Changes in the Use of Non-nutritive Sweeteners in the Chilean Food and Beverage Supply After the Implementation of the Food Labeling and Advertising Law

More than a Nuisance: Implications of Food Marketing for Public Health Efforts to Curb Childhood Obesity

Fifteen years ago, public health experts urged industry, governments, and advocates to take action to dramatically improve the unhealthy food-marketing environment surrounding children in order to address the global childhood obesity crisis. Since then, research has confirmed that food marketing to children has far-reaching negative effects on their diets and health, takes advantage of adolescent vulnerabilities, and contributes to health disparities. In addition, digital marketing has profoundly changed young people's engagement with brands. Moreover, reliance on industry self-regulation as a solution has proven ineffective. Government-led policies have been more successful, but they remain limited in scope and challenging to adopt and implement. New approaches are necessary to increase public and policy maker awareness that food marketing is more than a nuisance, that it threatens the long-term health of children and adolescents worldwide, and that meaningful governmental action is urgently required to curtail industry's negative impact on young people's well-being.

Pragmatic Carbohydrate Quality Metrics in Relation to Glycemic Index, Glycemic Load, and Front-of-Pack Warning Labels in Grain Foods

The challenges in the characterization of the nutritional quality of grain foods comprise obstacles to public health actions toward promotion of healthier grain-based foods. The present study investigated how carbohydrate metrics related to glycemic index (GI), glycemic load (GL), and warning labels of grain foods consumed by individuals living in São Paulo, Brazil. Information on intake of grain foods at individual level was obtained using 24 h recalls within a cross-sectional population-based survey conducted in 2015. There were 244 unique grain products reported by individuals in the survey, assessed through four metrics of carbohydrate quality, considering contents per 10 g of total carbohydrate: (1) ≥1 g fiber, (2) ≥1 g fiber and <1 g free sugars, (3) ≥1 g fiber and <2 g free sugars, and (4) ≥1 g fiber, and <2 g free sugars per 1 g of fiber. Outcomes included GI, GL, and inclusion of warning labels proposed by the Brazilian National Health Surveillance Agency (ANVISA), the Chilean Ministry of Health (1st and 3rd stages), and the Pan American Health Organization (PAHO). Metrics identified products with lower mean GI (-12.8 to -9.0 [p-values < 0.001]), and GL (-12.5 to -10.3 [p-values < 0.001]). Warning systems showed a certain degree of discrimination between products according to the metrics (p-value < 0.01 each); however, >50% of products with good nutritional quality according to the carbohydrate metrics still would receive warnings. Findings suggest that carbohydrate metrics identified products with lower GI and GL, and current warning labels may not adequately capture overall nutritional quality of grain foods.

Consistency of the Initial and Updated Version of the Nutri-Score with Food-Based Dietary Guidelines: A French Perspective

BACKGROUND

To help consumers to make healthier food choices, 7 European countries have implemented the front-of-pack nutrition label Nutri-Score. The algorithm was updated in 2022-2023 by the Nutri-Score European scientific committee, based on the current scientific knowledge.

OBJECTIVES

The aim of this study was to investigate the consistency of the newly internationally developed algorithm with the French food-based dietary guidelines (FBDG) and compare the respective performances of the initial and updated algorithm.

METHODS

Three complementary French food composition databases were used to access extensive coverage of the food supply in France (n = 46,752): the Oqali, OpenFoodFacts, and CIQUAL databases. Based on the French FBDG, a list of 41 criteria was defined by which the consistency between French FBDG and the Nutri-Score was assessed (eg, consumption of fresh vegetables is promoted in FBDG, thus the Nutri-Score should rate favorably such products).

RESULTS

Of all criteria, the initial algorithm met 63% (26/41) of them, whereas the revised algorithm met 85% (35/41) of them. Improvements achieved by the updated version of the Nutri-Score in alignment with the FBDG were particularly observed for high-fat products (ie, fatty fish, nuts, and seeds), sweet products (ie, ice creams and sweet spreads), salty products (ie, savory snacks and salted nuts), dairy beverages, and beverages with artificial sweeteners.

CONCLUSIONS

The Nutri-Score's updated nutrient profiling system appears to rate foods more consistently regarding the French dietary guidelines and improved the currently existing system. This work supports the implementation of the updated nutrient profiling system underlying Nutri-Score.

Impact of implementation of front-of-package nutrition labeling on sugary beverage consumption and consequently on the prevalence of excess body weight and obesity and related direct costs in Brazil: An estimate through a modeling study

RATIONALE

Intake of sugary beverages has been associated with obesity and chronic non-communicable diseases, thereby increasing the direct health costs related to these diseases. Front-of-package nutrition labeling (FoPNL) aims to help consumers understand food composition, thereby improving food choices and preventing the development of such diseases.

