A policy study on front-of-pack nutrition labeling in the Americas: emerging developments and outcomes.

Poor nutrition is one of the leading causes of non-communicable diseases (NCDs), especially in the WHO Region of the Americas (AMRO). In response, international organisations recommend front-of-pack nutrition labelling (FOPNL) systems that present nutrition information clearly to help consumers make healthier choices. In AMRO, all 35 countries have discussed FOPNL, 30 countries have formally introduced FOPNL, eleven have adopted FOPNL, and seven countries (Argentina, Chile, Ecuador, Mexico, Peru, Uruguay and Venezuela) have implemented FOPNL. FOPNL has gradually spread and evolved to better protect health by increasingly adopting larger warning labels, contrasting background devices for better salience, using "excess" instead of "high in" to improve efficacy, and adopting the Pan American Health Organization's (PAHO) Nutrient Profile Model to better define nutrient thresholds. Early evidence illustrates successful compliance, decreased purchases and product reformulation. Governments still discussing and waiting to implement FOPNL should follow these best practices to help reduce poor nutrition related NCDs. Translated versions of this manuscript are available in Spanish and Portuguese in the supplementary material.

Evaluating progress and addressing actions to eliminate industrially produced trans-fatty acids in the Americas.

Objective: To evaluate the progress toward the 2023 target for the elimination of industrially produced trans-fatty acids (IP-TFA) in the Region of the Americas and to highlight the achievements of the four strategic lines of action from the Plan of Action for the Elimination of IP-TFA 2020-2025. Methods: A survey based on the World Health Organization (WHO) REPLACE package was used to collect data. The REPLACE package outlines six strategic action areas (Review, Promote, Legislate, Assess, Create, Enforce) to support the prompt, complete, and sustained elimination of IP-TFA from the food supply. Information was cross-checked and updated until December 2021. Results: Thirty countries in the Region responded to the survey between November 2019 and July 2020, an 85.7% response rate. As of December 2021, 21 additional indicators of the Regional Plan of Action were met, out of which, four consisted of new enactments of PAHO/WHO best practice policies for the elimination of IP-TFA by countries since baseline data was collected in 2018. This has resulted in a 63.0% increase in the proportion of the population in the Americas protected from consuming IP-TFA in 2021, compared to the baseline in 2018. Conclusion: Despite results showing progress in the Region, actions are needed to strengthen country capacity building and strategies to eliminate IP-TFA and fully achieve the 2023 goal.

Evaluating progress and addressing actions to eliminate industrially produced trans-fatty acids in the Americas / Evaluar el progreso y abordar las medidas para eliminar los ácidos grasos trans de producción industrial en la Región de las Américas / Avaliar o progresso e abordar as ações para eliminar os ácidos graxos trans de produção industrial nas Américas

ABSTRACT Objective. To evaluate the progress toward the 2023 target for the elimination of industrially produced trans-fatty acids (IP-TFA) in the Region of the Americas and to highlight the achievements of the four strategic lines of action from the Plan of Action for the Elimination of IP-TFA 2020-2025. Methods. A survey based on the World Health Organization (WHO) REPLACE package was used to collect data. The REPLACE package outlines six strategic action areas (Review, Promote, Legislate, Assess, Create, Enforce) to support the prompt, complete, and sustained elimination of IP-TFA from the food supply. Information was cross-checked and updated until December 2021. Results. Thirty countries in the Region responded to the survey between November 2019 and July 2020, an 85.7% response rate. As of December 2021, 21 additional indicators of the Regional Plan of Action were met, out of which, four consisted of new enactments of PAHO/WHO best practice policies for the elimination of IP-TFA by countries since baseline data was collected in 2018. This has resulted in a 63.0% increase in the proportion of the population in the Americas protected from consuming IP-TFA in 2021, compared to the baseline in 2018. Conclusion. Despite results showing progress in the Region, actions are needed to strengthen country capacity building and strategies to eliminate IP-TFA and fully achieve the 2023 goal.

