Immediate effects of the implementation of nutritional warnings in Uruguay: awareness, self-reported use and increased understanding

Parent Experiences With Warning Labels After Policy Implementation in Uruguay

OBJECTIVE

To explore the perception and experiences of parents of children and adolescents during the first year of the mandatory implementation of nutritional warning labels in Uruguay.

DESIGN

Qualitative research based on semistructured interviews.

SETTING

Montevideo, Uruguay.

PARTICIPANTS

Twenty-eight parents of children and adolescents.

PHENOMENON OF INTEREST

Perception of and experiences with warning labels, a front-of-pack nutrition labeling scheme that has become increasingly popular in Latin America.

ANALYSIS

Content analysis of the transcripts based on a deductive-inductive approach.

RESULTS

Interview transcripts evidenced high awareness, acceptance, and understanding of warning labels among parents of children and adolescents. Most participants reported considering warnings for decision making and changing their purchase decisions because of their implementation, particularly when choosing foods for their children. They reported their children were aware of and understood warnings but did not tend to take them into account when choosing foods.

CONCLUSIONS AND IMPLICATIONS

Results from the present work contribute to the growing body of literature showing the effectiveness of warning labels. Lack of interest or perceived benefits and structural barriers emerged as key motives for not using the warnings when making purchasing decisions, suggesting the need to develop additional strategies to increase policy effectiveness.

Implementing front-of-pack nutrition warning labels in Mexico: important lessons for low- and middle-income countries

OBJECTIVE

To analyse the implementation of front-of-pack nutrition labelling (FOPNL) in Mexico.

DESIGN

Review of publicly accessible documents, including legislative websites, news sources, and government, intergovernmental, and advocacy reports. Usage of the policy cycle model to analyse the implementation and evaluation stages of Mexico's General Health Law, amended with FOPNL (2019-2022).

RESULTS

In October 2019, the government published a draft modification of the Norma Oficial Mexicana (Official Mexican Standard) to regulate and enforce a new FOPNL warning label system. A 60-d public consultation period followed (October-December 2019), and the regulation was published in March 2020 and implementation began in October 2020. An analysis of nine key provisions of the Standard revealed that the food and beverage industry and its allies weakened some original provisions including health claims, warnings for added sweeteners and display areas. On the other hand, local and international public health groups maintained key regulations including the ban on cartoon character advertisements, standardised portions and nutrient criteria following international best practices. Early implementation appears to have high compliance and helped contribute to reformulating unhealthy products. Continued barriers to implementation include industry efforts to create double fronts and market their cartoon characters on social media and through digitalised marketing.

CONCLUSION

Early success in implementing the new FOPNL system in Mexico was the result of an inclusive and participatory regulatory process dedicated to maintaining public health advances, local and international health advocacy support, and continued monitoring. Other countries proposing and enacting FOPNL should learn from the Mexican experience to maintain scientifically proven best practices, counter industry barriers and minimise delays in implementation.

Bringing down barriers to children's healthy eating: a critical review of opportunities, within a complex food system

This narrative review revises the scientific evidence of recent years on healthy eating in children and adolescents, making sense of promising avenues of action, from a food system perspective. A conceptual framework is provided to better understand how eating habits of children and adolescents are shaped to identify key multisectoral approaches that should be implemented to promote healthier diets. The following influencing factors are discussed: individual factors (physiological and psychological factors, food preferences and food literacy competencies), factors within the personal and socio-cultural food environments, external food environments, and the supply chain. In each section, the main barriers to healthy eating are briefly discussed focussing on how to overcome them. Finally, a discussion with recommendations of actions is provided, anchored in scientific knowledge, and transferable to the general public, industry, and policymakers. We highlight that multidisciplinary approaches are not enough, a systems approach, with a truly holistic view, is needed. Apart from introducing systemic changes, a variety of interventions can be implemented at different levels to foster healthier diets in children through fostering healthier and more sustainable food environments, facilitating pleasurable sensory experiences, increasing their food literacy, and enhancing their agency by empowering them to make better food related decisions. Acknowledging children as unique individuals is required, through interpersonal interactions, as well as their role in their environments. Actions should aim to enable children and adolescents as active participants within sustainable food systems, to support healthier dietary behaviours that can be sustained throughout life, impacting health at a societal level.