OBJECTIVE

To estimate, over five years, the impact of implementing FoPNL in Brazil on the prevalence of excess body weight and obesity in adults who consume sugary beverages and the direct costs related to such problems.

METHODS

A simulation study to performed to estimate the effect of FoPNL implementation on the prevalence of excess body weight and obesity. The VIGITEL research database (2019), published in the 2020 report, was used in this study (the final sample consisted of 12,471 data points representing 14,380,032 Brazilians). The scenarios were considered: base (trend in sugary beverage intake); 1 (base scenario associated with the changes in energy content of the purchased beverages observed after the first phase of the Chilean labeling law (-9.9%); and 2 (scenario 1 associated with reformulation of beverages, total energy reduction of -1.6%). Changes in body weight were estimated using the simulation model of Hall et al. (2011) over five years. A linear trend in the prevalence of obesity and excess body weight in the Brazilian population was considered. The impact of the prevalence of obesity and excess body weight on body mass index was estimated. In addition, the direct health costs related to obesity were estimated.

RESULTS

Energy consumption from sugary beverages after FoPNL implementation is expected to be reduced by approximately 28 kcal/day (95% CI, -30 to -27) considering scenario 1. In scenarios 1 and 2, without FoPNL, the prevalence of obesity and excess body weight over five years was estimated to be 25.3% and 25.2%, and 64.4% and 64.2%, respectively. By extrapolating the results to the entire Brazilian population, it was observed that the implementation of FoPNL may reduce the prevalence of obesity by -0.32 percentage points and -0.35 percentage points (scenario 1 and 2, respectively) and excess body weight by -0.42 percentage points and -0.48 percentage points (scenarios 1 and 2, respectively) in five years. It is estimated that after five years of implementation, it will be possible to save approximately US$ 5,5 millions (95% CI 4,7 to 8,8) in scenario 1, reaching approximately US$ 6,1 millions (95% CI 5,3 to 9,8) in scenario 2.

CONCLUSION

The results of this modeling study indicate that FoPNL may reduce prevalence of excess body weight and obesity, representing strategic public policies for obesity prevention.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Global trends in added sugars and non-nutritive sweetener use in the packaged food supply: drivers and implications for public health

OBJECTIVE

The health implications of excessive added sugar intakes have led to national policy actions to limit their consumption. Subsequently, non-nutritive sweeteners (NNS) may be used to maintain product sweetness. We aimed to assess trends in quantities of added sugars and NNS sold in packaged food and beverages worldwide, and the association between these trends and the number of national policy actions across regions to reduce added sugar consumption.

DESIGN

(i) Longitudinal analysis of Euromonitor sales data (2007-2019) to assess the quantity of added sugars (kg) and NNS (g) sold in packaged foods and beverages globally, across regions, and across country income categories; (ii) policy-mapping of policy actions targeting added sugar consumption globally from the NOURISHING database; and (iii) Spearman's correlations to assess the association between national policy actions across regions and changes in added sugar/NNS sales.

SETTING

Worldwide.

PARTICIPANTS

Not applicable.

RESULTS

Per capita volumes of NNS from beverage sales increased globally (36 %). Added sugars from beverage sales decreased in high-income countries (22 %) but increased in upper-middle-income countries (UMIC) and lower-middle-income countries (LMIC) (13-40 %). Added sugars from packaged food sales increased globally (9 %). Regions with more policy actions had a significant increase in NNS quantities from beverage sales (r = 0·68, P = 0·04). The sweetness of the packaged food supply (the sweetness of each NNS and added sugar, relative to sucrose, multiplied by sales volume) increased over time.

CONCLUSIONS

The increasing use of NNS to sweeten beverages globally, and in packaged food in UMIC and LMIC, may have health and dietary implications in the future. Their use as a substitute for added sugar should be considered in public health nutrition policymaking.

Estimating the dietary and health impact of implementing front-of-pack nutrition labeling in Canada: A macrosimulation modeling study

Background

Front-of-pack labeling (FOPL) has been identified as a cost-effective policy to promote healthy diets. Health Canada has recently published FOPL regulations that will require food and beverages that meet or exceed set thresholds for sodium, sugars, or saturated fat to display a 'high in' symbol on the front of the package. Although a promising measure, its potential impact on dietary intakes and health have not yet been estimated in Canada.

