Impact of the Food-Labeling and Advertising Law Banning Competitive Food and Beverages in Chilean Public Schools, 2014-2016

Why we struggle to make progress in obesity prevention and how we might overcome policy inertia: Lessons from the complexity and political sciences

Despite evidence for the effectiveness of policies that target obesogenic environments, their adoption remains deficient. Using methods and concepts from complexity and political science (Stock-and-Flow analysis and Punctuated Equilibrium Theory) and a qualitative literature review, we developed system maps to identify feedback loops that hinder policymaking on mitigating obesogenic environments and feedback loops that could trigger and sustain policy change. We found numerous self-reinforcing feedback loops that buttress the assumption that obesity is an individual problem, strengthening the biomedical and commercial weight-loss sectors' claim to "ownership" over solutions. That is, improvements in therapies for individuals with obesity reinforces policymakers' reluctance to target obesogenic environments. Random events that focus attention on obesity (e.g., celebrities dismissing soda) could disrupt this cycle, when actors from outside the medical and weight-loss sector (e.g., anti-weight stigma activists) successfully reframe obesity as a societal problem, which requires robust and politically relevant engagement with affected communities prior to such events taking place. Sustained prioritization of policies targeting obesogenic environments requires shared problem ownership of affected communities and nonhealth government sectors, by emphasizing cobenefits of policies that target obesogenic environments (e.g., ultraprocessed food taxation for raising revenue) and solutions that are meaningful for affected communities.

Did child obesity decline after 2016 food regulations in Chile?

We estimated trends in the prevalence of obesity and overweight among Chilean primary and secondary students before and after Chile's 2016 regulations on the marketing and availability of foods high in energy, total sugars, sodium, or saturated fat. We used data from Chile's Survey of Nutrition, which measured the body mass index (BMI) of students in government-funded schools. Using BMI thresholds defined by the World Health Organization, we calculated the prevalence of overweight and obesity for each year from 2013 to 2019 among students attending pre-kindergarten (age 4 years), kindergarten (age 5 years), first grade (6 years), and ninth grade (14 years). In ninth grade students, overweight and obesity prevalence rose by 2 percentage points over the 3 years after introduction of the 2016 regulations. In pre-kindergarten, kindergarten, and first grade, overweight and obesity fell 1 to 3 percentage points 1 year after the regulations were introduced, but rebounded to previous levels the next year. Chile's food regulations were not followed by a sustained decline in obesity in primary- and secondary-school students. Future research should examine whether and how children in Chile and other countries maintain high levels of overweight and obesity despite food regulations designed to reduce consumption of obesogenic foods and beverages.

Ultra-processed food consumption is associated with variations in daily routines in elementary schoolchildren during the COVID-19 pandemic in Chile

OBJECTIVE

To assess the association between child ultra-processed food (UPF) consumption and home-school learning environment characteristics during school closures due to the COVID-19 pandemic in schoolchildren with low- and middle income in Chile.

DESIGN

Cross-sectional. UPF consumption was collected using the Nova screener. We apply the structured days hypothesis (SDH) to assess home-school learning environment characteristics with three constructs that summarised school preparedness for online teaching and learning, school closure difficulties for caregivers and child routine. We explored associations between child UPF consumption and home-school environment characteristics using multivariate linear regression analyses after controlling for child demographic and school characteristics.

SETTING

Low- and middle-income neighbourhoods in southeastern Santiago, Chile.

PARTICIPANTS

Children from the Food Environment Chilean Cohort (n 428, 8-10 years old).

RESULTS

Based on the Nova score, child mean consumption of UPF was 4·3 (sd 1·9) groups. We found a statistically significant negative association between child routine for eating, play and study and child UPF consumption when we adjusted for child sociodemographic (model 1: β = -0·19, (95 % CI -0·40, 0·02)) and school characteristics (model 2: β = -0·20, (95 % CI -0·41, 0·00)). Associations between school preparedness for online teaching or school closure difficulties and UPF were not statistically significant.

