An assessment of the potential health impacts of food reformulation

Lessons for strengthening policymaking for obesity and diet-related noncommunicable disease prevention: A narrative synthesis of policy literature from the Western Pacific Region

Obesity and diet-related noncommunicable diseases (NCDs) have a profound impact on individuals, households, health care systems, and economies in low- and middle- income countries (LMICs), with the Western Pacific Region experiencing some of the highest impacts. Governments have committed to improving population diets; however, implementation challenges limit effective policy action. We undertook meta-narrative synthesis of the academic literature and used theories of policymaking and implementation to synthesize current knowledge of issues affecting the adoption and implementation of policies to prevent obesity and diet-related NCDs in LMICs in the Western Pacific Region. We found that political leadership and management of food and nutrition policies often diluted following policy adoption, and that nutrition and health advocates find it difficult to enforce policy compliance from actors outside their sectors. Opportunities for strengthening implementation of food and nutrition policies in the Western Pacific include (1) improved and earlier engagement between health policymakers and implementing agencies; (2) focusing on the need for increased accountability from governments, including through effective engagement and organization of actor networks, knowledge sharing, and in highlighting where stronger action is required; and (3) identifying and building the strategic capacities of policy actors in framing, advocacy, coalition-building, knowledge translation, and leadership.

Global nutritional challenges of reformulated food: A review

Food reformulation, the process of redesigning processed food products to make them healthier, is considered a crucial step in the fight against noncommunicable diseases. The reasons for reformulating food vary, with a common focus on reducing the levels of harmful substances, such as fats, sugars, and salts. Although this topic is broad, this review aims to shed light on the current challenges faced in the reformulation of food and to explore different approaches that can be taken to overcome these challenges. The review highlights the perception of consumer risk, the reasons for reformulating food, and the challenges involved. The review also emphasizes the importance of fortifying artisanal food processing and modifying microbial fermentation in order to meet the nutrient requirements of people in developing countries. The literature suggests that while the traditional reductionist approach remains relevant and yields quicker results, the food matrix approach, which involves engineering food microstructure, is a more complex process that may take longer to implement in developing economies. The findings of the review indicate that food reformulation policies are more likely to succeed if the private sector collaborates with or responds to the government regulatory process, and further research is conducted to establish newly developed reformulation concepts from different countries. In conclusion, food reformulation holds great promise in reducing the burden of noncommunicable diseases and improving the health of people around the world.

Estimating Canadian sodium intakes and the health impact of meeting national and WHO recommended sodium intake levels: A macrosimulation modelling study

BACKGROUND

Cardiovascular diseases (CVDs) are the second leading cause of total deaths in Canada. High blood pressure is the main metabolic risk factor for developing CVDs. It has been well established that excess consumption of sodium adversely affects blood pressure. Canadians' mean sodium intakes are well above recommended levels. Reducing dietary sodium intake through food reformulation has been identified as a cost-effective intervention, however, dietary sodium intake and the potential health impact of meeting recommended sodium intake levels due to food reformulation have not been determined in Canada.

OBJECTIVE

This study aimed to 1) obtain robust estimates of Canadians' usual sodium intakes, 2) model sodium intakes had foods been reformulated to align with Health Canada's sodium reduction targets, and 3) estimate the number of CVD deaths that could be averted or delayed if Canadian adults were to reduce their mean sodium intake to recommended levels under three scenarios: A) 2,300 mg/d-driven by a reduction of sodium levels in packaged foods to meet Health Canada targets (reformulation); B) 2,000 mg/d to meet the World Health Organization (WHO) recommendation; and C) 1,500 mg/d to meet the Adequate Intake recommendation.

METHODS

Foods in the University of Toronto's Food Label Information Program 2017, a Canadian branded food composition database, were linked to nationally representative food intake data from the 2015 Canadian Community Health Survey-Nutrition to estimate sodium intakes (and intakes had Health Canada's reformulation strategy been fully implemented). The Preventable Risk Integrated ModEl (PRIME) was used to estimate potential health impact.

RESULTS

Overall, mean sodium intake was 2758 mg/day, varying by age and sex group. Based on 'reformulation' scenario A, mean sodium intakes were reduced by 459 mg/day, to 2299 mg/day. Reducing Canadians' sodium intake to recommended levels under scenarios A, B and C could have averted or delayed 2,176 (95% UI 869-3,687), 3,252 (95% UI 1,380-5,321), and 5,296 (95% UI 2,190-8,311) deaths due to CVDs, respectively, mainly from ischaemic heart disease, stroke, and hypertensive disease. This represents 3.7%, 5.6%, and 9.1%, respectively, of the total number of CVDs deaths observed in Canada in 2019.

CONCLUSION

Results suggest that reducing sodium intake to recommended levels could prevent or postpone a substantial number of CVD deaths in Canada. Reduced sodium intakes could be achieved through reformulation of the Canadian food supply. However, it will require higher compliance from the food industry to achieve Health Canada's voluntary benchmark sodium reduction targets.

