The equitable impact of sugary drink taxation structures on sugary drink consumption among Canadians: a modelling study using the 2015 Canadian Community Health Survey-Nutrition.

OBJECTIVE: Estimate the impact of 20 % flat-rate and tiered sugary drink tax structures on the consumption of sugary drinks, sugar-sweetened beverages and 100 % juice by age, sex and socio-economic position. DESIGN: We modelled the impact of price changes - for each tax structure - on the demand for sugary drinks by applying own- and cross-price elasticities to self-report sugary drink consumption measured using single-day 24-h dietary recalls from the cross-sectional, nationally representative 2015 Canadian Community Health Survey-Nutrition. For both 20 % flat-rate and tiered sugary drink tax scenarios, we used linear regression to estimate differences in mean energy intake and proportion of energy intake from sugary drinks by age, sex, education, food security and income. SETTING: Canada. PARTICIPANTS: 19 742 respondents aged 2 and over. RESULTS: In the 20 % flat-rate scenario, we estimated mean energy intake and proportion of daily energy intake from sugary drinks on a given day would be reduced by 29 kcal/d (95 % UI: 18, 41) and 1·3 % (95 % UI: 0·8, 1·8), respectively. Similarly, in the tiered tax scenario, additional small, but meaningful reductions were estimated in mean energy intake (40 kcal/d, 95 % UI: 24, 55) and proportion of daily energy intake (1·8 %, 95 % UI: 1·1, 2·5). Both tax structures reduced, but did not eliminate, inequities in mean energy intake from sugary drinks despite larger consumption reductions in children/adolescents, males and individuals with lower education, food security and income. CONCLUSIONS: Sugary drink taxation, including the additional benefit of taxing 100 % juice, could reduce overall and inequities in mean energy intake from sugary drinks in Canada.

Associations between noticing public health education campaigns about cannabis and risk perceptions in the northern Canadian territories: a cross-sectional study.

This study investigated whether noticing cannabis education campaigns was associated with increased cannabis risk perceptions in Canada's three territories following non-medical cannabis legalization. Data were from the Cannabis Policy Study in the Territories, including 2452 participants, age ≥16 years residing in Yukon, Northwest Territories and Nunavut. Poisson regression with robust standard errors were used to estimate associations between noticing cannabis education campaigns and moderate to very high risk perceptions of daily cannabis smoking, vaping, edible use and exposure to second-hand cannabis smoke, adjusting for sociodemographic characteristics and cannabis-use frequency. Results were compared with associations with risk perceptions of daily alcohol consumption and cigarette smoking, not included in cannabis education campaigns. Interactions were examined between noticing education campaigns and age group and cannabis-use frequency. Cannabis education campaigns were noticed by 40.4% of respondents, with lower awareness among those with lower education and income. Noticing campaigns was associated with higher risk perceptions of daily cannabis smoking [adjusted risk ratio (RRadj) = 1.09, 95% confidence interval (CI): 1.02-1.16] and vaping (RRadj = 1.09, 95%CI: 1.02-1.16). Significant interactions were not found with age group or cannabis-use frequency. Findings are consistent with modest effects of cannabis education campaigns. Approaches are needed to increase reach of cannabis education campaigns, including among groups with lower education and income.

Qualitative analysis of UK women's attitudes to calorie-based alcohol marketing and alcohol calorie labelling.

Mandatory standardized nutritional information on alcoholic drinks such as energy, or calorie labelling, is a population-level public health measure aimed at addressing obesity and alcohol consumption. In the UK, such measures are not a statutory requirement, but some alcohol brands do include references to calories on their products and in their marketing materials, as a marketing strategy to encourage sales and consumption. This article presents findings of semi-structured individual (N = 43) and group (N = 9) interviews with 78 women living in the UK that aimed to gain insight into their attitudes towards calorie-based alcohol brand marketing, and alcohol calorie labelling (ACL) as a health policy. Three themes are presented that outline how women rejected calorie marketing and labelling; the potential positive and unintended impact on alcohol consumption and dietary/eating practices; and how views on calorie labelling were intertwined with women's attitudes towards marketing that draws on calorie messaging. A feminist anti-diet discourse, as well as a discourse of pleasure through alcohol consumption, was at play in women's accounts, which may limit the intended aims of ACLs. It is concluded that ACLs should be considered within the wider commercial context of alcohol marketing that draws on calories to promote sales and consumption, consideration of the gendered factors that may lead some to reject ACLs as a health policy, and the potential for unintended consequences.

