Decreases in purchases of energy, sodium, sugar, and saturated fat 3 years after implementation of the Chilean food labeling and marketing law: An interrupted time series analysis.

BACKGROUND: In 2016, Chile implemented a multiphase set of policies that mandated warning labels, restricted food marketing to children, and banned school sales of foods and beverages high in nutrients of concern ("high-in" foods). Chile's law, particularly the warning label component, set the precedent for a rapid global proliferation of similar policies. While our initial evaluation showed policy-linked decreases in purchases of high-in, a longer-term evaluation is needed, particularly as later phases of Chile's law included stricter nutrient thresholds and introduced a daytime ban on advertising of high-in foods for all audiences. The objective is to evaluate changes in purchases of energy, sugar, sodium, and saturated fat purchased after Phase 2 implementation of the Chilean policies. METHODS AND FINDINGS: This interrupted time series study used longitudinal data on monthly food and beverage purchases from 2,844 Chilean households (138,391 household-months) from July 1, 2013 until June 25, 2019. Nutrition facts panel data from food and beverage packages were linked at the product level and reviewed by nutritionists. Products were considered "high-in" if they contained added sugar, sodium, or saturated fat and exceeded nutrient or calorie thresholds. Using correlated random-effects models and an interrupted time series design, we estimated the nutrient content of food and beverage purchases associated with Phase 1 and Phase 2 compared to a counterfactual scenario based on trends during a 36-month pre-policy timeframe. Compared to the counterfactual, we observed significant decreases in high-in purchases of foods and beverages during Phase 2, including a relative 36.8% reduction in sugar (-30.4 calories/capita/day, 95% CI -34.5, -26.3), a 23.0% relative reduction in energy (-51.6 calories/capita/day, 95% CI -60.7, -42.6), a 21.9% relative reduction in sodium (-85.8 mg/capita/day, 95% CI -105.0, -66.7), and a 15.7% relative reduction in saturated fat (-6.4 calories/capita/day, 95% CI -8.4, -4.3), while purchases of not-high-in foods and drinks increased. Reductions in sugar and energy purchases were driven by beverage purchases, whereas reductions in sodium and saturated fat were driven by foods. Compared to the counterfactual, changes in both high-in purchases and not high-in purchases observed in Phase 2 tended to be larger than changes observed in Phase 1. The pattern of changes in purchases was similar for households of lower versus higher socioeconomic status. A limitation of this study is that some results were sensitive to the use of shorter pre-policy time frames. CONCLUSIONS: Compared to a counterfactual based on a 36-month pre-policy timeframe, Chilean policies on food labeling, marketing, and school food sales led to declines in nutrients of concern during Phase 2 of implementation, particularly from foods and drinks high in nutrients of concern. These declines were sustained or even increased over phases of policy implementation.

Monitoring sodium content in processed and ultraprocessed foods in Argentina 2022: compliance with National Legislation and Regional Targets.

OBJECTIVE: To assess the current Na levels in a variety of processed food groups and categories available in the Argentinean market to monitor compliance with the National Law and to compare the current Na content levels with the updated Pan American Health Organisation (PAHO) regional targets. DESIGN: Observational cross-sectional study. SETTING AND PARTICIPANTS: Argentina. Data were collected during March 2022 in the city of Buenos Aires in two of the main supermarket chains. We carried out a systematic survey of pre-packaged food products available in the food supply assessing Na content as reported in nutrition information panels. RESULTS: We surveyed 3997 food products, and the Na content of 760 and 2511 of them was compared with the maximum levels according to the Argentinean law and the regional targets, respectively. All food categories presented high variability of Na content. More than 90 % of the products included in the National Sodium Reduction Law were found to be compliant. Food groups with high median Na, such as meat and fish condiments, leavening flour and appetisers are not included in the National Law. In turn, comparisons with PAHO regional targets indicated that more than 50 % of the products were found to exceed the regional targets for Na. CONCLUSIONS: This evidence suggests that it is imperative to update the National Sodium Reduction Law based on regional public health standards, adding new food groups and setting more stringent legal targets.

Fruitful changes? Exploring household fruit purchase decisions following comprehensive food policy regulations in Chile.

