Mandatory labels,taxes and market forces: An empirical evaluation of fat policies

The public-health community views mandatory Front-of-Pack (FOP) nutrition labels and nutritional taxes as promising tools to control the growth of food-related chronic diseases. This paper uses household scanner data to propose an ex-ante evaluation and comparison of these two policy options for the fromage blanc and dessert yogurt market. In most markets, labelling is voluntary and firms display fat labels only on the FOP of low-fat products to target consumers who do not want to eat fat. We here separately identify consumer preferences for fat and for FOP fat labels by exploiting an exogenous difference in legal labelling requirements between these two product categories. Estimates of demand curves are combined with a supply model of oligopolistic price competition to simulate policies. We find that a feasible ad valorem fat tax dominates a mandatory FOP-label policy from an economic perspective, but both are equally effective in reducing average fat purchases.     

Ratio of geometric means to analyze continuous outcomes in meta-analysis: comparison to mean differences and ratio of arithmetic means using empiric data and simulation

Meta‐analyses pooling continuous outcomes can use mean differences (MD), standardized MD (MD in pooled standard deviation units, SMD), or ratio of arithmetic means (RoM). Recently, ratio of geometric means using ad hoc (RoGM _{ad hoc}) or Taylor series (RoGM _Taylor) methods for estimating variances have been proposed as alternative effect measures for skewed continuous data. Skewed data are suggested for summary measures of clinical parameters restricted to positive values which have large coefficients of variation (CV). Our objective was to compare performance characteristics of RoGM _{ad hoc} and RoGM _Taylor to MD, SMD, and RoM. We used empiric data from systematic reviews reporting continuous outcomes and selected from each the meta‐analysis with the most and at least 5 trials (Cochrane Database [2008, Issue 1]). We supplemented this with simulations conducted with representative parameters. Pooled results were calculated using each effect measure. Of the reviews, 232/5053 met the inclusion criteria. Empiric data and simulation showed that RoGM _{ad hoc} exhibits more extreme treatment effects and greater heterogeneity than all other effect measures. Compared with MD, SMD, and RoM, RoGM _Taylor exhibits similar treatment effects, more heterogeneity when CV ≤0.7, and less heterogeneity when CV > 0.7. In conclusion, RoGM _Taylor may be considered for pooling continuous outcomes in meta‐analysis when data are skewed, but RoGM _{ad hoc} should not be used. However, clinicians' lack of familiarity with geometric means combined with acceptable performance characteristics of RoM in most situations suggests that RoM may be the preferable ratio method for pooling continuous outcomes in meta‐analysis. Copyright © 2012 John Wiley & Sons, Ltd.     

Squeezing new life out of an old Sponge: how to modernise an anti-smoking media campaign to capture a new market

Objectives: The iconic Sponge anti‐smoking television advertisement was first made in Sydney, Australia, in 1979. In 2007, it was re‐made for a new generation of smokers. This paper examines the impact of the re‐made Sponge advertisement. Methods: Qualitative evaluation of the original Sponge ad by younger and older smokers (n=51) was followed by an online pre‐test survey of the modernised version (n=301). A continuous tracking telephone survey of smokers and recent quitters (quit in past 12 months) over 18 years monitored performance of the modernised version while on air in late 2007 (total n=453; seen ad n=380). Results: Qualitative research found that the concept of the original Sponge ad may motivate younger smokers – who had not previously seen the ad – to quit. Online pre‐testing demonstrated that the modernised version provided new information to 54% of 18–24 year olds (compared to 31% of older smokers). Tracking survey results indicated that believability of the modernised version was highest among 18–24 year olds (92%), that the ad was ‘attention‐grabbing’ (86%), and that it was effective at influencing quitting intentions. Effects were amplified by the generation of pressure from family and friends. Implications: The re‐made Sponge advertisement had a positive impact on smokers, and was particularly effective among the new market of smokers aged less than 40 years. Adapting successful mass media campaign material can be an effective and economical strategy to influence smokers.     