CONCLUSIONS

Variations in child routines during the COVID-19 pandemic were negatively associated with UPF intake in schoolchildren with low- and middle income. Our findings are consistent with the SDH, suggesting the school environment helps regulate eating behaviours. Future research should evaluate what happens when children return to in-person classes at school.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The influence of Chile's food labeling and advertising law and other factors on dietary and physical activity behavior of elementary students in a peripheral region: a qualitative study

BACKGROUND

In 2016, Chile implemented the Food Labeling and Advertising Law to fight childhood obesity through front-of-package food labelling, marketing restrictions and school activities and programs. Nevertheless, little is known on its influence on key stakeholders in vulnerable peripheral regions of the country. This study aimed at identifying important influencing factors including the Food Labeling and Advertising Law on dietary habits and physical activity patterns of second graders in Chile, as perceived by school representatives and the children themselves.

METHODS

Semi-structured interviews with four school directors and 17 groups of three second graders, informal interviews with 9 key teachers and 4 food services staff complemented with documented observations were carried out in four primary schools of the Chilean city of Punta Arenas, in the Magallanes Punta Arenas region. The different sources allowed for triangulation of results.

RESULTS

FLAL seems to have a negligible influence on young children's diet and physical activity in the study region. Barriers are children's deeply rooted dietary habits, excessive screen-time, the parents' lacking problem awareness, limited time for parenting practices and bad role modeling. Environmental barriers are overloaded schools due to insufficient coordination between governmental entities, lacking funds for sound teacher training and unsafe neighborhoods limiting children's play.

CONCLUSIONS

Policy interventions aimed at reducing childhood obesity need to include and empower schools, families and local communities as active partners and consider their framework conditions for greater influence on dietary habits and physical activity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Awareness of and Participation in School Food Programs in Youth from Six Countries

BACKGROUND

School-based meal programs can promote healthy dietary intake in youth. However, limited data exist regarding the impact of income-targeted school meal programs across countries, particularly among food-insecure youth.

OBJECTIVES

We examined self-reported awareness of and participation in free school meal programs, and associations with dietary intake in youth from 6 countries with differing national school meal policies.

METHODS

Data were collected through the 2019 International Food Policy Study Youth Survey, a cross-sectional survey of 10,565 youth aged 10-17 y from Australia, Canada, Chile, Mexico, the United Kingdom, and the United States. Regression models examined: 1) country differences in awareness of and participation in breakfast and lunch programs; and 2) associations between lunch program participation and intake of fruit and vegetables, and "less healthy" foods during the previous school lunch day.

RESULTS

Awareness of and participation in free breakfast and lunch programs varied across countries. Approximately half of USA and Chilean students participated in school lunch programs-the countries with the most comprehensive national policies-compared with one-fifth of students in the United Kingdom, and ∼5% in Australia, Canada, and Mexico (P < 0.001 for all contrasts). In the United States and Chile, more than two-thirds of youth with the highest level of food insecurity participated in lunch programs, compared with 45% in the United Kingdom, 27% in Canada, and ≤20% in Australia and Mexico. In all countries, youth reporting school lunch program participation were more likely to report fruit and vegetable intake during their previous school lunch (P < 0.001), and higher intake of "less healthy" food in all countries except the United States and Chile.

CONCLUSIONS

More comprehensive national policies were associated with greater participation in school meal programs, particularly among youth at greatest risk of food insecurity, as well as healthier dietary intake from school lunches.

A review of implementation and evaluation of Pan American Health Organization's policies to prevent childhood obesity in Latin America

Rationale

To inform future policies, the study objectives were to determine to what extent the policies included in the 5‐year Plan of Action for the Prevention of Obesity in Children and Adolescents—proposed by Pan American Health Organization (PAHO) and signed by 19 Latin America countries in 2014—have been implemented and evaluated.

Methods

A scoping review of the Governmental websites for Latin American countries and a literature review was conducted to identify whether policies have been implemented and evaluated. Key information was abstracted.

Results

The review identified 115 PAHO policies/interventions implemented (43% implemented after signing the proposed plan in 2014). Nearly all (18/19) countries implemented food guidelines or school feeding programs, but fiscal and marketing policies were less commonly implemented (6/19). Through the review, 44 evaluations of PAHO policies were identified of which 23% were qualitative and 77% quantitative. The results of these evaluations were in general positive (e.g., decrease in sugar‐sweetened beverages consumption following tax implementation) but no studies evaluated the outcome of reduced obesity.

