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

Benefits of population-level interventions for dementia risk factors: an economic modelling study for England

BACKGROUND

Individual-level interventions for dementia risk factors could reduce costs associated with dementia and some are cost-effective. We aimed to estimate the cost-effectiveness of population-level interventions for tackling dementia risk factors.

METHODS

In this economic modelling study, we included recommended population-based interventions from a previously published review article for which there was consistent and robust evidence of effectiveness in tackling a dementia risk factor (tobacco smoking, excess alcohol use, hypertension, obesity, air pollution, and head injury). We only included interventions if they had not been introduced in England or were in place but could be extended. The interventions studied were increases in tobacco pricing, minimum pricing for alcohol, raising alcohol price, salt reduction policies, sugar reduction policies, low emission zones, and compulsory helmet use for cycling by children (aged 5-18 years). We used published intervention effect sizes and relative risks for each risk factor and a Markov model to estimate progression to dementia in populations with and without the intervention, looking at lifetime risk, in the population of England.

FINDINGS

We estimated that reductions in excess alcohol use through minimum unit pricing would lead to cost-savings of £280 million and 4767 quality-adjusted life-years (QALYs) gained over an indefinite succession of age cohorts. Reformulation of food products to reduce salt would lead to cost-savings of £2·4 billion and 39 433 QALYs gained and reformulation to reduce sugar would lead to cost-savings of £1·046 billion and 17 985 QALYs gained. Reducing dementia risk from air pollution by introducing low emission zones in English cities with a population of 100 000 or more (that do not already impose restrictions) would lead to £260 million cost-savings and 5119 QALYs gained. Raising cigarette prices by 10% to reduce dementia risk from smoking would lead to 2277 QALYs gained and cost-savings of £157 million. Making bicycle helmets compulsory for children (aged 5-18 years) to reduce dementia risk from head injury would lead to cost-savings of £91 million and 1554 QALYs gained.

INTERPRETATION

Population-level interventions could help tackle life course dementia risk and save costs.

FUNDING

UK National Institute for Health and Care Research Three Schools dementia research programme.

Ultra-processed Food and Obesity: What Is the Evidence?

PURPOSE OF REVIEW

Obesity is a growing global healthcare concern. A proposed driver is the recent increase in ultra-processed food (UPF) intake. However, disagreement surrounds the concept of UPF, the strength of evidence, and suggested mechanisms. Therefore, this review aimed to critically appraise the evidence on UPF and obesity.

RECENT FINDINGS

Observational studies demonstrate positive associations between UPF intake, weight gain, and overweight/obesity, more clearly in adults than children/adolescents. This is supported by high-quality clinical data. Several mechanisms are proposed, but current understanding is inconclusive. Greater UPF consumption has been a key driver of obesity. There is a need to change the obesogenic environment to support individuals to reduce their UPF intake. The UPF concept is a novel approach that is not explained with existing nutrient- and food-based frameworks. Critical analysis of methodologies provides confidence, but future observational and experimental research outputs with greater methodological rigor will strengthen findings, which are outlined.

Approaches to Enhance Sugar Content in Foods: Is the Date Palm Fruit a Natural Alternative to Sweeteners?

The current levels of added sugars in processed foods impact dental health and contribute to a range of chronic non-communicable diseases, such as overweight, obesity, metabolic syndrome, type 2 diabetes, and cardiovascular diseases. This review presents sugars and sweeteners used in food processing, the current possibility to replace added sugars, and highlights the benefits of using dates as a new natural, nutritious and healthy alternative to synthetic and non-nutritive sweeteners. In the context of environmental sustainability, palm groves afford a propitious habitat for a diverse array of animal species and assume a pivotal social role by contributing to the provisioning of sustenance and livelihoods for local communities. The available literature shows the date as an alternative to added sugars due to its composition in macro and micronutrients, especially in bioactive components (fiber, polyphenols and minerals). Therefore, dates are presented as a health promoter and a preventative for certain diseases with the consequent added value. The use of damaged or unmarketable dates, due to its limited shelf life, can reduce losses and improve the sustainability of date palm cultivation. This review shows the potential use dates, date by-products and second quality dates as sugar substitutes in the production of sweet and healthier foods, in line with broader sustainability objectives and circular economy principles.

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.

