Examining the Role of Aguas Frescas in Assessment of Sugary Drink Intake among Mexican and Mexican American Adults.

BACKGROUND: Aguas frescas are Mexican drinks that are typically made with water, sugar, and fruit. Aguas frescas may be a significant component of sugary drink intake among Mexican and Mexican American (MA) adults. However, it is unclear whether survey respondents report aguas frescas consumption when it is not specifically queried in standardized beverage frequency instruments. OBJECTIVES: This study examined the prevalence of aguas frescas consumption, the sociodemographic correlates of aguas frescas intake, and how specifically querying aguas frescas intake affects sugary drink estimates among Mexican and MA adults. METHODS: Cross-sectional, online surveys were conducted in 2021 with 5,377 Mexican and 3,073 MA adults as part of the International Food Policy Study. Past 7-day consumption of sugar-sweetened beverages (SSBs), sugary drinks, and aguas frescas was assessed along with relevant covariates. Weighted analyses included logistic and linear regression, including models with correlation structure. RESULTS: An estimated 61.7% of Mexican and 28.7% of MA adults consumed aguas frescas. In Mexico, consumption was associated with female sex, low education, perceiving oneself as having about the right weight, having good to excellent health, and consuming an unhealthy amount of sugary drinks. For MAs, intake was associated with being younger, speaking Spanish, and perceiving oneself as having underweight or about the right weight. Among Mexican adults who consumed aguas frescas but did not report them unless specifically queried, the volume of SSB intake was 67.9% higher for females and 64.3% higher for males when aguas frescas were included. Among MAs, SSB intake was 56.9% higher for females and 44.1% higher for males. Most participants (79.9-85.2%) remained in the same sugary drink tertiles when including versus excluding aguas frescas. CONCLUSIONS: Aguas frescas should be queried during beverage intake assessments, as they contribute a non-trivial amount of added sugars to the diets of many Mexican and MA adults.

Closer to Home: A Quality Improvement Initiative to Optimize Satellite Site Bed Capacity.

BACKGROUND: The coronavirus disease 2019 pandemic resulted in the underutilization of inpatient beds at our satellite location. A lack of clarity and standardized admission criteria for the satellite led to frequent transfers to the main campus, resulting in patients traveling larger distances to receive inpatient care. We sought to optimize inpatient resource use at the satellite campus and keep patients "closer to home" by admitting eligible patients to that inpatient unit (LA4). Our aim was to increase bed capacity use at the satellite from 45% to 70% within 10 months. Our process measure was to increase the proportion of patients needing hospitalization who presented to the satellite emergency department (ED) and were then admitted to LA4 from 76% to 85%. METHODS: A multidisciplinary team used quality improvement methods to optimize bed capacity use. Interventions included (1) the revision and dissemination of satellite admission guidelines, (2) steps to create shared understanding of appropriate satellite admissions between ED and inpatient providers, (3) directed provider feedback on preventable main campus admissions, and (4) consistent patient and family messaging about the potential for transfer. Data were collected via chart review. Annotated run charts were used to assess the impact of interventions over time. RESULTS: Average LA4 bed capacity use increased from 45% to 69%, which was sustained for 1 year. The average percentage of patients admitted from the satellite ED to LA4 increased from 76% to 84%. CONCLUSIONS: We improved bed capacity use at our satellite campus through transparent admission criteria and shared mental models of patient care needs between ED and inpatient providers.

Self-reported decreases in the purchases of selected unhealthy foods resulting from the implementation of warning labels in Mexican youth and adult population.

BACKGROUND: Front-of-package nutritional warning labels (WLs) are designed to facilitate identification and selection of healthier food choices. We assessed self-reported changes in purchasing different types of unhealthy foods due to WLs in Mexico and the association between the self-reported reductions in purchases of sugary beverages and intake of water and sugar-sweetened beverages. METHODS: Data came from 14 to 17 year old youth (n = 1,696) and adults ≥ 18 (n = 7,775) who participated in the Mexican arm of the 2020-2021 International Food Policy Study, an annual repeat cross-sectional online survey. Participants self-reported whether the WLs had influenced them to purchase less of each of nine unhealthy food categories due to WLs. Among adults, a 23-item Beverage Frequency Questionnaire was used derive past 7-day intake of water and sugary beverages analyzed to determine the relationship between self-reported reductions in purchasing sugary drinks due to the WLs. Multilevel mixed-effects logistic regression models were fitted to estimate the percentage of participants who self-reported reducing purchases within each food group, and overall. Sociodemographic characteristics associated with this reduction were investigated as well. RESULTS: Overall, 44.8% of adults and 38.7% of youth reported buying less of unhealthy food categories due to the implementation of WL, with the largest proportion reporting decreased purchases of cola, regular and diet soda. A greater impact of WLs on the reported purchase of unhealthy foods was observed among the following socio-demographic characteristics: females, individuals who self-identified as indigenous, those who were overweight, individuals with lower educational levels, those with higher nutrition knowledge, households with children, and those with a significant role in household food purchases. In addition, adults who reported higher water intake and lower consumption of sugary beverages were more likely to report reduced purchases of sugary drinks due to the WLs. Adults who reported greater water intake and lower sugary beverages intake were significantly more likely to report buying fewer sugary drinks due to the WLs. CONCLUSION: Our findings suggest that implementation of WLs has reduced perceived purchases of unhealthy foods in Mexico. These results underscore the potential positive impact of the labeling policy particularly in subpopulations with lower levels of education and among indigenous adults.

