Awareness, use and understanding of nutrition labels among children and youth from six countries: findings from the 2019 - 2020 International Food Policy Study.

BACKGROUND: Nutrition facts tables (NFTs) on pre-packaged foods are widely used but poorly understood by consumers. Several countries have implemented front-of-package labels (FOPLs) that provide simpler, easier to use nutrition information. In October 2020, Mexico revised its FOPL regulations to replace industry-based Guideline Daily Amount (GDA) FOPLs with 'Warning' FOPLs, which display stop signs on foods high in nutrients of concern, such as sugar and sodium. This study examined self-reported awareness, use, and understanding of NFTs and FOPLs among young people in six countries with different FOPLs, with an additional focus on changes before and after implementation of Mexico's FOPL warning policy. METHODS: A 'natural experiment' was conducted using 'pre-post' national surveys in Mexico and five separate comparison countries: countries with no FOPL policy (Canada and the US), countries with voluntary FOPL policies (Traffic Lights in the UK and Health Star Ratings in Australia), and one country (Chile) with mandatory FOPL 'warnings' (like Mexico). Population-based surveys were conducted with 10 to 17-year-olds in 2019 (n = 10,823) and in 2020 (n = 11,713). Logistic regressions examined within- and between-countries changes in self-reported awareness, use, and understanding of NFTs and FOPLs. RESULTS: Across countries, half to three quarters of respondents reported seeing NFTs 'often' or 'all the time', approximately one quarter reported using NFTs when deciding what to eat or buy, and one third reported NFTs were 'easy to understand', with few changes between 2019 and 2020. In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were higher than for NFTs in all countries, and compared with GDA FOPLs in Mexico (p < .001). Mandated Warning FOPLs in Mexico and Chile had substantially higher levels of awareness, use, and understanding than the voluntary Traffic Lights in the UK and Health Star Ratings in Australia (p < .001 for all). CONCLUSIONS: Mandated easy-to-understand FOPLs are associated with substantially greater levels of self-reported awareness, use and understanding at the population-level compared to NFT and GDA-based labeling systems.

Awareness, use and understanding of nutrition labels among adults from five countries: Findings from the 2018-2020 International Food Policy Study.

Few studies have compared the effects of different front-of-package label (FOPL) systems in the 'real world'. This study assessed adults' awareness, use and understanding of nutrition facts labels (NFLs) and nationally implemented FOPLs such as Health Star Ratings (HSR), Traffic lights, and Guideline Daily Amounts (GDAs) in five countries, including before and after implementation of Mexico's warning FOPLs in 2020. Data were from the International Food Policy Study, an annual repeat cross-sectional study conducted in 2018-2020 among adults (N=64,032) in Australia, Canada, Mexico, the UK and the US. Self-reported awareness, use, and understanding of NFLs (in all five countries) and FOPLs (in Australia, Mexico, and UK) were assessed over time, between countries, and between NFLs and FOPLs. Most respondents in all countries reported seeing their country's NFLs (awareness) 'often' or 'all the time' across all three years, with one third to half of respondents using NFLs 'often' or 'all the time' (Australia: 43-45%; Canada: 47-50%; Mexico: 36-39%; UK: 32-34%; US: 47-49%), and approximately one half to two thirds finding NFLs 'easy' or 'very easy to understand' (56-57%; 67-69%; 51-54%; 48-51%; 70-71%). In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were highest among all countries with a FOPL (p<0.001), whereas awareness and use were lowest for Australia's HSR (p<0.001). In countries with FOPLs, self-reported understanding was higher for FOPLs than NFLs, except for the GDA FOPL in Mexico. Only modest changes were observed over time. Warning FOPLs were associated with greater levels of self-reported awareness, use and understanding among adults compared to NFLs and GDA-based FOPLs. FOPLs implemented on a voluntary basis, such as Australia's HSR, may be less likely to be seen and used.

Acceptability of an Online Module Addressing Weight Bias: Perspectives and Attitudes of Undergraduate Health Students and Instructors.

