Changes in food purchases after the Chilean policies on food labelling, marketing, and sales in schools: a before and after study

Characteristics of successful government-led interventions to support healthier populations: a starting portfolio of positive outlier examples

Despite progress on the Millennium and Sustainable Development Goals, significant public health challenges remain to address communicable and non-communicable diseases and health inequities. The Healthier Societies for Healthy Populations initiative convened by WHO's Alliance for Health Policy and Systems Research; the Government of Sweden; and the Wellcome Trust aims to address these complex challenges. One starting point is to build understanding of the characteristics of successful government-led interventions to support healthier populations. To this end, this project explored five purposefully sampled, successful public health initiatives: front-of-package warnings on food labels containing high sugar, sodium or saturated fat (Chile); healthy food initiatives (trans fats, calorie labelling, cap on beverage size; New York); the alcohol sales and transport ban during COVID-19 (South Africa); the Vision Zero road safety initiative (Sweden) and establishment of the Thai Health Promotion Foundation. For each initiative a qualitative, semistructured one-on-one interview with a key leader was conducted, supplemented by a rapid literature scan with input from an information specialist. Thematic analysis of the five interviews and 169 relevant studies across the five examples identified facilitators of success including political leadership, public education, multifaceted approaches, stable funding and planning for opposition. Barriers included industry opposition, the complex nature of public health challenges and poor interagency and multisector co-ordination. Further examples building on this global portfolio will deepen understanding of success factors or failures over time in this critical area.

Framing a New Nutrition Policy: Changes on Key Stakeholder's Discourses throughout the Implementation of the Chilean Food Labelling Law

The global implementation of structural policies to tackle obesity has been slow, likely because of the competing interests of governments and the food industry. We used the discussion of the Chilean Food Labeling Law to identify influential stakeholders in the media and their frames during different periods of the law's implementation. This involved a content analysis of the food regulation media coverage in five key periods from 2007, when the food bill was first introduced in Congress, to 2018, when the second phase of the law was implemented (N = 1295). We found that most of the law coverage was through elite press. Half of the sources were from the food industry (26.7%) and government (26.2%), while other stakeholders, were less prevalent. Frames were mostly competing, except for cooperation with the law. The main food industry frame used during the discussion of the law was the "economic threat" (41.9%), whose prevalence decreased at the post-implementation period (13%, p < 0.01). No other relevant stakeholders changed their framing. Our results highlight that there are several aspects of public health communication, such as the type of media used, the involvement of scholars and civil society, and the framing, that could be improved to advance food environment policies.

Structural responses to the obesity epidemic in Latin America: what are the next steps for food and physical activity policies?

Obesity is among the most complex public health challenges, particularly in Latin America, where obesity rates have increased faster than in any other region. Many countries have proposed or enacted comprehensive policies to promote adequate diet and physical activity under a structural framework. We summarize articles discussing the scope and impact of recently implemented obesity-related interventions in the light of a structural response framework. Overall, we find that: (1) market-based food interventions, including taxes on junk food, nutrition labelling, and marketing restrictions, decrease the consumption of targeted foods, (2) programs directly providing healthy foods are effective in reducing obesity, and (3) the construction of public areas for recreation increases the average frequency of physical activity. Although obesity-related interventions in the region have somewhat improved health behaviours, obesity prevalence remains on an upward trend. We discuss some opportunities to continue tackling the obesity epidemic in LATAM under a structural framework.

Qualitative analysis of front-of package labeling policy interactions between stakeholders and Health Canada

Background

Front-of-package labelling regulations proposed by Health Canada in their Healthy Eating Strategy (2016) were finally passed in 2022, but remain unimplemented. This study analyzed interactions that occurred between stakeholders and government related to this policy proposal to identify key themes and policy implications.

Methods

A qualitative framework analysis was conducted on publicly available documents for stakeholder correspondences related to front-of-package that occurred between 2016 and 2019 in Health Canada's Meetings and Correspondence on Healthy Eating database. Five sequential steps were applied: familiarization, identifying a thematic framework, indexing, charting, and mapping and interpretation. A complex systems (i.e., a dynamic system with multiple interconnecting components) lens was incorporated in the final step to deepen the analysis.

Results

Hundred and seventy-three documents were included, the majority from industry stakeholders (n = 108, 62.4%). Three overarching themes were identified: industry trying to control the agenda and resist regulation; questioning the evidence supporting the policy and its impact on the agri-food industry; and dismissing the need and effectiveness of the policy. Incorporating a complex system lens found industry and non-industry stakeholders held markedly different perspectives on how cohesive the system defined by the front-of-package labelling policy was, and the policy impact on its stability. Economic and opportunity costs were the main trade-offs, and symbol misinterpretation considered an unintended consequence by industry. Finally, some stakeholders argued for wider policy scope incorporating more products, while others requested a narrower approach through exemptions.

Conclusion

Interactions with industry stakeholders on health food policy proposals require careful consideration, given it may suit their interests to generate delays and policy discordance. Explicitly setting out the principles of engagement and actively encouraging non-industry stakeholder representation provides a more balanced approach to policy consultation and development.

Effects of front-of-package nutrition labelling systems on understanding and purchase intention in Jamaica: results from a multiarm randomised controlled trial

OBJECTIVE

To assess the effects of three different front-of-package labelling (FOPL) schemes on objective understanding and intention to purchase of products, in Jamaica.

SETTING

Supermarkets in Jamaica.

PARTICIPANTS

Adult supermarket shoppers in Jamaica (n=1206) aged 18 years old or older were included in the study, except for those visually impaired, or unable to give informed consent.

DESIGN

Multiarm parallel-group randomised trial.

INTERVENTIONS

Participants were randomly allocated to one of the three intervention groups or the control group. They were exposed to two-dimensional images of 12 mock-up products presented in random and balanced order. Participants assigned to the intervention groups were exposed to one FOPL scheme: black octagonal warning labels (OWL), magnifying glass high-in single icon (MGG) or traffic-light labelling (TFL). The control group was exposed to the nutrition facts up front.

OUTCOME MEASURES

OR for correctly understanding nutritional information (correctly selecting the least harmful option, correctly identifying sugars, sodium and/or saturated fats found to be in excess) and choosing to purchase the least harmful option (purchase intention), more often.

RESULTS

Compared with the control group, the odds for correctly selecting the least harmful option more often were 107% higher in the OWL group (OR 2.07, 95% CI 1.54 to 2.78; p<0.001), whereas the MGG (1.18, 95% CI 0.89 to 1.57; p=0.24) and the TFL (1.13, 95% CI 0.85 to 1.51; p=0.39) were inefficacious in improving such odds. OWL also resulted in the highest odds for correctly identifying a product with excessive amounts of sugars, sodium and/or saturated fats and for deciding to purchase the least harmful option or none of the options.

CONCLUSIONS

Octagonal warning labels performed best at improving the ability of adult shoppers in Jamaica to understand the nutrition information and at encouraging them to purchase the least harmful option more often.

Changes in children's and adolescents' dietary intake after the implementation of Chile's law of food labeling, advertising and sales in schools: a longitudinal study

BACKGROUND

In June 2016, a comprehensive food policy was implemented in Chile that included front-of-package warning labels on key nutrients of concern (total sugars, added saturated fats, sodium, and calories), child-directed food advertisement bans, and school regulations. The policy was implemented in 3 phases from 2016 to 2019 and the primary objective was to improve children's food environments. This study's objective was to assess changes in child and adolescent intake of key nutrients of concern (total sugars, saturated fats, and sodium) at school after the initial implementation of Chile's Law of Food Labeling and Advertisement.

METHODS

Longitudinal study of 349 children from the Food Environment Chilean Cohort (FECHIC) and 294 adolescents from the Growth and Obesity Cohort Study (GOCS). Data were from single 24-hour dietary recalls collected from 2016 to 2019. Fixed-effects models stratified by school, home, and other locations compared nutrient consumption in each year to consumption at the pre-policy 2016 baseline. Nutrient intakes are expressed as percent of total energy.