Use of online food delivery services among adults in five countries from the International Food Policy Study 2018-2021.

Aim: Online food delivery services (OFDS) are popular for purchasing meals prepared outside home, increasing access to energy-dense and nutrient-poor foods. This adversely impacts dietary choices and health outcomes. Our study examined trends in OFDS use in Australia, Canada, Mexico, the United Kingdom (UK), and the United States (US) from 2018 to 2021. Methods: Repeated annual cross-sectional data was sourced from the International Food Policy Study for five countries among adults over 18 years (N = 83,337). Weighted estimates for trends in i) the proportion of the respondent's purchasing meals per week using OFDS, and ii) average number (and standard deviation (SD)) of meals purchased per week using OFDS were assessed. Logistic regression models were fitted. Findings: OFDS use increased among adults between 2018-2021 (Australia: 17 % of respondents purchased at least one meal in the last 7 days using OFDS in 2018 to 25 % in 2021, Canada: 12 % to 19 %, Mexico: 28 % to 38 %, UK: 19 % to 28 %, and US: 17 % to 21 %). Average number of meals purchased per week outside home remained consistent for all countries over time (e.g., in Australia, 2.70 (SD 0.06) meals in 2018 and 2.63 (SD 0.06) in 2021). However, average number of meals purchased using OFDS nearly doubled between 2018 and 2021 (e.g., in Australia, 0.45 (SD 0.03) meals in 2018 to 0.81 (SD 0.04) in 2021). Conclusion: OFDS use is increasing and are substituting the conventional forms of purchasing meals outside home. Nutritional quality of foods sold, marketing practices and purchasing patterns on OFDS deserve further attention.

Sociodemographic differences in nutrition labels effect on Chilean and Mexican youth.

Objective: To examine sociodemographic differences in the awareness, understanding, use and effect of nutrition labels among Mexican and Chilean youth. Methods: Online surveys among youth (10-17 years) were obtained in 2019 (n=2631). Participants reported their awareness, understanding, and use of their country-specific nutrition facts tables (NFT) and front-of-pack labels (FOPL) (Chile: warning labels [WLs]; Mexico: guideline daily amounts [GDA]). Additionally, participants reported their perceived healthfulness of a sweetened fruit drink after viewing one of six versions of it with different FOPL (no-label control, Health Star Rating, WLs, GDAs, Traffic Light, or Nutri-Score) during an experimental task. Results: Higher self-reported nutrition knowledge was associated with higher NFT and FOPL awareness, understanding, and use, except for WL use. WLs were the most effective FOPL in decreasing the perceived healthfulness of the sweetened fruit drink compared to a no-label condition and other FOP labels. In Chile, the effect of GDA differed by income adequacy, while in Mexico Nutri-Score differed by age. Conclusions: Results suggest that nutrition label awareness, use, understanding, and impact differ across demographics, favoring higher income and nutrition knowledge. Despite this, WLs are likely to have a positive impact on nutrition-related knowledge and behaviors among Mexican and Chilean youth, independently of their socio-demographic groups.

Assessing transnational spillover effects of Mexico's front-of-package nutritional labeling system among Mexican Americans in the US.