Sodium in the New Zealand diet: proposed voluntary food reformulation targets will not meet the WHO goal of a 30% reduction in total sodium intake

PURPOSE

To simulate the potential impact of the HeartSAFE 2020 programme, a food reformulation initiative by the New Zealand (NZ) Heart Foundation, on sodium intake in the NZ adult population.

METHODS

A representative sample of NZ adults aged 15 years and older completed a 24-h diet recall survey, with 25% of participants completing a second diet recall, in the 2008/09 New Zealand Adult Nutrition Survey (n = 4721). These data were used to estimate sodium intakes of participants. The effect of altering the sodium content of 840 foods in 17 categories and 35 sub-categories included in the NZ HeartSAFE 2020 programme was simulated. The simulated sodium intake reductions in each food sub-category for the entire sample were calculated. Using sampling weights, simulated reductions in population sodium intake and by sociodemographic subgroups were also analysed.

RESULTS

Sodium intake from foods included in the HeartSAFE 2020 programme was 1307 mg/day (95% CI 1279, 1336) at baseline. After applying the HeartSAFE 2020 targets, potential sodium intake was 1048 mg/day (95% CI 1024, 1027). The absolute sodium reduction was 260 mg/day (95% CI 252, 268), corresponding to 20% sodium reduction for the foods included in the NZ HeartSAFE programme.

CONCLUSION

Current sodium targets featured in the NZ HeartSAFE programme will not meet the 30% sodium intake reduction set out by the WHO Global Action Plan. A more comprehensive strategy consistent with the WHO SHAKE Technical Package is needed to advance the goal of sodium intake reduction.

The relationship between voluntary product (re) formulation commitments and changes in the nutritional quality of products offered by the top packaged food and beverage companies in Canada from 2013 to 2017

Background

Food companies shape Canada’s food supply through voluntary actions and commitments concerning product (re)formulation; however, the extent that these initiatives translate into actual improvements in nutritional quality is unclear. This study examined changes in the nutritional quality of products offered by the top 22 packaged food and beverage companies in Canada from 2013 to 2017, in relation to the strength of their product (re) formulation actions and commitments.

Methods

The Food Company Reformulation (FCR) scoring tool was used to quantify the strength of companies’ reported recent actions and commitments to reduce energy and nutrients of concern in their products, with higher scores signifying stronger voluntary actions/commitments. Nutritional information for products was sourced from the University of Toronto FLIP 2013 (n = 6490) and 2017 (n = 8277) databases (n = 4074 matched products). Changes in product healthfulness were assessed using the Health Star Rating (HSR) system (with higher HSRs denoting healthier products) and calories, sodium, saturated fat, trans fat, and total and free sugar levels per 100 g/mL. Generalized estimating equations examined changes in nutritional quality in relation to FCR scores.

Results

Overall, mean HSRs increased significantly for 5 companies’ product portfolios and were reduced in 1 company’s product portfolio. There were significant reductions in calories, sodium, saturated fat in 2 companies’ portfolios and increases in 4, 3, and 8 companies’ portfolios, respectively. Trans fats increased significantly in 2 companies’ portfolios. Total and free sugars decreased significantly in 4 and 5 companies’ portfolios, respectively, and increased in 1 company’s portfolio. There was little change in the healthfulness of matched products. Higher FCR scores were not associated with greater increases in HSRs, or reductions in calories or nutrient amounts. FCR scores were negatively associated with HSRs and positively associated with total and free sugars. No relationship was observed between FCR scores and calories, sodium, saturated fat or trans fat.

Conclusions

Reporting stronger voluntary product (re) formulation actions and commitments was not associated with greater improvements in the healthfulness of products offered by Canada’s leading packaged food and beverage companies from 2013 to 2017, suggesting a need for stronger industry initiatives or mandatory government interventions to improve the healthfulness of the food supply.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12683-2.

Scaling-up food policies in the Pacific Islands: protocol for policy engagement and mixed methods evaluation of intervention implementation

BACKGROUND

There is a crisis of non-communicable diseases (NCDs) in the Pacific Islands, and poor diets are a major contributor. The COVID-19 pandemic and resulting economic crisis will likely further exacerbate the burden on food systems. Pacific Island leaders have adopted a range of food policies and regulations to improve diets. This includes taxes and regulations on compositional standards for salt and sugar in foods or school food policies. Despite increasing evidence for the effectiveness of such policies globally, there is a lack of local context-specific evidence about how to implement them effectively in the Pacific.

METHODS

Our 5-year collaborative project will test the feasibility and effectiveness of policy interventions to reduce salt and sugar consumption in Fiji and Samoa, and examine factors that support sustained implementation. We will engage government agencies and civil society in Fiji and Samoa, to support the design, implementation and monitoring of evidence-informed interventions. Specific objectives are to: (1) conduct policy landscape analysis to understand potential opportunities and challenges to strengthen policies for prevention of diet-related NCDs in Fiji and Samoa; (2) conduct repeat cross sectional surveys to measure dietary intake, food sources and diet-related biomarkers; (3) use Systems Thinking in Community Knowledge Exchange (STICKE) to strengthen implementation of policies to reduce salt and sugar consumption; (4) evaluate the impact, process and cost effectiveness of implementing these policies. Quantitative and qualitative data on outcomes and process will be analysed to assess impact and support scale-up of future interventions.

