SciBlogs

Posts Tagged obesity

UK doctors unite to tackle obesity Amanda Johnson Feb 25

No Comments

A new report published last week in the UK has come up with some comprehensive recommendations on tackling obesity. The report, Measuring up: the medical profession’s prescription for the nation’s obesity crisis, follows a 6-month inquiry by a steering group with representatives from 20 of the Royal Medical Colleges and Faculties.

The report begins by describing the UK as the ‘fat man’ of Europe, with two thirds of adults overweight or obese. Unfortunately, In New Zealand, the obesity figures are similar, with one in three adults overweight (37.0%) and a further one in four obese (27.8%).

The report presents an action plan and sets out key recommendations for healthcare professionals, local and national government, industry and schools which it believes will help tackle the nation’s obesity crisis.

Recommendations include:

1. Education and training programmes for healthcare professionals.

2. Investing £100m (NZ$181m) in weight management services in each of the next three financial years to extend and increase provision of weight management services across the country, to mirror the provision of smoking cessation services.

3. Nutritional standards for food in hospitals.

4. Increasing support for new parents by ‘skilling up’ the early years workforce to deliver basic food preparation skills to new mothers and fathers.

5. Applying mandatory food- and nutrient-based standards to all schools in England.

6. Reducing proximity of fast food outlets to schools, colleges, leisure centres and other places where children gather.

7. Implementing a ban on advertising of foods high in saturated fats, sugar and salt before 9pm.

8. For an initial one year period, taxing all sugary soft drinks, increasing the price by at least 20%. This would be an experimental measure, looking at price elasticity, substitution effects, and to what extent it has an impact upon consumption patterns and producer/retailer responses.

9. Major food manufacturers and supermarkets should agree in the next year a unified system of traffic light food labelling and visible calorie indicators for restaurants, especially fast food outlets.

10. Public Health England should provide guidance to Directors of Public Health in working with local authorities to encourage active travel and protect or increase green spaces to make the healthy option the easy option.

Some of the recommendations have attracted controversy, with a report from the BBC highlighting taxing fizzy drinks and banning junk food ads

The argument against a ‘Nanny State often arises when this type of report is published; however, Professor Terence Stephenson, a paediatrician and chair of the Academy of Medical Royal Colleges, told the BBC that there was no “silver bullet” for tackling obesity, instead the entire culture around eating needed to change to make it easier to make healthy decisions.

“I choose what I eat or whether I smoke, what people have told us is they want help to swim with the tide rather than against the current to make the healthy choice the easy one,” he said.

The report avoids the ‘blame game’, stating that obesity is not the fault of any one government, organisation or individual. Instead, they say, “it is a problem that has crept up on us and must now be tackled urgently through collective action.”

A lot of the recommendations highlight issues that are very relevant to New Zealand, and we should take note and watch carefully to see whether these recommendations are implemented in the UK, and if so, what effect they have.

We certainly need to start taking obesity seriously in this country, and we need to support those who want to make changes to improve their health, by promoting healthy environments (especially for children), by investing in weight management services, and by making healthy choices easier for people.

The fat tax debate is reignited again Amanda Johnson Dec 12

1 Comment

The debate about fat tax has been reignited with the publication of a new paper today (12 December 2012) by New Zealand researchers. Taxes on soft drinks and foods high in saturated fats, and subsidies for fruit and vegetables, could lead to beneficial dietary changes and potentially improve health, say the authors of this latest research.

Helen Eyles and her colleagues from the University of Auckland and the University of Otago (Wellington) reviewed all relevant modelling studies that investigated the association between food pricing strategies, food consumption and chronic diseases. In their combined analysis of 32 studies, the authors’ model predicted a 0.02% fall in energy intake from saturated fat for each 1% price increase. Also, a 10% increase in the price of soft drinks could decrease consumption by 1% to as much as 24%.

In contrast, the authors found that a 10% decrease in the price of fruits and vegetables could increase consumption by between 2% to 8%. The results also indicated better health outcomes for those on lower incomes, suggesting that food pricing strategies have the potential to reduce inequalities in health.

The authors do note that the majority of included studies (25/32) were of low quality, with substantial variability in model structures, data inputs, and the types and magnitudes of food taxes and subsidies assessed. There is also evidence, for ‘compensatory purchasing’; for example, if carbonated drinks are taxed, then there are non-carbonated but equally ‘sweet’ drinks available to choose from.