RESULTS

Compared to 2016 (pre-policy), total sugars consumed by children at school decreased 4.5 [-8.0, -0.9] percentage points (pp) and 11.8 [-15.4, -8.3] pp in 2018 and 2019 respectively. In 2019, children's saturated fats and sodium intake at school also decreased (1.1 [-1.9, -0.2] pp and 10.3 [-18.1, -2.5] mg/100 kcal respectively). Likewise, in adolescents, total sugars and saturated fats consumed at school decreased in 2018 (5.3 [-8.4, -2.2] pp and 1.5 [-2.7, -0.3] pp respectively). However, consumption of key nutrients of concern at other locations increased after implementation of the policy.

CONCLUSIONS

After initial implementation of Chile's Labeling Law, intake of most key nutrients of concern significantly declined at school. However, we found evidence of compensatory behavior in out-of-school settings. Further research is needed to evaluate what other actions are needed to impact overall diets in the long term both at schools and out of school.

City features related to obesity in preschool children: a cross-sectional analysis of 159 cities in six Latin American countries

Background

Childhood obesity is a rising global health problem. The rapid urbanization experienced in Latin America might impact childhood obesity through different pathways involving urban built and social features of cities. We aimed to evaluate the association between built and social environment features of cities and childhood obesity across countries and cities in Latin America.

Methods

Cross-sectional analysis of data from 20,040 children aged 1-5 years living in 159 large cities in six Latin American countries. We used individual-level anthropometric data for excess weight (overweight or obesity) from health surveys that could be linked to city-level data. City and sub-city level exposures included the social environment (living conditions, service provision and educational attainment) and the built environment (fragmentation, isolation, presence of mass transit, population density, intersection density and percent greenness). Multi-level logistic models were used to explore associations between city features and excess weight, adjusting for age, sex, and head of household education.

Findings

The overall prevalence of excess weight among preschool children was 8% but varied substantially between and within countries, ranging from 4% to 25%. Our analysis showed that 97% of the variability was between individuals within sub-city units and around 3% of the variance in z-scores of weight for height was explained by the city and sub-city levels. At the city-level, a higher distance between urban patches (isolation, per 1 SD increase) was associated with lower odds of excess weight (OR 0.90, 95% CI 0.82-0.99). Higher sub-city education was also associated with lower odds of excess weight, but better sub-city living conditions were associated with higher odds of excess weight.

Interpretation

Built and social environment features are related to excess weight in preschool children. Our evidence from a wide range of large Latin American cities suggests that urban health interventions may be suitable alternatives towards attaining the goal of reducing excess weight early in the life course.

Funding

The SALURBAL project (Salud Urbana en América Latina, Urban Health in Latin America) is funded by Wellcome [205177/Z/16/Z].

Estimating the dietary and health impact of implementing front-of-pack nutrition labeling in Canada: A macrosimulation modeling study

Background

Front-of-pack labeling (FOPL) has been identified as a cost-effective policy to promote healthy diets. Health Canada has recently published FOPL regulations that will require food and beverages that meet or exceed set thresholds for sodium, sugars, or saturated fat to display a 'high in' symbol on the front of the package. Although a promising measure, its potential impact on dietary intakes and health have not yet been estimated in Canada.

Objective

This study aims to estimate (1) the potential dietary impact of implementing a mandatory FOPL among Canadian adults; and (2) the number of diet-related non-communicable disease (NCD) deaths that could be averted or delayed due to these estimated dietary changes.

Methods

Baseline and counterfactual usual intakes of sodium, total sugars, saturated fats, and calories were estimated among Canadian adults (n = 11,992) using both available days of 24 h recalls from the 2015 Canadian Community Health Survey-Nutrition. The National Cancer Institute method was used to estimate usual intakes, and adjusted for age, sex, misreporting status, weekend/weekday, and sequence of recall. Estimated counterfactual dietary intakes were modeled from reductions observed in experimental and observational studies that examined changes in sodium, sugars, saturated fat, and calorie content of food purchases in the presence of a 'high in' FOPL (four counterfactual scenarios). The Preventable Risk Integrated ModEl was used to estimate potential health impacts.

Results

Estimated mean dietary reductions were between 31 and 212 mg/day of sodium, 2.3 and 8.7 g/day of total sugars, 0.8 and 3.7 g/day of saturated fats, and 16 and 59 kcal/day of calories. Between 2,183 (95% UI 2,008-2,361) and 8,907 (95% UI 8,095-9,667) deaths due to diet-related NCDs, mostly from cardiovascular diseases (~70%), could potentially be averted or delayed by implementing a 'high in' FOPL in Canada. This estimation represents between 2.4 and 9.6% of the total number of diet-related NCD deaths in Canada.

Conclusion

Results suggest that implementing a FOPL could significantly reduce sodium, total sugar, and saturated fat intakes among Canadian adults and subsequently prevent or postpone a substantial number of diet-related NCD deaths in Canada. These results provide critical evidence to inform policy decisions related to implementing FOPL in Canada.

Primordial prevention: Reducing consumption of sugar-sweetened beverages in racial/ethnic populations

Beyond pharmacotherapy in adulthood, primordial prevention in United States (U.S.) children and adolescents is needed to avoid the upcoming tsunami of cardiometabolic and cardiovascular disease (CVD). Healthcare disparities were unmasked by the disparate morbidity and mortality of COVID-19 in racial/ethnic populations, especially in persons with obesity, diabetes, and CVD. One potential successful strategic improvement of childhood cardiovascular health is to reduce sugar consumption in early life as CVD is the number one cause of death in patients with Type 2 diabetes (T2D). Furthermore, cardiologists treat more patients with T2D than endocrinologists. This commentary challenges cardiovascular specialists and other clinicians to address the increasing burden of cardiometabolic and CVD in adults, especially in racial/ethnic populations, by supporting primordial prevention in childhood.

Qualitative exploration of the reasons for not using nutritional warnings after policy implementation in Uruguay

Nutritional warnings have gained popularity, particularly in the region of the Americas, to facilitate the identification of products with excessive content of nutrients associated with non-communicable diseases and encourage healthier food choices. Although warnings have been shown to be effective, an in-depth understanding of the reasons why some consumers do not use them is still lacking. The aim of the present work was to explore self-reported use of nutritional warnings and to identify the reasons for not considering nutritional warnings for making food purchase decisions after policy implementation in Uruguay. A non-probabilistic sample of 858 Uruguayan participants was recruited using an advertisement on Facebook and Instagram. Through an online survey, self-reported use of nutritional warnings was asked using a closed-open ended questions. Participants who reported not considering warnings to make their purchase decisions were asked to explain the reasons why using an open-ended question. Responses were analysed using deductive coding, based on the Behavioural Drivers Model. Thirty seven percent of the participants stated that the warnings had not influenced their purchase decisions. Motives for not being influenced by the warnings were related to lack of interest, attitudes, lack of perceived self-efficacy, cognitive biases and limited rationality when making purchase decisions. In addition, structural barriers, such as availability, cost and trust in the food industry also emerged from participants' responses. Strategies to encourage the use of warnings should include communication campaigns and policies to address structural barriers related to the perceived availability and affordability of healthy foods.

Sweetener Purchases in Chile before and after Implementing a Policy for Food Labeling, Marketing, and Sales in Schools

Background

Chile's landmark food labeling and advertising policy led to major reductions in sugar purchases. However, it is unclear whether this led to increases in the purchases of nonnutritive sweeteners (NNS).

Objectives

The objective of this study was to assess the changes in NNS and caloric-sweetened (CS) products purchased after the law's first phase.