Changes in unprocessed healthy food purchases associated with the implementation of comprehensive food policy remain understudied. This study analyzes whether, following the announcement, modification, and implementation of Chile's Food Labeling and Advertising law targeting highly processed food (occurring in 2012, 2015, and 2016, respectively), households improved their fruit purchase decisions: purchase participation (i.e., buying likelihood) and purchase quantity. Expenditure data from a representative sample of Chilean households were employed, covering two consecutive survey waves conducted in 2011/2012 and 2016/2017. After controlling for socioeconomic factors (e.g., prices and income), results indicate that only purchase participation increased, providing weak support for positive spillover effects of a comprehensive food policy on fruit purchases. Subsample analyses reveal that this increase was driven by college-educated, childless, and low-income households and was stronger for sweeter and more convenient fruits. Considering that households in Chile do not meet health recommendations for daily fruit intake, additional policy efforts targeting healthy, unprocessed food consumption could be considered.

Analysis of the current vitamin A terminology and dietary regulations from vitamin A1 to vitamin A5.

Dietary recommendations on vitamin intake for human food fortification concerning vitamin A in various countries, larger economic zones and international organizations are mainly based on the Food and Agriculture Organization of the United Nations (FAO)/World Health Organization (WHO) "Codex Alimentarius standards". The general vitamin A terminology is based on regulations of the International Union of Pure and Applied Chemistry (IUPAC) that are used to describe the involved derivatives. These regulations and terminology were set up in the middle of the last century. Starting with the decade of the 80ies in the 20th century a large improvement of molecular biological methodologies, background physiological mechanisms as well as analytical techniques contributed to a large diversification of this simply claimed vitamin A terminology. Unfortunately, the following terminology and governmental regulations for food fortification are imprecise and non-harmonized. In this article we tried to unravel this terminology for updating terminology, nutritional suggestions and governmental regulations for vitamin A, which are currently based on various uncertainties. According to the current regulations, the newly found vitamin A5/X can be included in the current vitamin A terminology as "vitamin A5" or alternatively or even in parallel as a new vitamin A-independent terminology as "vitamin X". Based on the detailed knowledge of research from the early beginning of general vitamin A pathway identification towards detailed research of the last decades the commonly used and simplified term vitamin A with relevance for governmental recommendations on vitamin intake and food fortification advice was now more correctly sub-categorized to further vitamin A1, and A5 sub-categories with vitamin A1-alcohol as retinol, vitamin A2-alcohol as 3,4-didehydroretinol and vitamin A5-alcohol as 9-cis-13,14-dihydroretinol as their mainly relevant vitamin forms present in the human organism. Here we suggest and advise how the vitamin A terminology and further governmental regulations should be organized depending on a successful unraveling of the organization of the current vitamin A terminology.

Maternal anaemia prevention and control in China: A policy review.

Maternal anaemia is a major public health problem. Developing maternal anaemia prevention and control policies is an important prerequisite for carrying out evidence-based interventions. This article reviews maternal anaemia prevention and control policies in China, identifies gaps, and provides references for other countries. We examined policies concerning maternal nutrition and other related literature in China, identified through key databases and government websites, and conducted a narrative review of the relevant documentations guided by the Smith Policy-Implementing-Process framework. A total of 65 articles and documents were identified for analysis. We found that Chinese government has committed to reducing maternal anaemia at the policy level, with established objectives and a clear time frame. However, most of policies were not accompanied by operational guidelines, standardized interventions, and vigorous monitoring and evaluation mechanisms, and 85% of the policies don't have quantifiable objectives on anaemia. Maternal anaemia prevention and control services offered in clinical settings were primarily nutrition education and anaemia screening. Population-based interventions such as iron fortification have yet to be scaled up. Furthermore, medical insurance schemes in some regions do not cover anaemia prevention and treatment, and in other regions that offer coverage, the reimbursement rate is low. The number and capacity of health professionals is also limited. Policy changes should focus on the integration of evidence-based interventions into routine antenatal care services and public health service packages, standardization of dosages and provision of iron supplementation, streamline of reimbursement for outpatient expenses, and capacity building of health professionals.

Corporate political activity in the context of unhealthy food advertising restrictions across Transport for London: A qualitative case study.

