"Warning: ultra-processed": an online experiment examining the impact of ultra-processed warning labels on consumers' product perceptions and behavioral intentions.

BACKGROUND: Nutrient content and degree of processing are complementary but distinct concepts, and a growing body of evidence shows that ultra-processed foods (UPFs) can have detrimental health effects independently from nutrient content. 10 + countries currently mandate front-of-package labels (FOPL) to inform consumers when products are high in added sugars, saturated fat, and/or sodium. Public health advocates have been calling for the addition of ultra-processed warning labels to these FOPLs, but the extent to which consumers would understand and be influenced by such labels remains unknown. We examined whether the addition of ultra-processed warning labels to existing nutrient warning labels could influence consumers' product perceptions and purchase intentions. METHODS: In 2023, a sample of adults in Brazil (n = 1,004) answered an open-ended question about the meaning of the term "ultra-processed," followed by an online experiment where they saw four ultra-processed products carrying warning labels. Participants were randomly assigned to view either only nutrient warning labels or nutrient plus ultra-processed warning labels. Participants then answered questions about their intentions to purchase the products, product perceptions, and perceived label effectiveness. RESULTS: Most participants (69%) exhibited a moderate understanding of the term "ultra-processed" prior to the experiment. The addition of an ultra-processed warning label led to a higher share of participants who correctly identified the products as UPFs compared to nutrient warning labels alone (Cohen's d = 0.16, p = 0.02). However, the addition of the ultra-processed warning label did not significantly influence purchase intentions, product healthfulness perceptions, or perceived label effectiveness compared to nutrient warning labels alone (all p > 0.05). In exploratory analyses, demographic characteristics and prior understanding of the concept of UPF did not moderate the effect of ultra-processed warning labels. CONCLUSIONS: Ultra-processed warning labels may help consumers better identify UPFs, although they do not seem to influence behavioral intentions and product perceptions beyond the influence already exerted by nutrient warning labels. Future research should examine how ultra-processed warning labels would work for products that do and do not require nutrient warnings, as well as examine the benefits of labeling approaches that signal the health effects of UPFs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05842460. Prospectively registered March 15th, 2023.

Food Industry Compliance With the Display of Front-of-Package Warning Labels at the Final Phase (2020) of Chile's Labeling and Advertising Law.

Objectives. To investigate food industry compliance with the display of front-of-package warning labels (FOPLs) on products that exceed regulatory thresholds for being high in calories, added sugars, sodium, or saturated fats after full implementation of Chile's Food Labeling and Advertising Law. Methods. In 2020, trained dietitians took pictures of nutritional information and FOPLs on packaged products in supermarkets. We categorized foods and beverages as requiring FOPLs (or not) using their nutritional composition and ingredients as set out in government guidelines. We compared these classifications with the actual display of FOPLs. Results. About 62.5% of packaged foods and beverages displayed any FOPL. The most frequent label was for energy (38.7%), followed by sugars (35.2%), saturated fats (26.2%), and sodium (22.6%). Compliance with FOPL display was high (93.6% for any "high-in" designation). Lower compliance was observed in nonsausage meat products (83.5%) and soups (84.5%). Candies and sweet confectionery and sausages contributed most to noncompliance with any "high-in" designation. Conclusions. Following the law's full implementation, the food industry complied with the display of FOPLs. Mandatory policies with clear guidelines and monitoring systems can contribute to ensuring and sustaining high compliance. (Am J Public Health. Published online ahead of print September 26, 2024:e1-e8. https://doi.org/10.2105/AJPH.2024.307843).

Decreases in purchases of energy, sodium, sugar, and saturated fat 3 years after implementation of the Chilean food labeling and marketing law: An interrupted time series analysis.

