Background Sri Lanka has made progress in communicable diseases and poverty reduction, however malnutrition in all forms remains a public health challenge. Previous research has focused primarily on short-term interventions towards primary school aged children, in high-income countries, often targeting narrow outcomes, such as fruit and vegetable consumption. This study aims to address some of these limitations by assessing the long-term effectiveness of a school-based behavioural intervention among adolescents through holistic dietary changes to help prevent obesity, type 2 diabetes, and cardiovascular disease. Methods This study will involve 11–14 year old adolescents attending public schools within Colombo and Gampaha districts of Western Province, Sri Lanka. It is a three-arm cluster randomised controlled trial, with one class per school being selected to participate. Based on sample size/power calculations, the trial will involve 244 schools/classes. Schools will be randomly allocated in a 1:1:1 ratio to two intervention arms (Arms A and B) and one control arm (Arm C). Arm A consists of a non-financial reward; Arm B consists of non-financial reward & pre-commitment device and Arm C will be the control. A difference-in-differences approach will estimate the average treatment effect, adjusting for clustering, fixed effects, and relevant baseline covariates including but not limited to age, gender, and waist circumference. Subgroup analyses will also be conducted. Discussion This study aims to assess the feasibility and effectiveness of a holistic dietary behavioural interventions for adolescents aged 11–14. As the trial is school-based, participants and intervention staff cannot be blinded, but it will adhere to established procedures to maintain separation between staff that deliver the intervention and staff that take outcome measurements. As a minor percentage of children in this age group either study in private schools or drop out of school, we will not be missing a large percentage of children from our sampling framework. Registration Registered at ISRCTN (registration number: ISRCTN11340383) on 29 August 2025.

Learn about CoDiet, an international research initiative aimed at addressing diet-related diseases using innovative monitoring technologies and personalised nutrition. It was French lawyer and gastronome Anthelme Brillat-Savarin who famously said in 1826, “Tell me what you eat, and I will tell you what you are”. Long before science confirmed it, he discerned what we now know: the food we eat profoundly impacts our health. CoDiet is a four-year Horizon Europe project uniting 17 partners across ten countries, to better understand the complex relationship between diet and non-communicable diseases (NCDs) such as diabetes and cardiovascular diseases. The project exemplifies multidisciplinary collaboration, bringing together experts in nutrition, engineering and public health, to unlock how what we eat affects how we live.

BackgroundConsumption of foods high in fat, sugar, and sodium (HFSS) and obesity are rapidly increasing in India. Taxing HFSS foods has been proposed as one of the policy interventions to promote healthier diets globally. This study estimates the effect of this approach on nutrient intake, diet-related disease, and associated health and economic burdens in India.Methods and findingsWe use a nationally representative expenditure survey of 261,746 households, dietary requirements, and food composition tables to model individual nutrient intake. Consumer responsiveness to food price changes for three income terciles, captured in price elasticities, is estimated using an Almost Ideal Demand System model. Longer-term policy impacts are estimated through a novel dynamic microsimulation model, Health-GPS. Modelled policy outcomes include changes in risk exposures, disease incidence and burden, and total health expenditure. On average, 9.9% of total energy intake comes from HFSS items, based on the definition by the Food Safety and Standards Authority of India's Labelling and Display Amendment Draft Regulations 2022. Applying the highest Goods and Services Tax (GST) rate of 40% on HFSS items is associated with a persistent average per capita decrease of 0.1705 kg/m2 (95% CI: -0.1709, -0.1700) in body mass index and 45.8 mg (95% CI: -45.9, -45.7) in daily sodium intake. Over 30 years, this could reduce annual disease incidence by up to 1.72% (95% CI: -1.78%, -1.66%) on average and prevent 0.63 million (95% CI: -0.71, -0.55) disability-adjusted life years per year from ischaemic heart disease, chronic kidney disease, stroke, diabetes, and asthma, reducing total health expenditure by US$601 million (95% CI: -624, -578) per year. Larger absolute health gains accrue to higher-income individuals, reflecting higher baseline HFSS food intake. Given substitution patterns and a price-inelastic demand, the tax change is expected to generate a 92.0% (95% CI: 88.2%, 95.7%) increase in tax revenue from foods and beverages with only a minor effect on household spending (+1.0%, 95% CI: + 0.0%, + 1.9%). This analysis only captures the potential health impacts of changes in energy and sodium intakes. In addition, it does not model underlying temporal trends in disease incidence beyond those due to demographic changes, which would make our health impact estimates conservative if baseline disease risks were to increase in the future.ConclusionsHigher taxation of HFSS foods could help mitigate rising incidence of diet-related diseases and morbidity in India, reduce healthcare costs, and serve as an additional source of revenue for the government.