Multi-use physical activity trails in an urban setting and cardiovascular disease: a difference-in-differences analysis of a natural experiment in Winnipeg, Manitoba, Canada.

OBJECTIVE: To determine if expansion of multi-use physical activity trails in an urban centre is associated with reduced rates of cardiovascular disease (CVD). METHODS: This was a natural experiment with a difference in differences analysis using administrative health records and trail-based cycling data in Winnipeg, Canada. Prior to the intervention, each year, 314,595 (IQR: 309,044 to 319,860) persons over 30 years without CVD were in the comparison group and 37,901 residents (IQR: 37,213 to 38,488) were in the intervention group. Following the intervention, each year, 303,853 (IQR: 302,843 to 304,465) persons were in the comparison group and 35,778 (IQR: 35,551 to 36,053) in the intervention group. The natural experiment was the construction of four multi-use trails, 4-7 km in length, between 2010 and 2012. Intervention and comparison areas were based on buffers of 400 m, 800 m and 1200 m from a new multi-use trail. Bicycle counts were obtained from electromagnetic counters embedded in the trail. The primary outcome was a composite of incident CVD events: CVD-related mortality, ischemic heart disease, cerebrovascular events and congestive heart failure. The secondary outcome was a composite of incident CVD risk factors: hypertension, diabetes and dyslipidemia. RESULTS: Between 2014 and 2018, 1,681,125 cyclists were recorded on the trails, which varied ~ 2.0-fold across the four trails (2358 vs 4264 counts/week in summer months). Between 2000 and 2018, there were 82,632 CVD events and 201,058 CVD risk events. In propensity score matched Poisson regression models, the incident rate ratio (IRR) was 1.06 (95% CI: 0.90 to 1.24) for CVD events and 0.95 (95%CI: 0.88 to 1.02) for CVD risk factors for areas within 400 m of a trail, relative to comparison areas. Sensitivity analyses indicated this effect was greatest among households adjacent to the trail with highest cycling counts (IRR = 0.85; 95% CI: 0.75 to 0.96). CONCLUSIONS: The addition of multi-use trails was not associated with differences in CVD events or CVD risk factors, however the differences in CVD risk may depend on the level of trail use. TRIAL REGISTRATION: Trial registration number: NCT04057417 .

Changes in the dollar value of per capita alcohol, essential, and non-essential retail sales in Canada during COVID-19.

BACKGROUND: Multiple survey reports suggest that alcohol use has increased in Canada during the COVID-19 pandemic. However, less is known about how per capita alcohol sales, which predict population-level alcohol use, have changed and whether changes in alcohol sales differ from changes in sales of other products due to pandemic factors. METHODS: We obtained monthly retail sales data by industry from Statistics Canada, for the six largest provinces in Canada (containing 93% of the national population), between January 2010 and November 2020, representing time before and 9 months after the start of the pandemic in Canada. We used an interrupted time series analysis to estimate pandemic impacts on the dollar value of monthly per capita (per individuals 15+ years) alcohol, essential and non-essential retail sales. We adjusted our analyses for pre-pandemic sales trends, inflation, seasonality and changing population demographics over time. RESULTS: During the first 9 months of the pandemic, the values of per capita alcohol, essential and non-essential sales were, respectively, 13.2% higher, 3.6% higher and 13.1% lower than the average values during the same period in the prior 3 years. Interrupted time series models showed significant level change for the value of monthly per capita alcohol sales (+$4.86, 95% CIs: 2.88, 6.83), essential sales (-$59.80, 95% CIs: - 78.47, - 41.03) and non-essential sales (-$308.70, 95% CIs: - $326.60, - 290.79) during the pandemic. Alcohol sales were consistently elevated during the pandemic, and the pre- and post-pandemic slopes were comparable. In contrast, essential and non-essential retail sales declined in the early months of the pandemic before returning to regular spending levels. CONCLUSION: During the first 9 months of the pandemic, per capita alcohol sales were moderately elevated in Canada. In contrast, non-essential sales were lower than prior years, driven by large decreases during the initial months of the pandemic. These findings suggest that the pandemic was associated with increased population-level alcohol consumption, which may lead to increased alcohol-related harms. Ongoing research is needed to examine how factors, including pandemic-related stressors and specific alcohol sales-related policies, may have influenced changes in alcohol use and harms.