BACKGROUND: In 2016, Chile implemented a multiphase set of policies that mandated warning labels, restricted food marketing to children, and banned school sales of foods and beverages high in nutrients of concern ("high-in" foods). Chile's law, particularly the warning label component, set the precedent for a rapid global proliferation of similar policies. While our initial evaluation showed policy-linked decreases in purchases of high-in, a longer-term evaluation is needed, particularly as later phases of Chile's law included stricter nutrient thresholds and introduced a daytime ban on advertising of high-in foods for all audiences. The objective is to evaluate changes in purchases of energy, sugar, sodium, and saturated fat purchased after Phase 2 implementation of the Chilean policies. METHODS AND FINDINGS: This interrupted time series study used longitudinal data on monthly food and beverage purchases from 2,844 Chilean households (138,391 household-months) from July 1, 2013 until June 25, 2019. Nutrition facts panel data from food and beverage packages were linked at the product level and reviewed by nutritionists. Products were considered "high-in" if they contained added sugar, sodium, or saturated fat and exceeded nutrient or calorie thresholds. Using correlated random-effects models and an interrupted time series design, we estimated the nutrient content of food and beverage purchases associated with Phase 1 and Phase 2 compared to a counterfactual scenario based on trends during a 36-month pre-policy timeframe. Compared to the counterfactual, we observed significant decreases in high-in purchases of foods and beverages during Phase 2, including a relative 36.8% reduction in sugar (-30.4 calories/capita/day, 95% CI -34.5, -26.3), a 23.0% relative reduction in energy (-51.6 calories/capita/day, 95% CI -60.7, -42.6), a 21.9% relative reduction in sodium (-85.8 mg/capita/day, 95% CI -105.0, -66.7), and a 15.7% relative reduction in saturated fat (-6.4 calories/capita/day, 95% CI -8.4, -4.3), while purchases of not-high-in foods and drinks increased. Reductions in sugar and energy purchases were driven by beverage purchases, whereas reductions in sodium and saturated fat were driven by foods. Compared to the counterfactual, changes in both high-in purchases and not high-in purchases observed in Phase 2 tended to be larger than changes observed in Phase 1. The pattern of changes in purchases was similar for households of lower versus higher socioeconomic status. A limitation of this study is that some results were sensitive to the use of shorter pre-policy time frames. CONCLUSIONS: Compared to a counterfactual based on a 36-month pre-policy timeframe, Chilean policies on food labeling, marketing, and school food sales led to declines in nutrients of concern during Phase 2 of implementation, particularly from foods and drinks high in nutrients of concern. These declines were sustained or even increased over phases of policy implementation.

Estimated effects of reductions in processed meat consumption and unprocessed red meat consumption on occurrences of type 2 diabetes, cardiovascular disease, colorectal cancer, and mortality in the USA: a microsimulation study.

