Overweight and obesity in Canada has significantly increased during the last three decades, paralleled by increased intake of fat and sugar particularly sugary beverages leading to higher level of energy intake, as well as reduction in physical activity. Canadian Community Health Survey, Cycle 2.2, 2004 (CCHS 2.2), provides the opportunity to evaluate beverage intakes of Canadians in relation to overweight and obesity using Body Mass Index (BMI).<p> To examine the association between sugar-sweetened beverages and BMI in Canadian adults, we used data from CCHS 2.2 (n=14,304, aged >18 year and <65 year) in which dietary intake was assessed using 24-h recall. In various steps, data on beverage consumption were identified, coded and classified. Using descriptive statistics, we determined total gram intake and the contribution of each beverage to total energy intake among age/sex groups. To determine the most suitable patterns of beverage consumptions among Canadian adults, a cluster analysis K-means method was applied. Males and females were classified into distinct clusters based on the dominant pattern of beverage intakes. Finally, step-wise logistic regression models were used to determine associations between sugar-sweetened beverages and BMI, controlling for age, marital status, income, education, physical activity, total energy intake, immigration status, smoking habits and ethnicity. To account for complex survey design, all data were weighted and bootstrapped.<p> BMI in women with predominant fruit drink pattern (791.1±32.9 g) was significantly higher than those with no dominant pattern in beverage consumption (28.3±1 vs. 26.8±0.3 respectively, P<0.001). In women, high intake of fruit drinks was a significant predictor of overweight (OR=1.84, 95% C.I:1.06-3.20), obesity (OR=2.55, 95% C.I:1.46-4.47) and overweight/obesity (OR=2.05, 95% C.I:1.29-3.25). In men, mean BMI was not different among beverage consumption clusters and none of the beverages was a predictor for overweight and obesity. For the first time, in a nationally representative data, we report association of sugar-sweetened beverages and overweight and obesity in Canadian women.

Overweight and obesity in Canada has significantly increased during the last three decades, paralleled by increased intake of fat and sugar particularly sugary beverages leading to higher level of energy intake, as well as reduction in physical activity. Canadian Community Health Survey, Cycle 2.2, 2004 (CCHS 2.2), provides the opportunity to evaluate beverage intakes of Canadians in relation to overweight and obesity using Body Mass Index (BMI).<p> To examine the association between sugar-sweetened beverages and BMI in Canadian adults, we used data from CCHS 2.2 (n=14,304, aged >18 year and <65 year) in which dietary intake was assessed using 24-h recall. In various steps, data on beverage consumption were identified, coded and classified. Using descriptive statistics, we determined total gram intake and the contribution of each beverage to total energy intake among age/sex groups. To determine the most suitable patterns of beverage consumptions among Canadian adults, a cluster analysis K-means method was applied. Males and females were classified into distinct clusters based on the dominant pattern of beverage intakes. Finally, step-wise logistic regression models were used to determine associations between sugar-sweetened beverages and BMI, controlling for age, marital status, income, education, physical activity, total energy intake, immigration status, smoking habits and ethnicity. To account for complex survey design, all data were weighted and bootstrapped.<p> BMI in women with predominant fruit drink pattern (791.1±32.9 g) was significantly higher than those with no dominant pattern in beverage consumption (28.3±1 vs. 26.8±0.3 respectively, P<0.001). In women, high intake of fruit drinks was a significant predictor of overweight (OR=1.84, 95% C.I:1.06-3.20), obesity (OR=2.55, 95% C.I:1.46-4.47) and overweight/obesity (OR=2.05, 95% C.I:1.29-3.25). In men, mean BMI was not different among beverage consumption clusters and none of the beverages was a predictor for overweight and obesity. For the first time, in a nationally representative data, we report association of sugar-sweetened beverages and overweight and obesity in Canadian women.

