Resumen de evidencia para política: Estrategias de implementación de etiquetado nutricional de alimentos en restaurantes de comida rápida / Evidence brief for policy: strategies for the implementation of nutritional food labelling in fast-food restaurants

EL PROBLEMA: Chile presenta una de las prevalencias más altas de sobrepeso y obesidad a nivel mundial, alcanzando un 74,2% (39,8% sobrepeso, 31,2% obesidad, y 3,2% obesidad mórbida) según los datos de la última Encuesta Nacional de Salud (ENS).2 Para afrontar esta situación, en Chile se han implementado una serie de iniciativas como los impuestos a las bebidas azucaradas (aumentando los impuestos de 13% a 18% en aquellos productos con más de 6,25 g de azúcar por 100 ml de bebida y disminuyendo el impuesto de 13% a 10% en los productos con menos de 6,25 g de azúcar por 100 ml de bebida)3 , el Sistema Elige Vivir Sano del Ministerio de Desarrollo Social 4 y la ley de etiquetado frontal de alimentos con sellos con mensajes de advertencia nutricional (Ley 20.606)5 , el cual se implementó desde Junio 2016. Aunque la evidencia respecto del impacto de esta política en los hábitos de consumo y las decisiones de compra de alimentos por parte de la población no es totalmente concluyente,6 7 8 algunos grupos poblacionales (madres de niños pequeños) perciben que estas regulaciones están cambiando las percepciones, actitudes y algunos comportamientos hacia patrones de alimentación más saludables. Actualmente, la ley de etiquetado aplica exclusivamente a productos envasados, los que habitualmente son comprados en pequeños almacenes de barrio, ferias libres o supermercados. Sin embargo, una proporción importante de la población es consumidora de comida rápida ya sea de manera presencial ­ por ejemplo, acudiendo a locales independientes, a franquicias o a cadenas de comida rápida en centros comerciales ­ o a través de la compra remota y el reparto/entrega a domicilio de estos productos. Durante los últimos 2 años esta tendencia se ha intensificado dada las limitaciones a la movilidad impuestas - especialmente durante el año 2020 - para el manejo de la pandemia por COVID-19.10 Por lo tanto, es de interés del Ministerio de Salud explorar una posible extensión de la política de etiquetado frontal de advertencia, revisando la evidencia relacionada con la implementación de los etiquetados frontales de alimentos en otros ambientes de venta de alimentos como casinos, cafeterías y restaurantes de comida rápida. OPCIONES PARA ABORDAR EL PROBLEMA: A partir del problema identificado surge la posibilidad de extender la actual política de etiquetado frontal de alimentos empaquetados hacia locales de venta y consumo de comida rápida. De esta manera, las opciones de política para abordar el problema corresponden a alternativas de implementación de etiquetado nutricional. En este contexto, cabe precisar, en primer lugar, las definiciones de etiquetado de alimentos que serán utilizadas en este resumen de evidencia, para luego identificar las posibles opciones para abordar el problema. MÉTODOS: La metodología de la búsqueda sistemática de evidencia sobre las diferentes ubicaciones se describe en el Cuadro 1. Para cada opción se diseñó una estrategia de búsqueda en base a palabras claves sobre cada una de las ubicaciones de etiquetado nutricional, la que fue ejecutada en Epistemonikos. Además, se elaboró una segunda estrategia de búsqueda que incluyó todas las ubicaciones (ver Anexo 1). Las referencias identificadas con ambas estrategias, luego de eliminar duplicados, fueron cribadas por 2 investigadores de manera independiente. La selección de las revisiones sistemáticas y sus estudios primarios respondió a los siguientes criterios: 1. Evaluar el uso de etiquetados de nutrientes específicos interpretativos. 2. Que el ámbito en donde se realicen las investigaciones sea en restaurantes, cafeterías, cadenas o locales de comida rápida. 3. Incluir información respecto a alguno de los desenlaces considerados relevantes por el equipo elaborador y la contraparte: a. Consumo (ingesta calórica): cantidad de calorías ingeridas. b. Compras o ventas de productos con etiquetado nutricional: considera cambios en el volumen o proporción de productos vendidos/comprados (ej. cambio en la compra o venta de alimentos poco nutritivos o saludables), cambios en la frecuencia de compras de productos etiquetados y cambios en la cantidad de calorías compradas. c. Visibilidad del etiquetado: si el cliente identifica la presencia de una etiqueta asociada al producto que desea adquirir. d. Comprensión del etiquetado: si una vez que el cliente visualiza el etiquetado, logra comprender la información que contiene. e. Cambios de actitud del usuario (reporte subjetivo de cambios en la compra o consumo o en la intención de compra/consumo) y cambios en el comportamiento de la industria. f. Aceptabilidad o valoración de la política: evaluada subjetivamente por los clientes/consumidores. g. Costos. 4. Incluir comparaciones entre alguna(s) de las opciones de ubicación del etiquetado nutricional y una alternativa sin etiquetado. Es decir, un equivalente que permitiera "aislar" el efecto de la ubicación específica de etiquetado: por ejemplo, menú con etiquetado versus menú sin etiquetado. RESULTADOS De 674 resultados obtenidos inicialmente, se identificaron once revisiones sistemáticas [1 - 11] que respondían a la pregunta de interés (ver Figura 3). De éstas, nueve abordaron la opción de menú [2, 3, 5, 6, 7, 8, 9, 10, 11], seis la opción de soportes [1, 3, 4, 6, 10, 11], cuatro la opción de ambiente [1, 4, 6, 10], cuatro la de paquete contenedor del producto [1, 4, 6, 10] y dos la de etiquetado nutricional en contextos de venta virtual [2, 5]. CONSIDERACIONES DE IMPLEMENTACIÓN: Dado que gran parte de la literatura relacionada con los aspectos de implementación de los etiquetados nutricionales en establecimientos de comida rápida tienen un abordaje genérico, sin diferenciar entre las diferentes ubicaciones del etiquetado, las consideraciones de implementación se presentan de manera general para los diferentes grupos de interés. El análisis de barreras y facilitadores se basó principalmente en los resultados de una revisión sistemática identificada en la búsqueda inicial de este resumen de evidencia, la cual fue excluida del análisis de hallazgos de evidencia dado que no presentó evidencia de efectividad o impacto [24]. El objetivo de esta revisión sistemática fue sintetizar la evidencia de las barreras y facilitadores percibidos respecto de la implementación de intervenciones de etiquetado en los menús desde la perspectiva de la industria alimentaria. No hubo restricciones respecto del formato o esquema de etiquetado en los menús, tipos de estudios, lenguaje o año de publicación. La revisión identificó 17 estudios primarios, 8 de ellos utilizaron métodos cuantitativos para la recolección de datos, 7 utilizaron métodos cualitativos y 2 métodos mixtos. La mayoría de los estudios (n = 15) se realizaron en países de altos ingresos [24].