Methods

Longitudinal data on food and beverage purchases from 2,381 households collected from January 1, 2015 to December 31, 2017, were linked to nutritional information and categorized into added sweetener groups (unsweetened, NNS-only, CS-only, or NNS with CS). Logistic random-effects models and fixed-effects models were used to compare the percentage of households purchasing products and the mean volume purchased by sweetener category to a counterfactual based on pre-regulation trends.

Results

Compared with the counterfactual, the percentage of households purchasing any NNS beverages (NNS-only or NNS with CS) increased by 4.2 percentage points (pp) (95% CI: 2.8, 5.7; P < 0.01). This increase was driven by households purchasing NNS-only beverages (12.1 pp, 95% CI: 10.0, 14.2; P < 0.01). The purchased volume of beverages with any NNS increased by 25.4 mL/person/d (95% CI: 20.1, 30.7; P < 0.01) or 26.5%. Relative to the counterfactual, there were declines of -5.9 pp in households purchasing CS-only beverages (95% CI: -7.0, -4.7; P < 0.01). Regarding the types of sweeteners purchased, we found significant increases in the amounts of sucralose, aspartame, acesulfame K, and steviol glycosides purchased from beverages. Among foods, differences were minimal.

Conclusions

The first phase of Chile's law was associated with an increase in the purchases of beverages containing NNS and decreases in beverages containing CS, but virtually no changes in foods.

Nutritional Composition and Purchasing Patterns of Supermarket Prepared Foods Over Time

INTRODUCTION

Prepared (ready-to-eat) foods are sold in >90% of U.S. supermarkets, but little is known about their nutritional quality. This study examined trends in purchases of supermarket prepared foods and compared their nutritional profile with that of supermarket packaged foods and restaurant foods.

METHODS

Nutrition data were obtained on prepared foods sold from 2015 to 2019 in 2 supermarket chains (∼1,200 stores). One chain (193 stores) provided transaction-level sales data from 2015 to 2017. Analyses (conducted in 2021-2022) examined trends in the number of different prepared foods offered by the chains and trends in purchases of calories, total sugar, saturated fat, and sodium from prepared foods. Calorie and nutrient densities (i.e., per 100 g of food) and prevalence of being high in calories or nutrients (on the basis of Chilean standards) were analyzed among supermarket prepared foods, supermarket packaged foods, and restaurant foods consumed in the National Health and Nutrition Examination Surveys 2015-2018.

RESULTS

The number of different prepared foods offered at supermarket chains increased from 1,930 in 2015 to 4,113 in 2019. Calories per transaction purchased from supermarket prepared foods increased by 1.0 calories/month (95% CI=0.8, 1.1), a ∼3% annual increase, with similar trends for other nutrients. At supermarkets, >90% of prepared bakery and deli items and 61% of prepared entrees/sides were high in calories or another nutrient of concern, similar to supermarket packaged foods and restaurant foods.

CONCLUSIONS

Supply of and demand for supermarket prepared foods have grown substantially over time. These trends are concerning given these foods' overall poor nutritional quality.

Socioeconomic Patterns in Budget Share Allocations of Regulated Foods and Beverages in Chile: A Longitudinal Analysis

Chile has enacted stringent legislation regulating food and beverage labeling and advertising. This study assesses the changes in the average relative allocations of food and beverage budgets for regulated versus not regulated products in households of different socioeconomic and demographic backgrounds. A household fixed effect before-after model is estimated and the marginal effects in the changes of levels and trends in budget shares and purchased volumes after the implementation of the regulations are examined. The results highlight how impactful food policies can shift consumption toward healthier products.

Lived Experience and Perceptions of Adolescents on Prevention, Causes and Consequences of Double Burden of Malnutrition in Debre Berhan City, Ethiopia: A Qualitative Study

Background

The coexistence of undernutrition, overweight, and obesity within the same households and populations is recognized as the Double Burden of Malnutrition (DBM). A paradigm shift thinking is needed to mitigate its impact. School adolescents are the most vulnerable groups to DBM. However, lived experiences and perceptions on prevention, causes, and consequences of DBM were not well studied. Therefore, this study aims to explore the lived experiences and perceptions of adolescents about the prevention, causes, and consequences of DBM in Ethiopia.

Methods

A qualitative research method using phenomenology design was conducted among 20 purposively selected participants from private and government schools from June 3 to July 10, 2022. The further sampling process was guided by a saturation of ideas. In-depth and key informant interviews were conducted to collect the data. The most recent version of Open code 4.03 was utilized to generate meaningful codes, subthemes, and themes. The results were displayed using thematic analysis and respondents' well-spoken verbatims.

Results

The study explored the perceptions of adolescents on the causes, prevention, and consequences of DBM. The main causes of DBM identified were poor dietary and drinking habits, poor knowledge and attitude about nutrition, low financial income, unemployment, food insecurity, poor feeding culture, physical inactivity, poor food management, educational and school-related issues, national-related issues, frequent use of ultra-processed foods, and frequent out of home eating. The majority of students were not aware of how DBM will affect their health and academic performance over the long run.

Conclusion

The findings showed that despite school adolescents' variations in knowledge, lived experience, attitude, and perceptions, most of them have a poor understanding of the causes, consequences, and prevention mechanisms of the double burden of malnutrition. The results suggest the need for instituting double-duty interventions that have a double impact on the prevention of DBM.

Eating contexts determine the efficacy of nutrient warning labels to promote healthy food choices

Introduction

Unhealthy food choices increase the risk of obesity and its co-morbidities. Nutrition labels are a public health policy that aims to drive individuals toward healthier food choices. Chile has been an example of this policy, where mandatory nutrient warning labels (NWL) identify processed foods high in calories and critical nutrients. Eating contexts influence individual food choices, but whether eating contexts also influence how NWL alter the decision process and selection during food choice is unknown.

Methods

In an online mouse-tracking study, participants prompted to health, typical, or unrestricted eating contexts were instructed to choose between pairs of foods in the presence or absence of NWL. Conflict during choices was analyzed using mouse paths and reaction times.

Results

NWL increased conflict during unhealthy food choices and reduced conflict during healthy choices in all contexts. However, the probability that NWL reversed an unhealthy choice was 80% in a healthy, 37% in a typical, and 19% in an unrestricted context. A drift-diffusion model analysis showed the effects of NWL on choice were associated with an increased bias toward healthier foods in the healthy and typical but not in the unrestricted context.

Discussion

These data suggest that the efficacy of NWL to drive healthy food choices increases in a healthy eating context, whereas NWL are less effective in typical or unrestricted eating contexts.

Consumer behaviour and experiences in a naturalistic online grocery store: implications for nutrition research

Naturalistic online grocery stores could provide a novel setting for evaluating nutrition interventions. In 2021–2022, we recruited US adults (n 144, 59% low-income) to complete two weekly study visits: one in a naturalistic (‘mock’) online grocery store developed for research and one in a real online grocery store. Participants selected groceries and responded to survey questions. Analyses examined survey responses and expenditures on fifteen food categories (e.g., bread, sugar-sweetened beverages). Nearly all enrolled participants completed both visits (98% retention). Moreover, nearly participants all reported that their selections in the naturalistic store were similar to their usual purchases (95%) and that the naturalistic store felt like a real store (92%). Participants’ spending on food categories in the naturalistic store were moderately-to-strongly correlated with their spending in the real store (range of correlation coefficients: 0⋅36–0⋅67, all P-values < 0⋅001). Naturalistic online grocery stores may offer a promising platform for conducting nutrition research.

What does our region need in order to strengthen public policies on sugar-sweetened beverages? decision-makers' dialogue

In order to prioritize public policies to reduce the consumption of sugar-sweetened beverages in Argentina, Brazil, El Salvador and Trinidad and Tobago and to identify information gaps related to the burden of disease attributable to their consumption, a policy dialogue was held with government members, civil society organizations, researchers and communicators from Latin American and Caribbean countries. Presentations and deliberative workshops were conducted using semi-structured data collection tools and group discussions. The prioritized interventions were tax increases, front labeling, restriction of advertising, promotion and sponsorship, and modifications regarding the school environment. The main perceived barrier was the interference from the food industry. This dialogue among decision-makers led to the identification of priority public policies to reduce the consumption of sugar-sweetened beverages in the region.