DISCUSSION

The project will provide new evidence to support policy making, as well as developing a low-cost, high-tech, sustainable, scalable system for monitoring food consumption, the food supply and health-related outcomes.

Regulation and Consumer Interest in an Antioxidant-Enriched Ham Associated with Reduced Colorectal Cancer Risks

An economic experiment was conducted in France in 2020 to evaluate consumer attitudes toward two ham products associated with different colorectal cancer risks. We focused specifically on comparing a conventional ham and a new hypothetical antioxidant-enriched ham with a reduced risk of provoking colorectal cancer. Study participants were given descriptions of the two hams before carrying out successive rounds of willingness-to-pay (WTP) assessments. The results show that WTP was higher for the antioxidant-enriched ham than for the conventional ham. WTP estimates were also impacted by providing additional information about the reduction in colorectal cancer risk associated with the antioxidant-enriched ham. Based on the participants' WTP, we came up with ex ante estimates for the social impacts of introducing the antioxidant-enriched ham onto the market, and we suggest that it would be socially optimal to promote the product. Competition arising from pre-existing product labelling and marketing assertions could greatly limit the market potential of antioxidant-enriched ham, which suggests that alternative approaches may be necessary, such as regulations mandating antioxidant enrichment. These results also concern all countries with high levels of meat consumption.

Development and Validation of the General Dietary Behavior Inventory (GDBI) in Scope of International Nutrition Guidelines

Unhealthy eating is associated with various diseases, such as cardiovascular, neurodegenerative, or oncological. There are neither economical nor behavior-related questionnaires available in the German language to assess general dietary behavior. Therefore, the aim of this validation study was to develop an instrument considering these aspects and verifying its construct and criterion validity. The new questionnaire is based on the general nutrition recommendations of the World Health Organization and the German Nutrition Society. It consists of 16 items that contrast dietary behaviors on a semantic differential scale. Our German-speaking convenience sample consisted of 428 participants. The construct validity of the General Dietary Behavior Inventory (GDBI) could be confirmed by examining convergent and discriminant validity. Furthermore, criterion validity was confirmed (significant negative correlations with body weight, Body Mass Index, and positive correlations with physical/mental health as well as life satisfaction). A cluster analysis revealed two different dietary behavior clusters representing a rather healthy and a rather unhealthy dietary behavior cluster. The results indicate that the GDBI is a validated and economical instrument to assess general dietary behavior. In practical research, this questionnaire helps to assess dietary behavior and to derive interventions for a healthy dietary behavior in concordance with international nutrition recommendations.

The drivers, trends and dietary impacts of non-nutritive sweeteners in the food supply: a narrative review

Poor diets, including excess added sugar consumption, contribute to the global burden of disease. Subsequently, many nutrition policies have been implemented to reduce added sugar intake and improve population health, including taxes, education, labelling and environmental interventions. A potential consequence of these policy actions is the substitution of added sugars with non-nutritive sweeteners (NNS) in a variety of foods and beverages. NNS are used to reduce the energy and sugar content of foods and beverages while maintaining their palatability. Evidence of the toxicological risks of NNS is inconsistent, though concerns have been raised over the potential substitution effects of ultra-processed foods containing NNS for whole foods. This review aimed to provide an overview of current NNS food supply and consumption patterns, assess added sugar-reduction policies and their impact on NNS, and determine the impact of NNS on food choice, energy intake and diet quality. NNS are widely available in a variety of products, though most commonly in carbonated beverages, dairy products, confectionery, table-top sweeteners and fruit drinks. However, the longitudinal trends of different product categories, and differences between geographies and economy-income levels, require further study. Few studies have examined NNS consumption trends globally, though an increase in NNS consumption in beverages has been observed in some regions. Research examining how the increased availability of low-sugar, NNS-containing products affects global dietary patterns is limited, particularly in terms of their potential substitution effects.

Reformulation of Packaged Foods and Beverages in the Colombian Food Supply

Public discussion, advocacy, and legislative consideration of policies aimed at reducing consumption of processed foods, such as sugar-sweetened beverage (SSB) taxes and mandatory front-of-package (FOP) warning labels, may stimulate product reformulation as a strategy to prevent regulation. In Colombia, there have been major legislative pushes for SSB taxes and FOP labels, although neither has passed to date. In light of the ongoing policy debate and successful implementation of similar policies in Peru and Chile, we explored manufacturer reformulation in the Colombian food supply. We compared the quantities of nutrients of concern (including sugar, sodium, and saturated fat) from the nutrition facts panels of the same 102 packaged foods and 36 beverages from the top-selling brands in Colombia between 2016 and 2018. Our analyses showed a substantial decrease in median sugar content of beverages, from 9.2 g per 100 mL to 5.2 g per 100 mL, and an increase in the percentage of beverages containing non-nutritive sweeteners (NNS), from 33% to 64% (p = 0.003). No meaningful changes in the quantities of nutrients of concern among foods were observed. Our findings suggest little reformulation has occurred in Colombia in the absence of mandatory policies, except for the substitution of sugar with NNS among beverages.