Children's reaction to sugar reduced dairy desserts in the context of the implementation of nutritional warning labels: An exploratory study

The aim of the present work was to explore children's reaction to sugar reduction in the context of the implementation of nutritional warnings in Uruguay. The study was composed of two sessions involving three evaluation conditions: tasting without package information, package evaluation without tasting, and tasting with package information. A total of 122 children, ages ranging between 6 and 13 years old (47% girls) were involved in the study. In the first session, children's hedonic and emotional response to a regular and a sugar-reduced chocolate dairy dessert (without other sweeteners) was evaluated. In the second session, children first evaluated their expected liking, emotional associations and choice of packages differing in the presence of warning labels for excessive sugar content and cartoon character (2x2 design). Finally, they tasted the selected sample in the presence of the package and evaluated their liking, emotional associations, and intention to re-taste it. Although sugar reduction led to a significant reduction in overall liking, the dessert with 40% sugar reduction showed a mean overall score of 6.5 in a 9-point hedonic scale and was described using positive emoji (, , ). When the desserts were tasted with package information, no significant differences in the expected overall liking of the regular and sugar-reduced dessert were found. Regarding the effect of packaging elements, the presence of a warning label highlighting excessive content of sugar did not have a significant effect on children's choice. Instead, children's choices were defined by the presence of a cartoon character. Results from the present work provide additional evidence about the feasibility of reducing the sugar content and sweetness of dairy products targeted at children and stress the need to regulate the use of cartoon characters on products with an unfavorable nutritional profile. Methodological recommendations for sensory and consumer research with children are also discussed.

Improving the Nutrient Quality of Foods and Beverages Using Product Specific Standards for Nutrients to Limit Will Substantially Reduce Mean Population Intakes of Energy, Sodium, Saturated Fat and Sugars towards WHO Guidelines

BACKGROUND

International strategies to reduce chronic diseases have called for a reduction in the amounts of saturated fat (SAFA), trans fat (TFA), salt and sugars in the global food supply. This paper describes the development approach and potential impact of a set of standards for these nutrients to drive food (re)formulation.

METHODS

To set the standards, WHO nutrient guidelines for daily intake were translated into product group specific standards. The impact of reformulation towards these standards on population nutrient intakes was modelled using the food consumption data of five countries: UK, France, US, Brazil and China. The impact of the TFA standards could not be modelled due to lack of data.

RESULTS

(Re)formulation of foods and beverages towards these standards would substantially decrease mean population intakes of energy, sodium, SAFA and sugars, with reductions up to 30%.

CONCLUSIONS

These science-based standards for nutrients to limit could drive impactful reductions in energy, sodium, SAFA and sugars in food and beverage products, enabling mean population intakes to move closer to WHO nutrient guidelines.

Lower Strength Alcohol Products-A Realist Review-Based Road Map for European Policy Making

This paper reports the result of a realist review based on a theory of change that substitution of higher strength alcohol products with lower strength alcohol products leads to decreases in overall levels of alcohol consumption in populations and consumer groups. The paper summarizes the results of 128 publications across twelve different themes. European consumers are increasingly buying and drinking lower strength alcohol products over time, with some two fifths doing so to drink less alcohol. It tends to be younger more socially advantaged men, and existing heavier buyers and drinkers of alcohol, who take up lower strength alcohol products. Substitution leads to a lower number of grams of alcohol bought and drunk. Although based on limited studies, buying and drinking lower strength products do not appear to act as gateways to buying and drinking higher strength products. Producer companies are increasing the availability of lower strength alcohol products, particularly for beer, with extra costs of production offset by income from sales. Lower strength alcohol products tend to be marketed as compliments to, rather than substitutes of, existing alcohol consumption, with, to date, the impact of such marketing not evaluated. Production of lower strength alcohol products could impair the impact of existing alcohol policy through alibi marketing (using the brand of lower strength products to promote higher strength products), broadened normalization of drinking cultures, and pressure to weaken policies. In addition to increasing the availability of lower strength products and improved labelling, the key policy that favours substitution of higher strength alcohol products with lower strength products is an alcohol tax based on the dose of alcohol across all products.