Background Non-communicable diseases (NCDs) account for over 80% of deaths in Sri Lanka. Addressing these diseases is challenging due to their complex social, behavioural, and environmental causes. Community-based health promotion programmes focused solely on single risk factors and education provision show limited effectiveness. This study describes Happy Village Plus (HVP), a grassroots, community-based intervention designed to select and implement health promotion interventions aligned with communities’ health-related needs in Western Province, Sri Lanka. Methods HVP was conducted in six communities from November 2022 to June 2024. We recorded Capacity Building and Engagement Activities by type of activity and stakeholders engaged, and Community Interventions by approach and health determinant. Communities' health-related risk factor needs were obtained from individual-level data from 1712 individuals. Regression analyses were conducted to assess whether the community interventions chosen matched communities’ health-related needs. Findings A total of 1217 Capacity Building and Engagement activities were recorded. Community interventions (n = 975) most often addressed diet-related determinants, followed by physical activity and BMI, and to a lesser extent, tobacco and alcohol. For most communities, insufficient fruit and vegetable consumption was the most prevalent health-related need, followed by insufficient physical activity, alcohol use, and smoking. Our results show the selected interventions align with identified needs. Interpretation This paper demonstrates the feasibility of implementing grassroots, holistic, multi-faceted, community interventions covering a wide range of health determinants and NCD risk factors in a developing country context. We highlight that, when empowered, communities can select interventions that align with their health needs, with higher disease prevalence increasing the likelihood of choosing relevant interventions.

There is scant research examining income-based inequalities in risk factors of non-communicable diseases (NCDs) and inequities of preventive care services across the South Asian population. We conducted a cross-sectional study of 202,682 adults aged 18 or above in four South Asian countries: Bangladesh, India, Pakistan, and Sri Lanka. We combined South Asia Biobank (SAB) surveillance data with environmental mapping exposure and 24-h dietary recall to estimate income-based inequalities using concentration curves and concentration indices (CI) that measure the magnitude and directional inequality effects. We also computed the horizontal inequity index (HII) for need-standardised healthcare utilisation and advice by measuring the extent to which the distribution of health promotion advice matches the distribution of diet-related risk factor variables across the income distribution. We reported concentration index coefficients and standard errors. Inequalities in exposure and diet-related risk factors of NCDs were observed. Underweight was concentrated amongst the poor (CI = − 0.16, SE = 0.005, p < 0.001), while overweight and obesity were concentrated amongst the rich (CI = 0.11, SE = 0.003, p < 0.001). Non-recommended intake of fats (CI = 0.04, SE = 0.003, p < 0.001) and carbohydrates were concentrated amongst the rich (CI = 0.05, SE = 0.003, p < 0.001), while non-recommended intake of free sugars (CI = − 0.05, SE = 0.004, p < 0.001) and fruits and vegetables amongst the poor (CI = − 0.07, SE = 0.005, p < 0.001). Exposure to unhealthy outlets was concentrated amongst the rich (CI = 0.02, SE = 0.002, p < 0.001). There were persistent and pro-rich inequities in healthcare utilisation (HII = 0.02, SE = 0.002, p < 0.001) and advice for salt reduction (HII = 0.02, SE = 0.004, p < 0.001), fat reduction (HII = 0.02, SE = 0.004, p < 0.001), healthy weight (HII = 0.03, SE = 0.006, p < 0.001), and fruits and vegetables consumption (HII = 0.04, SE = 0.004, p < 0.001). These findings indicate the need to address and mitigate income-based inequalities in diet-related risk factors of NCDs and underscore the need of policies directed at mitigating NCDs risk exposure and achieving improved and equitable access to healthcare.

