Traffic Light System Can Increase Healthfulness Perception: Implications for Policy Making

Feasibility and Applicability of Implementing the Framework for Comprehensive Understanding of Structural Stigma in Mental Healthcare Systems: A Case Example of Nepal

INTRODUCTION

Mental health-related structural stigma is a multifaceted issue that significantly impacts access to quality mental healthcare, particularly in low-resource settings like Nepal. Therefore, there is a clear need to understand the complexities and identify gaps for targeted interventions through evaluations of various dimensions of structural stigma within healthcare systems. This study aimed to assess the feasibility and applicability of a mental health-related structural stigma measurement framework through its implementation in Nepal's healthcare system.

METHODS

A mixed-methods approach was employed, involving data mapping, key informant interviews and rating exercises with diverse stakeholders, including policymakers, health workers and people with lived experience (PWLEs). A visual analogue scale or Red/Amber/Green (RAG) rating scale was used to rate each indicator within the framework for the level of structural stigma based on the mapped information and their experiences. Data collection was carried out from May to June 2024.

RESULTS

Twenty key informants were interviewed for this exercise. Most indicators within the framework were endorsed as yellow, followed by red by participants referring to mid to high levels of structural stigma within the healthcare system. The findings also revealed that the stakeholders perceived the framework as acceptable and applicable for measuring mental health-related structural stigma in the healthcare system. However, challenges were noted regarding the clarity of some indicators, limitations of the three-coloured visual analogue rating and the need for comparator conditions.

CONCLUSION

The study underscores the measurement framework's value as a tool for identifying and addressing structural stigma in a mental healthcare system in a low-resource setting. Stakeholder engagement and contextual adaptation are crucial for its successful implementation. The insights gained can inform structural reforms and improve mental health service delivery, ultimately promoting greater equity and access for PWLEs.

PATIENT PUBLIC CONTRIBUTION

This framework being assessed in this study (FOCUS-MHS) was developed through extensive consultation with People with Lived Experiences (PWLEs) in Nepal and globally with the Global Mental Health Peer Network along with other stakeholders. Identification of documents, policies and studies, along with qualitative information mapped within the indicators, was informed by PWLEs involved in local study sites and by policymakers and health administrators. The reflections of the study participants-PWLEs, health administrators and policymakers, have guided further refinement of the framework for future use.

"Warning: ultra-processed": an online experiment examining the impact of ultra-processed warning labels on consumers' product perceptions and behavioral intentions

BACKGROUND

Nutrient content and degree of processing are complementary but distinct concepts, and a growing body of evidence shows that ultra-processed foods (UPFs) can have detrimental health effects independently from nutrient content. 10 + countries currently mandate front-of-package labels (FOPL) to inform consumers when products are high in added sugars, saturated fat, and/or sodium. Public health advocates have been calling for the addition of ultra-processed warning labels to these FOPLs, but the extent to which consumers would understand and be influenced by such labels remains unknown. We examined whether the addition of ultra-processed warning labels to existing nutrient warning labels could influence consumers' product perceptions and purchase intentions.

METHODS

In 2023, a sample of adults in Brazil (n = 1,004) answered an open-ended question about the meaning of the term "ultra-processed," followed by an online experiment where they saw four ultra-processed products carrying warning labels. Participants were randomly assigned to view either only nutrient warning labels or nutrient plus ultra-processed warning labels. Participants then answered questions about their intentions to purchase the products, product perceptions, and perceived label effectiveness.

RESULTS

Most participants (69%) exhibited a moderate understanding of the term "ultra-processed" prior to the experiment. The addition of an ultra-processed warning label led to a higher share of participants who correctly identified the products as UPFs compared to nutrient warning labels alone (Cohen's d = 0.16, p = 0.02). However, the addition of the ultra-processed warning label did not significantly influence purchase intentions, product healthfulness perceptions, or perceived label effectiveness compared to nutrient warning labels alone (all p > 0.05). In exploratory analyses, demographic characteristics and prior understanding of the concept of UPF did not moderate the effect of ultra-processed warning labels.

CONCLUSIONS

Ultra-processed warning labels may help consumers better identify UPFs, although they do not seem to influence behavioral intentions and product perceptions beyond the influence already exerted by nutrient warning labels. Future research should examine how ultra-processed warning labels would work for products that do and do not require nutrient warnings, as well as examine the benefits of labeling approaches that signal the health effects of UPFs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05842460. Prospectively registered March 15th, 2023.

