The major adverse effects related to intake of fruit juice and fast foods are obesity and its associated complications, dental caries, allergies, micro-organism contamination leading to infections, and risk of cancer due to carcinogenic and allergenic properties of some food additives [6]. As per National Family Health Survey 2015-16, the number of people with obesity has doubled over last 10 years in India; with an increasing trend of being overweight in children and adolescents [7]. Energy drinks also have added adverse effects due to their high caffeine content leading to neurological and psychiatric symptoms, and cardiac dysrhythmias [8]. To address the problem of obesity and related non-communicable diseases (NCDs), there is a need to develop guidelines related to consumption of foods and drinks that have the potential to increase this problem in children.

Globally, recommendations have been released by various countries on intake of fast food and sugar-sweetened beverages (fruit juices and energy drinks) in children and adolescents [9]. The present exercise was conducted by the Pediatric and Adolescent Nutrition Society (Nutrition Chapter of Indian Academy of Pediatrics) to formulate recommendations on consumption of fast food, fruit juices and energy drinks in children and adolescents in India.

These guidelines have been drafted, primarily for the purpose of prevention of chronic NCDs, including obesity and metabolic syndrome; and are limited to dietary interventions. Exclusive breastfeeding is recommended in first 6 months of life [10]. These guidelines are therefore intended for children and adolescents aged 6 months through 18 years. The guidelines are meant for children with normal growth and nutritional status and may not be applicable to children with undernutrition or other chronic systemic illnesses. These guidelines do not pertain to commercial formula for infants and young children (age <2 y); and therapeutic diets (e.g., F-75, F-100, and ready-to-use therapeutic foods (RUTF) for severe malnutrition; and special formulas for gastrointestinal disorders). The Group maintains that regular physical activity as per WHO recommendations [11] is essential along with healthy diet.

A National Consultative group was constituted by the Nutrition Chapter of the Indian Academy of Pediatrics, consisting of faculty from medical colleges, pediatric practitioners, office bearers of Indian Academy of Pediatrics, and representatives from the Ministry of Women and Child Development, World Health Organization, Unicef, Indian Council of Medical Research, and National Institute of Nutrition (Annexure 1). Four sub-committees were constituted to conduct detailed narrative reviews on the following topics: (i) Definitions and magnitude of the problem in India. (ii) Harmful/adverse effects on child/adolescent health; (iii) Evidence for strategies to prevent consumption; and (iv) Global recommendations and guidelines.

The first draft of the review was prepared after a literature review and was circulated to the members of the National Consultative Group for suggestions, comments and modifications. Suggestions were incorporated in the second draft and final review document was circulated to the Consultative Group before the meeting to frame guidelines.

The Group agreed that for advocacy purpose, there is a need to club certain categories of foods and drinks under a common name/acronym: foods which are undesirable either in nutrient content (in terms of calories, saturated and trans-fats, sugar, or salt), or quality (in terms of processing, packaging, preservation, preparation or storage); foods which have the potential to be consumed in large quantities because of their high palatability and flavors; and foods containing toxic substances such as caffeine, additives or colors. The terminology for such foods should be simple to understand, acceptable to lay population as well as pediatrician, and catchy to remember. The existing terminologies are discussed below:

Fast food: By definition, it includes foods that are "designed for ready availability, use, or consumption and with little consideration given to quality or significance" [12]. Though this term is well-known and acceptable, it does not always cover the whole category of unhealthy foods. Moreover, all fast foods (e.g., cut fruits and salads) are not unhealthy. On the other hand, many unhealthy foods take longer time to be prepared. The Group felt that the definition should be more focused on content of food rather than time taken to prepare the meal.

Junk food: These foods are defined as "foods (packed or non-packed, processed or non-processed) which contains little or limited presence of proteins, vitamins, phytochemicals, minerals and dietary fiber but are rich in fat (saturated fatty acids), salt and sugar and high in energy (calories) that are known to have negative impact on health if consumed regularly or in high amounts" [13]. This definition covers a vast variety of foods undesirable in their nutritional content. This terminology is also well-known and accepted by general population; however, the group felt that some unhealthy foods and drinks, which may not be deficient in micronutrients and minerals because of being fortified, get excluded from this definition.