Objective

This study aims to estimate (1) the potential dietary impact of implementing a mandatory FOPL among Canadian adults; and (2) the number of diet-related non-communicable disease (NCD) deaths that could be averted or delayed due to these estimated dietary changes.

Methods

Baseline and counterfactual usual intakes of sodium, total sugars, saturated fats, and calories were estimated among Canadian adults (n = 11,992) using both available days of 24 h recalls from the 2015 Canadian Community Health Survey-Nutrition. The National Cancer Institute method was used to estimate usual intakes, and adjusted for age, sex, misreporting status, weekend/weekday, and sequence of recall. Estimated counterfactual dietary intakes were modeled from reductions observed in experimental and observational studies that examined changes in sodium, sugars, saturated fat, and calorie content of food purchases in the presence of a 'high in' FOPL (four counterfactual scenarios). The Preventable Risk Integrated ModEl was used to estimate potential health impacts.

Results

Estimated mean dietary reductions were between 31 and 212 mg/day of sodium, 2.3 and 8.7 g/day of total sugars, 0.8 and 3.7 g/day of saturated fats, and 16 and 59 kcal/day of calories. Between 2,183 (95% UI 2,008-2,361) and 8,907 (95% UI 8,095-9,667) deaths due to diet-related NCDs, mostly from cardiovascular diseases (~70%), could potentially be averted or delayed by implementing a 'high in' FOPL in Canada. This estimation represents between 2.4 and 9.6% of the total number of diet-related NCD deaths in Canada.

Conclusion

Results suggest that implementing a FOPL could significantly reduce sodium, total sugar, and saturated fat intakes among Canadian adults and subsequently prevent or postpone a substantial number of diet-related NCD deaths in Canada. These results provide critical evidence to inform policy decisions related to implementing FOPL in Canada.

Reformulation of Top-Selling Processed and Ultra-Processed Foods and Beverages in the Peruvian Food Supply after Front-of-Package Warning Label Policy

Front-of-package warning label (FOPWL) policies incentivize the food industry to reduce the content of regulated nutrients in products. We explored changes in the content of nutrients of concern (sugar, saturated fat, trans fat, and sodium) and the percentage of products in the Peruvian food supply that would carry a FOPWL before and after Peru’s implementation of FOPWLs. Longitudinal data on the top-selling foods and beverages (n = 94) were collected at three time points: three months before the implementation of the policy, four months after, and two years after. Using the nutritional information declared on products’ labels, we compared quantities of nutrients of concern and the percentage of foods that would carry a FOPWL at each time point. Between the first and the third data collection, a decrease in the median sugar content of beverages was observed (from 9.0 to 5.9 g/100 mL, p = 0.005), accompanied by an increase in the use of nonnutritive sweeteners. This change drove the reduction of the percentage of beverages that would carry a FOPWL (from 59 to 31%, p = 0.011). Among foods, decreases were observed in saturated fat (from 6.7 to 5.9 g/100 g, p = 0.002). The percentage of foods that would carry a FOPWL according to their nutritional profile declined from before to after implementation of the policy (from 82 to 62%, p < 0.001). The study shows that the industry reformulated products in Peru after implementation of its FOPWL policy.

Did the sweetness of beverages change with the Chilean Food Labeling and Marketing Law? A before and after study

There has been a rapid proliferation of policies around the globe to reduce sugar consumption, yet there is little understanding as to whether these policies have led to changes in the overall sweetness of products, which is essential for understanding long-term effects on food preferences and intake. For example, the implementation of Chile’s Law on Food Labeling and Advertising led to decreases in the sugar content of non-alcoholic packaged beverages and increases in non-nutritive sweeteners (NNS) use in these beverages. Given that NNS have greater sweetness intensity than sugars, it is unclear what was the net effect of these changes on the sweetness of purchased beverages. Using longitudinal household purchase data (n &gt; 2,000 households), we measured the changes in the sweetness of beverage purchases after implementing the first phase of the Chilean law and examine if there were differences by key family sociodemographic variables. We developed three sweetness indices: (1) NNS sweetness, including the sweetness of the six NNS most consumed by Chileans; (2) total sugars sweetness, including the sweetness from total sugars; and (3) total sweetness, combining the sweetness from NNS and sugars. Using fixed-effects models, we compared the observed post-law purchases to a counterfactual based on pre-law trends. We found that NNS sweetness increased relative to the counterfactual, while total sugars sweetness decreased after the law. However, the absolute changes in NNS sweetness were almost entirely offset by the decreases in total sugar sweetness, leading to no change in the total sweetness of beverage purchases. Additionally, there were no differences in the sweetness changes by family sociodemographics. Our findings indicate that Chilean consumers are exposed to similar sweetness levels in their beverages after the law. Future research should explore whether sweetness also remained consistent in dietary intake.