Building Capacity and Advancing Regulatory Measures to Improve Food Environments in the Region of the Americas

Noncommunicable diseases (NCDs) are the main cause of death globally (70%) and in the Region of the Americas (80%), and poor diets are a leading driver of NCDs. In response, the Pan American Health Organization (PAHO)/World Health Organization (WHO) introduced a set of evidence-based regulatory measures to help countries improve diets through the reduced consumption of processed and ultra-processed foods. This paper aims to describe the needs of and propose actions for key actors to advance these measures. A workshop was designed to assess member states' regulatory capacity. A thematic analysis was conducted to analyze regional needs, successes and challenges. Thereafter, the Government Capacity-Building Framework for the prevention and control of NCDs was used to examine findings. The findings were organized in two sets: (i) PAHO/WHO actions to support member states and (ii) key actors' actions to advance regulatory policies. The results show notable regulatory progress across the Region of the Americas. However, progress differs between countries, with opportunities to strengthen measures in most countries, mainly in conflict of interest management. The results identified important actions to strengthen the regulatory capacity of PAHO/WHO member states. To maximize momentum for these actions, timelines must be identified, and political commitment can be boosted by applying human rights-based and food system-wide approaches.

How Promising Are "Ultraprocessed" Front-of-Package Labels? A Formative Study with US Adults

High levels of food processing can have detrimental health effects independent of nutrient content. Experts and advocates have proposed adding information about food processing status to front-of-package labeling schemes, which currently exclusively focus on nutrient content. How consumers would perceive "ultraprocessed" labels has not yet been examined. To address this gap, we conducted a within-subjects online experiment with a convenience sample of 600 US adults. Participants viewed a product under three labeling conditions (control, "ultraprocessed" label, and "ultraprocessed" plus "high in sugar" label) in random order for a single product. The "ultraprocessed" label led participants to report thinking more about the risks of eating the product and discouraging them from wanting to buy the product more than the control, despite not grabbing more attention than the control. The "ultraprocessed" plus "high in sugar" labels grabbed more attention, led participants to think more about the risks of eating the product, and discouraged them from wanting to buy the product more than the "ultraprocessed" label alone. "Ultraprocessed" labels may constitute promising messages that could work in tandem with nutrient labels, and further research should examine how they would influence consumers' actual intentions and behaviors.

Retrospective Analysis of Vitamin D Deficiency in an Adult Population of Arad County, Western Romania (2019-2022)

Vitamin D, a steroid hormone synthesized primarily in the skin upon exposure to ultraviolet light, is widely deficient across global populations. This study aimed to fill the data gap in Western Romania by measuring 25-hydroxy-vitamin D levels in a cohort of 7141 from Arad County. It was observed that women, younger adults (18-29 years), and older adults (70-79 years) had notably lower vitamin D levels compared to the average population. Additionally, there was a rise in vitamin D levels over the four-year span of 2018-2022, coinciding with the COVID-19 pandemic. Our research provides fresh data on those most susceptible to vitamin D deficiency and lays the groundwork for educational campaigns on vitamin D supplementation benefits.

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.

Assessing Biodiversity Conditions in Cocoa Agroforests with a Rapid Assessment Method: Outcomes from a Large-Scale Application in Ghana

Cocoa fields in West Africa traditionally kept other tree species to provide shade for cocoa trees and obtain food and other products. Measuring other trees is paramount to monitoring environmental conditions in cocoa agroforests, but it has been difficult to apply at a large scale. This study presents the results of a rapid assessment method applied in Ghana, developed to measure non-cocoa tree characteristics based on easily observed parameters using sample surveys and mapping tools. We collected data from over 8700 cocoa farms and evaluated their biodiversity performance based on 6 indicators classified according to recommended thresholds to benefit biodiversity conditions. Our results show that species richness, shade cover, and potential for tree succession have the lowest proportions of fields with the recommended levels, with variations among regions and districts. The methodological procedure allowed us to identify priority areas and indicators falling behind desirable thresholds, which can inform training and management approaches regarding biodiversity-friendly practices in cocoa fields tailored to the needs of the farmers. The analysis procedure was developed with open-access automated routines, allowing for easy updates and replication to other areas, as well as for other commodities, enabling comparisons at different spatial scales and contributing to monitoring biodiversity over time.