HFSS foods (foods high in fats, salts, or sugar): This nomenclature has been used by WHO and also proposed in the Ministry of Women and Child Development Report – 2015 [14]. This definition has focused on contents and includes both packaged and non-packaged foods. However, it does not include foods with harmful contents such as caffeine, food additives or colors or foods cooked in recycled oil. Also, this abbreviation is unlikely to be popular in lay public.

Ultra-processed foods: NOVA classification categorizes all foods and food products into four distinct groups based on type of processing underlying each group: Group 1 – Unprocessed or minimally processed foods; Group 2 – Processed culinary ingredients; Group 3 – Processed foods; and Group 4 – Ultra-processed foods. The fourth category – ultra-processed foods – includes formulations of ingredients, mostly of exclusive industrial use that result from a series of industrial processes, including fractioning of whole foods into substances (sugars, oils and fats, proteins, starches and fiber), hydrolysis or hydrogenation, food assembly, coloring and flavoring [15].This definition includes a large number of foods having undesirable nutrient content or/and toxins. It also introduces a new concept of obesogenic nature of these foods because of their hyperpalatibility, and also includes unhealthy foods that might not be deficient in micronutrients and mineral content (e.g., powdered milk supplements commonly advertised for increasing the palatability or nutritional value). But once again the definition has a few pitfalls. It mainly caters to packaged foods and seems to focus on process of making/packaging foods rather than the content. As a result, home prepared or freshly prepared (as in restaurants) nutritionally inappropriate foods may be left out.

Other definitions including EDLN (energy dense low-nutrient density foods), EDNPFC (energy dense and nutrient poor foods for children), and FMNV (foods of minimal nutritional value) have not gained popularity due to their complex terminology.

A recent pan Indian survey by CSE in 13,274 schoolchildren in the age group 9-17 years from 123 districts spread across 24 states and 1 union territory concluded that almost every child consumed packaged sugar-sweetened beverages (92.1%), salted packaged food (94.3%) and sweet packaged food (95.1%). Every other child (53%) consumed packaged food or beverages at least once a day [5]. Similarly, results of 21 studies from various regions of India conclude high prevalence of fast food consumption (30-100%) among school-children and college going undergraduates, both in government and private sector, rural and urban areas, and in both boys and girls [1,3,5,23-40]. The most common junk food items reportedly consumed are samosa, patties, burgers, manchurian, noodles, pizza, chips, chocolate, bakery products, soft drinks, sugar-sweetened beverages, and caffeinated drinks.

Revenue of fast food restaurants has increased from US $ 6 billion in 1970 to $160 billion in 2014 [41]. The market was further reported to increase from 495 billion USD (2014) to 602.8 billion USD (2.7% increase at annualized rate of 2.3% [42]. In past, in US around three-fourths of the money used to buy food was spent to prepare meals at home but now half of the money used to buy food is spent at restaurants – mainly at fast food restaurants [43]. Similar trend is observed in India where the expected worth of fast food market in 2020 is estimated to be US$ 27.57 billion with compound annual growth rate (CAGR) of 18% [44-46]. The Indian food service industry is projected to have a volume 77 billion transactions in 2022, with an increase of 28.5% since 2017 [47].

As per Federation of Indian Chambers of Commerce and Industry (FICCI) report 2018 [48], following factors are major reasons for boost in sales and growth of fast food in India.

Favorable demographics: India has high percentage of young population (consumer market with 33% population < 15 years and 50% < 24 years) and largest working age (15-54 years) population which is further predicted to rise by 135 million by 2022 (20% of the world’s working-age population).

Increase in women workforce: There is increased proportion of working women leading to decline in home-cooked meals and increasing ‘out of home’ food trends.

Growing middle class: There is increase in households with annual earnings between USD 5,000 - 10,000 (CAGR of 17% over the last 5 years) and USD 10,000-50,000 (CAGR of 20%) over the last 5 years, leading to more spending capacity on outside food.

Nuclear family: As per 2011 census there is increase in urban households having d"5 members. Fall in the average household size coupled with rising disposable income will lead to a greater discretionary spending, including eating out of home.

Online delivery/digitalization: Online options on internet/ smartphones are easily available to order food from any restaurant and get it delivered too with no waste of time, traffic hassles or quality compromise. Platforms like Foodpanda with revenue of INR 37 crore (FY 2015-16) with 15 million users/ month and Swiggy with revenue of INR 24 crore (2014) are increasingly becoming popular.

