Evidence Update: Media Literacy & the Effects of Added Sugar and Salt in Children’s Diets
Mary Anne Smith, PhD, RD January 20th, 2015
Acknowledgements
Project Objec+ves
Using a semi-‐systemaLc approach,
identify,
critically appraise & summarize
the highest quality, most recent evidence.
Research QuesLons
1. What is the effecLveness of media literacy programs targeted to children to protect them from the harms of unhealthy food and beverage adverLsing?
2. What are the health effects of added sugars in children’s diets?
3. What are the health effects of high salt in children’s diets?
QuesLon #1
1. What is the effecLveness of media literacy programs targeted to children to protect them from the harms of unhealthy food and beverage adverLsing?
2. What are the health effects of added sugar in children’s diets?
3. What are the health effects of high salt in children’s diets?
Media Literacy Background
• Food and beverage adverLsing can negaLvely affect children’s food preferences, choices, and intakes1-‐3
• Canadian children view 3.7 food/beverage ads per hour of television watched4
Media Literacy Background
Media Literacy: ability to access, analyze, evaluate, and communicate messages in a
variety of forms5
Adver+sing Literacy
Media Literacy Methods
• Databases searched: Trip, PubMed, CINAHL. Also Google scholar, Journal of Media Literacy EducaLon
• Focuses: adverLsing of less healthy foods and beverages, ≤ 17 years, English, secondary research, prioriLzaLon of arLcles published since 2009
• Reviewed: 5 secondary and 9 primary research arLcles
1. The literature base suffers from unsubstan+ated assump+ons. Namely: • ê adverLsing literacy = é suscepLbility to adverLsing6
• Younger children = More suscepLble
• Media literacy in an intervening variable between exposure and effects7
• Media influence can be raLonally controlled7
• Food and beverage adverLsing literacy is pregy much the same as other types of media literacy3
Media Literacy Results
Exposure Literacy Effects
Media Literacy Results 2. Media literacy intervenLons are more successful at
improving media-‐literacy related outcomes than changing ahtudes or behaviours • A counter-‐adverLsement for front-‐of-‐package promoLons helped children understand the adverLsement, but did not change children’s desire for the product8
• An online adverLsing literacy game helped children interpret advergames as a form of adverLsing, but did not change brand ahtudes or purchase intension for the product9
Media Literacy Results 3. Media literacy has been shown to be effecLve
across a wide variety of other contexts • A systemaLc review and meta-‐analysis of 51 media literacy intervenLons found a posiLve and significant intervenLon effect (weighted mean effect = 0.37, 95%CI 0.27, 0.47)10
• Smoking prevenLon11, 12; alcohol prevenLon13; eaLng disorder risk14
• Again, intervenLons were more successful at improving media understanding than in changing behaviours
Media Literacy Conclusions
• May help children understand adverLsing, but may not influence food preferences or purchasing decisions
• “May not be a strong opLon for agenuaLng the effects of food adverLsing directed to children”3
QuesLon #2
1. What is the effecLveness of media literacy programs targeted to children to protect them from the harms of unhealthy food and beverage adverLsing?
2. What are the health effects of added sugars in children’s diets?
3. What are the health effects of high salt in children’s diets?
Sugar Background
• Sugar intake in Canadian children 9-‐18 years: (CCHS, 2.211)
• ~25% of energy intake from natural and added sugars • Sor drinks accounted for 14.3% of total sugar intake
• Controversy over added sugar recommendaLons: • DRIs: ≤ 25% of total energy intake • World Health Organiza+on, Heart and Stroke Founda+on of Canada: ≤ 10% of total energy intake
Sugar Methods • Databases: Cochrane,
PubMed, CINAHL
• Focuses: Human studies, ≤ 18 years, English, secondary research, prioriLzaLon of arLcles published since 2009
• Reviewed: 15 secondary and 9 primary research arLcles
Hunger/SaLety Energy intake Hypoglycemia Cough/Cold
Obesity MalnutriLon Diabetes
Dental Caries Hypertension Dyslipidemia
HyperacLvity Learning CogniLon
AddicLon Substance Abuse
AuLsm Alzheimer's
Short-‐Term Long-‐Term
Physical
Mental
Good evidence that added sugars:
éEnergy intake16 ?é Obesity16, 18-‐25 ??? Diet Adequacy17 éDental Caries*26-‐27
≠HyperacLvity28 ≠Learning28 ≠CogniLon28
Short-‐Term Long-‐Term
Physical
Mental
• Evidence from secondary research
é = direct relaLonship ê = indirect relaLonship ??? = unclear relaLonship ≠ = no relaLonship
*RelaLonship mediated by several variables
≠ SaLety29
éUric Acid30, TG31 êHDL-‐C31
?é Systolic BP30, 31 ≠ LDL-‐C31, Diastolic BP30 éFasLng Insulin31
êInsulin SensiLvity31, 32
Short-‐Term Long-‐Term
Physical
Mental
Some evidence that added sugars:
• Evidence from primary research
é = direct relaLonship ê = indirect relaLonship ??? = unclear relaLonship ≠ = no relaLonship
No evidence that added sugars:
• No research studies met the inclusion criteria
Hypoglycemia Cough/Cold
AddicLon Substance Abuse
AuLsm Alzheimer's
Short-‐Term Long-‐Term
Physical
Mental
Sugar LimitaLons
• Majority of the research in this area used cross-‐secLonal designs
• Cannot be used to determine causality
• Discrepancies in how ‘added sugars’ are defined
• Difficult to isolate effect of a single nutrient source from other diet/lifestyle factors
Sugar Conclusions • Higher-‐quality primary research needed to elucidate many of the relaLonships
• Diets high in sugar can contribute to increased energy intake (and weight gain) and dental caries without proper oral care
• No relaLonship between sugar intake and hyperacLvity in children
QuesLon #3
1. What is the effecLveness of media literacy programs targeted to children to protect them from the harms of unhealthy food and beverage adverLsing?