RESUMEN Objetivo. Evaluar el progreso hacia el logro de la meta prevista para el 2023 para la eliminación de los ácidos grasos trans de producción industrial (AGT-PI) en la Región de las Américas y destacar los logros en las cuatro líneas estratégicas de acción del Plan de acción para la eliminación de los ácidos grasos trans de producción industrial 2020-2025. Métodos. Para recopilar datos se empleó una encuesta basada en el conjunto de medidas REPLACE de la Organización Mundial de la Salud (OMS). En el conjunto de medidas REPLACE se describen seis áreas de acción estratégica (revisar, promover, legislar, analizar, concientizar, exigir el cumplimiento) para apoyar la eliminación rápida, completa y sostenida de los AGT-PI del suministro de alimentos. Se verificó y se actualizó la información hasta diciembre del 2021. Resultados. Treinta países de la Región respondieron a la encuesta entre noviembre del 2019 y julio del 2020, una tasa de respuesta del 85,7%. Para diciembre del 2021, se habían cumplido 21 indicadores adicionales del plan de acción regional, cuatro de los cuales consistieron en políticas nuevas relativas a mejores prácticas de la OPS/OMS para la eliminación de los AGT-PI promulgadas por los países desde que se recopilaron los datos de las líneas de base en el año 2018. Esto implica un aumento del 63,0% de la proporción de la población de la Región protegida del consumo de AGT-PI en el 2021, en comparación con la línea de base del 2018. Conclusiones. A pesar de que los resultados muestran progreso en la Región, se necesitan medidas para fortalecer la capacidad y las estrategias de los países a fin de eliminar los AGT-PI y lograr plenamente el objetivo para el 2023.

RESUMO Objetivo. Avaliar o progresso rumo à meta de 2023 para a eliminação dos ácidos graxos trans de produção industrial (AGT-PI) na Região das Américas e destacar as conquistas já obtidas nas quatro linhas estratégicas de ação do Plano de Ação para Eliminar os AGT-PI 2020-2025. Métodos. Um levantamento com base no pacote REPLACE da Organização Mundial da Saúde (OMS) foi usado para coletar dados. O pacote REPLACE delineia seis áreas estratégicas de ação (Revisar, Promover, Legislar, Avaliar, Conscientizar, Estimular) para apoiar a eliminação rápida, completa e sustentada dos AGT-PI da cadeia produtiva de alimentos. As informações foram cruzadas e atualizadas até dezembro de 2021. Resultados. Trinta países da Região responderam à pesquisa entre novembro de 2019 e julho de 2020, o que corresponde a uma taxa de resposta de 85,7%. Até dezembro de 2021, 21 indicadores adicionais do Plano de Ação Regional haviam sido atingidos, quatro dos quais consistiam em novas promulgações de políticas consideradas boas práticas pela OPAS/OMS para a eliminação de AGT-PI pelos países em relação à linha de base de 2018. Isso resultou em um aumento de 63,0% na proporção da população nas Américas protegida do consumo de AGT-PI em 2021, em comparação com a linha de base de 2018. Conclusão. Apesar dos resultados demonstrarem progresso na Região, são necessárias ações para fortalecer a capacitação dos países e as estratégias para eliminar os AGT-PI e alcançar plenamente a meta para 2023.

Smoking cessation intentions and attempts one year after the federally mandated smoke-free housing rule.

The present study examines public housing residents' smoking cessation intentions, expectancies, and attempts one year after implementation of the Department of Housing and Urban Development's mandatory smoke-free rule in public housing. The sample includes 233 cigarette smokers, ages 18-80, who reside in the District of Columbia Housing Authority. Data collection occurred between March and August 2019. Descriptive statistics, chi-square, and Wilcoxon two-sample test analyses assessed smoking cessation intentions, expectancies, and attempts across resident demographics and characteristics. Findings showed 17.2% of residents reported not thinking about quitting, 39.1% reported thinking about quitting, and 48.6% reported thinking about quitting specifically because of the rule. Residents ages 60-80 were more likely to consider quitting because of the rule, compared to residents ages 18-59. Of those thinking of quitting, 58.6% were sure they could quit if they tried. Those thinking of quitting due to the rule (62.0%) were more likely to have made at least one quit attempt in the past 3 months than those i not attributinging thinking of quitting to the rule. Res Residents trying to quit reported an average of 2.7 attempts in the last 3 months;; most perceived evidence-based cessation supports as not helpful. A A majority reported thinking about quitting and attempting to quit but continuing to smoke, indicating a significant gap between intent to quit and successfully quitting. Results suggest that the rule positively influenced smoking behaviors. However, additional interventions are needed to assist public housing residents with successfully quitting smoking.

An accountability evaluation for the responsible use of celebrity endorsement by the food and beverage industry to promote healthy food environments for young Americans: A narrative review to inform obesity prevention policy.