We are in the grips of an obesity epidemic here inNew Zealand, with one in three adults now overweight and a further one in four obese. It is generally agreed that multiple strategies are needed to address the problem; but should a tax on fatty and sugary foods be implemented here in New Zealand?

Denmark last month scrapped its fat tax, which was implemented a year ago across-the-board on all foods with a saturated fat content above 2.3 percent. The hope was that consumption of unhealthy foods would be reduced. According to media reports, Danes simply began to do their grocery shopping internationally, heading to countries that didn’t levy a tax on fat. Although it has been suggested in a New Scientist article that the real reason for the repeal was to appease business interests.

Arguments in favour of a tax on unhealthy foods include the fact that a tax would provide funds to help towards the prevention of obesity (for example advertising campaigns to promote dietary improvements) and would also help fund future medical costs. It might also deter consumers from purchasing unhealthy foods and might encourage food manufacturers to alter the composition of their products to make them healthier. The results of this latest research would appear to support the introduction of a tax.

The authors of the research study suggest that “Based on modelling studies, taxes on carbonated drinks and saturated fat and subsidies on fruits and vegetables are associated with beneficial dietary change, with the potential for improved health.”

With obesity rates sky-rocketing in New Zealand, and given that obesity is associated with many diseases (including type 2 diabetes and cardiovascular disease) and with premature death, all aspects of addressing this problem need to be considered. Price certainly has an influence on food choice, and presenting healthier food options in a way that is more appetizing and appealing, as well as more affordable than the less healthy options, is likely to encourage their selection.

For more information about the research, which is freely available, follow this link to PLOS Medicine.

Obesity prevention starts in the womb Amanda Johnson Oct 18

No Comments

The annual scientific meeting of the Australian and New Zealand Obesity Society starts today; the theme of the meeting is ‘For our children’s children‘, and a fascinating programme has been put together with some great speakers who will be presenting their research on this important topic.

One of the keynote speakers for today (18 October) will be Professor Wayne Cutfield, who is a Professor in Paediatirc Endocrinology and Director of The Liggins Institute. He will be discussing the foetal footprint. You can listen to Professor Cutfield’s key messages, along with those of some of the other key speakers, via a Science Media Centre briefing held in advance of the conference.

Professor Wayne Cutfield told the Science Media Centre briefing that early life events are critically important and can contribute to increased risk of adult obesity and diabetes.

According to Professor Cutfield, common variants in genes account for less than 10% of common diseases – the impact of genetics is fixed and small. The environment is therefore very important and it isn’t just genes that cause chronic disease.

It is important, he says, to prevent obesity early. Children born small for gestational age (1-3%); premature babies (3-5%); and post-term babies (2-4%) all have an increased risk of obesity, insulin resistance and/or diabetes. First born children (60%) also have an increased risk of insulin resistance and high daytime blood pressure.

A study by Redwood et al that has just been completed showed that 250 women going through IVF had a limited change in diet or lifestyle in the period leading up to pregnancy (alcohol was consumed by 51%; a small number smoked – 2%; caffeine was consumed by 87%; and folic acid intakes were low among 17%). There was a perception that pregnancy doesn’t count until you have a positive pregnancy test, but in fact the impact of early life events begin very early in pregnancy. Diets were also high in fat and saturated fats; and low in carbohydrate, calcium iron and folic acid.

His conclusion was that the optimal foetal environment is delicately poised. Deviation from the average (too early/late/small) increases risk of obesity, diabetes and cardiovascular disease. The foetal environment – particularly the nutritional environment during pregnancy right from just prior to conception is important for life-long health.

There has been some media coverage of this issue today in the New Zealand Herald and 3 News and on Stuff.

It is quite clear that we need to improve nutrition education in women of reproductive age in terms of promoting optimal food intakes during pregnancy. Education, suggests Professor Cutfield, should begin in the teenage years when girls are still at school.

By ensuring the right nutrients are consumed right from the time when pregnancy is being planned and certainly during pregnancy while the baby is growing in the womb, we can at least give our children the best possible start in life. All women of childbearing age need to have access to these important messages about nutrition and health, both for themselves and for their future children. This could have a significant impact on the health of the nation in the future.