Weight bias and discrimination are highly pervasive and harmful to Canadians with higher weights. Researchers and practitioners who deliver, evaluate, and advise on dietary and weight-related interventions may inadvertently perpetuate weight bias through their work; however, trainees in these fields rarely have access to weight bias education within their applied health programs. This study evaluated the acceptability of an online educational weight bias module developed for undergraduate students enrolled in health courses. The intervention included a pre-recorded 20-minute online module with prompts for reflection or discussion, a self-assessment quiz, as well as a separate module and range of resources for instructors. Overall, 211 students from applied health courses and 4 instructors completed an online survey querying the module's delivery, impact, and relevance. Students agreed that the module provided useful information (82%), was easy to understand (97%), and was the right length (75%), but reported wanting more interactivity and engagement with the content. Instructors found the module engaging and useful and expressed interest in additional resources and support for weight bias education. Future research should explore the impact of weight bias education on students' weight-related attitudes and perceptions as well as feasibility and relevance of online features such as multimedia tools.

Self-Reported Impacts of the COVID-19 Pandemic on Diet-Related Behaviors and Food Security in 5 Countries: Results from the International Food Policy Study 2020.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of daily life, including dietary intake; however, few studies have reported its impacts on dietary behaviors and food security across multiple countries. OBJECTIVES: We examined self-reported impacts of COVID-19 on food behaviors, food security, and overall diet healthfulness in 5 countries. METHODS: Adults aged 18-100 years (n = 20,554) in Australia, Canada, Mexico, the United Kingdom, and the United States completed an online survey in November and December 2020 as part of the International Food Policy Study, an annual, repeat cross-sectional survey. Survey measures assessed perceived impacts of the COVID-19 pandemic on eating food prepared away from home, having food delivered from a restaurant, and buying groceries online, as well as perceived food security and overall diet healthfulness. Regression models examined associations between each outcome and sociodemographic correlates. RESULTS: Across all countries, 62% of respondents reported eating less food prepared away from home due to the pandemic, while 11% reported eating more. Some participants reported having less food delivered from a restaurant (35%) and buying fewer groceries online (17%), while other respondents reported more of each (19% and 25%, respectively). An average of 39% reported impacts on their food security, and 27% reported healthful changes to their overall diet. The largest changes for all outcomes were observed in Mexico. Participants who were younger, ethnic minorities, or had lower income adequacy tended to be more likely to report food-related changes in either direction; however, these relationships were often less pronounced among respondents in Mexico. CONCLUSIONS: Respondents reported important changes in how they sourced their food during the pandemic, with trends suggesting shifts towards less food prepared away from home and more healthful diets overall. However, changes in diet and food behaviors occurred in both healthful and less healthful directions, suggesting that dietary responses to the pandemic were highly variable.

Meat-Reduced Dietary Practices and Efforts in 5 Countries: Analysis of Cross-Sectional Surveys in 2018 and 2019.

BACKGROUND: Diets that reduce reliance on animal-source foods are recommended in some contexts. OBJECTIVES: This study aimed to compare proportions of respondents who reported following meat-reduced dietary practices (i.e., vegetarian, vegan, or pescatarian diets) and/or making efforts to reduce animal-source foods, and to examine sociodemographic correlates across 5 countries. METHODS: Online surveys were conducted in November and December 2018 and 2019 with 41,607 adults from Australia (n = 7926), Canada (n = 8031), Mexico (n = 8110), the United Kingdom (n = 9129), and the United States (n = 8411) as part of the International Food Policy Study. Respondents were asked whether they would describe themselves as vegetarian, vegan, or pescatarian, and whether they had made efforts to consume less red meat, less of all meats, or less dairy in the past year. Logistic regressions examined differences in the likelihood of each behavior between countries and sociodemographic subgroups. RESULTS: Approximately 1 in 10 respondents reported following a vegetarian, vegan, or pescatarian diet, ranging from 8.6% (Canada) to 11.7% (UK). In the past 12 months, the proportions of respondents who reported efforts to consume less red meat ranged from 34.5% (Australia) to 44.4% (Mexico), less of all meats ranged from 27.9% (US) to 35.2% (Mexico), and to consume less dairy ranged from 20.6% (UK) to 41.3% (Mexico). Respondents were more likely to report efforts to consume less animal-source products in 2019 compared to 2018 in most countries. Sociodemographic patterns varied by country; in general, women, those with higher education levels, and those in minority ethnic groups were more likely to report following meat-reduced dietary practices or efforts to consume fewer animal-source products. CONCLUSIONS: Nearly half of respondents reported following a meat-reduced diet or efforts to reduce animal-source products, with differences between countries and population subgroups. Population-level approaches and policies that support meat reduction may further reduce consumption of animal-source products.

