Dietary intake of low-income adults in South Africa: ultra-processed food consumption a cause for concern.

OBJECTIVE: Given the rapidly changing food environment and proliferation of ultra-processed foods (UPF) in South Africa (SA), this study aimed to critically evaluate dietary quality and adequacy of low-income adults using the Nova classification system and WHO and World Cancer Research Fund dietary guidelines. DESIGN: Secondary household data and 1-d 24-h recalls were analysed from two cross-sectional studies conducted in 2017-2018. Foods consumed were classified according to the Nova classification system. Compliance with WHO dietary guidelines and UPF consumption trends were evaluated. SETTING: Three low-income areas (Langa, Khayalitsha and Mount Frere) in SA were included. PARTICIPANTS: In total, 2521 participants (18-50 years) were included in the study. RESULTS: Participants had a mean energy intake of 7762 kJ/d. Most participants were within the acceptable WHO guideline range for saturated fat (80·4 %), total fat (68·1 %), Na (72·7 %) and free sugar (57·3 %). UPF comprised 39·4 % of diets among the average adult participant. Only 7·0 % of all participants met the WHO guideline for fruit and vegetables and 18·8 % met the guideline for fibre. Those within the highest quartile of share of energy from UPF consumed statistically higher amounts of dietary components to limit and were the highest energy consumers overall. CONCLUSIONS: Low-income adults living in SA are consuming insufficient protective dietary components, while UPF consumption is prevalent. Higher UPF consumers consume larger amounts of nutrients linked to increased chronic disease risk. Policy measures are urgently needed in SA to protect against the proliferation of harmful UPF and to promote and enable consumption of whole and less UPF.

Sociodemographic disparities in purchases of fruit drinks with policy relevant front-of-package nutrition claims.

OBJECTIVE: Our objectives were to describe sociodemographic characteristics associated with the purchase of (1) any fruit drinks and (2) fruit drinks with specific front-of-package (FOP) nutrition claims. DESIGN: Cross-sectional. SETTING: USA. PARTICIPANTS: We merged fruit drink purchasing data from 60 712 household-months from 5233 households with children 0-5 years participating in Nielsen Homescan in 2017 with nutrition claims data. We examined differences in predicted probabilities of purchasing any fruit drinks by race/ethnicity, income and education. We constructed inverse probability (IP) weights based on likelihood of purchasing any fruit drinks. We used IP-weighted multivariable logistic regression models to examine predicted probabilities of purchasing fruit drinks with specific FOP claims. RESULTS: One-third of households with young children purchased any fruit drinks. Non-Hispanic (NH) Black (51·6 %), Hispanic (36·3 %), lower-income (39·3 %) and lower-educated households (40·9 %) were more likely to purchase any fruit drinks than NH White (31·3 %), higher-income (25·8 %) and higher-educated households (30·3 %) (all P < 0·001). In IP-weighted analyses, NH Black households were more likely to purchase fruit drinks with 'Natural' and fruit or fruit flavour claims (6·8 % and 3·7 %) than NH White households (4·5 % and 2·7 %) (both P < 0·01). Lower- and middle-income (15·0 % and 13·8 %) and lower- and middle-educated households (15·4 % and 14·5 %) were more likely to purchase fruit drinks with '100 % Vitamin C' claims than higher-income (10·8 %) and higher-educated households (12·9 %) (all P < 0·025). CONCLUSIONS: We found a higher likelihood of fruit drink purchases in lower-income, lower-educated, NH Black and Hispanic households. Experimental studies should determine if nutrition claims may be contributing to disparities in fruit drink consumption.

The Influence of Front-of-Package Nutrition Labeling on Consumer Behavior and Product Reformulation.

Countries worldwide have implemented mandatory or voluntary front-of-package nutrition labeling systems. We provide a narrative review of (a) real-world evaluations of front-of-package nutrition labels that analyze objective sales data and (b) studies that objectively assess product reformulation in response to a front-of-package nutrition label implementation. We argue that there is sufficient scientific evidence to recommend that governments implement mandatory front-of-package nutrition labeling systems to improvepopulation health. We also present a conceptual framework to describe front-of-package label influence and provide recommendations for the optimal label design, emphasizing that labeling systems should be highly visible and salient, be simple and easy to understand, leverage automatic associations, and integrate informational and emotional messaging. The existing research suggests that Guideline Daily Amount labels should be avoided and that the Health Star Rating and Nutri-Score systems are promising but that systems with warning labels like the one in Chile are likely to produce the largest public health benefits.