OBJECTIVE: In 2020, Mexico implemented innovative front-of-package nutrition warning labels (FoPWLs) for packaged foods to increase the salience and understanding of nutrition information. This study evaluated Mexican Americans' self-reported exposure to Mexican FoPWLs and self-reported effects of FoPWLs on purchasing behavior. METHODS: The 2021 International Food Policy Study surveyed online panels of adult Mexican Americans in the US (n = 3361) to self-report on buying food at Mexican-oriented stores, noticing Mexican FoPWLs, and being influenced by FoPWLs to purchase less of eight different unhealthy foods (each assessed separately). After recoding the frequency of buying foods in Mexican stores and noticing FoPWLs (i.e., "often" or "very often" vs. less often), logistic models regressed these outcomes on sociodemographics, adjusting for post-stratification weights. RESULTS: Most participants (88.0%) purchased foods in Mexican stores. Of these, 64.1% reported noticing FoPWLs, among whom many reported that FoPWLs influenced them to buy fewer unhealthy foods (range = 32% [snacks like chips] - 44% [colas]). Participants were more likely to buy foods in Mexican stores and notice FoPWLs if they were younger, had ≥two children at home vs no children (AOR = 1.40, 95%CI = 1.15-1.71; AOR = 1.37, 95%CI = 1.03-1.80, respectively), and more frequently used Spanish (AOR = 1.91, 95%CI = 1.77-2.07; AOR = 1.87, 95%CI = 1.69-2.07). Also, high vs. low education (AOR = 1.51, 95%CI = 1.17-1.94) and higher income adequacy (AOR = 1.37, 95%CI = 1.25-1.51) were positively associated with noticing FoPWLs. Being female and more frequent Spanish use were consistently associated with reporting purchase of fewer unhealthy foods because of FoPWLs. CONCLUSIONS: Many Mexican Americans report both exposure to Mexican FOPWLs and reducing purchases of unhealthy foods because of them.

Sociodemographic differences in nutrition labels effect on Chilean and Mexican youth / Diferencias sociodemográficas en el efecto de las etiquetas nutricionales en las adolescentes de Chile y México / Diferenças sociodemográficas no efeito da rotulagem nutricional em adolescentes chilenos e mexicanos

[ABSTRACT]. Objective. To examine sociodemographic differences in the awareness, understanding, use and effect of nutrition labels among Mexican and Chilean youth. Methods. Online surveys among youth (10-17 years) were obtained in 2019 (n=2631). Participants reported their awareness, understanding, and use of their country-specific nutrition facts tables (NFT) and front-of-pack labels (FOPL) (Chile: warning labels [WLs]; Mexico: guideline daily amounts [GDA]). Additionally, participants reported their perceived healthfulness of a sweetened fruit drink after viewing one of six versions of it with different FOPL (no-label control, Health Star Rating, WLs, GDAs, Traffic Light, or Nutri-Score) during an exper- imental task. Results. Higher self-reported nutrition knowledge was associated with higher NFT and FOPL awareness, understanding, and use, except for WL use. WLs were the most effective FOPL in decreasing the perceived healthfulness of the sweetened fruit drink compared to a no-label condition and other FOP labels. In Chile, the effect of GDA differed by income adequacy, while in Mexico Nutri-Score differed by age. Conclusions. Results suggest that nutrition label awareness, use, understanding, and impact differ across demographics, favoring higher income and nutrition knowledge. Despite this, WLs are likely to have a positive impact on nutrition-related knowledge and behaviors among Mexican and Chilean youth, independently of their socio-demographic groups.

[RESUMEN]. Objetivo. Examinar las diferencias sociodemográficas por lo que respecta al conocimiento, la comprensión, el uso y el efecto de las etiquetas nutricionales en adolescentes de México y Chile. Métodos. En el 2019 se efectuó una encuesta en línea en adolescentes (10 a 17 años) (n=2631). Los participantes indicaron su conocimiento, comprensión y uso de los cuadros de información nutricional y los etiquetados frontales específicos de los empaques de su país (en el caso de Chile, las etiquetas de advertencia, y en el de México, las guías diarias de alimentación (GDA). Asimismo, se llevó a cabo un experimento en el que los participantes indicaron su percepción de lo saludable que era una bebida de fruta azucarada después de ver una de sus seis versiones con diferentes etiquetas frontales en los envases (control sin etiqueta, calificación de producto saludable mediante estrellas Health Star, etiquetas de advertencia, GDA, colores del semáforo, o sistema Nutri-Score). Resultados. El autorreporte de un mayor conocimiento sobre nutrición por parte de los participantes se aso- ció a un mayor conocimiento, comprensión y uso de los cuadros de información nutricional y los sistemas de etiquetado frontal, excepto en el caso del uso de las etiquetas de advertencia. Las etiquetas de advertencia fueron el sistema de etiquetado frontal más eficaz para reducir la percepción saludable del producto con respecto a la bebida de fruta azucarada, en comparación con la ausencia de etiqueta y el resto de los eti- quetados frontales. En Chile, el efecto de las GDA variaba en función de la adecuación del ingreso, mientras que en México el efecto del Nutri-Score difería según la edad. Conclusiones. Los resultados sugieren que el conocimiento, el uso, la comprensión y el efecto de las etique- tas nutricionales difieren entre los distintos grupos demográficos, de tal manera que son más favorables en las personas con mayores ingresos y conocimientos de nutrición. A pesar de esto, es probable que las etiquetas de advertencia tengan un impacto positivo sobre los conocimientos y los comportamientos relacionados con la nutrición en los adolescentes de México y Chile, con independencia de los grupos sociodemográficos de los que forman parte.