 

 

Unhealthy weight control among New Zealand kids Amanda Johnson Aug 30

No Comments

A new study just published this month by researchers at the University of Auckland has highlighted concerns about weight control behaviours among New Zealand adolescents, and has identified a number of ‘red flags’ for unhealthy weight loss.

The new findings were published last week (21 August 2012) in the International Journal of Behavioural Nutrition and Physical Activity by Dr Jennifer Utter and colleagues from the School of Population Health, University of Auckland.

The researchers collected data as part of a national health and wellbeing survey of secondary school students in New Zealand in 2007. In total 9,107 students aged 13-18 agreed to participate. Results showed that among students who had attempted to lose weight (around half of the children surveyed) 90% were eating less fatty food and 52% were eating fewer sweets.

Of concern, however, was that a significant number of children were adopting unhealthy weight control behaviours in order to reduce their weight; for example vomiting (7.8%), diet pills (3.5%), smoking cigarettes (9%), fasting (12.5%) and skipping meals (31.4%). Students who adopted the more unhealthy weight control behaviours had significantly lower wellbeing scores and higher depression scores.

The authors of this research suggest that as skipping meals and fasting were the most common unhealthy weight control behaviours that routine assessment by clinicians should include screening for meal skipping and fasting.

This is an interesting study, especially in the light of the new Food and Nutrition Guidelines for Children and Young People published by the Ministry of Health earlier this month. The latest figures for the prevalence of obesity show that among 2-14 year olds 20.9% were overweight and a further 8.3% were obese; and among 15-19 year olds 22.1% were overweight and a further 12.6% were obese.

Weight issues are obviously affecting a significant number of New Zealand children and we need to make sure that good healthy strategies are put in place to help these children manage their weight effectively. Children need to be supported with advice based on the Ministry of Health Food and Nutrition Guidelines and Guidelines for Weight Management in Children and Young People. In terms of diet; a healthy diet should be encouraged that is low in saturated fats, sugar, and salt, includes a variety of foods, such as wholegrain cereals, rice, pasta, fruits, vegetables, and lean proteins. Water and milk should replace sugary drinks, and high-energy takeaway foods and snacks should be avoided. Children should also be encouraged to take part in regular moderate-intensity or vigorous physical activity for at least 60 minutes per day.

This approach should be promoted to all children with weight issues, however, following the publication of this research we all need to keep a particular eye out for ‘red flags’ such as fasting and meal skipping so we can intervene with appropriate help and support.

Is the food industry ripe for scrutiny? Amanda Johnson Jun 20

No Comments

The journal PLoS Medicine (Public Library of Science Medicine) has today (June 20) launched a special series of articles highlighting the influence and impact of the food industry.

Seven articles, published over the next three weeks, will examine the activities and influence of ‘Big Food’ (defined as the multinational food and beverage industry with huge and concentrated market power) in the health arena. The series aims to stimulate debate by examining the activities and influence of the food industry in global health.

The series kicks off with an editorial suggesting that the food industry is ripe for scrutiny. It is suggested that ‘Big Food’ is shaping the field of global health and that this is a concern since food companies’ primary obligation is to drive profit by selling food.

Then there is an essay on ‘Big Food’, food systems and global health by David Stuckler and Marion Nestle. They outline three possible ways to view the debate: firstly, voluntary self-regulation with no further engagement by the public health community; secondly, developing partnerships between public health advocates and industry, in order to make positive changes from within;  the third ‘critical view’ approach recognises the conflicts of interest between corporations that profit from unhealthy food and public health.

The authors support the critical view since they have found no evidence for health gains through partnerships. They suggest that to promote health, the food industry would need to make and market healthier foods so as to shift consumption away from highly processed, unhealthy foods. Yet such foods are inherently less profitable. They finish by urging public health professionals to place as high a priority on nutrition as they do on HIV, infectious diseases and other disease threats. They also suggest supporting initiatives that restrict marketing to children, offer better nutrition standards for school meals and introducing taxes on sugar sweetened beverages (SSBs).

The final paper released today, by Lori Dorfman and colleagues, compares the soda and tobacco industries in terms of corporate and social responsibility. In summary, the authors state that because SSBs are implicated in the global obesity crisis, major soda companies have recently employed elaborate, expensive, multi-national corporate social responsibility (CSR) campaigns. Such campaigns, they argue, are a way to focus responsibility on consumers rather than on the corporation and are a way to bolster the popularity of their products. They suggest that this is also a way of preventing regulation. It is recommended that public health advocates need to counter industry CSRs with strong de-normalization campaigns to educate the public and policy makers about the social ills caused by SSBs.