Junk Food Intake Among Adults in the United States.

BACKGROUND: There is no consensus on how to define "junk food." In 2016, Chile implemented the most comprehensive set of obesity-preventive regulations in the world, including criteria to define unhealthy foods. OBJECTIVES: The objective of this study was to examine the amount of energy, sodium, sugar, and saturated fat consumed by US adults defined as junk food using the Chilean criteria. METHODS: We used 2 nationally representative surveys of food intake in 10,001 US adults: NHANES 2015-2016 and NHANES 2017-2018. The main outcome measures were the contributions of energy, total sugars, saturated fat, and sodium deriving from junk food sources. Mean intake and proportion of energy, sugar, saturated fat, and sodium for junk food overall and each food category were calculated. RESULTS: Overall, 47% of energy, 75% of total sugar, 46% of sodium, and 48% of saturated fat consumed by US adults derived from junk food sources. Sugar-sweetened beverages (SSBs) were responsible for more than 40% of total sugar intake deriving from junk foods. Non-Hispanic black adults had the highest mean energy, total sugar, and sodium intake deriving from junk foods, with non-Hispanic white adults having the highest saturated fat intake. Non-Hispanic black adults had the highest intake of total sugar deriving from junk food sources of SSBs (26.7 g/d), with SSBs representing >40% of total sugar intake deriving from junk food sources for all race/ethnic groups. CONCLUSIONS: Foods that meet the Chilean criteria for junk food provide approximately half or more daily energy and food components to limit in the diet of US adults, with important differences observed between race/ethnic groups. Policy efforts to reduce junk food intake, particularly the intake of SSBs, must be expanded to improve the cardiometabolic health equitably in the United States.

Whole Grain and Refined Grains: An Examination of US Household Grocery Store Purchases.

BACKGROUND: The health benefits related to intake of whole grain foods are well established. Consumption of whole grains in the US population is low, and whole grain content can vary greatly depending upon the specific products that are purchased. OBJECTIVES: To examine the proportion of products purchased by US households containing whole grain and refined grain ingredients using time-specific food composition data, and examine whether purchases differ between income, race or ethnicity, and household make-up. METHODS: Nationally representative Nielsen Homescan 2018 data were used. Each barcoded product captured in Nielsen Homescan 2018 was linked with ingredient information using commercial nutrition databases in a time-relevant manner. Packaged food products containing whole grain ingredients, refined grain ingredients, neither, or both were identified. The percentage of packaged food products containing whole grain and refined grain ingredients purchased by US households was determined overall, by demographic subgroup, and by food category. RESULTS: The proportion of packaged food purchases containing refined grain ingredients was significantly higher than whole grain ingredients (30.9% compared with 7.9%; P < 0.0001). Lower income households and households with children purchased a significantly higher proportion of products containing refined grain ingredients, with no nutritionally meaningful racial or ethnic differences observed. Concerningly, across all demographic subgroups >90% of bread purchases contained refined grain ingredients, and the 5 categories with the largest proportion of whole grain ingredients contributed to <20% of overall US household packaged food purchases. CONCLUSIONS: US households are purchasing a significantly higher proportion of packaged food products containing refined grain ingredients than whole grain ingredients. Future policy changes are needed to provide incentives and information (e.g., front-of-pack labels) to aid in encouraging manufacturers to increase whole grain product offerings while decreasing refined grain offerings, and to encourage consumers to substitute away from refined grain products toward whole grain products.

Applying and comparing various nutrient profiling models against the packaged food supply in South Africa.