Introduction:Appropriately designed food taxes can improve diet quality and health. Fiscal levers are used in several countries to combat the rise in obesity and diet-related diseases. This study aims to investigate public attitudes, knowledge and policy preferences regarding food taxes for promoting healthy eating in the UK. Methods:A survey was administered through YouGov Plc to a nationally representative sample of 2125 adults, gathering information on: acceptability and support for different types of food taxes, awareness and knowledge of existing taxes and preferences for the characteristics of possible new taxes. Results:Overall, 48% of respondents support higher taxes on unhealthy foods, rising to 72% if taxes made healthy foods more affordable. Respondents with high socioeconomic status and those living in London showed the highest support. Respondents had limited awareness of existing food and beverage taxes and prioritised discretionary items such as cakes and crisps for possible increased taxation. Conclusions:The survey shows a high level of support for taxing unhealthy foods, as well as concern for the affordability of healthy foods. A carefully designed holistic approach to food taxation can be part of a wider public health strategy and can be favourably met by the general population in the UK.

While reformulation policies are commonly used to incentivise manufacturers to improve the nutrient profile of the foods and beverages they produce, only a few countries have implemented mandatory reformulation policies. This paper aimed to review evidence on the design, implementation challenges and effectiveness of mandatory reformulation policies and compare them to voluntary reformulation policies. The systematic search retrieved seventy-one studies including twelve on mandatory reformulation policies. Most mandatory reformulation policies were aimed at reducing trans-fatty acids or sodium in foods. Overall, mandatory reformulation policies were found to be more effective than voluntary ones in improving dietary intakes. Mandatory policies were implemented when voluntary policies either failed or were found to be insufficient to improve the composition of foods. Typical features of mandatory policies could also improve the design of voluntary policies. Examples include strict but attainable targets and a tight monitoring of compliance.

Building on the success of the Soft Drinks Industry Levy (SDIL), new tax proposals have been considered in the public health policy debate in the UK. To inform such debate, estimates of the potential impacts of alternative tax scenarios are of critical importance. Using a modelling approach, we studied the effects of two tax scenarios: (1) a hypothetical excise tax designed to tax food products included in the Sugar Reduction Programme (SRP), accounting for pack size to reduce the convenience of purchasing larger quantities at once; (2) an ad valorem tax targeting products based on the UK Nutrient Profile Model (NPM). Simulations of scenario 1 show a reduction in sugar purchased of up to 38 %, with the largest decreases observed for sweet confectionery with a tiered tax, similar in structure to the SDIL. Expected food reformulation in scenario 1 led to further decreases in sugar purchased for all categories. In scenario 2, under the assumption that the tax would not affect purchases of healthier products, a 20 % tax on less healthy products would reduce total sugar purchased by 4·3 % to 14·7 % and total energy by 4·7 % to 14·8 %. Despite some limitations and assumptions, our results suggest that new fiscal policy options hold a significant potential for improving diet quality beyond what has been achieved by the SDIL and SRP. An estimated increase in consumer expenditures in both scenarios suggests that attention needs to be paid to potentially regressive effects in the design of any new food taxes.

The built environment around schools that are regularly accessed by young people is determined by governments, national and regional policies in each country or region. Zoning regulations for tobacco and alcohol sales are expected to restrict availability and access by young people. This study aimed to examine (non) compliance with tobacco and alcohol zoning regulations around schools in Bangladesh, India, Pakistan and Sri Lanka. In a representative sample of geographic locations in Bangladesh, India North (Delhi) and India South (Chennai), Pakistan and Sri Lanka, the built environment was mapped by systematically walking all streets within the site boundary to collect data on different types of tobacco and alcohol retailers and schools. Data was collected on KoboToolBox, and the maps indicating zoning compliance were created using ArcGIS. Descriptive analysis of outlet compliance to the zoning laws was conducted at the national and school levels, with heterogeneity analyses done by school type, income level and outlet type for tobacco and alcohol. The zoning regulations for tobacco and alcohol differed among the settings ranging from 50 to 100 m for tobacco and absolute bans to 500 m for on-premise alcohol. Among the five different settings within the four countries, 441 areas were studied, including 3615 schools. Non-compliance with the zoning laws is evident in all jurisdictions for both tobacco and alcohol. Within restricted zones around schools (location non-compliant with zoning laws), 12–38