The Metabolic Matrix: Re-engineering ultraprocessed foods to feed the gut, protect the liver, and support the brain

Ultraprocessed food is established as a metabolic disruptor acting to increase adiposity, reduce mitochondrial efficiency, drive insulin resistance, alter growth, and contribute to human morbidity and mortality. Consumer packaged goods (CPG) companies are beginning to understand the detrimental impact of the food they market, and have employed substitution strategies to reduce salt, sugar, and fat. However, the harms of ultraprocessed foods are far more complex than any single component, and are not ameliorated by such simple substitutions. Over the past 2 years, the authors have worked with the Kuwaiti Danish Dairy Company (KDD) to conduct a comprehensive scientific evaluation of their entire commercial food and beverage portfolio. Assay of the macronutrients, micronutrients, additives, and toxins contained in each of their products was undertaken to determine the precise nature of each product's ingredients as well as the health impacts of processing. The authors formed a Scientific Advisory Team (SAT) and developed a tiered "Metabolic Matrix" founded in three science-based principles: (1) protect the liver, (2) feed the gut, and (3) support the brain. The Metabolic Matrix categorizes each product and provides the criteria, metrics, and recommendations for improvement or reformulation. Real-time consultation with the KDD Executive and Operations teams was vital to see these procedures through to fruition. This scientific exercise has enabled KDD to lay the groundwork for improving the health, well-being, and sustainability of their entire product line, while maintaining flavor, economic, and fiscal viability. This process is easily transferrable, and we are sharing this effort and its approaches as a proof-of-concept. The key aim of our work is to not only make ultraprocessed food healthier but to urge other food companies to implement similar analysis and reformulation of their product lines to improve the metabolic health and well-being of consumers worldwide.

Analysis of the policy process for the implementation of nutritional warning labels in Uruguay

OBJECTIVE

To analyse the process for the development and implementation of mandatory nutritional warning labels in Uruguay, in order to inform future nutrition policy making and strategic engagement by public health actors.

DESIGN

The study design drew on policy analysis methodology and case study research methodology. Two main sources of information were selected and analysed for the current study: eighteen official documents from the Uruguayan government and 259 news reports, published between June 2017 and February 2021.

SETTING

Uruguay, Latin America.

RESULTS

The Uruguayan Ministry of Public Health led a cross-sectoral working group composed of diverse governmental stakeholders, international organisations and the academia to develop the front-of-package nutrition labelling policy. A robust evidence-based approach, based on rigorous scientific knowledge generated in the country, was followed. However, changes in the systemic governing coalition as a consequence of a change in government led to a delay in the entry into force and changes in the regulation. The food industry was the main opponent to the warning label regulation and relied on widely reported corporate political activities to influence the policy process: information and messaging, legal action, policy substitution, opposition, fragmentation and destabilisation.

CONCLUSIONS

Key insights to inform future policy action in Uruguay and other jurisdictions were derived. Results stressed the importance of an evidence-based approach for policy design and the early engagement with actors from all the political system.

Wide and increasing suitability for Aedes albopictus in Europe is congruent across distribution models

The Asian tiger mosquito (Aedes albopictus), a vector of dengue, Zika and other diseases, was introduced in Europe in the 1970s, where it is still widening its range. Spurred by public health concerns, several studies have delivered predictions of the current and future distribution of the species for this region, often with differing results. We provide the first joint analysis of these predictions, to identify consensus hotspots of high and low suitability, as well as areas with high uncertainty. The analysis focused on current and future climate conditions and was carried out for the whole of Europe and for 65 major urban areas. High consensus on current suitability was found for the northwest of the Iberian Peninsula, southern France, Italy and the coastline between the western Balkans and Greece. Most models also agree on a substantial future expansion of suitable areas into northern and eastern Europe. About 83% of urban areas are expected to become suitable in the future, in contrast with ~ 49% nowadays. Our findings show that previous research is congruent in identifying wide suitable areas for Aedes albopictus across Europe and in the need to effectively account for climate change in managing and preventing its future spread.