Effects of Menu Labeling Policies on Transnational Restaurant Chains to Promote a Healthy Diet: A Scoping Review to Inform Policy and Research

There is insufficient evidence that restaurant menu labeling policies are cost-effective strategies to reduce obesity and diet-related non-communicable diseases (NCDs). Evidence suggests that menu labeling has a modest effect on calories purchased and consumed. No review has been published on the effect of menu labeling policies on transnational restaurant chains globally. This study conducted a two-step scoping review to map and describe the effect of restaurant menu labeling policies on menu reformulation. First, we identified national, state, and municipal menu labeling policies in countries from global databases. Second, we searched four databases (i.e., PubMed, CINHAL/EBSCO, Web of Science, and Google Scholar) for peer-reviewed studies and gray-literature sources in English and Spanish (2000–2020). Step 1 identified three voluntary and eight mandatory menu labeling policies primarily for energy disclosures for 11 upper-middle and high-income countries, but none for low- or middle-income countries. Step 2 identified 15 of 577 studies that met the inclusion criteria. The analysis showed reductions in energy for newly introduced menu items only in the United States. We suggest actions for governments, civil society organizations, and the restaurant businesses to develop, implement, and evaluate comprehensive menu labeling policies to determine whether these may reduce obesity and NCD risks worldwide.

Effects of product reformulation on sugar intake and health-a systematic review and meta-analysis

Context

Obesity, type 2 diabetes, and dental caries are all major public health problems in the United Kingdom and contribute substantially to healthcare costs.

Objective

A systematic review and meta-analysis was conducted to determine the effect of product reformulation measures on sugar intake and health outcomes.

Data sources

Using a combination of terms, the following databases were searched-The Cochrane Library, EMBASE, MEDLINE (Ovid), and Scopus. Additionally, multiple gray literature searches were undertaken.

Data extraction

A total of 16 studies met the inclusion criteria. There were 4 randomized controlled trials, 6 studies that modeled reformulation in a country, 5 studies that modeled a different approach of reformulation, and 1 study was both a modelling study of a different approach to reformulation and a retrospective observational study. The studies were assessed for risk of bias and overall quality of evidence was rated using the Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) framework.

Results

Results from randomized controlled trials suggest that consumption of reformulated products can reduce sugar intake and body weight. The pooled estimates were -11.18% (95% confidence interval [CI], -19.95 to -2.41; P < 0.00001) for changes in percentage of sugar intake, -91.00 g/day (95%CI, -148.72 to -33.28; P< 0.00001) for changes in sugar intake in grams per day, and -1.04 kg (95%CI, -2.16 to -0.08; P= 0.0002) for changes in body weight. However, the quality of the evidence was very low. Results from the other studies suggested that reformulation can reduce sugar intake and improve health. Much of the evidence draws on modeling studies.

Conclusions

This systematic review and meta-analysis suggests that product reformulation to reduce sugar content could reduce sugar intake in individuals and thus improve population health. These findings provide an important starting point for ongoing work on sugar reformulation.

Stars versus warnings: Comparison of the Australasian Health Star Rating nutrition labelling system with Chilean Warning Labels

OBJECTIVE

The Health Star Rating (HSR) is a voluntary front-of-pack nutrition labelling system that rates products from ½ to 5 stars (five being healthiest). The Chilean Warning Label system displays warnings on foods high in sugar, saturated fat, sodium, or energy. We aimed to evaluate alignment between the systems.

METHODS

New Zealand packaged products (n=13,868) were classified according to the two systems. Alignment was assessed by cross-checking the number of products meeting the criteria for warnings against star ratings. Products with no warnings but an HSR <2, or with >1 warning but an HSR of ≥3.5 were considered outliers.

RESULTS

Two-thirds of products met the criteria for at least one warning. There was a significant positive relationship between the number of warnings and mean HSR: 0 warnings = HSR 3.77±.0166 (p<0.001), 1 warning = HSR 2.70±.0206 (p<0.001) and >1 warning = HSR 2.00±.0160 (p<0.001). The systems were non-aligned for 1,117 products (8%).

CONCLUSION

HSR and the Chilean Warning Label systems are broadly aligned. Non-alignment is due to the Chilean system restricting warnings to foods containing added ingredients and HSR awarding points for positive components. Implications for public health: These results could be helpful in informing improvements to the HSR system.

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.

The ineligibility of food products from across the EU for marketing to children according to two EU-level nutrient profile models

Background

A variety of nutrient profiling models have been developed to restrict food marketing to children. Previous assessments have shown substantial differences in terms of model strictness and agreement, but EU-wide data on how leading products in the various national markets perform against these health-minded nutrition criteria are unavailable.

Objective

To evaluate the nutritional composition of the pre-packaged food offer in selected categories sold at scale in the EU using criteria of two nutrient profile models intended to restrict food marketing to children.

Methods

The nutrient profile models of the private-sector EU Pledge and of the World Health Organization's Regional Office for Europe were applied to a commercial database with sales and nutritional information of 2691 pre-packaged products from five product categories (breakfast cereals, ready meals, processed meat, processed seafood, and yoghurts) and 20 EU countries. This study describes the criteria not met, the product ineligibility rates, and the distances to the various criteria thresholds.