Relationship between front-of-pack labeling and nutritional characteristics of food products: An attempt of an analytical approach

The adoption of supplementary nutrition information, i.e., front-of-pack labeling (FOPL), on pre-packed food products is advocated as a tool to improve the consumers' knowledge of the nutrient content or the nutritional quality of foods, but also to drive products reformulation by the food industry. Ultimately, FOPL should help people to select foods in order to compose an overall balanced diet, which is essential for health. However, the extent to which the different FOPL systems proposed in the European Union (EU) (interpretative or informative) are effectively able to convey the information useful to improve both food choices and dietary habits of the consumers is still under debate and needs to be analyzed in detail. The use of 3 FOPL schemes proposed within the EU (Nutri-Score, Keyhole and NutrInform Battery) to compare products available on the Italian market within different food categories, highlights some critical issues: (1) different FOPL provide to consumers different kinds of information; (2) systems based on similar theoretical approaches can provide conflicting information; (3) the algorithms on which interpretative FOPL are based can give the same summary information for products differing in nutrient composition, impact on the overall dietary balance and therefore on the health of people with different characteristics, physiological/pathological conditions, and nutritional requirements; (4) on the other hand, products with similar nutrient composition can obtain different interpretative FOPL; (5) informative systems are generally more complex and require greater both attention and knowledge from the consumer; (6) FOPL based on 100 g of product overlook the role of portion (and frequency of consumption) in determining the nutrient intake without informing on the contribution of a single food to the overall diet; (7) FOPL based on scoring systems could promote the reformulation of selected products, especially with a composition very close to the threshold limits; (8) for the portion-based informative FOPL systems, the incentive for reformulation could essentially involve the reduction of portion size. Finally, the importance of nutritional education interventions, which are required to encourage the use by consumers of informative FOPL systems, cannot be neglected to improve the quality of diets regardless of the FOPL used.

Nutrient profiles of commercially produced complementary foods available in Cambodia, Indonesia and the Philippines

OBJECTIVE

To assess the nutritional suitability of commercially produced complementary foods (CPCF) marketed in three South-East Asian contexts.

DESIGN

Based on label information declared on the products, nutrient composition and content of CPCF were assessed against the WHO Europe nutrient profile model (NPM). The proportion of CPCF that would require a 'high sugar' warning was also determined.

SETTING

Khsach Kandal district, Cambodia; Bandung City, Indonesia; and National Capital Region, Philippines.

PARTICIPANTS

CPCF products purchased in Cambodia (n 68) and Philippines (n 211) in 2020, and Indonesia (n 211) in 2017.

RESULTS

Only 4·4 % of products in Cambodia, 10·0 % of products in Indonesia and 37·0 % of products in the Philippines fully complied with relevant WHO Europe NPM nutrient composition requirements. Sixteen per cent of CPCF in Cambodia, 27·0 % in Indonesia and 58·8 % in the Philippines contained total sugar content levels that would require a 'high sugar' warning.

CONCLUSIONS

Most of the analysed CPCF were not nutritionally suitable to be promoted for older infants and young children based on their nutrient profiles, with many containing high levels of sugar and sodium. Therefore, it is crucial to introduce new policies, regulations and standards to limit the promotion of inappropriate CPCF in the South-East Asia region.

Systematic Review of the Effect on Caries of Sugars Intake: Ten-Year Update

An update of the systematic review of evidence on the association between amount of sugars intake and dental caries, as well as on the effect of restricting sugars intake to <10% and <5% energy (E) on caries, was conducted, almost 10 y since the review that informed the World Health Organization (WHO) Guideline on Sugars. The aim was to systematically review epidemiological data published from 2011 to 2020 on the amount of sugars consumption and levels of caries and to report the findings for adults and children. Data sources included MEDLINE, EMBASE, Cochrane Database, Cochrane Central Register of Controlled Trials, Latin American and Caribbean Health Sciences, China National Knowledge Infrastructure, Scopus, and Google Scholar. Eligible studies reported the amount of sugars and caries, measured as prevalence, incidence, or severity. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Risk of bias was assessed using the Office of Health Assessment and Translation tool. Vote counting and harvest plots provided the basis for evidence synthesis. From 488 new papers identified, 23 studies were eligible: 4 cohort, 1 case-controlled, 12 cross-sectional, and 6 ecological. Eleven of 15 studies in children and 6 of 8 studies in adults reported at least 1 positive association between sugars and caries. Six of 7 studies in children and 4 of 4 studies in adults, with data enabling comparison of caries levels with sugars intakes >10%E and <10%E, showed lower caries when sugars intake was <10%E. Amalgamating with original studies yielded 64 of 78 studies showing at least 1 positive association, 20 of 78 a null association, and 3 of 78 a negative association between sugars and caries. GRADE profiles of new and original cohort data confirmed "moderate-quality" evidence that caries is lower when sugars intake is <10%E. Furthermore, new cohort data upgraded the quality of evidence (from "very low" to "low") for lower caries when free sugars are <5%E. The findings support and strengthen original evidence underpinning the WHO recommendations for sugars.