World Heart Federation Policy Brief: Front-Of-Pack Labelling: Unhealthy Changes in the Global Food System

On World Food Day, the World Heart Federation calls on governments to implement mandatory front-of-pack food labels. The World Heart Federation (WHF) has developed a new policy brief on front-of-pack labelling (FOPL) aimed at improving global standards on nutrition and creating healthy food environments. Poor diet is responsible for more deaths worldwide than any other risk factor, and is a leading cause of obesity, type 2 diabetes, and cardiovascular disease (CVD). Global estimates suggest that almost 2.3 billion children and adults are overweight. The growing availability of ultra-processed foods, which contain high levels of sugars, sodium, saturated fats and refined carbohydrates, is a key contributor to the current obesity epidemic, which is increasingly impacting low- and middle-income countries. The WHF Front-of-Pack Labelling Policy Brief highlights front-of-pack labelling as a way to create environments where consumers are able to make better informed, healthier food choices for themselves and their families. Currently, a wide variety of front-of-pack labelling systems have been implemented by governments and food manufacturers around the world, with varying levels of success. The new WHF Policy Brief provides evidence-based, practical guidance that can be adapted to local contexts. It highlights that in order the be implemented successfully, FOPL systems must take into account consumer literacy and prevailing cultural norms around food and nutrition. FOPL must be mandatory, government-led, and accompanied by broad public nutrition education initiatives. The WHF Policy Brief includes a set of policy recommendations to give governments the tools they need to select the FOPL system that will best meet the needs of their populations, including recommendations on how to develop an effective FOPL programme, how to implement it successfully, and how to monitor and evaluate outcomes.

Effects on consumers' subjective understanding of a new front-of-pack nutritional label: a study on Italian consumers

Front-of-pack nutritional label (FOPL) systems have been developed worldwide to amplify and simplify nutritional information and induce healthier choices. This study explores consumers' internal reactions - in terms of subjective understanding and liking - to a new FOPL: the NutrInform Battery. The investigation aims to assess the clear comprehension by consumers of the information provided by the NutrInform Battery FOPL scheme, based on a sample of 200 Italian respondents, in a real-life setting, with products representative of the most widely consumed food categories, using a between-subject design. Participants were randomly assigned to one of the two conditions: products marked with NutrInform Battery or Nutri-Score labels. The results provided evidence of the effectiveness of NutrInform Battery in being perceived by consumers as an informative FOPL scheme. Specifically, consumers found NutrInform Battery more informative and helpful than Nutri-Score in terms of their understanding of the product composition.

Prevalence of Product Claims and Marketing Buzzwords Found on Health Food Snack Products Does Not Relate to Nutrient Profile

Growth in the consumer health and wellness industry has led to an increase of packaged foods marketed as health food (HF) products. In consequence, a ‘health halo’ around packaged HF has arisen that influences consumers at point-of-purchase. This study compared product claims (nutrient content claims (NCC), health claims and marketing ‘buzzwords’) displayed on packaged HF snack products sold in HF stores and HF aisles in supermarkets to equivalent products sold in regular aisles (RA) of supermarkets. Product Health Star Rating (HSR), nutrient profile and price were also compared. Data were collected for 2361 products from three supermarket chains, two HF chains and one independent HF store in Sydney, Australia. Mann-Whitney U tests compared the product claims, HSR, nutrient composition and unit ($) price. HF snacks displayed significantly more product claims per product compared to RA foods (HSR ≤ 2.5), median (IQR) 5.0(4.0) versus 1.0(2) and (HSR > 2.5) 4.0(4.0) versus 3.0(4), respectively (p < 0.001). A significantly different HSR was evident between HF and RA snack products, median 2.5(0) versus 2.0(1.5), respectively (p < 0.001). HF snacks cost significantly more than RA snack foods, irrespective of product HSR (p < 0.001). These findings support the recommendation for revised labelling regulations and increased education regarding consumers food label interpretation.

