new researches in nutrition

Are Ultra-Processed Foods Really all that Unhealthy?

Processed foods have been blamed for many health problems, but dietary research is tricky and nuanced

Amos Zeeberg, OpenMind Magazine

Can You Eat Cicadas? Can Your Dog Do So?

Here’s what a chef, a vet and two anthropologists have to say about eating periodical cicadas

Meghan Bartels

Could Magnesium and TikTok’s ‘Sleepy Girl Mocktail’ Actually Help You Sleep?

TikTok’s “sleepy girl mocktails” remind us how important magnesium is for sleep and health

Jocelyn Solis-Moreira

Your Body Has Its Own Built-In Ozempic

Popular weight-loss and diabetes drugs, such as Ozempic and Wegovy, target metabolic pathways that gut microbes and food molecules already play a key role in regulating

Christopher Damman, The Conversation US

Ozempic and Other Weight-Loss Drugs Are Sparking a Risky New War on Obesity

The world has launched into an era of injectables not just to treat obesity but to manage weight. Is that all good news?

Arthur Caplan

How Much Caffeine Is Too Much?

Caffeine can help you feel energized. But is there a limit to how much your body can handle?

Joanna Thompson

We Need to Better Understand Malnutrition-Related Diabetes

Food insecurity saps the health of people and economies worldwide. Addressing it would pay dividends

Jameel Barkat, Amit Sadhukhan

How Do Ultraprocessed Foods Affect Your Health?

Ultraprocessed foods have become a mainstay of modern diets and could be taking a toll on our health

Lori Youmshajekian

How the Daughter of Sharecroppers Revolutionized Preschoolers' Health

Flemmie Pansy Kittrell, the first Black woman to earn a Ph.D. in nutrition in 1936, showed the importance of good health and developed a program that became the model for Head Start

Carol Sutton Lewis, Danya AbdelHameid, Elah Feder, The Lost Women of Science Initiative

Spicy Food Probably Doesn’t Cause Long-Term Harm

While spicy food can cause pain, it isn’t linked to higher mortality rates

Paul D. Terry, The Conversation US

How to Figure Out if Moderate Drinking Is Too Risky for You

New research shows any alcohol can harm your body, but the increased risk may not be huge

Lydia Denworth

Period Food Cravings Are Real. A New Brain Finding Could Explain Why They Happen

A new study suggests that changes in the brain's sensitivity to insulin during phases of the menstrual cycle may be linked to appetite

Healthy Living Guide 2023/2024

A Digest on Healthy Eating and Healthy Living “The apple in your hand is the body of the cosmos.” – Thich Nhat Hanh Happy New Year, and welcome to the fourth edition of the Healthy Living Guide! 2023 was an exciting year in the Department of Nutrition, as we celebrated the launch of the Thich […] Continue reading

WHO releases updated guidelines on defining healthy diets

Harvard experts say most recommendations are well-supported, but guidance on total fat intake omits decades of evidence The World Health Organization (WHO) has released updated guidelines for defining healthy diets, with particular attention to carbohydrates, total fat, and specific types of fat such as saturated and trans fats. The guidelines are an addition to their […] Continue reading

Unpacking WHO guidelines on non-sugar sweeteners

The World Health Organization (WHO) released a new guideline on non-sugar sweeteners (NSS)—often referred to as artificial or low-calorie sweeteners—that advises against use of NSS to control body weight or reduce the risk of noncommunicable diseases. After conducting a research review, they concluded that replacing sugar sweeteners with NSS did not promote weight loss in […] Continue reading

Healthy Living Guide 2022/2023

A Digest on Healthy Eating and Healthy Living Throughout 2022, food and nutrition were often in the spotlight, perhaps most notably with the White House Conference on Hunger, Nutrition, and Health. The national strategy that emerged from the event (the first of its kind since the original conference in 1969) aims at ending hunger and […] Continue reading

Navigating infant formula shortages

Infant formula shortages in the U.S. have occurred in the past two years largely due to widespread pandemic-related supply-chain problems. A national shortage of infant formula is undoubtedly alarming for families since infants require formula when human milk is not accessible or not available in adequate amounts. Although breastfeeding is encouraged, it is not always […] Continue reading

Healthy Living Guide 2021/2022

A Digest on Healthy Eating and Healthy Living Over the course of 2021, many of us continued to adapt to a “new normal,” characterized by a return to some pre-pandemic activities mixed with hobbies or habits that have emerged since 2020’s lockdowns. On the topic of food and eating, according to one U.S. consumer survey […] Continue reading

Healthy Living Guide 2020/2021

A Digest on Healthy Eating and Healthy Living As we transition from 2020 into 2021, the COVID-19 pandemic continues to affect nearly every aspect of our lives. For many, this health crisis has created a range of unique and individual impacts—including food access issues, income disruptions, and emotional distress. Although we do not have concrete […] Continue reading

Dietary Guidelines for Americans 2020 released

The 9th edition of the Dietary Guidelines for Americans 2020-2025 is out, with the tagline to Make Every Bite Count. Intended for policy makers, healthcare providers, nutrition educators, and Federal nutrition program operators, the new edition has expanded to almost 150 pages, providing nutrition guidelines for even more age groups throughout the life cycle. As […] Continue reading

COVID-19 and Obesity

This page will be updated as new information becomes available. Last update: 10.24.20 The novel Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) has created a global pandemic with its syndrome, COVID-19. The number of people affected by COVID-19 continues to increase worldwide, and information about risk factors for severe COVID-19 and mortality is emerging almost […] Continue reading

Pregunte al Experto: El rol de la dieta y los suplementos nutricionales durante COVID-19

El distanciamiento social y el lavado de manos son los métodos más eficaces y comprobados para reducir el riesgo y la propagación de la enfermedad del coronavirus (COVID-19). Sin embargo, junto con preguntas generales sobre cómo comprar y preparar alimentos de forma segura (discutidos aquí), muchos se preguntan sobre el rol específico de la dieta […] Continue reading

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Recent Advances in Nutrition and Diabetes

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No new data were created or analyzed in this study.