BACKGROUND: High consumption of processed meat and unprocessed red meat is associated with increased risk of multiple chronic diseases, although there is substantial uncertainty regarding the relationship for unprocessed red meat. We developed a microsimulation model to estimate how reductions in processed meat and unprocessed red meat consumption could affect rates of type 2 diabetes, cardiovascular disease, colorectal cancer, and mortality in the US adult population. METHODS: We used data from two versions of the US National Health and Nutrition Examination Survey, one conducted during 2015-16 and one conducted during 2017-18, to create a simulated US population. The starting cohort was restricted to respondents aged 18 years or older who were not pregnant and had 2 days of dietary-recall data. First, we used previously developed risk models to estimate the baseline disease risk of an individual. For type 2 diabetes we used a logistic-regression model and for cardiovascular disease and colorectal cancer we used Cox proportional-hazard models. We then multiplied baseline risk by relative risk associated with individual processed meat and unprocessed red meat consumption. Prevented occurrences of type 2 diabetes, cardiovascular disease, colorectal cancer, and mortality were computed by taking the difference between the incidence in the baseline and intervention scenarios. All stages were repeated for ten iterations to correspond to a 10-year time span. Scenarios were reductions of 5%, 10%, 30%, 50%, 75%, and 100% in grams consumed of processed meat, unprocessed red meat, or both. Each scenario was repeated 50 times for uncertainty analysis. FINDINGS: The total number of individual respondents included in the simulated population was 8665, representing 242 021 876 US adults. 4493 (51·9%) of 8665 individuals were female and 4172 (48·1%) were male; mean age was 49·54 years (SD 18·38). At baseline, weighted mean daily consumption of processed meat was 29·1 g, with a 30% reduction being 8·7 g per day, and of unprocessed red meat was 46·7 g, with a 30% reduction being 14·0 g per day. We estimated that a 30% reduction in processed meat intake alone could lead to 352 900 (95% uncertainty interval 345 500-359 900) fewer occurrences of type 2 diabetes, 92 500 (85 600-99 900) fewer occurrences of cardiovascular disease, 53 300 (51 400-55 000) fewer occurrences of colorectal cancer, and 16 700 (15 300-17 700) fewer all-cause deaths during the 10-year period. A 30% reduction in unprocessed red meat intake alone could lead to 732 600 (725 700-740 400) fewer occurrences of type 2 diabetes, 291 500 (283 900-298 800) fewer occurrences of cardiovascular disease, 32 200 (31 500-32 700) fewer occurrences of colorectal cancer, and 46 100 (45 300-47 200) fewer all-cause deaths during the 10-year period. A 30% reduction in both processed meat and unprocessed red meat intake could lead to 1 073 400 (1 060 100-1 084 700) fewer occurrences of type 2 diabetes, 382 400 (372 100-391 000) fewer occurrences of cardiovascular disease, 84 400 (82 100-86 200) fewer occurrences of colorectal cancer, and 62 200 (60 600-64 400) fewer all-cause deaths during the 10-year period. INTERPRETATION: Reductions in processed meat consumption could reduce the burden of some chronic diseases in the USA. However, more research is needed to increase certainty in the estimated effects of reducing unprocessed red meat consumption. FUNDING: The Wellcome Trust.

Examining the 2021 Cash Value Benefit Increase and WIC Participant Food Purchases.

INTRODUCTION: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutritious foods to more than six million low-income families. In June 2021, WIC increased the amount of money provided for fruits and vegetables (FV), but studies have not investigated whether this increase changed WIC participant FV purchases. The objective was to estimate the association between the FV funding increase and WIC shopper FV purchases. METHODS: This evaluation uses longitudinal food transaction data from 496 stores in a grocery store chain in North Carolina between June 2020 and April 2022 and a propensity score weighted difference-in-differences (DID) approach to estimate the association between the FV funding increase and FV and other food group purchases. Analyses were conducted in 2023 and 2024. RESULTS: WIC shoppers' WIC-eligible FV purchases increased by $12.4 per shopper per month (adjusted confidence interval [ACI], $12.0-$12.9) after the FV benefit increase, which was $9.3 (ACI, $8.7-$10.0) more than non-WIC shoppers. The monthly volume and unique varieties of FV purchased also increased more among WIC shoppers relative to non-WIC shoppers (DID 67.1 ounces [ACI, 61.9-72.3] and DID 2.1 varieties [ACI, 2.0-2.3]). There were also increases in the volume of processed foods (DID 22.0 ounces [ACI, 17.2, 26.9]) and sugar-sweetened beverages (DID 49.1 ounces [ACI, 33.4, 64.9]) purchased among WIC shoppers relative to non-WIC shoppers. CONCLUSIONS: Increased WIC FV funding was associated with greater FV purchases. Research is needed to understand the effects of this policy on total dietary intake.

Online retail nudges to help parents with lower-income choose healthy beverages for their children: A randomized clinical trial.