BACKGROUND: Diets with high proportions of foods high in fat, sugar, and/or salt (HFSS) contribute to malnutrition and rising rates of childhood obesity, with effects throughout the life course. Given compelling evidence on the detrimental impact HFSS advertising has on children's diets, the World Health Organization unequivocally supports the adoption of restrictions on HFSS marketing and advertising. In February 2019, the Greater London Authority introduced novel restrictions on HFSS advertising across Transport for London (TfL), one of the most valuable out-of-home advertising estates. In this study, we examined whether and how commercial actors attempted to influence the development of these advertising restrictions. METHODS AND FINDINGS: Using requests under the Freedom of Information Act, we obtained industry responses to the London Food Strategy consultation, correspondence between officials and key industry actors, and information on meetings. We used an existing model of corporate political activity, the Policy Dystopia Model, to systematically analyse arguments and activities used to counter the policy. The majority of food and advertising industry consultation respondents opposed the proposed advertising restrictions, many promoting voluntary approaches instead. Industry actors who supported the policy were predominantly smaller businesses. To oppose the policy, industry respondents deployed a range of strategies. They exaggerated potential costs and underplayed potential benefits of the policy, for instance, warning of negative economic consequences and questioning the evidence underlying the proposal. Despite challenging the evidence for the policy, they offered little evidence in support of their own claims. Commercial actors had significant access to the policy process and officials through the consultation and numerous meetings, yet attempted to increase access, for example, in applying to join the London Child Obesity Taskforce and inviting its members to events. They also employed coalition management, engaging directly and through business associations to amplify their arguments. Some advertising industry actors also raised the potential of legal challenges. The key limitation of this study is that our data focused on industry-policymaker interactions; thus, our findings are unable to present a comprehensive picture of political activity. CONCLUSIONS: In this study, we identified substantial opposition from food and advertising industry actors to the TfL advertising restrictions. We mapped arguments and activities used to oppose the policy, which might help other public authorities anticipate industry efforts to prevent similar restrictions in HFSS advertising. Given the potential consequences of commercial influence in these kinds of policy spaces, public bodies should consider how they engage with industry actors.

Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms.

Actions to address different forms of malnutrition are typically managed by separate communities, policies, programmes, governance structures, and funding streams. By contrast, double-duty actions, which aim to simultaneously tackle both undernutrition and problems of overweight, obesity, and diet-related non-communicable diseases (DR-NCDs) have been proposed as a way to effectively address malnutrition in all its forms in a more holisitic way. This Series paper identifies ten double-duty actions that have strong potential to reduce the risk of both undernutrition, obesity, and DR-NCDs. It does so by summarising evidence on common drivers of different forms of malnutrition; documenting examples of unintended harm caused by some undernutrition-focused programmes on obesity and DR-NCDs; and highlighting examples of double-duty actions to tackle multiple forms of malnutrition. We find that undernutrition, obesity, and DR-NCDs are intrinsically linked through early-life nutrition, diet diversity, food environments, and socioeconomic factors. Some evidence shows that programmes focused on undernutrition have raised risks of poor quality diets, obesity, and DR-NCDs, especially in countries undergoing a rapid nutrition transition. This Series paper builds on this evidence to develop a framework to guide the design of double-duty approaches and strategies, and defines the first steps needed to deliver them. With a clear package of double-duty actions now identified, there is an urgent need to move forward with double-duty actions to address malnutrition in all its forms.

School nutrition laws in the US: do they influence obesity among youth in a racially/ethnically diverse state?

BACKGROUND/OBJECTIVES: Little is known about the separate or combined effects of state and national nutrition policies regulating food and beverages in schools on child overweight/obesity (OV/OB) and related racial/ethnic disparities. We investigated the influence of school nutrition policies enacted in California, independently and in combination with the United States' national policy "Healthy Hunger Free Kids Act" (HHFKA) on childhood OV/OB and racial/ethnic disparities. SUBJECTS/METHODS: An interrupted time series design was used with data from 12,363,089 child-level records on 5th- and 7th-graders in California public schools to estimate sex- and racial/ethnic-specific time trends in OV/OB prevalence during three periods: before the California nutrition policies (2002-2004); when only California policies were in effect (2005-2012); and when they were in effect simultaneously with HHFKA (2013-2016). RESULTS: Before the state's policies, OV/OB prevalence increased annually among children in most subgroups. Improvements in OV/OB trends were observed for almost all groups after the California policies were in effect, with further improvements after the addition of HFFKA. The total change in annual log-odds of OV/OB, comparing the periods with both state and federal policies versus no policies, ranged from -0.08 to -0.01 and varied by grade, sex, and race/ethnicity. Within each sex and grade, the greatest changes were among African-American (-0.08 to -0.02, all p < 0.05) followed by Latino children (-0.06 to -0.01, all p < 0.05). Although disparities narrowed among these groups versus White children after the dual policy period, disparities remained large. CONCLUSIONS: State and national nutrition policies for schools may have contributed to containing the upward trend in childhood OV/OB and racial/ethnic OV/OB disparities within California. However, sizable OV/OB prevalence and disparities persist. To end the epidemic, promote healthy weight and increase health equity, future efforts should strengthen state and national policies to improve food quality in schools, particularly those serving populations with the highest OV/OB prevalence.