The Role of Front-of-Package Nutrition Labels with and without Explanatory Videos on Parent and Child Food Choices

The aim of this research was to determine whether parent/child pairs choosing products from a grocery aisle labeled with front-of-package (FOP) nutrition labels would make more healthful choices than pairs who viewed the same items without labels, and to determine the added value of viewing an explanatory video before choosing. In this experiment, 175 parent/child pairs chose USD 20 worth of packaged foods and beverages from a grocery aisle in a research laboratory and were randomly assigned to see products that either did or did not have 0-4-star FOP labels, with more stars indicating more healthful products. Among those participants with access to FOP labels, half were randomly assigned to view a 30 s video explaining the FOP labels before selecting foods. Participants who saw the explanatory video before selecting among products with FOP labels chose foods with significantly more stars than participants who saw the FOP-labeled products without the video; however, there was no significant difference in mean stars on selected products between the group that saw the videos and the control group that saw neither the video nor FOP labels. We conclude that explaining new FOP labels to consumers may be necessary for the labels to prompt more healthful choices.

The estimated dietary and health impact of implementing the recently approved 'high in' front-of-package nutrition symbol in Canada: a food substitution scenario modeling study

Background

Front-of-pack labeling (FOPL) has been identified as a cost-effective policy to promote healthy food environments and to help consumers make healthier food choices. Consumer surveys report that after implementation of mandatory 'high in' FOPL symbols between 30 and 70% of consumers choose or were willing to choose products with fewer 'high in' symbols. Health Canada has recently published FOPL regulations that will require prepackaged food and beverages that meet or exceed thresholds for sodium, total sugars, or saturated fat to display a 'high in' FOPL nutrition symbol.

Objectives

The aims were to estimate the potential (1) dietary impact of substituting foods with similar foods that would display at least one less 'high in' symbol, and (2) the number of diet-related noncommunicable disease (NCD) deaths that could be averted or delayed due to estimated dietary changes.

Methods

Baseline and counterfactual intakes of sodium, total sugars, saturated fats, and energy were estimated among Canadian adults (n = 11,992) using both available days of 24 h-recall data from the 2015 Canadian Community Health Survey-Nutrition (CCHS). Similar foods to those reported in CCHS that would display at least one less 'high in' symbol (n = 239) were identified using a Canadian branded food composition database. Based on current FOPL consumer research, identified foods were substituted for 30, 50, and 70% of randomly selected CCHS-Nutrition adult participants and for all adult participants. Potential health impacts were estimated using the Preventable Risk Integrated ModEl.

Results

Mean dietary reductions of between 73 and 259 mg/day of sodium, 2.0 and 6.9 g/day of total sugars, 0.2 and 0.5 g/day of saturated fats, and 14 and 46 kcal/day of energy were estimated. Between 2,148 (95% UI 1,913-2,386) and 7,047 (95% UI 6,249-7,886) of deaths due to diet-related NCDs, primarily from cardiovascular diseases (70%), could potentially be averted or delayed if Canadians choose products with fewer 'high in' symbols.

Conclusion

Results suggest that FOPL could significantly reduce sodium and total sugar intakes among Canadian adults, the consequences of which could avert or delay an important number of diet-related NCD deaths. These findings provide relevant data to support the importance of the impending FOPL regulations.