Indiana University-Purdue University Indianapolis (IUPUI) / Communities and States are increasingly targeting the consumption of sugar sweetened beverages (SSBs), especially soda, in their efforts to curb childhood obesity. However, the empirical evidence based on which policy makers design the relevant policies is not causally interpretable. In the present study, we suggest a modeling framework that can be used for making causal estimation and inference in the context of childhood obesity. This modeling framework is built upon the two-stage residual inclusion (2SRI) instrumental variables method and have two levels – level one models children’s lifestyle choices and level two models children’s energy balance which is assumed to be dependent on their lifestyle behaviors. We start with a simplified version of the model that includes only one policy, one lifestyle, one energy balance, and one observable control variable. We then extend this simple version to be a general one that accommodates multiple policy and lifestyle variables. The two versions of the model are 1) first estimated via the nonlinear least square (NLS) method (henceforth NLS-based 2SRI); and 2) then estimated via the maximum likelihood estimation (MLE) method (henceforth MLE-based 2SRI). Using simulated data, we show that 1) our proposed 2SRI method outperforms the conventional method that ignores the inherent nonlinearity [the linear instrumental variables (LIV) method] or the potential endogeneity [the nonlinear regression (NR) method] in obtaining the relevant estimators; and 2) the MLE-based 2SRI provides more efficient estimators (also consistent) compared to the NLS-based one. Real data analysis is conducted to illustrate the implementation of 2SRI method in practice using both NLS and MLE methods. However, due to data limitation, we are not able to draw any inference regarding the impacts of lifestyle, specifically SSB consumption, on childhood obesity. We are in the process of getting better data and, after doing so, we will replicate and extend the analyses conducted here. These analyses, we believe, will produce causally interpretable evidence of the effects of SSB consumption and other lifestyle choices on childhood obesity. The empirical analyses presented in this dissertation should, therefore, be viewed as an illustration of our newly proposed framework for causal estimation and inference.

INTRODUCTION: Research has strongly linked increased consumption of sugar-sweetened beverages (SSBs) to obesity/overweight in youth. AIM: This study aims to: (1) examine SSB consumption rates in high school students nationwide, (2) explore association between SSB consumption and adiposity (overweight/obesity), (3) examine gender, racial/ethnic, and physical activity (PA) status differences in SSB consumption. METHODS: The Youth Risk Behavior Survey (YRBS)-2015 was employed in this study. Weighted percentages were used to examine differences in SSB consumption and adiposity prevalence by gender, race and PA status. Multivariate logistic regression was used to determine association between SSB consumption and adiposity. Adjusted and unadjusted odds ratios and 95% CIs were calculated. RESULTS: Overall, 20% of students drank sodas daily ≥ 1 times a day and about 14% drank sports drinks daily. More male students consumed both sodas and sports drinks than female students. Soda consumption was largest in the group with zero days PA (25%) and consumption of sports drinks was highest in the daily PA category (24%) than the other categories. Multivariate logistic regression revealed higher odds of obesity among male students as compared to female students (OR=1.7, 95% CI=1.4, 2.1) and among Hispanic students as compared to white students (OR=1.5, 95% CI=1.2, 1.8), after adjusting for all other covariates. Students who engaged in daily PA had lower odds of obesity than those who had no PA (OR=0.6, 95% CI=0.5, 0.8). There was no significant difference in the odds of obesity between those who consumed SSBs and those who did not. DISCUSSION: This study provides insight into SSB consumption trends in US adolescents by socio- demographic factors and PA status, as well as its association with adiposity. Male gender, certain racial minorities and lack of physical activity can potentially be responsible for greater SSB consumption. Sports drinks consumption is high even in physically active youth. Lack of association between SSB intake and adiposity may be due to the limited SSBs included.

The purpose of this study was to explore awareness and opinions about sugar-sweetened beverage policy—specifically pouring rights contracts—on a university campus. Participants were 915 students, staff, and faculty currently studying or under employment at the University of Iowa. Participants completed an online survey. Nearly two-thirds (64.2%) of participants reported not being aware of pouring rights prior to completing the survey. Over one-third (38.0%) of participants reported they agreed with universities engaging in pouring rights contracts, while 30.9% of participants neither agreed or disagreed, and 31.0% disagreed with universities engaging in pouring rights contracts. Respondents who identified as male, undergraduate students, and those who agreed that individuals are responsible for their own sugar-sweetened beverage consumption were more likely to support engaging in pouring rights contracts. Understanding awareness, support, and determinants of support for pouring rights contracts is important for those involved in establishing policies targeting sugar-sweetened beverage availability on college campuses.