How Often Are Dental Care Workers Exposed to Occupational Characteristics that Put Them at Higher Risk of Exposure and Transmission of COVID-19? A Comparative Analysis.

INTRODUCTION: Occupational characteristics of dental care - including closed environment, proximity to staff and patients and the use of aerosol-generating procedures - put workers at high risk of COVID-19 exposure and transmission. We describe the frequency of workplace situations that potentially increase the risk of exposure to COVID-19 in dental care compared with other occupations including health care. METHODS: We conducted a cross-sectional study using sociodemographic and occupational data from the 2016 Canadian census linked to workplace characteristics from the Occupational Information Network (O*NET) dataset. We assessed frequency of workplace indicators using an intensity score from 0 (low) to 100 (high) from O*NET on exposure to infection or disease, physical proximity to others, indoor controlled environments, standard protective equipment and specialized protective equipment. RESULTS: In 2016, 87 815 Canadians worked in the 5 dentistry occupations of interest: dentists; denturists; dental hygienists and dental therapists; dental technologists, technicians and laboratory assistants; and dental assistants. These occupations were routinely ranked in the top 10 of all occupations examined in terms of exposure to workplace indicators that increase the risk of exposure to COVID-19. Dental hygienists and dental therapists, dental assistants, dentists and denturists, rank as the top 4 occupations, in that order, with the highest exposure to disease or infection and physical proximity to others combined. CONCLUSIONS: Compared with other occupations, dental care workers are at a higher risk of occupational exposure to COVID-19. These results support the development of workplace guidance to reduce the risk of COVID-19 transmission and enhance the well-being of the dental care workforce.

Testing the efficacy of and parents' preferences for nutrition labels on children's menus from a full-service chain restaurant: results of an online experiment.

OBJECTIVE: Test the efficacy and perceived effectiveness of nutrition labels on children's menus from a full-service chain restaurant in an online study. DESIGN: Using a between-groups experiment, parents were randomised to view children's menus displaying one of five children's nutrition labelling conditions: (i) No Nutrition Information (control); (ii) Calories Only; (iii) Calories + Contextual Statement (CS); (iv) Calories, Sodium + CS; or (v) Calories and Sodium in Traffic Lights + CS. Parents hypothetically ordered up to one entrée, side, beverage and dessert for their child, then rated and ranked all five labelling conditions on the level of perceived effectiveness. SETTING: Online survey. PARTICIPANTS: 998 parents with a 3-12 year old child. RESULTS: Parents exposed to menus displaying 'Calories, Sodium + CS' selected significantly fewer calories 'overall' (entrées + side + dessert + beverage) compared to parents exposed to the control condition (-53·1 calories, P < 0·05). Parents selected 'entrees' with significantly fewer calories and lower sodium when exposed to menus with 'Calories + CS' (-24·3 calories, P < 0·05); 'Calories, Sodium + CS' (-25·4 calories, -56·1 mg sodium, P < 0·05 for both); and 'Calories and Sodium in Traffic Lights + CS' (-29·1 calories, -58·6 mg sodium, P < 0·05 for both). Parents exposed to menus with 'Calories, Sodium + CS' and 'Calories and Sodium in Traffic Lights + CS' were more likely to notice and understand nutrition information compared to other nuntrition labelling conditions. Parents perceived the menu with 'Calories and Sodium in Traffic Lights + CS' as most effective (P < 0·05). CONCLUSIONS: Menus disclosing calories, sodium and a contextual statement increased the proportion of parents who noticed and understood nutrition information, and resulted in parents selecting lower calorie and sodium entrées for their children in the hypothetical purchase task.

School-Age Children Can Recall Some Foods and Beverages Consumed the Prior Day Using the Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24) without Assistance.