The prevalence of diabetes is on the increase worldwide, being one of the fastest growing international health emergencies in the 21st century. Diabetes that is not well managed can have significant impact on morbidity and mortality, including being a risk factor for stroke, renal dysfunction, leg amputation, cardiovascular diseases, loss of vision, and neuropathy. The economic costs of diabetes can also be quite profound through direct medical costs to individuals, families and healthcare systems, and loss of work and wages. Strategies for managing diabetes often include regular physical activity, smoking cessation, maintaining health body weight, and healthy diet. In addition, nutritional interventions in the management of diabetes may involve reduction of calories in diets, the use of diets with low glycaemic index, and increasing the fibre content of diets.

The role of dietary fibre in health and diseases such as diabetes, cardiovascular disease, colon cancer, and obesity has been the subject of significant interest. While it has been revealed that dietary fibre plays a role in the pathogenesis of chronic diseases, an evolving area of research and attention is its effect on gut microbiota and type 2 diabetes. There is evidence that diets that are high in fat and low in fibre may promote gut microbiota dysbiosis as a result of the loss of beneficial and protective microbes, while a high-fibre diet could inhibit protein fermentation and promote gut microbial eubiosis. Dietary fibre has been reported to be a major energy source for intestinal bacteria and thus can significantly affect the diversity of gut microflora.

Therefore, the current editorial provides an overview of the articles published in the Special Issue on recent advances in nutrition and diabetes. It focuses on the role of diet in the pathophysiology and management of diabetes including its effect on gut microbiota. In this regard, Ojo et al. [ 1 ] conducted a systematic review and meta-analysis of randomised controlled trials and sought to evaluate the role of dietary fibre in modulating gut microbiota dysbiosis in patients with type 2 diabetes. The authors relied on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Electronic databases including EBSCOHost with links to Health Sciences Research Databases, EMBASE, Google Scholar, and reference lists of articles were searched for relevant studies.

Searches were conducted from date of commencement of the database to 5 August 2020, and these were based on the Population, Intervention, Comparator, Outcomes, Studies (PICOS) framework [ 1 ].

There were nine studies which met the inclusion criteria and were selected for the systematic review and meta-analysis. Four distinct areas were identified, namely, the effect of dietary fibre on gut microbiota, the role of dietary fibre on short-chain fatty acids (SCFAs), glycaemic control, and adverse events [ 1 ]. The authors found significant difference ( p < 0.01) in the relative abundance of Bifidobacterium with a mean difference of 0.72 (95% CI, 0.56, 0.89) total SCFAs ( p = 0.02), with a standardised mean difference of 0.5 (95% CI, 0.08, 0.91) between the dietary fibre group compared with placebo. However, there were no significant differences ( p > 0.05) between the groups with respect to acetic acid, propionic acid, and butyric acid [ 1 ].

Furthermore, there was significant improvement ( p = 0.002) in glycated haemoglobin, with a mean difference of −0.18 (95% CI, −0.29, −0.06) in the dietary fibre group compared with placebo, although differences between the two groups were not significant ( p > 0.05) in relation to fasting blood glucose and homeostatic model assessment of insulin resistance (HOMA-IR) [ 1 ]. The two groups were not significantly different ( p > 0.05) in the subjects who reported adverse events.

The promotion of gut microbes which are SCFA producers in greater diversity and abundance by dietary fibre may be responsible for the improvement in glycated haemoglobin, which could be due in part to increased glucagon-like peptide-1 (GLP-1) production. There is evidence that Bifidobacterium lactis could increase glycogen synthesis, decrease expression of hepatic gluconeogenesis genes, improve translocation of glucose transport-4, and promote glucose uptake [ 1 ]. Furthermore, the reduction in body weight of participants in the intervention group compared with control is another area of interest, as this may have contributed to the observed improvement in glycated haemoglobin [ 1 ]. Ojo et al. [ 1 ] concluded that dietary fibre can significantly improve ( p < 0.05) the relative abundance of Bifidobacterium, total SCFAs, and glycated haemoglobin. However, the authors observed that dietary fibre did not appear to have significant effect ( p > 0.05) on fasting blood glucose, HOMA-IR, acetic acid, propionic acid, butyric acid, and adverse events.

In a review by Salaza et al. [ 2 ], it was noted that the dysfunction of the gut microbiota is a contributory factor in the pathophysiology of diabetes. It was also reported that the lipid products derived from the gut microbiota may interact with cells from the immune system, and this may have immunomodulatory effect. In particular, microbiota dysbiosis could cause increased production of lipopolysaccharides leading to damage to the intestinal barrier [ 2 ]. The prevailing pro-inflammatory environment can lead to a state of insulin resistance and hyperglycaemia [ 2 ]. In contrast, the production of SCFAs during eubiosis is useful in maintaining the integrity of the intestinal barrier [ 2 ]. The authors suggested that dysbiosis of the gut microbiota can be reversed through the modification of the eating habits of patients or with the administration of prebiotics, probiotics, and symbiotics.

In a related study, Ren et al. [ 3 ] conducted a randomised controlled trial to determine the effect of an almond-based low carbohydrate diet on depression and glycometabolism, gut microbiota, and fasting GLP-1 in patients with type 2 diabetes. Forty-five participants with type 2 diabetes who were recruited from the diabetes club and the Endocrine Division of the First and Second Affiliated Hospital of Soochow University were randomly assigned to a low-carbohydrate diet (LCD) or a low-fat diet (LFD) [ 3 ]. The dietary intervention was for a period of 3 months, including 22 participants in the LCD group and 23 in the LFD group. The measures of depression and biochemical parameters such as glycated haemoglobin, gut microbiota, and GLP-1 concentration were assessed at baseline and post intervention. The two groups were then compared. Ren et al. [ 3 ] found that LCD significantly improved depression and glycated haemoglobin ( p < 0.01) and increased SCFAs producing bacteria Roseburia , Ruminococcus , and Eubacterium . In addition, the GLP-1 concentration in the LCD group was higher than that in the LFD group ( p < 0.05). The authors concluded that LCD may provide beneficial effect on depression and glycometabolism in patients with type 2 diabetes. It was further suggested that the role of LCD in improving depression in patients with type 2 diabetes may be related to its role in stimulating the growth of SCFAs-producing bacteria, increasing SCFA production and further maintaining GLP-1 secretion [ 3 ].