Towards unified and impactful policies to reduce ultra-processed food consumption and promote healthier eating.

The global surges in obesity and nutrition-related non-communicable diseases (NCDs) have created a need for decisive new food policy initiatives. A major concern has been the impact of ultra-processed foods (UPFs) and ultra-processed drinks on weight gain and on the risk of several NCDs. These foods, generally high in calories, added sugar, sodium, and unhealthy fats, and poor in fibre, protein, and micronutrients, have extensive negative effects on human health and on the environment (due to their associated carbon emission and water use). There is a growing tendency worldwide, and especially in South America, for food companies to add micronutrients to UPFs to make health claims regarding these products, to which food-regulating authorities refer to fake foods. Although more than 45 countries and smaller subregional or urban entities have created taxes on ultra-processed drinks, such as sugar-sweetened beverages, only a few have adopted taxes on snacks and other UPFs, and none have added major subsidies for truly healthy, fresh or minimally processed food for people from lower socioeconomic backgrounds. Another major focus has been on developing effective package labelling. A smaller number of countries have selected the most impactful warning labels and linked them with other measures to create a mutually reinforcing set of policies; a few other countries have developed effective school food policies. We herein present in-depth results from key countries involved in all these actions and in comprehensive marketing controls, and conclude with our recommendations for the future. This field is quite new; progress to date is substantial, but much more is left to learn.

The Nutritional Profile and On-Pack Marketing of Toddler-Specific Food Products Launched in Australia between 1996 and 2020.

With the food system evolving, it is not clear how the nutrition and on-pack claims of toddler foods have been impacted. Data on the trends in Australia are lacking, so we sought to determine the changes in the nutrition and on-pack claims of toddler-specific packaged foods over time. A retrospective cross-sectional analysis was conducted using the Mintel Global New Products Database. The number of toddler-specific foods increased from 1996 to 2020. Over time, a lower proportion of meals and snacks were classified as "ultra-processed", but a higher proportion of snacks were classified as "discretionary". Meals launched after 2014 had higher median values for energy, saturated fat, and sugar than those in earlier years. Toddler snacks launched after 2014 had lower median values for sodium, and higher median values for fat, saturated fat, and sugar than those in earlier years. The mean number of total claims per package increased over time for snacks, with an increase in unregulated claims for both meals and snacks. Public health action is needed to ensure that the retail food environment for young children is health-promoting, including stringent and clear regulations for on-pack claims, and compositional guidelines and guidance on how to reduce the number of ultra-processed foods for toddlers.