Consumption of Ultra-Processed Foods Is Associated with Free Sugars Intake in the Canadian Population

Excess sugar consumption can lead to noncommunicable diseases (NCDs) such as type 2 diabetes. Increasingly, ultra-processed foods (UPF) are suspected to be great contributors to free sugars intake in the population's diet. Thus, the aim of this study was to investigate the association between UPF consumption and free sugars intake in the Canadian population. We used data from one 24 h-recall of the nationally representative 2015 Canadian Community Health Survey-Nutrition (CCHS). Food items were classified according to the NOVA system, and to estimate free sugars intake, we used the University of Toronto's Food Label Information Program (FLIP) 2017 database. Results: Almost half of the population's energy intake (45.7%) came from UPF. On average, 221.5 kcal/day came from free sugars, and most of these calories (71.5%) came from UPF. Public health policies aiming to decrease consumption of UPF should be a priority considering their important contribution to sugar intake in the population.

Impact of Measures Aiming to Reduce Sugars Intake in the General Population and Their Implementation in Europe: A Scoping Review

Objectives: Implementing public health measures is necessary to decrease sugars intake, which is associated with increased risk of noncommunicable diseases. Our scoping review aimed to identify the types of measures implemented and evaluated to decrease sugars intake in the population and to assess their impact.

Methods: Following a review of systematic reviews (SRs) published in 2018, we systematically searched new SR (May 2017–October 2020) in electronic databases. We also searched the measures implemented in Europe in the NOURISHING database. Two researchers selected the reviews, extracted and analysed the data.

Results: We included 15 SRs assessing economic tools (n = 5), product reformulation and labels/claims (n = 5), and educational/environmental interventions (n = 7). Economic tools, product reformulation and environmental measures were effective to reduce sugar intake or weight outcomes, while labels, education and interventions combining educational and environmental measures found mixed effects. The most frequently implemented measures in Europe were public awareness, nutritional education, and labels.

Conclusion: Among measures to reduce sugar intake in the population, economic tools, product reformulation, and environmental interventions were the most effective, but not the more frequently implemented in Europe.

Effectiveness of food environment policies in improving population diets: a review of systematic reviews

Unhealthy population diets contribute to the burden of non-communicable diseases. Policies targeting food environments (FE policies) may improve population diets. This review of systematic reviews aims to summarise recent evidence of the effectiveness of FE policies in improving diets. We searched PubMed for systematic reviews published from January 2010 onwards. Eligible FE policies included: nutrition and food labelling, provision of foods in public institutions or specific settings, price, marketing, nutrition quality and portion size, and availability of foods in retail and food service establishments. A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2) instrument was used to assess review quality. Reviews of critically low quality were excluded. Results were narratively reported in text and tables. The search identified 1102 records after removing duplicates. Following screening and quality assessment we included 12 systematic reviews. Two reviews focused on nutrition and food labelling, two on provision of foods in school settings, four on price, none on marketing policies, three on nutrition quality and portion size and one on the availability of foods in retail and food service establishments. Pricing policies (tax/subsidy) appear effective in altering intake and purchase of targeted foods and beverages. FE policies targeting the availability of foods in retail and food establishments, food provision in school settings, product reformulation and the size of portions/packages or items of tableware also appear effective. Overall, policies targeting food environments appear effective in improving population diets. However, there is a need for further high-quality evidence.