Higher experimentation and changing consumer preferences: Increasing indulgence in smaller cities and eating-out as an experience, growth in chained retail, and increase in business potential in transit locations are other factors leading to growth of fast food industry in India.

It has been observed from large, nationally representative databases, obtained by questionnaire based cross-sectional studies, that nearly half of the daily average dietary energy in children comes from ultra-processed food [49-51]. As the contribution of ultra-processed foods to total energy intake increased, the dietary contents of carbohydrates, free sugars, total fats, saturated fats, and sodium increased; with free sugars and sodium intake increasing by 85% and 55%, respectively. Also, a linear inverse association was seen between the dietary contribution of ultra-processed foods and the dietary content of protein, fiber, potassium, minerals and vitamins [49,51].

A questionnaire-based study including 72,900 children (17 countries) showed that children having more frequent consumption of fast food had a significantly higher BMI [52]. This association was independent of the gender or affluence of the country. Studies in children have proven that regular consumers of sugar sweetened beverages (SSB) between meals had a higher risk of being overweight/obese compared to non-consumers [53,54]. This adverse outcome was reiterated by a systematic review showing that 8 out of 12 studies found higher consumption of soft drinks/sweetened beverages to be associated with higher levels of body fat [55].

Longitudinal studies have demonstrated that increased frequency of fast-food consumption during adolescence is associated with increased weight gain [56,57]. A recent longitudinal study of 307 children of low socioeconomic status, from Brazil, showed that ultra-processed food consumption at preschool age was a predictor of an increase in waist circumference from preschool to school age, with every 10% increase in energy intake from ultraprocessed foods, resulting in 0.7 cm increase in waist circumference [58]. In a systematic review by Costa, et al. [57], six longitudinal studies showed a positive association between higher consumption of ultra-processed foods and levels of body fat. Another systematic review from South Asian countries found a significant positive correlation between frequent consumption of these foods and the risk of overweight and obesity [59].

Studies have shown a positive association between ultra-processed diet and cardiometabolic alterations in children and adolescents. While a study from Spain identified an association of "Western" dietary pattern with a higher concentration of adiponectin and interleukin-6 [60], studies from Korea and China found "Western diet" to be associated with higher levels of LDL cholesterol, triglycerides and fasting glucose and lower concentrations of HDL [61,62]. A prospective study further established that the consumption of ultra-processed products at preschool age was a significant predictor of an increase in total and LDL cholesterol concentrations from preschool to school age [63]. Also, higher chances of insulin resistance with ‘‘Western’’ food patterns have been shown in another study from Mexico [64].

Studies show inconsistent results regarding the association between fast food consumption and hypertension in children and adolescents. Data of 5267 children, selected by random sampling from 30 primary schools in China, showed a definite association between "Western" dietary pattern and systolic blood pressure [62], as also did the results of another cross-sectional study of students from Brazil [65]. In contrast, a large study from Iran, (CASPIAN-IV Study) involving 14,880 students, aged 6-18 years failed to show significant association between fast food intake and blood pressure [66]. Another study from China on 1626 students failed to demonstrate any association between fast food consumption and hypertension or obesity [67].

Evidence shows that fast food consumers are prone to adverse psychological behavior. Among many studies, the one in Norwegian adolescents, showed that those with high scores on a ‘junk/convenient’ eating pattern were more likely to have hyperactivity-inattention disorders and those with high scores on a ‘snacking’ eating pattern were more likely to have symptoms of conduct/oppositional disorders, compared to those with lower scores [68]. The latest nationwide cross-sectional sample survey from China, including 14,500 adolescents of grade 7-12, assessing psychological symptoms using Multi-dimensional Sub-health Questionnaire of Adolescents (MSQA) and eating habits found that fast foods pattern, sugar sweetened beverages pattern and the meats pattern were significantly associated with higher risk of psychological symptoms [69].

It is hypothesized that unhealthy diets affect mental state and brain function through oxidative stress processes, inflammation, and stress response systems [70]; while vitamins, antioxidants, beta-carotene, and minerals in fruits and vegetables are associated with lower levels of inflammation and oxidative stress markers [71].