BACKGROUND: Technological innovations allow for collection of 24-h recalls (24HRs) in a broader range of studies than previously possible. The web-based Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24) has been shown to be feasible and to perform well in capturing true intake among adults. However, data to inform use with children are limited. OBJECTIVE: This observational feeding study was conducted to evaluate children's ability to accurately report a lunchtime meal using ASA24 without assistance. METHODS: The study was conducted among children (n = 100) aged 10-13 y within a school setting. Students were served an individual cheese pizza, baby carrots, ranch dip, yogurt, a cookie, and 1 choice of water, juice, or milk. Plate waste was collected and weighed. The next day, participants completed ASA24 and a sociodemographic questionnaire. Descriptive statistics were generated to determine match rates by food item and age, and linear regression analyses were conducted to examine associations between sociodemographic characteristics and accuracy of reported energy and nutrient intake. Associations between true and reported energy and nutrient intakes and portion sizes were assessed with use of t tests. RESULTS: Just under half (49%) of children fully completed ASA24 (median time, 41 min). Children reported an exact, close, or far match for 58% of all foods and beverages consumed, ranging from 29% for dip to 76% for pizza, but also reported some items not consumed as part of the study meal. Older children completed the recall in a shorter time than younger children (mean 31 among 13 y compared with 52 min among 10 y). Intakes of energy (39%), protein (33%), and sodium (78%) were significantly overestimated, whereas portion sizes for cookies (53%) and juice (69%) were underestimated. CONCLUSIONS: Children can report some foods and drinks consumed using ASA24, but our findings suggest challenges with independent completion, necessitating research to examine strategies, such as training and resources, to support data quality.

Calorie Intake from Alcohol in Canada: Why New Labelling Requirements are Necessary.

We estimated calorie intake from alcohol in Canada, overall and by gender, age, and province, and provide evidence to advocate for mandatory alcohol labelling requirements. Annual per capita (aged 15+) alcohol sales data in litres of pure ethanol by beverage type were taken from Statistics Canada's CANSIM database and converted into calories. The apportionment of consumption by gender, age, and province was based on data from the Canadian Tobacco, Alcohol and Drug Survey. Estimated energy requirements (EER) were from Canada's Food Guide. The average drinker consumed 250 calories, or 11.2% of their daily EER in the form of alcohol, with men (13.3%) consuming a higher proportion of their EER from alcohol than women (8.2%). Drinkers consumed more than one-tenth of their EER from alcohol in all but one province. By beverage type, beer contributes 52.7% of all calories derived from alcohol, while wine (20.8%); spirits (19.8%); and ciders, coolers, and other alcohol (6.7%) also contribute substantially. The substantial caloric impact of alcoholic drinks in the Canadian diet suggests that the addition of caloric labelling on these drinks is a necessary step.

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.

"We Have a Right to Know": Exploring Consumer Opinions on Content, Design and Acceptability of Enhanced Alcohol Labels.

AIMS: This study aimed to refine content and design of an enhanced alcohol label to provide information that best supports informed drinking and to gauge consumer acceptability of enhanced alcohol labels among a subset of consumers. METHODS: Five focus groups (n = 45) were conducted with stakeholders and the general public (age 19+) across one jurisdiction in northern Canada. Interviews were transcribed and analyzed using NVivo software. RESULTS: The majority of participants showed strong support for enhanced alcohol labels with an emphasis on the consumers' right to know about the health risks related to alcohol. Participants preferred larger labels that included standard drink (SD) information, national low-risk drinking guidelines presented as a chart with pictograms, cancer health messaging and a pregnancy warning. Supporting introduction of the labels with a web resource and an educational campaign was also recommended. CONCLUSIONS: Displaying enhanced labels on alcohol containers that include SD information, low-risk drinking guidelines and other health messaging in an accessible format may be an effective way to better inform drinkers about their consumption and increase awareness of alcohol-related health risks. Introduction of enhanced labels shows potential for consumer support. SHORT SUMMARY: Focus group findings indicate strong support for enhanced alcohol labels displaying SD information, national drinking guidelines, health messaging and a pregnancy warning. Introduction of enhanced alcohol labels in tandem with an educational campaign may be an effective way to better inform Canadian drinkers and shows potential for consumer support.