'Joining the Dots': Individual, Sociocultural and Environmental Links between Alcohol Consumption, Dietary Intake and Body Weight-A Narrative Review

Alcohol is energy-dense, elicits weak satiety responses relative to solid food, inhibits dietary fat oxidation, and may stimulate food intake. It has, therefore, been proposed as a contributor to weight gain and obesity. The aim of this narrative review was to consolidate and critically appraise the evidence on the relationship of alcohol consumption with dietary intake and body weight, within mainstream (non-treatment) populations. Publications were identified from a PubMed keyword search using the terms 'alcohol', 'food', 'eating', 'weight', 'body mass index', 'obesity', 'food reward', 'inhibition', 'attentional bias', 'appetite', 'culture', 'social'. A snowball method and citation searches were used to identify additional relevant publications. Reference lists of relevant publications were also consulted. While limited by statistical heterogeneity, pooled results of experimental studies showed a relatively robust association between acute alcohol intake and greater food and total energy intake. This appears to occur via metabolic and psychological mechanisms that have not yet been fully elucidated. Evidence on the relationship between alcohol intake and weight is equivocal. Most evidence was derived from cross-sectional survey data which does not allow for a cause-effect relationship to be established. Observational research evidence was limited by heterogeneity and methodological issues, reducing the certainty of the evidence. We found very little qualitative work regarding the social, cultural, and environmental links between concurrent alcohol intake and eating behaviours. That the evidence of alcohol intake and body weight remains uncertain despite no shortage of research over the years, indicates that more innovative research methodologies and nuanced analyses are needed to capture what is clearly a complex and dynamic relationship. Also, given synergies between 'Big Food' and 'Big Alcohol' industries, effective policy solutions are likely to overlap and a unified approach to policy change may be more effective than isolated efforts. However, joint action may not occur until stronger evidence on the relationship between alcohol intake, food intake and weight is established.

Use of GRADE in evidence syntheses published in high-impact-factor nutrition journals: A methodological survey

OBJECTIVE

To identify and describe the use of the GRADE approach for rating the certainty of evidence in nutrition systematic reviews (SRs).

STUDY DESIGN AND SETTING

We systematically searched for SRs using GRADE that were published between 2015 and 2019 in the 10 "nutrition" journals with the highest impact factor according to the JCR 2018.

RESULTS

Out of 800 SRs, 55 SRs of randomized control trials (RCTs) and/or nonrandomized studies (NRSs) used GRADE. Forty-seven SRs (5.9%) rated the outcome specific certainty of evidence (n = 36 in 2018/2019). We identified a total of 465 certainty of evidence outcome ratings (n = 335 RCT ratings), ranging from very-low (28.8%) to low (41%), moderate (26.5%), and high (3.7%). Very-low and high certainty of evidence ratings accounted for 61.4% and 0.8% of ratings in SRs of NRSs, compared to 16.1% and 4.8% in SRs of RCTs. Certainty of evidence was downgraded mostly for risk of bias (37.8%) and imprecision (33%) in SRs of RCTs and for imprecision (32.7%), risk of bias (29.4%) and inconsistency (29%) in SRs of NRSs.

CONCLUSION

Our study suggests a need for directing more attention toward strengthening acceptance of GRADE as well as building knowledge of the GRADE methodology in nutrition evidence synthesis.

What is the impact of food reformulation on individuals' behaviour, nutrient intakes and health status? A systematic review of empirical evidence

Food reformulation aimed at improving the nutritional properties of food products has long been viewed as a promising public health strategy to tackle poor nutrition and obesity. This paper presents a review of the empirical evidence (i.e., modelling studies were excluded) on the impact of food reformulation on food choices, nutrient intakes and health status, based on a systematic search of Medline, Embase, Global Health and sources of grey literature. Fifty-nine studies (in 35 papers) were included in the review. Most studies examined food choices (n = 27) and dietary intakes (n = 26). The nutrients most frequently studied were sodium (n = 32) and trans fatty acids (TFA, n = 13). Reformulated products were generally accepted and purchased by consumers, which led to improved nutrient intakes in 73% of studies. We also conducted two meta-analyses showing, respectively, a -0.57 g/day (95%CI, -0.89 to -0.25) reduction in salt intake and an effect size for TFA intake reduction of -1.2 (95% CI, -1.79 to -0.61). Only six studies examined effects on health outcomes, with studies on TFA reformulation showing overall improvement in cardiovascular risk factors. For other nutrients, it remains unclear whether observed improvements in food choices or nutrient intakes may have led to an improvement in health outcomes.

Have socio-economic inequalities in sugar purchasing widened? A longitudinal analysis of food and beverage consumer data from British households, 2014-2017

OBJECTIVE

To examine socio-economic inequalities in decreases in household sugar purchasing in Great Britain (GB).