[RESUMO]. Objetivo. Analisar diferenças sociodemográficas em termos de conhecimento, compreensão, uso e efeito da rotulagem nutricional entre adolescentes mexicanos e chilenos. Métodos. Foram realizadas pesquisas on-line entre adolescentes de 10 a 17 anos ao longo de 2019 (n=2631). Os participantes relataram que conheciam, compreendiam e usavam as tabelas de informação nutricional e a rotulagem frontal de embalagens específicas de seus respectivos países (Chile: rotulagem de advertência; México: valores diários de referência). Além disso, os participantes relataram sua percepção sobre a saud- abilidade de um suco de fruta adoçado depois de ver uma de seis versões diferentes de rotulagem frontal (controle sem rótulo, Health Star Rating, rótulos de advertência, valores diários de referência, semáforo nutri- cional ou Nutri-Score) durante uma tarefa experimental. Resultados. Um maior conhecimento autodeclarado sobre nutrição foi associado a maior conhecimento, compreensão e uso de tabelas de informação nutricional e rotulagem frontal, com exceção do uso de rótu- los de advertência. Os rótulos de advertência foram o tipo de rotulagem frontal mais efetivo para reduzir a percepção de saudabilidade do suco de fruta adoçado em comparação com o controle sem rótulo e outros tipos de rotulagem frontal. No Chile, o efeito dos valores diários de referência variou de acordo com a renda, enquanto no México o Nutri-Score variou de acordo com a idade. Conclusões. Os resultados sugerem que o conhecimento, a compreensão, o uso e o impacto da rotulagem nutricional variam de acordo com fatores demográficos, favorecendo uma renda mais alta e conhecimento sobre nutrição. Apesar disso, é provável que os rótulos de advertência tenham um impacto positivo sobre o conhecimento e os comportamentos relativos à nutrição entre adolescentes mexicanos e chilenos, indepen- dentemente do grupo sociodemográfico a que pertencem.

Self-reported decreases in the purchases of selected unhealthy foods resulting from the implementation of warning labels in Mexican youth and adult population.

Background: Front-of-package nutritional warning labels (WLs) are designed to facilitate identification and selection of healthier food choices. We assessed self-reported changes in purchasing different types of unhealthy foods due to WLs in Mexico and the association between the self-reported reductions in purchases of sugary beverages and intake of water and sugar-sweetened beverages. Methods: Data came from 14-17 year old youth (n=1,696) and adults ≥18 (n=7,775) who participated in the Mexican arm of the 2020-2021 International Food Policy Study, an annual repeat cross-sectional online survey. Participants self-reported whether the WLs had influenced them to purchase less of each of ten unhealthy food categories due to WLs. Among adults, a 23-item Beverage Frequency Questionnaire was used derive past 7-day intake of water and sugary beverages analyzed to determine the relationship between self-reported reductions in purchasing sugary drinks due to the WLs. Multilevel mixed-effects logistic regression models were fitted to estimate the percentage of participants who self-reported reducing purchases within each food group, and overall. Sociodemographic characteristics associated with this reduction were investigated as well. Results: Overall, 44.8% of adults and 38.7% of youth reported buying less of unhealthy food categories due to the implementation of WL, with the largest proportion reporting decreased purchases of cola, regular and diet soda. A greater impact of WLs on the reported purchase of unhealthy foods was observed among the following socio-demographic characteristics: females, individuals who self-identified as indigenous, those who were overweight, individuals with lower educational levels, those with higher nutrition knowledge, households with children, and those with a significant role in household food purchases. In addition, adults who reported higher water intake and lower consumption of sugary beverages were more likely to report reduced purchases of sugary drinks due to the WLs. Adults who reported greater water intake and lower sugary beverages intake were significantly more likely to report buying fewer sugary drinks due to the WLs. Conclusion: Our findings suggest that implementation of WLs has reduced purchases of unhealthy foods in Mexico. These results underscore the positive impact of the labeling policy particularly in subpopulations with lower levels of education and among indigenous adults.

Effects of front-of-package caffeine and sweetener disclaimers in Mexico: cross-sectional results from the 2020 International Food Policy Study.