Ultraprocessed Food: Addictive, Toxic, and Ready for Regulation.

Past public health crises (e.g., tobacco, alcohol, opioids, cholera, human immunodeficiency virus (HIV), lead, pollution, venereal disease, even coronavirus (COVID-19) have been met with interventions targeted both at the individual and all of society. While the healthcare community is very aware that the global pandemic of non-communicable diseases (NCDs) has its origins in our Western ultraprocessed food diet, society has been slow to initiate any interventions other than public education, which has been ineffective, in part due to food industry interference. This article provides the rationale for such public health interventions, by compiling the evidence that added sugar, and by proxy the ultraprocessed food category, meets the four criteria set by the public health community as necessary and sufficient for regulation-abuse, toxicity, ubiquity, and externalities (How does your consumption affect me?). To their credit, some countries have recently heeded this science and have instituted sugar taxation policies to help ameliorate NCDs within their borders. This article also supplies scientific counters to food industry talking points, and sample intervention strategies, in order to guide both scientists and policy makers in instituting further appropriate public health measures to quell this pandemic.

Association between the price of ultra-processed foods and obesity in Brazil.

BACKGROUND AND AIMS: To estimate the relationship between the price of ultra-processed foods and prevalence of obesity in Brazil and examine whether the relationship differed according to socioeconomic status. METHODS AND RESULTS: Data from the national Household Budget Survey from 2008/09 (n = 55 570 households, divided in 550 strata) were used. Weight and height of all individuals were used. Weight was measured by using portable electronic scales (maximum capacity of 150 kg). Height (or length) was measured using portable stadiometers (maximum capacity: 200 cm long) or infant anthropometers (maximum capacity: 105 cm long). Multivariate regression models (log-log) were used to estimate price elasticity. An inverse association was found between the price of ultra-processed foods (per kg) and the prevalence of overweight (Body mass index (BMI) ≥25 kg/m2) and obesity (BMI ≥30 kg/m2) in Brazil. The price elasticity for ultra-processed foods was -0.33 (95% CI: -0.46; -0.20) for overweight and -0.59 (95% CI: -0.83; -0.36) for obesity. This indicated that a 1.00% increase in the price of ultra-processed foods would lead to a decrease in the prevalence of overweight and obesity of 0.33% and 0.59%, respectively. For the lower income group, the price elasticity for price of ultra-processed foods was -0.34 (95% CI: -0.50; -0.18) for overweight and -0.63 (95% CI: -0.91; -0.36) for obesity. CONCLUSION: The price of ultra-processed foods was inversely associated with the prevalence of overweight and obesity in Brazil, mainly in the lowest socioeconomic status population. Therefore, the taxation of ultra-processed foods emerges as a prominent tool in the control of obesity.

Association between consumption of ultra-processed foods and serum C-reactive protein levels: cross-sectional results from the ELSA-Brasil study.

BACKGROUND: There may be a direct association between consumption of ultra-processed foods and C-reactive protein (CRP) levels, under the assumption that the high glycemic index of these food products could stimulate the entire chronic inflammation cascade, along with an indirect association mediated by obesity. The types of food consumed, including ultra-processed products, strongly influence obesity, and are also associated with higher serum CRP levels. OBJECTIVE: Our aim was to investigate whether the caloric contribution of ultra-processed foods to diet is associated with CRP levels, independent of body mass index (BMI). DESIGN AND SETTING: Cross-sectional analysis on the Longitudinal Study of Adult Health (ELSA-Brasil) baseline cohort (2008-2010). METHODS: Dietary information, obtained through a food frequency questionnaire, was used to estimate the percentage of energy contribution from ultra-processed food to individuals' total caloric intake. CRP levels were the response variable. Sex-specific associations were estimated using generalized linear models with gamma distribution and log-link function. RESULTS: Ultra-processed food accounted for 20% of total energy intake. Among men, after adjustments for sociodemographic characteristics, there was no association between ultra-processed food intake and CRP levels. Among women, after adjustment for sociodemographic characteristics, smoking and physical activity, the highest tercile of ultra-processed food intake was associated with mean CRP levels that were 14% higher (95% confidence interval: 1.04-1.24) than those of the lowest tercile. However, after considering BMI, this association lost statistical significance. CONCLUSION: Our findings suggest that the positive association of ultra-processed food consumption with CRP levels among women seems to be mediated by the presence of adiposity.

