Development and application of the TFA macrosimulation model: a case study of modelling the impact of trans fatty acid (TFA) elimination policies in Brazil.

INTRODUCTION: The consumption of trans-fatty acids (TFA) is directly associated with cardiovascular disease risk and is responsible for a significant health burden globally. The policy strategies for reducing TFA include limiting their content in foods and eliminating partially hydrogenated oils (PHO) in the market. This study aims to describe a comparative risk assessment macrosimulation model and to apply this tool to estimate the potential reductions in CVD mortality gained from the compared scenarios of TFA reduction/elimination in Brazil. METHODOLOGY: We developed and implemented a comparative risk assessment macrosimulation model estimates the potential CVD mortality reduction (coronary heart disease - CHD- and stroke) if TFA intake is reduced in diets. The TFA macrosimulation model estimates the change in the annual number of NCD deaths between baseline with current TFA consumption levels and alternate or counterfactual scenarios, such as considering different limits to TFA content in foods and the elimination of PHO in Brazil in 2018. The model incorporated additional outputs related to other impacts of TFA reduction on DPP, such as Years of Life Lost, Years of Productive Life Lost, and related economic impacts of premature deaths. RESULTS: In 2018, a 2% limit for TFA in the oils and fats and a 5% limit of TFAs for other foods could avert or postpone approximately 2,000 deaths (UI 95% 1,899-2,142) and save US$ 32.1 million savings in productivity losses to the economy associated to premature deaths. An intermediate scenario, applying a 2% limit of TFA in all food products In Brazil could prevent or postpone approximately 6,300 deaths (UI 95% 5,925-6,684) and the premature deaths prevented would represent US$ 100.2 million in economic saving. Finally, by banning PHO, approximately 10,500 deaths could be prevented or postponed (UI 95% 9,963 - 10,909), corresponding to US$ 166.7 million in savings to the economy because of premature deaths. CONCLUSION: The TFA macrosimulation model can efficiently compare different policy scenarios for trans fats reduction policies at the country level and proves that the elimination of PHOs from the food market in Brazil may significantly reduce the health burden of trans fatty acids in the country compared to other policy options. The model also represents a useful public health tool to support TFA reduction and elimination policies in other countries.

[Nutrient profile of food products exempted from the application of front-ofpackage warnings during the first stage of the Healthy Eating Law in Peru: case studyPerfil nutricional de produtos alimentícios isentos da aplicação de advertências na parte frontal da embalagem durante a primeira etapa da Lei de Alimentação Saudável no Peru: estudo de caso]. / Perfil de nutrientes de productos alimentarios eximidos de la aplicación de advertencias en el frente del envase durante la primera etapa de la Ley de alimentación saludable en Perú: estudio de caso.

OBJECTIVE: Identify the nutritional profile of food products exempted from presenting one or more front-ofpackage nutritional warnings during the first stage of Law 30,021 on the Promotion of Healthy Eating for Children and Adolescents in Peru. METHODS: Data were collected on 188 products from points of sale in the city of Lima. The convenience sample included products that until September 17, 2021 were exempted by the legislation from presenting any of the warning labels for sugar, sodium, or saturated fats. An assessment was made of the proportion of products that would be required to apply one or more warning labels when the second stage of the legislation takes effect. It was also calculated how many products exempted from the application of warning labels contain excess sugar, sodium, or saturated fats, according to the criteria of the Pan American Health Organization (PAHO). RESULTS: 76.1% of the products exceeded at least one of the thresholds for sugar, sodium, or saturated fats that entered in force in September 2021. The proportion of products that the law exempts from warnings and that contain excess sugar, sodium, or saturated fats according to PAHO will be 4.2, 3.4, and 2.3 times lower, respectively, in the second stage. CONCLUSION: During the first stage of the law's entry into force, 58%, 42%, and 28.2% of the products exempted from the presentation of warning labels contained excess sugar, saturated fats, or sodium, respectively, according to PAHO.