BACKGROUND: Nudges offer a promising tool to reduce sugary drink intake among children who are most at risk for diet-related disease. OBJECTIVE: To examine the impact of online store nudges on purchases of sugary drinks for children in lower-income households. METHODS: Caregivers with lower-income were recruited to an online shopping experiment and instructed to spend $10-$30 on three beverages for their child aged 1-5 years. Participants were randomized to navigate an online supermarket in its standard version (n = 1106) or a version with nudges (n = 1135), including a product placement nudge (i.e. placing healthy beverages in prominent positions) and a swap nudge (i.e. offering a swap of water, plain milk and/or 100% fruit juice upon selection of sugary drinks). RESULTS: On average, participants purchased 1887 (SD = 2113) and 620 (SD = 1528) calories from sugary drinks per basket in the control and experimental conditions, respectively. Model-based results indicate that those in the experimental condition purchased 1267 (95% CI: 1419, 1114) fewer calories from sugary drinks, and fewer grams of total sugar (ß = -253.5 g (95% CI: -286.3, -220.6)) and added sugar (ß = -287.8 g (95% CI: -323.1, -252.5)) purchased from sugary drinks. CONCLUSION: Nudges may be an effective, acceptable, scalable strategy for leading caregivers in lower-income households to purchase fewer sugary drinks for their children.

Examining the effects of brand and licensed characters on parents' perceptions of Children's breakfast cereals.

Brand and licensed characters frequently appear on children's breakfast cereal boxes and are known to affect children's product perceptions, selection, and consumption. However, less is known about their impact on parents' perceptions of foods they purchase for their child. The present study assessed the impact of brand and licensed characters featured on three children's breakfast cereal packages on parents' intentions and perceptions in an online experiment. Parents of children aged 2-12 years (n = 1013) were randomized into one of two conditions: breakfast cereals containing brand and licensed characters or breakfast cereals without any characters. Within each condition, participants viewed three breakfast cereal brands in random order per their assigned condition and reported their purchase intentions, healthfulness perceptions, and perceptions of appeal to children using 5-point Likert scales. No significant differences in purchase intentions (p = 0.91), perceived healthfulness (p = 0.52) or perceived child appeal (p = 0.59) were observed between the experimental and control groups. However, exploratory moderation analyses revealed that educational attainment moderated the impact of experimental condition on purchase intentions (p for interaction = 0.002) such that participants with a bachelor's degree in the character condition reported 0.36 points lower purchase intentions compared to the control with no difference between conditions for those with an associate's degree/trade school or high school degree or less. This study did not find an impact of brand and licensed characters on children's breakfast cereals, suggesting that their primary appeal is directly to children. Parents with higher educational attainment may be skeptical of characters on cereal brands. Additional research on the impact of brand and licensed characters on other products, in real-world settings, is needed.

National Policies to Limit Food Marketing and Competitive Food Sales in Schools: A Global Scoping Review.

School food environments contribute to children's nutritional intake and overall health. As such, the World Health Organization and other public health organizations encourage policies that restrict children's access and exposure to foods and beverages that do not build health in and around schools. This global scoping review explores the presence and characteristics of policies that restrict competitive food sales and marketing for unhealthy foods across 193 countries using evidence from policy databases, gray literature, peer-reviewed literature, and primary policy documents. Policies were included if they were nationally mandated and regulated marketing and/or competitive foods in the school environments. Worldwide, only 28% of countries were found to have any national-level policy restricting food marketing or competitive food sales in schools: 16% of countries restrict marketing, 25% restrict competitive foods, and 12% restrict both. Over half of policies were found in high-income countries. No low-income countries had either policy type. Eight marketing policies (27%) and 14 competitive foods policies (29%) lacked explicit guidelines for either policy monitoring or enforcement. Future research is needed to assess the prevalence of policies aimed at improving other key aspects of the school food environment, such as dietary quality of school meals or food procurement, as well as assess the implementation and efficacy of existing policies.

The impact of an eco-score label on US consumers' perceptions of environmental sustainability and intentions to purchase food: A randomized experiment.

