BackgroundPrevious reviews have suggested that infrastructural interventions can be effective in promoting cycling. Given inherent methodological complexities in the evaluation of such changes, it is important to understand whether study results obtained depend on the study design and methods used, and to describe the implications of the methods used for causality. The aims of this systematic review were to summarize the effects obtained in studies that used a wide range of study designs to assess the effects of infrastructural interventions on cycling and physical activity, and whether the effects varied by study design, data collection methods, or statistical approaches.MethodsSix databases were searched for studies that evaluated infrastructural interventions to promote cycling in adult populations, such as the opening of cycling lanes, or the expansion of a city-wide cycling network. Controlled and uncontrolled studies that presented data before and after the intervention were included. No language or date restrictions were applied. Data was extracted for any outcome presented (e.g. bikes counted on the new infrastructure, making a bike trip, cycling frequency, cycling duration), and for any purpose of cycling (e.g. total cycling, recreational cycling, cycling for commuting). Data for physical activity outcomes and equity effects was extracted, and quality assessment was conducted following previous methodologies and the UK Medical Research Council guidance on natural experiments. The PROGRESS-Plus framework was used to describe the impact on subgroups of the population.Studies were categorized by outcome, i.e. changes in cycling behavior, or usage of the cycling infrastructure. The relative change was calculated to derive a common outcome across various metrics and cycling purposes. The median relative change was presented to evaluate whether effects differed by methodological aspects.ResultsThe review included 31 studies and all were conducted within urban areas in high-income countries. Most of the evaluations found changes in favor of the intervention, showing that the number of cyclists using the facilities increased (median relative change compared to baseline: 62%; range: 4 to 438%), and to a lesser extent that cycling behavior increased (median relative change compared to baseline: 22%; range: − 21 to 262%). Studies that tested for statistical significance and studies that used subjective measurement methods (such as surveys and direct observations of cyclists) found larger changes than those that did not perform statistical tests, and those that used objective measurement methods (such as GPS and accelerometers, and automatic counting stations). Seven studies provided information on changes of physical activity behaviors, and findings were mixed. Three studies tested for equity effects following the opening of cycling infrastructure.ConclusionsStudy findings of natural experiments evaluating infrastructural interventions to promote cycling depended on the methods used and the approach to analysis. Stu...

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Consumption of coffee, one of the most popular beverages around the world, has been associated with a lower risk of cardiovascular and all-cause mortality in population-based studies. However, little is known about these associations in patient populations. This prospective study aimed to examine the consumption of caffeinated and decaffeinated coffee in relation to cardiovascular disease (CVD) mortality, ischemic heart disease (IHD) mortality, and all-cause mortality in patients with a prior myocardial infarction (MI). We included 4365 Dutch patients from the Alpha Omega Cohort who were aged 60-80 y (21% female) and had experienced an MI <10 y before study enrollment. At baseline (2002-2006), dietary data including coffee consumption over the past month was collected with a 203-item validated food-frequency questionnaire. Causes of death were monitored until 1 January 2013. HRs for mortality in categories of coffee consumption were obtained from multivariable Cox proportional hazard models, adjusting for lifestyle and dietary factors. Most patients (96%) drank coffee, and the median total coffee intake was 375 mL/d (∼3 cups/d). During a median follow-up of 7.1 y, a total of 945 deaths occurred, including 396 CVD-related and 266 IHD-related deaths. Coffee consumption was inversely associated with CVD mortality, with HRs of 0.69 (95% CI: 0.54, 0.89) for >2-4 cups/d and 0.72 (0.55, 0.95) for >4 cups/d, compared with 0-2 cups/d. Corresponding HRs were 0.77 (95% CI: 0.57, 1.05) and 0.68 (95% CI: 0.48, 0.95) for IHD mortality and 0.84 (95% CI: 0.71, 1.00) and 0.82 (95% CI: 0.68, 0.98) for all-cause mortality, respectively. Similar associations were found for decaffeinated coffee and for coffee with additives. Drinking coffee, either caffeinated or decaffeinated, may lower the risk of CVD and IHD mortality in patients with a prior MI. This study was registered at clinicaltrials.gov as NCT03192410.