Use of nutritional warning labels at the point of purchase: An exploratory study using self-reported measures and eye-tracking

Nutritional warning labels are gaining relevance in the region of the Americas as a policy tool to reduce information asymmetry and encourage healthier food choices. However, empirical evidence about consumer experiences with warning labels after implementation is still scarce. In this context, the aim of the present work was to explore the use of nutritional warning labels after policy implementation in Uruguay, using a combination of eye-tracking and self-reported data. The study was conducted in three supermarkets, in two regional capitals, 19 months after the entry into force of the policy. A total of 224 participants were intercepted while entering the facilities of the supermarket and asked to wear a mobile eye-tracker while making their food purchases. Then, they were asked a series of questions about their awareness and use of warning labels. Although participants reported high awareness and understanding of the labels, active search and use at the point of purchase was low. Only 6% of the consumers declared having actively searched for the warning labels and 7% fixated their gaze on the labels. The majority of the participants (72%) who declared having seen the warnings on a product, purchased it anyway. However, 56% declared having changed their food choice decisions as a consequence of the implementation of the policy. Participants' accounts about reasons for (not) taking into account the warning labels provide relevant insights for the development of strategies to encourage citizens to increase policy effectiveness and encourage healthier food choices.

Efficacy of front-of-pack warning label system versus guideline for daily amount on healthfulness perception, purchase intention and objective understanding of nutrient content of food products in Guatemala: a cross-over cluster randomized controlled experiment

BACKGROUND

Front-of-package warning labels (FOPWL) have been adopted in many countries aiming at reducing the consumption of unhealthy food and drink products and have also been considered in Guatemala. The aim of the study is to evaluate the efficacy of FOPWL versus Guidelines for Daily Amount (GDA) on products' healthfulness perception (HP), purchase intention (PI) and the objective understanding of the nutrient content (UNC) in Guatemala.

METHODS

Participants (children and adults) (n = 356) were randomly assigned to evaluate either FOPWL or GDA during a crossover cluster randomized experiment in rural and urban areas across 3 phases of exposure. During phase 1, participants evaluated mock-up images of single products (single task) and compared pairs of products within the same food category (comparison task) without any label. In phase 2, participants evaluated labels only (without any product), and during phase 3, they evaluated the same products and questions from phase 1, now depicting the assigned front-of-package label. We generated indicators for single-task questions and scores for comparison tasks, one for each HP, PI and UNC questions. We used intention-to-treat, difference-in-difference regression analysis to test whether exposure to FOPWL was associated with HP, PI and UNC, compared to GDA. We also tested models for children and adults and by area (rural/urban) separately adjusting for sociodemographic variables.

RESULTS

In single tasks, FOPWL significantly decreased the PI (β -18.1, 95%CI -23.3, -12.8; p < 0.001) and the HP (β -13.2, 95%CI -18.4, -7.9; p < 0.001) of unhealthy food products compared to GDA. In the comparison task, FOPWL significantly increased the UNC (β 20.4, 95%CI 17.0, 23.9; p < 0.001), improved PI towards healthier choices (OR 4.5, 95%CI 2.9, 7.0 p < 0.001) and HP (OR 5.6, 95%CI 2.8, 11.1; p < 0.001) compared to GDA. Similar results were found in children and adults and in urban and rural settings.

CONCLUSIONS

FOPWL reduces products' healthfulness perception and purchase intention, and increases understanding of products' nutrient content compared to GDA.

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.

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.

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.

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.

Do they really support "your freedom of choice"? FoPNL and the food industry in Brazil

Introduction

In 2020, Brazil approved the introduction of a new front-of-package nutrition labeling (FoPNL) in the format of a magnifying glass (MG) after years of discussion. There is currently a lack of understanding of the role of the food industry in that process. This study aimed to describe the corporate political activity (CPA) of the food industry and conflicts of interest situations, as they happened during the development and approval of a new FoPNL system in Brazil.

Materials and methods

We undertook bibliographical and documentary searches using material from food companies, trade associations and front groups involved in the regulatory process. We (1) collected information about the case study context, (2) collected data from documentary sources, and (3) prepared a synthesis of the results and a timeline of key events.

