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.

Could Google Help Curb Online Advertising of Unhealthy Foods to U.S. Children?

INTRODUCTION: In 2020, Google took voluntary action to restrict food and beverage advertising through its online channels in the European Union/United Kingdom using Google's own nutrient profiling model to identify products eligible to be marketed to children through its Google Display Network. The objective of this study was to evaluate the potential impact of the Google policy, if applied to the U.S. market, on restricting online advertising of the top-selling packaged foods and beverages in the U.S. METHODS: The top 25 U.S. food and beverage manufacturers were identified. Nutrient data for products from these manufacturers were sourced from Label Insight (a Nielsen IQ company) in 2021. Each product was examined against four nutrient profiling models: the Google nutrient profiling model, the WHO Europe nutrient profiling model, the Pan American Health Organization nutrient profiling model, and the Chilean government nutrient profiling model. RESULTS: Under Google's nutrient profiling model, 18% of 14,188 products were eligible to be advertised to children, representing $44 billion in revenue for the top 25 U.S. manufacturers of the >$240 billion generated annually. The Google nutrient profiling model permitted the most products to be advertised to children of all four nutrient profiling models examined. CONCLUSIONS: U.S. children engage extensively with online media. In place of government regulation, the Google advertising policy and related nutrient profiling model would limit online advertising of the most unhealthful products to children, if the policy were to be applied to the U.S. market. The effectiveness of the policy would be strengthened by refining the Google nutrient profiling model to better align with nutrient profiling models developed by authoritative health agencies, including the WHO.

Industrial Use of Phosphate Food Additives: A Mechanism Linking Ultra-Processed Food Intake to Cardiorenal Disease Risk?

The consumption of ultra-processed food (UPF) keeps rising, and at the same time, an increasing number of epidemiological studies are linking high rates of consumption of UPF with serious health outcomes, such as cardiovascular disease, in the general population. Many potential mechanisms, either in isolation or in combination, can explain the negative effects of UPF. In this review, we have addressed the potential role of inorganic phosphate additives, commonly added to a wide variety of foods, as factors contributing to the negative effects of UPF on cardiorenal disease. Inorganic phosphates are rapidly and efficiently absorbed, and elevated serum phosphate can lead to negative cardiorenal effects, either directly through tissue/vessel calcification or indirectly through the release of mineral-regulating hormones, parathyroid hormone, and fibroblast growth factor-23. An association between serum phosphate and cardiovascular and bone disease among patients with chronic kidney disease is well-accepted by nephrologists. Epidemiological studies have demonstrated an association between serum phosphate and dietary phosphate intake and mortality, even in the general American population. The magnitude of the role of inorganic phosphate additives in these associations remains to be determined, and the initial step should be to determine precise estimates of population exposure to inorganic phosphate additives in the food supply.

Food Additives in Ultra-Processed Packaged Foods: An Examination of US Household Grocery Store Purchases.

BACKGROUND: Food additives have been used mainly in the past century to perform specific functions in foods. Some types of food additives have been linked to adverse health outcomes, yet there is little research examining food additives in the US food supply. OBJECTIVE: To examine the proportion of products purchased by US households containing four common technical food additives using time-specific food composition data and examine whether purchases have changed over time. PARTICIPANTS/SETTING: Nielsen Homescan Consumer Panels, 2001 and 2019. MAIN OUTCOME MEASURES: The proportion of packaged food products containing common types of food additives purchased by US households was determined overall and by food category. STATISTICAL ANALYSIS PERFORMED: Differences were examined using Student t test; P value < 0.001 was considered significant. RESULTS: Between 2001 and 2019, the proportion of food products purchased by US households that contained additives increased from 49.6% to 59.5% (P < 0.001). The proportion of carbonated soft drinks purchased containing flavors decreased, with a subsequent increase in purchases containing nonnutritive sweeteners. Baby foods showed a 20% increase in the proportion of purchases containing additives and >15% increase in the proportion of purchases containing three or more additives. CONCLUSIONS: There is convincing evidence that US household purchases of common types of technical food additives are increasing. Despite some positive changes such as a decrease in the use of added flavors in carbonated soft drinks, across most food categories an increase in purchases of all types of products containing additives was observed. In particular the finding that purchases of baby food products containing additives have increased substantially is crucial in informing future research in this area and warrants further investigation.

Evaluation of a Salt-Reduction Consumer Awareness Campaign Targeted at Parents Residing in the State of Victoria, Australia.