OBJECTIVE: This study aimed to apply the newly developed Chile Adjusted Model (CAM) nutrient profiling model (NPM) to the food supply in South Africa (SA) and compare its performance against existing NPMs as an indication of suitability for use to underpin food policies targeted at discouraging consumption of products high in nutrients associated with poor health. DESIGN: Cross-sectional analysis of the SA packaged food supply comparing the CAM to three other NPMs: SA health and nutrition claims (SA HNC), Chilean warning octagon (CWO) 2019, and Pan-American Health Organization (PAHO) NPM. SETTING: The SA packaged food supply based on products stocked by supermarkets in Cape Town, SA. PARTICIPANTS: Packaged foods and beverages (N=6474) available in 2018 were analyzed. RESULTS: 49% of products contained excessive amounts of nutrients of concern (considered non-compliant) according to the criteria of all four models. Only 10.9% of products were not excessive in any nutrients of concern (considered compliant) according to all NPMs evaluated. The CAM had an overall non-compliance level of 73.2%, and was comparable to the CWO 2019 for foods (71.2% and 71.1% respectively). The CAM was the strictest NPM for beverages (80.4%) due to the criteria of non-sugar sweeteners and free sugars. The SA HNC was the most lenient with non-compliance at 52.9%. This was largely due to the inclusion of nutrients to encourage, which is a criterion for this NPM. CONCLUSION: For the purpose of discouraging products high in nutrients associated with poor health in SA, the CAM is a suitable NPM.

South Africa's Health Promotion Levy on Pricing and Acquisition of Beverages in Local Spazas and Supermarkets.

OBJECTIVE: In response to concern over rising sugar-sweetened beverage (SSB) consumption, in April 2018, South Africa became the first Sub-Saharan African country to implement an SSB tax. We assess changes in pricing and acquisition of beverages from local supermarkets and small stores among 18-39 year old adults living in one township in the Western Cape, before and after tax implementation. This study is among the first evaluations of an SSB tax on the local food environment in a low-income township. DESIGN: Store beverage pricing and participant surveys were cross-sectional, analyzed 1 month before and 11 months after implementation of the tax (March 2018 and March 2019). SETTING: Langa, Western Cape, South Africa. PARTICIPANTS: Surveyed participants were residents of Langa between 18-39 years old (N=2,693 in 2018 and N=2,520 in 2019). RESULTS: Prices of taxed SSBs increased significantly among small shops and supermarkets between 2018 and 2019. There were non-significant decreases in prices of untaxed beverages in small shops, but prices of untaxed beverages increased in supermarkets. Across all store types, there was a 9 percentage point decrease in the probability of purchasing regular soda weekly pre/post-implementation. Reductions in purchasing were larger in small shops than supermarkets. CONCLUSIONS: We found some differential impacts of the levy on pricing and acquisition of beverages by retailer type in one low-income township. As other Sub-Saharan African countries consider similar fiscal policies to curb soda consumption, obesity and related diseases, this work can be used to understand the implications of these policies in the retail setting.

Prevalence and demographic correlates of online grocery shopping: results from a nationally representative survey during the COVID-19 pandemic.

OBJECTIVE: To estimate the prevalence of online grocery shopping in a nationally representative sample and describe demographic correlates with online grocery shopping. DESIGN: The Nielsen COVID-19 Shopper Behavior Survey was administered to a subset of Nielsen National Consumer Panel participants in July 2020. We used survey weighted-multivariable logistic regression to examine demographic correlates of having ever online grocery shopped. SETTING: Online survey. PARTICIPANTS: 18 598 Nielsen National Consumer Panel participants in the USA. RESULTS: Thirty-nine percent of respondents had purchased groceries online, and among prior purchasers, 89 % indicated that they would continue to online grocery shop in the next month. Canned/packaged foods were the most shopped for grocery category online, followed by beverages, fresh foods and lastly frozen foods. In adjusted analyses, younger respondents (39 years or less) were more likely (47 %) to have ever shopped for groceries online than older age groups (40-54 years, 55-64 years and 65+ years) (29 %, 22 % and 23 %, respectively, all P < 0·001). Those with greater than a college degree were more likely to have ever grocery shopped online (45 %) than respondents with some college education (39 %) and with a high school education or less (32 %) (both P < 0·001). Having children, having a higher income and experiencing food insecurity, particularly among higher income food-insecure households, were also associated with a higher probability of prior online grocery shopping. CONCLUSIONS: The COVID-19 pandemic accelerated the transition to online grocery shopping. Future research should explore the nutrition implications of online grocery shopping.

Effect of different front-of-package food labels on identification of unhealthy products and intention to purchase the products- A randomised controlled trial in South Africa.