McKenzie et al. [ 4 ] assessed the effect of type 2 diabetes prevention programme aimed at reducing hyperglycaemia and normalising glycaemia in order to delay or prevent the progression to type 2 diabetes. The study involved 96 patients with prediabetes who received intervention involving carbohydrate restricted nutrition therapy for two years that was delivered through remote care team. It was found that the estimated cumulative incidence of normoglycemia and type 2 diabetes at two years were 52.3% and 3%, respectively [ 4 ]. There was significant decrease in the prevalence of metabolic syndrome, obesity, and suspected hepatic steatosis at two years [ 4 ].

There is evidence that the inflammation due to gingivitis and/or periodontitis tends to worsen during pregnancy due to hormonal changes, and these have implications for maternal health beyond the oral cavity [ 5 ]. For example, this inflammation could lead to a low-grade systemic inflammatory and metabolic disturbances which can have an impact on pregnancy outcomes [ 5 ]. Therefore, there appears to be a relationship between periodontal inflammation and diabetes, and thus managing inflammatory periodontal diseases may improve glycaemic control and associated diabetic complications. In recognition of this, Rodrigues Amorim Adegboye et al. [ 5 ] conducted a randomised controlled trial to explore the effect of a non-pharmacological multi-component intervention on periodontal health and metabolic and inflammatory profiles among pregnant women with periodontitis. The study involved 69 pregnant women receiving prenatal care in a Brazilian public health centre who were randomly allocated to four groups: (1) fortified sachet (vitamin D and calcium) and powdered milk plus periodontal therapy during pregnancy (early PT), (2) placebo sachet and powdered milk plus early PT, (3) fortified sachet and powdered milk plus late PT (after delivery), and (4) placebo sachet and powdered milk plus late PT [ 5 ]. The mean bleeding on probing (BOP) was significantly reduced in the early PT groups, while BOP worsened in the late PT groups. No significant effect of fortification on BOP was observed, and there were also no significant differences in the glucose levels and birthweight among the groups [ 5 ].

The use of dietary interventions such as dietary fibre and low carbohydrate diet in modulating gut microbiota dysbiosis, promoting SCFAs production and glycaemic control in patients with type 2 diabetes is evident. However, as this is an evolving area of research, more studies are needed to further understand the mechanism of the role of diets on gut microbiota.

This research received no external funding.

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Data availability statement, conflicts of interest.

The author declares no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Nutrition News

Nutrition is the science that interprets the interaction of nutrients and other substances in food in relation to maintenance, growth, reproduction, health, and disease of an organism. It includes food intake, absorption, assimilation, biosynthesis, catabolism, and excretion. The diet of an organism can significantly impact its physical and mental health, influencing various aspects of well-being from immune response and physical development to cognitive function and chronic disease prevention. Essential nutrients required by the human body include carbohydrates, proteins, fats, vitamins, and minerals. These compounds provide energy, support growth and repair of tissues, and help regulate body processes. Public health recommendations promote balanced diets rich in fruits, vegetables, whole grains, and lean proteins, while minimizing processed foods high in sugar, salt, and unhealthy fats. Nutrition science also examines how environmental and social factors, such as access to food and eating habits, affect dietary intake and overall health.

Health July 11, 2024

Liquid Gold: The Lifesaving Power of Plant Oils in Your Bloodstream

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Scientists Debunk 4 Popular Myths About the Safety of Intermittent Fasting

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Food, Depression, and Anxiety: How Dietary Patterns Sculpt Brain Chemistry and Mood

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The Truth About Fish and Pregnancy: What’s Safe and What’s Not

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Unlocking Nutritional Success: A Clinician’s Guide to Anti-Obesity Medication Diets

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NIH releases strategic plan to accelerate nutrition research over next 10 years

What if each of us had individualized dietary recommendations that helped us decide what, when, why, and how to eat to optimize our health and quality of life? This precision nutrition approach — developing targeted and effective diet interventions in a diverse population — is among the ambitious goals set out by the 2020-2030 Strategic Plan for National Institutes of Health Nutrition Research.

NIH, guided by its Nutrition Research Task Force (NRTF) and armed with the insights from the nutrition science community, practitioners, the public, and others, has created a bold vision to advance nutrition science discoveries over the next 10 years. With a focus on precision nutrition, the plan reflects the wide range of nutrition research supported across NIH – over $1.9 billion in fiscal year 2019. The strategic plan calls for a multidisciplinary approach through expanded collaboration across NIH Institutes and Centers to accelerate nutrition science and uncover the role of human nutrition in improving public health and reducing disease.

The strategic plan is organized around four strategic goals that answer key questions in nutrition research:

• Spur Discovery and Innovation through Foundational Research: What do we eat and how does it affect us?
• Investigate the Role of Dietary Patterns and Behaviors for Optimal Health: What and when should we eat? 
• Define the Role of Nutrition Across the Lifespan: How does what we eat promote health across our lifespan?
• Reduce the Burden of Disease in Clinical Settings: How can we improve the use of food as medicine?

The plan has five cross-cutting areas relevant to all these strategic goals, including minority health and health disparities; health of women; rigor and reproducibility; data science, systems science, and artificial intelligence; and training the nutrition scientific workforce.

The strategic plan aligns with the National Nutrition Research Roadmap 2016-2021 created by the Interagency Committee on Human Nutrition Research, a trans-federal government committee charged with enhancing the coordination and communication among multiple federal agencies conducting nutrition research.

As the plan is put into action, NIH will continue to seek input from the nutrition community and others. The task force will guide the plan’s application through implementation working groups that will pursue opportunities to:

• advance the priorities identified in each of the strategic goals and cross-cutting research areas
• catalyze nutrition research at NIH-funded universities and institutions and in NIH labs

The task force will track the progress of the plan and post information on its website.  

Materials: 2020-2030 Strategic Plan for NIH Nutrition Research

• Francis S. Collins, M.D., Ph.D., director of the National Institutes of Health
• Griffin P. Rodgers, M.D., M.A.C.P, director of the National Institute of Diabetes and Digestive and Kidney Diseases and chair of NRTF

To schedule an interview with Dr. Collins, please email [email protected] or call 301-496-5787. To schedule an interview with Dr. Rodgers, please contact email [email protected] or call (301) 496-3583.

About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov .

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Nutrition therapy articles from across Nature Portfolio

Nutrition therapy is the treatment of a medical condition, for example diabetes mellitus, through changes in diet, by adjusting quantity, quality and methods of nutrient intake. In the USA, medical nutrition therapy has a legal definition and is provided by a registered dietitian.