Interhospital transfers of patients with surgical emergencies: areas for improvement

Objective: To review mortality associated with interhospital transfers of patients with surgical emergencies from rural and peripheral metropolitan areas. Design: A retrospective case note review. Setting: All hospitals within an area health service including metropolitan and rural hospitals. Subjects: All patients with a surgical emergency who died in hospital after interhospital transfer within an area health service. Main outcome measures: Factors associated with death and interhospital transfer. Results: In total, 22 patients were identified. The mean age was 77 years. Thirty‐six per cent of patients were assessed by a surgeon prior to transfer. The mean time taken for transfer was five hours. Ten patients were physiologically unstable prior to transfer. No medical escort accompanied these patients. Four patients deteriorated during the transport process. Seventy‐three per cent of patients arrived out of normal working hours. Fifty per cent of patients required an operation within 24 hours of arrival. All of these patients had significant medical co‐morbidities. Seventy‐two per cent of these operations were performed out of hours as an emergency case. Twenty‐three per cent did not receive any operative intervention or intensive care admission at the tertiary referral centre. Forty‐one per cent of deaths were related to peritonitis and intra‐abdominal soiling. Conclusions: Hospital systemic issues associated with mortality included extensive time delays in transfers, an inadequate transport process and frequent out‐of‐hours emergency operations. Patient features related to mortality included advanced age, significant medical co‐morbidity and surgical pathology with a poor prognosis. Improvements concerning interhospital transfers of patients should address both systemic and patient issues.     

An audit of the prevalence of recorded nicotine dependence treatment in an Australian psychiatric hospital

Objectives: To investigate the prevalence of recorded smoking status, nicotine dependence assessment, and nicotine dependence treatment provision; and to examine the patient characteristics associated with the recording of smoking status. Method: A retrospective systematic medical record audit was conducted of all psychiatric inpatient discharges over a six‐month period (1 September 2005 to 28 February 2006), at a large Australian psychiatric hospital, with approximately 2,000 patient discharges per year. A one‐page audit tool identifying patient characteristics and prevalence of recorded nicotine dependence treatment, and requiring ICD‐10‐AM diagnoses coding was used. Results: From 1,012 identified discharges, 1,000 medical records were available for audit (99%). Documentation of smoking status most frequently occurred on the admission form (28.8%) and diagnoses summary (41.6%). Documentation of nicotine dependence was not found in any record, and recording of any nicotine dependence treatment was negligible (0‐0.5%). The rate of recorded smoking status on discharge summaries was 6%. Patients with a diagnosis of alcohol, cannabis, sedative use disorders or asthma were twice as likely to have their smoking status recorded compared to those who did not have these diagnoses. Conclusions: Mental health services, by failing to diagnose and document treatment for nicotine dependence, do not conform to current clinical practice guidelines, despite nicotine dependence being the most commonly diagnosed psychiatric disorder. Implications: Considerable system change and staff support is required to provide an environment where a primary prevention approach such as smoking care can be sustained.     

Framing and signalling effects of taxes on sugary drinks: A discrete choice experiment among households in Great Britain

Taxes on sugar‐sweetened beverages (SSBs) are in place in many countries to combat obesity with emerging evidence that these are effective in reducing purchases of SSBs. In this study, we tested whether signalling and framing the price increase from an SSB tax explicitly as a health‐related, earmarked measure reduces the demand for SSBs more than an equivalent price increase. We measured the demand for non‐alcoholic beverages with a discrete choice experiment (DCE) administered online to a randomly selected group of n = 603 households with children in Great Britain (GB) who regularly purchase SSBs. We find a suggestive evidence that a price increase leads to a larger reduction in the probability of choosing SSBs when it is signalled as a tax and framed as a health‐related and earmarked policy. Respondents who did not support a tax on SSBs, who were also more likely to choose SSBs in the first place, were on average more responsive to a price increase framed as an earmarked tax than those who supported the tax. The predictive validity of the DCE, to capture preferences for beverages, was confirmed using actual purchase data. The findings imply that a well‐signalled and earmarked tax on SSBs could improve its effectiveness at reducing the demand.     