Front-of-package labels indicating a product's environmental footprint (i.e., eco-score labels) offer promise to shift consumers towards more sustainable food choices. This study aimed to understand whether eco-score labels impacted consumers' perceptions of environmental sustainability and intentions to purchase sustainable and unsustainable foods. US parents (n = 1,013) completed an online experiment in which they were shown 8 food products (4 sustainable and 4 unsustainable). Participants were randomized to a control (n = 503, barcode on product packaging) or eco-score label group (n = 510, eco-score label on product packaging). The eco-score label was color-coded with a grade of A-F based on the product's environmental footprint, where "A" indicates relative sustainability and "F" indicates relative unsustainability. Participants rated each product's environmental sustainability and their future likelihood of purchase. We used multilevel mixed-effects linear regression models and examined moderation by product category and sociodemographic characteristics. The eco-score label lowered perceived sustainability of unsustainable products by 13% in relative terms or -0.4 in absolute terms (95% CI -0.5, -0.3; p<0.001). The eco-score label increased perceived sustainability of sustainable products by 16% in relative terms or 0.6 in absolute terms (95% CI 0.5, 0.7, p<0.001). Effects on purchase intentions were smaller, with a 6% decrease for unsustainable products (p = 0.001) and an 8% increase for sustainable products (p<0.001). For unsustainable products, the effect of eco-score labels on sustainability perceptions was greater for older adults, men, participants with higher educational attainment, and participants with higher incomes. For sustainable products, the effect of ecolabels on sustainability perceptions was greater for those with higher educational attainment. Eco-score labels have the potential to direct consumers towards more sustainable products. Future studies should investigate eco-score label effectiveness on behavioral outcomes.

Impact of nutrient warning labels on Colombian consumers' selection and identification of food and drinks high in sugar, sodium, and saturated fat: A randomized controlled trial.

OBJECTIVE: This study assessed the impact of nutrient warnings on product selection and ability to identify food products high in nutrients of concern in Colombia. METHODS: In an online experiment (May-June 2023), Colombian adults were randomized to a nutrient warning, guideline daily amounts (GDA), Nutri-Score, or no-label condition (n = 8,004). Participants completed selection tasks between two fruit drinks labeled according to their condition, one high in sugar and one not. Next, participants answered questions about products high in sugar, sodium, and/or saturated fat ("high-in" product). Finally, they selected which label would most discourage them from consuming a high-in product. RESULTS: Fewer participants (17%) exposed to the nutrient warning indicated they would purchase the high-sugar fruit drink compared to Nutri-Score (27%, Holm-adjusted (adj) p<0.001) and no label conditions (31%, adj p<0.001); there were no differences between the nutrient warning and GDA label (14%, adj p = 0.087). Compared to the nutrient warning, the GDA label was slightly more effective at helping consumers identify which drink was high in sugar (89% versus 92%, adj p<0.001), while the Nutri-Score and no-label conditions were less effective. Compared to all other conditions, nutrient warnings were more effective at helping participants identify that products were high in nutrients of concern, were more effective at decreasing intentions to purchase these high-in products and were perceived as more effective. Nutrient warnings were most often selected as the label that most discouraged consumption. CONCLUSIONS: Nutrient warnings are a promising policy to help consumers identify and discourage consumption of products high in nutrients of concern. TRIAL REGISTRATION: Trial Registration: NCT05783726.

Effects of red meat taxes and warning labels on food groups selected in a randomized controlled trial.

BACKGROUND: High consumption of red and processed meat contributes to both health and environmental harms. Warning labels and taxes for red meat reduce selection of red meat overall, but little is known about how these potential policies affect purchases of subcategories of red meat (e.g., processed versus unprocessed) or of non-red-meat foods (e.g., cheese, pulses) relevant to health and environmental outcomes. This study examined consumer responses to warning labels and taxes for red meat in a randomized controlled trial. METHODS: In October 2021, we recruited 3,518 US adults to complete a shopping task in a naturalistic online grocery store. Participants were randomly assigned to one of four arms: control (no warning labels or tax), warning labels only (health and environmental warning labels appeared next to products containing red meat), tax only (prices of products containing red meat were increased 30%) or combined warning labels + tax. Participants selected items to hypothetically purchase, which we categorized into food groups based on the presence of animal- and plant-source ingredients (e.g., beef, eggs, pulses), meat processing level (e.g., processed pork versus unprocessed pork), and meat species (e.g., beef versus pork). We assessed the effects of the warning labels and tax on selections from each food group. RESULTS: Compared to control, all three interventions led participants to select fewer items with processed meat (driven by reductions in processed pork) and (for the tax and warning labels + tax interventions only) fewer items with unprocessed meat (driven by reductions in unprocessed beef). All three interventions also led participants to select more items containing cheese, while only the combined warning labels + tax intervention led participants to select more items containing processed poultry. Except for an increase in selection of pulses in the tax arm, the interventions did not affect selections of fish or seafood (processed or unprocessed), eggs, or plant-based items (pulses, nuts & seeds, tofu, meat mimics, grains & potatoes, vegetables). CONCLUSIONS: Policies to reduce red meat consumption are also likely to affect consumption of other types of foods that are relevant to both health and environmental outcomes. TRIAL REGISTRATION: NCT04716010 on www. CLINICALTRIALS: gov .

