The Potential Effectiveness of Front-of-Pack Nutrition Labeling for Improving Population Diets.

Nutrition labeling on the front of food packages can support more healthful purchase decisions and encourage favorable reformulation. This systematic literature review applied Cochrane methods to synthesize and appraise the evidence on the effectiveness of front-of-pack labeling (FOPL) on diet-related outcomes and food reformulation to inform policy recommendations. The search was conducted on 11 academic and gray literature databases, from inception to July 2022. Evidence was synthesized using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation), vote counting, and meta-analyses, where appropriate. Overall, 221 articles were included in the review. The randomized controlled trial evidence suggested that, compared with when no FOPL was present, FOPL likely improved consumer understanding of the nutritional quality/content of foods (moderate certainty of evidence), and the healthfulness of food choices (moderate certainty) and purchases (moderate certainty). Interpretive FOPL had a greater effect on these outcomes compared with noninterpretive systems (moderate certainty). There was inconsistency in the best-performing interpretive FOPL system.

The Potential Effectiveness of Nutrient Declarations and Nutrition and Health Claims for Improving Population Diets.

Nutrition labeling supports healthier diets by aiding purchase decisions and stimulating reformulation. This systematic literature review applied Cochrane methods to synthesize and appraise evidence on the effectiveness of nutrient declarations and nutrition and health claims on diet-related outcomes. The search spanned 11 academic databases, from inception to July 2022. Evidence was synthesized using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) and vote counting. Data were available from 170 studies. Randomized controlled trials (RCTs) suggest that nutrient declarations likely improved consumer understanding of the nutritional quality/content of foods (moderate certainty) and may improve the healthfulness of choices (low certainty) versus no label. RCT evidence also suggests that claims likely increased consumer perceptions of food healthfulness and increased choice and purchases of labeled foods (both moderate certainty), irrespective of nutritional quality. To improve label understanding and avoid misinterpretation, nutrient declarations may incorporate interpretive elements and claims can apply disqualifying conditions for their usage, on the basis of overall nutritional quality.

Which parents provide zero-alcohol beverages to adolescents? A survey of Australian parents' practices and intentions.

OBJECTIVE: Zero-alcohol beverages (<0.5% alcohol by volume) appear and taste similar to alcoholic beverages but are regulated similarly to soft drinks in many countries, blurring the distinction between alcoholic and non-alcoholic beverages. How parents view provision of zero-alcohol beverages to adolescents is likely a key determinant of adolescent consumption. We investigated factors associated with parents' provision of zero-alcohol beverages to adolescents, including attitudes toward zero-alcohol beverages and demographic, knowledge, and behavioural factors known to be associated with provision of alcoholic beverages. METHODS: We conducted an online cross-sectional survey of N = 1197 Australian parents of adolescents aged 12-17 years in April-May 2022. We examined associations with zero-alcohol beverage provision using binomial logistic regression, and with future provision intentions using multinomial logistic regression analyses. RESULTS: Factors significantly associated (p < .001) with parents' provision and future intentions to provide zero-alcohol beverages to their adolescent included beliefs that zero-alcohol beverages had benefits for adolescents (Adjusted Odds Ratio [AOR] 2.69 (provision); 3.72 (intentions)), provision of alcoholic beverages (AOR 2.67 (provision); 3.72 (intentions)), and an incorrect understanding of alcohol guidelines for adolescents (AOR 2.38 (provision); 1.95 (intentions)). CONCLUSIONS: Parents' provision and intentions to provide zero-alcohol beverages were associated with beliefs about zero-alcohol beverages as well as some factors associated with provision of alcoholic beverages. Precautionary advice to parents that the provision of zero-alcohol beverages may serve to normalise alcohol consumption may be warranted.

Zero alcohol products and adolescents: A tool for harm reduction or a trojan horse?