Background and ObjectiveApproximately 20% of US children and adolescents consume pizza on any given day; and pizza intake is associated with higher intakes of energy, sodium, and saturated fat. The reformulation of pizza products has yet to be evaluated as a viable option to improve diets of the US youth. This study modeled the effect on nutrient intakes of two potential pizza reformulation strategies based on the standards established by the Nestlé Nutritional Profiling System (NNPS).MethodsDietary intakes were retrieved from the first 24hr-recall of the National Health and Nutrition Examination Survey (NHANES) 2011–12, for 2655 participants aged 4–19 years. The composition of pizzas in the NHANES food database (n = 69) were compared against the NNPS standards for energy, total fat, saturated fat, sodium, added sugars, and protein. In a reformulation scenario, the nutrient content of pizzas was adjusted to the NNPS standards if these were not met. In a substitution scenario, pizzas that did not meet the standards were replaced by the closest pizza, based on nutrient content, that met all of the NNPS standards.ResultsPizzas consistent with all the NNPS standards (29% of all pizzas) were significantly lower in energy, saturated fat and sodium than pizzas that were not. Among pizza consumers, modeled intakes in the reformulation and substitution scenarios were lower in energy (-14 and -45kcal, respectively), saturated fat (-1.2 and -2.7g), and sodium (-143 and -153mg) compared to baseline.ConclusionsPotential industry wide reformulation of a single food category or intra-category food substitutions may positively impact dietary intakes of US children and adolescents. Further promotion and support of these complimentary strategies may facilitate the adoption and implementation of reformulation standards.

Nutrient profiling ranks foods based on their nutrient composition, with applications in multiple aspects of food policy. We tested the capacity of a category-specific model developed for product reformulation to improve the average nutrient content of foods, using five national food composition datasets (UK, US, China, Brazil, France). Products (n = 7183) were split into 35 categories based on the Nestlé Nutritional Profiling Systems (NNPS) and were then classified as NNPS ‘Pass’ if all nutrient targets were met (energy (E), total fat (TF), saturated fat (SFA), sodium (Na), added sugars (AS), protein, calcium). In a modelling scenario, all NNPS Fail products were ‘reformulated’ to meet NNPS standards. Overall, a third (36%) of all products achieved the NNPS standard/pass (inter-country and inter-category range: 32%–40%; 5%–72%, respectively), with most products requiring reformulation in two or more nutrients. The most common nutrients to require reformulation were SFA (22%–44%) and TF (23%–42%). Modelled compliance with NNPS standards could reduce the average content of SFA, Na and AS (10%, 8% and 6%, respectively) at the food supply level. Despite the good potential to stimulate reformulation across the five countries, the study highlights the need for better data quality and granularity of food composition databases.

Background Smoke-free policies in outdoor areas and semi-private and private places (eg, cars) might reduce the health harms caused by tobacco smoke exposure (TSE). We aimed to investigate the effect of smoke-free policies covering outdoor areas or semi-private and private places on TSE and respiratory health in children, to inform policy. MethodsIn this systematic review and meta-analysis, we searched 13 electronic databases from date of inception to Jan 29, 2021, for published studies that assessed the effects of smoke-free policies in outdoor areas or semi-private or private places on TSE, respiratory health outcomes, or both, in children. Non-randomised and randomised trials, interrupted time series, and controlled before-after studies, without restrictions to the observational period, publication date, or language, were eligible for the main analysis. Two reviewers independently extracted data, including adjusted test statistics from each study using a prespecified form, and assessed risk of bias for effect estimates from each study using the Risk of Bias in Non-Randomised Studies of Interventions tool. Primary outcomes were TSE in places covered by the policy, unplanned hospital attendance for wheezing or asthma, and unplanned hospital attendance for respiratory tract infections, in children younger than 17 years. Random-effects meta-analyses were done when at least two studies evaluated policies that regulated smoking in similar places and reported on the same outcome. This study is registered with PROSPERO, CRD42020190563. FindingsWe identified 5745 records and assessed 204 full-text articles for eligibility, of which 11 studies met the inclusion criteria and were included in the qualitative synthesis. Of these studies, seven fit prespecified robustness criteria as recommended by the Cochrane Effective Practice and Organization of Care group, assessing smoke-free cars (n=5), schools (n=1), and a comprehensive policy covering multiple areas (n=1). Risk of bias was low in three studies, moderate in three, and critical in one. In the meta-analysis of ten effect estimates from four studies, smoke-free car policies were associated with an immediate TSE reduction in cars (risk ratio 0•69, 95% CI 0•55-0•87; 161 466 participants); heterogeneity was substantial (I² 80•7%; p<0•0001). One additional study reported a gradual TSE decrease in cars annually. Individual studies found TSE reductions on school grounds, following a smoke-free school policy, and in hospital attendances for respiratory tract infection, following a comprehensive smoke-free policy. Interpretation Smoke-free car policies are associated with reductions in reported child TSE in cars, which could translate into respiratory health benefits. Few additional studies assessed the effect of policies regulating smoking in outdoor areas and semi-private and private places on children's TSE or health outcomes. On the basis of these findings, governments should consider including private cars in comprehensive smoke-free policies to protect child health.