Association between consumption of ultra-processed foods and serum C-reactive protein levels: cross-sectional results from the ELSA-Brasil study

ABSTRACT BACKGROUND: There may be a direct association between consumption of ultra-processed foods and C-reactive protein (CRP) levels, under the assumption that the high glycemic index of these food products could stimulate the entire chronic inflammation cascade, along with an indirect association mediated by obesity. The types of food consumed, including ultra-processed products, strongly influence obesity, and are also associated with higher serum CRP levels. OBJECTIVE: Our aim was to investigate whether the caloric contribution of ultra-processed foods to diet is associated with CRP levels, independent of body mass index (BMI). DESIGN AND SETTING: Cross-sectional analysis on the Longitudinal Study of Adult Health (ELSA-Brasil) baseline cohort (2008-2010). METHODS: Dietary information, obtained through a food frequency questionnaire, was used to estimate the percentage of energy contribution from ultra-processed food to individuals' total caloric intake. CRP levels were the response variable. Sex-specific associations were estimated using generalized linear models with gamma distribution and log-link function. RESULTS: Ultra-processed food accounted for 20% of total energy intake. Among men, after adjustments for sociodemographic characteristics, there was no association between ultra-processed food intake and CRP levels. Among women, after adjustment for sociodemographic characteristics, smoking and physical activity, the highest tercile of ultra-processed food intake was associated with mean CRP levels that were 14% higher (95% confidence interval: 1.04-1.24) than those of the lowest tercile. However, after considering BMI, this association lost statistical significance. CONCLUSION: Our findings suggest that the positive association of ultra-processed food consumption with CRP levels among women seems to be mediated by the presence of adiposity.

[Neighbourhood deprivation and community nutrition environment: associations between the social and built environment and food availability]. / Stadtteildeprivation und Lebensmittelumwelt: Zusammenhänge von sozialen und baulichen Merkmalen der Wohnumgebung und Lebensmittelverfügbarkeit.

OBJECTIVE: Eating habits are influenced by individual socioeconomic status (SES). As the association between neighbourhood characteristics and food availability is still unclear, we investigated the community nutrition environment in different neighbourhoods. METHODS: Using official data of the city of Leipzig, we selected three neighbourhoods which differed in terms of their social (2 deprived vs. 1 affluent) and built (1 large housing estates vs. 2 historic buildings) environment. Data on food outlets were assessed via direct observation (ground truthing). RESULTS: Social and residential environment characteristics are associated with food availability. The proportion of fast food outlets is higher in deprived neighbourhoods compared to the affluent one (25%, 30.4% vs. 13.5%). Neighbourhoods with historic buildings offer a greater variety of food outlets. CONCLUSION: The greater availability of unhealthy food may contribute to the development of obesity. Preventive measures should consider the physical and social environment.

Assessment of some traditional cardiovascular risk factors in medical doctors in Southern Nigeria.

INTRODUCTION: Almost one third of deaths globally are caused by cardiovascular diseases (CVDs). Certain occupations may promote the development and worsening of risk factor for CVDs. We assessed some traditional cardiovascular risk factors and lifestyle choices that may predispose to CVDs in medical doctors in a tertiary health facility in Southern Nigeria. STUDY DESIGN: Cross-sectional study. PARTICIPANTS AND METHODS: One hundred sixty-nine apparently healthy medical doctors were recruited. A structured self-administered questionnaire was used to gather data on CVD risk factors. Anthropometric and blood pressure (BP) measurements were taken. RESULTS: Majority were males (68.0%), aged 20-39 years (43.8%), single (62.7%), and house officers (58.0%) with<1 year (48.5%) work experience. Over half were either overweight or obese. While 77.2% of those not centrally obese were males, only about 22.8% of females did not meet the criteria for central obesity (P-value < 0.05). While respondents had BP in prehypertensive (48.2%), stage 1 (18.5%), or stage 2 hypertension (3.6%) ranges, only 7.7% had a previous diagnosis of hypertension. Only 25.4% took fruits on a daily basis and engaged in aerobic exercises up to 30 minutes daily or at least 3-5 times a week. Other poor lifestyle choices included non-lean meat intake (76.8%), low water intake (88.2%), and junk food and soda drinks intake (daily 28%, weekly 51.2%). CONCLUSION: Findings of a high prevalence of overweight/obesity, physical inactivity, and junk food intake and low fruits intake among doctors is worrisome. There is a need to educate doctors on adopting healthier lifestyles to reduce risk of CVDs.