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Fermented foods and gastrointestinal health: underlying mechanisms

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Irritable bowel syndrome and mental health comorbidity — approach to multidisciplinary management

Up to one-third of people with irritable bowel syndrome (IBS) also experience anxiety or depression. In this Review, we highlight common challenges that arise when managing patients with IBS and co-occurring anxiety and depression, and provide recommendations for tailoring clinical assessment and treatment.

• Heidi M. Staudacher
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News and Comment

Integrating social nutrition principles into the treatment of steatotic liver disease

Ivancovsky-Wajcman et al. outline the need for a holistic preventive hepatology approach, involving social nutrition and social prescribing, to address the public health threat of metabolic dysfunction-associated steatotic liver disease (MASLD). They argue that this will facilitate individuals’ engagement in behavioural modifications to treat MASLD.

• Dana Ivancovsky-Wajcman
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l -arginine inhibits arthritis and bone loss by reprogramming osteoclast metabolism

New research shows that the amino acid l -arginine ameliorates arthritis and inhibits inflammatory bone loss by altering energy metabolism in osteoclasts.

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Our Favorite Nutrition Takeaways From 2024, So Far

Is red wine good for your heart? Are ultraprocessed foods really that bad for you? We have answers to these questions and more.

By Alice Callahan

If you’re looking to freshen up your food habits, summer is the season to do it. Farmers’ markets are overflowing. Backyard grills are firing. Picnic blankets are unfurling. And school pickups have slowed to a halt, giving us more time to cook and enjoy relaxed outdoor meals with friends.

Whatever your food goals, you’re bound to find at least a few morsels of wisdom in some of our favorite nutrition articles of 2024 — whether it’s learning to take the latest TikTok health hack with a grain of salt, or actually cutting back on salt.

Here are 10 important nutrition takeaways from the year, so far.

1. A Mediterranean eating pattern may be worth a try.

There’s a reason the Mediterranean diet is so beloved by nutrition experts: Decades of research have linked it to various health benefits, including reduced risks of cardiovascular disease, Type 2 diabetes, cognitive decline and certain types of cancer. And best of all, it’s not a “diet” in the colloquial sense: There’s no counting calories or cutting out foods.

If you’re interested in adopting this way of eating — which focuses on whole grains , fruits and vegetables , legumes , nuts and seeds , and healthy fats — check out the guide we created with our colleagues at NYT Cooking.

2. A glass of wine a day will not keep the doctor away.

A few decades ago, it was commonly understood that a daily glass or two of red wine was good for your heart. It was an appealing idea that was backed by research at the time. But the science has since changed , experts say, and the latest evidence suggests that the risks of drinking alcohol — including red wine — outweigh any potential benefits.

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What you eat at 40 may affect how healthy you are at 70

If you eat well now, you may live better later. A diet rich in fruits and vegetables, whole grains and unsaturated fats in midlife can improve the chances of good mental, physical and cognitive health decades later, a new report shows.

A study presented at a major nutrition conference Tuesday builds on years of research that a daily diet filled with highly nutritious foods can reduce the risk of developing common chronic diseases and help maintain cognitive functioning in older age.

Harvard researchers analyzed 30 years of data on over 106,000 participants from the Nurses’ Health Study and the Health Professionals Follow-Up Study . The study included 70,467 women and 36,464 men. At the beginning of the study in 1986, the participants were at least 39 years old and free of chronic disease.

As part of the long-term study, the participants filled out an extensive food frequency questionnaire every four years, from 1986 to 2010, registered dietician Anne-Julie Tessier, lead author and research associate at Harvard School of Public Health, said.

The Harvard researchers tracked every participant’s personal diet over time to see how well they matched to eight highly nutritious dietary patterns.

The diets they compared the food questionnaires to included:

• The D ASH d iet , a meal plan intended to prevent or lower blood pressure by focusing on vegetables, fruits and whole grains. The eating plan, developed by the National Institutes of Health, is considered a flexible diet because it doesn't eliminate any food groups and also helps with weight loss.
• The alternative healthy eating index (AHEI) — which closely adheres to to the U.S. dietary guidelines by encouraging more legumes, nuts and vegetables and lower amounts of red meat and processed meats. The research found the strongest correlation between the AHEI diet and healthier aging, Tessier said.
• The planetary health diet , an eating plan that minimizes animal products and emphasizes fruits, vegetables, whole grains, and healthy fats. It allows modest amounts of meat and dairy.

Overall, they found that a higher intake of fruits, vegetables, whole grains, unsaturated fats, nuts, legumes and low-fat dairy had greater odds of aging well. People whose diets consisted of more trans fats, sodium, red and processed meats had lower odds of healthy aging. 

What is 'healthy aging'?

Based on the women and men's self-reports in the database, the researchers interpreted “healthy aging” as surviving to at least age 70 and having good cognitive function, mental health, physical function — and being free of chronic diseases, such as diabetes, heart disease, stroke, kidney failure and most cancers.

After analyzing the 30-year data, the researchers found approximately half of the participants had died, with only 9% surviving to age 70 or older free of disease and unimpaired physical and cognitive health. 

However, the participants who most closely adhered to a healthy eating pattern were associated with 43% to 84% greater chances of aging well compared with those who did not.

What we eat now affects how we feel later

The new research has limitations. Similar to most nutrition research, the study is observational and based on self-reports. It doesn’t prove that following a nutritious dietary pattern closely will lead to longer life or healthier aging. It hasn’t yet been published in a journal but is currently under peer review, Tessier said.

Yet numerous studies have already demonstrated that diet and physical activity reduce the risk of all of these conditions and thus can increase the likelihood of "healthy aging," Dr. R. Sean Morrison, chair for the Brookdale Department of Geriatrics and Palliative Medicine at Mount Sinai Hospital, said.

“It’s important to take into consideration that those who have healthy diets are more likely to exercise, more likely to live in socially advantaged neighborhoods, have access to support that others do not have, and are likely to have better access to health care,” said Morrison, who was not associated with the new study.

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In fact, the researchers analyzed variables that could potentially influence the results, including BMI, ancestry, smoking status, alcohol intake, physical activity, medical and family history, socio-economic status, marital status and whether participants were living alone, Tessier noted. 

“We were surprised by the strength of the association between healthy eating patterns in midlife and a healthy later life, even after considering several other factors, like physical activity, that are also known to impact health,” she added.