Research has shown that celebrity endorsement is a marketing strategy primarily used to promote highly processed food and beverage products to children and adolescents, which negatively influences their diet quality and increases their risks of obesity. This study conducted an accountability evaluation to examine government, expert, and industry policies, guidelines, recommendations, and practices regarding using celebrity endorsement to support healthy marketing environment for young Americans. This study used the National Academy of Medicine's LEAD principles (i.e., locate, evaluate, and assemble evidence to inform decisions) to identify and synthesize relevant evidence between January 2000 and December 2019. We categorized the evidence in a five-step accountability framework and assigned each step a progress score (i.e., none, limited, some, and extensive). The findings showed that the US government made no progress to appoint an independent empowered body to evaluate celebrity endorsement practices. Stakeholders made some progress to take and hold industry and government to account and limited progress to share the account and to strengthen accountability structures. We suggest actions for diverse stakeholders to substantially strengthen accountability structures to ensure that celebrity endorsement is used to promote only healthy food environments to reduce obesity risks for young Americans.

Development of a Responsible Policy Index to Improve Statutory and Self-Regulatory Policies that Protect Children's Diet and Health in the America's Region.

In 2010, 193 Member States of the World Health Organization (WHO) endorsed World Health Assembly Resolution WHA63.14 to restrict the marketing of food and beverage products high in fat, sugar and salt (HFSS) to children to prevent obesity and non-communicable diseases (NCDs). No study has examined HFSS marketing policies across the WHO regional office countries in the Americas. Between 2018 and 2019, a transdisciplinary team examined policies to restrict HFSS food and beverage product marketing to children to develop a responsible policy index (RESPI) that provides a quality score based on policy characteristics and marketing techniques. After designing the RESPI, we conducted a comprehensive literature review through October 2019 to examine policies in 14 countries in the WHO Americans Region. We categorized policies (n = 38) as either self-regulatory or statutory and calculated the RESPI scores, ranked from 0 (lowest) to 10 (highest). Results showed Brazil, Canada, Chile, and Uruguay had the highest RESPI scores associated with statutory policies that restricted point of sale, cartoon, licensed media characters and celebrities; and HFSS products in schools and child care settings, and broadcast and print media. Policymakers can use the RESPI tool to evaluate marketing policies within and across geopolitical boundaries to protect children's diet and health.

Mapping the Celebrity Endorsement of Branded Food and Beverage Products and Marketing Campaigns in the United States, 1990-2017.

Celebrity endorsement used to promote energy-dense and nutrient-poor (EDNP) food and beverage products may contribute to poor dietary habits. This study examined celebrity endorsement of branded food and beverage products and marketing campaigns in the United States (US) from 1990 to 2017. Celebrity endorsement data were collected from peer-reviewed and grey literature. Interactive data visualizations were created for the endorsement relationships between celebrities, companies and products whose nutritional profiles were compared with the US Department of Agriculture's (USDA's) Smart Snacks Standards. Logistic regression was used to explore associations between celebrities' demographic profiles and the nutritional profiles of products. Results showed 542 celebrities were associated with 732 endorsements representing 120 brands of 59 companies across 10 food and beverage categories. Two thirds (67.2%; n = 80) of the brands represented EDNP products that did not align with the USDA's Smart Snacks Standards. Logistic regression analysis indicated that Millennial (p = 0.008) and male celebrities (p = 0.041) were more likely to endorse EDNP products than Generation Z teen and female celebrities, respectively. No statistical significance was observed for celebrities of other demographic profiles. This study may inform future policies and actions of the US government, industry, researchers and consumer advocacy organizations to use celebrity endorsement to promote healthy food environments for Americans.

Progress Evaluation for Transnational Restaurant Chains to Reformulate Products and Standardize Portions to Meet Healthy Dietary Guidelines and Reduce Obesity and Non-Communicable Disease Risks, 2000-2018: A Scoping and Systematic Review to Inform Policy.

Transnational restaurant chains sell food and beverage products in 75 to 139 countries worldwide linked to obesity and non-communicable diseases (NCDs). This study examined whether transnational restaurant chains reformulated products and standardized portions aligned with healthy dietary guidelines and criteria. Firstly, we describe the transnational restaurant industry structure and eating trends. Secondly, we summarize results from a scoping review of healthy dietary guidelines for restaurants. Thirdly, we describe a systematic review of five electronic databases (2000-2018) to identify studies on nutrient profile and portion size changes made by transnational restaurants over 18 years. We used Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, identified 179 records, and included 50 studies conducted in 30 countries across six regions. The scoping review found a few expert-recommended targets for restaurants to improve offerings, but no internationally accepted standard for portions or serving sizes. The systematic review results showed no standardized assessment methods or metrics to evaluate transnational chain restaurants' practices to improve menu offerings. There was wide variation within and across countries, regions, firms, and chains to reduce energy, saturated and trans fats, sodium, and standardized portions. These results may inform future research and encourage transnational chain restaurants to offer healthy product profiles and standardized portions to reduce obesity and NCD risks worldwide.