From 2015 to 2020 a state-wide salt-reduction initiative was launched in Victoria, Australia, including an awareness campaign focused on parents with children <18 years of age. To evaluate the impact of the campaign on salt-related knowledge, attitudes and behaviors (KABs) we have assessed trends in salt-related KAB pre- and post-delivery of the campaign in parents, as well as within the wider adult population. Cross-sectional surveys of adults aged 18-65 years were undertaken pre- (2015: n = 821 parents; n = 1527 general sample) and post-campaign (2019: n = 935 parents; n = 1747 general sample). KABs were assessed via an online survey. Data were analyzed with regression models and adjusted for covariates. Among parents, around one-quarter of salt-related KABs shifted in a positive direction, but changes were small: there was a 6% (95% CI 2, 11%) increase in the percentage who knew the main source of salt in the diet and reductions in the percentage who reported placing a salt shaker on the table (-8% (95%CI -12, -3)) and that their child added salt at the table (-5% (95% -9, -0.2)). Among the wider adult sample, even fewer shifts in KAB were observed, with some behaviors worsening at follow-up. These findings indicate that this consumer awareness campaign had minimum impact.

Evaluation of a state-wide intervention on salt intake in primary schoolchildren living in Victoria, Australia.

OBJECTIVE: In 2015, the Victorian Salt Reduction Partnership launched a 4-year multifaceted salt reduction intervention designed to reduce salt intake by 1 g/d in children and adults living in Victoria, Australia. Child-relevant intervention strategies included a consumer awareness campaign targeting parents and food industry engagement seeking to reduce salt levels in processed foods. This study aimed to assess trends in salt intake, dietary sources of salt and discretionary salt use in primary schoolchildren pre- and post-delivery of the intervention. DESIGN: Repeated cross-sectional surveys were completed at baseline (2010-2013) and follow-up (2018-2019). Salt intake was measured via 24-h urinary Na excretion, discretionary salt use behaviours by self-report and sources of salt by 24-h dietary recall. Data were analysed with multivariable-adjusted regression models. SETTING: Victoria, Australia. PARTICIPANTS: Children aged 4-12 years. RESULTS: Complete 24-h urine samples were collected from 666 children at baseline and 161 at follow-up. Mean salt intake remained unchanged from baseline (6·0; se 0·1 g/d) to follow-up (6·1; 0·4 g/d) (P = 0·36), and there were no clear differences in the food sources of salt and at both time points approximately 70 % of children exceeded Na intake recommendations. At follow-up, 14 % more parents (P = 0·001) reported adding salt during cooking, but child use of table salt and inclusion of a saltshaker on the table remained unchanged. CONCLUSION: These findings show no beneficial effect of the Victorian Salt Reduction Partnership intervention on children's salt intake. More intensive, sustained and coordinated efforts between state and federal stakeholders are required.

Junk Food Intake Among Adults in the United States.

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

The Contribution of Major Food Categories and Companies to Household Purchases of Added Sugar in Australia.

BACKGROUND: The Australian Government will soon be releasing a series of sugar reformulation targets for packaged foods. OBJECTIVE: To estimate the amount of added sugar purchased from packaged food and beverages and the relative contribution that food categories and food companies made to these purchases in 2018. The secondary objective was to examine differences in purchases of added sugar across income levels. DESIGN: Cross-sectional study. PARTICIPANTS/SETTING: We used 1 year of grocery purchase data from a nationally representative panel of Australian households (the NielsenIQ Homescan panel), combined with a packaged food and beverage database (FoodSwitch). MAIN OUTCOME MEASURES: Added sugar purchases (grams per day per capita), purchase-weighted added sugar content (grams per 100 g) and total weight of products (with added sugar) purchased (grams per day per capita). STATISTICAL ANALYSES PERFORMED: Food categories and food companies were ranked according to their contribution to added sugar purchases. Differences in added sugar purchases by income levels were assessed by 1-factor analysis of variance. RESULTS: Added sugar information was available from 7188 households and across 26,291 unique foods and beverages. On average, the amount of added sugar acquired from packaged foods and beverages was (mean ± SE) 35.9 ± 0.01 g/d per capita. Low-income households purchased 11.0 g/d (95% CI: 10.9-11.0 g/d, P < .001) more added sugar from packaged products than high-income households per capita. The top 10 food categories accounted for 82.2% of added sugar purchased, largely due to purchases of chocolate and sweets, soft drinks, and ice cream and edible ices. Out of 994 food companies, the top 10 companies contributed to 62.1% of added sugar purchases. CONCLUSIONS: The Australian Government can strengthen their proposed sugar reduction program by adding further category-specific targets, prioritizing engagement with key food companies and considering a broader range of policies to reduce added sugar intakes across the Australian population.