The impact of voluntary front-of-pack nutrition labelling on packaged food reformulation: A difference-in-differences analysis of the Australasian Health Star Rating scheme.

BACKGROUND: Front-of-pack nutrition labelling (FoPL) of packaged foods can promote healthier diets. Australia and New Zealand (NZ) adopted the voluntary Health Star Rating (HSR) scheme in 2014. We studied the impact of voluntary adoption of HSR on food reformulation relative to unlabelled foods and examined differential impacts for more-versus-less healthy foods. METHODS AND FINDINGS: Annual nutrition information panel data were collected for nonseasonal packaged foods sold in major supermarkets in Auckland from 2013 to 2019 and in Sydney from 2014 to 2018. The analysis sample covered 58,905 unique products over 14 major food groups. We used a difference-in-differences design to estimate reformulation associated with HSR adoption. Healthier products adopted HSR more than unhealthy products: >35% of products that achieved 4 or more stars displayed the label compared to <15% of products that achieved 2 stars or less. Products that adopted HSR were 6.5% and 10.7% more likely to increase their rating by ≥0.5 stars in Australia and NZ, respectively. Labelled products showed a -4.0% [95% confidence interval (CI): -6.4% to -1.7%, p = 0.001] relative decline in sodium content in NZ, and there was a -1.4% [95% CI: -2.7% to -0.0%, p = 0.045] sodium change in Australia. HSR adoption was associated with a -2.3% [-3.7% to -0.9%, p = 0.001] change in sugar content in NZ and a statistically insignificant -1.1% [-2.3% to 0.1%, p = 0.061] difference in Australia. Initially unhealthy products showed larger reformulation effects when adopting HSR than healthier products. No evidence of a change in protein or saturated fat content was observed. A limitation of our study is that results are not sales weighted. Thus, it is not able to assess changes in overall nutrient consumption that occur because of HSR-caused reformulation. Also, participation into labelling and reformulation is jointly determined by producers in this observational study, impacting its generalisability to settings with mandatory labelling. CONCLUSIONS: In this study, we observed that reformulation changes following voluntary HSR labelling are small, but greater for initially unhealthy products. Initially unhealthy foods were, however, less likely to adopt HSR. Our results, therefore, suggest that mandatory labelling has the greatest potential for improving the healthiness of packaged foods.

Anticipatory changes in British household purchases of soft drinks associated with the announcement of the Soft Drinks Industry Levy: A controlled interrupted time series analysis.

BACKGROUND: Sugar-sweetened beverage (SSB) consumption is positively associated with obesity, type 2 diabetes, and cardiovascular disease. The World Health Organization recommends that member states implement effective taxes on SSBs to reduce consumption. The United Kingdom Soft Drinks Industry Levy (SDIL) is a two-tiered tax, announced in March 2016 and implemented in April 2018. Drinks with ≥8 g of sugar per 100 ml (higher levy tier) are taxed at £0.24 per litre, drinks with ≥5 to <8 g of sugar per 100 ml (lower levy tier) are taxed at £0.18 per litre, and drinks with <5 g sugar per 100 ml (no levy) are not taxed. Milk-based drinks, pure fruit juices, drinks sold as powder, and drinks with >1.2% alcohol by volume are exempt. We aimed to determine if the announcement of the SDIL was associated with anticipatory changes in purchases of soft drinks prior to implementation of the SDIL in April 2018. We explored differences in the volume of and amount of sugar in household purchases of drinks in each levy tier at 2 years post announcement. METHODS AND FINDINGS: We used controlled interrupted time series to compare observed changes associated with the announcement of the SDIL to the counterfactual scenario of no announcement. We used data from Kantar Worldpanel, a commercial household purchasing panel with approximately 30,000 British members that includes linked nutritional data on purchases. We conducted separate analyses for drinks liable for the SDIL in the higher, lower, and no-levy tiers controlling with household purchase volumes of toiletries. At 2 years post announcement, there was no difference in volume of or sugar from purchases of higher-levy-tier drinks compared to the counterfactual of no announcement. In contrast, a reversal of the existing upward trend in volume (ml) of and amount of sugar (g) in purchases of lower-levy-tier drinks was seen. These changes led to a -96.1 ml (95% confidence interval [CI] -144.2 to -48.0) reduction in volume and -6.4 g (95% CI -9.8 to -3.1) reduction in sugar purchased in these drinks per household per week. There was a reversal of the existing downward trend in the amount of sugar in household purchases of the no-levy drinks but no change in volume purchased. At 2 years post announcement, these changes led to a 6.1 g (95% CI 3.9-8.2) increase in sugar purchased in these drinks per household per week. There was no evidence that volume of or amount of sugar in purchases of all drinks combined was different from the counterfactual. This is an observational study, and changes other than the SDIL may have been responsible for the results reported. Purchases consumed outside of the home were not accounted for. CONCLUSIONS: The announcement of the UK SDIL was associated with reductions in volume and sugar purchased in lower-levy-tier drinks before implementation. These were offset by increases in sugar purchased from no-levy drinks. These findings may reflect reformulation of drinks from the lower levy to no-levy tier with removal of some but not all sugar, alongside changes in consumer attitudes and beliefs. TRIAL REGISTRATION: ISRCTN Registry ISRCTN18042742.