2. What are the health effects of added sugars in children’s diets?
3. What are the health effects of high salt in children’s diets?
Salt Background
• Salt intake in Canadian children 9-‐18 years: (CCHS, 2.233)
• ~97% of boys and ~82% of girls exceed the tolerable upper limit for sodium
• EsLmates do not include salt added during cooking or at the table
• In adults, salt intake linked to: – Hypertension – Cardiovascular disease – Renal disease – Kidney Stones – Stomach Cancer
Salt Methods • Databases: Cochrane,
PubMed, CINAHL, TRIP
• Focuses: Human studies, ≤ 18 years, English, secondary research, prioriLzaLon of arLcles published since 2009
• Reviewed: 5 secondary and 16 primary research dd arLcles
Muscle Cramps Dizziness Electrolyte Disturbances DehydraLon
Nausea VomiLng/Diarrhea Asthma Symptoms
High Blood Pressure Cardiovascular Disease
Kidney Damage Kidney Stones
Obesity Edema
Stomach Cancer Osteoporosis
Stress OvereaLng
Depression Anxiety
Alzheimer's
Short-‐Term Long-‐Term
Physical
Mental
Good evidence that high salt diets:
éBlood Pressure34 ≠Asthma*35
Short-‐Term Long-‐Term
Physical
Mental
• Evidence from secondary research
é = direct relaLonship ê = indirect relaLonship ??? = unclear relaLonship ≠ = no relaLonship
*Mostly based on adult data
??? Asthma38, 39 éCalcium ExcreLon36 ≠ Bone Turnover36 ≠ Potassium ExcreLon37 ≠ HydraLon40-‐43 éSSB intake41-‐43
??? Blood Pressure44-‐49
éBMI50, 51 éBody Fat %50
éWaist Circumference51
Short-‐Term Long-‐Term
Physical
Mental
Some evidence that high salt diets:
• Evidence from primary research
é = direct relaLonship ê = indirect relaLonship ??? = unclear relaLonship ≠ = no relaLonship
No evidence that high salt diets:
• No research studies met the inclusion criteria
Muscle Cramps Dizziness Nausea
VomiLng/Diarrhea
Cardiovascular Disease
Kidney Damage Kidney Stones
Edema Stomach Cancer Osteoporosis
Stress OvereaLng
Depression Anxiety
Alzheimer's
Short-‐Term Long-‐Term
Physical
Mental
Salt LimitaLons • Majority of the research in this area used cross-‐secLonal designs
• Cannot be used to determine causality
• Differences in how sodium is measured • Dietary intake vs. urinary excreLon
• As with sugar, difficult to isolate effect of a single nutrient source from other diet/lifestyle factors
Salt Conclusions • More research is needed – parLcularly research that can determine causality
• Diets high in salt likely contribute to increased blood pressure, and may negaLvely affect calcium retenLon, BMI, body fat %, and waist circumference
• Likely no relaLonship between salt intake and hydraLon status or bone turnover in children
Take Home Messages
Media Literacy: 1. Media literacy intervenLons (in any area) are
typically beger at educaLng rather than changing ahtudes or behaviours
2. “May not be a strong opLon for agenuaLng the effects of food adverLsing directed to children”3
Take Home Messages
Added Sugars: 1. Need higher quality research in children that
standardizes ‘sugar’ 2. Sugar is not associated with hyperacLvity or
behaviour problems in children, but is associated with increased energy intake (possibly leading to weight gain) and dental caries when oral care is inadequate
Take Home Messages
Salt: 1. Need research that can determine causality and
more research in children 2. Salt is not associated with hydraLon status, but
may be associated with blood pressure, sugar-‐sweetened beverage intake, weight status, and calcium excreLon
QuesLons?
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