Availability, healthiness, and price of packaged and unpackaged foods in India: A cross-sectional study.

Background: Vulnerable populations are the most prone to diet-related disease. The availability, healthiness, and price of foods have established associations with diet-related disease in communities. However, data describing this in India are sparse, particularly in urban slums and rural areas. Aim: To quantify and compare availability, healthiness, and price of packaged and unpackaged foods and beverages in India, and to identify opportunities to improve diets and health of vulnerable populations. Methods: Nutrition data and price were collected on foods and beverages available at 44 stores in urban, urban slum, and rural areas in four states in India between May and August 2018. Healthiness was assessed using the Australasian Health Star Rating system and product retail prices were examined. Comparisons in the findings were made across state, community area type, and adherence to current and draft Indian food labeling regulations. Results: Packaged foods and beverages (n = 1443, 89%) were more prevalent than unpackaged (n = 172, 11%). Unpackaged products were healthier than packaged (mean Health Star Rating = 3.5 vs 2.0; p < 0.001) and lower in price (median price per 100 g/ml: 13.42 Indian rupees vs 25.70 Indian rupees; p < 0.001), a pattern observed across most community area types and states. 96% of packaged products were compliant with current Indian labeling regulations but only 23% were compliant with proposed labeling regulations. Conclusions: Unpackaged products were on average much healthier and lower in price than packaged foods and beverages. Food policies that support greater availability, accessibility and consumption of unpackaged foods, while limiting consumption of packaged foods, have enormous potential for sustaining the health of the Indian population.

Changes in the Presence of Nonnutritive Sweeteners, Sugar Alcohols, and Free Sugars in Australian Foods.

BACKGROUND: In parallel with growing consumer interest in reducing sugar intake, manufacturers have increased availability of food and beverage products containing nonnutritive sweeteners (NNSs). However, emerging evidence indicates that specific NNS types have differential effects on cardiometabolic health. OBJECTIVE: This study examined overall changes in the presence of NNSs, sugar alcohols, and free sugars in the Australian food supply and the use of specific NNS types. PARTICIPANTS/SETTING: Data for 21,051 products in 2015 and 21,366 products in 2019 were extracted from The George Institute's FoodSwitch database. MAIN OUTCOME MEASURES: The proportion of products containing NNSs, sugar alcohols, free sugars, and a combination of these, as well as proportion of products containing specific NNS types. STATISTICAL ANALYSES PERFORMED: Changes between 2015 and 2019 were examined using Pearson χ2 tests. RESULTS: Between 2015 and 2019, there was a significant increase in the proportion of food and beverage products containing NNSs (from 3.8% to 4.3%; P < .001) and a significant decrease in products containing free sugars (from 62.7% to 59.9%; P < .001),) driven primarily by nondairy beverages. There were changes in the use of specific NNS types between 2015 and 2019, with a large increase in the use of steviol glycosides (from 33.7% to 50.2%) and a large decrease in the use of sucralose (from 42.4% to 30.5%), aspartame (from 21.0% to 14.4%), and acesulfame K (from 57.4% to 27.7%) (P < .05 for all). CONCLUSIONS: These findings on the use of different NNS, sugar alcohol, and free sugar ingredients and combinations provide important research insights and will be useful in informing government policies that address sugars and other sweeteners in Australian foods.

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

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

Estimating the potential impact of the Australian government's reformulation targets on household sugar purchases.

BACKGROUND: Countries around the world are putting in place sugar reformulation targets for packaged foods to reduce excess sugar consumption. The Australian government released its voluntary sugar reformulation targets for nine food categories in 2020. We estimated the potential impact of these targets on household sugar purchases and examined differences by income. For comparison, we also modelled the potential impact of the UK sugar reduction targets on per capita sugar purchases as the UK has one of the most comprehensive sugar reduction strategies in the world. METHODS: Grocery purchase data from a nationally representative consumer panel (n=7,188) in Australia was linked with a large database (FoodSwitch) with product-specific sugar content information for packaged foods (n=25,261); both datasets were collected in 2018. Potential reductions in per capita sugar purchases were calculated overall and by food category. Differences in sugar reduction across income level were assessed by analysis of variance. RESULTS: In 2018, the total sugar acquired from packaged food and beverage purchases consumed at-home was 56.1 g/day per capita. Australia's voluntary reformulation targets for sugar covered 2,471/25,261 (9.8%) unique products in the FoodSwitch dataset. Under the scenario that all food companies adhered to the voluntary targets, sugar purchases were estimated to be reduced by 0.9 g/day per capita, which represents a 1.5% reduction in sugar purchased from packaged foods. However, if Australia adopted the UK targets, over twice as many products would be covered (n=4,667), and this would result in a more than four times greater reduction in sugar purchases (4.1 g/day per capita). It was also estimated that if all food companies complied with Australia's voluntary sugar targets, reductions to sugar would be slightly greater in low-income households compared with high-income households by 0.3 g/day (95%CI 0.2 - 0.4 g/day, p<0.001). CONCLUSIONS: Sugar-reduction policies have the potential to substantially reduce population sugar consumption and may help to reduce health inequalities related to excess sugar consumption. However, the current reformulation targets in Australia are estimated to achieve only a small reduction to sugar intakes, particularly in comparison to the UK's sugar reduction program.