Dietary Practices Among Stroke-survivors-Racial/Ethnic Differences.

BACKGROUND: Healthy lifestyle choices, particularly optimal nutrition, are crucial to stroke prevention and reducing risk of recurrent stroke. Racial differences exist in poststroke outcomes; however, few studies have examined the influence of race on poststroke diet or nutrition practices, despite nutrition being critical to stroke recovery. The objective of this analyzes was therefore to examine racial/ ethnic differences in nutrition activities among stroke survivors using data from the National Health and Nutrition Examination Surveys. METHODS: Cross-sectional data from National Health and Nutrition Examination Surveys (2011-2014) were analyzed for adults (n = 431) who responded "yes" that they had been told by a health professional that they had a stroke. The main outcome measure was food consumption/nutrition behavior. Descriptive statistics were conducted for demographic characteristics. Pearson Chi square statistics were performed for baseline demographic and clinical comparisons. A negative binomial regression analysis was utilized for racial/ethnic comparisons of dietary/nutrition behaviors. RESULTS: The mean age of the sample was 66.6 years (Standard Deviation, 12.7) but the mean age of stroke onset was 57.9 years (Standard Deviation, 15.8), with Mexican American/Hispanics experiencing their strokes at a younger age than other racial groups (P < .007). After controlling for baseline differences in key demographic and clinical covariates variables, Blacks consumed a higher number of ready-to-eat foods (P = .000) in the past 30 days while Mexican American/Hispanics consumed a higher number of frozen meals/pizza in the past 30 days (P = .004). CONCLUSIONS: Racial/ethnic differences in poststroke nutrition practices, highlight a potential need for focused nutrition counseling for minority population at higher risk of poor poststroke outcomes.

Estimation of weekly intake of cadmium and lead by consumption of commercial ready-to-feed infant foods.

The purpose of this survey was to estimate the safety of ready-to-eat infant foods in terms of Pb and Cd content. The studied samples were ready-to-eat infant products: dinners (n = 74), soups (n = 27) and desserts (n = 82) containing components of animal origin: meat and/or milk. Cd and Pb content was determined using a GF-AAS method. The analysed products contained 1.82-3.54 µg Pb and 1.32-1.50 µg Cd per kg. The content of Pb per kg of the product can be represented as dinners > soups > desserts, whereas the content of Cd was dinners > desserts > soups. The analysed ready-to-eat products could be regarded as safe, because they supply 12-month-old infants with Pb in an amount accounting for nearly 22% BMDL01 and Cd accounting for ca. 8.6% of the total weekly intake.

Growth of Clostridium perfringens in sous vide cooked ground beef with added grape seed extract.

The growth of Clostridium perfringens from spore inocula was studied in sous vide cooked ground beef with added 0 to 3% grape seed extract (GSE). C. perfringens did not grow at 4 °C with or without GSE present. Lag time (LT) was 95 h in control samples at 15 °C, whereas 1-3% GSE addition significantly (p < .05) extended LT to 244 h or longer. Generation time (GT) in 3% GSE added beef was similar to that of control (19 h, 3% GSE versus 18 h, control) at 15 °C. At 20 °C, GT was 1.5 h in samples without GSE; however, 1-3% GSE addition extended GT about 2-3 folds (p < .05). Lag time at 20 °C was 23 h in control samples, while LT was 40-59 h in samples containing GSE. Interestingly, GSE did not affect LT at 25 °C; however, significantly (p < .05) longer GT was observed in 3% GSE added samples than the other sample groups. Additionally, GSE from 1 to 3% in beef extended the period needed to reach 6 log cfu/g at 15 or 20 °C, while 3% GSE was required at 25 °C. The findings suggest that GSE exhibits concentration and temperature dependent inhibitory effect on growth of C. perfringens in sous vide cooked ground beef. Grape seed extract can be used to extend the shelf-life and ensure the microbiological safety of sous vide cooked meat products.

Limiting trans Fats in Foods: Use of Partially Hydrogenated Vegetable Oils in Prepacked Foods in Slovenia.