The Science Media Centre today published a Science Alert with the views of senior academics and researchers who give a New Zealand perspective on this issue, and there has already been some media interest in this topic.

I’m delighted to see this series of papers published as I think the time is right for close scrutiny of the food industry. While it is important not to polarise the debate and place sole blame for obesity and other food-related problems on the food industry, there are areas that need to be considered — particularly the marketing of inappropriate foods to children (especially pre-schoolers), and the provision of healthy foods in the school setting. It may be that some of these areas do require some regulation.

In the meantime, let’s not forget that obesity is a complex problem not caused by a single factor. Tackling the issue in New Zealand requires a multi-faceted approach, including the promotion of good nutrition and regular physical activity across all sectors of society.

Managing obesity in primary care Amanda Johnson May 16

No Comments

A new paper published yesterday (14 May 2012) in the Canadian Medical Association Journal has reviewed the literature from January 2006 to July 2011 to establish the most effective methods for managing the ever increasing problem of obesity in the primary care setting.

Say the authors, ’there is an urgent need to find simple, effective strategies for improving weight loss counselling in clinical practice’.

This is an interesting review that covers the whole spectrum of treatment from diet to exercise and psychological interventions.

Overall, there is clear evidence that a holistic approach is the most effective. Dietary interventions show that dietary adherence and calorie restriction are more important than macronutrient composition. In terms of physical activity, interventions that combine exercise and diet certainly resulted in a greater reduction of weight than dietary interventions alone. Behaviour change is also an important component of weight loss and cognitive behavioural therapy, when combined with diet and exercise intervention, resulted in greater weight loss than diet or exercise alone.

This latest review confirms that the best approach to tackling weight management is the one that is currently recommended in the New Zealand Ministry of Health Clinical Guidelines on Weight Management, which promotes the FAB approach (this stands for ‘food’, ‘activity’, and ‘behaviour’). The FAB approach is a comprehensive lifestyle approach that incorporates diet, physical activity and behavioural strategies as the first treatment option for weight loss and sustained weight maintenance.

Weight maintenance is also addressed in this review paper, with a nice summary of the key indicators of successful maintenance of weight loss from the National Weight Control Registry, which includes information on more than 5000 people who have lost more than 30kg and kept it off for an average of six years. The keys to success are to engage in a high level of physical activity, to eat a diet low in fat and calories, to eat breakfast, to self-monitor weight on a regular basis, to keep a consistent eating pattern, and to catch ‘slips’ before they turn into larger re-gains in weight. All pretty sensible advice really!

New study shows discrimination against obese people Amanda Johnson May 09

1 Comment

A new study published this month in the International Journal of Obesity by an international collaboration of researchers from New Zealand, Australia, the UK and Hawaii, has shown that discrimination against obese people is occurring in the work place. Researchers used a newly-developed measure of anti-fat prejudice, the universal measure of bias (UMB), to predict workplace discrimination against obese people. Lead researcher Kerry O’Brien, from Monash University in Australia, said the nature of the study initially was concealed from the participants to avoid biased results.

Under the guise of a personnel selection task, 102 participants were asked to give an assessment of obese and non-obese women applying for a managerial position. Participants viewed resumes that had attached either a photo of a pre-bariatric surgery obese woman (body mass index (BMI 38—41) or a photo of the same woman post-bariatric surgery (BMI=22—24). Results showed that obesity discrimination was widespread, and was displayed across all selection criteria, such as starting salary, leadership potential and likelihood of selection for the job.

The fact that overweight and obese people are discriminated against is nothing new. Back in the1980s, research showed that strong prejudice against obese people is evident in children as young as 6 years of age.

Further research in the 1980s found that this discrimination continues into adult life, with obese people attaining a lower social class than comparable non-obese people. The social handicap of obesity in this study was independent of parental social class, intelligence or education and the authors emphasise the importance of changing public attitudes to obesity.

Now, over 25 years later, it seems nothing much has changed, despite the increasing prevalence of overweight and obesity in New Zealand and across the world. The results from this latest study, say the authors, provide support for the use of this type of research to assess, understand and reduce anti-fat prejudice and discrimination.