OBJECTIVE: Front-of-package warning labels introduced in Mexico in 2020 included disclaimers that caution against allowing children to consume products with non-sugary sweeteners and caffeine. We examined the awareness and use of the disclaimers among Mexican adults and youth 1 month after the regulation was implemented. We also investigated their impact on the perceived healthfulness of industrialised beverages designed for children. DESIGN: Data on the awareness and use of the disclaimers were analysed. Two between-subjects experiments examined the effect of a sweetener disclaimer (Experiment 1, youth and adults) or a caffeine disclaimer (Experiment 2, only adults) on the perceived healthfulness of industrialised beverages. Interactions between experimental conditions and demographic characteristics were tested. SETTING: Online survey in 2020. PARTICIPANTS: Mexican adults (≥18 years, n 2108) and youth (10-17 years, n 1790). RESULTS: Most participants (>80 %) had seen the disclaimers at least rarely, and over 60 % used them sometimes or frequently. The sweetener disclaimer led to a lower perceived healthfulness of a fruit drink (adults: 2·74 ± 1·44; youth: 2·04 ± 0·96) compared with the no-disclaimer condition (adults: 3·17 ± 1·54; youth: 2·32 ± 0·96) (t's: >4·0, P values: <0·001). This effect was larger among older adults and male youth. The caffeine disclaimer did not affect adult's perceived healthfulness of a caffeinated drink (t = 0·861, P value = 0·3894). CONCLUSIONS: There were high awareness and use of the sweeteners and caffeine disclaimers shortly after the warning labels were implemented. The sweetener disclaimer appears to be helping consumers modify their perceptions regarding industrialised beverages for children. Findings may help decision-makers improve the regulation and better target communication strategies.

Public support for food policies in Mexican adults: Findings from the International Food Policy Study, 2017-2021.

Deaths attributable to unhealthful eating underscore the need to improve dietary patterns through upstream, policy-led solutions. The approval and successful implementation of food policies is partly determined by their public acceptance. Little is known about public support for food policies in Mexico. We aimed to investigate the level of public support for 30 food policies, grouped into 5 domains, and their associated characteristics among Mexican adults. Data are from the 2017-2021 International Food Policy Study (IFPS), a cross-sectional web-based survey of adults. Differences in public support across years were estimated using linear regression models. The association between demographic characteristics and policy support was analyzed using multivariate logistic regression models. The highest mean support was for the subsidies and benefits domain, followed by the labelling and reformulation domain. The level of support varied across years and policy domains. Support was higher in 2019 compared to 2017 and 2018, and subsequently lower in 2020 and 2021 compared to previous years. Older age was associated with greater support across all domains (OR ranged from 0.002 to 0.004, p < 0.01). Female participants and those selfidentifying as indigenous showed greater support for certain policy domains, whereas higher income adequacy was associated with lower support for other policy domains. In Mexico, support for food policies varies across subpopulations. Our findings may serve as a guide to the development and promotion of food policies in Mexico, as well as to improve their feasibility and success.

Implementation of a Peer-to-Peer Support Program in a Quaternary Pediatric Medical Center.

Healthcare worker burnout is a growing epidemic associated with multiple negative outcomes. Compounding the routine stresses of clinical practice, involvement in adverse events can be emotionally devastating. Healthcare organizations have an obligation to mitigate burnout and promote engagement and resiliency. Many institutions have launched wellness initiatives, but the value of these programs is unclear. Here, we describe the implementation of a peer-to-peer support program at our quaternary pediatric medical center. This proactive program is unique in its referral process and scope and has demonstrated efficacy in mitigating the emotional impact of adverse effects. In total, our institution has trained 125 peer supporters. Since initiation, there have been a total of 2187 referrals made to the program. Data collected in 2022 from these referrals showed a 60.3% (n = 1220) response rate to the offer of support. A survey was sent to frontline clinicians from divisions with trained supporters. Of 963 respondents, 71.8% (n = 691) agreed that this program was a valuable resource, and 81.3% (n = 783) recommended peer support to be offered to those involved in adverse and stressful events. Our experience supports that the implementation of a proactive, peer-to-peer support program is both feasible and valuable.

Awareness, use and understanding of nutrition labels among children and youth from six countries: findings from the 2019 - 2020 International Food Policy Study.