DESIGN

Longitudinal, population-based study.

SETTING

Data were obtained from the GB Kantar Fast-Moving Consumer Goods (FMCG) panel (2014-2017), a nationally representative panel study of food and beverages bought and brought into the home. We estimated changes in daily sugar purchases by occupational social grade from twenty-three food groups, using generalised estimating equations (household-level clustering).

PARTICIPANTS

British households who regularly reported food and beverages to the GB Kantar FMCG (n 28 033).

RESULTS

We found that lower social grades obtained a lower proportion of sugar from healthier foods and a greater proportion of sugar from less healthy foods and beverages. In 2014, differences in daily sugar purchased between the lowest and the highest social grades were 3·9 g/capita/d (95 % CI 2·9, 4·8) for table sugar, 2·4 g (95 % CI 1·8, 3·1) for sugar-sweetened beverages, 2·2 g (95 % CI 1·5, 2·8) for chocolate and confectionery and 1·0 g (95 % CI 0·7, 1·3) for biscuits. Conversely, the lowest social grade purchased less sugar from fruits (2·1 g (95 % CI 1·5, 2·8)) and vegetables (0·7 g (95 % CI 0·5, 0·8)) than the highest social grade. We found little evidence of change in social grade differences between 2014 and 2017. These results suggest that recent overall declines in sugar purchases are largely equally distributed across socio-economic groups.

CONCLUSIONS

This suggests that recent population-level policy activity to reduce sugar consumption in GB does not appear to exacerbate or reduce existing socio-economic inequalities in sugar purchasing. Low agency, population-level policies may be the best solution to improving population diet without increasing inequalities.

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.

Patterns of beverage purchases amongst British households: A latent class analysis

BACKGROUND

Beverages, especially sugar-sweetened beverages (SSBs), have been increasingly subject to policies aimed at reducing their consumption as part of measures to tackle obesity. However, precision targeting of policies is difficult as information on what types of consumers they might affect, and to what degree, is missing. We fill this gap by creating a typology of beverage consumers in Great Britain (GB) based on observed beverage purchasing behaviour to determine what distinct types of beverage consumers exist, and what their socio-demographic (household) characteristics, dietary behaviours, and weight status are.

METHODS AND FINDINGS

We used cross-sectional latent class analysis to characterise patterns of beverage purchases. We used data from the 2016 GB Kantar Fast-Moving Consumer Goods (FMCG) panel, a large representative household purchase panel of food and beverages brought home, and restricted our analyses to consumers who purchase beverages regularly (i.e., >52 l per household member annually) (n = 8,675). Six categories of beverages were used to classify households into latent classes: SSBs; diet beverages; fruit juices and milk-based beverages; beer and cider; wine; and bottled water. Multinomial logistic regression and linear regression were used to relate class membership to household characteristics, self-reported weight status, and other dietary behaviours, derived from GB Kantar FMCG. Seven latent classes were identified, characterised primarily by higher purchases of 1 or 2 categories of beverages: 'SSB' (18% of the sample; median SSB volume = 49.4 l/household member/year; median diet beverage volume = 38.0 l), 'Diet' (16%; median diet beverage volume = 94.4 l), 'Fruit & Milk' (6%; median fruit juice/milk-based beverage volume = 30.0 l), 'Beer & Cider' (7%; median beer and cider volume = 36.3 l; median diet beverage volume = 55.6 l), 'Wine' (18%; median wine volume = 25.5 l; median diet beverage volume = 34.3 l), 'Water' (4%; median water volume = 46.9 l), and 'Diverse' (30%; diversity of purchases, including median SSB volume = 22.4 l). Income was positively associated with being classified in the Diverse class, whereas low social grade was more likely for households in the classes SSB, Diet, and Beer & Cider. Obesity (BMI > 30 kg/m2) was more prevalent in the class Diet (41.2%, 95% CI 37.7%-44.7%) despite households obtaining little energy from beverages in that class (17.9 kcal/household member/day, 95% CI 16.2-19.7). Overweight/obesity (BMI > 25 kg/m2) was above average in the class SSB (66.8%, 95% CI 63.7%-69.9%). When looking at all groceries, households from the class SSB had higher total energy purchases (1,943.6 kcal/household member/day, 95% CI 1,901.7-1,985.6), a smaller proportion of energy from fruits and vegetables (6.0%, 95% CI 5.8%-6.3%), and a greater proportion of energy from less healthy food and beverages (54.6%, 95% CI 54.0%-55.1%) than other classes. A greater proportion of energy from sweet snacks was observed for households in the classes SSB (18.5%, 95% CI 18.1%-19.0%) and Diet (18.8%, 95% CI 18.3%-19.3%). The main limitation of our analyses, in common with other studies, is that our data do not include information on food and beverage purchases that are consumed outside the home.