Conclusions

PAHO recommended policies have been implemented to various degrees in Latin America since 2014 and more research is required to understand their impacts on child and adolescent obesity.

Food Availability in Different Food Environments Surrounding Schools in a Vulnerable Urban Area of Santiago, Chile: Exploring Socioeconomic Determinants

The analysis of the food environment is used to identify areas with gaps in the availability of healthy foods and can be used as a public policy assessment tool. In recent decades, Chile has implemented several strategies and regulations to improve food environments, with encouraging results. Little is known about the scope of these measures in socially vulnerable environments. This study is part of a project that seeks to build an integrated intervention model for healthy school environments in a vulnerable area of Santiago, Chile. The objective of this study was to evaluate the availability of healthy and unhealthy foods around schools and the relationship between it and socioeconomic determinants of the school community in the Chilean context. A cross-sectional study to measure the food environment of informal markets (street food), formal markets (stores), and institutions (schools) was conducted in and around 12 schools (100 m surrounding schools) in a vulnerable urban area of Santiago, Chile. A lack of healthy foods was observed, which was related to some socio-economic determinants and the multidimensional poverty was the most relevant. The diagnosis of food environments around schools can represent an important target for governments to implement policies focused at improving the availability of healthy foods.

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

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

Implementation of a regulatory food policy to reduce availability of energy-dense foods in Costa Rican high schools

OBJECTIVE

To assess the extent to which mandatory Guidelines to improve the school food environment were being implemented in Costa Rican high schools and to explore the perspectives of key policy actors towards the Guidelines.

DESIGN

Semi-structured interviews and site observations. Interviews were recorded, transcribed verbatim and imported to NVivo 12 for analysis. Inductive and deductive themes were identified, and elements of the RE-AIM framework and the social process framework were used when classifying these themes.

SETTING

Sixteen public high schools in San José, Costa Rica.

PARTICIPANTS

High school principal and kiosk concessionaires.

RESULTS

Products that did not adhere to the Guidelines were still widely available in schools, and amongst the most prevalent challenges to implementation that emerged from our interviews, were a lack of understanding of the policy content, a lack of monitoring and accountability, and competing values amongst actors which affected their views on the role that the school must have in offering a healthy food environment.

CONCLUSION

Most products offered in high schools did not meet the criteria required by the mandatory Guidelines, and several contextual factors were found to influence implementation. Strengthening the implementation of the Costa Rican Guidelines will require further actions at the governmental and school levels.

The Revolution Will Be Hard to Evaluate: How Co-Occurring Policy Changes Affect Research on the Health Effects of Social Policies

Extensive empirical health research leverages variation in the timing and location of policy changes as quasi-experiments. Multiple social policies may be adopted simultaneously in the same locations, creating co-occurrence that must be addressed analytically for valid inferences. The pervasiveness and consequences of co-occurring policies have received limited attention. We analyzed a systematic sample of 13 social policy databases covering diverse domains including poverty, paid family leave, and tobacco use. We quantified policy co-occurrence in each database as the fraction of variation in each policy measure across different jurisdictions and times that could be explained by covariation with other policies. We used simulations to estimate the ratio of the variance of effect estimates under the observed policy co-occurrence to variance if policies were independent. Policy co-occurrence ranged from very high for state-level cannabis policies to low for country-level sexual minority-rights policies. For 65% of policies, greater than 90% of the place-time variation was explained by other policies. Policy co-occurrence increased the variance of effect estimates by a median of 57-fold. Co-occurring policies are common and pose a major methodological challenge to rigorously evaluating health effects of individual social policies. When uncontrolled, co-occurring policies confound one another, and when controlled, resulting positivity violations may substantially inflate the variance of estimated effects. Tools to enhance validity and precision for evaluating co-occurring policies are needed.

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

BACKGROUND

In 2016, Chile implemented a unique law mandating front-of-package warning labels, restricting marketing, and banning school sales for products high in calories, sodium, sugar, or saturated fat. We aimed to examine changes in the calorie, sugar, sodium, and saturated fat content of food and beverage purchases after the first phase of implementation of this law.