Practical Strategies for Improving Sustainability and Scale-up of Noncommunicable Disease-related Public Health Interventions: Lessons from the Better Health Program in Southeast Asia

Introduction

The Better Health Program has been addressing key health system issues in the prevention and control of noncommunicable diseases (NCDs) in Malaysia, Thailand, Vietnam, and the Philippines. As the program comes to an end, the sustainability and scaling-up of issues have assumed importance.

Objectives

The objective is to assess how well sustainability and scale-up strategies have been integrated into the design and implementation of a 3-year multicountry technical program; to explore enablers and barriers of sustainability and scaling up; and to identify practical strategies that can improve sustainability and scale-up of Better Health Program interventions.

Methods

We applied a staged approach to explore barriers and enablers and to identify practical strategies to improve sustainability and scale-up of four NCD interventions: community-based obesity prevention, front-of-pack labeling, local learning networks (LLNs), and NCD surveillance. We extracted evidence from peer-reviewed literature and local documents. We also conducted in-depth interviews with the implementation teams and key stakeholders. We conducted a thematic synthesis of the resulting information to identify practical strategies that improve sustainability and scale-up of the four interventions.

Results

Strong engagement of stakeholders at higher levels of the health system was identified as the main enabler, while limited funding and commitment from local governments were identified as a key barrier to sustainability and scale-up. Strengthening the social and institutional anchors of community health volunteers, enhancing evidence-based advocacy for front-of-pack labeling, trailblazing the LLN innovation, and securing the commitment of local governments in the implementation of NCD surveillance were among the key strategies for improving sustainability and scale-up of Better Health Program interventions in Malaysia, Thailand, Philippines, and Vietnam, respectively.

Conclusions

This study identified practical strategies for improving sustainability and scale-up of NCD-related interventions. Implementation of the strategies that had high priority and feasibility will improve the sustainability of critical elements of the program in the respective countries.

A five-country study of front- and back-of-package nutrition label awareness and use: patterns and correlates from the 2018 International Food Policy Study

OBJECTIVE

This study aimed to identify correlates of nutrition label awareness and use, particularly subgroup differences among consumers. Two label types were assessed: (1) nutrition facts tables (NFt) in Australia, Canada, Mexico, UK, and USA and (2) front-of-package (FOP) labels, including mandatory Guideline Daily Amounts (Mexico), voluntary Health Star Ratings (Australia) and voluntary Traffic Lights (UK).

DESIGN

Respondents were recruited using Nielsen Consumer Insights Global Panel (n 21 586) and completed online surveys in November-December 2018. Linear regression and generalised linear mixed models examined differences in label use and awareness between countries and label type based on sociodemographic, knowledge-related and dietary characteristics.

SETTING

Australia, Canada, Mexico, UK and USA.

PARTICIPANTS

Adults (≥18 years).

RESULTS

Respondents from the USA, Canada and Australia reported significantly higher NFt use and awareness than those in Mexico and the UK. Mexican respondents reported the highest level of FOP label awareness, whereas UK respondents reported the highest FOP label use. NFt use was higher among females, 'minority' ethnic groups, those with higher nutrition knowledge and respondents with 'adequate literacy' compared with those with 'high likelihood of limited literacy'. FOP label use was higher among those with a 'high likelihood of limited literacy' compared with 'adequate literacy' across countries.

CONCLUSIONS

Lower use of mandatory Guideline Daily Amount labels compared with voluntary FOP labelling systems provides support for Mexico's decision to switch to mandatory 'high-in' warning symbols. The patterns of consumer label use and awareness across sociodemographic and knowledge-related characteristics suggest that simple FOP labels may encourage broader use across countries.

Awareness, use and understanding of nutrition labels among adults from five countries: Findings from the 2018-2020 International Food Policy Study

Few studies have compared the effects of different front-of-package label (FOPL) systems in the 'real world'. This study assessed adults' awareness, use and understanding of nutrition facts labels (NFLs) and nationally implemented FOPLs such as Health Star Ratings (HSR), Traffic lights, and Guideline Daily Amounts (GDAs) in five countries, including before and after implementation of Mexico's warning FOPLs in 2020. Data were from the International Food Policy Study, an annual repeat cross-sectional study conducted in 2018-2020 among adults (N=64,032) in Australia, Canada, Mexico, the UK and the US. Self-reported awareness, use, and understanding of NFLs (in all five countries) and FOPLs (in Australia, Mexico, and UK) were assessed over time, between countries, and between NFLs and FOPLs. Most respondents in all countries reported seeing their country's NFLs (awareness) 'often' or 'all the time' across all three years, with one third to half of respondents using NFLs 'often' or 'all the time' (Australia: 43-45%; Canada: 47-50%; Mexico: 36-39%; UK: 32-34%; US: 47-49%), and approximately one half to two thirds finding NFLs 'easy' or 'very easy to understand' (56-57%; 67-69%; 51-54%; 48-51%; 70-71%). In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were highest among all countries with a FOPL (p<0.001), whereas awareness and use were lowest for Australia's HSR (p<0.001). In countries with FOPLs, self-reported understanding was higher for FOPLs than NFLs, except for the GDA FOPL in Mexico. Only modest changes were observed over time. Warning FOPLs were associated with greater levels of self-reported awareness, use and understanding among adults compared to NFLs and GDA-based FOPLs. FOPLs implemented on a voluntary basis, such as Australia's HSR, may be less likely to be seen and used.

School environments and obesity: a systematic review of interventions and policies among school-age students in Latin America and the Caribbean

BACKGROUND

The rapid rise in obesity rates among school children in Latin America and the Caribbean (LAC) could have a direct impact on the region's physical and mental health, disability, and mortality. This review presents the available interventions likely to reduce, mitigate and/or prevent obesity among school children in LAC by modifying the food and built environments within and around schools.

METHODS

Two independent reviewers searched five databases: MEDLINE, Web of Science, Cochrane Library, Scopus and Latin American and Caribbean Health Sciences Literature for peer-reviewed literature published from 1 January 2000 to September 2021; searching and screening prospective studies published in English, Spanish and Portuguese. This was followed by data extraction and quality assessment using the Cochrane risk-of-bias tool (RoB 2) and the Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I), adopting also the PRISMA 2020 guidelines. Due to the heterogeneity of the intervention's characteristics and obesity-related measurements across studies, a narrative synthesis was conducted.

RESULTS

A total of 1342 research papers were screened, and 9 studies were included; 4 in Mexico, and 1 each in Argentina, Brazil, Chile, Colombia, and Ecuador. Four studies reported strategies for modifying food provision; four other targeted the built environment, (modifying school premises and providing materials for physical activity); a final study included both food and built environment intervention components. Overall, two studies reported that the intervention was significantly associated with a lower increase over time in BMI/obesity in the intervention against the control group. The remaining studies were non-significant.

CONCLUSIONS

Data suggest that school environmental interventions, complementing nutritional and physical education can contribute to reduce incremental childhood obesity trends. However, evidence of the extent to which food and built environment components factor into obesogenic environments, within and around school grounds is inconclusive. Insufficient data hindered any urban/rural comparisons. Further school environmental intervention studies to inform policies for preventing/reducing childhood obesity in LAC are needed.

Comparing Latin American nutrient profile models using data from packaged foods with child-directed marketing within the Brazilian food supply

OBJECTIVES

This study aimed to examine and compare the extent to which different nutrient profile models (NPMs) from Latin America (LA) identify packaged foods and beverages with child-directed marketing sold in Brazil as being high in nutrients associated to the risk of non-communicable diseases (NCDs).