Findings

Between 48% (EU Pledge) and 68% (WHO Europe) of the 2691 products analysed were found to be ineligible for marketing to children. The criteria thresholds most often not met were those for total sugars (in breakfast cereals, yoghurts), salt (in processed meat, processed seafood, ready meals), and fibre (in breakfast cereals). Total and saturated fat criteria also played a substantial role in rendering yoghurt products ineligible, and the energy criterion did so for ready meals.

Interpretation

A large number of food products selling at scale in the EU do not meet the criteria of two EU-level nutrient profile models intended to restrict food marketing to children. Given the considerable market share of many such products, they are likely to be consumed widely and in some cases regularly, including by children, even without being marketed to them. Nutrient profile models could serve as benchmarking tools for monitoring and evaluating food product reformulation efforts.

Nutritional composition of the food supply: a comparison of soft drinks and breakfast cereals between three European countries based on labels

BACKGROUND/OBJECTIVES

Monitoring of processed products at the brand level was implemented in Austria, France and Romania on the basis of the Oqali methodology during the Joint Action on Nutrition and Physical Activity (JANPA) to compare the nutritional quality of the food offering. The objective of this paper is to present the results obtained during this study.

SUBJECTS/METHODS

Collected data were those available on product packaging. In total, 2155 soft drinks and 943 breakfast cereals were classified in a standardised list of product families and analysed in a harmonised way. For each product family, mean values for sugar, fat, saturated fat, salt and dietary fibres were compared between countries. Common products across countries were also studied.

RESULTS

For all the studied nutrients, significant differences were observed between countries, with a higher sugar content for Romania in regular carbonated and non-carbonated beverages containing fruits, regular lemonades and regular tonics and bitters (together with Austria for tonics), for France in fruit beverages with more than 50% fruit, and for Austria in low-sugar beverages containing tea. For France, higher nutrient contents were also observed for sugar in chocolate-flavoured cereals, filled cereals and cornflakes, and other plain cereals (at a similar level as Romania for cornflakes), and for saturated fats in honey/caramel cereals and crunchy mueslis. These differences were explained by a different food offering in the three countries, but also by differences in nutrient contents for common products. This study also showed high variability of the nutrient content within a product family, suggesting a real potential for product reformulation.

CONCLUSIONS

National tools, at the branded products level, are essential to monitor the nutritional quality of the food offering, and to follow up on processed food reformulations.

Modeled industry-wide food and beverage reformulations reduce the gap between current and nutritionally adequate dietary intakes among French adults

PURPOSE

The objective was to assess the capacity of food reformulations to reduce the required dietary changes to reach overall nutritional adequacy in the French adult population.

METHODS

Reformulation standards, defined using the Nestlé Nutritional Profiling System (NNPS), were applied to the French food composition database (CIQUAL-2013), classifying foods into "PASS" or "FAIL". Baseline nutritional intakes were estimated for 1838 adults of the INCA2 French national survey according to three scenarios based on: (1) the original food composition database (CURRENT), (2) a "reformulated" database in which the nutrient composition of FAIL products was adjusted to the NNPS standards (REFORMULATION), and (3) a "substituted" database in FAIL products were replaced by the most nutritionally similar PASS products from the same NNPS-category (SUBSTITUTION). For each scenario, starting from each baseline diet, a new optimized diet was modeled to fulfill a complete set of nutrient recommendations while remaining closest to the respective baseline diet. To quantify the dietary changes needed to reach nutritional adequacy in the optimized diets, the total dietary deviation (TDD) was calculated as the sum in quantities (grams) of the absolute difference between observed and optimized amount of repertoire foods (i.e., foods already consumed) plus the amount of non-repertoire foods (i.e., new foods added).

RESULTS

TDD was significantly lower in the REFORMULATION and the SUBSTITUTION scenarios compared to CURRENT (1269 g/day, 1191 g/day and 1494 g/day, respectively). This was explained by smaller shifts among repertoire foods and less additions of non-repertoire foods.

CONCLUSIONS

Nutritional reformulation of the food supply may reduce the dietary changes required to achieve nutritionally adequate diets, but would not suffice to reach the complete set of nutrient recommendations.

The impact of food reformulation on nutrient intakes and health, a systematic review of modelling studies

BACKGROUND

Unhealthy diet is a risk factor for adverse health outcomes. Reformulation of processed foods has the potential to improve population diet, but evidence of its impact is limited. The purpose of this review was to explore the impact of reformulation on nutrient intakes, health outcomes and quality of life; and to evaluate the quality of modelling studies on reformulation interventions.

METHODS

A systematic review of peer-reviewed articles published between January 2000 and December 2017 was performed using MEDLINE, ScienceDirect, Embase, Scopus, Cochrane, and the Centre for Reviews and Dissemination of the University of York. Additional studies were identified through informal searches on Google and specialized websites. Only simulation studies modelling the impact of food reformulation on nutrient intakes and health outcomes were included. Included articles were independently extracted by 2 reviewers using a standardized, pre-piloted data form, including a self-developed tool to assess study quality.