INTRODUCTION: Zero alcohol products (ZAPs) could reduce alcohol-related harms by acting as a substitute for alcoholic beverages. However, concerns have been raised regarding the potential for these products to expose young people to additional alcohol-related stimuli, further normalising alcohol use and acting as a gateway to underage alcohol consumption. Scarce research has examined whether these concerns are warranted. METHOD: This project comprised two parts involving Australian adolescents aged 15-17 years. Part 1 was a series of 5 online focus groups (n = 44) that provided initial insights into perceptions of and experiences with ZAPs. Part 2 was a national online survey (n = 679) that assessed the generalisability of the focus group findings and identified factors associated with ZAP-related attitudinal and behavioural outcomes. RESULTS: ZAPs were found to be salient and attractive to Australian adolescents. Over a third of surveyed adolescents (37%) had tried ZAPs. The focus group participants and survey respondents generally perceived ZAPs in a positive light, seeing them as a useful alternative to alcohol for both adolescents and adults who want to circumvent social expectations to use alcohol. Some of the study participants acknowledged the potential for ZAPs to serve as a gateway to alcohol use and recommended reducing their visibility and accessibility. CONCLUSION: ZAPs are likely exposing minors to additional alcohol-related stimuli potentially increasing their risk of underage alcohol consumption. Regulatory responses to ZAPS need to protect young people from the potential adverse consequences of ZAPs exposure while enabling the products to be used by adults as an alcohol substitute.

The lasting impact of the Go for 2&5 campaign.

ISSUE ADDRESSED: Little is known about the executional techniques that are most likely to make healthy eating messages memorable over the longer term. The aim of this exploratory study was to identify factors contributing to the ongoing salience of the Go for 2&5 social marketing campaign among older audience members. METHODS: Interviews were conducted with 75 Western Australians aged 60+ years. A peer-interviewing method was used whereby eight older people recruited and interviewed members of their extended peer groups. The interview guide included questions about interviewees' recollections of healthy eating messages across their lifespans. RESULTS: Around one in five interviewees discussed the Go for 2&5 campaign that was on air in Western Australia between 2002 and 2011. These discussions focused on either specific advertisement features that were considered to be especially memorable (in particular, humour and the use of anthropomorphised depictions of produce) and/or their recollection of the number of daily servings of fruits and vegetables recommended in the campaign. Few were able to recall other healthy eating campaigns, and in some cases it was assumed that advertisements for specific food stores or products constituted health advice. CONCLUSIONS: Different campaign attributes may influence shorter-term attitudinal and behavioural responses versus longer-term recall. The characteristics of the Go for 2&5 campaign appear to have enabled it to achieve relatively high levels of recall among older people. SO WHAT?: The study results suggest that some advertising approaches that activate the peripheral route to persuasion may achieve recall over a longer period of time.

Development and validation of the Perceived Effectiveness of Nutrition Messages Scale.

An understanding of the extent to which target audiences consider different nutrition-related messages to be effective could assist campaign developers design more persuasive communications. Accordingly, this study sought to develop and assess the utility of the Perceived Effectiveness of Nutrition Messages Scale (PENMS). A longitudinal online survey was completed by Australian adults (n = 5,014 at Time 1 and 2,880 at Time 2). At T1, respondents saw one of two messages promoting healthy eating. They were then administered the PENMS, and asked how likely they were to engage in the behaviour specified in the message. Respondents completed the PENMS again at T2. An exploratory factor analysis was performed on PENMS scores and measures of reliability and validity obtained. Two factors were identified: 'effects perceptions' (Factor 1) and 'message perceptions' (Factor 2). Internal consistency of scores was 0.82 for Factor 1 and 0.70 for Factor 2. Test re-test reliability was 0.76 and 0.69 for Factors 1 and 2, respectively. Scores on both factors were moderately correlated with behavioural intentions. The favourable results for PENMS scores suggest the scale may be a useful tool for assessing the extent to which target audiences consider different nutrition-related messages to be effective.

Selective industry adoption of a voluntary front-of-pack nutrition label results in low and skewed uptake: 10-year results for the Health Star Rating.

Front-of-pack nutrition labelling (FOPNL) on packaged foods is recommended by the World Health Organization to promote healthier diets. Our aim was to assess uptake of Australia's FOPNL, the Health Star Rating (HSR), overall and by HSR score received (0.5 (less healthy) to 5.0 (more healthy) in 0.5 increments) after ten years of voluntary implementation. In a sample of 21,197 products, we found HSR uptake of 37% overall in 2023. Uptake was unevenly distributed, with 24% of products with an HSR ≤ 3 displaying the label, compared to 53% of products scoring ≥3.5 (p < 0.001). Low HSR uptake on poorly rated products demonstrates that most food manufacturers will only display FOPNL where marketing value exists in a voluntary system. Poor and uneven HSR uptake limits consumers' ability to meaningfully use the label to compare and choose healthier products. Government action is urgently required to make the HSR system mandatory.

Assessing the Policy Implications of Different Definitions for Added Sugars: An Analysis Across the Australian Packaged Food and Beverage Supply.