MATERIALS AND METHODS

In this cross-sectional study, we evaluated 3,464 foods found in the five largest Brazilian supermarkets. Child-directed marketing was coded using the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) protocol. Differences in medians of sugar, saturated fats, and sodium per 100 kcal in foods, with the presence and absence of child-directed marketing, were tested using the Mann-Whitney test. We compared six NPMs in LA and examined to what extent they targeted these products using prevalence ratios. Analyses were performed overall and by the degree of food processing according to the Nova food classification.

RESULTS

We found 1,054 packages with child-directed marketing. Among these, candies, cakes and pies, sauces and creams, and sugar-sweetened beverages were significantly higher in sugar, saturated fat, and sodium per 100 kcal than products that are not targeted at children (p < 0.05). Compared with PAHO and the Mexico models, the Brazilian NPMs would allow three times more ultra-processed foods to omit warnings for sodium (p < 0.05). The Uruguayan NPM also flagged fewer ultra-processed foods high in sodium (p < 0.05). The Brazilian model also allows four times more sugar-sweetened beverages and six times more dairy drinks to omit warnings for sugar than the Mexico and PAHO models. In comparison to all other NPMs, the Brazilian model showed the worst performance in identifying baked goods as high in sodium. Chile, Uruguay, and Peru models would also target significantly less sugar-sweetened beverages and high in at least one critical nutrient than PAHO and Mexico models.

CONCLUSION

Compared with other NPMs in LA, the NPM criteria adopted in Brazil are more permissive and less likely to inform consumers of the poor nutritional quality of ultra-processed foods and beverages with child-directed marketing.

A policy study on front-of-pack nutrition labeling in the Americas: emerging developments and outcomes

Poor nutrition is one of the leading causes of non-communicable diseases (NCDs), especially in the WHO Region of the Americas (AMRO). In response, international organisations recommend front-of-pack nutrition labelling (FOPNL) systems that present nutrition information clearly to help consumers make healthier choices. In AMRO, all 35 countries have discussed FOPNL, 30 countries have formally introduced FOPNL, eleven have adopted FOPNL, and seven countries (Argentina, Chile, Ecuador, Mexico, Peru, Uruguay and Venezuela) have implemented FOPNL. FOPNL has gradually spread and evolved to better protect health by increasingly adopting larger warning labels, contrasting background devices for better salience, using "excess" instead of "high in" to improve efficacy, and adopting the Pan American Health Organization's (PAHO) Nutrient Profile Model to better define nutrient thresholds. Early evidence illustrates successful compliance, decreased purchases and product reformulation. Governments still discussing and waiting to implement FOPNL should follow these best practices to help reduce poor nutrition related NCDs. Translated versions of this manuscript are available in Spanish and Portuguese in the supplementary material.

The influence of front-of-pack nutritional labels on eating and purchasing behaviors: a narrative review of the literature

BACKGROUND

Front-of-Pack Nutritional Labels are considered a useful tool to help consumers orient themselves in their food choices and direct their behavior toward a healthier diet. FOPNL development and use are part of a framework that includes cognitive, biological, hedonic and cultural aspects, able to affect consumers' eating and purchasing behavior.

AIM

Given the complexity of the matter, the aim of this narrative review is to analyze the combination of different factors that drive food choices and eating behaviors and to highlight some aspects that are not fully studied.

METHODS

The authors conducted the research using a top-down approach at first, followed by a bottom-up approach; starting with general considerations about the purchasing process, gradually narrowing the discussion to a specific sub-population, and finally extending the discussion back to more general reasonings about the direction to adopt in future, or at least to evaluate, for effective communication.

RESULTS

Biases and attitudes toward food products were found to regularly interfere with buying behavior patterns, making it impossible to standardize an average consumer. This reflects in current research, increasing the complexity of the topic. All determinants influencing food choices are often assessed individually rather than in a synergistic and multidimensional context, while the purchasing scenario is characterized by multiple stimuli to which the consumer is subjected. FOPNLs' impact on perceived healthiness has been studied in different conditions, but some population subgroups have not been sufficiently represented. In particular, the effect of FOPNLs on consumers suffering from eating disorders is understudied and needs further attention. Furthermore, some approaches can be compared to "negative nutrition" or "loss-framed communication", putting nutrients out of context, emphasizing losses more than gains and risking promoting negative feelings in consumers.

CONCLUSION

Due to the heterogeneity of studies, evidence on what works best in driving people to adopt lasting lifestyle changes is still mixed. Science communicators and policymakers should consider the possibility that a multi-component approach incorporating nutrition information and education may be a key strategy to promote consumers' self-consciousness and to support them in their cognitive efforts toward a healthy and sustainable diet.

LEVEL OF EVIDENCE

Level V, narrative review.

The estimated burden of ultra-processed foods on cardiovascular disease outcomes in Brazil: A modeling study

Introduction

Ultra-processed foods (UPF) have been associated with an increased risk of cardiovascular diseases (CVD). This study aimed to estimate CVD premature deaths, incident cases, and disability adjusted life-years (DALYs) attributable to the consumption of UPF in Brazilian adults in 2019.

Methods

A validated a comparative risk assessment model was adapted to estimate the burden of major CVD outcomes (coronary heart disease and stroke) attributable to the consumption of UPF in Brazilian adults aged 30 to 69 years. The model inputs included nationally representative data of the UPF contribution to the total energy of the diet, national official demographic records, CVD outcomes (incidence, deaths and DALYs) from the Global Burden of Disease study for 2019, and relative risks from meta-analysis studies.

Results

We estimated that approximately 19,200 premature deaths (95% uncertainty intervals - UI, 7,097 to 32,353), 74,900 new cases (95% UI, 25,983 to 128,725), and 883,000 DALYs/year (95% UI, 324,279 to 1,492,593) from CVD were attributable to the consumption of UPF in Brazil, corresponding to about 22% of the premature deaths from CVD and to 33% of the total premature all-cause deaths attributable to UPF intake among Brazilian adults. Reducing UPF consumption by 10% in the adult population would avert approximately 11% of the premature CVD deaths, equivalent to 2,100 deaths/year (95% UI, 697 to 4,511). A 20% reduction in UPF intake would avert approximately 21% of the premature CVD deaths or 4,100 deaths (95% UI, 1,413 to 8,047), and a 50% reduction in UPF intake would avert about 52% of the premature CVD deaths, corresponding to 9,900 deaths/year (95% UI, 3,682 to 17,820). If UPF consumption among adults was reduced to that of the first quintile of UPF intake in the baseline scenario, approximately 81% of the premature CVD deaths would be averted, corresponding to some 15,600 deaths/year (95% UI, 5,229 to 27,519).

Conclusion

Our study estimated a high burden of premature CVD outcomes attributable to the consumption of UPF in Brazil. Our findings support food policies aimed at reducing the consumption of UPF, such as fiscal and regulatory policies, which are imperative to prevent CVD in Brazil.

Did the sweetness of beverages change with the Chilean Food Labeling and Marketing Law? A before and after study

There has been a rapid proliferation of policies around the globe to reduce sugar consumption, yet there is little understanding as to whether these policies have led to changes in the overall sweetness of products, which is essential for understanding long-term effects on food preferences and intake. For example, the implementation of Chile’s Law on Food Labeling and Advertising led to decreases in the sugar content of non-alcoholic packaged beverages and increases in non-nutritive sweeteners (NNS) use in these beverages. Given that NNS have greater sweetness intensity than sugars, it is unclear what was the net effect of these changes on the sweetness of purchased beverages. Using longitudinal household purchase data (n &gt; 2,000 households), we measured the changes in the sweetness of beverage purchases after implementing the first phase of the Chilean law and examine if there were differences by key family sociodemographic variables. We developed three sweetness indices: (1) NNS sweetness, including the sweetness of the six NNS most consumed by Chileans; (2) total sugars sweetness, including the sweetness from total sugars; and (3) total sweetness, combining the sweetness from NNS and sugars. Using fixed-effects models, we compared the observed post-law purchases to a counterfactual based on pre-law trends. We found that NNS sweetness increased relative to the counterfactual, while total sugars sweetness decreased after the law. However, the absolute changes in NNS sweetness were almost entirely offset by the decreases in total sugar sweetness, leading to no change in the total sweetness of beverage purchases. Additionally, there were no differences in the sweetness changes by family sociodemographics. Our findings indicate that Chilean consumers are exposed to similar sweetness levels in their beverages after the law. Future research should explore whether sweetness also remained consistent in dietary intake.