The steady rise in overweight and obesity in Europe disproportionately affects people and communities with a lower socio-economic position (SEP). Many obesity prevention approaches exist, but these have had limited reach and unsatisfactory effects thus far, especially in low-SEP populations. In this context, there is a need for implementation of effective individual-level and population-based preventive strategies that also tackle health inequalities. Effective strategies require consideration of the complex and cross-domain obesity risk factors across the life course. Feasible and acceptable strategies require multisectoral collaborations and innovative approaches, including a whole-of community and systems perspective. With the Horizon Europe-funded OBCT project, we aim to quantify the relative contribution of biological, socio-cultural and built environment factors to obesity and the interactions of these risks within and across various life course stages; and translate the resulting knowledge into practical, equitable, and effective tools for action. These tools will include: a comprehensive obesity risk screener; a map of the obesogenicity of neighbourhood environments as well as trends in obesity prevalence of each European country; recommendations for lifestyle behaviours (diet, physical activity, sedentary behaviours) to prevent obesity during key life transition stages; a decision support dashboard for policy makers; and co-developed toolboxes to support implementation of policy recommendations in low-SEP communities. OBCT's outputs will highlight the areas and domains in which obesity should be targeted and will empower the research community, policymakers, health professionals and residents in Europe to adapt and implement strategies to effectively reduce obesity risk, particularly in low-SEP communities.

Background The increasing prevalence of diet-related non-communicable diseases (NCDs) in South Asia is concerning, with type 2 diabetes projected to rise to 68%, compared to the global increase of 44%. Encouraging healthy diets requires stronger policies for healthier food environments. Methods This study reviewed and assessed food environment policies in Bangladesh, India, Pakistan, and Sri Lanka from 2020 to 2022 using the Healthy Food Environment Policy Index (Food-EPI) and compared them with global best practices. Seven policy domains and six infrastructure support domains were considered, employing 47 good practice indicators to prevent NCDs. Stakeholders from government and non-governmental sectors in South Asia (n = 148) were invited to assess policy and infrastructure support implementation using the Delphi method. Findings Implementation of food environment policies and infrastructure support in these countries was predominantly weak. Labelling, monitoring, and leadership policies received a moderate rating, with a focus on food safety, hygiene, and quality rather than obesity prevention. Key policy gaps prioritized for attention included front-of-pack labelling, healthy food subsidies, unhealthy food taxation, restrictions on unhealthy food promotion, and improvements in school nutrition standards to combat NCDs. Interpretation Urgent action is required to expand food policies beyond hygiene and food security measures. Comprehensive strategies targeting NCD prevention are crucial to combat the escalating burden of NCDs in the region. Funding This research was funded by the NIHR (16/136/68 and 132960) with aid from the UK Government for global health research. Petya Atanasova also acknowledges funding from the Economic and Social Research Council (ESRC) (ES/P000703/1). The views expressed are those of the authors and not necessarily of the NIHR, the UK government or the ESRC.