BACKGROUND: Nutrition facts tables (NFTs) on pre-packaged foods are widely used but poorly understood by consumers. Several countries have implemented front-of-package labels (FOPLs) that provide simpler, easier to use nutrition information. In October 2020, Mexico revised its FOPL regulations to replace industry-based Guideline Daily Amount (GDA) FOPLs with 'Warning' FOPLs, which display stop signs on foods high in nutrients of concern, such as sugar and sodium. This study examined self-reported awareness, use, and understanding of NFTs and FOPLs among young people in six countries with different FOPLs, with an additional focus on changes before and after implementation of Mexico's FOPL warning policy. METHODS: A 'natural experiment' was conducted using 'pre-post' national surveys in Mexico and five separate comparison countries: countries with no FOPL policy (Canada and the US), countries with voluntary FOPL policies (Traffic Lights in the UK and Health Star Ratings in Australia), and one country (Chile) with mandatory FOPL 'warnings' (like Mexico). Population-based surveys were conducted with 10 to 17-year-olds in 2019 (n = 10,823) and in 2020 (n = 11,713). Logistic regressions examined within- and between-countries changes in self-reported awareness, use, and understanding of NFTs and FOPLs. RESULTS: Across countries, half to three quarters of respondents reported seeing NFTs 'often' or 'all the time', approximately one quarter reported using NFTs when deciding what to eat or buy, and one third reported NFTs were 'easy to understand', with few changes between 2019 and 2020. In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were higher than for NFTs in all countries, and compared with GDA FOPLs in Mexico (p < .001). Mandated Warning FOPLs in Mexico and Chile had substantially higher levels of awareness, use, and understanding than the voluntary Traffic Lights in the UK and Health Star Ratings in Australia (p < .001 for all). CONCLUSIONS: Mandated easy-to-understand FOPLs are associated with substantially greater levels of self-reported awareness, use and understanding at the population-level compared to NFT and GDA-based labeling systems.

Public Support for Nutrition-Related Actions by Food Companies in Australia: A Cross-Sectional Analysis of Findings from the 2020 International Food Policy Study.

Unhealthy food environments contribute to unhealthy population diets. In Australia, the government currently relies on voluntary food company actions (e.g., related to front-of-pack labelling, restricting promotion of unhealthy foods, and product formulation) as part of their efforts to improve population diets, despite evidence that such voluntary approaches are less effective than mandatory policies. This study aimed to understand public perceptions of potential food industry nutrition-related actions in Australia. An online survey was completed by 4289 Australians in 2020 as part of the International Food Policy Study. The level of public support was assessed for six different nutrition-related actions related to food labelling, food promotion, and product formulation. High levels of support were observed for all six company actions, with the highest support observed for displaying the Health Star Rating on all products (80.4%) and restricting children's exposure to online promotion of unhealthy food (76.8%). Findings suggest the Australian public is strongly supportive of food companies taking action to improve nutrition and the healthiness of food environments. However, given the limitations of the voluntary action from food companies, mandatory policy action by the Australian government is likely to be needed to ensure company practices align with public expectations.

Patterns and correlates of nutrition knowledge across five countries in the 2018 international food policy study.

BACKGROUND: Nutrition knowledge is an important determinant of diet-related behaviour; however, the use of disparate assessment tools creates challenges for comparing nutrition knowledge levels and correlates across studies, geographic contexts, and populations. Using the Food Processing Knowledge (FoodProK) score - a measure of nutrition knowledge based on consumers' ability to understand and apply the concept of food processing in a functional task - nutrition knowledge levels and associated correlates were assessed in five countries. METHODS: Adults, aged ≥18 years, were recruited through the Nielsen Consumer Insights Global Panel in Australia (n = 3997), Canada (n = 4170), Mexico (n = 4044), the United Kingdom (UK) (n = 5363), and the United States (US) (n = 4527). Respondents completed web-based surveys in November-December 2018. Functional nutrition knowledge was measured using the FoodProK score. Linear regression models examined associations between FoodProK score and sociodemographic, dietary behaviours, and knowledge-related characteristics. RESULTS: FoodProK scores (maximum, 8 points) were highest in Canada (mean: 5.1) and Australia (5.0), followed by the UK (4.8), Mexico (4.7), and the US (4.6). Health literacy and self-rated nutrition knowledge were positively associated with FoodProK scores (p < .001). FoodProK scores were higher among those who reported vegetarian/other dietary practices (p < .001); made efforts to consume less sodium, trans fats, or sugars (p < .001); ≥60 years (p = 0.002), female (p < .001), and 'majority' ethnic group respondents in their respective countries (p < .001). CONCLUSIONS: This study found differences in consumers' ability to distinguish levels of food processing for common foods, with somewhat lower levels of nutrition knowledge in countries with the highest intake of highly processed foods. Nutrition knowledge differences based on consumer characteristics highlight the need for accessible policy interventions that support uptake of healthy eating efforts across populations to avoid exacerbating nutrition-related disparities. Tools such as the FoodProK can be used to evaluate the impact of policies targeting nutrition knowledge across contexts.