CONCLUSIONS

Amongst households that regularly purchase beverages, those that mainly purchased high volumes of SSBs or diet beverages were at greater risk of obesity and tended to purchase less healthy foods, including a high proportion of energy from sweet snacks. These households might additionally benefit from policies targeting unhealthy foods, such as sweet snacks, as a way of reducing excess energy intake.

Reformulation of sugar contents in Canadian prepackaged foods and beverages between 2013 and 2017 and resultant changes in nutritional composition of products with sugar reductions

Objective:

To quantify total sugar reformulation in Canadian prepackaged foods and beverages between 2013 and 2017 and identify changes in the nutritional composition of the foods and beverages reformulated to be lower in total sugar.

Design:

Longitudinal examination of foods and beverages present in both 2013 and 2017 collections of the University of Toronto’s Food Label Information Program database (n 6628 matched products). The proportion of products with changes in sugar levels was determined. Wilcoxon signed-rank test was used to examine changes in sugar levels overall for products lower or higher in sugar and changes in nutrient composition for products lower in sugar.

Setting:

Largest grocery retailers by market share in Canada.

Participants:

Canadian prepackaged foods and beverages.

Results:

The majority (76·6 %) of products had no change in total sugar content, 12·4 % were reformulated to be lower in sugar and 11·0 % were higher in sugar. A median sugar reduction of 19·0 % (1·6 g) was seen among products lower in sugar which was offset by a median 18·0 % (1·5 g) increase among products higher in sugar. Overall, median levels of energies and other nutrients stayed the same or decreased among products reformulated to be lower in sugar, the exception was for starch, which increased.

Conclusions:

Limited progress was made to reformulate foods and beverages to be lower in total sugar between 2013 and 2017. Results from this study identify areas in the food supply where attention may be needed to avoid unintended consequences of sugar-focused reformulation in terms of overall nutritional composition.

Role of different nutrient profiling models in identifying targeted foods for front-of-package food labelling in Brazil

Objective:

To compare the degree of strictness and agreement of different nutrient profiling models (NPM) used to identify which foods would be required to show front-of-package (FOP) warning labels.

Design:

Using data of 11 434 packaged foods found in the five largest food retailers in Brazil, we used two published NPM: the Pan American Health Organization (PAHO) model and the NPM used in the Chilean nutritional FOP labelling policy, and compared them with a NPM proposed by the Brazilian National Health Surveillance Agency (Anvisa). The proportion of foods that would be required to show FOP warning labels was calculated overall and by food category. We also tested whether a modified version of the PAHO NPM would behave similarly to the original version.

Setting:

Brazil.

Results:

Two-thirds of the packaged products (62 %) would receive FOP warning labels under the PAHO NPM, as compared with 45 % of products using the proposed Anvisa NPM and 41 % if the Chilean NPM was applied. The PAHO NPM identified more foods high in critical nutrients such as sweetened dairy and non-dairy beverages, canned vegetables and convenience foods. Overall agreement between models was considered good with kappa coefficient ranging from 0·57 to 0·92 but was lower for some food categories.

Conclusions:

We found variations in the degree of strictness and agreement between assessed NPM. The PAHO NPM identified more foods and beverages high in sugar which are among the top contributors to sugar and energy intake in Brazil.