Compared with other OECD countries, Bermuda ranks third globally in terms of income inequality globally. During the COVID-19 pandemic, anecdotal evidence suggested, significant fluctuations in the food demand and supply. We aimed to examine the impact of the COVID-19 pandemic on food insecurity, with a focus on the availability and affordability of various foods in Bermuda. We utilized a cross-sectional study design to investigate potential drivers of food insecurity within the local population. To gauge the level of household food insecurity we relied on the Bermuda Omnibus survey (N = 400) undertaken by Total Research Associates Ltd via telephone. To assess changes in food availability and affordability we conducted semi-structured interviews with key stakeholders who played pivotal roles in shaping food accessibility availability and affordability of food in Bermuda. These interviews were systematically analysed using the framework method. We performed analyses of food retail and import data to evaluate fluctuations in food prices and their impact on food availability and affordability. We found statistically significant associations between changes in food consumption, household income, and government aid. Food aid beneficiaries ate fewer fruits and vegetables by 50% [95% CI:17%-83%] and less fresh meat and fish by 39% [95 CI:3%-75%] compared with residents who did not receive any aid during the COVID-19 period from March 2020 to March 2021. Although we did not identify statistically significant food price increases feeding programmes played a pivotal role in preventing food insecurity during the pandemic in Bermuda. However, a lack of monitoring regarding the nutritional quality within the programmes, allowed a wide availability of foods high in sugar, salts, and fats, disproportionately affected low-income populations. In conclusion, food availability in Bermuda remained largely unaffected during the pandemic. Nevertheless, the surge in demand for feeding programs underscores underlying food security challenges in Bermuda and warrants further attention.

Introduction: Appropriately designed food taxes can improve diet quality and health. Fiscal levers are used in several countries to combat the rise in obesity and diet-related diseases. This study aims to investigate public attitudes, knowledge, and policy preferences regarding food taxes for promoting healthy eating in the UK. Methods: A survey was administered through YouGov Plc to a nationally representative sample of 2,125 adults, gathering information on: acceptability and support for different types of food taxes, awareness and knowledge of existing taxes, and preferences for the characteristics of possible new taxes. Results: Overall, 48% of respondents support higher taxes on unhealthy foods, rising to 72% if taxes made healthy foods more affordable. Respondents with high socio-economic status and those living in London showed the highest support. Respondents had limited awareness of existing food and beverage taxes, and prioritised discretionary items such as cakes and crisps for possible increased taxation. Conclusions: The survey shows a high level of support for taxing unhealthy foods, as well as concern for the affordability of healthy foods. A carefully designed holistic approach to food taxation can be part of a wider public health strategy and can be favourably met by the general population in the UK. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was supported by NIHR Public Health Research Programme grant number NIHR133974. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics Approval Statement: Name of Committee: Imperial College London Research Governance and Integrity Team. Reference no: 22IC7545 I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors. Data may be obtained from a third party (YouGov Plc.) and are not publicly available.

The UK government launched a two-component sugar-reduction programme in 2016, one component is the taxation of sugar-sweetened beverages, the Soft Drinks Industry Levy, and the second is a voluntary sugar reduction programme for products contributing most to children's sugar intakes. These policies provided incentives both for industry to change the products they sell and for people to change their food and beverage choices through a ' signalling ' effect that has raised awareness of excess sugar intakes in the population. In this study, we aimed to identify the relative contributions of the supply- and demand-side drivers of changes in the sugar density of food and beverages purchased in Great Britain. While we found that both supply- and demand-side drivers contributed to decreasing the sugar density of beverage purchases (reformulation led to a 19% reduction, product renewal 14%, and consumer switching between products 8%), for food products it was mostly supply-side drivers (reformulation and product renewal). Reformulation contributed consistently to a decrease in the sugar density of purchases across households, whereas changes in consumer choices were generally in the opposite direction, offsetting benefits of reformulation. We studied the social gradient of sugar density reduction for breakfast cereals, achieved mostly by reformulation, and found increased reductions in sugar purchased by households of lower socio-economic status. Conversely, there was no social gradient for soft drinks. We conclude that taxes and reformulation incentives are complementary and combining them in a programme to improve the nutritional quality of foods increases the probability of improvements in diet quality.

Taxation on food and non-alcoholic beverages are increasingly employed to promote healthier diets and combat the escalating rates of obesity and diet-related non-communicable diseases. While sugar-sweetened beverages have been the primary focus of such taxes, taxation of high-fat, salt, or sugar (HFSS) foods, and the impact of such taxes are less clear. We conducted a systematic literature review and assessment of the evidence gathered from 20 studies on the impacts of health taxes on HFSS foods around the world. We focused on impacts on sales and consumption of taxed foods, on health outcomes, and on possible unintended consequences (e.g., substitution towards unhealthier products, job losses, ripple effects on businesses, and potential economic burden on lower-income consumers). We found evidence of decreasing sales, or purchases, and intakes of taxed HFSS foods, especially when taxes were combined with subsidies on healthy foods. Higher tax rates were more effective in reducing purchases or consumption. Tax effects differed by income level, with the lowest-income groups being most responsive. In experimental studies, combining taxes and subsidies contributed to mitigating regressive financial impacts of taxes.