METHODS

This before and after study used longitudinal data on food and beverage purchases from 2381 Chilean households from Jan 1, 2015, to Dec 31, 2017. Nutrition facts panel data from food and beverage packages were linked to household purchases at the product level using barcode, brand name, and product description. Nutritionists reviewed each product for nutritional accuracy and categorised it as high-in if it contained added sugar, sodium, or saturated fat and exceeded phase 1 nutrient or calorie thresholds, and thus was subject to the labelling, marketing, and school regulations. Using fixed-effects models, we examined the mean nutrient content (overall calories, sugar, saturated fat, and sodium) of purchases in the post-policy period compared to a counterfactual scenario based on pre-policy trends.

FINDINGS

Compared with the counterfactual scenario, overall calories purchased declined by 16·4 kcal/capita/day (95% CI -27·3 to -5·6; p=0·0031) or 3·5%. Overall sugar declined by 11·5 kcal/capita/day (-14·6 to -8·4; p<0·0001) or 10·2%, and saturated fat declined by 2·2 kcal/capita/day (-3·8 to -0·5; p=0·0097) or 3·9%. The sodium content of overall purchases declined by 27·7 mg/capita/day (-46·3 to -9·1; p=0·0035) or 4·7%. Declines from high-in purchases drove these results with some offset by increases in not-high-in purchases. Among high-in purchases, relative to the counterfactual scenario, there were notable declines of 23·8% in calories purchased (-49·4 kcal/capita/day, 95% CI -55·1 to -43·7; p<0·0001), 36·7% in sodium purchased (-96·6 mg/capita/day,-105·3 to -87·8; p<0·0001), and 26·7% in sugar purchased (-20·7 kcal/capita/day, -23·4 to -18·1; p<0·0001).

INTERPRETATION

The Chilean phase 1 law of food labelling and advertising policies were associated with reduced high-in purchases, leading to declines in purchased nutrients of concern. Greater changes might reasonably be anticipated after the implementation of phases 2 and 3.

FUNDING

Bloomberg Philanthropies, International Development Research Center, and Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health.

What to Do When Everything Happens at Once: Analytic Approaches to Estimate the Health Effects of Co-Occurring Social Policies

Social policies have great potential to improve population health and reduce health disparities. Increasingly, those doing empirical research have sought to quantify the health effects of social policies by exploiting variation in the timing of policy changes across places. Multiple social policies are often adopted simultaneously or in close succession in the same locations, creating co-occurrence that must be handled analytically for valid inferences. Although this is a substantial methodological challenge for researchers aiming to isolate social policy effects, only in a limited number of studies have researchers systematically considered analytic solutions within a causal framework or assessed whether these solutions are being adopted. We designated 7 analytic solutions to policy co-occurrence, including efforts to disentangle individual policy effects and efforts to estimate the combined effects of co-occurring policies. We used an existing systematic review of social policies and health to evaluate how often policy co-occurrence is identified as a threat to validity and how often each analytic solution is applied in practice. Of the 55 studies, only in 17 (31%) did authors report checking for any co-occurring policies, although in 36 studies (67%), at least 1 approach was used that helps address policy co-occurrence. The most common approaches were adjusting for measures of co-occurring policies; defining the outcome on subpopulations likely to be affected by the policy of interest (but not other co-occurring policies); and selecting a less-correlated measure of policy exposure. As health research increasingly focuses on policy changes, we must systematically assess policy co-occurrence and apply analytic solutions to strengthen studies on the health effects of social policies.

Food environment solutions for childhood obesity in Latin America and among Latinos living in the United States

The food environment is a major contributor to unhealthy diets in children and, therefore, to the increasing rates of obesity. Acclaimed by scholars across the world, Latin American countries have been leaders in implementing policies that target different aspects of the food environment. Evidence on the nature and to what extent children are exposed and respond to unhealthy food environments in the region and among Latinos in the United States is, however, deficient. The objective of this review is to use the integrated International Network for Food and Obesity/noncommunicable diseases (NCDs) Research, Monitoring and Action Support (INFORMAS) framework to create healthy food environment to (i) compare the key elements of childhood obesity-related food environments in Latin America and for Latinos living in the United States; (ii) describe the evidence on solutions to improve childhood obesity-related food environments; and (iii) identify research priorities to inform solutions to fight childhood obesity in these populations. We found that an integrated body of evidence is needed to inform an optimal package of policies to improve food environments to which children in Latin America and Latino children in the United States are exposed and more efficiently translate policy solutions to help curb growing childhood obesity levels across borders.