The Conceptual Framework for the International Food Policy Study: Evaluating the Population-Level Impact of Food Policy.

An unhealthy diet is among the leading global causes of death and disability. Globally, a range of policies are being implemented to support healthy food choices at a population level, including novel polices in the areas of food marketing, nutrition labeling, and taxation of less healthy foods. There is a need to evaluate and inform the implementation of these policies, including their impacts on marginalized population subgroups. The International Food Policy Study (IFPS) consists of repeated cross-sectional surveys conducted in 5 high- and upper-middle-income countries: Australia, Canada, Mexico, the United Kingdom, and the United States. In each country, approximately 4000 adults and 1200 children and youth (aged 10-17) were recruited from a global commercial panel to complete an online survey using consistent measures and methodologies across countries. The first annual IFPS surveys were conducted in 2017 with adults; annual surveys for young people aged 10-17 were launched in 2019 in the same countries, as well as in Chile. The design of the IFPS surveys creates a framework for evaluating "natural experiments" in food policies, including comparisons over time within countries implementing the policy and comparisons with countries in which the policy was not implemented. IFPS surveys have 3 primary areas of focus: 1) knowledge, attitudes, and beliefs associated with specific policies; 2) diet-related behaviors; and 3) dietary intake, including 24-hour dietary recalls for adults in 4 of the 5 countries. Surveys also assess food insecurity, income adequacy, sex and gender, race/ethnicity, and a range of other measures to assess trends among priority subgroups. Overall, the IFPS project has the potential to address important gaps in national monitoring surveys for dietary patterns, and to evaluate the impacts of novel food policies implemented in any of the 5 countries over the study period.

Tax awareness and perceived cost of sugar-sweetened beverages in four countries between 2017 and 2019: findings from the international food policy study.

BACKGROUND: The public health benefits of sugar-sweetened beverage (SSB) taxes often rely on, among other things, changes to consumer purchases. Thus, perceived cost of SSBs and signalling effects-via awareness of the tax-may impact the effectiveness of SSB taxes on consumer purchases. OBJECTIVE: The study sought to examine perceived cost of SSBs, tax awareness, and changes in beverage purchasing over time and across four countries with and without SSB taxes. METHODS: The study used data from the 2017, 2018 and 2019 waves of the International Food Policy Study. Annual cross-sectional online surveys were conducted in Australia, Mexico, UK and US, which captured perceived cost of SSBs relative to non-SSBs in all countries (with Australia as a no-tax comparator), and measures of tax awareness and participants' reported changes in beverage purchasing in response to SSB taxes in Mexico (tax implemented in 2014), UK (tax implemented in 2018) and US (subnational taxes since 2015). Logistic regression models evaluated the measures across years and socio-demographic groups. RESULTS: Perceived cost of SSBs relative to non-SSBs was higher in Mexico (all three years) and the UK (2018 and 2019 following tax implementation) than Australia and the US. Tax awareness was higher in UK than Mexico, and decreased over time among Mexican respondents. Patterns of reported beverage purchasing changes in response to the tax were similar across Mexico, UK and US, with the largest changes reported by Mexican respondents. Respondents with characteristics corresponding to lower socioeconomic status were less likely to be aware of an SSB tax, but more likely to perceive SSBs to cost more than non-SSBs and report changes in purchasing in response to the tax, where there was one. CONCLUSIONS: This study suggests that in countries where a national SSB tax was present (Mexico, UK), perceived cost of SSBs and tax awareness were higher compared to countries with no SSB tax (Australia) or subnational SSB taxes (US), respectively, and suggests that perceived cost and tax awareness represent distinct constructs. Improving the 'signalling effect' of existing SSB taxes may be warranted, particularly in tax settings where consumer behaviour change is a policy objective.

The impact of health warnings for sugar-sweetened beverages on consumer perceptions of advertising.