An accountability evaluation for the International Food & Beverage Alliance's Global Policy on Marketing Communications to Children to reduce obesity: A narrative review to inform policy.

United Nations (UN) organizations have urged governments to restrict the marketing of unhealthy food and nonalcoholic beverage products to children. This study conducted an accountability evaluation for the International Food & Beverage Alliance's (IFBA's) Global Policy on Marketing Communications to Children (Global Policy) compared with UN and other best-practice recommendations. We used the National Academy of Medicine's LEAD (ie, locate, evaluate, assemble evidence to inform decisions) framework to identify evidence (January 2004 to October 2018). We assigned a progress score (ie, none, limited, some, extensive) for five accountability steps. No progress was made to appoint an empowered body to evaluate IFBA's Global Policy. IFBA and the Access to Nutrition Foundation made some progress to take and share the account. Diverse actors made no progress to hold IFBA to account for nonadherence or to strengthen accountability structures for future compliance. IFBA could strengthen its Global Policy to align with best practices. UN organizations and other stakeholders should encourage IFBA firms to restrict the marketing of unhealthy foods and beverages to reduce children's obesity risk. This evaluation is relevant to all firms and industry associations that market products to children that undermine their diet and health.

Conocimiento y uso del etiquetado nutrimental de alimentos y bebidas industrializados en México / Knowledge and use of nutrient labelling of industrialized foods and beverages in Mexico

Resumen: Objetivo: Documentar el conocimiento y uso de la información de las diferentes etiquetas colocadas en los productos industrializados en México. Material y métodos: En una submuestra de la Encuesta Nacional de Salud y Nutrición de Medio Camino 2016, se aplicó un cuestionario semiestructurado, desarrollado por investigadores libres de conflicto de interés, previamente validado y piloteado en población de diferentes estratos socioeconómicos, grupos de edad y regiones del país. Resultados: Se entrevistó a 8 667 adultos ≥20 años de edad. El etiquetado más utilizado para la elección de alimentos y bebidas industrializados fue la "tabla nutrimental" 41.5% (IC95% 36.9-46.3) y el de menor uso el "sello nutrimental" 4.3% (IC95% 3.1-5.7). Conclusiones: Es de suma importancia que las instancias reguladoras, en coordinación con la Secretaría de Salud, implementen un etiquetado frontal rápido de leer y de fácil comprensión con criterios nutrimentales que garanticen el cumplimiento de lo expuesto en los documentos oficiales, así como la estandarización del porcentaje de consumo de azúcar al recomendado por la OMS o a una menor cantidad dada la alerta epidemiológica por diabetes que experimenta el país.

Abstract: Objective: To keep record of the knowledge and use of information of the different food labels on industrialized products in Mexico. Materials and methods: We administered a semi-structured survey-developed by researchers free of conflict interest-in a subsample of the National Health and Nutrition Survey, 2016. This survey was previously validated and piloted in different populations of varying socioeconomic levels and age and country regions. Results: Data was collected from a total of 8 667 individuals ≥20 years of age. The most frecuent type of label on industrialized foods and beverages was the nutrient table, with 41.5% (95%CI 36.9-46.3) and the least used was the nutrient seal, 4.3% (95%CI 3.1-5.7). Conclusions: It is of critical importance that the regulating authorities and the Ministry of Health, implement criteria that guarantee the compliance of recommendations promulgated in official documents. As well as the standarization of the percentage of recommended sugar intake based on WHO standards or lower considering the epidemiological alert for diabetes that the country is experiencing.

[Knowledge and use of nutrient labelling of industrialized foods and beverages in Mexico]. / Conocimiento y uso del etiquetado nutrimental de alimentos y bebidas industrializados en México.

OBJECTIVE: To keep record of the knowledge and use of information of the different food labels on industrialized products in Mexico. MATERIALS AND METHODS: We administered a semi-structured survey-developed by research¬ers free of conflict interestin a subsample of the National Health and Nutrition Survey, 2016. This survey was previously validated and piloted in different populations of varying socio¬economic levels and age and country regions. RESULTS: Data was collected from a total of 8 667 individuals ≥20 years of age. The most frecuent type of label on industrialized foods and beverages was the nutrient table with 41.5% (95%CI 36.9- 46.3) and the least used was the nutrient seal, 4.3% (95%CI 3.1-5.7). CONCLUSIONS: It is of critical importance that the regulating authorities and the Ministry of Health, implement criteria that guarantee the compliance of recommendations promulgated in official documents. As well as the standarization of the percentage of recommended sugar intake based on WHO standards or lower considering the epidemiological alert for diabetes that the country is experiencing.