This whole issue has been widely reported by the media, both in New Zealand and overseas; with articles in the New Zealand Herald the Australian Herald Sun and the UK Daily Telegraph.

You would imagine that overweight and obesity being so common in this day and age, that there would be more compassion, understanding and support in our society, but this latest research suggests this is not the case.

Clearly there is an urgent need for promoting improved diet, exercise and behaviour modification as a way of tackling the ever-increasing problem of obesity in New Zealand. But in the meantime, we need to reduce anti-fat sentiments in the population, and particularly in the workforce, where valuable skills and human resources may be going to waste as a result of inappropriate discrimination.

Defining ‘best’ foods is a matter of ‘fact’, not ‘perception’ Amanda Johnson Mar 20

2 Comments

I was shocked to read an article in the Sunday Star Times a week ago (11 March) by Lee-Anne Wann that was full of inaccuracies, was misleading, and could be potentially dangerous for some people.

The article Defining ‘best’ foods is a matter of perception made the following incorrect claims:

1. Not all people carry excess body fat because of excess calories.

FACT: For weight loss to occur, a calorie deficit is ESSENTIAL!

Here is a quote from the Obesity Task Force Report of the British Nutrition Foundation (which I edited some years ago), written by some of the world’s leading experts in obesity:

’One of the few statements about obesity that can be made with absolute certainly is that obesity can only occur when energy intake remains higher than energy expenditure, for an extended period of time. This is the incontrovertible foundation stone upon which any theories of obesity must be built.’

I think this sums it up nicely.

2. Butter is an excellent source of iodine.

FACT: No, actually, it isn’t. Butter contains negligible amounts of this important mineral. This dangerous misinformation may put people at risk of iodine deficiency, particularly those with high requirements such as pregnant and breastfeeding women. Bread made with iodised salt, fish and eggs are good sources of iodine.

3. Full fat coconut cream has a huge host of benefits.

FACT: Both butter and coconut cream are high in saturated fatty acids, which can increase the risk of cardiovascular disease. Intake of such foods should be kept to a minimum. For people at high risk of CVD, consuming such products could put their health at risk.

4. Otago University have published a list of 49 foods to avoid

FACT: The NEEDNT food list, to which this statement refers, is not ’Otago University’s 49 Foods to Avoid’ as stated in the article. In fact, it is a tool designed to help obese people replace certain foods that are high in calories with lower-calorie, more nutritious alternatives. It is intended to be used in a clinical context by health professionals, in conjunction with other relevant nutrition information. The Science Media Centre held a briefing on this last month, which received quite a bit of coverage.

I know other dietitians were equally alarmed by some of the claims made in the article, and Dietitians New Zealand, our professional association, contacted the Sunday Star Times to express their concerns last week. Unfortunately their letter was not published, although the original article did attract some attention in the letters page this week (18 March).

It’s a real shame that once the inaccuracies in the article had been clearly pointed out by Dietitians New Zealand (a leading expert organisation in the field of diet and nutrition), that the correct information was not published in the paper the following week.

Nutrition policy for 2012 Amanda Johnson Jan 11

1 Comment

A media release yesterday (10 January) from the University of Otago highlighted concerns about nutrition policy in New Zealand, and the fact that it seems to favour the food industry. This follows on from a paper published late last year in the Journal of Public Health Nutrition — Nutrition policy in whose interests? A New Zealand case study.

The paper, by Gabrielle Jenkin and colleagues, examines whose interests (the food industry or public health) are served by nutrition policies and why. By studying  submissions to an enquiry by the Health Select Committee into Obesity and Type 2 diabetes held in 2006, their research compared the positions of the food industry and public health groups, and assessed whether the interests were getting equal consideration, or whether one group was being favoured over the other. The positions of submitters from the food industry and public health groups such as the National Heart Foundation were compared with the 2007 Labour Government’s response to the committee’s recommendations and the resulting national nutrition policy.

Results showed that the Government’s position was largely aligned with the food industry interests in relation to national obesity strategy, food industry policy, and advertising and marketing policies. In relation to nutrition policy in schools, the Government’s position was in line with public health interests — industry was opposed to mandatory food and nutrition policies in schools, although did support the ‘free fruit in schools’ initiative and inclusion of nutrition education in the school curriculum.