Examining differences in children and adolescents' exposure to food and beverage marketing in Canada by sociodemographic characteristics: Findings from the International Food Policy Study Youth Survey, 2020.

BACKGROUND: Many countries, including Canada, are considering regulations to restrict food and beverage marketing to children. However, little evidence is available outside of the US on how marketing exposure differs across sociodemographic subgroups. OBJECTIVE: To investigate potential associations between child and adolescent sociodemographic characteristics and exposure to food and beverage marketing in Canada. METHODS: Participants (n = 3780) aged 10-17 self-reported exposure to food and beverage marketing across food categories, locations and marketing techniques. Logistic regression models tested relationships between sociodemographics (age, sex, ethnicity and income adequacy) and marketing exposure. RESULTS: Among other differences identified, 13-17 years old were more likely than 10-12 years old to report seeing unhealthy food marketing online. Girls were more likely than boys to see such marketing online and in retail settings, while boys were more likely to see it in video games. Minority ethnicities (including Indigenous youth) and respondents with lower income adequacy generally reported more exposure than White and higher income respondents, respectively. CONCLUSIONS: This study highlights important differences in marketing exposure among youth of different sociodemographic groups in Canada, including greater exposure to marketing among those most disadvantaged and emphasizes the essential need to consider food marketing across equity groups when developing restrictions on marketing to kids.

Awareness of Canada's Food Guide Among Canadian Youth.

Purpose: Canada's Food Guide (CFG) contains recommendations for healthy eating for Canadians. The objective was to examine the awareness of and learning about CFG by Canadian youth.Methods: Cross-sectional online surveys were conducted with 3,674 youth aged 10-17 years in Canada in November/December 2019. Logistic binary regression models examined awareness of CFG, learning about CFG in school, and learning about healthy eating in schools in the past 12 months.Results: Most participants reported hearing of CFG (84.5%), learning about CFG in school (86.6%), and learning about healthy eating in school (65.4%) in the past 12 months. Awareness of CFG was higher among females (OR: 1.61; 95% CI: 1.32-1.96), older youth (1.70; 1.39-2.07), and those in Atlantic Canada (OR: 1.77; 95% CI: 1.10, 2.84). Significantly fewer East/Southeast Asian, South Asian, Latino, and Middle Eastern participants reported hearing of CFG compared to white participants (p < 0.05 for all). Unstated/missing BMI (0.56; 0.45-0.71) and living in BC (OR: 0.61; 95% CI: 0.45, 0.82) were negatively associated with hearing about CFG. Similar results were observed in the models on learning about CFG and healthy eating in school.Conclusions: This study indicates discrepancies in awareness of CFG among youth by sex, ethnicity, region, and BMI which may suggest differences in use of CFG and healthy eating behaviours.

Awareness, use and understanding of nutrition labels among adults from five countries: Findings from the 2018-2020 International Food Policy Study.

Few studies have compared the effects of different front-of-package label (FOPL) systems in the 'real world'. This study assessed adults' awareness, use and understanding of nutrition facts labels (NFLs) and nationally implemented FOPLs such as Health Star Ratings (HSR), Traffic lights, and Guideline Daily Amounts (GDAs) in five countries, including before and after implementation of Mexico's warning FOPLs in 2020. Data were from the International Food Policy Study, an annual repeat cross-sectional study conducted in 2018-2020 among adults (N=64,032) in Australia, Canada, Mexico, the UK and the US. Self-reported awareness, use, and understanding of NFLs (in all five countries) and FOPLs (in Australia, Mexico, and UK) were assessed over time, between countries, and between NFLs and FOPLs. Most respondents in all countries reported seeing their country's NFLs (awareness) 'often' or 'all the time' across all three years, with one third to half of respondents using NFLs 'often' or 'all the time' (Australia: 43-45%; Canada: 47-50%; Mexico: 36-39%; UK: 32-34%; US: 47-49%), and approximately one half to two thirds finding NFLs 'easy' or 'very easy to understand' (56-57%; 67-69%; 51-54%; 48-51%; 70-71%). In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were highest among all countries with a FOPL (p<0.001), whereas awareness and use were lowest for Australia's HSR (p<0.001). In countries with FOPLs, self-reported understanding was higher for FOPLs than NFLs, except for the GDA FOPL in Mexico. Only modest changes were observed over time. Warning FOPLs were associated with greater levels of self-reported awareness, use and understanding among adults compared to NFLs and GDA-based FOPLs. FOPLs implemented on a voluntary basis, such as Australia's HSR, may be less likely to be seen and used.

Screening screeners: calculating classification indices using correlations and cut-points.