Results/Discussion

During the FoPNL regulatory process in Brazil, the food industry opposed the introduction of warning labels, a model supported by health authorities and implemented with success in other countries in Latin America. The food industry rather promoted a traffic-light labeling system, known to be less effective at guiding individuals to make healthier food choices. Later in the process, when it was evident that its preferred model would not be used, and a MG would rather be introduced, the food industry argued for the use of a different version of this FoPNL model. We found that the food industry, all along the process, was directly involved in and influenced the development of the FoPNL, by providing technical support, advising and lobbying policymakers. The food industry also established relationships with a consumer non-governmental organization and nutrition professional societies. The food industry also produced and disseminated information supporting its position in order to influence public opinion and high-level decision makers, and used the legal system to delay the process.

Conclusion

The FoPNL in Brazil is neither aligned with the recommendations of international health organizations nor with existing independent scientific evidence. The new FoPNL, as adopted in Brazil, reflects some of the preferences of the industry; it is likely that the influence of that sector during the legislative process was pivotal, even if its initial proposal was not adopted.

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.

Front-of-package nutrition labeling as a driver for healthier food choices: Lessons learned and future perspectives

This work aims to provide a comprehensive overview of the use of front-of-package nutritional labeling (FOPL), identify and characterize the major existing FOPL systems, examine the impact of FOPL systems on consumer behavior, and discuss future perspectives. The searched databases were PubMed, Scopus, and Web of Science, and papers in English, Portuguese, Spanish, and French were considered. The integrative review method was used, comprising 68 papers. The FOPL system from more than 47 countries from North America, South America, Africa, Europe, Australia, and Asia was included in this study. The two main ways to characterize FOPL are the level of interpretation and the type of information provided. Interpretive schemes (such as warning labels, multiple traffic lights, and Nutri-Score) appear to lead to better consumer understanding and support healthier food purchases. However, due to the differences among the results and the specificity of the contexts in which they are used, it is impossible to define one FOPL interpretation scheme superior to the others. Some potential factors that influence the effectiveness of FOPL on consumer attitudes have been identified, such as food taste, as a major intrinsic factor. Extrinsic factors, such as price, food category, cultural diversity, politics, and economics, were also relevant. The lack of availability of similar alternatives, lack of understanding of the importance of FOPL, and lower levels of income and education were also some cognitive and social aspects impairing FOPL effectiveness. Prospects for the United States, Europe, Brazil, Colombia, and Argentina were discussed.

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.

Two countries, similar practices: the political practices of the food industry influencing the adoption of key public health nutrition policies in Guatemala and Panama

OBJECTIVE

To identify the corporate political activity (CPA) strategies used by food industry actors during the development of two public health nutrition policies in Central America: Law #570 (taxation of sugar-sweetened beverages) in Panama and Bill #5504 (labelling and food marketing regulations) in Guatemala.

DESIGN

We triangulated data from publicly available information from 2018 to 2020, (e.g. industry and government materials; social media material) with semi-structured interviews with key stakeholders.

SETTING

Guatemala and Panama.

PARTICIPANTS

Government, academia and international organisations workers in health and nutrition.

DESIGN

CPA strategies were categorised according to an existing internationally used taxonomy into action-based, instrumental strategies (coalition management, information management, direct involvement and influence in policy, legal action) and discursive strategies.

RESULTS

Instrumental strategies included the establishment of relationships with policymakers and direct lobbying against the proposed public policies. Discursive strategies were mainly criticising on the unfounded ground that they lacked evidence of effectiveness and will imply negative impacts on the economy. The industry pointed at individuals for making their own food choices, in order to shift the focus away from the role of its products in contributing to ill health.

CONCLUSION

We provide evidence of the political practices used by the food industry to interfere with the development and implementation of public health nutrition policies to improve diets in Central America. Policymakers, public health advocates and the public should be informed about those practices and develop counterstrategies and arguments to protect the public and policies from the vested interests of the food industry.