Dietary quality and dietary greenhouse gas emissions in the USA: a comparison of the planetary health diet index, healthy eating index-2015, and dietary approaches to stop hypertension.

BACKGROUND: The Planetary Health Diet Index (PHDI) measures adherence to the dietary pattern presented by the EAT-Lancet Commission, which aligns health and sustainability targets. There is a need to understand how PHDI scores correlate with dietary greenhouse gas emissions (GHGE) and how this differs from the carbon footprints of scores on established dietary recommendations. The objectives of this study were to compare how the PHDI, Healthy Eating Index-2015 (HEI-2015) and Dietary Approaches to Stop Hypertension (DASH) relate to (a) dietary GHGE and (b) to examine the influence of PHDI food components on dietary GHGE. METHODS: We used life cycle assessment data from the Database of Food Recall Impacts on the Environment for Nutrition and Dietary Studies to calculate the mean dietary GHGE of 8,128 adult participants in the 2015-2016 and 2017-2018 cycles of the National Health and Nutrition Examination Survey (NHANES). Poisson regression was used to estimate the association of (a) quintiles of diet score and (b) standardized dietary index Z-scores with dietary GHGE for PHDI, HEI-2015, and DASH scores. In secondary analyses, we used Poisson regression to assess the influence of individual PHDI component scores on dietary GHGE. RESULTS: We found that higher dietary quality on all three indices was correlated with lower dietary GHGE. The magnitude of the dietary quality-dietary GHGE relationship was larger for PHDI [-0.4, 95% CI (-0.5, -0.3) kg CO2 equivalents per one standard deviation change] and for DASH [-0.5, (-0.4, -0.6) kg CO2-equivalents] than for HEI-2015 [-0.2, (-0.2, -0.3) kg CO2-equivalents]. When examining PHDI component scores, we found that diet-related GHGE were driven largely by red and processed meat intake. CONCLUSIONS: Improved dietary quality has the potential to lower the emissions impacts of US diets. Future efforts to promote healthy, sustainable diets could apply the recommendations of the established DASH guidelines as well as the new guidance provided by the PHDI to increase their environmental benefits.

A policy approach to identifying food and beverage products that are ultra-processed and high in added salt, sugar and saturated fat in the United States: a cross-sectional analysis of packaged foods.

Background: Governments globally aim to reduce the intake of unhealthy foods. Many policies exist that aim to address foods high in saturated fat, salt and sugar (HFSS) but the identification of ultra-processed foods (UPF) have presented a greater challenge due to the lack of an appropriate policy definition. To support policymakers, we provide approaches that can support governments to identify both HFSS foods and UPFs. Methods: Four approaches combining elements of UPF definitions (i.e., presence of additives) and HFSS definitions were compared attempting to simplify and standardize the identification of less healthy products. Nationally representative food purchase data from NielsenIQ linked with nutrition facts label data were used to examine the mean proportion of product volume purchased by US households to be targeted. Differences between approaches were examined using Student t test; Bonferroni adjusted P value < 0.0001 was considered significant. Findings: In 2020, 50% of 33,054,687 products purchased by US households were considered UPFs (65% of foods and 38% of beverages) and 43% HFSS (65% of foods and 26% of beverages), however there was not 100% agreement between the two definitions (P < 0.0001). By starting with HFSS criteria and adding elements of UPF (colors and flavors), we were able to provide a method with 100% agreement between the identification of UPFs and HFSS products. Interpretation: Results demonstrated how combining HFSS criteria with UPF criteria can be used to identify less healthy foods and ensure policymakers have both a simple and accurate method to target products for policy intervention. Funding: Bloomberg Philanthropies and the Global Food Research Program of UNC-Chapel Hill provided funds.