Changes in Nutrient Declaration after the Food Labeling and Advertising Law in Chile: A Longitudinal Approach

Chile has implemented several strategies to decrease the burden of obesity and chronic diseases. The Food Labeling and Advertising Law (Law 20.606) requires a front-of-package "high in" warning label when energy and nutrients of concern (ENC) (total sugar, saturated fats, sodium) exceed established limits. This study aims to evaluate the impact of Law 20.606 on the ENC declaration of packaged foods in Chile, before and after the law implementation. We analyzed food nutritional labeling declarations from 70% of the most consumed packaged foods in Chile. Data collection was conducted in 2013 and 2019 in Santiago. Pictures from all sides of the package were taken from 476 products, classified into 16 food groups. All food groups had changes in the ENC declaration during the study period. Total sugar content showed the highest reduction (-15.0%; p = 0.001). Dairy, confitures and similar and sugary beverages had the greatest reduction in energy and total sugar content (p < 0.01). Energy, total sugar and sodium front of package "high in" simulation was significantly reduced in dairy, sugary beverages, flour-based foods, confitures and similar, fish and seafoods, fats and oils, spices, condiments and sauces and sugars (p < 0.05). We observed that companies reformulated products to adapt to the new regulation.

Nutritional Quality of Food and Beverages Offered in Supermarkets of Lima According to the Peruvian Law of Healthy Eating

The purpose of this paper was to determine the foods and beverages offered in the city of Lima, Peru, that would be subject to front-of-package warning labels (octagons) according to the thresholds for the two phases (6 and 39 months after the approval) for nutrients of concern (sugar, sodium, saturated fat, and trans-fat) included in the Peruvian Law of Healthy Eating. An observational, descriptive cross-sectional study was conducted that evaluated the nutritional composition of processed and ultra-processed foods that are sold in a supermarket chain in Lima. Of all the processed and ultra-processed foods captured, foods that report nutritional information and do not require reconstitution to be consumed were included. A descriptive analysis was carried out by food categories to report the nutrient content and the percentage of foods that would be subject to front-of-package warning labels. Results: A total of 1234 foods were evaluated, according to the initial thresholds that became effective 6 months after the law was implemented; 35.9% of foods had two octagons; 34.8% had one octagon; 15.8% had no octagons; 12% had three octagons; and no products had four octagons. At 39 months, when the final and more restrictive thresholds become effective, 4.8% did not have octagons. The majority of processed and ultra-processed foods that are sold in a Peruvian supermarket chain carry at least one octagon, and more than 10% of them carry octagons for three of the four nutrients of concern.

An evaluation of Chile's Law of Food Labeling and Advertising on sugar-sweetened beverage purchases from 2015 to 2017: A before-and-after study

BACKGROUND

Chile's Law of Food Labeling and Advertising, implemented in 2016, was the first national regulation to jointly mandate front-of-package warning labels, restrict child-directed marketing, and ban sales in schools of all foods and beverages containing added sugars, sodium, or saturated fats that exceed set nutrient or calorie thresholds. The objective of this study is to evaluate the impact of this package of policies on household beverage purchases.