Background: In recent years, various definitions of "added sugars" have emerged across jurisdictions. Although it is clear how these definitions differ, there is limited understanding of the policy implications associated with these variations. Objective: To test the potential policy implications of different definitions of "added sugars" on the Australian packaged food supply, we developed a method to estimate the content of "added sugars" in packaged foods and applied this to 3 different definitions of "added sugars": (i) United States Food and Drug Administration (US FDA) added sugar definition, (ii) the World Health Organization (WHO) free sugar definition, and (iii) a comprehensive definition that was developed from a review of the evidence on "added sugars." Methods: Using a representative sample of 25,323 Australian packaged foods, the "added sugar" content and proportion of products that contain "added sugar" under the 3 definitions were estimated. In addition, a comparative analysis exploring the impact of the US FDA definition (least comprehensive) vs. the comprehensive definition was conducted to understand potential implications of adopting different regulatory definitions in Australia. Results: The US FDA definition identified the lowest number and proportion of products with any "added sugars" at 14,380 products (representing 56.8% of all products), followed by the WHO free sugar definition at 15,168 products (59.9%) and the comprehensive definition at 16,260 products (64.2%). The mean estimates for "added sugars" were 8.5 g/100 g, 8.7 g/100 g, and 9.6 g/100 g for the US FDA, WHO, and comprehensive definitions, respectively. Compared with the US FDA definition, the comprehensive definition captured an additional 7.4% of products, largely driven by nonalcoholic beverages, special foods and fruit, vegetables, nuts, and legumes. Conclusions: Despite small variations in different "added sugars" definitions, their application has some significant policy implications. Findings highlight the importance of applying a comprehensive regulatory definition that adequately captures all sugars that have been linked to poor health.

Australians' perceptions of the potential effects of increased access to alcohol via autonomous delivery services: A multi-method study.

INTRODUCTION: Rapid technological change will affect how people access harmful products. For example, automated delivery services are forecast to provide fast and affordable product access options for those purchasing alcohol. Information about the potential impacts of such innovations on alcohol purchase and consumption behaviors is lacking. The aim of this study was to explore how consumers may respond to future scenarios where alcohol is available via a range of autonomous alcohol delivery options. METHODS: In a two-stage process, qualitative individual interviews (n = 100) and a quantitative online survey (n = 1078) were conducted with Australians aged 18+ years. Quotas were used to achieve national representation on key demographic variables. Participants were exposed to scenarios outlining how autonomous vehicles are likely to be used for alcohol deliveries in the future and asked to discuss their intentions to use such services and their perceptions of any impacts on alcohol consumption at a societal level. RESULTS: Automated alcohol deliveries were generally considered to be highly convenient and therefore likely to be popular. Around one-third (37%) of survey respondents reported an intention to use such automated alcohol delivery services once they are available and almost half (47%) expected overall levels of alcohol consumption to increase across the population. CONCLUSION: Given potential levels of uptake, careful consideration needs to be given to the development and implementation of appropriate policy and regulatory frameworks to minimize the increased risk of alcohol-related harm associated with enhanced alcohol availability resulting from the emerging availability of autonomous delivery services.

The absence of mandatory pregnancy warning labels in online alcohol purchasing contexts.

INTRODUCTION: As people increasingly migrate to online shopping platforms, hard-won improvements in requirements for consumer information provision at the point of sale are being eroded. An example is the alcohol pregnancy warning label for packaged alcoholic beverages that has been recently introduced in Australia and New Zealand. The aim of the present study was to assess the extent to which the pregnancy warning was visible at the online point of sale when the requirement became mandatory in August 2023. METHODS: Data for alcohol products sold on the websites of the two largest alcohol retailers in Australia were web-scraped from 1 to 3 August 2023. The captured data for 8343 alcoholic beverages were inspected to determine whether the pregnancy warning was visible. RESULTS: Virtually no products (0.1%) had the mandatory warning visible on the main sales page, and only 7% enabled visibility of the warning via optional product image rotation functionality. DISCUSSION AND CONCLUSIONS: The almost complete absence of the mandatory pregnancy warnings on the main product pages of major alcohol retailers' websites highlights the regulatory problems posed by the emerging shift to online shopping. The very low prevalence of visible pregnancy warnings is likely to be an overestimate of the extent to which consumers would be exposed to warnings due to images being counted as being present regardless of their quality or readability. New regulation is needed to ensure that mandatory information requirements for harmful products are applied to online shopping contexts.