OBJECTIVE: In February 2020, San Francisco proposed mandatory health warnings for sugar-sweetened beverage (SSB) advertisements. Industry legal challenges stated that the warning would detract from advertisers' ability to convey their intended message and mislead consumers into believing that SSB cause weight gain regardless of consumption amount, lifestyle or intake of other energy-dense foods. DESIGN: Online between-group experiments tested the impact of SSB warnings on advertising outcomes and consumer perceptions. Respondents were randomised to view six SSB print advertisements with or without a health warning ('Warning' and 'No Warning' condition, respectively). Linear and binary logistic regression models tested differences between groups, including ad recall, brand perceptions and beliefs about SSB health effects. SETTING: Panelists from the US Nielsen Global Panel. PARTICIPANTS: Sixteen to 65-year-old respondents (n 1064). RESULTS: Overall, 69·2 % of participants in the 'Warning' condition recalled seeing warnings on SSB ads. Compared with the 'No Warning' condition, participants in the 'Warning' condition who reported noticing the warnings were equally likely to recall the brands featured in the SSB ads and to recall specific attributes of the final ad they viewed. Similarly, no differences were observed between groups in perceptions of SSB, such as perceived taste, or in the prevalence of false beliefs regarding the health effects of SSB and intake of other sugary foods on weight gain. CONCLUSIONS: Overall, there was no evidence that SSB health warnings detracted from attention to promotional elements in advertisements or that the warnings misled consumers into false beliefs about SSB as the exclusive cause of weight gain.

Impact of sugar taxes and front-of-package nutrition labels on purchases of protein, calcium and fibre.

Taxes and front-of-package (FOP) labels can be effective interventions for reducing consumption of sugar, saturated fat, and sodium; however, few studies have examined their impact on intake of 'positive' nutrients. The current study explored the impact of sugar taxes and FOP labels on the protein, calcium and fibre density of snack food purchases. A total of 3584 Canadians aged 13 years and older participated in an experimental marketplace using a 3 × 8 between-within group experiment. Participants received $5 and viewed images of 20 snack food products available for purchase. Participants were randomized to one of five FOP label conditions (no label, high in, multiple traffic light, health star rating, or nutrition grade) and completed three within-subject purchasing tasks with different sugar tax conditions (no tax, 20%, tiered). Upon conclusion, participants received the product and any change from one of the purchasing tasks. The results indicate that participants purchased snack foods with higher fibre density when either sugar tax was applied (+0.1 g/100 kcal) compared to no tax, and when they were assigned to see the multiple traffic light (+0.4 g/100 kcal) or health star rating (+0.3 g/100 kcal) FOP labels, compared to no FOP label. There were no significant differences in the protein or calcium density of snack foods purchased across the tax or FOP labelling conditions. Overall, the findings suggest that as consumers respond to tax or labelling policies by moving away from sugars, sodium, and saturated fat, there may be no downside-or even an increase-in 'positive' nutrient density.

Taxes and front-of-package labels improve the healthiness of beverage and snack purchases: a randomized experimental marketplace.

BACKGROUND: Sugar taxes and front-of-package (FOP) nutrition labelling systems are strategies to address diet-related non-communicable diseases. However, there is relatively little experimental data on how these strategies influence consumer behavior and how they may interact. This study examined the relative impact of different sugar taxes and FOP labelling systems on beverage and snack food purchases. METHODS: A total of 3584 Canadians 13 years and older participated in an experimental marketplace study using a 5 (FOP label condition) × 8 (tax condition) between-within group experiment. Participants received $5 and were presented with images of 20 beverages and 20 snack foods available for purchase. Participants were randomized to one of five FOP label conditions (no label; 'high in' warning; multiple traffic light; health star rating; nutrition grade) and completed eight within-subject purchasing tasks with different taxation conditions (beverages: no tax, 20% tax on sugar-sweetened beverages (SSBs), 20% tax on sugary drinks, tiered tax on SSBs, tiered tax on sugary drinks; snack foods: no tax, 20% tax on high-sugar foods, tiered tax on high-sugar foods). Upon conclusion, one of eight selections was randomly chosen for purchase, and participants received the product and any change. RESULTS: Compared to those who saw no FOP label, participants who viewed the 'high in' symbol purchased less sugar (- 2.5 g), saturated fat (- 0.09 g), and calories (- 12.6 kcal) in the beverage purchasing tasks, and less sodium (- 13.5 mg) and calories (- 8.9 kcal) in the food tasks. All taxes resulted in substantial reductions in mean sugars (- 1.4 to - 4.7 g) and calories (- 5.3 to - 19.8 kcal) purchased, and in some cases, reductions in sodium (- 2.5 to - 6.6 mg) and saturated fat (- 0.03 to - 0.08 g). Taxes that included 100% fruit juice ('sugary drink' taxes) produced greater reductions in sugars and calories than those that did not. CONCLUSIONS: This study expands the evidence indicating the effectiveness of sugar taxation and FOP labelling strategies in promoting healthy food and beverage choices. The results emphasize the importance of applying taxes to 100% fruit juice to maximize policy impact, and suggest that nutrient-specific FOP 'high in' labels may be more effective than other common labelling systems at reducing consumption of targeted nutrients.