This study aimed to evaluate the effect of different labels on participants identifying products high in nutrients of concern; identifying unhealthy products, and intention to purchase unhealthy products. This blinded randomised controlled trial included a representative sample of South African households (n = 1951). Per household we selected a member primarily responsible for food purchases. Participants were randomised into the Warning Label (WL), Guideline Dietary Amounts (GDA) or Multiple Traffic Light (MTL) arms. Each participant answered questions in a no label condition (control) followed by same questions in the label condition (experiment). Complete data were collected and analysed for 1948 participants (WL = 33.7%, GDA = 32.1% and MTL = 34.2%). The probability of correctly identifying products high in nutrients of concern and identifying products as being unhealthy was higher with the WL compared to the GDA or MTL for most items. There was no difference in performance between the GDA and the MTL when considering all items together. A higher percentage of participants reported a lower intention to purchase an unhealthy product after exposure to the WL compared to MTL for 5 out of 6 products; 2 out of 6 products for the WL compared to GDA and 2 out of 6 products for GDA compared to MTL. Compared to the control condition, exposure to each of the labels resulted in better identification of nutrients of concern, unhealthy products and a lower intention to purchase when considering all specific outcome items together. The WL showed a higher potential to enable South African consumers to identify products high in nutrients of concern, identify unhealthy products and discourage purchasing of unhealthy products.

Examining Changes in Food Security, Perceived Stress, and Dietary Intake in a Cohort of Low-Wage Workers Experiencing an Increase in Hourly Wage.

OBJECTIVE: To determine whether an increase in hourly wages was associated with changes in food security and perceived stress among low-wage workers. We also determined whether changes in food security and stress were associated with changes in diet. SETTING: Wages is a prospective cohort study following 974 low-wage workers in Minneapolis, MN, where an ordinance is incrementally increasing minimum wage to US$15/hr from 2018 to 2022, and a comparison community with no minimum wage ordinance (Raleigh, NC). Interaction models were estimated using generalized estimating equations. PARTICIPANTS: Analyses used two waves of data (2018 [baseline], 2019) and included 219 and 321 low-wage workers in Minneapolis and Raleigh (respectively). RESULTS: Average hourly wages increased from US$9.77 (SD US$1.69) to US$11.67 (SD US$4.02). Changes in wages were not associated with changes in food security (odds ratio = 1.05, 95% confidence interval [CI] [0.89, 1.23], p = .57) or stress (ß = -0.01, 95% CI [-0.04, 0.03], p = .70) after 1 year of policy implementation. Changes in food security were not associated with changes in diet. However, we found significant changes in the frequency of fruit and vegetable intake across time by levels of stress, with decreased intake from Wave 1 to 2 at low levels of stress, and increased intake at high levels of stress (incidence rate ratio = 1.17, 95% CI [1.05, 1.31], p = .01). CONCLUSIONS: Changes in wages were not associated with changes in food security or stress in a sample of low-wage workers. Future research should examine whether full implementation of a minimum wage increase is associated with changes in these outcomes.

Excise Taxes as a Policy Lever for Reaching Healthy North Carolina 2030 Targets.

Excise taxes can raise the price of unhealthy products, reducing consumption and associated health risks and costs. Raising state excise taxes on tobacco, alcohol, and sugary drinks and allowing local governments to do the same are win-win strategies for achieving three Healthy North Carolina 2030 health behavior targets while increasing state revenues.

Taxed and untaxed beverage intake by South African young adults after a national sugar-sweetened beverage tax: A before-and-after study.