Switches in food and beverage product purchases can reduce greenhouse gas emissions in Australia.

Switching between similar food and beverage products may reduce greenhouse gas emissions (GHGe). Here, using consumer data linked to 23,550 product-specific GHGe values, we estimated annual GHGe attributable to product purchases consumed at home in Australia and calculated reductions from specific switches. Potential changes to mean Health Star Rating, mean energy density and the proportion of ultraprocessed foods purchased were assessed. Approximately 31 million tonnes of GHGe were attributable to products consumed at home in 2019, the three highest contributors of GHGe being 'meat and meat products' (49%), 'dairy' (17%) and 'non-alcoholic beverages' (16%). Switching higher-emission products for 'very similar' lower-emission products could reduce total emissions by 26%. Switches to 'less similar' lower-emission products could lead to a 71% reduction. Switches had little impact on the average Health Star Rating, energy density of purchases and proportion of ultraprocessed foods purchased. Directing manufacturing and marketing towards lower-environmental-impact products and signposting such options to consumers are key.

Extent of alignment between the Australian Dietary Guidelines and the NOVA classification system across the Australian packaged food supply.

AIMS: The Australian Dietary Guidelines are currently being revised and ultra-processed foods have been identified as a high priority action area. To better understand how well the current Dietary Guidelines align with level of processing classifications, the aim of this study was to assess the alignment between the Australian Dietary Guidelines and the NOVA classification system for classifying the healthiness of packaged foods. METHODS: Data were sourced from the Australian FoodSwitch dataset, which included 28 071 packaged food and beverage products available in major Australian supermarkets in 2022. Products were classified as (i) core or discretionary (Australian Dietary Guidelines) and (ii) non-ultra-processed or ultra-processed (NOVA). Agreement between the two systems (core vs. non-ultra-processed and discretionary vs. ultra-processed) was evaluated using the kappa statistic. RESULTS: There was 'moderate' agreement (κ = 0.41, 95% CI: 0.40-0.42) between the Australian Dietary Guidelines and the NOVA system, with 69.8% of products aligned across the two systems. Alignment was more common for discretionary foods (80.6% were ultra-processed) than core foods (59.9% aligned were not-ultra-processed). Food categories exhibiting the strongest levels of alignment included confectionary, foods for specific dietary use, and egg and egg products. Discordance was most common for convenience foods, sugars, honey and related products, and cereal and grain products. CONCLUSIONS: Despite moderate alignment between the Australian Dietary Guidelines and NOVA, the discordance observed for almost one-third of products highlights the opportunity to develop recommendations for ultra-processed foods within the guidelines to advise Australians how these foods should be considered as part of a healthy diet.

"They start on the zero-alcohol and they wanna try the real thing": Parents' views on zero-alcohol beverages and their use by adolescents.

OBJECTIVE: Zero-alcohol beverages containing 0.0-0.5% alcohol by volume may offer public health benefits if individuals use them to substitute for alcohol-containing products, thereby reducing alcohol use. There are, however, concerns that zero-alcohol beverages may encourage adolescents' earlier interest in alcohol and increase exposure to alcohol company branding. As this poses a challenge for parents, we studied parents' views on zero-alcohol beverages and their provision to adolescents. METHODS: We interviewed n=38 parents of 12-17-year-olds and used reflexive thematic analysis to interpret interview data. RESULTS: Parents considered zero-alcohol beverages to be 'adult beverages' that potentially supported reduced adult drinking but were unnecessary for adolescents. Parents were concerned that adolescent zero-alcohol beverage use could normalise alcohol consumption and be a precursor to alcohol initiation. There was a potential conflict between moderate provision in 'appropriate' contexts, and potential benefits, which were each supported by some parents. Uncertainty on health qualities was also reported. CONCLUSIONS: Parents reported conflicting and cautious views on zero-alcohol beverage provision to adolescents. IMPLICATIONS FOR PUBLIC HEALTH: As evidence on the impacts of zero-alcohol beverage availability develops, parent-targeted messages highlighting the potential risk of normalisation of alcohol use for young people could be developed, in conjunction with broader policy responses.

Modifying the Health Star Rating nutrient profiling algorithm to account for ultra-processing.