RESULTS

A total of 33 studies met the selected inclusion criteria, with 20, 5 and 3 studies addressing sodium, sugar and fats reformulation respectively, and 5 studies addressing multiple nutrients. Evidence on the positive effects of reformulation on consumption and health was stronger for sodium interventions, less conclusive for sugar and fats. Study features were highly heterogeneous including differences in methods, the type of policy implemented, the extent of the reformulation, and the spectrum of targeted foods and nutrients. Nonetheless, partial between-study comparisons show a consistent relationship between percentages reformulated and reductions in individual consumption. Positive results are also shown for health outcomes and quality of life measures, although comparisons across studies are limited by the heterogeneity in model features and reporting. Study quality was often compromised by short time-horizons, disregard of uncertainty and time dependencies, and lack of model validation.

CONCLUSIONS

Reformulation models highlight relevant improvements in diets and population health. While models are valuable tools to evaluate reformulation interventions, comparisons are limited by non-homogeneous designs and assumptions. The use of validated models and extensive scenario analyses would improve models' credibility, providing useful insights for policy-makers.

REVIEW REGISTRATION

A research protocol was registered within the PROSPERO database (ID number CRD42017057341).

The Food Supply Prior to the Implementation of the Chilean Law of Food Labeling and Advertising

This study aimed to evaluate the composition of the food supply ahead of the implementation of the Chilean Law of Food Labeling and Advertising (Law 20.606) in June 2016. The INFORMAS (International Network for Food and Obesity/Non-communicable Diseases (NCDs) Research, Monitoring and Action Support) framework for monitoring the composition of the food supply was used. The Law’s initial (2016) and final (2019) limits were used to evaluate if foods would receive a “High in” warning for Calories, Sodium, Sugars and/or Saturated Fats (initial/final, solids: >350/275 kcal; >800/400 mg; >22.5/10 g; >6/4 g; liquids: >100/70 kcal; >100/100 mg; >6/5 g; >3/3 g respectively). Foods were excluded if they required reconstitution, had missing information or if total labeled energy was estimated as incorrect (n = 942). In February 2015 and 2016, fieldworkers photographed a purposeful sample of packaged food and beverage products (n = 5421 and n = 5479) from 6 different supermarkets in Santiago, Chile. Seven percent of foods had no added critical nutrients (n = 720). Two-thirds of products had critical nutrients exceeding at least one initial limit indicative of a “high in” warning. Under the final phase limits, only 17% of foods would have zero warning labels. By 2019, 10 of the 17 food and beverage categories studied are predicted to have less than half of their products without a high in sodium warning label. While 8 of the 17 categories studied are predicted to have less than half their products without a high in total sugars or a high in total calories warning label, respectively; while even fewer food and beverage categories are predicted to be without a high in saturated fat warning label. Most products will have to be reformulated to avoid at least one front-of-package warning label.

Cross-sectional survey of the amount of sugar and energy in cakes and biscuits on sale in the UK for the evaluation of the sugar-reduction programme

OBJECTIVES

To investigate the variation in sugar and energy content of cakes and biscuits available in the UK.

DESIGN

We carried out a cross-sectional survey in 2016 of 381 cakes and 481 biscuits available in nine main UK supermarkets.

METHODS

The sugar and energy content was collected from product packaging and nutrition labelling of cake and biscuit products.

RESULTS

The average sugar content in cakes and biscuits was 36.6±7.6 and 30.0±9.2 g/100 g, respectively. The mean energy content was 406±37 for cakes and 484±38 kcal/100 g for biscuits. There was a large variation in sugar and energy content between different cake and biscuit categories and within the same category. 97% of cakes and 74% of biscuits would receive a 'red' (high) label for sugar.

CONCLUSIONS

This research makes available baseline data of the cakes and biscuits market in the UK for future evaluation of the recently launched sugar-reduction programme. The study showed that reductions in sugar and energy content of cakes and biscuits are possible, since there was a large variation in sugar and energy content between different cake and biscuit categories and within the same category. A reduction in sugar and energy content, and overall cake and biscuit consumption, can help reduce overall sugar and energy intake in the UK and thus reduce the risk of obesity and dental caries.

Beetroot improves oxidative stability and functional properties of processed foods: singular and combined effects with chocolate

Oxidation is a significant problem in processed foods affecting their physico-chemical, shelf life and health properties. Natural antioxidants could be viable alternatives to synthetic variants for safely improving antioxidation properties of processed foods. The aim of this study was to assess the singular and combined effects of beetroot and chocolate on the oxidative stability of a high fat and protein processed food (sponge cake) during storage and gastrointestinal digestion. Cakes were prepared and assessed for antioxidant potential, polyphenols, and oxidative stability, and macronutrient oxidation during simulated gastro-intestinal digestion. Beetroot significantly improved the antioxidant and polyphenol profiles of sponge cake which further improved with chocolate addition. Beetroot also significantly increased the oxidative stability and shelf-life of sponge cake, and these effects were enhanced when combined with chocolate. Chocolate significantly reduced lipid oxidation during the gastric phase of digestion. However, both chocolate and beetroot did not curtail lipid oxidation in the intestinal phase, nor protein oxidation at any of the phases. Promisingly, beetroot and chocolate addition did not affect textural parameters and delayed staling by up to 2 days. Overall, the benefits of beetroot and chocolate addition were manifested more in the food system than during its digestion. Beetroot improves the oxidative stability and shelf life of processed foods, and its effects could be enhanced through combining with other natural products.