Though studies have shown association between SSB and dental caries, the same has not been seen with intake of 100% fruit juices [72]. Data from the 1999-2004 National Health and Nutrition Examination Survey of 2,290 children aged 2-5 years, failed to show an association between caries and consumption of 100 percent fruit juice even after covariate adjustment [73].

Besides the added effect of excessive calorie consumption on weight gain, the most dreaded complication of caffeine containing energy drinks (CCED) is its cardiovascular toxicity. Worldwide, there has been an increase in the number of presentations to emergencies due to complications of caffeine containing energy drinks, especially among adolescents and young adults [74]. Caffeine being structurally similar to adenosine, binds and thereby blocks its receptors, with an overdose resulting in tachycardia followed by arrhythmias – supraventricular or ventricular, hypotension and even death [75]. The common expectation of an "energy boost", making CCED very popular among vulnerable adolescents, leads to over-consumption, which affects sleep, causes negative psychological effects and thereby paradoxically potentiates further mental stress [76,77].

Based on available evidence, the Group has evolved the consensus statements summarizing the adverse effects of the JUNCS foods (Box 2), along with level of evidence (LOE) [78].

Banning the sale of JUNCS foods in and around the vicinity of schools is seen as an effective intervention in reducing its consumption [79-81]. Government of Australia has developed policies in schools regulating healthy food options in school canteens; but many school canteen menus were found to be non-compliant and served banned foods [82,83]. Locatelli, et al. [84] from Brazil studied the impact of school meals on food consumption in 86,600 ninth grade students in public and private schools. They reported that regular consumption of school meals positively influenced the eating habits promoting a healthy diet; even though only 22.8% of enrolled children consumed school meals regularly. "Let’s Move Salad Bars to School" as a part of the "Let’s move" movement was launched in 2010 by Michelle Obama in the United States to raise awareness of having salad bars in school canteens in order to improve child nutrition [85]. Slusser, et al. [86] reported that after the introduction of salad bar in 337 children (ages 7-11) studying in three Los Angeles Unified School District elementary schools, there was a significant increase in frequency (2.97 to 4.09, P<0.001) of fruits and vegetables consumed among the children with a significantly lower mean energy (P=0.03), cholesterol (P=0.02), saturated fat (P<0.001) and total fat intakes (P=0.03). A systematic review has also demonstrated that replacing sugar sweetened beverages (SSB) with drinking water in school canteens and vending machines reduces the consumption of SSB and lowers the body mass index (BMI) [87].

Evidence supports "Front of Pack" nutrition labeling as an intervention as it helps consumers to make healthier choices at point of purchase. However, a survey conducted in Delhi schools revealed that only 24.6% of children always looked at the content label and 28.8% never checked the label [79]. A market survey conducted by National Institute of Nutrition revealed that even though the food labeling regulation in India is at par with the developed world it is usually not read at the point of purchase; therefore there is a need to evolve and experiment symbol-based labeling of foods in India [88].Countries have different labeling systems like the "key hole" symbol in Nordic countries, a "traffic light" labeling system in United Kingdom, and "Health of Star Rating System" in Australia [89-91]. Evidence suggests that labeling of energy drinks also has a significant impact on their purchase, especially in adolescents [92].

There is low quality evidence available in favor of caloric labeling of menus in restaurants [93]. Two systematic reviews conducted to study the effectiveness of caloric labeling at point of purchase on caloric consumption concluded that caloric labeling alone may not be sufficient in decreasing purchase and consumption [94,95].

Advertisement of JUNCS foods leads to unhealthy food choices thereby leading to obesity. In a survey conducted in Delhi schools, 85.1% students reported that television was the major source of junk food advertising, followed by magazines (78.5 %), internet (29.5%) and billboards in and around their schools (22%). The study also revealed that junk food advertising created a desire to consume them in 88.7 % students [79]. Russel, et al. [96] in a systematic review and meta-analysis (11 studies) reported that food advertising on television (TV) resulted in increased dietary intake among children. Enough evidence is available that proves that advertisements of fast foods and nonalcoholic beverages on TV, print media, and online portals (such as You Tube) positively impacts its consumption and adversely affects the BMI [97-100]. Marketing strategies directed to children, promotion using popular personalities and premiums like free toys influence children’s decision regarding purchase of advertised products [101, 102]. Roberto, et al. [103] reported that children perceived the food item with licensed characters to taste better than those presented in plain packages (P<.001).