Legal Feasibility and Implementation of Federal Strategies for a National Retail-Based Fruit and Vegetable Subsidy Program in the United States.

Policy Points Suboptimal intake of fruit and vegetables is associated with increased risk of diet-related diseases. A national retail-based fruit and vegetable subsidy program could broadly benefit the health of the entire population. Existing fruit and vegetable subsidy programs can inform potential implementation mechanisms; Congress's powers to tax, spend, and regulate interstate commerce can be leveraged to create a federal program. Legal and administrative feasibility considerations support a conditional funding program or a federal-state cooperative program combining regulation, licensing, and state or local options for flexible implementation strategies. Strategies to engage key stakeholders would enable the program to utilize lessons learned from existing programs. CONTEXT: Suboptimal intake of fruit and vegetables (F&Vs) is associated with increased risk of diet-related diseases. Yet, there are no US government programs to support increased F&V consumption nationally for the whole population, most of whom purchase food at retail establishments. To inform policy discussion and implementation, we identified mechanisms to effectuate a national retail-based F&V subsidy program. METHODS: We conducted legal and policy research using LexisNexis, the UConn Rudd Center Legislation Database, the Centers for Disease Control and Prevention Chronic Disease State Policy Tracking System, the US Department of Agriculture's website, Congress.gov, gray literature, and government reports. First, we identified existing federal, state, local, and nongovernmental organization (NGO) policies and programs that subsidize F&Vs. Second, we evaluated Congress's power to implement a national retail-based F&V subsidy program. FINDINGS: We found five federal programs, three federal bills, four state laws, and 17 state (including the District of Columbia [DC]) bills to appropriate money to supplement federal food assistance programs with F&Vs; 74 programs (six multistate, 22 state [including DC], and 46 local) administered by state and local governments and NGOs that incentivize the purchase of F&Vs for various subpopulations; and two state laws and 11 state bills to provide tax exemptions for F&Vs. To create a national F&V subsidy program, Congress could use its Commerce Clause powers or its powers to tax or spend, through direct regulation, licensing, taxation, tax incentives, and conditional funding. Legal and administrative feasibility considerations support a voluntary conditional funding program or, as a second option, a mandatory federal-state cooperative program combining regulation and licensing. CONCLUSIONS: Multiple existing programs provide an important foundation to inform potential implementation mechanisms for a national F&V subsidy program. Results also highlight the value of state and local participation to leverage existing networks and stakeholder knowledge.

Children's Fruit "Juice" Drinks and FDA Regulations: Opportunities to Increase Transparency and Support Public Health.

Objectives. To compare children's drink products that contain or purport to contain juice and evaluate labels in light of US Food and Drug Administration (FDA) regulations.Methods. In 2019, we analyzed federal law for drinks that contain or purport to contain juice by using LexisNexis and FDA's Web site, identified top-selling children's "juice" drinks in fruit punch flavors, gathered labels in store and online, and extracted data from the principal display and information panels.Results. FDA regulations permit a wide range of names, claims, and fruit vignettes on drinks that contain or purport to contain juice, reflecting the product's flavor and not necessarily its ingredients. We identified 39 brands of children's drinks, including 100% juice (n = 7), diluted juices (n = 11), juice drinks (n = 8), fruit-flavored drinks (n = 8), and flavored waters (n = 5), with nonuniform statements of identity; vitamin C and low-sugar claims; and fruit vignettes representing 19 fruits. Many products contained added sugar and nonnutritive sweeteners but little to no juice.Conclusions. Principal display panels rendered it difficult to differentiate among product types, identify those with added sweeteners, and distinguish healthier products. Revised labeling regulations are warranted to support public health.