<p>Various factors, including low levels of physical activity (PA), and high consumption levels of sugar-sweetened drinks (SD), have been implicated in the general increase of fat mass (FM) levels seen in youth. <b>Purpose</b>: To determine if a significant relationship exists between fat mass (FM) and physical activity (PA) or sugar-sweetened drink (SD), in boys and girls, using longitudinal analysis. <b>Methods</b>: 105 boys and 103 girls were assessed repeatedly during childhood and adolescence, for a maximum of 7 years. Height was measured annually, as was fat free mass (FFM) and FM estimated by dual X-ray absorptiometry (DXA). PA was evaluated bi-annually using a questionnaire for children (PAQ-C/A: 1 low, 5 high), and SD was assessed using a 24-hour dietary intake questionnaire completed 1-4 times/year. Years from peak height velocity were used as a biological age indicator. Random effects models were used to analyze the data, subsequent to log linearization of the FM variable since it was not initially normally distributed. <b>Results</b>: The constructed model, controlling for maturation, FFM, and adjusted energy intake, found no interaction effect between SD and PA (p>0.05). After removal of the interaction term from the model, SD was found to have no significant relationship (p>0.05) with FM of boys or girls. In contrast, PA level was found to have a significant relationship (p<0.05) with FM of males; but not with FM of females. <b>Conclusion</b>: The longitudinal models employed revealed a significant negative relationship between level of PA and FM in males but not females, after controlling for maturational status, body size and dietary energy intake. This finding lends support, to proponents of increasing PA in youth to control FM. Regarding SD and FM, the models employed showed no relationship. Future investigation with more complex models, accounting for more covariates, may be warranted in this area.</p>

<p>Various factors, including low levels of physical activity (PA), and high consumption levels of sugar-sweetened drinks (SD), have been implicated in the general increase of fat mass (FM) levels seen in youth. <b>Purpose</b>: To determine if a significant relationship exists between fat mass (FM) and physical activity (PA) or sugar-sweetened drink (SD), in boys and girls, using longitudinal analysis. <b>Methods</b>: 105 boys and 103 girls were assessed repeatedly during childhood and adolescence, for a maximum of 7 years. Height was measured annually, as was fat free mass (FFM) and FM estimated by dual X-ray absorptiometry (DXA). PA was evaluated bi-annually using a questionnaire for children (PAQ-C/A: 1 low, 5 high), and SD was assessed using a 24-hour dietary intake questionnaire completed 1-4 times/year. Years from peak height velocity were used as a biological age indicator. Random effects models were used to analyze the data, subsequent to log linearization of the FM variable since it was not initially normally distributed. <b>Results</b>: The constructed model, controlling for maturation, FFM, and adjusted energy intake, found no interaction effect between SD and PA (p>0.05). After removal of the interaction term from the model, SD was found to have no significant relationship (p>0.05) with FM of boys or girls. In contrast, PA level was found to have a significant relationship (p<0.05) with FM of males; but not with FM of females. <b>Conclusion</b>: The longitudinal models employed revealed a significant negative relationship between level of PA and FM in males but not females, after controlling for maturational status, body size and dietary energy intake. This finding lends support, to proponents of increasing PA in youth to control FM. Regarding SD and FM, the models employed showed no relationship. Future investigation with more complex models, accounting for more covariates, may be warranted in this area.</p>