Mortality prediction of the nutrient profile of the Chilean front-of-pack warning labels: Results from the Seguimiento Universidad de Navarra prospective cohort study

Background and aims

Front-of-Pack (FoP) nutrition labelling has been established as a policy, empowering consumers to choose healthy food options for preventing diet-related non-communicable diseases. This study aimed to evaluate the association between the nutrient profile underlying the Chilean warning label score and all-cause mortality and to conduct a calibration with the Nutri-Score in a large cohort of Spanish university graduates.

Materials and methods

This prospective cohort study analysed 20,666 participants (8,068 men and 12,598 women) with a mean (standard deviation) age of 38 years (±12.4) from the SUN cohort. Dietary food intake was assessed by a validated semi-quantitative food-frequency questionnaire at baseline and after 10 years of follow-up. The warning label score was calculated by considering the threshold of nutrients (sugar, saturated fat, and sodium) and energy density per 100 g/ml of product, as established by Chilean Legislation. Participants were classified according to quartiles of consumption of daily label score: Q1 (≤5.0), Q2 (>5.0–7.1), Q3 (>7.1–9.8), and Q4 (>9.8). Time-dependent, multivariable-adjusted Cox models were applied. To compare the performance of the warning label score and Nutri-Score to predict mortality, we used the Akaike information criterion (AIC) and Bayesian information criterion (BIC) methods.

Results

During a median of 12.2 years of follow-up, 467 deaths were identified. A higher score in the warning label values (lower nutritional quality) was associated with an increased risk of all-cause mortality [HR (95% CI) Q4 vs. Q1: 1.51 (1.07–2.13); p-trend = 0.010] and cancer mortality [HR (95% CI) Q4 vs. Q1: 1.91 (1.18–3.10); p-trend = 0.006]. However, no statistically significant association was found for cardiovascular mortality. Furthermore, the warning label score and Nutri-Score exhibited comparable AIC and BIC values, showing similar power of prediction for mortality.

Conclusion

A diet with a higher warning label score (>9.8 per day) was a good predictor of all cases and cancer mortality in a large Spanish cohort of university graduates. Also, the warning label score was capable to predict mortality as well as the Nutri-Score. Our findings support the validity of the warning label score as a FoP nutrition labelling policy since it can highlight less healthy food products.

Processed foods purchase profiles in urban India in 2013 and 2016: a cluster and multivariate analysis

OBJECTIVES

Sales of ultraprocessed foods (UPFs) and beverages are rising in low-income and middle-income countries. Such foods are often linked with weight gain, obesity, type 2 diabetes and hypertension-diseases that are on the rise in India. This paper analysed patterns in purchases of processed and UPF by urban Indian households.

SETTING

Panel data from Kantar -Worldpanel Division, India for 2013 and 2016.

PARTICIPANTS

58 878 urban Indian households.

METHODS

We used K-mean partition clustering and multivariate regression to analyse patterns in processed food (PF) and UPF purchase for urban India.

RESULTS

Three-quarters of urban Indian households purchased over ten PF groups. Mean per person annual PF purchase was 150 kg. UPF purchase was low at 6.4 kg in 2016 but had grown by 6% since 2013. Cluster analysis identified three patterns of consumption, characterised by low (54% of the households in 2016), medium (36%) and high (10%) PF purchase quantities. High cluster households purchased over three times as much PFs and UPF as the low cluster households. Notably, salt purchases were persistently high across clusters in both years (>3.3 kg), while sweet snack and ready-to-eat food purchases grew consistently in all clusters between 2013 and 2016. A positive and significant association was found between household purchases of UPF and their socioeconomic status as well as ownership of durables, such as refrigerator, colour television and washing machine (all p<0.001). Spatial characteristics including size of town (p<0.05) in which the household is located were also positively associated with the purchase of UPF.

CONCLUSION

Results suggest the need for tailored regional and city level interventions to curb the low but growing purchase of UPF. New data on obesity and rise of non-communicable diseases, the results are concerning given the links between lifestyle changes and the speed of urbanisation in Indian cities.

Comparison of two front-of-pack nutrition labels for Brazilian consumers using a smartphone app in a real-world grocery store: A pilot randomized controlled study

One of the suggestions for improving the understanding of food labels is implementing front-of-pack nutrition labeling (FoPNL), where nutritional information is objectively made available to consumers. Scientific data on the best FoPNL model to be adopted for the Brazilian population is still emerging, especially in real-world purchase situations. This study aims to evaluate/compare the proposed Brazilian and Mexican FoPNL systems, on different outcome measures, using an application, in dairy foods available in a supermarket aisle. This pilot randomized controlled trial in a real-world purchase situation was conducted in June/July 2021. A total of 230 participants were randomly allocated to one of the three study arms (Mexican and Brazilian FoPNL systems or control—nutritional information table and ingredients list). Using a smartphone, the participants scanned a product barcode and received the allocated FoPNL (with information about excessive added sugars, sodium, and/or saturated fat content) or the control. After, they answered questions related to our primary outcome (decision to buy or not to buy a product) and secondary outcomes (perceived healthiness, facilitation of a quick purchase decision, and identification of excess nutrients). The Mexican FoPNL system performed better in the primary outcome (3.74 ± 1.34) and “facilitation of a quick purchase decision” (3.59 ± 1.31), compared to the control (3.28 ± 1.45;p = 0.043 and 3.11 ± 1.42; p = 0.029). The Mexican FoPNL system performed better in supporting consumers to identify dairy foods, among the selected sample in this study, high in added sugars than the control (82.2% and 63.5% of correct answers, respectively; p = 0.009). For saturated fats, the Brazilian FoPNL resulted in 93.1% of correct answers against 48.2% for the control and 58.9% for the Mexican system (p ≤ 0.001). The Mexican FoPNL system facilitated consumer decision-making on when to buy or not to buy a selected dairy product and in helping to quickly decide which dairy products to buy, among the selected sample in this study, compared to the control. Considering the right answers of critical nutrients in excess or not, both models of FoPNL, delivered by a smartphone app, performed well.

Labels Affect Food Choices, but in What Ways?

To reduce obesity and thus promote healthy food choices, front-of-pack (FOP) labels have been introduced. Though FOP labels help identify healthy foods, their impact on actual food choices is rather small. A newly developed so-called swipe task was used to investigate whether the type of label used (summary vs. nutrient-specific) had differential effects on different operationalizations of the "healthier choice" measure (e.g., calories and sugar). After learning about the product offerings of a small online store, observers (N = 354) could, by means of a swipe gesture, purchase the products they needed for a weekend with six people. Observers were randomly assigned to one of five conditions, two summary label conditions (Nutri-Score and HFL), two nutrient (sugar)-specific label conditions (manga and comic), or a control condition without a label. Unexpectedly, more products (+7.3 products)-albeit mostly healthy ones-and thus more calories (+1732 kcal) were purchased in the label conditions than in the control condition. Furthermore, the tested labels had different effects with respect to the different operationalizations (e.g., manga reduced sugar purchase). We argue that the additional green-labeled healthy products purchased (in label conditions) "compensate" for the purchase of red-labeled unhealthy products (see averaging bias and licensing effect).