Testing the Efficacy of Alcohol Labels with Standard Drink Information and National Drinking Guidelines on Consumers' Ability to Estimate Alcohol Consumption.

AIMS: Despite the introduction of national drinking guidelines in Canada, there is limited public knowledge of them and low understanding of 'standard drinks (SDs)' which limits the likelihood of guidelines affecting drinking behaviour. This study tests the efficacy of alcohol labels with SD information and Canada's Low-Risk Drinking Guidelines (LRDGs) as compared to %ABV labels on consumers' ability to estimate alcohol intake. It also examines the label size and format that best supports adults' ability to make informed drinking choices. METHODS: This research consisted of a between-groups experiment (n = 2016) in which participants each viewed one of six labels. Using an online survey, participants viewed an alcohol label and were asked to estimate: (a) the amount in a SD; (b) the number of SDs in an alcohol container and (c) the number of SDs to consume to reach the recommended daily limit in Canada's LRDG. RESULTS: Results indicated that labels with SD and LRDG information facilitated more accurate estimates of alcohol consumption and awareness of safer drinking limits across different beverage types (12.6% to 58.9% increase in accuracy), and labels were strongly supported among the majority (66.2%) of participants. CONCLUSION: Labels with SD and LRDG information constitute a more efficacious means of supporting accurate estimates of alcohol consumption than %ABV labels, and provide evidence to inform potential changes to alcohol labelling regulations. Further research testing labels in real-world settings is needed. SHORT SUMMARY: Results indicate that the introduction of enhanced alcohol labels combining standard drink information and national drinking guidelines may be an effective way to improve drinkers' ability to accurately assess alcohol consumption and monitor intake relative to guidelines. Overall support for enhanced labels suggests probable acceptability of introduction at a population level.

School and classroom effects on Daily Physical Activity (DPA) policy implementation fidelity in Ontario classrooms: a multi-level analysis.

BACKGROUND: This paper examines school and classroom effects on Daily Physical Activity (DPA) policy implementation in classrooms in Ontario, Canada. In 2005 the Ontario Ministry of Education mandated a policy requiring school boards to "ensure that all elementary students, including students with special needs, have a minimum of twenty minutes of sustained MVPA each school day during instructional time". Based on an adaptation of Chaudoir's conceptual framework, this paper contributes to understanding the extent to which school factors (as reported by administrators) and classroom factors (as reported by teachers) are associated with policy implementation fidelity at the classroom level. METHODS: Cross-sectional online surveys were conducted in 2014 with elementary school administrators and teachers, based on representative random samples of schools and classrooms. A measure assessing implementation fidelity was developed from the six required components of the policy and for this paper fidelity at the classroom level is treated as the outcome variable. Several school- and classroom-level measures were also included in the surveys and a number of these were selected for inclusion here. Data from the two surveys were merged and selected variables were included in the multi-level analysis. Two-level logistic regression models were conducted to account for nesting of classrooms within schools and a series of models were conducted to identify factors associated with implementation fidelity. RESULTS: The analytic sample for this study included 170 school administrators and 307 classroom teachers from corresponding schools. Findings from the multi-level logistic regression analyses indicated that only classroom/teacher-level factors were significantly associated with implementation fidelity at the classroom level. None of the school/administrator predictors were significantly related to fidelity. The most parsimonious model included five significant classroom/teacher predictors: teachers' perception of DPA as realistic and achievable; confidence (self-efficacy); scheduling DPA in timetables; lack of space; and lack of time. CONCLUSIONS: Findings from the study indicate the theoretical and practical importance of addressing classroom and teacher factors since they are most proximal to implementation fidelity to the policy. Several of these factors also reflect complex structural and organizational contexts, indicating that a systems approach to understanding and supporting DPA implementation fidelity is warranted.

Grocery Shopping, Dinner Preparation, and Dietary Habits among Adolescents and Young Adults in Canada.