Background: In the U.S., Hispanics have among the highest rates of overweight and obesity when compared to other racial/ethnic groups placing them at a greater risk for obesity-related disease. Identifying intervention strategies to reduce caloric intake and/or improve cardiometabolic health in Hispanics is critical to reducing morbidity and mortality among this large and growing population. Evidence exists to support diet-specific behavioral interventions, including beverage modifications, in reducing obesity-related health risks. However, the acceptability and feasibility of a beverage intervention in obese Hispanic adults has not been robustly evaluated. Methods: The objective of this pilot study is to assess the feasibility and acceptability of a randomized, controlled beverage intervention in 50 obese Hispanic adults ages 18-64 over 8-weeks. Eligible participants were obese (30-50.0 kg/m(2)), between the ages 18-64, self-identified as Hispanic, and were able to speak, read, and write in either English and/or Spanish. Study recruitment was completed August 2017. Upon the completion of baseline assessments, participants will be randomized to either Mediterranean lemonade, Green Tea, or flavored water control. After completing a 2-week washout period, participants will be asked to consume 32 oz. per day of study beverage for 6-weeks while avoiding all other sources of tea, lemonade, citrus, juice, and other sweetened beverages; water is permissible. Primary outcomes will be recruitment, retention, and acceptability of the intervention strategies. Our study will also evaluate participant-reported tolerance and as an exploratory aim, assess safety/toxicity-related to renal and/or liver function. Fasting blood samples will be collected at baseline and 8-weeks to assess the primary efficacy outcomes: total cholesterol, high-density lipoprotein (HDL), and low-density lipoprotein (LDL). Secondary outcomes include fasting glucose, hemoglobin A1c (HbA1c), and high-sensitivity C-reactive protein (hs-CRP). Discussion: This pilot study will provide important feasibility, safety, and early efficacy data necessary to design a larger, adequately-powered randomized controlled trial.

The former finance minister stated in his budget speech in 2016 that sugar tax would come into force in South Africa from 1 April 2017. The treasury's reason for implementing sugar taxation is to reduce the health problems caused by sugar. It is nothing new to use fiscal measures to recover both taxes and to prevent health problems but it was not yet possible to reach a definite conclusion about the impact of sugar tax on the consumption of sugary drinks and the prevalence of obesity. The reason for this is that there is evidence that the implementation of food tax in different countries has shown different results in terms of public health issues and tax benefits. In South Africa, the implementation of sugar tax can either reduce the prevalence of obesity and thereby have a positive effect on the economy or its implementation may adversely affect the economy. If treasury does not implement sugar tax the economy can also be adversely affected by the prevalence of obesity. This dissertation deals with the effects of non-communicable diseases and sugar tax on the South African economy. The focus is on how sugar tax is being implemented internationally and how South Africa intends to implement sugar tax. / Die voormalige minister van finansies het in sy begrotingstoespraak in 2016 vermeld dat suikerbelasting vanaf 1 April 2017 in Suid-Afrika in werking gaan tree. Die tesourie se rede vir die implementering van suikerbelasting is om, in samewerking met die Departement van Gesondheid, die gesondheidsprobleme wat deur suiker veroorsaak word te verminder. Dit is niks nuuts om fiskale maatstawwe te gebruik om beide belasting in te vorder en gesondheidsprobleme te voorkom nie, maar dit was nog nie moontlik om tot ’n definitiewe gevolgtrekking te kom oor die impak van suikerbelasting op die verbruik van suikerversoete drankies en die voorkoms van vetsug nie. Die rede hiervoor is dat daar bewyse is dat die implementering van voedselbelasting in verskillende lande verskillende resultate getoon het in terme van openbare gesondheidskwessies en belastingvoordele. In Suid-Afrika kan die implementering van suikerbelasting óf die voorkoms van vetsug verminder en sodoende die ekonomie bevoordeel óf die implementering daarvan kan die ekonomie negatief beïnvloed. Indien die tesourie nie suikerbelasting implementeer nie kan die ekonomie as gevolg van die voorkoms van vetsug negatief beïnvloed word. Die kern van hierdie skripsie handel oor die gevolge van nieoordraagbare siektes en suikerbelasting op die Suid-Afrikaanse ekonomie. Daar word spesifiek gefokus op hoe suikerbelasting internasionaal geïmplementeer word en hoe Suid-Afrika beoog om suikerbelasting te implementeer. / Mini Dissertation (LLM)--University of Pretoria, 2017. / Mercantile Law / LLM / Unrestricted