Front-of-Package Labels on Unhealthy Packaged Foods in India: Evidence from a Randomized Field Experiment

Policies to require front-of-package labels (FOPLs) on packaged foods may help Indian consumers to better identify foods high in nutrients of concern, including sugar, saturated fat, and sodium, and discourage their consumption, which are outcomes that are critical for preventing rises in diet-related non-communicable disease. The objective was to test whether FOPLs helped Indian consumers identify “high-in” packaged foods and reduce intentions to purchase them. We conducted an in-person randomized experiment (n = 2869 adults between ages 18 and 60 years old) in six states of India in 2022. Participants were randomized to one of five FOPLs: a control label (barcode), warning label (octagon with “High in [nutrient]”), Health Star Rating (HSR), Guideline Daily Amount (GDA), or traffic light label. Participants then viewed a series of packaged foods high in sugar, saturated fat, or sodium with the assigned FOPL, and rated product perceptions and label reactions. Fewer than half of participants in the control group (39.1%) correctly identified all products high in nutrient(s) of concern. All FOPLs led to an increase in this outcome, with the biggest differences observed for the warning label (60.8%, p < 0.001), followed by the traffic light label (54.8%, p < 0.001), GDA (55.0%, p < 0.001), and HSR (45.0%, p < 0.01). While no FOPLs led to a reduction in intentions to purchase the packaged foods, the overall pattern of results suggested that warning labels are the most effective FOPL to help Indian consumers identify unhealthy foods.

A scoping review of outdoor food marketing: exposure, power and impacts on eating behaviour and health

BACKGROUND

There is convincing evidence that unhealthy food marketing is extensive on television and in digital media, uses powerful persuasive techniques, and impacts dietary choices and consumption, particularly in children. It is less clear whether this is also the case for outdoor food marketing. This review (i) identifies common criteria used to define outdoor food marketing, (ii) summarises research methodologies used, (iii) identifies available evidence on the exposure, power (i.e. persuasive creative strategies within marketing) and impact of outdoor food marketing on behaviour and health and (iv) identifies knowledge gaps and directions for future research.

METHODS

A systematic search was conducted of Medline (Ovid), Scopus, Science Direct, Proquest, PsycINFO, CINAHL, PubMed, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and a number of grey literature sources. Titles and abstracts were screened by one researcher. Relevant full texts were independently checked by two researchers against eligibility criteria.

RESULTS

Fifty-three studies were conducted across twenty-one countries. The majority of studies (n = 39) were conducted in high-income countries. All measured the extent of exposure to outdoor food marketing, twelve also assessed power and three measured impact on behavioural or health outcomes. Criteria used to define outdoor food marketing and methodologies adopted were highly variable across studies. Almost a quarter of advertisements across all studies were for food (mean of 22.1%) and the majority of advertised foods were unhealthy (mean of 63%). The evidence on differences in exposure by SES is heterogenous, which makes it difficult to draw conclusions, however the research suggests that ethnic minority groups have a higher likelihood of exposure to food marketing outdoors. The most frequent persuasive creative strategies were premium offers and use of characters. There was limited evidence on the relationship between exposure to outdoor food marketing and eating behaviour or health outcomes.

CONCLUSIONS

This review highlights the extent of unhealthy outdoor food marketing globally and the powerful methods used within this marketing. There is a need for consistency in defining and measuring outdoor food marketing to enable comparison across time and place. Future research should attempt to measure direct impacts on behaviour and health.

“I Like the One With Minions”: The Influence of Marketing on Packages of Ultra-Processed Snacks on Children's Food Choices

Objective

This study aimed to assess the most consumed school snacks using the free listing and understand how marketing strategies on food labels influenced children's perceptions of snacks via focus groups.

Design

The study design involved free lists and semi-structured focus group interviews.

Setting

São Paulo, Brazil.

Participants

A total of 69 children were involved in this study.

Phenomenon of Interest

Children's perceptions of food labels.

Analysis

Food groups mentioned on the free lists were analyzed for their frequency and priority of occurrence. The focus groups were analyzed through content analysis.

Results

Juices and chips were the most salient snacks, with availability and flavor as reasons for their consumption. Children found images on labels appealing, which created a desire for the food, although could be deceptive. Snacks perceived as healthy were encouraged by parents, and children could more easily convince them to buy snacks with health claims. Colors and brands were important to catch children's attention and make the snack recognizable. Television commercials and mascots reinforced marketing strategies on labels.

Conclusions and Implications

Our results point to the need for public health strategies to deal with the obesity epidemic through creating and implementing specific legislation to regulate food labels to discourage the consumption of unhealthy snacks and prohibit food marketing targeted at children.

Changes in nonnutritive sweetener intake in a cohort of preschoolers after the implementation of Chile's Law of Food Labelling and Advertising

BACKGROUND

The first phase of Chile's Law of Food Labelling and Advertising showed important declines in the sugar content of packaged foods, but it is unknown whether the law led to an increase in nonnutritive sweetener (NNS) intake, particularly among preschool children.

OBJECTIVES

Estimate the changes in preschoolers' NNS intake after the first phase of the Chilean law.

METHODS

We used 24-h dietary recalls collected in 2016 (pre-law) and 2017 (post-law) from a cohort of preschoolers (n = 875). The primary caretaker was the respondent of the recalls. Information on NNS was obtained from nutrition facts panels collected annually and linked to dietary data. We used logistic regression to estimate the changes in the proportion of preschoolers who consume NNS and two-part models to estimate the changes in mean intake. We determined the percentage of children that surpassed the acceptable daily intake (ADI) of each NNS using the National Cancer Institute method.

RESULTS

The proportion of consumers of at least one NNS increased from 77.9% to 92.0% (p-value < 0.01). The mean intake increased for sucralose, aspartame, acesulfame-K and steviol glycosides (+20.3, +15.1, +6.1 and +3.3 mg/day, respectively). In addition, NNS dietary sources changed for sucralose and steviol glycosides, becoming industrialized juices and dairy beverages more relevant while tabletop NNS became less relevant. None of the children surpassed the ADI.

CONCLUSIONS

NNS intake increased in preschoolers after the first phase of a national policy that promoted sugar reformulation.

Why Don't You [Government] Help Us Make Healthier Foods More Affordable Instead of Bombarding Us with Labels? Maternal Knowledge, Perceptions, and Practices after Full Implementation of the Chilean Food Labelling Law

Experimental and real-life evaluations show that the use of front-of-package warning labels (FoP) in unhealthy foods is well understood and can modify people's behaviors. However, it is unclear whether these effects remain in the long term because of the risk of message fatigue. The purpose of this study is to explore after four years of implementation of the Chilean Food Labelling law people's dietary behavior and FoP labels attention. Nine focus groups of mothers (7-10 people each) of children (2-14 yo) were conducted in Santiago, Chile, and macrocodes were developed, combining an iterative process of deductive and inductive thematic analyses. We found that mothers experienced labels' fatigue but also had greater knowledge about nutrition and appreciation for more natural foods. This greater knowledge about better nutrition interferes with the perception that healthier and less processed foods are financial and physically inaccessible. The key role of schools as an environment for promoting healthier diets in children was strengthened by the mothers. These results suggest that policies based on providing consumer information need reinforcement campaigns to maintain their effectiveness and that we also need to advance policies to improve access and affordability of healthy foods to ensure better diets.

Expenditures on sugar-sweetened beverages in Jamaica and its association with household budget allocation

Background

Sugar-sweetened beverages (SSB) consumption is associated with overweight and obesity, which are important drivers for the increasing healthcare and other social costs. If expenditures on SSB decrease expenditures on other goods and services, such as education and healthcare, this “crowding-out” may have a lasting effect. The main objectives of this article are, first, to estimate the statistical association between the decision of spending in SSB and several households’ sociodemographic characteristics; and second, to estimate the association between the decision of buying SSB and budget allocation across categories in Jamaica.