OBJETIVO: Documentar el conocimiento y uso de la información de las diferentes etiquetas colocadas en los productos industrializados en México. MATERIAL Y MÉTODOS: En una submuestra de la Encuesta Nacional de Salud y Nutrición de Medio Camino 2016, se aplicó un cuestionario semiestructurado, desarrollado por investigadores libres de conflicto de interés, previamente validado y piloteado en población de diferentes estratos socioeconómicos, grupos de edad y regiones del país. RESULTADOS: Se entrevistó a 8 667 adultos ≥20 años de edad. El etiquetado más utilizado para la elección de alimentos y bebidas industrializados fue la "tabla nutrimental" 41.5% (IC95% 36.9-46.3) y el de menor uso el "sello nutrimental" 4.3% (IC95% 3.1-5.7). CONCLUSIONES: Es de suma importancia que las instancias reguladoras, en coordinación con la Secretaría de Salud, implementen un etiquetado frontal rápido de leer y de fácil comprensión con criterios nutrimentales que garanticen el cumplimiento de lo expuesto en los documentos oficiales, así como la estandarización del porcentaje de consumo de azúcar al recomendado por la OMS o a una menor cantidad dada la alerta epidemiológica por diabetes que experimenta el país.

Characterization of Breakfast Cereals Available in the Mexican Market: Sodium and Sugar Content.

Preschool Mexican children consume 7% of their total energy intake from processed breakfast cereals. This study characterized the nutritional quality and labelling (claims and Guideline Daily Amount (GDA)) of the packaged breakfast cereals available in the Mexican market. Photographs of all breakfast cereals available in the 9 main food retail chains in the country were taken. The nutrition quality of cereals was assessed using the United Kingdom Nutrient Profiling Model (UKNPM). Claims were classified using the International Network for Food and Obesity/non-communicable Diseases Research, Monitoring and Action Support (INFORMAS) taxonomy and the GDA was defined according to the Mexican regulation, NOM-051. Overall, a total of 371 different breakfast cereals were analysed. The nutritional profile showed that 68.7% were classified as "less healthy". GDAs and claims were displayed more frequently on the "less healthy" cereals. Breakfast cereals within the "less healthy" category had significantly higher content of energy, sugar and sodium (p < 0.001). Most of the claims were displayed in the "less healthy" cereals (n = 313). This study has shown that there is a lack of consistency between the labelling on the front of the pack and the nutritional quality of breakfast cereals.

Nutritional quality of foods and non-alcoholic beverages advertised on Mexican television according to three nutrient profile models.

BACKGROUND: Evidence supports that television food advertisements influence children's food preferences and their consumption. However, few studies have examined the extent and nature of food marketing to children in low and middle income countries. This study aims to assess the nutritional quality of foods and beverages advertised on Mexican TV, applying the Mexican, World Health Organization (WHO) European and United Kingdom (UKNPM) nutrient profile models, before the Mexican regulation on food marketing came into effect. METHODS: We recorded 600 h on the four national public and free TV channels with the highest national ratings, from December 2012 to April 2013. Recordings were done for 40 randomly selected (week, weekend, school and vacation) days, from 7 am to 10 pm. Nutritional information per 100 g/ml of product was obtained from the product labels or company websites. RESULTS: A total of 2,544 food and non-alcoholic beverage advertisements were broadcast, for 275 different products. On average, the foods advertised during cartoon programming had the highest energy (367 kcal) and sugar (30.0 g) content, while foods advertised during sport programming had the highest amount of total fat (9.5 g) and sodium (412 mg) content. More than 60 % of the foods advertised did not meet any nutritional quality standards. 64.3 % of the products did not comply with the Mexican nutritional standards, as compared with 83.1 % and 78.7 % with WHO Europe and UKNPM standards, respectively. The food groups most frequently advertised were beverages (24.6 %), followed by chocolate and confectionery sugar (19.7 %), cakes, sweet biscuits and pastries (12.0 %), savory snacks (9.3 %), breakfast cereals (7.1 %), ready-made food (6.4 %) and dairy products (6.0 %). CONCLUSION: The majority of foods and beverages advertised on Mexican TV do not comply with any nutritional quality standards, and thus should not be marketed to children. The nutritional quality standards applied by the Mexican regulation are much weaker than those applied by the WHO Europe and United Kingdom. The Mexican government should improve the nutrition standards in its new regulation, especially the sugar cut off points.