METHOD AND FINDINGS

In this observational study, monthly longitudinal data on packaged beverage purchases were collected from urban-dwelling households (n = 2,383) participating in the Kantar WordPanel Chile Survey from January 1, 2015, to December 31, 2017. Beverage purchases were linked to nutritional information at the product level, reviewed by a team of nutritionists, and categorized as "high-in" or "not high-in" according to whether they contained high levels of nutrients of concern (i.e., sugars, sodium, saturated fat, or energy) according to Chilean nutrient thresholds and were thus subject to the law's warning label, marketing restriction, and school sales ban policies. The majority of high-in beverages were categorized as such because of high sugar content. We used fixed-effects models to compare the observed volume as well as calorie and sugar content of postregulation beverage purchases to a counterfactual based on preregulation trends, overall and by household-head educational attainment. Of households included in the study, 37% of household heads had low education (less than high school), 40% had medium education (graduated high school), and 23% had high education (graduated college), with the sample becoming more educated over the study period. Compared to the counterfactual, the volume of high-in beverage purchases decreased 22.8 mL/capita/day, postregulation (95% confidence interval [CI] -22.9 to -22.7; p < 0.001), or 23.7% (95% CI -23.8% to -23.7%). High-educated and low-educated households showed similar absolute reductions in high-in beverage purchases (approximately 27 mL/capita/day; p < 0.001), but for high-educated households this amounted to a larger relative decline (-28.7%, 95% CI -28.8% to -28.6%) compared to low-educated households (-21.5%, 95% CI -21.6% to -21.4%), likely because of the high-educated households' lower level of high-in beverage purchases in the preregulation period. Calories from high-in beverage purchases decreased 11.9 kcal/capita/day (95% CI -12.0 to -11.9; p < 0.001) or 27.5% (95% CI -27.6% to -27.5%). Calories purchased from beverages classified as "not high-in" increased 5.7 kcal/capita/day (95% CI 5.7-5.7; p < 0.001), or 10.8% (10.8%-10.8%). Calories from total beverage purchases decreased 7.4 kcal/capita/day (95% CI -7.4 to -7.3; p < 0.001), or 7.5% (95% CI -7.6% to -7.5%). A key limitation of this study is the inability to assess causality because of its observational nature. We also cannot determine whether observed changes in purchases are due to reformulation or consumer behavioral change, nor can we parse out the effects of the labeling, marketing, and school sales ban policies.

CONCLUSIONS

Purchases of high-in beverages significantly declined following implementation of Chile's Law of Food Labeling and Advertising; these reductions were larger than those observed from single, standalone policies, including sugar-sweetened-beverage taxes previously implemented in Latin America. Future research should evaluate the effects of Chile's policies on purchases of high-in foods, dietary intake, and long-term purchasing changes.

The Relationship between Self-Reported Exposure to Sugar-Sweetened Beverage Promotions and Intake: Cross-Sectional Analysis of the 2017 International Food Policy Study

Sugar-sweetened beverage (SSB) consumption is independently associated with several non-communicable diseases, so policymakers are increasingly implementing measures, such as marketing regulation, to reduce intake. To help understand how such measures work, this study examined the association between SSB consumption and self-reported exposure to SSB promotions, both overall and by type of promotion, and whether these relationships vary between the UK, USA, Canada, Mexico, and Australia. Cross-sectional analysis of the online 2017 International Food Policy Study was performed (n = 15,515). Participants were grouped into 5265 (34%) non-, 5117 (33%) low-, and 5133 (33%) high-SSB consumers. Multinomial logistic regression models examined whether SSB consumption varied by exposure to total SSB promotion and by type: traditional, digital, recreational environment, and functional environment. Multiplicative interactions were included to investigate international variations. An additional unit of total self-reported SSB promotion exposure increased the likelihood of participants being low SSB consumers (relative risk ratio (RRR) = 1.08, 95% confidence interval (CI) = 1.06–1.10) and high SSB consumers (RRR = 1.13, 95% CI = 1.11–1.16). Only exposure to traditional and digital promotion increased the likelihood of participants being SSB consumers, though this may be explained by degree of exposure, which was not measured in this study. Some evidence illustrated international variation in these relationships.

Understanding the rise of cardiometabolic diseases in low- and middle-income countries

Increases in the prevalence of noncommunicable diseases (NCDs), particularly cardiometabolic diseases such as cardiovascular disease, stroke and diabetes, and their major risk factors have not been uniform across settings: for example, cardiovascular disease mortality has declined over recent decades in high-income countries but increased in low- and middle-income countries (LMICs). The factors contributing to this rise are varied and are influenced by environmental, social, political and commercial determinants of health, among other factors. This Review focuses on understanding the rise of cardiometabolic diseases in LMICs, with particular emphasis on obesity and its drivers, together with broader environmental and macro determinants of health, as well as LMIC-based responses to counteract cardiometabolic diseases.