PURPOSE: The current study aimed to characterize grocery shopping and dinner preparation behaviours among young people in Canada and to examine associations with eating habits. METHODS: A cross-sectional online survey was conducted with 2008 participants aged 16-24 from across Canada. The survey measured self-reported grocery shopping and dinner preparation behaviours, frequency of eating breakfast and eating meals prepared away from home, frequency of vegetable and fruit intake, and socio-demographic characteristics. Chi-square tests examined differences in proportions; logistic and linear regressions examined dietary habits, including covariates for grocery shopping and dinner preparation and socio-demographics. RESULTS: Overall, 37.3% had helped with grocery shopping in the past week, and 84.3% had participated in dinner preparation at least 1 day in the past week. Engaging in shopping at least once weekly was associated with increased vegetable and fruit consumption only, whereas more frequent engagement in dinner preparation was associated with increased vegetable and fruit consumption, more frequent breakfast consumption, and fewer meals consumed that were prepared away from home (P < 0.001 for all). CONCLUSIONS: Increased participation in grocery shopping and dinner preparation were associated with healthier dietary habits. Interventions that increase these behaviours may contribute to improving dietary behaviours among adolescents and young adults.

Consumers' Response to an On-Shelf Nutrition Labelling System in Supermarkets: Evidence to Inform Policy and Practice.

Policy Points: On-shelf nutrition labelling systems in supermarkets, such as the Guiding Stars system, are intended to provide consumers with simple, standardized nutrition information to support more informed and healthier food choices. Policies that support the provision of simplified nutrition labelling systems may encourage consumers to make positive shifts in food-purchasing behaviors. The shifts in consumer food-purchasing patterns observed in our study after the introduction of the Guiding Stars system in supermarkets translated into measurable nutritional benefits, including more items purchased with slightly less trans fat and sugar and more fiber and omega-3 fatty acids. This study is one of the first to report the positive impact of an on-shelf nutrition labelling system on supermarket sales and revenues-key information that was specifically requested by the US National Academies, as such labelling interventions may be more sustainable if they lead to higher revenues. CONTEXT: Providing a nutrition rating system on the front of food packages or on retail shelf tags has been proposed as a policy strategy for supporting healthier food choices. Guiding Stars is an on-shelf nutrition labelling system that scores foods in a supermarket based on nutritional quality; scores are then translated into ratings of 0 to 3 stars. It is consistent with evidence-informed recommendations for well-designed labels, except for not labelling 0-star products. The largest supermarket retailer in Canada rolled out the Guiding Stars system in supermarkets across Ontario, Canada. The aim of our study was to examine the extent to which consumers respond to an on-shelf nutrition labelling system in supermarkets to inform current and future nutrition labelling policies and practices. METHODS: Capitalizing on a natural experiment, we conducted a quasi-experimental study across 3 supermarket banners (or "chains") in Ontario, one of which implemented the Guiding Stars system in 2012. We used aggregated supermarket transaction data to test the effect of Guiding Stars on the nutritional quality of food purchases in intervention supermarkets relative to control supermarkets. We also conducted exit surveys among 783 randomly selected shoppers from intervention and control supermarkets to assess consumer awareness, understanding, trust, and self-reported use of the labelling system. FINDINGS: Relative to control supermarkets, shoppers in intervention supermarkets made small but significant shifts toward purchasing foods with higher nutritional ratings; however, shifts varied in direction and magnitude across food categories. These shifts translated into foods being purchased with slightly less trans fat and sugar and more fiber and omega-3 fatty acids. We also found increases in the number of products per transaction, price per product purchased, and total revenues. Results of the exit surveys indicate a modest proportion of consumers were aware of, understood, and trusted Guiding Stars in intervention supermarkets, and a small proportion of consumers reported using this system when making purchasing decisions. However, 47% of shoppers exposed to Guiding Stars were confused when asked to interpret the meaning of a 0-star product that does not display a rating on the shelf tag. CONCLUSIONS: This study demonstrates support for policies promoting on-shelf nutrition labels designed according to evidence-informed principles, but policymakers should move forward with caution when investing in such systems until research has confirmed optimal label design, clarified the mechanisms through which dietary intake is improved, and assessed associations with nutrition-related health outcomes.

Examining the impact of a province-wide physical education policy on secondary students' physical activity as a natural experiment.