A probabilistic intake model to estimate the impact of reformulation by the food industry among Irish consumers

This project quantified the impact that voluntary reformulation efforts of the food industry had on the Irish population's nutrient intake. Nutrient composition data on reformulated products were collected from 14 major food companies for two years, 2005 and 2012. Probabilistic intake assessments were performed using the Irish national food consumption surveys as dietary intake data. The nutrient data were weighted by market shares replacing existing food composition data for these products. The reformulation efforts assessed, significantly reduced mean energy intakes by up to 12 kcal/d (adults), 15 kcal/d (teens), 19 kcal/d (children) and 9 kcal/d (pre-schoolers). Mean daily fat intakes were reduced by up to 1.3 g/d, 1.3 g/d, 0.9 g/d and 0.6 g/d, saturated fat intakes by up to 1.7 g/d, 2.3 g/d, 1.8 g/d and 1 g/d, sugar intakes by up to 1 g/d, 2 g/d, 3.5 g/d and 1 g/d and sodium intakes by up to 0.6 g/d, 0.5 g/d, 0.2 g/d, 0.3 g/d for adults, teenagers, children and pre-school children, respectively. This model enables to assess the impact of industry reformulation amongst Irish consumers' nutrient intakes, using consumption, food composition and market share data.

Food reformulation and nutritional quality of food consumption: an analysis based on households panel data in France

Background/objectives

We aimed to quantify the contribution of food reformulation to changes in the nutritional quality of consumers’ food purchases, and compare it with the impact of substitutions made by consumers.

Subjects/methods

Using a brand-specific data set in France, we considered the changes in the nutrient content of food products in four food sectors over a 3-year period. These data were matched with data on consumers’ purchases to estimate the change in the nutritional quality of consumers’ purchases. This change was divided into three components: the reformulation of food products, the launching of new products and the consumers’ substitutions between products. Key nutrients were selected for each food group: breakfast cereals (sugar, fats, SFA, fiber, and sodium), biscuits and cakes (sugar, fats, SFA, and fiber), potato chips (fats, SFA, and sodium) and soft drinks (sugar).

Results

Product reformulation initiatives have improved existing products for most food group-nutrient pairs. In particular, the contribution of food reformulation to the change in nutritional quality of food purchases was strong in potato chips (the sales-weighted mean SFA and sodium contents decreased by 31.4% to 52.1% and 6.7% to 11.1%, respectively), and breakfast cereals (the sales-weighted mean sodium content decreased by 7.3% to 9.7%). Regarding the launching of new products, the results were ambiguous. Consumers’ substitutions between food items were not generally associated to an improvement in the nutritional quality of the food purchases.

Conclusions

Policies aiming to promote food reformulation may have greater impact than those promoting changes in consumer behavior.

Product reformulation and nutritional improvements after new competitive food standards in schools

OBJECTIVE

In 2012, Massachusetts enacted school competitive food and beverage standards similar to national Smart Snacks. These standards aim to improve the nutritional quality of competitive snacks. It was previously demonstrated that a majority of foods and beverages were compliant with the standards, but it was unknown whether food manufacturers reformulated products in response to the standards. The present study assessed whether products were reformulated after standards were implemented; the availability of reformulated products outside schools; and whether compliance with the standards improved the nutrient composition of competitive snacks.

DESIGN

An observational cohort study documenting all competitive snacks sold before (2012) and after (2013 and 2014) the standards were implemented.

SETTING

The sample included thirty-six school districts with both a middle and high school.

RESULTS

After 2012, energy, saturated fat, Na and sugar decreased and fibre increased among all competitive foods. By 2013, 8 % of foods were reformulated, as were an additional 9 % by 2014. Nearly 15 % of reformulated foods were look-alike products that could not be purchased at supermarkets. Energy and Na in beverages decreased after 2012, in part facilitated by smaller package sizes.

CONCLUSIONS

Massachusetts' law was effective in improving the nutritional content of snacks and product reformulation helped schools adhere to the law. This suggests fully implementing Smart Snacks standards may similarly improve the foods available in schools nationally. However, only some healthier reformulated foods were available outside schools.