Dr. Lawrence Appel, professor of medicine at the School of Medicine at John Hopkins University, who was not part of the research, said the study results support previous findings. Appel's research focuses on preventing chronic diseases through nutritional approaches and was the lead author in the study that coined the DASH diet.

“This study joins a chorus of other studies that link healthy dietary behaviors earlier in life with better health, decades later,” he said.

For Mount Sinai's Morrison, "the bottom line for healthy aging —which we have known for a long time — is to eat a healthy diet, exercise, avoid tobacco products, use sunscreen, get enough sleep, and participate in social activities.

Shiv Sudhakar, M.D., is an infectious disease specialist and health contributor to NBC News Health. He works in addiction medicine, so is very passionate about decreasing substance abuse, combating homelessness and improving mental health. 

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• Estimated changes in free sugar consumption one year after the UK soft drinks industry levy came into force: controlled interrupted time series analysis of the National Diet and Nutrition Survey (2011–2019)
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• http://orcid.org/0000-0003-1857-2122 Nina Trivedy Rogers 1 ,
• http://orcid.org/0000-0002-3957-4357 Steven Cummins 2 ,
• Catrin P Jones 1 ,
• Oliver Mytton 3 ,
• Mike Rayner 4 ,
• Harry Rutter 5 ,
• Martin White 1 ,
• Jean Adams 1
• 1 MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus , University of Cambridge , Cambridge , UK
• 2 Department of Public Health, Environments & Society , London School of Hygiene & Tropical Medicine , London , UK
• 3 Great Ormond Street Institute of Child Health , University College London , London , UK
• 4 Nuffield Department of Population Health , University of Oxford , Oxford , UK
• 5 Department of Social and Policy Sciences , , University of Bath , Bath , UK
• Correspondence to Dr Nina Trivedy Rogers, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, University of Cambridge, Cambridge, CB2 1TN, UK; nina.rogers{at}mrc-epid.cam.ac.uk

Background The UK soft drinks industry levy (SDIL) was announced in March 2016 and implemented in April 2018, encouraging manufacturers to reduce the sugar content of soft drinks. This is the first study to investigate changes in individual-level consumption of free sugars in relation to the SDIL.

Methods We used controlled interrupted time series (2011–2019) to explore changes in the consumption of free sugars in the whole diet and from soft drinks alone 11 months after SDIL implementation in a nationally representative sample of adults (>18 years; n=7999) and children (1.5–19 years; n=7656) drawn from the UK National Diet and Nutrition Survey. Estimates were based on differences between observed data and a counterfactual scenario of no SDIL announcement/implementation. Models included protein consumption (control) and accounted for autocorrelation.

Results Accounting for trends prior to the SDIL announcement, there were absolute reductions in the daily consumption of free sugars from the whole diet in children and adults of 4.8 g (95% CI 0.6 to 9.1) and 10.9 g (95% CI 7.8 to 13.9), respectively. Comparable reductions in free sugar consumption from drinks alone were 3.0 g (95% CI 0.1 to 5.8) and 5.2 g (95% CI 4.2 to 6.1). The percentage of total dietary energy from free sugars declined over the study period but was not significantly different from the counterfactual.

Conclusion The SDIL led to significant reductions in dietary free sugar consumption in children and adults. Energy from free sugar as a percentage of total energy did not change relative to the counterfactual, which could be due to simultaneous reductions in total energy intake associated with reductions in dietary free sugar.

• PUBLIC HEALTH

Data availability statement

Data are available in a public, open access repository. Data from the National Diet and Nutrition Survey years 1–11 (2008–09 to 2018–19) can be accessed on the UK Data Service ( https://ukdataservice.ac.uk/ ).

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/jech-2023-221051

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WHAT IS ALREADY KNOWN ON THIS TOPIC

High intakes of free sugars are associated with a range of non-communicable diseases. Sugar sweetened beverages constitute a major source of dietary free sugars in children and adults.

The UK soft drink industry levy (SDIL) led to a reduction in the sugar content in many sugar sweetened beverages and a reduction in household purchasing of sugar from drinks.

No previous study has examined the impact of the SDIL on total dietary consumption of free sugars at the individual level.

WHAT THIS STUDY ADDS

There were declining trends in the intake of dietary free sugar in adults and children prior to the UK SDIL.

Accounting for prior trends, 1 year after the UK SDIL came into force children and adults further reduced their free sugar intake from food and drink by approximately 5 g/day and 11 g/day, respectively. Children and adults reduced their daily free sugar intake from soft drinks alone by approximately 3 g/day and approximately 5 g/day, respectively.

Energy intake from free sugars as a proportion of total energy consumed did not change significantly following the UK SDIL, indicating energy intake from free sugar was reducing simultaneously with overall total energy intake.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

The UK SDIL was associated with significant reductions in consumption of free sugars from soft drinks and across the whole diet and reinforces previous research indicating a reduction in purchasing. This evidence should be used to inform policy when extending or considering other sugar reduction strategies.

Energy intake from free sugars has been falling but levels remain higher than the 5% recommendation set by the WHO. Reductions in dietary sugar in relation to the SDIL may have driven significant reductions in overall energy.

Introduction

High consumption of free sugars is associated with non-communicable diseases. 1 Guidelines from the World Health Organization (WHO) and the UK Scientific Advisory Committee on Nutrition (SACN) suggest limiting free sugar consumption to below 5% of total energy intake to achieve maximum health benefits, 1 2 equivalent to daily maximum amounts of 30 g for adults, 24 g for children (7–10 years) and 19 g for young children (4–6 years). In the UK, consumption of free sugar is well above the recommended daily maximum, although levels have fallen over the last decade. 3 For example, adolescents consume approximately 70 g/day 4 and obtain 12.3% of their energy from free sugars. 3 Sugar sweetened beverages (SSBs) constitute a major source of free sugar in the UK diet, 2 5 and are the largest single source for children aged 11–18 years where they make up approximately one-third of their daily sugar intake. 6 A growing body of evidence has shown a link between consumption of SSBs and higher risk of weight gain, type 2 diabetes, coronary heart disease and premature mortality, 7 such that the WHO recommends taxation of SSBs in order to reduce over-consumption of free sugars and to improve health. 8 To date, >50 countries have introduced taxation on SSBs, which has been associated with a reduction in sales and dietary intake of free sugar from SSBs. 9 Reductions in the prevalence of childhood obesity 10 11 and improvements in dental health outcomes 12 13 have also been reported.