BACKGROUND: The purpose of this paper is to examine the impact of a province-wide physical education (PE) policy on secondary school students' moderate to vigorous physical activity (MVPA). METHODS: Policy: In fall 2008, Manitoba expanded a policy requiring a PE credit for students in grades 11 and 12 for the first time in Canada. The PE curriculum requires grades 11 and 12 students to complete a minimum of 55 h (50% of course hours) of MVPA (e.g., ≥30 min/day of MVPA on ≥5 days a week) during a 5-month semester to achieve the course credit. STUDY DESIGNS: A natural experimental study was designed using two sub-studies: 1) quasi-experimental controlled pre-post analysis of self-reported MVPA data obtained from census data in intervention and comparison [Prince Edward Island (PEI)] provinces in 2008 (n = 33,619 in Manitoba and n = 2258 in PEI) and 2012 (n = 41,169 in Manitoba and n = 4942 in PEI); and, 2) annual objectively measured MVPA in cohorts of secondary students in intervention (n = 447) and comparison (Alberta; n = 224) provinces over 4 years (2008 to 2012). ANALYSIS: In Study 1, two logistic regressions were conducted to model the odds that students accumulated: i) ≥30 min/day of MVPA, and ii) met Canada's national recommendation of ≥60 min/day of MVPA, in Manitoba versus PEI after adjusting for grade, sex, and BMI. In Study 2, a mixed effects model was used to assess students' minutes of MVPA per day per semester in Manitoba and Alberta, adjusting for age, sex, BMI, school location and school SES. RESULTS: In Study 1, no significant differences were observed in students achieving ≥30 (OR:1.13, 95% CI:0.92, 1.39) or ≥60 min/day of MVPA (OR:0.92, 95% CI: 0.78, 1.07) from baseline to follow-up between Manitoba and PEI. In Study 2, no significant policy effect on students' MVPA trajectories from baseline to last follow-up were observed between Manitoba and Alberta overall (-1.52, 95% CI:-3.47, 0.42), or by covariates. CONCLUSIONS: The Manitoba policy mandating PE in grades 11 and 12 had no effect on student MVPA overall or by key student or school characteristics. However, the effect of the PE policy may be underestimated due to the use of a nonrandomized research design and lack of data assessing the extent of policy implementation across schools. Nevertheless, findings can provide evidence about policy features that may improve the PE policy in Manitoba and inform future PE policies in other jurisdictions.

'How many calories did I just eat?' An experimental study examining the effect of changes to serving size information on nutrition labels.

OBJECTIVE: To test modifications to nutrition label serving size information on understanding of energy (calorie) content among youth and young adults. DESIGN: Participants completed two online experiments. First, participants were randomly assigned to view a beverage nutrition label with a reference amount of per serving (250 ml), per container (473 ml) or a dual-column format with both reference amounts. Participants were then randomized to view a cracker nutrition label which specified a single serving in small font, a single serving in large font, or the number of servings per bag with single serving information below. In both experiments, participants estimated energy content. Logistic regression analysis modelled correct energy estimation. Finally, participants reported their preference for serving size display format. SETTING: Canada. SUBJECTS: Canadian youth and young adults (n 2008; aged 16-24 years). RESULTS: In experiment 1, participants randomized to view the nutrition label with per container or dual column were more likely to correctly identify energy content than those using per serving information (P<0·01). For experiment 2, the serving size display format had no association with correct energy estimation. The majority of participants (61·9 %) preferred the serving size format that included servings per package. CONCLUSIONS: Labelling foods with nutrition information using a serving size reference amount for the entire container increased understanding of energy content. Consumers prefer nutrition labels that include more prominently featured serving size information. Additional modifications that further improve consumers' accuracy should be examined. These results have direct implications for nutrition labelling policy.

Evaluation of Daily Physical Activity (DPA) policy implementation in Ontario: surveys of elementary school administrators and teachers.