Beyond the Chair: Public Health and Governmental Measures to Tackle Sugar

Limiting free sugars to <5% of energy intake is a World Health Organization evidence-based recommendation to protect oral health throughout the life course. Achieving this requires a concerted approach with upstream interventions, including legislation underpinning community interventions and health promotion. Global production and trade are the main drivers of sugars consumption, which can be addressed only through prioritization of health impacts in agricultural and trade agreements, including pricing and subsidies. Increasing evidence demonstrates the benefit, including dental benefits, of taxes on sugar-sweetened beverages, a major source of sugars—with taxes based on sugars content being favored due to the dual impact in incentivizing consumers to buy less and encouraging producers to use less through product reformulation. A benefit of product reformulation is that the potential impact on sugars intake occurs independent of consumer behavior change, making the benefits more equitable across social groups. Evidence from meta-analysis indicates that sugars reformulation and portion size reduction could lower energy intake by more than 10% and 16%, respectively. Sophisticated and targeted digital marketing of products high in sugars is another key driver of sugars intake. With the exception of children’s television broadcasting, marketing of products high in sugars is largely unregulated, and increased awareness of modern marketing strategies and more stringent regulation are urgently needed. To ensure a commercial level playing field, mandatory approaches are required. Midstream actions include creating healthier food environments in neighborhoods, community settings (schools, sports centers, hospitals), and workplaces. Only through coalition among authorities responsible for planning and health will “obesogenic and cariogenic” environments be replaced with those that make healthy choices the easiest choice. It is recognized that providing nutrition health education alone is insufficient to achieve necessary sugars reduction; however, education has a key role to play in changing social norms and creating drive for change.

Variations in Sugar Content of Flavored Milks and Yogurts: A Cross-Sectional Study across 3 Countries

BACKGROUND

The consumption of dairy products is encouraged at all life stages as a nutrient-rich component of the diet. However, many milk and yogurt products, particularly flavored varieties, may contain large amounts of free sugar.

OBJECTIVES

The aim of this paper was to evaluate the availability and sugar content of flavored milks and yogurts in supermarkets across 3 countries: Australia, England, and South.

METHODS

Nutrition information for flavored milks and yogurts was collected by trained researchers and supplemented by crowd-sourced data from a smartphone application. Data were extracted in April 2018 and 3724 milk and yogurt products were available for analysis. Mean sugar concentrations were compared across countries with the use of ANOVA followed by Tukey's post-hoc pairwise comparisons. Sugar concentrations were compared with the UK's "green" traffic-light classifications.

RESULTS

Approximately 74% (n = 2753) of all products were flavored. Flavored products contained nearly twice the average total sugar content of unflavored products, with substantial variability: mean total sugar was 9.1 g/100 mL (range: 4.3-15.0 g/100 mL) and 11.5 g/100 g (range: 0.1-22.6 g/100 g) for flavored milks and yogurts, respectively. Free sugars contributed an estimated 41% and 42% of total sugar in milks and yogurts, respectively. Flavored milks in England had ∼0.7 g/100 mL higher total sugar on average compared with Australia and South Africa (P ≤ 0.04), whereas flavored yogurts in South Africa had the lowest average total sugar (∼2 g/100 g lower than England and Australia; P < 0.001). Less than 4% of flavored products would receive a "green" rating under the UK traffic-light labeling scheme.

CONCLUSIONS

In Australia, England, and South Africa, flavored milks and yogurts are highly prevalent in the food supply and contain significantly higher concentrations of total and added sugars than unflavored products.

How Much Can Product Reformulation Improve Diet Quality in Households with Children and Adolescents?

Improvements in the healthfulness of packaged foods and beverages through reformulation could help reduce the prevalence of obesity among children and adolescents through improved diet quality. This study assessed changes in calories and four nutrients (saturated fat, total sugars, sodium, and dietary fiber) from 2012 through 2014 for packaged products frequently consumed by children and adolescents, simulated effects of potential improvements in 12 frequently consumed product categories based on actual purchasing patterns, and compared differences in prices of healthier versus less healthy products. Analysis of trends showed limited evidence that healthfulness of foods improved over the years examined. Simulation results showed minimal changes for calories and sodium, but daily intake of saturated fat could decrease by 4%, sugar consumption could decrease by 5%, and dietary fiber consumption could increase by 11% if products were reformulated to meet an existing healthfulness standard. Using a higher standard, caloric intake could decline by 4%, saturated fat by 6%, sugar by 9%, and sodium by 4%, and dietary fiber could increase by 14%. Healthier versions of most products ranged from an average of 3 to 12 cents more per serving, but not all healthier versions were more costly. Overall, reformulation is a potential avenue for improving diet quality in households with children and adolescents, but price could be a barrier to purchasing healthier products for some households.