The Use of Non-Nutritive and Low-Calorie Sweeteners in 19,915 Local and Imported Pre-Packaged Foods in Hong Kong.

This study aims to examine the use of non-nutritive (NNSs) and low-calorie sweeteners (LCSs) in pre-packaged foods in Hong Kong and the differences in the number of NNSs/LCSs used between products from different regions. In a cross-sectional audit, the types of NNSs/LCSs used in 19,915 pre-packaged foods in Hong Kong were examined by searching the ingredients list of the included products for keywords related to 20 common NNSs/LCSs and their respective E-numbers. Prevalence of use of NNSs and LCSs, the co-presence of NNSs/LCSs and free sugar ingredients (FSI), and the number of NNSs/LCSs used in the included foods were computed. Pearson's χ2 test was used to compare the total number of NNSs and/or LCSs used in food items from different regions. Sucralose (E955) was the most commonly used NNS (1.9%), followed by acesulfame K (E950, 1.6%). Sorbitol was the most commonly used LCS (2.9%). Overall, the use of LCSs was less common compared with NNSs (3.7% vs. 4.5%). The use of different types of NNSs varied substantially between food types. Notably, 20.2% of potato crisps and 15.2% of other crisps or extruded snacks contained at least one NNS and/or LCS. Co-presence of FSIs and NNSs/LCSs were most common in confectionery (15.7%) and snack foods (15.5%). Asian prepackaged foods were more likely to contain NNSs/LCSs (10.1%) compared with those from other regions. To conclude, NNSs/LCSs were used in a wide range of non-diet pre-packaged products which could be a public health concern due to their higher consumption frequencies than "diet" products.

Correction to: Contribution of major food companies and their products to household dietary sodium purchases in Australia.

An amendment to this paper has been published and can be accessed via the original article.

Types and Amounts of Nonnutritive Sweeteners Purchased by US Households: A Comparison of 2002 and 2018 Nielsen Homescan Purchases.

BACKGROUND: Purchases of foods containing nonnutritive sweetener (NNS) alone or in combination with caloric sweeteners (CS) has increased in recent years in the United States. At the same time clinical evidence is emerging of different cardiometabolic effects of each NNS type. OBJECTIVE: To examine the prevalence and volume purchased of commonly consumed types of NNS in packaged food and beverage products comparing 2002 and 2018 using data from nationally representative samples of US households. PARTICIPANTS/SETTING: Nielsen Homescan Consumer Panels (The Nielsen Company); 2002 and 2018. MAIN OUTCOME MEASURES: Prevalence and volume of foods and beverages purchased containing CS, NNS, both CS and NNS, or neither CS nor NNS, as well as prevalence and volume of products containing specific NNS types. STATISTICAL ANALYSES PERFORMED: Differences examined using Student t test, P value of <.05 considered significant. RESULTS: Volume of products purchased containing CS decreased comparing 2002 and 2018 (436.6 ± 1.6 to 362.4 ± 1.3 g/d; P < .05), yet increased for products containing both CS and NNS (10.8-36.2 g/d; P < .05). Regarding specific types of NNS, changes were noted in the prevalence of households purchasing products containing saccharin (1.3%-1.1%; P < .05), aspartame (60.0%-49.4%; P < .05), rebaudioside A (0.1%-25.9%) and sucralose (38.7%-71.0%). Non-Hispanic whites purchased twice the volume of products containing NNS compared to Hispanics and non-Hispanic blacks in both years. Beverages were predominantly responsible for larger volume per capita purchases of products containing only NNS as well as both CS and NNS. CONCLUSIONS: A decline in purchases of products containing CS occurred in tandem with an increase in purchases of products containing both CS and NNS, along with a large shift in the specific types of NNS being purchased by US households. New NNS types enter the market regularly, and it is important to monitor changes in the amount of NNS and products containing NNS that consumers purchase.

Contribution of major food companies and their products to household dietary sodium purchases in Australia.