Consumption of industrially produced trans-fatty acids (TFAs) is a well-established health risk factor that correlates with the increased risk of developing cardiovascular disease. The recommended TFA intake is as low as possible, within the context of a nutritionally adequate diet. Different countries have introduced different measures to minimize the exposure of their population to TFAs. Previous data have shown that TFA content has significantly decreased in Western European countries, while this was not the case in many Central-Eastern European countries, including Slovenia. In the absence of regulatory requirements, a number of awareness campaigns were launched in Slovenia since 2015, with the common goal of lowering the use of partially hydrogenated oils (PHO), which are considered a major source of TFAs. To determine if this goal had been reached, we performed an assessment of the exposure of the population to prepacked foods containing PHOs in years 2015 and 2017. Altogether, data on the composition of 22,629 prepacked foods was collected from food labels, using a specifically developed smartphone application. Furthermore, the food categories with the most frequent use of PHOs were identified. The proportion of PHO-containing products was determined for each specific food category, and adjusted with the market share data. The results showed that in 2015, vegetable cream substitutes, soups, and biscuits were the categories with the highest penetration of declared PHO content. In 2017, the proportion of products with PHO decreased considerably. In vegetable cream substitutes the percentage of PHO containing items dropped from 30 down to 4%, in soups it decreased from 21 to 5%, in biscuits from 17 to 8%, and in crisps and snacks from 10 to 4%. However, PHO content remained notable among cakes, muffins, pastries, and biscuits. We can conclude that the voluntary guidelines and regular public communication of the risks related to the TFA consumption has had a considerable effect on the food supply, but did not result in sufficient removal of PHOs from foods.

Total and Free Sugar Content of Pre-Packaged Foods and Non-Alcoholic Beverages in Slovenia.

Scientific evidence of the association between free sugar consumption and several adverse health effects has led many public health institutions to take measures to limit the intake of added or free sugar. Monitoring the efficiency of such policies and the amount of free sugar consumed requires precise knowledge of free sugar content in different food products. To meet this need, our cross-sectional study aimed at assessing free sugar content for 10,674 pre-packaged food items available from major Slovenian food stores during data collection in 2015. Together, 52.6% of all analyzed products contained free sugar, which accounted for an average of 57.5% of the total sugar content. Food categories with the highest median free sugar content were: honey and syrups (78.0 g/100 g), jellies (62.9 g/100 g), chocolate and sweets (44.6 g/100 g), jam and spreads (35.9 g/100 g), and cereal bars (23.8 g/100 g). Using year-round sales data provided by the retailers, the data showed that chocolate, sweets, and soft drinks alone accounted for more than 50% of all free sugar sold on the Slovenian market. The results of this study can be used to prepare more targeted interventions and efficient dietary recommendations.

Process Evaluation and Costing of a Multifaceted Population-Wide Intervention to Reduce Salt Consumption in Fiji.

This paper reports the process evaluation and costing of a national salt reduction intervention in Fiji. The population-wide intervention included engaging food industry to reduce salt in foods, strategic health communication and a hospital program. The evaluation showed a 1.4 g/day drop in salt intake from the 11.7 g/day at baseline; however, this was not statistically significant. To better understand intervention implementation, we collated data to assess intervention fidelity, reach, context and costs. Government and management changes affected intervention implementation, meaning fidelity was relatively low. There was no active mechanism for ensuring food companies adhered to the voluntary salt reduction targets. Communication activities had wide reach but most activities were one-off, meaning the overall dose was low and impact on behavior limited. Intervention costs were moderate (FJD $277,410 or $0.31 per person) but the strategy relied on multi-sector action which was not fully operationalised. The cyclone also delayed monitoring and likely impacted the results. However, 73% of people surveyed had heard about the campaign and salt reduction policies have been mainstreamed into government programs. Longer-term monitoring of salt intake is planned through future surveys and lessons from this process evaluation will be used to inform future strategies in the Pacific Islands and globally.

Processed and ultra-processed food consumption among children aged 13 to 35 months and associated factors.

The aim of this study was to evaluate the consumption of processed and ultra-processed foods among children aged 13-35 months and its associated factors. We studied 1,185 children within the BRISA cohort in São Luís, Maranhão State, Brazil. The food consumption was investigated using a 24-hour recall, and the percentages of daily caloric intake and nutrients were estimated by food groups according to "NOVA" classification. We chose to categorize children belonging to the upper tertile of the distribution as having a high consumption of processed and ultra-processed food products. The Poisson regression model with robust variance estimation using a hierarchical modeling approach was used to calculate the prevalence ratios (PRs) of variables associated with high consumption of processed and ultra-processed food products. The mean energy intake was 1,226Kcal/day. After adjustments, there was a higher proportion of high consumption of processed and ultra-processed food products among children whose mothers had < 12 years of education and among children who were older than 16 months. Mothers with low schooling and children older than 16 months should be the targets of interventions aimed at reducing consumption of these food products and preventing adverse health outcomes in later life.