OBJETIVO: Identificar o perfil nutricional de produtos alimentícios isentos da aplicação de um ou mais selos de advertência nutricional na parte frontal da embalagem durante a primeira etapa de vigência da Lei 30021 de Promoção da Alimentação Saudável para Crianças e Adolescentes do Peru. MÉTODOS: Foram coletados dados de 188 produtos em pontos de venda da cidade de Lima. A amostra por conveniência incluiu produtos que, até 17 de setembro de 2021, estavam isentos, pela legislação, de apresentar quaisquer advertências para açúcar, sódio ou gorduras saturadas. Foi avaliada a proporção de produtos que seriam obrigados a apresentar um ou mais selos de advertência quando a segunda etapa da legislação entrasse em vigor. Verificou-se quantos produtos isentos da apresentação de advertências, pela legislação, contêm excesso de açúcar, sódio ou gorduras saturadas, segundo os critérios da Organização Pan-Americana da Saúde (OPAS). RESULTADOS: 76,1% dos produtos ultrapassaram pelo menos um dos limiares para açúcar, sódio ou gorduras saturadas vigentes a partir de setembro de 2021. A proporção de produtos isentos de apresentar advertências, pela legislação, e que contêm excesso de açúcar, sódio ou gorduras saturadas, segundo a OPAS, será 4,2, 3,4 e 2,3 vezes menor, respectivamente, a partir da segunda etapa. CONCLUSÃO: Durante a primeira etapa de vigência da lei, 58%, 42% e 28,2% dos produtos isentos da apresentação de advertências continham excesso de açúcar, gorduras saturadas ou sódio, respectivamente, segundo a OPAS.

Perfil de nutrientes de productos alimentarios eximidos de la aplicación de advertencias en el frente del envase durante la primera etapa de la Ley de alimentación saludable en Perú: estudio de caso

[RESUMEN]. Objetivo. Identificar el perfil nutricional de productos alimentarios eximidos de presentar uno o más sellos de advertencia nutricional en el frente del envase durante la primera etapa de vigencia de la Ley 30021 de Promoción de la Alimentación Saludable para Niños, Niñas y Adolescentes de Perú. Métodos. Se recolectaron datos de 188 productos desde puntos de venta de la ciudad de Lima. La muestra por conveniencia incluyó productos que hasta el 17 de septiembre de 2021 estaban eximidos por la legislación de presentar alguna de las advertencias para el azúcar, el sodio o las grasas saturadas. Se evaluó la proporción de productos que estarían obligados a aplicar uno o más sellos de advertencia a partir de la entrada en vigencia de la segunda etapa de la legislación. Se verificó cuántos productos eximidos de la aplicación de advertencias por la legislación contienen exceso de azúcar, sodio o grasas saturadas según los criterios de la Organización Panamericana de la Salud (OPS). Resultados. El 76,1% de los productos superaba al menos uno de los umbrales para el azúcar, el sodio o las grasas saturadas vigentes a partir de septiembre de 2021. La proporción de productos eximidos de presentar advertencias por la legislación y que contienen exceso de azúcar, sodio o grasas saturadas según la OPS será 4,2, 3,4 y 2,3 veces menor, respectivamente, a partir de la segunda etapa. Conclusión. Durante la primera etapa de vigencia de la ley, 58%, 42% y 28,2% de los productos eximidos de la presentación de advertencias contenían exceso de azúcar, grasas saturadas o sodio, respectivamente, según la OPS.