In March 2016 the UK government announced the UK soft drink industry levy (SDIL), a two-tier levy on manufacturers, importers and bottlers of soft drinks which would come into force in March 2018. 14 The levy was designed to incentivise manufacturers to reformulate and reduce the free sugar content of SSBs (see details in online supplemental text 1 ).

Supplemental material

One year after the UK SDIL was implemented there was evidence of a reduction in the sugar content of soft drinks 15 and households on average reduced the amount of sugar purchased from soft drinks by 8 g/week with no evidence of substitution with confectionary or alcohol. 16 However, lack of available data meant it was not possible to examine substitution of purchasing other sugary foods and drinks, which has previously been suggested in some but not all studies. 17 18 Household purchasing only approximates individual consumption because it captures only those products brought into the home, products may be shared unequally between household members, and it does not account for waste.

To examine the effects of the SDIL on total sugar intake at the individual level, in this study we used surveillance data collected using 3- or 4-day food diaries as part of the UK National Diet and Nutrition Survey (NDNS). We aimed to examine changes in absolute and relative consumption of free sugars from soft drinks alone and from both food and drinks (allowing us to consider possible substitutions with other sugary food items), following the announcement and implementation of the UK SDIL.

Data source

We used 11 years of data (2008–2019) from the NDNS. Data collection, sampling design and information on response is described in full elsewhere. 19 In brief, NDNS is a continuous national cross-sectional survey capturing information on food consumption, nutritional status and nutrient intake inside and outside of the home in a representative annual sample of approximately 500 adults and 500 children (1.5–18 years) living in private households in the UK. Participants are sampled throughout the year, such that in a typical month about 40 adults and 40 children participate (further details are shown in online supplemental text 2 ).

Outcomes of interest

Outcomes of interest were absolute and relative changes in the total intake of dietary free sugar from (1) all food and soft drinks combined and (2) from soft drinks alone. A definition of free sugar is given in online supplemental text 3 . Drink categories examined were those that fell within the following NDNS categories: soft drinks – not low calorie; soft drinks – low calorie; semi-skimmed milk; whole milk; skimmed milk; fruit juice, 1% fat milk and other milk and cream. Additionally, we examined absolute and relative changes in percentage energy from free sugar in (1) food and soft drinks and (2) soft drinks alone. While examination of changes in sugar consumption and percentage energy from sugar across the whole diet (food and drink) captures overall substitutions with other sugar-containing products following the UK SDIL, examination of sugar consumption from soft drinks alone provides a higher level of specificity to the SDIL.

Protein intake was selected as a non-equivalent dependent control. It was not a nutritional component specifically targeted by the intervention or other government interventions and therefore is unlikely to be affected by the SDIL but could still be affected by confounding factors such as increases in food prices 20 (see online supplemental text 4 ).

Statistical analysis

Controlled interrupted time series (ITS) analyses were performed to examine changes in the outcomes in relation to the UK SDIL separately in adults and children. We analysed data at the quarterly level over 11 years with the first data point representing dates from April to June 2008 and the last representing dates from January to March 2019. Model specifications are shown in online supplemental text 5 . Where diary date entries extended over two quarters, the earlier quarter was designated as the time point for analysis. Generalised least squares models were used. Autocorrelation in the time series was determined using Durbin–Watson tests and from visualisations of autocorrelation and partial correlation plots. Autocorrelation-moving average correlation structure with order (p) and moving average (q) parameters were used and selected to minimise the Akaike information criterion in each model. Trends in free sugar consumption prior to the announcement of SDIL in April 2016 were used to estimate counterfactual scenarios of what would have happened if the SDIL had not been announced or come into force. Thus, the interruption point was the 3-month period beginning April 2016. Absolute and relative differences in consumption of free sugars/person/day were estimated by calculating the difference between the observed and counterfactual values at quarterly time point 45. To account for non-response and to ensure the sample distribution represented the UK distribution of females and males and age profile, weights provided by NDNS were used and adapted for analysis of adults and children separately. 21 A study protocol has been published 22 and the study is registered ( ISRCTN18042742 ). For changes to the original protocol see online supplemental text 6 . All statistical analyses were performed in R version 4.1.0.

Data from 7999 adults and 7656 children were included across 11 years representing approximately 40 children and 40 adults each month. Table 1 gives descriptive values for the outcomes of interest. Compared with the pre-announcement period, free sugars consumed from all soft drinks reduced by around one-half in children and one-third in adults in the post-announcement period. Total dietary free sugar consumption and percentage of total dietary energy derived from free sugars also declined. Mean protein consumption was relatively stable over both periods in children and adults. The age and sex of the children and adults were very similar in the pre- and post-announcement periods.

• View inline

Mean amount of free sugar (g) consumed in children and adults per day during the study period before and after the announcement of the soft drinks industry levy (SDIL)

All estimates of change in free sugar consumption referred to below are based on g/individual/day in the 3-month period beginning January 2019 and compared with the counterfactual scenario of no UK SDIL announcement and implementation.

Change in free sugar consumption (soft drinks only)

In children, consumption of free sugars from soft drinks was approximately 27 g/day at the start of the study period but fell steeply throughout. By the end of the study period mean sugar consumption from soft drinks was approximately 10 g/day ( figure 1 ). Overall, relative to the counterfactual scenario, there was an absolute reduction in daily free sugar consumption from soft drinks of 3.0 g (95% CI 0.1 to 5.8) or a relative reduction of 23.5% (95% CI 46.0% to 0.9%) in children ( table 2 ). In adults, free sugar consumption at the beginning of the study was lower than that of children (approximately 17 g/day) and was declining prior to the SDIL announcement, although less steeply ( figure 1 ). Following the SDIL announcement, free sugar consumption from soft drinks appeared to decline even more steeply. There was an absolute reduction in free sugar consumption from soft drinks of 5.2 g (95% CI 4.2 to 6.1) or a relative reduction of 40.4% (95% CI 32.9% to 48.0%) in adults relative to the counterfactual ( figure 1 , table 2 ).