Response of mammary tumors to caloric restriction for different time periods during the promotion phase

Rats treated with 7,12‐dimethylbenz[a]anthracene were subjected to 25 % caloric restriction for varying times during the promotion/progression phase of mammary tumorigenesis. Caloric restriction was inhibitory to a statistically significant extent when it was maintained for the entire four‐month study or only during the first or last two months. Restriction for the first month with subsequent ad libitum feeding led to rapid weight gain with concomitant appearance of tumors. These data indicate that caloric restriction can be instituted late in the tumorigenic process with an acute response of tumor growth to caloric intake or body weight.     

Women in transition: Being versus becoming or being and becoming

Women are at the center of all life transitions whether the transitions are within the family, such as maturation, or because of national modernization or a move to an urban center, or because of relocation to another nation. Ironically, women's roles in these transitions are ignored at best and misrepresented at worst. What we need is a raising of consciousness, an awareness of these women among us who are struggling with the being‐versus‐becoming dilemma of living in a new culture, and who would like to solve it by integrating being true to the values of their country of origin and becoming a valued citizen of the host country both for themselves and for their family.     

The case for improving road safety in Pacific Islands: a population‐based study from Fiji (TRIP 6)

Objective : To estimate the incidence and demographic characteristics associated with road traffic injuries (RTIs) resulting in deaths or hospital admission for 12 hours or more in Viti Levu, Fiji. Methods : Analysis of the prospective population‐based Fiji Injury Surveillance in Hospitals database (October 2005 – September 2006). Results: Of the 374 RTI cases identified (17% of all injuries), 72% were males and one third were aged 15–29 years. RTI fatalities (10.3 per 100,000 per year) were higher among Indians compared to Fijians. Two‐thirds of deaths (largely ascribed to head, chest and abdominal trauma) occurred before hospital admission. Conclusion and implications: While the RTI fatality rate was comparable to the global average for high‐income countries, the level of motorisation in Fiji is considerably lower. To avert rising RTI rates with increasing motorisation, Fiji requires a robust road safety strategy alongside effective trauma‐care services and a reliable population‐based RTI surveillance system.     

The multiple mini-interview for selection of international medical graduates into family medicine residency education

Context The multiple mini‐interview (MMI) was used to measure professionalism in international medical graduate (IMG) applicants for family medicine residency in Alberta for positions accessed through the Alberta International Medical Graduate (AIMG) Program. This paper assesses the evidence for the MMI’s reliability and validity in this context. Methods A group of 71 IMGs participated in our 12‐station MMI designed to assess professionalism competency. A 10‐point scale evaluated applicants on ability to address the objectives of the situation, interpersonal skills, suitability for a residency and for family medicine, and overall performance. We conducted generalisability and decision studies to assess the reliability of MMI scores. We assessed the validity by examining the differences in MMI scores associated with session, track and socio‐demographic characteristics of applicants and by measuring the correlations between MMI scores and scores on compulsory examinations, including the AIMG objective structured clinical examination, the Medical Council of Canada Evaluating Examination (MCCEE) and the Medical Council of Canada Qualifying Examination Part I (MCCQE I). We measured the correlation between MMI and non‐requisite MCCQE Part II (MCCQE II) scores that were provided. Results The reliability as indicated by the generalisability coefficient associated with average station scores was 0.70 with one interviewer per station. There were no statistically significant differences in total MMI scores or mean station sum scores based on session, track, applicant age, gender, years since medical school completion, or language of medical school. There were low, non‐significant correlations with OSCE overall (r = 0.15), MCCEE (r = 0.01) and MCCQE I (r = 0.06) scores and a higher non‐significant correlation with MCCQE II scores (r = 0.33). Conclusions There is evidence that the MMI offers a reliable and valid assessment of professionalism in IMG doctors applying for Canadian family medicine residencies and that this clinically situated MMI assessed facets of competency other than those assessed by the OSCE.     