Background Most health surveys have experienced a decline in response rates. A structured approach to evaluate whether a decreasing - and potentially more selective - response over time biased estimated trends in health behaviours is lacking. We developed a framework to explore the role of differential non-response over time. This framework was applied to a repeated cross-sectional survey in which the response rate gradually declined. Methods We used data from a survey conducted biannually between 1995 and 2017 in the city of Rotterdam, The Netherlands. Information on the sociodemographic determinants of age, sex, and ethnicity was available for respondents and non-respondents. The main outcome measures of prevalence of sport participation and watching TV were only available for respondents. The framework consisted of four steps: 1) investigating the sociodemographic determinants of responding to the survey and the difference in response over time between sociodemographic groups; 2) estimating variation in health behaviour over time; 3) comparing weighted and unweighted prevalence estimates of health behaviour over time; and 4) comparing associations between sociodemographic determinants and health behaviour over time. Results The overall response rate per survey declined from 47% in 1995 to 15% in 2017. The probability of responding was higher among older people, females, and those with a Western background. The response rate declined in all subgroups, and a faster decline was observed among younger persons and those with a non-Western ethnicity as compared to older persons and those with a Western ethnicity. Variation in health behaviours remained constant. Prevalence estimates and associations did not follow the changes in response over time. On the contrary, the difference in probability of participating in sport gradually decreased between males and females, while no differential change in the response rate was observed. Conclusions Providing insights on non-response patterns over time is essential to understand whether declines in response rates may have influenced estimated trends in health behaviours. The framework outlined in this study can be used for this purpose. In our example, in spite of a major decline in response rate, there was no evidence that the risk of non-response bias increased over time.

Background: Replacement of saturated fatty acids (SFAs) with unsaturated fatty acids (UFAs), especially polyunsaturated fatty acids (PUFAs), has been associated with a lower risk of ischemic heart disease (IHD). Whether this replacement is beneficial for drug-treated patients with cardiac disease is not yet clear. Objective: In a prospective study of Dutch patients with cardiac disease (Alpha Omega Cohort), we examined the risk of cardiovascular disease (CVD) and IHD mortality when the sum of SFAs and trans fatty acids (TFAs) was theoretically replaced by total UFAs, PUFAs, or cis monounsaturated fatty acids (MUFAs). Design: We included 4146 state-of-the-art drug-treated patients aged 60-80 y with a history of myocardial infarction (79% male patients) and reliable dietary data at baseline (2002)(2003)(2004)(2005)(2006). Cause-specific mortality was monitored until 1 January 2013. HRs for CVD mortality and IHD mortality for theoretical, isocaloric replacement of dietary fatty acids (FAs) in quintiles (1-5) and continuously (per 5% of energy) were obtained from Cox regression models, adjusting for demographic factors, medication use, and lifestyle and dietary factors. Results: Patients consumed, on average, 17.5% of energy of total UFAs, 13.0% of energy of SFAs, and ,1% of energy of TFAs. During w7 y of follow-up, 372 CVD deaths and 249 IHD deaths occurred. Substitution modeling yielded significantly lower risks of CVD mortality when replacing SFAs plus TFAs with total UFAs [HR in quintile 5 compared with quintile 1: 0.45 (95% CI: 0.28, 0.72)] or PUFAs [HR: 0.66 (95% CI: 0.44, 0.98)], whereas HRs in cis MUFA quintiles were nonsignificant. HRs were similar for IHD mortality. In continuous analyses, replacement of SFAs plus TFAs with total UFAs, PUFAs, or cis MUFAs (per 5% of energy) was associated with significantly lower risks of CVD mortality (HRs between 0.68 and 0.75) and IHD mortality (HRs between 0.55 and 0.70). Conclusion: Shifting the FA composition of the diet toward a higher proportion of UFAs may lower CVD mortality risk in drug-treated patients with cardiac disease. This study was registered at clinicaltrials.gov as NCT03192410.Am J Clin Nutr 2017;106:895-901.