A Qualitative Exploration of Spanish-Speaking Latina Women's Experiences Participating in WIC Before and During the COVID-19 Pandemic.

BACKGROUND: More than one-third of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants identify as Latino, but participation has been declining and individuals who speak predominantly Spanish face additional barriers to participation. During the COVID-19 pandemic, there were changes in WIC eligibility and benefits that may have been differentially accessible to Spanish-speaking Latina participants due to factors such as language barriers and lack of awareness of changes. Understanding Spanish-speaking Latinas' experiences with the WIC program generally and during the pandemic can inform efforts to equitably implement future emergency food response policies and improve the WIC program and Latina participant enrollment more broadly. OBJECTIVE: This study aimed to understand the perceptions and experiences of Spanish-speaking Latina WIC participants with the WIC program generally and with COVID-19 pandemic-related policy changes made to the WIC program. DESIGN: Qualitative in-depth interviews were conducted virtually in Spanish in August 2022 using a semi-structured guide. PARTICIPANTS/SETTING: Study participants were 18 Spanish-speaking Latina adult WIC participants living in North Carolina recruited using convenience sampling. ANALYSIS: All interviews were recorded, transcribed, and coded in Spanish. Thematic analysis with inductive coding was used to derive key themes. RESULTS: Perceptions about the WIC program in this sample were mixed. Participants felt positively about the healthfulness of foods included in the WIC food packages but expressed concern about the monthly benefit amounts being too low and the cultural appropriateness of food options. Pandemic policy changes, such as remote appointments and the Cash Value Benefit increase were perceived positively; however, barriers to using benefits during this time included limited communication from WIC agencies, food shortages, and concerns about not being granted US citizenship or permanent resident status due to use of WIC (ie, public charge rule). Social networks played an important role in learning about and enrolling in WIC and navigating food shortages during the pandemic. CONCLUSIONS: Concerns about the cultural appropriateness of foods provided, communication challenges, and the public charge rule emphasized the need for resources dedicated in the WIC program to improving Spanish-speaking Latina women's experiences with WIC.

Adherence to the Planetary Health Diet Index and correlation with nutrients of public health concern: an analysis of NHANES 2003-2018.

BACKGROUND: The Planetary Health Diet Index (PHDI) is a novel measure adapted to quantify alignment with the dietary evidence presented by the EAT-Lancet Commission on Food, Planet, Health. OBJECTIVES: To examine how population-level health and sustainability of diet as measured by the PHDI changed from 2003 to 2018, and to assess how PHDI correlated with inadequacy for nutrients of public health concern (iron, calcium, potassium, and fiber) in the United States. METHODS: We estimated survey-weighted trends in PHDI scores and median intake of PHDI components in a nationally representative sample of 33,859 adults aged 20+ y from 8 cycles (2003-2018) of the National Health and Nutrition Examination Survey with 2 d of dietary recall data. We used the National Cancer Institute method to examine how PHDI correlated with inadequate intake of iron, calcium, potassium, and fiber. RESULTS: Out of a theoretical range of 0-140, the median PHDI value increased by 4.2 points over the study period, from 62.7 (95% confidence interval [CI]: 62.0, 63.4) points in 2003-2004 to 66.9 (66.2, 67.7) points in 2017-2018 (P-trend < 0.001), although most of this change occurred before 2011-2012 and plateaued thereafter. For adequacy components that are encouraged for consumption, nonstarchy vegetable intake significantly decreased over time, whereas whole grains, nuts and seeds, and unsaturated oils increased. For moderation components with recommended limits for consumption, poultry and egg intake increased, but red and processed meat, added sugars, saturated fats, and starchy vegetables decreased over time. Higher PHDI values were associated with a lower probability of iron, fiber, and potassium inadequacy. CONCLUSIONS: Although there have been positive changes over the past 20 y, there is substantial room for improving the health and sustainability of the United States diet. Shifting diets toward EAT-Lancet recommendations would improve nutrient adequacy for iron, fiber, and potassium. Policy action is needed to support healthier, more sustainable diets in the United States and globally.