Background: Low health literacy is a significant problem affecting our country.  While the associations between low health literacy and poorer health outcomes have been well documented (Berkman et al., 2011), the literature lacks evidence of effective strategies to address health literacy in the context of health behaviors such as diet and physical activity (PA). Likewise, few interventions have reported on how health literacy status influences performance and engagement in the intervention. Two potential intervention strategies include the teach back method or teach to goal approach and interactive voice response (IVR) technology. These strategies hold promise as a means of improving health literacy and reaching vulnerable, low health literate populations, but these strategies have not been widely explored in the literature (Paasche-Orlow et al., 2005; Baker et al., 2011; Schillinger et al., 2009; Bennett et al., 2012; Piette et al., 1999). Primary Aims: This research was embedded in a larger trial, Talking Health, which is a 6-month, 2 group randomized controlled trial to determine the effects of a health behavior intervention on reducing sugar-sweetened beverage (SSB) consumption in Southwest Virginians. The primary aims of this study were to examine the associations between health literacy status and 1) number of rounds of teach back needed to reinforce key concepts, 2) proportion of correct answers on the first round of teach back, 3) level of intervention engagement (i.e., completion rates for teach back call, IVR calls, and small group classes), and 4) perceptions of the intervention components. Methods: The data reported represent the first 3 cohorts of the Talking Health trial including participants in Lee, Giles, and Pulaski Counties. Eligibility requirements included being 18 years or older, English speaking, consuming at least 200 calories per day from SSB, able to participate in moderate intensity PA, and having reliable access to a telephone. Data were collected at baseline and at the 6-month follow-up assessment. Health literacy was assessed using the validated Newest Vital Sign. Participants were randomized to a behavioral intervention aimed at decreasing SSB consumption (SipSmartER) or to a matched-contact control group targeting PA (Move More). Both groups participated in 3 small group education sessions, received a live teach back call, and 11 supportive IVR calls. Participants completed a summative evaluation at the 6-month follow-up, which captured their perceptions of the intervention components. ANOVAs were used to measure differences in outcomes by health literacy status, randomized condition, and interactions. Results: Of the 125 enrolled participants, 92.0% were Caucasian, 76.8% were female, 29.6% had d high school education, 64.0% had <$25,000 annual household income, and 32.8% had low health literacy skills. Eighty-five participants (68.0%) completed the teach back call. The overall model when looking at the degree to which health literacy status and randomized condition predicted the number of rounds of teach back needed to reinforce key concepts was significant (F= 8.323, p < 0.001). Out of 3 possible teach back attempts, participants in the low health literacy category required a significantly higher number of teach back attempts as compared to those with high health literacy (F= 16.769, p <0.001), and participants randomized to Move More required a significantly higher number of teach back attempts compared to SipSmartER participants (F=7.296, p= 0.008). Similarly, the overall model when looking at the degree to which health literacy status and randomized condition predicted the proportion correct on the first round of teach back was significant (F= 9.836, p<0.001), such that those with higher health literacy status  (F= 19.176, p< 0.001) and those randomized to SipSmartER condition answered a significantly higher proportion of questions correct (F= 9.783, p= 0.002). Intervention engagement including completion of the small group education sessions, the live teach back call, and the IVR calls did not vary significantly across randomized condition or literacy levels. Low health literate participants had a significantly higher overall perceived satisfaction with the IVR, as compared to high health literate participants (F= 5.849, p= 0.020). However, perceptions of other intervention components (e.g., small group sessions, teach back call, personal action plans, drink diaries/exercise logs,) were similar among participants with low and high health literacy status and across randomized conditions.   Conclusion: These data confirm the importance for multiple teach back opportunities and additional exposure to health information to ensure participant comprehension of key intervention content"in particular for those with lower health literacy. This research also supports that IVR is an effective approach to reaching vulnerable, low health literate populations. Future research should investigate the efficacy and cost-effectiveness of utilizing teach back methods delivered using automated technologies. Future research also is needed to determine how teach back performance are related to other study factors such as retention, engagement, and health outcomes. / Master of Science