Influence of front-of-package nutrition labels on beverage healthiness perceptions: Results from a randomized experiment.

The current study explored the influence of three summary indicator front-of-pack (FOP) nutrition labels on consumer perceptions of the healthiness of different beverage products. In 2016, a total of 675 respondents in southwestern Ontario aged 16 and over viewed images of soda, unflavoured milk and chocolate milk displaying one of four FOP label conditions (no FOP label, numeric rating, health star rating (HSR), or simplified traffic light (STL)), and rated the products' healthiness. Participants also indicated their preference for summary indicator versus nutrient-specific FOP labels. Logistic regression models comparing correct responses across label conditions found no differences across label conditions for unflavoured milk or soda. Consumers in the HSR and STL conditions were more likely to correctly perceive a chocolate milk beverage as 'moderately healthy' (p = 0.004, p = 0.016). No differences in responses were identified across sociodemographic groups. Most respondents (93%) indicated that they would like to see a health rating or nutrient-specific information on the front of food products. Results of this study suggest that the influence of FOP labels may vary based on the nutritional quality of food products, and may have the greatest influence on consumer perceptions of 'nutritionally ambiguous' foods. Consumers indicated almost unanimous support for implementing FOP nutrition labelling systems.

Evaluation of the online Beverage Frequency Questionnaire (BFQ).

BACKGROUND: The contribution of beverages to overall diet is of increasing interest to researchers and policymakers, particularly in terms of consumption of drinks high in added sugars; however, few tools to assess beverage intake have been developed and evaluated. This study aimed to evaluate the relative validity of a new online Beverage Frequency Questionnaire (BFQ) among young adults in Canada. METHODS: A cross-sectional relative validation study was conducted among young adults aged 16-30 years (n = 50). Participants completed a 17-item BFQ, a 7-day food record (7dFR), and a single-item measure of sugary drink intake. Pearson correlations and paired t-tests were used to evaluate correlation and agreement between the measures for 17 individual beverage categories, total drink consumption, total alcoholic beverage consumption, and two definitions of drinks with excess sugars. Cognitive interviews were conducted to examine participant interpretation and comprehensiveness of the BFQ. RESULTS: Estimates of beverage intake based on the BFQ and the 7dFR were highly correlated, specifically for the total number and volume of beverages consumed, total alcoholic beverage consumption, sugary drink intake, and each of the 17 beverage categories with 3 exceptions: coffee or tea with sugar or cream, specialty coffees, and hard alcohol with caloric mix. Paired t-tests between the BFQ and the 7dFR indicated that the average reported volume was significantly different only for sweetened fruit drinks. The single-item measure of sugary beverage intake was not significantly correlated with the 7dFR. Cognitive interviewing demonstrated high comprehension levels, and confirmed the appropriateness of the BFQ beverage categories and sizes. CONCLUSIONS: Overall, the results suggest that the BFQ performed well relative to a 7dFR and had high usability among this study population, indicating its promise for collecting population-level data on beverage intake, including sugar-sweetened beverages, which are known indicators of diet and health.

Do manufacturer 'nutrient claims' influence the efficacy of mandated front-of-package labels?