Benchmarking the transparency, comprehensiveness and specificity of population nutrition commitments of major food companies in Malaysia.

BACKGROUND: The aim of this study was to assess the commitments of food companies in Malaysia to improving population nutrition using the Business Impact Assessment on population nutrition and obesity (BIA-Obesity) tool and process, and proposing recommendations for industry action in line with government priorities and international norms. METHODS: BIA-Obesity good practice indicators for food industry commitments across a range of domains (n = 6) were adapted to the Malaysian context. Euromonitor market share data was used to identify major food and non-alcoholic beverage manufacturers (n = 22), quick service restaurants (5), and retailers (6) for inclusion in the assessment. Evidence of commitments, including from national and international entities, were compiled from publicly available information for each company published between 2014 and 2017. Companies were invited to review their gathered evidence and provide further information wherever available. A qualified Expert Panel (≥5 members for each domain) assessed commitments and disclosures collected against the BIA-Obesity scoring criteria. Weighted scores across domains were added and the derived percentage was used to rank companies. A Review Panel, comprising of the Expert Panel and additional government officials (n = 13), then formulated recommendations. RESULTS: Of the 33 selected companies, 6 participating companies agreed to provide more information. The median overall BIA-Obesity score was 11% across food industry sectors with only 8/33 companies achieving a score of > 25%. Participating (p < 0.001) and global (p = 0.036) companies achieved significantly higher scores than non-participating, and national or regional companies, respectively. Corporate strategy related to population nutrition (median score of 28%) was the highest scoring domain, while product formulation, accessibility, and promotion domains scored the lowest (median scores < 10%). Recommendations included the establishment of clear targets for product formulation, and strong commitments to reduce the exposure of children to promotion of unhealthy foods. CONCLUSIONS: This is the first BIA-Obesity study to benchmark the population nutrition commitments of major food companies in Asia. Commitments of companies were generally vague and non-specific. In the absence of strong government regulation, an accountability framework, such as provided by the BIA-Obesity, is essential to monitor and benchmark company action to improve population nutrition.

The political construction of public health nutrition problems: a framing analysis of parliamentary debates on junk-food marketing to children in Australia.

OBJECTIVE: Junk-food marketing contributes significantly to childhood obesity, which in turn imposes major health and economic burdens. Despite this, political priority for addressing junk-food marketing has been weak in many countries. Competing interests, worldviews and beliefs of stakeholders involved with the issue contribute to this political inertia. An integral group of actors for driving policy change are parliamentarians, who champion policy and enact legislation. However, how parliamentarians interpret and portray (i.e. frame) the causes and solutions of public health nutrition problems is poorly understood. The present study aimed to understand how Australian parliamentarians from different political parties frame the problem of junk-food marketing. DESIGN: Framing analysis of transcripts from the Australian Government's Parliamentary Hansard, involving development of a theoretical framework, data collection, coding transcripts and thematic synthesis of results. SETTINGS: Australia. PARTICIPANTS: None. RESULTS: Parliamentarian framing generally reflected political party ideology. Liberal parliamentarians called for minimal government regulation and greater personal responsibility, reflecting the party's core values of liberalism and neoliberalism. Greens parliamentarians framed the issue as systemic, highlighting the need for government intervention and reflecting the core party value of social justice. Labor parliamentarians used both frames at varying times. CONCLUSIONS: Parliamentarians' framing was generally consistent with their party ideology, though subject to changes over time. This project provides insights into the role of framing and ideology in shaping public health policy responses and may inform communication strategies for nutrition advocates. Advocates might consider using frames that resonate with the ideologies of different political parties and adapting these over time.

Food and beverage marketing in schools: school superintendents' perspectives and practices after the healthy, Hunger-Free Kids Act.