BACKGROUND: In an effort to prevent and reduce the prevalence rate of people with obesity and diabetes, South Africa implemented a sugar-content-based tax called the Health Promotion Levy in April 2018, one of the first sugar-sweetened beverage (SSB) taxes to be based on each gram of sugar (beyond 4 g/100 ml). This before-and-after study estimated changes in taxed and untaxed beverage intake 1 year after the tax, examining separately, to our knowledge for the first time, the role of reformulation distinct from behavioral changes in SSB intake. METHODS AND FINDINGS: We collected single-day 24-hour dietary recalls from repeat cross-sectional surveys of adults aged 18-39 years in Langa, South Africa. Participants were recruited in February-March 2018 (pre-tax, n = 2,459) and February-March 2019 (post-tax, n = 2,489) using door-to-door sampling. We developed time-specific food composition tables (FCTs) for South African beverages before and after the tax, linked with the diet recalls. By linking pre-tax FCTs only to dietary intake data collected in the pre-tax and post-tax periods, we calculated changes in beverage intake due to behavioral change, assuming no reformulation. Next, we repeated the analysis using an updated FCT in the post-tax period to capture the marginal effect of reformulation. We estimated beverage intake using a 2-part model that takes into consideration the biases in using ordinary least squares or other continuous variable approaches with many individuals with zero intake. First, a probit model was used to estimate the probability of consuming the specific beverage category. Then, conditional on a positive outcome, a generalized linear model with a log-link was used to estimate the continuous amount of beverage consumed. Among taxed beverages, sugar intake decreased significantly (p < 0.0001) from 28.8 g/capita/day (95% CI 27.3-30.4) pre-tax to 19.8 (95% CI 18.5-21.1) post-tax. Energy intake decreased (p < 0.0001) from 121 kcal/capita/day (95% CI 114-127) pre-tax to 82 (95% CI 76-87) post-tax. Volume intake decreased (p < 0.0001) from 315 ml/capita/day (95% CI 297-332) pre-tax to 198 (95% CI 185-211) post-tax. Among untaxed beverages, sugar intake increased (p < 0.0001) by 5.3 g/capita/day (95% CI 3.7 to 6.9), and energy intake increased (p < 0.0001) by 29 kcal/capita/day (95% CI 19 to 39). Among total beverages, sugar intake decreased significantly (p = 0.004) by 3.7 (95% CI -6.2 to -1.2) g/capita/day. Behavioral change accounted for reductions of 24% in energy, 22% in sugar, and 23% in volume, while reformulation accounted for additional reductions of 8% in energy, 9% in sugar, and 14% in volume from taxed beverages. The key limitations of this study are an inability to make causal claims due to repeat cross-sectional data collection, and that the magnitude of reduction in taxed beverage intake may not be generalizable to higher income populations. CONCLUSIONS: Using a large sample of a high-consuming, low-income population, we found large reductions in taxed beverage intake, separating the components of behavioral change from reformulation. This reduction was partially compensated by an increase in sugar and energy from untaxed beverages. Because policies such as taxes can incentivize reformulation, our use of an up-to-date FCT that reflects a rapidly changing food supply is novel and important for evaluating policy effects on intake.

Sugar-Sweetened Beverage Reduction Policies: Progress and Promise.

Evidence showing the effectiveness of policies to reduce the consumption of sugar-sweetened beverages (SSBs) is growing. SSBs are one of the largest sources of added sugar in the diet and are linked to multiple adverse health conditions. This review presents a framework illustrating the various types of policies that have been used to reduce SSB exposure and consumption; policies are organized into four categories (financial, information, defaults, and availability) and take into consideration crosscutting policy considerations (feasibility, impact, and equity). Next, for each category, we describe a specific example and provide evidence of impact. Finally, we discuss crosscutting policy considerations, the challenge of choosing among the various policy options, and important areas for future research. Notably, no single policy will reduce SSB consumption to healthy levels, so an integrated policy approach that adapts to changing market and consumption trends; evolving social, political, and public health needs; and emerging science is critical.

Socio-economic and racial/ethnic disparities in the nutritional quality of packaged food purchases in the USA, 2008-2018.

OBJECTIVE: To determine whether disparities exist in the nutritional quality of packaged foods and beverage purchases by household income, education and race/ethnicity and if they changed over time. DESIGN: We used Nielsen Homescan, a nationally representative household panel, from 2008 to 2018 (n = 672 821 household-year observations). Multivariate, multilevel regressions were used to model the association between sociodemographic groups and a set of nutritional outcomes of public health interest, including nutrients of concern (sugar, saturated fat and Na) and calories from specific food groups (fruits, non-starchy vegetables, processed meats, sugar-sweetened beverages and junk foods). SETTING: Household panel survey. PARTICIPANTS: Approximately 60 000 households each year from the USA. RESULTS: Disparities were found by income and education for most outcomes and widened for purchases of fruits, vegetables and the percentage of calories from sugar between 2008 and 2018. The magnitude of disparities was largest by education. Disparities between Black and White households include the consumption of processed meats and the percentage of calories from sugar, while no disparities were found between White and Hispanic households. Disparities have been largely persistent, as any significant changes over time have been substantively small. CONCLUSIONS: Policies to improve the healthfulness of packaged foods must be expanded beyond SSB taxes, and future research should focus on what mediates the relationship between education and diet so as not to exacerbate disparities.