Modeled dietary impact of industry-wide food and beverage reformulations in the United States and France

Background: Food reformulation has been identified as a strategy to improve nutritional intakes; however, little is known about the potential impact of industry-wide reformulations.Objective: The aim of the study was to model the dietary impact of food and beverage reformulation following the Nestlé Nutritional Profiling System (NNPS) standards for children, adolescents, and adults in the United States and France.Design: Dietary intakes of individuals aged ≥4 y were retrieved from nationally representative surveys: the US NHANES 2011-2012 (n = 7456) and the French Individual and National Survey on Food Consumption (n = 3330). The composition of all foods and beverages consumed were compared with the NNPS standards for energy, total and saturated fats, sodium, added sugars, protein, fiber, and calcium. Two scenarios were modeled. In the first, the nutrient content of foods and beverages was adjusted to the NNPS standards if they were not met. In the second, products not meeting the standards were replaced by the most nutritionally similar alternative meeting the standards from the same category. Dietary intakes were assessed against local nutrient recommendations, and analyses were stratified by body mass index and socioeconomic status.Results: Scenarios 1 and 2 showed reductions in US adults' mean daily energy (-88 and -225 kcal, respectively), saturated fats (-4.2, -6.9 g), sodium (-406, -324 mg), and added sugars (-29.4, -35.8 g). Similar trends were observed for US youth and in France. The effects on fiber and calcium were limited. In the United States, the social gradient of added sugars intake was attenuated in both scenarios compared with the baseline values.Conclusions: Potential industry-wide reformulation of the food supply could lead to higher compliance with recommendations in both the United States and France, and across all socioeconomic groups. NNPS standards seemed to be especially effective for nutrients consumed in excess.

Testing the Capacity of a Multi-Nutrient Profiling System to Guide Food and Beverage Reformulation: Results from Five National Food Composition Databases

Nutrient profiling ranks foods based on their nutrient composition, with applications in multiple aspects of food policy. We tested the capacity of a category-specific model developed for product reformulation to improve the average nutrient content of foods, using five national food composition datasets (UK, US, China, Brazil, France). Products (n = 7183) were split into 35 categories based on the Nestlé Nutritional Profiling Systems (NNPS) and were then classified as NNPS 'Pass' if all nutrient targets were met (energy (E), total fat (TF), saturated fat (SFA), sodium (Na), added sugars (AS), protein, calcium). In a modelling scenario, all NNPS Fail products were 'reformulated' to meet NNPS standards. Overall, a third (36%) of all products achieved the NNPS standard/pass (inter-country and inter-category range: 32%-40%; 5%-72%, respectively), with most products requiring reformulation in two or more nutrients. The most common nutrients to require reformulation were SFA (22%-44%) and TF (23%-42%). Modelled compliance with NNPS standards could reduce the average content of SFA, Na and AS (10%, 8% and 6%, respectively) at the food supply level. Despite the good potential to stimulate reformulation across the five countries, the study highlights the need for better data quality and granularity of food composition databases.

Nutrient profiling for product reformulation: public health impact and benefits for the consumer

The food industry holds great potential for driving consumers to adopt healthy food choices as (re)formulation of foods can improve the nutritional quality of these foods. Reformulation has been identified as a cost-effective intervention in addressing non-communicable diseases as it does not require significant alterations of consumer behaviour and dietary habits. Nutrient profiling (NP), the science of categorizing foods based on their nutrient composition, has emerged as an essential tool and is implemented through many different profiling systems to guide reformulation and other nutrition policies. NP systems should be adapted to their specific purposes as it is not possible to design one system that can equally address all policies and purposes, e.g. reformulation and labelling. The present paper discusses some of the key principles and specificities that underlie a NP system designed for reformulation with the example of the Nestlé nutritional profiling system. Furthermore, the impact of reformulation at the level of the food product, dietary intakes and public health are reviewed. Several studies showed that food and beverage reformulation, guided by a NP system, may be effective in improving population nutritional intakes and thereby its health status. In order to achieve its maximum potential and modify the food environment in a beneficial manner, reformulation should be implemented by the entire food sector. Multi-stakeholder partnerships including governments, food industry, retailers and consumer associations that will state concrete time-bound objectives accompanied by an independent monitoring system are the potential solution.

Modeled Dietary Impact of Pizza Reformulations in US Children and Adolescents

Background and Objective

Approximately 20% of US children and adolescents consume pizza on any given day; and pizza intake is associated with higher intakes of energy, sodium, and saturated fat. The reformulation of pizza products has yet to be evaluated as a viable option to improve diets of the US youth. This study modeled the effect on nutrient intakes of two potential pizza reformulation strategies based on the standards established by the Nestlé Nutritional Profiling System (NNPS).

Methods

Dietary intakes were retrieved from the first 24hr-recall of the National Health and Nutrition Examination Survey (NHANES) 2011–12, for 2655 participants aged 4–19 years. The composition of pizzas in the NHANES food database (n = 69) were compared against the NNPS standards for energy, total fat, saturated fat, sodium, added sugars, and protein. In a reformulation scenario, the nutrient content of pizzas was adjusted to the NNPS standards if these were not met. In a substitution scenario, pizzas that did not meet the standards were replaced by the closest pizza, based on nutrient content, that met all of the NNPS standards.

Results

Pizzas consistent with all the NNPS standards (29% of all pizzas) were significantly lower in energy, saturated fat and sodium than pizzas that were not. Among pizza consumers, modeled intakes in the reformulation and substitution scenarios were lower in energy (-14 and -45kcal, respectively), saturated fat (-1.2 and -2.7g), and sodium (-143 and -153mg) compared to baseline.

Conclusions

Potential industry wide reformulation of a single food category or intra-category food substitutions may positively impact dietary intakes of US children and adolescents. Further promotion and support of these complimentary strategies may facilitate the adoption and implementation of reformulation standards.