Salt-related practices and its association with 24-hour urinary sodium excretion in an Uruguayan population cohort

Objectives.

To evaluate the association between knowledge, attitudes, and behavior (KAB) towards sodium use and sodium intake measured by 24-hour urinary collection in an adult cohort from Uruguay (Genotype Phenotype and Environment of Hypertension Study, GEFA-HT-UY).

Methods.

In a cross-sectional study (n = 159), a single 24-hour urinary sample, participants' physical, biochemical and blood pressure measurements and questionnaire data were collected. The association between KAB and 24-hour urinary sodium excretion was assessed using general linear models.

Results.

Mean age of participants was 49.8±15.5 years, 67.9% were women, and mean 24-hour urinary sodium excretion was 3.6±1.7 g/day. Although 90.6% of participants exceeded the maximum recommended intake as indicated by urinary sodium excretion, more than half misperceived their actual intake, reporting consuming “the right amount.” Almost three-quarters of the participants reported being concerned about the amount of sodium in their diet, but only 52.8% reported taking action to control it. Lack of procedural knowledge was observed. There was no association between KAB and sodium use and intake assessed by 24-hour urinary sodium excretion.

Conclusions.

The lack of association between KAB towards the use of sodium and intake measured by 24-hour urinary excretion reflects the need to support people with opportunities and motivations to reduce sodium consumption. Structural actions to promote an adequate food environment, such as the effective implementation of the front-of-package nutrition labeling in Uruguay, are positive steps.

A Qualitative Exploration of Parents' Food Choices During Early Childhood

OBJECTIVE

To explore parents' accounts of the goals they seek when choosing foods for their young children through the lens of goal-systems theory.

DESIGN

In-depth interviews with parents of children aged from 6 months to 5 years.

SETTING

Montevideo, Uruguay.

PARTICIPANTS

Forty-two parents (aged 19-44 years, 90% female).

PHENOMENON OF INTEREST

Parents' personal experiences, feelings, and opinions related to how they choose foods for their children.

ANALYSIS

Content analysis based on deductive-inductive coding.

RESULTS

Parents' accounts confirmed they intended to pursue different goals when choosing foods for their children. Health-related goals mainly motivated the selection of healthy foods, but they also drove the selection of some ultra-processed products because of misconceptions about their healthiness. Pleasure and enjoyment motivated the selection of ultra-processed products, whereas stress avoidance was associated with selecting convenient foods. The selection of unhealthy foods raised conflicts between goals, which were solved using goal shielding, changes in risk perception and/or compensatory health beliefs.

CONCLUSIONS AND IMPLICATIONS

Results point to the need for communication campaigns and community-based interventions to introduce changes in how ultra-processed products are conceptualized and increase the associations between healthy foods and children's pleasure and enjoyment to promote healthier eating patterns during infancy and early childhood.

Understanding of front of package nutrition labels: Guideline daily amount and warning labels in Mexicans with non-communicable diseases

One strategy for the prevention and treatment of non-communicable diseases (NCDs) is the implementation of the front-of-pack labeling (FoPL) in foods and beverages. In 2020, Mexico adopted the warning label system (WL) as a new public health policy, whose aim is to help consumers make healthier food choices. Previously, the Guideline Daily Amount (GDA) was the labelling used it. This paper aims to compare the understanding of two FoPL, the GDA and the WL, through the identification of unhealthy products in Mexicans with NCDs. We analyzed data from 14,880 Mexican adults older than 20 years old with NCDs (overweight-obesity (OW/O), self-reported diabetes mellitus 2 (DM2), or/and hypertension (HT), or/and dyslipidemia (Dys)). Participants were randomly assigned to one of two groups: the GDA labeling or WL. Each group had to respond to a survey and had to classify food products images as healthy or unhealthy according to the labelling system to which they were assigned. The correct classification was determined according to the criteria of Chile’s labeling nutrient profile stage 3. To evaluate the correct classification in each one of the groups we evaluated the differences in proportions. Logistic regression models were used to assess the likelihood to correctly classify the product according to participants’ number of diseases and WL information, taking GDA label as a reference. Participants who used the information contained in the GDA label misclassified food product labels in greater proportion (70%), mostly participants with three or more NCDs (participants with OW/O+ HT+ Dys, represent 42.3% of this group); compared with those who used WL (50%). The odds of correct classification of food products using WL image were two times greater compared to GDA image in participants with NCDs; being greater in participants with three or more NCDs. The study results highlight the usefulness of WL as it helps Mexicans with NCDs to classify unhealthy food products more adequately compared with GDA.