World Health Organization has recommended a fiscal policy on levy taxation on unhealthy food to encourage healthy eating habits [104]. Thow, et al. [105] conducted a systematic review (24 studies) that showed taxes and subsidies influenced consumption in the desired direction, with larger taxes being associated with more significant changes in consumption, body weight and disease incidence. However, the quality of the evidence of all the studies included in the review was generally low. Mhurchu, et al. [106] in a randomized controlled trial concluded that pricing strategies can act as a promising intervention to effect population dietary habits. Colchero, et al. [107] reported that tax on SSBs was associated with reductions in their purchases.

School-based interventions are seen to be an effective strategy in reducing the consumption of the JUNCS foods. Gordon, et al. [108] in a systematic review (48 studies) of school cafeteria interventions reported that fast and intuitive thinking interventions like emoticon labeling, incentives, convenience and appeal were more common (89%) and more effective in significantly reducing BMI as compared to mixed interventions (67%) and slow and cognitively defined interventions (33%) like classroom nutritional programs and educational programs. Avery, et al. [109] concluded from their systematic review and meta-analysis that school-based education programs focusing on reducing SSB consumption offer opportunities for implementing effective and sustainable interventions. Their effective-ness can be improved by peer support and changing the school environment to support educational programs.

Dietary guidelines on permissible amount of fats, carbohydrates, protein, free sugar, salt and micronutrients are available in more than 60 countries. World Health Organization [110] and Dietary Guidelines for Americans (2015-2020) limit intake of free sugars to less than 10% of total energy intake [111]. The Science Advisory Committee for Nutrition (SACN) from UK (2015) and ESPGHAN Committee on Nutrition (2017) [112,113] recommended free sugars intake of 5% or less of total dietary intake for adults and children aged over two years. Australian and New Zealand dietary guidelines also recommend limiting consumption of added sugars. For fats, WHO and US dietary guidelines recommend that total fat should not exceed 30% of total energy intake, saturated fatty acid intake should be <10% of total energy intake and trans fatty acids to <1% [111,114]. Further, salt intake should be less than 5 g/d (2g/d sodium) [115].

Advertisement and marketing: United Kingdom in 2006 banned advertisements for foods high in fat, sugar or salt (HFSS) in television programs made for children age 4-15 years [99]. Mexico, Brazil, Taiwan, Canada, South Korea, Chile and Ireland have also taken steps to regulate advertisement, marketing and sales of these products. Some countries like Denmark, Hungary, France have introduced economic policies as recommended by the WHO in 2008 [116]. United States in 2014 mandated that schools will no longer be allowed to sell unhealthy junk food and SSBs in their cafeterias, vending machines or students store [117].

In 2015, Delhi High Court set a ban on sale of HFSS food, including sugar-sweetened carbonated and non-carbonated beverages, within the school or within 50 meters of its premises [80]. Ministry of Women and Child Development has also issued similar guidelines and advised all school canteen foods to be color-coded (green, yellow, orange) based on nutritional value. The color-coded canteen policy was also endorsed by FSSAI [118-120].

American Academy of Pediatrics (AAP) has recommended no fruit juices for children below 12 months of age [121]. British Nutrition Foundation has limited fruit juice to maximum of 1 portion (150 mL) a day [122] whereas Australian guidelines limit consumption of fruit juice to half cup with no added sugar, to be taken occasionally [123].

Food labeling: United States Food and Drug Administration directed that any juice reconstituted from pulp must be mentioned on the label and must list the percentage of all the other ingredients [121]. In UK fruit juices must not be labeled with no added sugar claim and sugar must not be added to fruit juice; also the words ‘containing naturally occurring sugars’ must also appear [124].

Advertisement and marketing: In March 2018, the UK government, proposed to ban vast majority of fruit juices from advertising aimed at children [125]. In France, Government directed that all advertisements related to drinks high in fat, sugar and salt must carry a health message or a warning; unlimited refills of sugary drinks are banned [126]. Australian Taskforce has also recommended against the sale of SSBs in school canteens and vending machines [127].