Given the recent push for universal screening, it is important to take into account how well a screener identifies children at risk for reading problems as well as how screener and sample information contribute to this classification. Picking the best cut-point for a particular sample and screening goal can be challenging given that test manuals often report classification information for a specific cut-point and sample base rate which may not generalize to other samples. By assuming a bivariate normal distribution, it is possible to calculate all of the classification information for a screener based on the correlation between the screener and outcome, the cut-point on the outcome (i.e., the base rate in the sample), and the cut-point on the screener. We provide an example with empirical data to validate these estimation procedures. This information is the basis for a free online tool that provides classification information for a given correlation between screener and outcome and cut-points on each. Results show that the correlation between screener and outcome needs to be greater than .9 (higher than observed in practice) to obtain good classification. These findings are important for researchers, administrators, and practitioners because current screeners do not meet these requirements. Since a correlation is dependent on the reliability of the measures involved, we need screeners with better reliability and/or multiple measures to increase reliability. Additionally, we demonstrate the impact of base rate on positive predictive power and discuss how gated screening can be useful in samples with low base rates.

Adults' Exposure to Unhealthy Food and Beverage Marketing: A Multi-Country Study in Australia, Canada, Mexico, the United Kingdom, and the United States.

BACKGROUND: Food marketing increases product appeal, purchasing, and consumption, using diverse strategies and locations to reach consumers. OBJECTIVES: The aim of this study was to examine differences in adults' self-reported exposure to various marketing strategies (brand and licensed characters, celebrities, and sponsorship of sports and cultural events) and locations (television, radio, and digital media) across 5 countries: Australia, Canada, Mexico, the United Kingdom, and the United States. METHODS: We analyzed cross-sectional survey data on self-reported exposure to food marketing strategies and locations collected in 2018 by the International Food Policy Study. Participants (n = 21,678) aged ≥18 years completed an online survey. Exposures to unhealthy food marketing strategies and locations in the prior 30 days were self-reported. Regression models examined differences in marketing exposure and locations across countries. RESULTS: The average number of unhealthy food marketing strategies to which participants reported being exposed ranged from 0.5 in the United Kingdom to 2.3 in Mexico. Self-reported exposure to strategies across all countries was highest for brand characters (32%), followed by licensed characters (22%). In total, the reported mean exposure of marketing locations was 1.6 in the prior month. Television was the most prevalent location (44%), followed by digital marketing (32%). Adjusted models indicated that the odds of reporting exposure to marketing strategies and marketing locations were higher for Mexico compared to the rest of the countries. CONCLUSIONS: Adults report a variety of exposures to unhealthy food marketing in all countries, but exposure was highest in Mexico. Special attention should be paid to regulating marketing strategies, such as brand characters and licensed characters, and locations, such as television and digital marketing.

Adolescents' media usage and self-reported exposure to advertising across six countries: implications for less healthy food and beverage marketing.

OBJECTIVES: The study objectives were to examine: (1) adolescents' media viewing habits, (2) associations with media viewing and self-reported exposure to unhealthy food and beverage advertising and (3) differences in trends among younger and older adolescents in six high and upper middle-income countries. DESIGN: Repeat cross-sectional online survey. SETTING: Australia, Canada, Chile, Mexico, the United Kingdom (UK) and the United States of America (USA). PARTICIPANTS: Respondents to the International Food Policy Study who provided information on all variables of interest in November-December 2019 aged 10-17 years (n=9171). OUTCOME MEASURES: Self-reported exposure to screen-based media (screen time by media channel), use of social media platforms and self-reported location and frequency of exposure to unhealthy food and beverage advertising. RESULTS: The average amount of time spent in front of various screens ranged from 7.6 hours to 10.2 hours across countries per week day, which may include possible viewing of multiple media channels simultaneously. Overall, Instagram was the most popular social media platform (52%-68% by country), followed by Facebook (42%-79%) and Snapchat (28%-52%). The percentage of respondents who self-reported having seen unhealthy food advertisements in the past 30 days was highest on television (43%-69%), followed by digital media (27%-60%) and gaming applications (10%-17%). Self-reported daily exposure to advertising varied between countries for sugary drinks (10%-43%) and fast food (19%-44%) and was positively associated with self-reported screen time. Self-reported exposure to screen-based media and social media platforms differed by sociodemographic characteristics and was higher among older adolescents than younger adolescents. CONCLUSIONS: The important amount of time spent on screen-based media reported by adolescents and large percentage of adolescents reporting social media usage, coupled with high rates of self-reported advertising exposure, support the need for policies to restrict marketing of unhealthy food and beverages appealing to adolescents on screen-based media.