UN Food System Summit Fails to Address Real Healthy and Sustainable Diets Challenges

Evidence of the impacts of corporate food systems on people’s health raised concerns about the multiple outcomes of malnutrition and climate change, including commodities production and high consumption of ultra-processed food products. The COVID-19 pandemic overwhelms this scenario, highlighting the urgency for improvements in governance spaces and regulatory measures that can tackle the advance of large corporations, which act exclusively based on their private interests.

A human rights-based approach to non-communicable diseases: mandating front-of-package warning labels

Across the globe, the consumption of energy-dense and nutrient-poor foods and beverages has escalated rates of diet-related non-communicable diseases (NCDs), driven by deceptive marketing tactics from the food and beverage industry. The international community has increasingly recognized the need to provide consumers with accurate health information on food and beverage products as part of their right to health. In July 2020, the U.N. Special Rapporteur on the right to health released a powerful Statement calling for the adoption of front-of-package warning labeling to tackle NCDs. Just a few weeks after the Statement's release, the Pan American Health Organization published a report highlighting the relevance of front-of-package labeling as a policy tool for the prevention of NCDs in the Americas, demonstrating further support to this regulatory intervention.In this piece, we explain why front-of-package warning labeling should be part of a comprehensive strategy to promote healthier lives, delving into the human-rights aspects of front-of-package labels. In particular, we explore the role the food and beverage industry play in increasing the consumption of unhealthy foods and beverages, and the relevance of scientific evidence free from conflicts of interest to adequately protect the right to health and health-related rights.

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.

Marketing of commercial foods for infant and young children in Uruguay: sugary products, health cues on packages and fun social products on Facebook

OBJECTIVE

To analyse the content of the marketing of commercial foods for infants and young children on packages and social media.

DESIGN

Commercial foods targeted at children, regarded as potential breast-milk substitutes according to the Uruguayan breast-feeding standard, were considered: dairy products; teas, juices and bottled waters; glucose solutions; cereals and mixtures of fruits and vegetables. All the products sold at forty-four retail outlets were purchased. A Facebook search was performed to identify accounts of these products. For each account, all the content posted by the brands between July 2017 and July 2019 was recorded. The visual and textual information included in the packages and Facebook posts was analysed using content analysis. Products were classified using the nutrient profile model of the Pan American Health Organization.

SETTING

Montevideo, Uruguay.

RESULTS

Seventy-six unique commercial foods targeted at infants and young children were identified, 96 % of which were excessive in sugar. Packages frequently included textual and visual elements to convey health-related associations, including images of fruits and vegetables, nutrient content claims and endorsement logos. Ten Facebook accounts were identified, which generated 302 posts. Parents and caregivers were the main target audience of the posts, which mainly included content related to fun and social aspects of food consumption. Additionally, the posts frequently conveyed the idea that products would contribute to children's growth and development.

CONCLUSIONS

Results suggest the need to implement comprehensive regulations on the marketing of commercial foods targeted at children, regarded as potential breast-milk substitutes according to the Uruguayan breast-feeding standard.