From the most to the least flexible nutritional profile: Classification of foods marketed in Brazil according to the Brazilian and Mexican models

Nutrient profiling is the science of classifying or ranking foods according to their nutritional composition, for reasons related to disease prevention and health promotion. To be effective, policies such as front-of-pack nutrition labeling (FoPNL) must have an adequate nutritional profile model, since it will determine which products will be eligible to receive a FoPNL. This study aimed to determine the percentage of packaged food and drink products available in Brazil that would be subject to FoPNL under two different legislations: Brazilian and Mexican. This is a cross-sectional study in which we collected information on food products (photos of the ingredients list, the front label, the barcode, and the nutrition facts table) from one of the largest stores of a supermarket chain in the city of Belo Horizonte-MG, Brazil, from March to May 2021 (~6 months after the publication of the Brazilian legislation about FoPNL and a year and a half before the legislation came into force). The products were classified in relation to the BNPM (added sugars, saturated fats, and sodium) and the MNPM (energy, free sugars, saturated fats, trans fats, sodium, non-sugar sweeteners, and caffeine). A total of 3384 products were collected and, after applying the exclusion criteria, 3,335 products were evaluated. Of these, 2,901 would be eligible to receive FoPNL in Brazil and 2,914 would be eligible to receive FoPNL in Mexico. According to the BNPM, 56.7% (95% CI 54.9; 58.5%) of the products were “high in” critical nutrients, 27.1% (95% CI 25.5; 28.7%) of the products in added sugars, 26.7% (95% CI 25.2; 28.4%) of the products in saturated fats, and 21.4% (95% CI 19.9; 22.9%) of the products in sodium. As for the MNPM, 96.8% (95% CI 96.1; 97.4%) of them were “high in” up to five critical nutrients and up to two warning rectangles (caffeine and non-sugar sweeteners), 45.8% (95% CI 44.0; 47.6%) of them in free sugars, 43.7% (95% CI 41.9; 45.5%) of them in saturated fats, and 47.9% (95% CI 46.1; 49.7%) of them in sodium. We concluded that the eligibility to receive FoPNL by BNPM and MNPM was relatively similar between products; however, almost all products would have at least one FoPNL and/or warning rectangles according to Mexican legislation, and nearly half of them would have at least one FoPNL, considering BNPM. The MNPM is much more restrictive than the BNPM. The Nutrient Profile Model (NPM) that regulates FoPNL, and other health policies, must be carefully defined to ensure that foods are properly classified according to their healthiness.

Nutritional Quality of Pre-Packaged Foods in China under Various Nutrient Profile Models

This study used various nutrient profile models (NPMs) to evaluate the nutritional quality of pre-packaged foods in China to inform future food policy development. Nutrition data for pre-packaged foods were collected through FoodSwitch China in 2017-2020. The analyses included 73,885 pre-packaged foods, including 8236 beverages and 65,649 foods. Processed foods (PFs) and ultra-processed foods (UPFs) accounted for 8222 (11.4%) and 47,003 (63.6%) of all products, respectively. Among the 55,425 PFs and UPFs, the overall proportion of products with an excessive quantity of at least one negative nutrient was 86.0% according to the Chilean NPM (2019), 83.3% for the Pan American Health Organization NPM (PAHO NPM), and 90.6% for the Western Pacific Region NPM for protecting children from food marketing (WPHO NPM), respectively. In all NPMs, 70.4% of PFs and UPFs were identified as containing an excessive quantity of at least one negative nutrient, with higher proportions of UPFs compared to PFs. Food groups exceeding nutrient thresholds in most NPMs included snack foods, meat and meat products, bread and bakery products, non-alcoholic beverages, confectionery, and convenience foods. In conclusion, PFs and UPFs accounted for three-fourths of pre-packaged foods in China, and the majority of PFs and UPFs exceeded the threshold for at least one negative nutrient under all three NPMs. Given the need to prevent obesity and other diet-related chronic diseases, efforts are warranted to improve the healthiness of foods in China through evidence-based food policy.