Processed and ultra-processed food consumption among children aged 13 to 35 months and associated factors / Consumo de alimentos processados e ultraprocessados e fatores associados em crianças entre 13 e 35 meses de idade / Consumo de alimentos procesados y ultraprocesados y factores asociados en niños entre 13 y 35 meses de edad

Abstract: The aim of this study was to evaluate the consumption of processed and ultra-processed foods among children aged 13-35 months and its associated factors. We studied 1,185 children within the BRISA cohort in São Luís, Maranhão State, Brazil. The food consumption was investigated using a 24-hour recall, and the percentages of daily caloric intake and nutrients were estimated by food groups according to "NOVA" classification. We chose to categorize children belonging to the upper tertile of the distribution as having a high consumption of processed and ultra-processed food products. The Poisson regression model with robust variance estimation using a hierarchical modeling approach was used to calculate the prevalence ratios (PRs) of variables associated with high consumption of processed and ultra-processed food products. The mean energy intake was 1,226Kcal/day. After adjustments, there was a higher proportion of high consumption of processed and ultra-processed food products among children whose mothers had < 12 years of education and among children who were older than 16 months. Mothers with low schooling and children older than 16 months should be the targets of interventions aimed at reducing consumption of these food products and preventing adverse health outcomes in later life.

Resumo: O estudo teve como objetivo avaliar o consumo de alimentos processados e ultraprocessados por crianças entre 13 e 35 meses de idade e fatores associados. Estudamos 1.185 crianças da coorte BRISA em São Luís, Maranhão, Brasil. O consumo alimentar foi investigado com um recordatório de 24 horas, e os percentuais de ingestão diária de calorias e nutrientes foram estimados por grupos de alimentos de acordo com a classificação "NOVA". Optamos por categorizar as crianças pertencentes ao tercil superior da distribuição como tendo consumo elevado de produtos alimentícios processados e ultraprocessados. Foi utilizado um modelo de regressão Poisson com estimativa robusta de variância com modelagem hierárquica para calcular as razões de prevalência (RPs) das variáveis associadas ao consumo elevado de produtos alimentícios processados e ultraprocessados. A ingestão calórica média era 1.226Kcal/dia. Após os ajustes, houve uma proporção maior de consumo elevado de produtos alimentícios processados e ultraprocessados entre crianças cujas mães tinham menos de 12 anos de escola e entre crianças com mais de 16 meses de idade. As mães com baixa escolaridade e crianças acima de 16 meses devem ser alvos de intervenções para reduzir o consumo desses produtos alimentícios e prevenir os desfechos de saúde adversos na adolescência e idade adulta.

Resumen: El objetivo de este estudio fue evaluar el consumo de alimentos procesados y ultraprocesados por parte de niños entre 13 y 35 meses de edad y sus factores asociados. Estudiamos a 1.185 niños de la cohorte BRISA en São Luís, Maranhão, Brasil. El consumo alimentario fue investigado con un recordatorio de 24 horas, y los porcentajes de ingesta diaria de calorías y nutrientes fueron estimados por grupos de alimentos, de acuerdo con la clasificación "NOVA". Optamos por categorizar a los niños pertenecientes al tercil superior de la distribución como de consumo elevado de productos alimenticios procesados y ultraprocesados. Se utilizó un modelo de regresión Poisson de estimativa robusta de variancia con modelaje jerárquico para calcular las razones de prevalencia (RPs) de las variables asociadas al consumo elevado de productos alimenticios procesados y ultraprocesados. La ingesta calórica media era 1.226Kcal/día. Tras los ajustes, hubo una proporción mayor de consumo elevado de productos alimenticios procesados y ultraprocesados entre niños, cuyas madres contaban con menos de 12 años de escuela y entre niños con más de 16 meses de edad. Las madres con baja escolaridad y niños por encima de 16 meses deben ser objetivo de intervenciones para reducir el consumo de esos productos alimenticios y prevenir desenlaces de salud adversos en la adolescencia y edad adulta.

Evaluating the Effectiveness of New York City Health Policy Initiatives in Reducing Cardiovascular Disease Mortality, 1990-2011.