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Observed and modelled daily consumption (g) of free sugar from drink products per adult/child from April 2008 to March 2019. Red points show observed data and solid red lines (with light red shadows) show modelled data (and 95% CIs) of free sugar consumed from drinks. The dashed red line indicates the counterfactual line based on pre-announcement trends and if the announcement and implementation had not happened. Modelled protein consumption from drinks (control group) was removed from the graph to include resolution but is available in the supplementary section. The first and second dashed lines indicate the announcement and implementation of the soft drinks industry levy (SDIL), respectively.

Change in free sugar consumption in food and drink and energy from free sugar as a proportion of total energy compared with the counterfactual scenario of no announcement and implementation of the UK soft drinks industry levy (SDIL)

Change in total dietary free sugar consumption (food and soft drinks combined)

Consumption of total dietary free sugars in children was approximately 70 g/day at the beginning of the study but this fell to approximately 45 g/day by the end of the study ( figure 2 ). Relative to the counterfactual scenario, there was an absolute reduction in total dietary free sugar consumption of 4.8 g (95% CI 0.6 to 9.1) or relative reduction of 9.7% (95% CI 18.2% to 1.2%) in children ( figure 2 ; table 2 ). In adults, consumption of total dietary free sugar consumption at the beginning of the study was approximately 60 g/day falling to approximately 45 g/day by the end of the study ( figure 2 ). Relative to the counterfactual scenario there was an absolute reduction in total dietary free sugar consumption in adults of 10.9 g (95% CI 7.8 to 13.9) or a relative reduction of 19.8% (95% CI 25.4% to 14.2%). Online supplemental figures show that, relative to the counterfactual, dietary protein consumption and energy from protein was more or less stable across the study period (see online supplemental figures S3–S6 ).

Observed and modelled daily consumption (g) of free sugar from food and drink products per adult/child from April 2008 to March 2019. Red points show observed data and solid red lines (with light red shadows) show modelled data (and 95% CIs) of free sugar consumed from food and drinks. The dashed red line indicates the counterfactual line based on pre-announcement trends and if the announcement and implementation had not happened. Modelled protein consumption from food and drinks (control group) was removed from the graph to include resolution but is available in the supplementary section. The first and second dashed lines indicate the announcement and implementation of the soft drinks industry levy (SDIL), respectively.

Change in energy from free sugar as a proportion of total energy

The percentage of energy from total dietary free sugar decreased across the study period but did not change significantly relative to the counterfactual scenario in children or adults, with relative changes in free sugar consumption of −7.6 g (95% CI −41.7 to 26.5) and −24.3 g (95% CI −54.0 to 5.4), respectively (see online supplemental figure S1 and table 2 ). Energy from free sugar in soft drinks as a proportion of total energy from soft drinks also decreased across the study period but did not change significantly relative to the counterfactual (see online supplemental figure S2 ).

Summary of main findings

This study is the first to examine individual level consumption of free sugars in the total diet (and in soft drinks only) in relation to the UK SDIL. Using nationally representative population samples, we found that approximately 1 year following the UK SDIL came into force there was a reduction in total dietary free sugar consumed by children and adults compared with what would have been expected if the SDIL had not been announced and implemented. In children this was equivalent to a reduction of 4.8 g of free sugars/day from food and soft drinks, of which 3 g/day came from soft drinks alone, suggesting that the reduction of sugar in the diet was primarily due to a reduction of sugar from soft drinks. In adults, reductions in dietary sugar appeared to come equally from food and drink with an 11 g reduction in food and drink combined, of which 5.2 g was from soft drinks only. There was no significant reduction compared with the counterfactual in the percentage of energy intake from free sugars in the total diet or from soft drinks alone in both children and adults, suggesting that energy intake from free sugar was reducing simultaneously with overall total energy intake.

Comparison with other studies and interpretation of results

Our finding of a reduction in consumption of free sugars from soft drinks after accounting for pre-SDIL announcement trends is supported by previous research showing a large reduction in the proportion of available soft drinks with over 5 g of sugar/100 mL, the threshold at which soft drinks become levy liable. 15 Furthermore, efforts of the soft drink industry to reformulate soft drinks were found to have led to significant reductions in the volume and per capita sales of sugar from these soft drinks. 23

Our findings are consistent with recent research showing reductions in purchasing of sugar from soft drinks of approximately 8 g/household/week (equivalent to approximately 3 g/person/week or approximately 0.5 g/person/day) 1 year after the SDIL came into force. 16 The estimates from the current study suggest larger reductions in consumption (eg, 3 g free sugar/day from soft drinks in children) than previously reported for purchasing. Methodological differences may explain these differences in estimated effect sizes. Most importantly, the previous study used data on soft drink purchases that were for consumption in the home only. In contrast, we captured information on consumption (rather than purchasing) in and out of the home. Consumption of food and particularly soft drinks outside of the home in young people (1–21 years) increases with age and makes a substantial contribution to total free sugar intakes, highlighting the importance of recording both in home and out of home sugar consumption. 4 Purchasing and consumption data also treat waste differently; purchase data record what comes into the home and therefore include waste, whereas consumption data specifically aim to capture leftovers and waste and exclude it from consumption estimates. While both studies use weights to make the population samples representative of the UK, there may be differences in the study participant characteristics in the two studies, which may contribute to the different estimates.

Consistent with other studies, 24 we found that across the 11-year study period we observed a downward trend in free sugar and energy intake in adults and children. 3 A decline in consumption of free sugars was observed in the whole diet rather than just soft drinks, suggesting that consumption of free sugar from food was also declining from as early as 2008. One reason might be the steady transition from sugar in the diet to low-calorie artificial sweeteners, which globally have had an annual growth of approximately 5.1% between 2008 and 2015. 25

Public health signalling around the time of the announcement of the levy may also have contributed to the changes we observed. Public acceptability and perceived effectiveness of the SDIL was reported to be high 4 months before and approximately 20 months after the levy came into force. 26 Furthermore, awareness of the SDIL was found to be high among parents of children living in the UK, with most supporting the levy and intending to reduce purchases of SSBs as a result. 27 Health signalling was also found following the implementation of the SSB tax in Mexico, with one study reporting that most adults (65%) were aware of the tax and that those aware of the tax were more likely to think the tax would reduce purchases of SSBs, 28 although a separate study found that adolescents in Mexico were mostly unaware of the tax, 29 suggesting that public health signalling may differ according to age.