Association between hourly wages and dietary intake after the first phase of implementation of the Minneapolis minimum wage ordinance.

OBJECTIVE: In 2018, Minneapolis began phased implementation of an ordinance to increase the local minimum wage to $15/h. We sought to determine whether the first phase of implementation was associated with changes in frequency of consumption of fruits and vegetables (F&V), whole-grain-rich foods, and foods high in added sugars among low-wage workers. DESIGN: Natural experiment. SETTING: The Wages Study is a prospective cohort study of 974 low-wage workers followed throughout the phased implementation of the ordinance (2018-2022). We used difference-in-difference analysis to compare outcomes among workers in Minneapolis, Minnesota, to those in a comparison city (Raleigh, North Carolina). We assessed wages using participants' pay stubs and dietary intake using the National Cancer Institute Dietary Screener Questionnaire. PARTICIPANTS: Analyses use the first two waves of Wages data (2018 (baseline), 2019) and includes 267 and 336 low-wage workers in Minneapolis and Raleigh, respectively. RESULTS: After the first phase of implementation, wages increased in both cities, but the increase was $0·84 greater in Minneapolis (P = 0·02). However, the first phase of the policy's implementation was not associated with changes in daily frequency of consumption of F&V (IRR = 1·03, 95 % CI: 0·86, 1·24, P = 0·73), whole-grain-rich foods (IRR = 1·23, 95 % CI: 0·89, 1·70, P = 0·20), or foods high in added sugars (IRR = 1·13, 95 % CI: 0·86, 1·47, P = 0·38) among workers in Minneapolis compared to Raleigh. CONCLUSIONS: The first phase of implementation of the Minneapolis minimum wage policy was associated with increased wages, but not with changes in dietary intake. Future research should examine whether full implementation is associated dietary changes.

How should we evaluate sweetened beverage tax policies? A review of worldwide experience.

Over 45 jurisdictions globally have implemented sweetened beverage taxes. Researchers and policymakers need to assess whether and how these taxes change beverage demand and supply, their intended and unanticipated health, economic and equity impacts. Lessons from such evaluations can maximise the policies' success and impact on non-communicable disease prevention globally. We discuss key theoretical, design and methodological considerations to help policymakers, funders and researchers commission and conduct rigorous evaluations of these policies and related disease prevention efforts. We encourage involving the perspectives of various stakeholders on what evaluations are needed given the specific context, what data and methods are appropriate, readily available or can be collected within time and budget constraints. A logic model /conceptual system map of anticipated implications across sectors and scales should help identify optimal study design, analytical techniques and measures. These models should be updated when synthesising findings across diverse methods and integrating findings across subpopulations using similar methods.

Would A National Sugar-Sweetened Beverage Tax In The United States Be Well Targeted?

Sugar-sweetened beverage (SSB) taxes have been proposed to discourage excessive sugar consumption, but it is unclear how high- vs. low-SSB purchasers respond to such taxes. We first examine heterogeneity in the purchase and financial effects of a national SSB tax across different types of households buying varying amounts of SSBs. We find high-SSB purchasers are less responsive to SSB price changes than low purchasers but make larger absolute reductions in SSB purchases in response to the tax, given their notably greater purchase levels prior to the tax. Nonetheless, the economic burden of the tax falls more heavily on high-SSB purchasers who are more likely comprised of lower-income households. We then investigate whether the income regressivity of the tax will be mitigated if low-income households are targeted by fruit and vegetable (FV) subsidies. We show that depending on the tax pass-through and subsidy rates, FV subsidies can fully offset high-SSB purchasers' tax burdens, and subsidy transfers are distributed relatively uniformly across the SSB purchase distribution of low-income households. Therefore, FV subsidy transfers would be financially more beneficial to low- and moderate-SSB purchasers because they bear smaller shares of the tax burden than high-SSB purchasers.

Did high sugar-sweetened beverage purchasers respond differently to the excise tax on sugar-sweetened beverages in Mexico?