OBJECTIVE: To examine consumers' ability to correctly interpret front-of-package (FOP) 'high in' warnings in the presence of a voluntary claim for the same or a different nutrient. DESIGN: A between-group experimental task assigned respondents to view food products labelled as 'high in sodium', with a 'reduced sodium' claim positioned next to the warning, away from the warning or absent. A second experiment assigned participants to view a food product labelled as 'high in sugar', with a 'reduced fat' claim positioned next to the warning, away from the warning or absent. For both tasks, respondents were asked to identify whether the products were high in the indicated nutrient. SETTING: Online survey (2016). SUBJECTS: Canadians aged 16-32 years (n 1000) were recruited in person from five major cities in Canada. RESULTS: Respondents were less likely to correctly identify a product as 'high in sodium' when packages also featured a voluntary 'reduced sodium' claim, with a stronger effect when the claim was positioned away from the FOP symbol (P<0·001). The number of correct responses was similar across conditions when the nutrient claim was for a different nutrient than the one featured in the FOP 'high in' warning. CONCLUSIONS: The findings demonstrate that the presence of a voluntary nutrient claim can undermine the efficacy of mandated FOP labels for the same nutrient. Countries considering nutrient-specific FOP warnings, including Canada, should consider regulations that would prohibit claims for nutrients that exceed the threshold for nutrient-specific FOP warnings.

The impact of price and nutrition labelling on sugary drink purchases: Results from an experimental marketplace study.

OBJECTIVE: To examine the effect of front-of-package (FOP) nutrition labelling and sugary drink taxation on consumer beverage purchases. METHODS: A total of 675 respondents aged 16 years and older participated in an experimental marketplace study using a 4 × 5 within-between group design. Participants were randomised to one of four labelling conditions (no label; star rating; high sugar symbol; health warning) and completed five within-subject purchase tasks. Beverage prices in each task corresponded to 'tax' conditions: 0%, 10%, 20%, 30% and a variable tax proportional to free sugar level. In each task, participants selected from 20 commercially available beverages; upon conclusion, one of five selections was randomly chosen for purchase. RESULTS: As price increased, participants were significantly less likely to select a sugary drink, and selected drinks with fewer calories and less free sugar (p < 0.001 for all). The overall effect of labelling was not statistically significant, although there was a trend for the 'high sugar' label to reduce the likelihood of selecting a sugary drink (p = 0.11) and encouraging participants to select drinks with less free sugar (p = 0.11). CONCLUSIONS: Increasing price was associated with reduced sugary drink purchases. Enhanced FOP labelling results highlight the need for further research to investigate their potential impact. The study adds empirical support for taxation to reduce sugary drink consumption.

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.

Examining differences in children and adolescents' exposure to food and beverage marketing in Canada by sociodemographic characteristics: Findings from the International Food Policy Study Youth Survey, 2020.

BACKGROUND: Many countries, including Canada, are considering regulations to restrict food and beverage marketing to children. However, little evidence is available outside of the US on how marketing exposure differs across sociodemographic subgroups. OBJECTIVE: To investigate potential associations between child and adolescent sociodemographic characteristics and exposure to food and beverage marketing in Canada. METHODS: Participants (n = 3780) aged 10-17 self-reported exposure to food and beverage marketing across food categories, locations and marketing techniques. Logistic regression models tested relationships between sociodemographics (age, sex, ethnicity and income adequacy) and marketing exposure. RESULTS: Among other differences identified, 13-17 years old were more likely than 10-12 years old to report seeing unhealthy food marketing online. Girls were more likely than boys to see such marketing online and in retail settings, while boys were more likely to see it in video games. Minority ethnicities (including Indigenous youth) and respondents with lower income adequacy generally reported more exposure than White and higher income respondents, respectively. CONCLUSIONS: This study highlights important differences in marketing exposure among youth of different sociodemographic groups in Canada, including greater exposure to marketing among those most disadvantaged and emphasizes the essential need to consider food marketing across equity groups when developing restrictions on marketing to kids.

Comparing the Effects of Four Front-of-Package Nutrition Labels on Consumer Purchases of Five Common Beverages and Snack Foods: Results from a Randomized Trial.