OBJECTIVE: Children are surrounded by ubiquitous forms of unhealthy food marketing at home and in schools. The US Department of Agriculture now restricts food and beverage marketing that does not meet Smart Snacks in School standards. School superintendents, as districts' top administrators, play a critical role in ensuring marketing policies are implemented and adhered to; however, there is limited research involving this stakeholder group. The current study examined superintendents' perspectives on food marketing in schools and the marketing provision in wellness policies, as well as experiences with the implementation of such policies. DESIGN: Qualitative focus groups and follow-up interviews (with focus group participants) were conducted by trained researchers. SETTING: Focus groups occurred at The School Superintendents' annual meeting; follow-up interviews were over the telephone. PARTICIPANTS: Superintendents and assistant superintendents (n 39) from twenty-three states participated. Interviews were recorded and professionally transcribed; transcripts were team-coded in Atlas.ti using an iteratively revised coding guide to facilitate theme generation. RESULTS: Despite common concerns that marketing to children was 'insidious', superintendents reported a wide range of food and beverage marketing policies. In addition, the main issue is fundraising - such as 'restaurant nights' - that results in marketing that occurs on- and off-campus and afterschool. CONCLUSIONS: Discrepancies between perspectives and practices point to the challenges that superintendents face with budgetary constraints, as well as relationships with parent-teacher organisations. These findings provide important insights about superintendents' perspectives and challenges, particularly for government and child health advocates supporting school districts, to implement these policies.

Influence of front-of-pack labelling and regulated nutrition claims on consumers' perceptions of product healthfulness and purchase intentions: A randomized controlled trial.

Mandatory front-of-pack (FOP) labelling was proposed in Canada to highlight foods with high contents of sugars, sodium and/or saturated fats, which would be displayed on labels along with the mandatory Nutrition Facts table and voluntary nutrition claims. In an online survey, participants (n = 1997) were randomized to one of four FOP labelling conditions: 1) control, 2) warning label, 3) health star rating or 4) traffic light labelling. Participants were shown four drinks (a healthier drink with or without a disease risk reduction claim, a healthier drink with or without a nutrient content claim, a less healthy drink with or without a disease risk reduction claim and a less healthy drink with or without a nutrient content claim) in random order and one at a time. Participants rated perceived product healthfulness and purchase intentions using a 7-point Likert scale. Participants could access the Nutrition Facts table while viewing labels. Results showed less healthy drinks displaying any FOP labelling were perceived as less healthy compared to the control. In healthier drinks, health star rating and traffic light labelling created a 'halo' effect, which was not observed with warning labels. Similar results were observed with purchase intentions. Drinks displaying a disease risk reduction claim were perceived as healthier than those without (p < 0.001) regardless of product's healthfulness. The effect of a nutrient content claim was not significantly different. The effect of FOP labelling and claims was mitigated for those who used the Nutrition Facts table. FOP labelling was likely helpful for consumers with different levels of health literacy. Overall, FOP labelling had significantly stronger influence than nutrition claims on consumers' perceptions; however, the effect of each FOP label varied on healthier and less healthy drinks.

Status of Beverages Served to Young Children in Child Care After Implementation of California Policy, 2012-2016.

INTRODUCTION: Since 2012, licensed California child care centers and homes, per state policy, are required to serve only unflavored low-fat or nonfat milk to children aged 2 years or older, no more than one serving of 100% juice daily, and no beverages with added sweeteners, and they are required to ensure that drinking water is readily accessible throughout the day. We evaluated adherence to the policy after 4 years in comparison to the adherence evaluation conducted shortly after the policy went into effect. METHODS: Licensed California child care sites were randomly selected in 2012 and 2016 and surveyed about beverage practices and provisions to children aged 1-5 years. We used logistic regression to analyze between-year differences for all sites combined and within-year differences by site type and participation in the federal Child and Adult Care Food Program (CACFP) in self-reported policy adherence and beverage provisions. RESULTS: Respondents in 2016 (n = 680), compared with those in 2012 (n = 435), were more adherent to California's 2010 Healthy Beverages in Child Care Act overall (45.1% vs 27.2%, P < .001) and with individual provisions for milk (65.0% vs 41.4%, P < .001), 100% juice (91.2% vs 81.5%, P < .001), and sugar-sweetened beverages (97.4% vs 93.4%, P = .006). In 2016, centers compared with homes (48.5% vs 28.0%, P = .001) and CACFP sites compared with non-CACFP sites (51.6% vs 27.9%, P < .001) were more adherent to AB2084 overall. DISCUSSION: Beverage policy adherence in California child care has improved since 2012 and is higher in CACFP sites and centers. Additional policy promotion and implementation support is encouraged for non-CACFP sites and homes. Other states should consider adopting such policies.

Association of the Healthy, Hunger-Free Kids Act With Dietary Quality Among Children in the US National School Lunch Program.