In 2016 the UK government announced a voluntary sugar reduction programme as part of its childhood obesity plan (which also included SDIL) with the aim of reducing sugar sold by industry by 5% no later than 2018 and by 20% in time for 2020 through both reformulation and portion size reduction. 30 While the programme only managed to achieve overall sugar reductions of approximately 3.5%, this did include higher reductions in specific products such as yoghurts (−17%) and cereals (−13%) by 2018 which may have contributed to some of the observed reductions in total sugar consumption (particularly from foods) around the time of the SDIL. While there is strong evidence that the UK SDIL led to significant reformulation 15 and reductions in purchases of sugar from soft drinks, 16 the products targeted by the sugar reduction programme were voluntary with no taxes or penalties if targets were not met, possibly leading to less incentive for manufacturers to reformulate products that were high in sugar. The 5-year duration of the voluntary sugar reduction programme also makes it challenging to attribute overall reductions using interruption points that we assigned to the ITS to align with the date of the SDIL announcement. The soft drinks categories in our study included levy liable and non-levy liable drinks because we wanted to examine whether individuals were likely to substitute levy liable drinks for high sugar non-liable options. The decline in sugar consumed overall and in soft drinks in relation to the levy suggests that individuals did not change their diets substantially by substituting more sugary foods and drinks. This is consistent with findings from a previous study that found no changes in relation to the levy in sugar purchased from fruit juice, powder used to make drinks or confectionery. 16

Consistent with previous analyses, 3 our findings showed that there was a downward trend in energy intake from sugar as a proportion of total energy across the duration of the study. While there was no reduction compared with the counterfactual scenario (which was also decreasing), our estimates suggest that, by 2019, on average energy from sugar as a proportion of all energy appears to be in line with the WHO recommendation of 10% but not the more recent guidelines of 5% which may bring additional health benefits. 1 31 This finding may suggest that reductions in energy intake from sugar were reducing in concert with overall energy intake and indeed may have been driving it. However, the magnitude of calories associated with the reduction in free sugars, compared with the counterfactual scenario in both adults and children, was modest and thus potentially too small to reflect significant changes in the percentage of energy from sugar. In children, a daily reduction of 4.8 g sugar equates to approximately 19.2 kilocalories out of an approximate daily intake of approximately 2000 kilocalories which is equivalent to approximately 1% reduction in energy intake. Furthermore, overall measures of dietary energy are also likely to involve a degree of error reducing the level of precision in any estimates.

Our estimates of changes in sugar consumption in relation to SDIL suggest that adults may have experienced a greater absolute reduction in sugar than children, which is not consistent with estimates of the distributional impact of the policy. 32 However, our understanding may be aided by the visualisations afforded by graphical depictions of our ITS graphs. Children’s consumption of sugar at the beginning of the study period, particularly in soft drinks, was higher than in adults but reducing at a steeper trajectory, which will have influenced our estimated counterfactual scenario of what would have happened without the SDIL. This steep downward trajectory could not have continued indefinitely as there is a lower limit for sugar consumption. No account for this potential ‘floor effect’ was made in the counterfactual. Adults had a lower baseline of sugar consumption, but their trajectory of sugar consumption decreased at a gentler trajectory, potentially allowing more scope for improvement over the longer run.

Reductions in the levels of sugar in food and drink may have also impacted different age groups and children and adults differently. For example, the largest single contributor to free sugars in younger children aged 4–10 years is cereal and cereal products, followed by soft drinks and fruit juice. By the age of 11–18 years, soft drinks provide the largest single source (29%) of dietary free sugar. For adults the largest source of free sugars is sugar, preserves and confectionery, followed by non-alcoholic beverages. 5

Strengths and limitations

The main strengths of the study include the use of nationally representative data on individual consumption of food and drink in and out of the home using consistent food diary assessment over a 4-day period, setting it apart from other surveys which have used food frequency questionnaires, 24 hour recall, shortened dietary instruments or a mixture of these approaches across different survey years. 33 The continual collection of data using consistent methods enabled us to analyse dietary sugar consumption and energy quarterly over 11 years (or 45 time points) including the announcement and implementation period of the SDIL. Information on participant age allowed us to examine changes in sugar consumption in adults and children separately. Limited sample sizes restricted our use of weekly or monthly data and prevented us from examining differences between sociodemographic groups. At each time point we used protein consumption in food and drink as a non-equivalent control category, strengthening our ability to adjust for time-varying confounders such as contemporaneous events. The trends in counterfactual scenarios of sugar consumption and energy from free sugar as part of total energy were based on trends from April 2008 to the announcement of the UK SDIL (March 2016); however, it is possible that the direction of sugar consumption may have changed course. Ascribing changes in free sugar consumption to the SDIL should include exploration of other possible interventions that might have led to a reduction in sugar across the population. We are only aware of the wider UK government’s voluntary sugar reduction programme implemented across overlapping timelines (2015–2020) and leading to reductions in sugar consumption that were well below the targets set. 30 In turn, under-reporting of portion sizes and high energy foods, which may be increasingly seen as less socially acceptable, has been suggested as a common error in self-reported dietary intake with some groups including older teenagers and females, especially those who are living with obesity, more likely to underestimate energy intake. 34 35 However, there is no evidence to suggest this would have changed as a direct result of the SDIL. 36

Conclusions

Our findings indicate that the UK SDIL led to reductions in consumption of dietary free sugars in adults and children 1 year after it came into force. Energy from free sugar as a proportion of overall energy intake was falling prior to the UK SDIL but did not change in relation to the SDIL, suggesting that a reduction in sugar may have driven a simultaneous reduction in overall energy intake.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

For NDNS 2008–2013, ethical approval was obtained from the Oxfordshire A Research Ethics Committee (Reference number: 07/H0604/113). For NDNS 2014–2017, ethical approval was given from the Cambridge South NRES Committee (Reference number: 13/EE/0016). Participants gave informed consent to participate in the study before taking part.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

X @stevencjcummins

Contributors OM, SC, MR, HR, MW and JA conceptualised and acquired funding for the study. NTR carried out statistical analyses. NTR and JA drafted the manuscript. All authors contributed to the article and approved the submitted version.

As the guarantor, NTR had access to the data, controlled the decision to publish and accepts full responsibility for the work and the conduct of the study.

Funding NTR, OM, MW and JA were supported by the Medical Research Council (grant Nos MC_UU_00006/7). This project was funded by the NIHR Public Health Research programme (grant nos 16/49/01 and 16/130/01) to MW. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health and Social Care, UK. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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