BACKGROUND: Front-of-package (FOP) nutrition labeling systems differ in how they rate food and beverage products. There is a need to examine the implications of these differences, including their focus on nutrients of public health concern. OBJECTIVE: Our aim was to examine the impacts of 4 common FOP labels on consumers' purchases of products that received conflicting ratings across FOP systems. DESIGN: In an experimental marketplace, participants were randomized to complete a series of purchases under 1 of 5 FOP conditions: no label, "high in" nutrient labels, multiple traffic light, Health Star Rating, or a 5-color nutrition grade. PARTICIPANTS/SETTING: A final sample of 3,584 Canadians (13 years and older) were recruited from shopping centers in March to May 2018. MAIN OUTCOME MEASURES: Probability of purchasing was assessed for 5 product categories (100% fruit juice, plain milk, chocolate milk, cheese snacks, and diet beverages), which received conflicting ratings across the FOP conditions. STATISTICAL ANALYSES: Separate generalized linear mixed models estimated the influence of FOP condition on 5 binary outcomes (1 = purchased, 0 = not purchased) corresponding to the product categories. RESULTS: Few differences were observed among the full sample. Among participants who noticed the labels (n = 1,993), those in the Health Star Rating condition were 4.5 percentage points (95% CI -7.0 to -1.9) more likely to purchase 100% fruit juice (compared to multiple traffic light) and 3.3 (95% CI 0.4 to 6.2) and 3.0 percentage points (95% CI 0.1 to 6.1) more likely to purchase cheese snacks (compared to no label and "high in"). "High in" labels produced fewer purchases of chocolate milk than no label. CONCLUSIONS: Despite some similarities, existing FOP systems differ in the extent to which they promote or dissuade purchases of common product categories. Although the Health Star Rating might encourage purchases of products with certain positive nutritional attributes, "high in" and multiple traffic light systems might more effectively discourage purchases of products contributing nutrients of public health concern.

Exploring the main and moderating effects of individual-level characteristics on consumer responses to sugar taxes and front-of-pack nutrition labels in an experimental marketplace.

INTERVENTION: This study examined whether the impacts of sugar taxes and front-of-pack (FOP) nutrition labels differ across socio-demographic subgroups. RESEARCH QUESTION: What are the main and moderating effects of individual-level characteristics on the nutrient content of participants' purchases in response to varying taxation levels and FOP labels? METHODS: Data from an experimental marketplace were analyzed. A sample of 3584 Canadians aged 13 years and older received $5 to purchase an item from a selection of 20 beverages and 20 snack foods. Participants were shown products with one of five FOP labels and completed eight within-subject purchasing tasks with different tax conditions. Linear mixed models were used to estimate the main and moderating effects of 11 individual-level variables on the sugars, sodium, saturated fats, and calorie content of participants' purchases. RESULTS: Participants who were younger, male, and more frequent consumers of sugary drinks purchased products containing more sugars, sodium, saturated fats, and calories. Sex and age moderated the relationship between tax condition and sugars or calories purchased: female participants were more responsive than males to a tax that included fruit juice, and younger participants were more responsive to all sugar tax conditions than older participants. Reported thirst and education level also moderated the relationship between tax condition and calories purchased. No individual-level characteristics moderated the effects of FOP labels. CONCLUSION: A small proportion (7 of 176) of the moderating effects tested in this study were significant. Sugar taxes and FOP labelling policies may therefore produce similar effects across key socio-demographic groups.