Background Many countries have sought to incentivise soft drinks manufacturers to reduce sugar in their products as part of efforts to address a growing prevalence of obesity. Are their policies effective?Methods Using a difference-in-differences design, we compared trends in the sugar content of 10 695 new sugar-sweetened beverages (SSB) launched between 2010 and 2019 in six European markets, including the UK and France (taxes designed to incentivise reformulation), the Netherlands (policy based on voluntary agreements to reduce sugar), Germany, Italy and Spain (no national policies).Results The announcement in 2016 and adoption in 2018 of the UK tax led to yearly reductions in average sugar content of 17% (95% CI: 15-19%) to 31% (13-48%) between 2016 and 2019, compared to 2015, while the 2018 French tax produced a 6% (95% CI: 5-7%) sugar reduction only in 2018, compared to 2017, shortly after it was redesigned to provide a stronger incentive for reformulation. Voluntary agreements implemented in the Netherlands in 2014 led to an 8% (95% CI: 4-13%) sugar reduction only in 2015, compared to 2013.Conclusion The analysis supports the conclusions that sugar reductions in new SSBs have been greater in countries that have adopted specific policies to encourage them; a sugar-based tax design encourages more sugar reductions than a volume-based tax design; the tax rate and the amount of the tax reduction from switching to the next lower tier in a sugar-based tax design may be critical to incentivize reformulation.

To help health economic modelers respond to demands for greater use of complex systems models in public health. To propose identifiable features of such models and support researchers to plan public health modeling projects using these models. A working group of experts in complex systems modeling and economic evaluation was brought together to develop and jointly write guidance for the use of complex systems models for health economic analysis. The content of workshops was informed by a scoping review. A public health complex systems model for economic evaluation is defined as a quantitative, dynamic, non-linear model that incorporates feedback and interactions among model elements, in order to capture emergent outcomes and estimate health, economic and potentially other consequences to inform public policies. The guidance covers: when complex systems modeling is needed; principles for designing a complex systems model; and how to choose an appropriate modeling technique. This paper provides a definition to identify and characterize complex systems models for economic evaluations and proposes guidance on key aspects of the process for health economics analysis. This document will support the development of complex systems models, with impact on public health systems policy and decision making.

Childhood obesity is an increasingly severe public health problem, with a prospective impact on health. We propose an exposome approach to identify actionable risk factors for this condition. Our assumption is that relationships between external exposures and outcomes such as rapid growth, overweight, or obesity in children can be better understood through a "meet-in-the-middle" model. This is based on a combination of external and internal exposome-based approaches, that is, the study of multiple exposures (in our case, dietary patterns) and molecular pathways (metabolomics and epigenetics). This may strengthen causal reasoning by identifying intermediate markers that are associated with both exposures and outcomes. Our biomarker-based studies in the STOP consortium suggest (in several ways, including mediation analysis) that branched-chain amino acids (BCAAs) could be mediators of the effect of dietary risk factors on childhood overweight/obesity. This is consistent with intervention and animal studies showing that higher intake of BCAAs has a positive impact on body composition, glycemia, and satiety. Concerning food, of particular concern is the trend of increasing intake of ultra-processed food (UPF), including among children. Several mechanisms have been proposed to explain the impact of UPF on obesity and overweight, including nutrient intake (particularly proteins), changes in appetite, or the role of additives. Research from the Avon Longitudinal Study of Parents and Children cohort has shown a relationship between UPF intake and trajectories in childhood adiposity, while UPF was related to lower blood levels of BCAAs. We suggest that an exposome-based approach can help strengthening causal reasoning and support policies. Intake of UPF in children should be restricted to prevent obesity.