Dietary quality and cardiometabolic indicators in the USA: A comparison of the Planetary Health Diet Index, Healthy Eating Index-2015, and Dietary Approaches to Stop Hypertension.

BACKGROUND: The Planetary Health Diet Index (PHDI) measures adherence to the sustainable dietary guidance proposed by the EAT-Lancet Commission on Food, Planet, Health. To justify incorporating sustainable dietary guidance such as the PHDI in the US, the index needs to be compared to health-focused dietary recommendations already in use. The objectives of this study were to compare the how the Planetary Health Diet Index (PHDI), the Healthy Eating Index-2015 (HEI-2015) and Dietary Approaches to Stop Hypertension (DASH) relate to cardiometabolic risk factors. METHODS AND FINDINGS: Participants from the National Health and Nutrition Examination Survey (2015-2018) were assigned a score for each dietary index. We examined disparities in dietary quality for each index. We used linear and logistic regression to assess the association of standardized dietary index values with waist circumference, blood pressure, HDL-C, fasting plasma glucose (FPG) and triglycerides (TG). We also dichotomized the cardiometabolic indicators using the cutoffs for the Metabolic Syndrome and used logistic regression to assess the relationship of the standardized dietary index values with binary cardiometabolic risk factors. We observed diet quality disparities for populations that were Black, Hispanic, low-income, and low-education. Higher diet quality was associated with improved continuous and binary cardiometabolic risk factors, although higher PHDI was not associated with high FPG and was the only index associated with lower TG. These patterns remained consistent in sensitivity analyses. CONCLUSIONS: Sustainability-focused dietary recommendations such as the PHDI have similar cross-sectional associations with cardiometabolic risk as HEI-2015 or DASH. Health-focused dietary guidelines such as the forthcoming 2025-2030 Dietary Guidelines for Americans can consider the environmental impact of diet and still promote cardiometabolic health.

Understanding Whether Price Tag Messaging Can Amplify the Benefits of Taxes: An Online Experiment.

INTRODUCTION: Excise taxes on unhealthy products like sugary drinks and tobacco can reduce purchases of these products. However, little research has investigated whether messages at the point of purchase, such as enhanced price tags, can increase the effects of taxes by heightening psychological reactions. This study aimed to examine whether including messages about taxes on price tags could amplify the benefits of excise taxes on unhealthy products. METHODS: In 2022, an online study recruited 1,013 U.S. parents to view seven price tag messages (e.g., "includes a 19% sugary drink tax") and a control (i.e., standard price tag with the tax included in the price) displayed in random order alongside sugary drinks. Participants were randomly assigned to view a caution-symbol icon or no icon on price tags. Analyses were conducted in 2023. RESULTS: All seven messages discouraged parents from buying sugary drinks for their children compared to control (average differential effects [ADEs] ranged from 0.28 to 0.48, all p<0.001). All messages led to greater attention to the price tag (ADEs ranged from 0.24 to 0.41, all p<0.001) and greater consideration of the cost of sugary drinks (ADEs ranged from 0.31 to 0.50, all p<0.001). Icons elicited higher cost consideration than text-only price tags (ADE=0.15, p<0.010), but not discouragement (p=0.061) or attention (p=0.079). CONCLUSIONS: Messaging on price tags could make excise taxes more effective. Policymakers should consider requiring messaging on price tags when implementing taxes.