False discovery rate and permutation test: An evaluation in ERP data analysis

Current analysis of event‐related potentials (ERP) data is usually based on the a priori selection of channels and time windows of interest for studying the differences between experimental conditions in the spatio‐temporal domain. In this work we put forward a new strategy designed for situations when there is not a priori information about ‘when’ and ‘where’ these differences appear in the spatio‐temporal domain, simultaneously testing numerous hypotheses, which increase the risk of false positives. This issue is known as the problem of multiple comparisons and has been managed with methods that control the false discovery rate (FDR), such as permutation test and FDR methods. Although the former has been previously applied, to our knowledge, the FDR methods have not been introduced in the ERP data analysis. Here we compare the performance (on simulated and real data) of permutation test and two FDR methods (Benjamini and Hochberg (BH) and local‐fdr, by Efron). All these methods have been shown to be valid for dealing with the problem of multiple comparisons in the ERP analysis, avoiding the ad hoc selection of channels and/or time windows. FDR methods are a good alternative to the common and computationally more expensive permutation test. The BH method for independent tests gave the best overall performance regarding the balance between type I and type II errors. The local‐fdr method is preferable for high dimensional (multichannel) problems where most of the tests conform to the empirical null hypothesis. Differences among the methods according to assumptions, null distributions and dimensionality of the problem are also discussed. Copyright © 2009 John Wiley & Sons, Ltd.     

Cost evaluation of providing evidence‐based dietetic services for weight management in adults: In‐person versus eHealth delivery

Aim

To compare the theoretical costs of best‐practice weight management delivered by dietitians in a traditional, in‐person setting compared to remote consultations delivered using eHealth technologies.

Methods

Using national guidelines, a framework was developed outlining dietitian‐delivered weight management for in‐person and eHealth delivery modes. This framework mapped one‐on‐one patient–dietitian consultations for an adult requiring active management (BMI ≥ 30 kg/m²) over a one‐year period using both delivery modes. Resources required for both the dietitian and patient to implement each treatment mode were identified, with costs attributed for material, fixed, travel and personnel components. The resource costs were categorised as either establishment or recurring costs associated with the treatment of one patient.

Results

Establishment costs were higher for eHealth compared to in‐person costs ($1394.21 vs $90.05). Excluding establishment costs, the total (combined dietitian and patient) cost for one patient receiving best‐practice weight management for 12 months was $560.59 for in‐person delivery, compared to $389.78 for eHealth delivery. Compared to the eHealth mode, a higher proportion of the overall recurring delivery costs was attributed to the patient for the in‐person mode (46.4% and 33.9%, respectively).

Conclusions

Although it is initially more expensive to establish an eHealth service mode, the overall reoccurring costs per patient for delivery of best‐practice weight management were lower compared to the in‐person mode. This theoretical cost evaluation establishes preliminary evidence to support alternative obesity management service models using eHealth technologies. Further research is required to determine the feasibility, efficacy and cost‐effectiveness of these models within dietetic practice.     

Ascorbylperoxide Contaminating Parenteral Nutrition Is Associated With Bronchopulmonary Dysplasia or Death in Extremely Preterm Infants

Background: Ascorbylperoxide (AscOOH) is a hydrogen peroxide–dependent by‐product of ascorbic acid that contaminates parenteral nutrition. In a guinea pig model, it caused oxidized redox potential, increased apoptosis, and decreased alveolarization. AscOOH detoxification is carried out by glutathione peroxidase (GPX). We hypothesize that extremely preterm infants have limited capacity for AscOOH detoxification. Our objective was to determine if there is an association between an early level of urinary AscOOH and later development of bronchopulmonary dysplasia (BPD) or death. Materials and Methods: This prospective cohort study included 51 infants at <29 weeks of gestation. Baseline clinical characteristics and clinical outcomes data were collected. Urine samples were collected on days 3, 5, and 7 of life for urinary AscOOH. Blood samples on day 7 were collected for total plasma glutathione, GPX, and glutathione reductase. χ², Student's t test, Spearman correlation (r), linear regression (adjusted r²), and repeated‐measure analysis of variance were used as appropriate. P < .05 was considered significant. Results: Urinary AscOOH increased over time (P = .001) and was higher in infants who later developed BPD or died (P = .037). Compared with adults and full‐term infants, total plasma glutathione concentration was low (median, 1.02 µmol/L; 25th–75th percentiles, 0.49–1.76 µmol/L), whereas GPX and glutathione reductase activities were sufficient (3.98 ± 1.25 and 0.36 ± 0.01 nmol/min/mg of protein, respectively). Conclusion: Extremely preterm infants have low glutathione levels, which limit their capacity to detoxify AscOOH. Higher first‐week urinary AscOOH levels are associated with an increased incidence of BPD or death.     