RéSUMé: INTERVENTION: Dans cette étude, nous avons cherché à déterminer si les effets des taxes sur le sucre et de l'étiquetage nutritionnel sur le devant des emballages sont les mêmes dans différents sous-groupes sociodémographiques. QUESTION DE RECHERCHE: Quels sont les principaux effets et les effets modérateurs des caractéristiques individuelles sur le contenu nutritionnel des achats des participants quand le niveau des taxes et l'étiquetage sur le devant des emballages varient? MéTHODE: Nous avons analysé les données d'un marché expérimental. Nous avons offert à un échantillon de 3 584 Canadiens de 13 ans et plus 5 $ pour acheter un article parmi 20 boissons et 20 grignotines. Les participants se sont fait présenter des produits portant l'une de cinq étiquettes sur le devant de l'emballage et ont effectué huit tâches d'achat intra-sujet avec différentes modalités de taxation. Des modèles linéaires mixtes ont servi à estimer les principaux effets et les effets modérateurs de 11 variables individuelles sur la teneur en sucres, en sodium, en graisses saturées et en calories des achats des participants. RéSULTATS: Les jeunes, les participants de sexe masculin et les consommateurs fréquents de boissons sucrées ont acheté des produits contenant plus de sucres, de sodium, de graisses saturées et de calories. Le sexe et l'âge ont modéré la relation entre la modalité de taxation et les sucres ou les calories achetés : les filles et les femmes étaient plus sensibles que les garçons et les hommes à une taxe incluant les jus de fruits, et les jeunes étaient plus sensibles à toutes les modalités de taxation du sucre que les participants plus âgés. La soif et le niveau d'instruction autodéclarés ont aussi modéré la relation entre la modalité de taxation et les calories achetées. Aucune caractéristique individuelle n'a modéré les effets des étiquettes sur le devant des emballages. CONCLUSION: Seule une petite proportion (7 sur 176) des effets modérateurs testés dans l'étude était significative. Les politiques de taxation du sucre et d'étiquetage sur le devant des emballages pourraient donc produire des effets semblables dans plusieurs groupes sociodémographiques clés.

Experimental study of front-of-package nutrition labels' efficacy on perceived healthfulness of sugar-sweetened beverages among youth in six countries.

Front-of-package (FOP) nutrition labels have been proposed as a strategy to help limit sugar-sweetened beverage (SSB) consumption among youth. However, few studies have examined the efficacy of FOP labels in youth across different countries. A between-group experiment was conducted to examine the impact of FOP labels (no-label control, Health Star Rating, 'High in' Octagon, Guideline Daily Amount (GDA), Traffic Light, or Nutri-Score) on perceived healthfulness of an SSB. The study was conducted online in November-December 2019 with 10,762 children aged 10-17 from six countries: Australia, Canada, Chile, Mexico, the United Kingdom, and the United States. A binary logistic regression model tested the impacts of FOP label condition, country, and sociodemographic characteristics on participants' likelihood of perceiving the SSB to be Unhealthy. Compared to the control condition, participants in each of the five FOP label conditions were significantly more likely to perceive the SSB as Unhealthy (p < 0.002). The 'High in' Octagon label had the greatest impact on perceived healthfulness across five out of six countries, whereas the GDA and Nutri-Score labels demonstrated the lowest impact across all six countries. The impact of FOP labels was consistent across sex, age, race/ethnicity, and perceived income adequacy. FOP labels can significantly reduce the perceived healthfulness of SSBs among youth across multiple countries. The current study adds to the evidence that 'high in' labels, which use intuitive symbols such as the octagon 'stop sign', are the most efficacious labels for helping consumers identify foods high in nutrients of concern, including SSBs.

How Does the Probability of Purchasing Moderately Sugary Beverages and 100% Fruit Juice Vary Across Sugar Tax Structures?

OBJECTIVE: Sugar-sweetened beverage taxes are increasingly used to discourage sugar intake; however, the impact on consumer preferences for particular products is largely unknown. This study explored the impact of two tax structures (tiered vs. nontiered and inclusive vs. exclusive of 100% fruit juice) on participants' probability of purchasing moderately sugary beverages and 100% fruit juice. METHODS: A sample of 3,584 Canadians aged 13 years and older completed a series of beverage purchasing tasks, each corresponding to a different tax condition, within an experimental marketplace. Tax conditions included a no-tax control, plus four taxes varying by structure (tiered vs. nontiered) and whether or not 100% fruit juice was included. RESULTS: The odds of purchasing a moderately sugary beverage were higher under tiered versus nontiered taxes. Purchases of higher sugar beverages differed little across tiered versus nontiered structures. Odds of purchasing 100% fruit juice were lower when these products were taxed versus not taxed. CONCLUSIONS: Results suggest that two key tax structures are likely to function as expected; taxes including 100% fruit juice products may lead to lower probability of purchasing fruit juice, and taxes incorporating multiple tiers may be more likely to encourage purchases of moderately sugary products than nontiered formats.