AIM: To modify the Australian and New Zealand Health Star Rating to account for ultra-processing and compare the alignment of the modified ratings with NOVA classifications and the current Australian Dietary Guidelines classifications of core (recommended foods) and discretionary (foods to limit). METHODS: Data was cross-sectionally analysed for 25 486 products. Four approaches were compared to the original Health Star Rating: (1) five 'negative' points added to ultra-processed products (modification 1; inclusion approach); (2) ultra-processed products restricted to a maximum of 3.0 Health Stars (modification 2; capping approach); (3 and 4) same approach used for modifications 1 and 2 but only applied to products that already exceeded 10 'negative' points from existing Health Star Rating attributes (modifications 3 and 4, respectively; hybrid approaches). Alignment occurred when products (i) received <3.5 Health Stars and were NOVA group 4 (for NOVA comparison) or discretionary (for Dietary Guidelines comparison), or (ii) received ≥3.5 Health Stars and were NOVA groups 1-3 or core. RESULTS: All Health Star Rating modifications resulted in greater alignment with NOVA (ranging from 69% to 88%) compared to the original Health Star Rating (66%). None of the modifications resulted in greater alignment to the Dietary Guidelines classifications overall (69% to 76%, compared with 77% for the original Health Star Rating), but alignment varied considerably by food category. CONCLUSIONS: If ultra-processing were incorporated into the Australian and New Zealand Health Star Rating, consideration of ultra-processing within the broader dietary guidance framework would be essential to ensure coherent dietary messaging to Australians.

Evaluación de la comprensión objetiva de 5 modelos de etiquetado frontal de alimentos en consumidores argentinos: resultados de un estudio comparativo / Assessment of the objective understanding of 5 models of Front-of-Package labels in argentine consumers: results from a comparative study

La obesidad y las enfermedades no transmisibles (ENT), se hallan en aumento en Argentina. Mantener una alimentación poco saludable es considerado uno de los factores de riesgo más importante en el desarrollo de dichas enfermedades. Los etiquetados en el frente de un envase (ENFE) son una herramienta útil para orientar al consumidor acerca de la calidad nutricional de los productos y para realizar compras más saludables. La eficiencia de los ENFE depende de la facilidad con que la información es entendida correctamente. El objetivo de este estudio fue evaluar la comprensión objetiva de los consumidores argentinos con respecto a cinco ENFE [Sistema de clasificación de estrellas de salud (HSR), semáforos múltiples (MTL), Nutri-Score, ingesta de referencia (RI), Símbolos de Advertencias]. Durante el 2018 se reclutaron 1001 participantes argentinos a quienes, a través de una encuesta online se les pidió clasificar 3 productos de tres categorías de alimentos (pizza, bizcochuelos/budines y cereales de desayuno) de acuerdo a su calidad nutricional. Luego de esta actividad, se les asignó al azar, uno de los cinco ENFE y se les pidió que volvieran a clasificar los mismos alimentos, pero esta vez con el etiquetado en el envase. El cambio en la capacidad de clasificar correctamente los productos en las dos tareas fue evaluado utilizando una regresión logística ordinal. Para las tres categorías de alimentos, Nutri-Score mostró un mejor desempeño, seguido de MTL, HSR, Símbolos de Advertencias y RI. Nutri-Score surgió como el ENFE más eficiente para transmitir la información sobre la calidad nutricional de los alimentos para los consumidores argentinos(AU).

Obesity and non-communicable diseases (NCDs) are on the increase in Argentina. Maintaining an unhealthy diet is considered one of the most important risk factors in the development of these diseases. Front-of-package labels (FOPLs) are a useful tool to guide the consumer about the nutritional quality of the products as well as making healthier choices when buying. The efficiency of the FOPLs depends on the ease with which the information they provide is correctly understood. The objective of this study was to evaluate the objective understanding of Argentine consumers regarding five FOPLs [Health Star Rating System (HSR), Multiple Traffic Lights (MTL), Nutri-Score, Reference Intakes (RI), Warning Symbols]. During 2018, 1001 Argentine participants were recruited and, through an online survey, they were asked to classify 3 products from three categories of food (pizza, sponge cake and breakfast cereals) according to their nutritional quality. After this activity, they were randomly assigned one of the five FOPLs and asked to re-classify the same foods, but this time with the labeling on the packaging. The change in the ability to correctly classify the products in the two tasks was evaluated using an ordinal logistic regression. For the three food categories, Nutri-Score showed a better performance, followed by MTL, HSR, Warning Symbols and RI. Nutri-Score emerged as the most efficient FOPL to transmit information on the nutritional quality of food for Argentine consumers(AU).