Low daily smoking estimates derived from sales monitored tobacco use in six remote predominantly Aboriginal communities

Objective : To estimate daily cigarette consumption among residents aged 15+ in five remote central Australian predominantly Aboriginal communities. Methods : Estimation of average daily cigarette consumption derived from a 12‐month (2007) complete sales audit of cigarettes in isolated communities where no other tobacco supplies are available, using two assumptions of smoking prevalence (50% and 70%). Results : Across the five communities, daily smoking consumption averaged 8.3 cigarettes per day (assuming a 50% smoking prevalence) or 5.9 cigarettes per day (assuming a 70% smoking prevalence). The corresponding amounts spent per smoker per day were $4.13 or $2.95, representing 12.7%‐9.1% of the maximum $453.30 per fortnight unemployment allowance for a single person. Conclusion : While smoking prevalence may be high in these Aboriginal communities, smoking frequency is low compared to that in the wider Australian community. These results are consistent with other studies. Approaches to cessation premised on assumptions of nicotine dependence in such populations are likely to be misconceived.     

Perceived Effectiveness of Antismoking Ads and Association with Quit Attempts Among Smokers: Evidence from the Tips From Former Smokers Campaign

Background. Measures of perceived effectiveness (PE) of ads have been validated to predict changes in cognitive precursors of quit attempts, but a relationship between PE and actual quit attempts has not been shown in population-based studies. We analyzed smokers’ PE ratings of ads from the national Tips From Former Smokers (Tips) campaign to (1) establish the validity of PE in predicting quit attempts in a large, nationally representative sample of smokers; (2) identify behavioral and demographic correlates of PE among respondents; and (3) examine whether PE is influenced by matching the race/ethnicity of ad participants with that of the ad viewer.Methods. We used survey data from two waves (baseline and follow-up) of a longitudinal online cohort of adult U.S. cigarette smokers. Respondents were shown one or more of 14 Tips campaign ads and were asked to assess each ad in terms of PE. We used multivariate models to estimate the association between baseline PE and prospective quit attempts; cross-sectional associations between PE and various respondent characteristics, including race/ethnicity, desire to quit, and health conditions; and the association between race/ethnicity of respondents and Tips ad participants.Results. Higher PE at baseline was associated with increased odds of a quit attempt at follow-up. Higher PE scores were associated with non-Hispanic black race, Hispanic ethnicity, higher desire to quit, presence of a chronic health condition, and presence of a mental health condition. There was no relationship between PE scores and matched race/ethnicity of the respondent and Tips ad participants.Conclusions. This is the first study to demonstrate an association between PE scores for antismoking ads and prospective quit attempts in a large, nationally representative sample of smokers. Our findings also provide strong evidence that racial/ethnic minority subpopulations, including non-Hispanic blacks and Hispanics, react more favorably to Tips campaign ads irrespective of race/ethnicity of the ad participant. This suggests that message characteristics (e.g., graphic visuals and emotional content) may play a more important role in PE than race/ethnicity of ad participants.     

Enteral feeding induces early intestinal adaptation in a parenterally fed neonatal piglet model of short bowel syndrome