Importance: The Healthy, Hunger-Free Kids Act of 2010, implemented nationwide in 2012, was intended to improve the nutritional quality of meals served in the National School Lunch Program (NSLP). Objective: To assess whether there was an association between the Healthy, Hunger-Free Kids Act of 2010 and dietary quality of lunch for students participating in the NSLP, stratified by income. Design, Setting, Participants: Serial cross-sectional study design, using National Health and Nutrition Examination Survey (NHANES) data from 2007-2008, 2009-2010, 2013-2014, and 2015-2016, of students who were surveyed in the NHANES and were attending schools participating in the NSLP. Individuals who were aged 5 to 18 years, in kindergarten through 12th grade, enrolled in a school that served school lunch, and had a reliable weekday dietary recall were included. Exposures: The Healthy, Hunger-Free Kids Act of 2010 (prepolicy period: 2007-2010; postpolicy period: 2013-2016), with participation in the NSLP estimated based on an algorithm. Main Outcomes and Measures: The primary outcome was dietary quality of intake for lunch, measured by the Healthy Eating Index-2010 (HEI-2010) score (range, 0-100; 0 indicates a diet with no adherence to the 2010 Dietary Guidelines for Americans and 100 indicates a diet with complete adherence to the guidelines). Results: Among 6389 students included in the surveys (mean age, 11.7 [95% CI, 11.6-11.9] years; 3145 [50%] female students; 1880 [56%] were non-Hispanic white), 32% were low-income, 12% were low-middle-income, and 56% were middle-high-income students. A total of 2472 (39%) were participants in the NSLP. Among low-income students, the adjusted mean prepolicy HEI-2010 score was 42.7 and the postpolicy score was 54.6 among NSLP participants and the adjusted mean prepolicy score was 34.8 and postpolicy score was 34.1 among NSLP nonparticipants (difference in differences, 12.6 [95% CI, 8.9-16.3]). Among low-middle-income students, the adjusted mean prepolicy HEI-2010 score was 40.4 and postpolicy score was 54.8 among NSLP participants and the adjusted mean prepolicy score was 34.2 and postpolicy score was 36.1 among NSLP nonparticipants (difference in differences, 12.4 [95% CI, 4.9-19.9]). Among middle-high-income students, the adjusted mean HEI-2010 prepolicy score was 42.7 and postpolicy score 55.5 for NSLP participants and the adjusted mean prepolicy score was 38.9 and prepolicy score was 43.6 for NSLP nonparticipants (difference in differences, 8.1 [95% CI, 4.2-12.0]). Conclusions and Relevance: In a serial cross-sectional study of students, the Healthy, Hunger-Free Kids Act of 2010 was associated with better changes in dietary quality for lunch among presumed low-income, low-middle-income, and middle-high-income participants in the NSLP compared with nonparticipants.

Mapping and Analysis of US State and Urban Local Sodium Reduction Laws.

CONTEXT: Excessive sodium consumption contributes to high blood pressure, which is a risk factor for cardiovascular disease. OBJECTIVES: To (1) identify state and urban local laws addressing adult or general population sodium consumption in foods and beverages and (2) align findings to a previously published evidence classification review, the Centers for Disease Control and Prevention Sodium Quality and Impact of Component (QuIC) evidence assessment. DESIGN: Systematic collection of sodium reduction laws from all 50 states, the 20 most populous counties in the United States, and the 20 most populous cities in the United States, including Washington, District of Columbia, effective on January 1, 2019. Relevant laws were assigned to 1 or more of 6 interventions: (1) provision of sodium information in restaurants or at point of purchase; (2) consumer incentives to purchase lower sodium foods; and provision of lower sodium offerings in (3) workplaces, (4) vending machines, (5) institutional meal services, and (6) grocery, corner, and convenience stores. The researchers used Westlaw, local policy databases or city Web sites, and general nutrition policy databases to identify relevant laws. RESULTS: Thirty-nine sodium reduction laws and 10 state laws preempting localities from enacting sodium reduction laws were identified. Sodium reduction laws were more common in local jurisdictions and in the Western United States. Sodium reduction laws addressing meal services (n = 17), workplaces (n = 12), labeling (n = 13), and vending machines (n = 11) were more common, while those addressing grocery stores (n = 2) or consumer incentives (n = 6) were less common. Laws with high QuIC evidence classifications were generally more common than laws with low QuIC evidence classifications. CONCLUSIONS: The distribution of sodium laws in the US differed by region, QuIC classification, and jurisdiction type, indicating influence from public health and nonpublic health factors. Ongoing research is warranted to determine how the strength of public health evidence evolves over time and how those changes correlate with uptake of sodium reduction law.