Health gains through loss frames: Testing the effectiveness of message framing on citizens' use of nutritional warnings

The aim of the present work was twofold: (i) to evaluate the effect of nutritional warnings and health-related packaging cues (nutrient claim and images of natural foods) on consumers' food choices, and (ii) to evaluate the influence of two types of messages (gain-framed and loss-framed) aimed at encouraging the use of such warnings and packaging cues on food choices. A total of 510 participants were recruited using an advertisement on Facebook and Instagram targeted at Uruguayan adult users. Participants were randomly allocated to one of three experimental groups: control (n = 167), loss-framed messages (n = 177) and gain-framed messages (n = 166). Then, they completed a choice-conjoint task involving packages of crackers differing in three variables: nutritional warnings (present vs. absent), nutrient claim (present vs. absent) and images of seeds and wheat (present vs. absent). Warnings were the most relevant package element driving choices, even when participants were not exposed to any type of message. Exposure to loss-framed messages led to changes in the relative importance attached to the package characteristics, whereas gain-framed messages did not. Graphic pieces conveying messages encouraging the use of nutritional warnings by stressing the negative consequences of excessive consumption of sugar, fat, and sodium increased the relative importance attached to nutritional warnings and decreased the relative importance attached to health-related cues (nutrient claims and images of seeds and wheat). These results suggest that public awareness campaigns aimed at encouraging citizens to use nutritional warnings should emphasize the negative health consequences of excessive intake of sugar, fat, and sodium.

Listening to the voices of adolescents for the design of strategies to promote healthy eating: an exploratory study in a Latin American country

OBJECTIVE

To explore adolescents' views about the foods they consume and to identify their ideas about strategies to encourage healthier eating habits.

DESIGN

Individual questionnaires based on open-ended questions and group discussions (6-8 participants) were used to address the objectives. Data were analysed using content analysis based on deductive-inductive coding.

SETTING

Montevideo and its metropolitan area (Uruguay, Latin America).

PARTICIPANTS

Totally, 102 adolescents (aged between 11 and 15 years, 52 % female) recruited at two educational institutions.

RESULTS

Adolescents reported frequently consuming ultra-processed products and fast food although they were perceived as bad for their health, whereas they reported an infrequent consumption of fruits and vegetables. Multifaceted strategies to promote healthy eating habits emerged from adolescents' accounts, including public awareness campaigns, nutrition education programmes, nutrition label standards and regulations, and changes in food availability and affordability.

CONCLUSIONS

Results from the present work suggest that co-creation with adolescents may be an effective way to inform the development of strategies to promote healthier eating habits. The strategies suggested by adolescents were mainly focused on behaviour change communication, who emphasised the importance of social media and the involvement of celebrities and influencers. The need for educational and communication strategies to raise awareness of the social and environmental drivers of eating patterns among adolescents was identified.

Do nutritional warnings encourage healthier choices on food ordering websites? An exploratory experimental study in Uruguay

OBJECTIVE

To evaluate if the inclusion of nutritional warnings in food ordering websites can discourage consumers from purchasing foods with excessive content of nutrients associated with non-communicable diseases (NCD).

DESIGN

Participants were randomly assigned to one of the two experimental conditions: control (n 225) or nutritional warnings (n 222). Nutritional warnings corresponded to separate black octagonal signs containing the word 'Excess' followed by the corresponding nutrient: total fat, saturated fat, sugars and sodium. Participants were asked to purchase a lunch for themselves using a simulated food ordering website.

SETTING

Online study in Uruguay.

PARTICIPANTS

Convenience sample of 447 Uruguayan participants, recruited using social media.

RESULTS

In the control condition, 76 % of the participants selected a dish or a beverage with excessive content of at least one nutrient in the simulated food ordering website. When nutritional warnings were included, this percentage significantly decreased to 62 % (P = 0·002). In addition, nutritional warnings caused a significant reduction in the percentage of participants who selected dishes with excessive content of total fat: 50 % v. 62 % (P = 0·012).

CONCLUSIONS

Results from the present work provide preliminary evidence that the inclusion of nutritional warnings in food ordering websites could discourage consumers from selecting dishes and beverages with excessive content of nutrients associated with NCD.