Methods

Using the Jamaican Household Expenditure Survey 2004–2005 a generalized ordered probit model was estimated to examine the association between socioeconomic variables and the decision to spend on SSB. Seemingly Unrelated Regression Equations (SURE) of all the expenditure groups (except the SSB group) were used to estimate the association between the decision of buying SSB and budget allocation on other goods and services.

Results

Expenditures on SSB are negatively affected by the size of the household and the area of residence (rural households spend more on SSB than urban ones), while having a larger proportion of children (15 or younger) and having a larger total budget is associated to more expenditures on SSB. Households with positive expenditure on SSB allocate significantly less budget to “Healthcare” and “Education”, when compared to those who did not buy SSB.

Conclusions

SSB expenditures may displace expenditures in necessary goods and services, which implies that decreasing the proportion of budget spent on SSB may have important present and future consequences on poorer households’ human capital accumulation and future incomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12959-7.

Rebalancing the marketing of healthier versus less healthy food products

Jean Adams discusses the evidence around food marketing restrictions and how they may be an effective way to support public health.

Whole Grain and Refined Grains: An Examination of US Household Grocery Store Purchases

BACKGROUND

The health benefits related to intake of whole grain foods are well established. Consumption of whole grains in the US population is low, and whole grain content can vary greatly depending upon the specific products that are purchased.

OBJECTIVES

To examine the proportion of products purchased by US households containing whole grain and refined grain ingredients using time-specific food composition data, and examine whether purchases differ between income, race or ethnicity, and household make-up.

METHODS

Nationally representative Nielsen Homescan 2018 data were used. Each barcoded product captured in Nielsen Homescan 2018 was linked with ingredient information using commercial nutrition databases in a time-relevant manner. Packaged food products containing whole grain ingredients, refined grain ingredients, neither, or both were identified. The percentage of packaged food products containing whole grain and refined grain ingredients purchased by US households was determined overall, by demographic subgroup, and by food category.

RESULTS

The proportion of packaged food purchases containing refined grain ingredients was significantly higher than whole grain ingredients (30.9% compared with 7.9%; P < 0.0001). Lower income households and households with children purchased a significantly higher proportion of products containing refined grain ingredients, with no nutritionally meaningful racial or ethnic differences observed. Concerningly, across all demographic subgroups >90% of bread purchases contained refined grain ingredients, and the 5 categories with the largest proportion of whole grain ingredients contributed to <20% of overall US household packaged food purchases.

CONCLUSIONS

US households are purchasing a significantly higher proportion of packaged food products containing refined grain ingredients than whole grain ingredients. Future policy changes are needed to provide incentives and information (e.g., front-of-pack labels) to aid in encouraging manufacturers to increase whole grain product offerings while decreasing refined grain offerings, and to encourage consumers to substitute away from refined grain products toward whole grain products.

Front-of-Pack Labeling in Chile: Effects on Employment, Real Wages, and Firms' Profits after Three Years of Its Implementation

This study evaluates the impact of Chile’s innovative law on Food Labeling and Advertising, enacted in June 2016, on employment and real wages and profit margins for the food and beverage manufacturing sectors in the 2016–2019 period, using unique company-specific monthly data from Chile’s tax collection agency (measuring aggregate employment, real wages, average size of firms, and gross profit margins of the food and beverage manufacturing sector). Interrupted-time series analyses (ITSA) on administrative data from tax-paying firms was used and compared to synthetic control groups of sectors not affected by the regulations. ITSA results show no effect on aggregate employment nor on the average size of the firms, while they show negligible effects on real wages and gross margin of profits (as proportion of total sales), after the first two stages of the implementation (36 months), despite significant decreases in consumption in certain categories (sugar-sweetened beverages, breakfast cereals, etc.). Despite the large declines found in purchases of unhealthy foods, employment did not change and impacts on other economic outcomes were small. Though Chile’s law, is peculiar there is no reason to believe that if similar regulations were adopted elsewhere, they would have different results.

The nutrition transition to a stage of high obesity and noncommunicable disease prevalence dominated by ultra-processed foods is not inevitable

The Nutrition Transition model is presented with the nature and pace of change in key stages varying by location and subpopulations. At present, all high-income and many low- and middle-income countries are in a stage of the transition where nutrition-related noncommunicable diseases including obesity, type 2 diabetes, and hypertension are dominating adult morbidity and mortality and are very high or growing rapidly in prevalence. Some countries still have key subpopulations facing hunger and undernutrition defined by stunting or extreme thinness among adults. We call these double burden of malnutrition countries. All low- and middle-income countries face rapid growth in consumption of ultra-processed food and beverages, but it is not inevitable that these countries will reach the same high levels of consumption seen in high-income countries, with all the negative impacts of this diet on health. With great political and civil society commitment to adoption of policies shown in other countries to have improved dietary choices and social norms around foods, we can arrest and even reverse the rapid shift to diets dominated by a stage of high ultra-processed food intake and increasing prevalence of nutrition-related noncommunicable diseases.

Warning labels and interpretive nutrition labels: Impact on substitution between sugar and artificially sweetened beverages, juice and water in a real-world selection task

Effective strategies to reduce free sugar intake are needed. This study examined exposure to a warning label, independently and in conjunction with a Health Star Rating (HSR) label, on the selection of commercially available cold beverages with real decision-making stakes. Participants (N = 511, 47.9% female, mean = 21.7 (SD = 6.1) years) accessed an online convenience store app via an on-campus laptop to select one of 10 beverages (5 sugar-sweetened beverages [SSBs], 1100% fruit juice, 2 artificially sweetened beverages [ASBs] and 2 waters). The task was repeated with the addition of a warning label on high-sugar drinks in Round 2, and the addition of an HSR label on all drinks in Round 3. Participants were informed that they would receive a complementary drink (valued at <$5AUD) based on their selections following the completion of a brief questionnaire. Baseline results indicated that SSBs and waters were the most and least popular choices, respectively. For both males and females, there was a significant decrease in SSB selection (p < 0.001) and significant increase in ASB and water selection (p < 0.001) following the addition of warning labels to high-sugar drinks. The decreased selection of SSBs and increased selection of waters was maintained in Round 3 when HSR labels were added to all drinks. 100% fruit juice selection decreased with the addition of a warning label for females only (p < 0.01), but increased following the addition of a 4-star HSR label, for both males (p < 0.05) and females (p < 0.001). Warning labels reduced young adults' selection of SSBs and promoted substitution to water. The HSR reinforced this effect for the least healthy drinks. Increased water selection may be further enhanced by ensuring that warning label thresholds and HSR algorithms align to present consistent messaging.

The WHO South-East Asia Region Nutrient Profile Model Is Quite Appropriate for India: An Exploration of 31,516 Food Products

The rapid rise in prevalence of overweight/obesity, as well as high prevalence of type 2 diabetes and other nutrition-related noncommunicable diseases, has led the Food Safety and Standards Authority of India (FSSAI) to propose a front-of-package labeling (FOPL) regulation. An effective FOPL system applies a nutrient profile model that identifies foods high in sugar, sodium, and saturated fat that would receive a warning label for consumers to effectively discern between more and less healthy foods. Previous Nutrition Alchemy data collected by the food industry (n = 1306 products) estimated that approximately 96% of foods in India would have at least one warning label based on the FSSAI proposed FOPL. This near universal coverage of warning labels may be inaccurate and misleading. To address this, the current study compared two nutrient profile models, the WHO South-East Asia Region Organization (SEARO) and the Chilean Warning Octagon (CWO) Phase 3, applied to food products available in the Indian market from 2015-2020, collected through Mintel Global New Products Database (n = 10,501 products). Results suggest that 68% of foods and beverages would have at least one ' high-in' level warning label. This study highlights the need to include a more comprehensive sample of food products for assessing the value of warning labels.