Beginning in 2002, New York City (NYC) implemented numerous policies and programs targeting cardiovascular disease (CVD) risk factors. Using death certificates, we analyzed trends in NYC-specific and US mortality rates from 1990 to 2011 for all causes, any CVD, atherosclerotic CVD (ACVD), coronary artery disease (CAD), and stroke. Joinpoint analyses quantified annual percent change (APC) and evaluated whether decreases in CVD mortality accelerated after 2002 in either NYC or the total US population. Our analyses included 1,149,217 NYC decedents. The rates of decline in mortality from all causes, any CVD, and stroke in NYC did not change after 2002. Among men, the decline in ACVD mortality accelerated during 2002-2011 (APC = -4.8%, 95% confidence interval (CI): -6.1, -3.4) relative to 1990-2001 (APC = -2.3%, 95% CI: -3.1, -1.5). Among women, ACVD rates began declining more rapidly in 1993 (APC = -3.2%, 95% CI: -3.8, -2.7) and again in 2006 (APC = -6.6%, 95% CI: -8.9, -4.3) as compared with 1990-1992 (APC = 1.6%, 95% CI: -2.7, 6.0). In the US population, no acceleration of mortality decline was observed in either ACVD or CAD mortality rates after 2002. Relative to 1990-2001, atherosclerotic CVD and CAD rates began to decline more rapidly during the 2002-2011 period in both men and women-a pattern not observed in the total US population, suggesting that NYC initiatives might have had a measurable influence on delaying or reducing ACVD mortality.

Labelling completeness and sodium content of packaged foods in India.

OBJECTIVE: To estimate the proportion of products meeting Indian government labelling regulations and to examine the Na levels in packaged foods sold in India. DESIGN: Nutritional composition data were collected from the labels of all packaged food products sold at Indian supermarkets in between 2012 and 2014. Proportions of products compliant with the Food Safety Standards Authority of India (FSSAI) regulations and labelled with Na content, and mean Na levels were calculated. Comparisons were made against 2010 data from Hyderabad and against the UK Department of Health (DoH) 2017 Na targets. SETTING: Eleven large chain retail stores in Delhi and Hyderabad, India. SUBJECTS: Packaged food products (n 5686) categorised into fourteen food groups, thirty-three food categories and ninety sub-categories. RESULTS: More packaged food products (43 v. 34 %; P<0·001) were compliant with FSSAI regulations but less (32 v. 38 %; P<0·001) reported Na values compared with 2010. Food groups with the highest Na content were sauces and spreads (2217 mg/100 g) and convenience foods (1344 mg/100 g). Mean Na content in 2014 was higher in four food groups compared with 2010 and lower in none (P<0·05). Only 27 % of foods in sub-categories for which there are UK DoH benchmarks had Na levels below the targets. CONCLUSIONS: Compliance with nutrient labelling in India is improving but remains low. Many packaged food products have high levels of Na and there is no evidence that Indian packaged foods are becoming less salty.

Young Adult Risk Factors for Cancer: Obesity, Inflammation, and Sociobehavioral Mechanisms.

INTRODUCTION: The paper assesses social disparities in the burdens of metabolic and inflammatory risks for cancer in the U.S. young adult population and examines psychosocial and behavioral mechanisms in such disparities. METHODS: Using data of 7,889 individuals aged 12-32 years from the National Longitudinal Study of Adolescent to Adult Health from 1994 to 2009, generalized linear models were used to assess the sex, race/ethnicity, and SES differences in the risks of obesity and inflammation, measured by C-reactive protein. Further tests examined the extent to which social isolation, smoking, physical inactivity, alcohol abuse, and illicit drug use explain social differentials in each biomarker outcome. RESULTS: Women, blacks, Hispanics, and socioeconomically disadvantaged groups had higher risks of obesity and elevated C-reactive protein, with the SES gradients being more pronounced in female participants. Health-related behaviors showed large variation across sex, race, and SES strata. After adjusting for these behavioral variables, sex, and race disparities in obesity and excess inflammation in blacks diminished, whereas the adolescent SES disparity in obesity remained. The associations of adolescent and young adult SES disadvantage and inflammation were also explained by behavioral mechanisms. Behavioral factors associated with higher risks of obesity and inflammation differed, with the exception of fast food consumption, a risk factor for both. CONCLUSIONS: This study provides new knowledge of social distribution of early life exposures to physiologic precedents to cancer development later in life with implications for prevention and early intervention of modifiable risky behaviors in adolescents and young adults.