Nutritional Description of Foods with Low- and No-Calorie Sweeteners in Spain: The BADALI Project

The use of low- and no-calorie sweeteners (LNCS) in foods has increased in recent years in response to the negative effects of free sugar on health. However, the health impact of LNCS is still unclear. Studies of the prevalence of LNCS in foods have been published previously, including in Spain. However, the use of health (HCs) and nutrition claims (NCs) to promote these foods and a full nutritional characterization are largely lacking. For this purpose, we used the BADALI database with 4218 foods present in the Spanish market. Our results show that 9.3% of foods have LNCS (including both intense and polyols). Sucralose and acesulfame K were the intense sweeteners most frequently used (52.4% and 48.2%, respectively), whereas maltitol was the preferred polyol (20.3%). Of all foods with LNCS, 30% also had added sugar. Many more foods with LNCS presented HCs and NCs than those without. Sugar was the nutrient most frequently claimed in NCs for LNCS-containing foods, whereas vitamins were for those without these sweeteners. NCs compliance with regulation was similar in both conditions (60.1% for foods without and 63.9% for foods with LNCS). As expected, foods with LNCS had less total sugar content and energy. Surprisingly, the nutrient profile of yogurts with LNCS changed completely: less total and saturated fat, whereas more proteins and sodium. Biscuits with LNCS contained more fibre. The results of our study reveal that the prevalence of LNCS is becoming high in some food types in Spain and that foods containing LNCS are more frequently promoted with HCs/NCs. In addition, it confirms the general reduction in energy and sugar content expected in foods with LNCS. Furthermore, it suggests a reformulation of products beyond sugar content.

Sweetness of Chilean Infants' Diets: Methodology and Description

Sugars and other sweeteners contribute to the sweet taste of foods; exposure to this taste could alter appetite regulation and preferences for sweet products. Despite this, there is no widely accepted methodology for estimating overall diet sweetness. The objective of this study was to develop a methodology to estimate diet sweetness and describe diet sweetness in a cohort of Chilean infants. In order to estimate diet sweetness density, the sweetness intensity of foods was obtained from existing databases and from sensory evaluations in products with no available information and then linked to 24-h dietary recalls of infants at 12 and 36 months of age. Diet sweetness density was significantly and positively associated with total sugars and non-nutritive sweeteners intakes. The main food sources of sweetness at 12 months were fruits (27%) and beverages (19%). Sweetness density increased 40% between 12 and 36 months (from 1196 to 1673, p < 0.01), and sweetness density at both ages was significantly associated. At 36 months, beverages and dairy products were the main sources of sweetness (representing 32.2% and 28.6%, respectively). The methodology presented here to estimate the sweetness density of the diet could be useful for other studies to help elucidate different effects of exposure to high sweetness.

Prevalence of low-calorie sweeteners and related front-of-package claims in the Brazilian packaged food supply

BACKGROUND

Low-calorie sweeteners (LCS) are increasingly being used worldwide, including in foods and beverages commonly consumed by children.

OBJECTIVE

To examine the prevalence of LCS in packaged foods and beverages sold in Brazil, whether LCS are added to products with advertising directed to children, and whether foods and beverages with LCS include front-of-package (FoP) LCS-related health and nutrition claims.

DESIGN

Cross-sectional study.

SETTING

A sample (n = 11,434) of packaged foods and beverages sold by the top five largest Brazilian food retailers was examined to identify LCS and added sugars and a subsample (n = 3,491) was examined to determine the presence of advertising directed to children and FoP LCS-related claims in foods and beverages with LCS.

MAIN OUTCOME AND MEASURES

The prevalence of foods and beverages with different types of LCS in the Brazilian food supply, among ultra-processed foods and beverages and among foods and beverages with added sugars were measured. Foods and beverages with advertising directed to children were checked to see if these products had LCS, and how many products with LCS had FoP labels with LCS-related claims.

STATISTICAL ANALYSES

Mean and 95% confidence intervals were used to determine the overall prevalence of foods and beverages with LCS and in the different assessed stratifications.

RESULTS

The prevalence of LCS was 9.3% (95% CI 8.8, 9.9) in Brazilian packaged foods and beverages, 14.6% (95% CI 13.8, 15.4) in ultra-processed products alone, and 5.7% (95% CI 4.2, 7.7) in foods and beverages with advertising directed to children. About 83% of food and beverage with LCS were also sweetened with added sugars. LCS were most frequently added to nonalcoholic sweetened beverages, breakfast cereals, and granola bars. Forty percent of foods and beverages with LCS did not present any front-of-package LCS-related claim.

CONCLUSION

This study shows that LCS are present in 15% of ultra-processed foods and beverages in Brazil, largely used in combination with added sugars, and are found in foods and beverages with advertising directed to children. Clearer FoP information regarding the presence of LCS, in particular in products with advertising directed to children, can help consumers make more informed choices regarding LCS consumption.