The school nutrition policy was subsequently overturned by the National Government, which according to the lead author Gabrielle Jenkin suggests a strengthening of industry’s influence on our national nutrition policy. She says: ’allowing schools to profit from the sale of unhealthy foods to their students is personally concerning to me as a parent, and should send alarm bells to other parents’. I agree!

Setting nutrition policy is a complex issue and it is important to work with all sectors of society, including the food industry, to seek solutions to the current obesity crisis in New Zealand.  However, industry should not be setting the agenda for nutrition policy for New Zealanders.

The first priority for those in charge of food policy needs to be to promote good health and protect the most vulnerable in our community, such as children, who have high nutritional needs. Every child in New Zealand should have access to healthy and nutritious food. Junk food that is high in fat and sugar should not be directly promoted to our children — particularly in the school environment where we, as parents, have little influence or control.

Individuals, of course, do have responsibility for their own health and for what foods they eat, but by creating a better environment we can make it easier for people to make healthier food choices. Marketing, advertising and promotional strategies around unhealthy foods certainly need consideration, and if self-regulation by industry is unsuccessful, then Government regulation will be needed to control the marketing of unhealthy foods.

The necessity of having healthy food policies in schools is clear cut. By educating children about the importance of good nutrition, we will be creating a healthier, more nutritionally-aware generation. Also, the extention of strategies such as the provision of healthy breakfasts, school milk, and fruit in schools, would all be excellent initiatives — particularly in lower decile schools.

Provision of junk food, whether this is served in the school tuck shop or canteen, or sold as a fund-raiser, should be abolished in the school environment.

Should New Zealand have a fat tax? Amanda Johnson Oct 04

8 Comments

This week it was reported in the media that Denmark has become the first country in the world to introduce a fat tax on food, with a surcharge on foods high in saturated fat of 16 kroner ($NZ3.80) per kg of saturated fats in a product.

According to Radio New Zealand, Health Minister Tony Ryall has ruled out a fat tax for New Zealand, saying that a fat tax would add to the burden on many families in tight economic times.

We are in the grips of an obesity epidemic here in New Zealand, and last month the new National Diet and Nutrition survey showed that the prevalence of obesity among men had jumped from 17 percent in 1997 to 27.7 percent in 2008-2009 and from 20.6 percent in women to 27.8 percent. Among Maori, 40.7 percent of men were obese, and 48.1 percent of women. But is a fat tax really the answer to our burgeoning obesity problem?

The debate about fat tax is not new and this latest move by Denmark has sparked media headlines around the world — with the LA Times suggesting that the ‘food police’ have stormed Denmark and the UK’s Independent newspaper suggesting that consumers are hoarding provisions ahead of the price rise.

Concerns about the introduction of a fat tax have been largely centred on the fact that such a tax may hit low-income families harder as they may be buying a higher proportion of the less healthy foods. It has also been argued that simply changing the pricing of foods won’t change people’s eating habits. In addition, it is difficult to categorize some foods as good or bad — dairy products such as the full fat versions of milk and cheese can be high in fat but a good source of calcium, protein and other important nutrients. Such foods can make an important nutritional contribution to the diets of young children or frail and malnourished older people who may need the extra nutrients provided by such products. If a tax was introduced it would have to be carefully implemented.

Here in New Zealand, the Fight the Obesity Epidemic (FOE) organisation published a report on fat tax, Cutting the Fat: How a fat tax can help fight obesity in August, 2004. In the report they outline the benefits of such a scheme, highlighting four key benefits of introducing a fat tax. Firstly, a fat tax would provide funds for prevention and medical treatment of obesity; secondly, a fat tax may deter the purchase of unhealthy products; thirdly, there would be strong incentives to manufacturers to alter product composition; and finally, a tax would provide revenue that could be used to fund complementary measures (such as a major public awareness campaign) to encourage consumers to have a more balanced diet.

However, FOE also state that ’possible introduction of a fat tax is a potentially controversial topic should not inhibit discussion of this or any other measures that may facilitate the lifestyle changes necessary to stem the tide of the obesity epidemic.’

With obesity rates sky-rocketing in New Zealand, and given that obesity is associated with many diseases and with premature death, all aspects of addressing this problem need to be considered. Price certainly has an influence on food choice, and presenting healthier food options in a way that is more appetizing and appealing, as well as more affordable than the less healthy options, is likely to their encourage selection.

Network-wide options by YD - Freelance Wordpress Developer