BACKGROUND: School-based structured opportunities for physical activity can provide health-related benefits to children and youth, and contribute to international guidelines recommending 60 min of moderate-to-vigorous physical activity (MVPA) per day. In 2005, the Ministry of Education in Ontario, Canada, released the Daily Physical Activity (DPA) policy requiring school boards to "ensure that all elementary students, including students with special needs, have a minimum of twenty minutes of sustained MVPA each school day during instructional time". This paper reports on the first provincial study evaluating implementation fidelity to the DPA policy in Ontario elementary schools and classrooms. Using an adapted conceptual framework, the study also examined associations between implementation of DPA and a number of predictors in each of these respective settings. METHODS: Separate cross-sectional online surveys were conducted in 2014 with Ontario elementary school administrators and classroom teachers, based on a representative random sample of schools and classrooms. An implementation fidelity score was developed based on six required components of the DPA policy. Other survey items measured potential predictors of implementation at the school and classroom levels. Descriptive analyses included frequency distributions of implementation fidelity and predictor variables. Bivariate analyses examining associations between implementation and predictors included binary logistic regression for school level data and generalized linear mixed models for classroom level data, in order to adjust for school-level clustering effects. RESULTS: Among administrators, 61.4 % reported implementation fidelity to the policy at the school level, while 50.0 % of teachers reported fidelity at the classroom level. Several factors were found to be significantly associated with implementation fidelity in both school and classroom settings including: awareness of policy requirements; scheduling; monitoring; use of resources and supports; perception that the policy is realistic and achievable; and specific barriers to implementation. CONCLUSIONS: Findings from the surveys indicate incomplete policy implementation and a number of factors significantly associated with implementation fidelity. The results indicate a number of important implications for policy, practice and further research, including the need for additional research to monitor implementation and its predictors, and assess the impacts of study recommendations and subsequent outcomes of a reinvigorated DPA moving forward.

Estimating the impact of various menu labeling formats on parents' demand for fast-food kids' meals for their children: An experimental auction.

This study experimentally tested whether parents' demand for fast-food kids' meals for their children is influenced by various menu labeling formats disclosing calorie and sodium information. The study also examined the effect of various menu labeling formats on parents' ability to identify fast-food kids' meals with higher calorie and sodium content. Online surveys were conducted among parents of children aged 3-12. Parents were randomized to view 1 of 5 menu conditions: 1) No Nutrition Information; 2) Calories-Only; 3) Calories + Contextual Statement (CS); 4) Calories, Sodium, + CS; and, 5) Calorie and Sodium in Traffic Lights + CS. Using an established experimental auction study design, parents viewed replicated McDonald's menus according to their assigned condition and were asked to bid on 4 Happy Meals. A randomly selected price was chosen; bids equal to or above this price "won" the auction, and bids less than this price "lost" the auction. After the auction, participants were asked to identify the Happy Meal with the highest calories and sodium content. Adjusting for multiple comparisons and covariates, the Calories, Sodium, + CS menu had a mean attributed value across all 4 Happy Meals which was 8% lower (-$0.31) than the Calories + CS menu (p < 0.05). Significantly more parents in the 4 menu conditions providing calories were able to correctly identify the Happy Meal with the highest calories (p < 0.0001) and significantly more parents in the 2 conditions providing sodium information were able to correctly identify the Happy Meal with the highest sodium content (p < 0.0001). Menus disclosing both calories and sodium information may reduce demand for fast-food kids' meals and better support parents in making more informed and healthier food choices for their children.

Comprehension and Use of Nutrition Facts Tables among Adolescents and Young Adults in Canada.

PURPOSE: Limited evidence exists on the comprehension and use of Nutrition Facts tables (NFt) among adolescents and young adults. This study provides an account of how young people engage with, understand, and apply nutrition information on the current and modified versions of the NFt to compare and choose foods. METHODS: Participants aged 16-24 years (n = 26) were asked to "think aloud" while viewing either the current or 1 of 5 modified NFts and completing a behavioural task. The task included a questionnaire with 9 functional items requiring participants to define, compare, interpret, and manipulate serving size and percentage daily value (%DV) information on NFts. Semi-structured interviews were conducted to further probe thought processes and difficulties experienced in completing the task. RESULTS: Equal serving sizes on NFts improved ability to accurately compare nutrition information between products. Most participants could define %DV and believed it can be used to compare foods, yet some confusion persisted when interpreting %DVs and manipulating serving-size information on NFts. Where serving sizes were unequal, mathematical errors were often responsible for incorrect responses. CONCLUSIONS: Results reinforce the need for equal serving sizes on NFts of similar products and highlight young Canadians' confusion when using nutrition information on NFts.