and wealth status
Reference: Pries et al. (2019)
ARCH NEPAL STUDY: PRODUCT
LABELS
The nutrient content of the 15 most commonly consumed products from
several categories were analysed:
– Infant cereal: N = 3 products
– Biscuits: N = 4 products
– Chocolates: N = 2 products
– Instant noodles: N = 2 products
– Savory snacks: N = 2 products
– Sugar sweetened beverages: N = 2 products
NUTRIENT COMPOSITION
RESULTS
VS. LABEL – INFANT CEREALS
Iron Calcium ZincTotal
sugar
Total
sodium
Infant
cereal A48% 34% 36% 116% 42%
Infant
cereal B-80%
Not on
label
Not on
label
Not on
label
Not on
label
Infant
cereal C-83% -85%
Not on
label
Not on
label
NOTE: = if percent difference <10%
NUTRIENT COMPOSITION RESULTS
VS. LABEL– INSTANT NOODLES
Iron Calcium ZincTotal
sugar
Total
sodium
Noodle A -17% 27%Not on
label
Not on
label200%
Noodle B -23%Not on
label13% 37%
NOTE: = if percent difference <10%
How can we protect young children’s diets in changing
food environments?
• Listening to caregivers’ reasons for use
• Marketing regulations
• Product standards
POLICY SOLUTIONS
GLOBAL GUIDANCE FOR MARKETING
REGULATIONS CHILDREN < 2 YEARSBreast-milk
substitutes
Commercial
complementary
foods
Other commercial
processed foods
(ex. junk food)
???
MARKETING: PRODUCT CLAIMS
“G for
Genius”
“Enriched
with vitamins
+ minerals”
“So
healthy”
“Packed
with fruit
goodness”
“Contains
protein,
calcium,
vitamin D”
SOLUTION: MARKETING
REGULATION
Example: Front of pack labeling regulations in Chile
HOW CAN WE PROTECT YOUNG
CHILDREN’S DIETS: PRODUCT
STANDARDS
• Standards for food fortification and corporate
accountability
– Often what is actually in a package does not match
what is on label
– Consideration for fortified complementary foods as
well
HOW CAN WE PROTECT YOUNG
CHILDREN’S DIETS: PRODUCT
STANDARDS
Reference: Changing Markets Foundation, Cereal offender: is Kellogg’s breaking its breakfast promise? (2019)
HOW CAN WE PROTECT YOUNG
CHILDREN’S DIETS: PRODUCT
STANDARDS
• Standards for food fortification and corporate
accountability
– Often what is actually in a package does not match what
is on label
– Consideration for fortified complementary foods as well
• Fortification of junk foods
– Does this make a product “healthy”?? reformulation
is necessary
CONCLUSIONS
• Consumption of unhealthy processed foods during the complementary
feeding period can contribute to both overnutrition and undernutrition.
• Caregivers often know these foods are unhealthy, but turn to them for young
child feeding because they are convenient and tasty.
• Given changing food system, how to protect young children’s diets:
– Marketing/labeling regulations to improve caregiver awareness
– Reformulation and fortification standards
– Consider the drivers of these food choices
REFERENCES
1. Monteiro CA, Moubarac JC, Cannon G, Ng SW, Popkin B. Ultra-processed products are becoming dominant in the global food system.
Obes. Rev. 14, 21–28 (2013).
2. Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr. Rev. 70, 3–21 (2012).
3. Popkin BM. The nutrition transition and its health implications in lower-income countries. Public Health Nutr. 1, 5–21 (1998).
4. Huffman S, Piwoz E, Vosti S, Dewey K. Babies, soft drinks and snacks: a concern in low-and middle-income countries? Maternal & Child
Nutrition 10, 562–574 (2014) .
5. Pries AM, Huffman SL, Champeny M, Adhikary I, Benjamin M, Coly AN, Diop EHI, Mengkheang K, Sy NY, Dhungel S, Feeley A, Vitta B,
Zehner E. Consumption of commercially produced snack foods and sugar-sweetened beverages during the complementary feeding period in
four African and Asian urban contexts. Maternal and Child Nutrition, 13(Suppl 2): DOI: 10.1111/mcn.12412 (2017).
6. Ministry of Health and Population (MOHP) Nepal, New ERA & ICF International Inc. Nepal Demographic and Health Survey 2016.
Kathmandu, Nepal: Ministry of Health, Nepal (2017).
7. Pries AM, Rehman AM, Filteau S, Sharma N, Upadhyay A, Ferguson EL. Unhealthy snack food and beverage consumption is associated
with lower dietary adequacy and length-for-age z-scores among 12-23 month-olds in Kathmandu Valley, Nepal. Journal of Nutrition.
DOI:10.1093/jn.nxz140 (2019).
8. Pries AM, Sharma N, Upadhyay A, Rehman AM, Filteau S, Ferguson EL. Energy intake from unhealthy snack food/beverage among 12-23-
month-old children in urban Nepal. Maternal and Child Nutrition, 15(Suppl 4): DOI: 10.1111/mcn.12775 (2019).
9. Pries AM, Filteau S, Ferguson EF. Snack food and beverage consumption in low- and middle-income countries: a systematic review.
Maternal and Child Nutrition, 15(Suppl 4): DOI: 10.1111/mcn.12729 (2019).
10. Sharma N, Ferguson EF, Upadhyay A, Zehner E, Filteau S, Pries AM. Perceptions of commercial snack food and beverages for infant and
young child feeding: a mixed-methods study among caregivers in Kathmandu Valley, Nepal. Maternal and Child Nutrition, 15(Suppl 4): DOI:
10.1111/mcn.12711 (2019).
THANK YOU!
THANK YOU!
HKI: Nisha Sharma, Atul Upadhyay, Babita Adhikari, Anushka
Thapa, Pratik Niraula, Sonia Thebe, Dale Davis, Elizabeth Zehner,
Mary Champeny, Mackenzie Green, Rolf Klemm, Gary Mundy
LSTHM : Elaine Ferguson, Suzanne Filteau, Andrea Rehman