Conflicting Messages on Food and Beverage Packages: Front-of-Package Nutritional Labeling, Health and Nutrition Claims in Brazil

We assessed the prevalence of front-of-package (FoP) claims in the Brazilian packaged food supply and examined whether foods with claims were more likely to be high in critical nutrients. Using data from a random 30% subsample of 11,434 foods and beverages collected in the five largest food retailers in Brazil in 2017 (n = 3491), we classified claims into nutrition, health, and environment. We examined whether foods with claims were more likely to be high in critical nutrients using 95% confidence intervals. Claims were found in 41.2% of the products. Nutrition claims were the most prevalent (28.5%), followed by health (22.1%), and environment-related claims (5.2%). More than 85% of the breakfast cereals, granola bars, and nectars contained claims, which were found in 51% of the dairy beverages. Foods with nutrition claims were more likely to be high in critical nutrients (65.3%; 95% CI 62.3, 68.2% vs. 54.1% 95% CI 52.1, 56.0). Products with health (52.9%; 95% CI 49.3, 56.4% vs. 58.5%; 95% CI 56.6, 60.3) and environment-related claims (33.5%; 95% CI 27.0, 40.8% vs. 58.6%; 95% CI 56.9, 60.2%) were less likely to be high in critical nutrients. FoP claims are prevalent in Brazil, and nutrition claims are more likely to have a poorer nutritional profile. Policymakers should consider restricting the presence of claims on unhealthy products.

Anticipatory effects of the implementation of the Chilean Law of Food Labeling and Advertising on food and beverage product reformulation

This study evaluated the anticipated food and beverage product reformulation by industry before the Chilean Law of Food Labeling and Advertising (Law 20.606) was implemented in June 2016 requiring a front-of-package (FOP) warning label for products high in sodium, total sugars, saturated fats, and/or total energy. Fieldworkers photographed a purposive sample of packaged food and beverage products in February 2015 (n = 5421) and February 2016 (n = 5479) from six different supermarkets in Santiago, Chile. The same products collected in both years (n = 2086) from 17 food and beverage categories with added critical nutrients (nutrients of concern: sodium, total sugars, and saturated fats) were included in this longitudinal study. The average change in energy and critical nutrient content was estimated by category. The number of warning labels potentially avoided because of reformulation was determined. Between February 2015 and February 2016, no category experienced reductions >5% average change in energy or critical nutrient content; and some increased in critical nutrient content. Few products (<2%) would have avoided at least one warning label with reformulation. In a diverse sample of food and beverage products, there was minimal reformulation by industry in anticipation of the implementation of the 2016 Chilean Law of Food Labeling and Advertising.

Can front-of-pack nutrition labeling influence children's emotional associations with unhealthy food products? An experiment using emoji

Food products targeted at children are usually marketed using persuasive elements aimed at creating positive hedonic and emotional associations. For this reason, changes in children's emotional associations with unhealthy food products can discourage their consumption. In this context, the aim of the present study was to compare children's emotional associations with food products featuring different front-of-pack (FOP) nutrition labelling schemes. A total of 492 children (6-12 years old) were randomly divided into three groups, each of which evaluated a series of packages featuring different FOP nutrition labelling schemes: guidelines daily amount (GDA), traffic light system (TLS) and nutritional warnings. For each of the six packages and three unpackaged products, children were asked to select all the emoji from a list that described how they would feel eating the product. Data were analyzed using generalized linear models. FOP nutrition labelling significantly influenced the frequency of use five of the 16 emoji. In general, children who evaluated packages with directive and semi-directive schemes used emoji associated with positive emotions less frequently than those who evaluated packages with the GDA system. The effect of FOP nutrition labelling scheme on emotional associations was moderated by age and type of school. The effect of directive and semi-directive FOP nutritional schemes, in special nutritional warnings, tended to be higher for younger children and children from public schools. These results suggest that FOP nutrition labelling may contribute to discouraging consumption of products with high content of nutrients associated with non-communicable diseases among children.

Nutrient-Based Warning Labels May Help in the Pursuit of Healthy Diets

In this commentary we argue that the newest paradigm of front-of-package labels, represented by the characteristics found in the Chilean warning label, has the greatest potential to promote healthy diets compared with the Keyhole symbol, the multiple traffic light label, the Health Star Ratings system, and the 5-Color Nutrition label. Warning labels: (1) are consistent in the information they communicate; (2) discourage the purchase and consumption of noncore foods that characterize unhealthy diets; (3) are more likely to reinforce other regulatory measures; and (4) are more likely to encourage reformulation and are less likely to be used as a marketing tool by the food industry. Ongoing empirical evaluation of the impact of warning labels on consumer behavior and product reformulation is essential.