Background: Successful small intestinal (SI) adaptation following surgical resection is essential for optimizing newborn growth and development, but the potential for adaptation is unknown. The authors developed an SI resection model in neonatal piglets supported by intravenous and enteral nutrition. Methods: Piglets (n = 33, 12–13 days old) were randomized to 80% SI resection with parenteral nutrition feeding (R‐PN), 80% SI resection with PN + enteral feeding (R‐EN), or sham SI transection with PN + enteral feeding (sham‐EN). In resected pigs, the distal 100 cm of ileum (residual SI) and 30 cm of proximal SI were left intact. All pigs received parenteral nutrition postsurgery. Enteral nutrition piglets received continuous gastric infusion of elemental diet from day 3 (40:60 parenteral nutrition:enteral nutrition). Piglets were killed 4, 6, or 10 days postsurgery. Results: By 10 days, R‐EN piglets had longer residual SI than R‐PN and sham‐EN pigs (P < .05). At days 6 and 10, R‐EN piglets had greater weight per length of intact SI (P < .05) and isolated mucosa (P < .05) compared to other groups. Greater gut weight in R‐EN piglets was facilitated by a greater cellular proliferation index (P < .01) by 4 days compared to other groups and greater overall ornithine decarboxylase activity vs R‐PN piglets (P < .05). Conclusions: This new model demonstrated profound SI adaptation, initiated early postsurgery by polyamine synthesis and crypt cell proliferation and only in response to enteral feeding. These changes translated to greater gut mass and length within days, likely improving functional capacity long term.     

Development of a methodology to assess the nutrient profile of popular UK meals

In order to characterise the nutrient profile of popular meals and to identify ways to improve this, a methodology was developed to assess the profile of meals by developing meal‐based nutritional criteria for macronutrients, fibre, salt and selected food groups and comparing this with recipe analysis of both homemade and partly pre‐made dishes (those using products such as cook‐in sauces and frozen meal components). Meals were compared with the criteria per portion and with front‐of‐pack labelling guidelines per 100 g. The results indicate that many popular UK meals, both homemade and partly pre‐made, would benefit from changes to improve their nutritional profile. Generally, the dishes made with partly pre‐made ingredients met criteria for total energy, total sugars and salt but often exceeded criteria for saturates and did not provide enough fibre or fruits and vegetables. Conversely, the comparable homemade dishes tended to meet the criteria for fibre and fruit and vegetables but were also more likely to exceed the criteria for saturates. A simple visual model, called the Nutrition Compass, for representing key results for each dish was developed. Relatively simple changes to dishes, such as adding extra vegetables and pulses, using wholegrains or potatoes with skins, using less salt or high salt ingredients and swapping higher fat dairy and meat ingredients for lower fat versions, could make significant improvements to the nutrient profile of many popular dishes. Such changes should be communicated to consumers, both by health professionals and by the food industry, in particular via recipes provided on pack or in other media for pre‐prepared meal components.     

When the larger objective matters more: support workers’ epistemic and deontic authority over adult service‐users

We report on how support workers sometimes over‐ride the wishes of people living with cognitive impairments. This can happen when they are both involved in some project (such as an institutionally‐managed game, a physical journey, an educational activity and so on). The support worker might use their deontic authority (to propose, decide or announce future actions) to do things that advance the over‐arching project, in spite of proposals for what are cast as diversions from the person with impairments. They might also use their epistemic authority (their greater knowledge or cognitive capacity) to trump their clients’ choices and preferences in subordinate projects. Not orienting to suggested courses of actions is generally interactionally dispreferred and troublesome, but, although the providers do sometimes orient to their actions as balking their clients’ wishes, they usually do not, and encounter little resistance. We discuss how people with disabilities may resist or palliate such loss of control, and the dilemmas that support staff face in carrying out their duties.     

A joint marginal‐conditional model for multivariate longitudinal data

Multivariate longitudinal data frequently arise in biomedical applications; however, their analyses are often performed one outcome at a time, or jointly using existing software in an ad hoc fashion. A main challenge in the proper analysis of such data is the fact that the different outcomes are measured on different unknown scales. Methodology for handling the scale problem has been previously proposed for cross‐sectional data, and here we extend it to the longitudinal setting. We consider modeling the longitudinal data using random effects, while leaving the joint distribution of the multiple outcomes unspecified. We propose an estimating equation together with an expectation‐maximization–type (expectation‐substitution) algorithm. The consistency and the asymptotic distribution of the parameter estimates are established. The method is evaluated using extensive simulations and applied to a longitudinal nutrition data set from a large dietary intervention trial on breast cancer survivors, the Women's Healthy Eating and Living Study.