American Academy of Pediatrics and the American College of Sports Medicine (ACSM) have stated that energy drinks are not intended for children and adolescents; also not recommended before and after strenuous activity. They have advised against mixing energy drinks with alcohol [128, 129]. Water is advocated as the main source of hydration, even during exercise. European Food Safety Authority (EFSA) have concluded that maximum caffeine intake of 3 mg/kg/d (maximum 200 mg/d) can be considered safe for children and adolescents [130]. Canada Health Association considers 2.5 mg/kg/d intake of total caffeine as safe [131].

Labeling: All energy drinks should have the advisory statement stating "not recommended for children or pregnant or breast-feeding women" or similar [132]. Further, European Union Soft Drinks Association (UNESDA) asked that the statement must be placed in the same field of vision as the name of the beverage, followed by a reference to the caffeine content expressed in mg per 100 mL [133]. American Beverage Association (ABA) have stressed upon quantitative caffeine declaration to be separate and apart from the Nutrition Facts Panel [134].

Advertisement and marketing: American Beverage Association (ABA) recommends that marketing of energy drinks should not be permitted to children younger than 12 years of age [134]. Any images of children on company website and advertisement in media where target audience is children is also prohibited. No commercial promotion is permitted in primary and secondary schools and within 100 meters [132,134]. European Union has also not permitted marketing or sampling in audience where more than 35% are children less than 16 years of age [133]. In India, FSSAI has recommended that non-alcoholic beverages with caffeine content more than 145 mg/L of caffeine will be labelled as caffeinated beverage and caffeine content in these beverages should not cross 300 mg/L, irrespective of the source of the caffeine [135].

Based on the review of evidence, and the deliberations during, before and after the meeting, the group arrived at the following consensus guidelines:

1. General Recommendations

2. Fruit juices

3. Caffeinated drinks

1. Guidelines for Schools

2. Guidelines for Labeling

3. Guidelines for Advertisements

The Group agrees that advertising has strong impact on dietary intake. Advertisement of the JUNCS foods may lead to unhealthy food choices (LOE 1a) and is likely to be associated with increasing obesity (LOE 2a).

4. Guidelines for Marketing

Contributors: All authors were part of the National Consultation (Annexure 1) that formulated these Guidelines. PG, DS, PK and DiS conceived the Consultation and Guidelines, prepared its agenda, and executed administratively. NB, HGM, KM and SK extensively reviewed the literature and also wrote the first draft of respective sections assigned to them. Review of literature was peer reviewed by PK, DS and PG. The draft recommendations were prepared by DS. KEE, RD, RH, USK, KI, SSG, JPD, NM, AG, AKR, SB, RS, RRK, BJP, STS and DiS actively participated in the consultation and/or subsequent discussions and provided critical inputs at every stage to finalize the draft recommendations. HPS led the consultation and discussions and crystallized the output. He provided intellectual inputs and overall guidance at every step. RRK, USK, RH, STS, BJP and DiS provided the administrative support from the Indian Academy of Pediatrics and coordinated between the Consultative Group and Executive Board members of the Academy. The final document was drafted by NB, HGM, KM, SK; compiled by NB; and edited by DS, PK and PG. All authors approved the final Recommendation paper.

Funding: None. Competing interest: None stated.

Chairperson: Piyush Gupta; Convener: Praveen Kumar

Members (in alphabetical order): AK Rawat, Anju Pradhan Sinha (ICMR, Delhi), Devindra Shakappa (NIN, Hyderabad), Dheeraj Shah, Digant D Shastri, Hema Gupta Mittal, HPS Sachdev, JH Panwal (MoWCD), KE Elizabeth, Kirtisudha Mishra, Kristin Indumathi, Nidhi Bedi, Niranjan Mohanty, Raghvendra Singh, Rekha Harish, Rupal Dalal, Srikanta Basu, Sumaira Khalil, Upendra S Kinjawadekar.

Could not attend: AP Dubey, Abner Daniel (UNICEF), Ajay Gaur, Alka Mathur, Arjan De Wagt (UNICEF), Bakul Jayant Parekh, CP Bansal, JP Dadhich (BPNI), Rachita Gupta (WHO-India), R Remesh Kumar, Santosh T Soans, Sheetal S Gandhi, Sila Deb (UNICEF), Umesh Kapil, Virendra Kumar.

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