BACKGROUND: The Australian federal government will soon release voluntary sodium reduction targets for 30 packaged food categories through the Healthy Food Partnership. Previous assessments of voluntary targets show variable industry engagement, and little is known about the extent that major food companies and their products contribute to dietary sodium purchases among Australian households. METHODS: The aim of this cross-sectional study was to identify the relative contribution that food companies and their products made to Australian household sodium purchases in 2018, and to examine differences in sodium purchases by household income level. We used 1 year of grocery purchase data from a nationally representative consumer panel of Australian households who reported their grocery purchases (the Nielsen Homescan panel), combined with database that contains product-specific sodium content for packaged foods and beverages (FoodSwitch). The top food companies and food categories were ranked according to their contribution to household sodium purchases. Differences in per capita sodium purchases by income levels were assessed by 1-factor ANOVA. All analyses were modelled to the Australian population in 2018 using sample weights. RESULTS: Sodium data were available from 7188 households who purchased 26,728 unique products and purchased just under 7.5 million food product units. Out of 1329 food companies, the top 10 accounted for 35% of unique products and contributed to 58% of all sodium purchased from packaged foods and beverages. The top three companies were grocery food retailers each contributing 12-15% of sodium purchases from sales of their private label products, particularly processed meat, cheese and bread. Out of the 67 food categories, the top 10 accounted for 73% of sodium purchased, particularly driven by purchases of processed meat (14%), bread (12%) and sauces (11%). Low-income Australian households purchased significantly more sodium from packaged products than high-income households per capita (452 mg/d, 95%CI: 363-540 mg/d, P < 0.001). CONCLUSIONS: A small number of food companies and food categories account for most of the dietary sodium purchased by Australian households. Prioritizing government engagement with these groups could deliver a large reduction in population sodium intake.

Salt-Related Knowledge, Attitudes and Behaviors (KABs) among Victorian Adults Following 22-Months of a Consumer Awareness Campaign.

The Australian population consumes more salt than recommended and this increases the risk of raised blood pressure and cardiovascular disease. In 2015, a state-wide initiative was launched in the Australian state of Victoria to reduce population salt intake. This study examines whether salt-related knowledge, attitudes and behaviors (KABs) of Victorian adults changed following the first 22 months of a consumer awareness campaign targeting parents. Repeated cross-sectional surveys of adults (18-65 years) recruited from research panels. Analyses were weighted to reflect the Victorian population. In both surveys mean age of participants (1584 in 2015 and 2141 in 2018) was 41 years, and 51% were female. This includes 554 parents/caregivers in 2015 and 799 in 2018. Most indicators of KAB remained unchanged. Among parents/caregivers the percentage who agreed limiting salt in their child's diet was important increased by 8% (p = 0.001), and there was a 10% reduction in the percentage who reported placing a saltshaker on the table and a 9% reduction in those who reported their child added salt at the table (both p < 0.001). Some small adverse effects on other indicators were also observed. During the first 22 months of a salt reduction consumer awareness campaign, there were limited changes in KAB overall, however the target audience reported positive changes regarding their children, which aligned with the campaign messages.

Recent Trends in Junk Food Intake in U.S. Children and Adolescents, 2003-2016.

INTRODUCTION: In the U.S., there is no consensus of how to define junk food. Strict regulations on what constitutes junk food denoted by front-of-package labels can serve as the basis for statutory actions. Chile was the first country to adopt this approach, and several countries have followed suit. This study examined the proportion of calories and nutrients of concern consumed by U.S. children and adolescents defined as junk food using the Chilean label criteria and the changes between 2003 and 2016. METHODS: Data were obtained from 4 nationally representative food intake surveys in 13,016 U.S. children and adolescents: National Health and Nutrition Examination Survey 2003-2004, 2005-2006, 2013-2014, and 2015-2016, with analysis performed in 2019. Nutritional content of each consumed food was compared with nutrient thresholds from the Chilean regulation for energy, saturated fat, total sugars, and sodium per 100 g. RESULTS: Between 2003 and 2016, there was a 10 percentage point decrease (71.1%-61.3%, p<0.01) in the proportion of foods consumed that were classified as junk food. A significant decrease was seen in mean intake of calories (1,610-1,367 kcal/day, p<0.01), total sugar (88.8-64.2 g/day, p<0.01), saturated fat (22.6-20.5 g/day, p<0.01), and sodium (2,306-2,044 mg/day, p<0.01). CONCLUSIONS: Although junk food intake has decreased since 2003-2006, diets of U.S. children and adolescents remain dominated by less-healthy foods. These results can help guide policy regulations regarding foods and beverages accessible in schools and marketed to children, adolescents, and their caregivers.