OBJECTIVE: To estimate changes in taxed and untaxed beverages by volume of beverage purchased after a sugar-sweetened beverage (SSB) tax was introduced in 2014 in Mexico. DESIGN: We used household purchase data from January 2012 to December 2015. We first classified the sample into four groups based on pre-tax purchases of beverages: (i) higher purchases of taxed beverages and lower purchases of untaxed beverages (HTLU-unhealthier); (ii) higher purchases of both types of beverages (HTHU); (iii) lower purchases of taxed and untaxed beverages (LTLU); and (iv) lower purchases of taxed beverages and higher purchases of untaxed beverages (LTHU-healthier). Next, we estimated differences in purchases after the tax was implemented for each group compared with a counterfactual based on pre-tax trends using a fixed-effects model. SETTING: Areas with more than 50 000 residents in Mexico. PARTICIPANTS: Households (n 6089). RESULTS: The HTLU-unhealthier and HTHU groups had the largest absolute and relative reductions in taxed beverages and increased their purchases of untaxed beverages. Households with lower purchases of untaxed beverages (HTLU-unhealthier and LTLU) had the largest absolute and relative increases in untaxed beverages. We also found that among households with higher purchases of taxed beverages, the group with lowest socio-economic status had the greatest reduction in purchases of taxed beverages. CONCLUSIONS: Evidence associating the SSB tax with larger reductions among high purchasers of taxed beverages prior to the tax is relevant, as higher SSB purchasers have a greater risk of obesity, diabetes and other cardiometabolic outcomes.

How Does the Healthfulness of the US Food Supply Compare to International Guidelines for Marketing to Children and Adolescents?

Objectives Food marketing to children is pervasive and linked to increased preference and intake of unhealthy foods. The World Health Organization (WHO) developed the only multi-country nutrient criteria, and Chile recently released the world's most comprehensive regulation to identify foods that should not be marketed to children. Our objective was to examine the proportion of US packaged food and beverage products eligible for marketing to children under the WHO Europe Nutrient Profile Model (NPM) and the 2019 Chilean regulation. Methods Data for this study are from Label Insight's 2017 Open Access branded food database. Each product was assigned to one of 13 food categories, and nutritional content compared to both the NPM and Chilean criteria. The proportion of US products meeting criteria for marketing to children using both schemes was examined overall and by category. Agreement between the two criteria was examined using Cohen's Kappa. Results Of 17,740 US products, 21% were eligible to be marketed to children using the WHO criteria and 26% using the Chilean criteria. 'Egg and egg products' and 'Seafood' had the highest proportion of products eligible for marketing to children under both schemes. 'Confectionery' and 'Snack foods' had the lowest proportion eligible. Conclusions for practice The WHO NPM and Chilean criteria both restrict less healthy items from being marketed to children. Regulatory agencies in the US developing policies should consider the implementation of nutrient criteria to restrict the marketing of less healthy foods and beverages to children and adolescents.

Understanding heterogeneity in price changes and firm responses to a national unhealthy food tax in Mexico.

To address the high prevalence of overweight and obesity in Mexico, an eight percent ad valorem excise tax on non-essential energy-dense foods came into effect on 1 January 2014. This paper estimates price changes after the tax implementation among the top four food categories and by leading vs. non-leading firms using purchase information from over 6000 urban households in the 2012-2015 Nielsen Mexico Consumer Panel. We create product-city-month specific prices that correct for potential biases associated with household and retailer characteristics. Using these corrected prices, we conduct before and after quasi-experimental analyses and find that price increases were larger than eight percent for cookies but were less than eight percent for ready-to-eat cereals, salty snacks, and pre-packaged sweet bread. For the latter food group, event-study analyses on the gradual price change over time suggest that price changes might be the result of an increasing price trend rather than the tax implementation. Firm-level analyses mostly show that price increases by the leading firms were larger than the overall increase at the food market level, helping explain variability in post-tax declines in food purchases as reported in other research. We also find that price changes are generally underestimated when we do not correct prices for biases associated with households and retailers. These results improve our understanding of the mechanisms behind heterogeneous changes in purchases after the tax implementation. Additionally, these results can assist policymakers when designing or improving taxes on non-essential energy-dense foods at a time when these policy options are high on the agenda in many places.