[ABSTRACT]. Objective. Identify the nutritional profile of food products exempted from presenting one or more front-of-package nutritional warnings during the first stage of Law 30,021 on the Promotion of Healthy Eating for Children and Adolescents in Peru. Methods. Data were collected on 188 products from points of sale in the city of Lima. The convenience sample included products that until September 17, 2021 were exempted by the legislation from presenting any of the warning labels for sugar, sodium, or saturated fats. An assessment was made of the proportion of products that would be required to apply one or more warning labels when the second stage of the legislation takes effect. It was also calculated how many products exempted from the application of warning labels contain excess sugar, sodium, or saturated fats, according to the criteria of the Pan American Health Organization (PAHO). Results. 76.1% of the products exceeded at least one of the thresholds for sugar, sodium, or saturated fats that entered in force in September 2021. The proportion of products that the law exempts from warnings and that contain excess sugar, sodium, or saturated fats according to PAHO will be 4.2, 3.4, and 2.3 times lower, respectively, in the second stage. Conclusion: During the first stage of the law's entry into force, 58%, 42%, and 28.2% of the products exempted from the presentation of warning labels contained excess sugar, saturated fats, or sodium, respectively, according to PAHO.

[RESUMO]. Objetivo. Identificar o perfil nutricional de produtos alimentícios isentos da aplicação de um ou mais selos de advertência nutricional na parte frontal da embalagem durante a primeira etapa de vigência da Lei 30021 de Promoção da Alimentação Saudável para Crianças e Adolescentes do Peru. Métodos. Foram coletados dados de 188 produtos em pontos de venda da cidade de Lima. A amostra por conveniência incluiu produtos que, até 17 de setembro de 2021, estavam isentos, pela legislação, de apresentar quaisquer advertências para açúcar, sódio ou gorduras saturadas. Foi avaliada a proporção de produtos que seriam obrigados a apresentar um ou mais selos de advertência quando a segunda etapa da legislação entrasse em vigor. Verificou-se quantos produtos isentos da apresentação de advertências, pela legislação, contêm excesso de açúcar, sódio ou gorduras saturadas, segundo os critérios da Organização Pan-Americana da Saúde (OPAS). Resultados. 76,1% dos produtos ultrapassaram pelo menos um dos limiares para açúcar, sódio ou gorduras saturadas vigentes a partir de setembro de 2021. A proporção de produtos isentos de apresentar advertências, pela legislação, e que contêm excesso de açúcar, sódio ou gorduras saturadas, segundo a OPAS, será 4,2, 3,4 e 2,3 vezes menor, respectivamente, a partir da segunda etapa. Conclusão. Durante a primeira etapa de vigência da lei, 58%, 42% e 28,2% dos produtos isentos da apresentação de advertências continham excesso de açúcar, gorduras saturadas ou sódio, respectivamente, segundo a OPAS.

An Assessment of Government Capacity Building to Restrict the Marketing of Unhealthy Food and Non-Alcoholic Beverage Products to Children in the Region of the Americas.

The Pan American Health Organization (PAHO) Strategic Plan 2020-2025 committed to reduce children's consumption of energy-dense nutrient-poor food and beverage products high in fat, sugar and salt (HFSS) and promote healthy eating patterns to reduce malnutrition in all forms. This paper describes the capacity-building needs in PAHO's Member States to restrict the marketing of HFSS food and beverages to children. We asked Ministries of Health officials or national institutes/departmental representatives (n = 35) to complete a 28-item web-based survey (January to July 2020). Capacity-building needs were assessed using an adapted version of the World Health Organization's government capacity-building framework with three modules: public health infrastructure, policies and information systems. Notable achievements for the PAHO's Plan of Action were identified. State representatives reported strong infrastructure and information systems; however, policy improvements are needed to increase comprehensive national responses. These include using a constitutional health and human rights approach within the policies, policies that document conflict of interest from non-state actors, and strengthening regulatory oversight for digital media platforms. These findings provide baseline data and we suggest priorities for further action to strengthen national governments' capacity-building and to accelerate the development, implementation, and monitoring systems to restrict the marketing of HFSS food and non-alcoholic beverages to children in the region of the Americas.

Towards Preventing and Managing Conflict of Interest in Nutrition Policy? An Analysis of Submissions to a Consultation on a Draft WHO Tool.

BACKGROUND: With multi-stakeholder approaches central to efforts to address global health challenges, debates around conflict of interest (COI) are increasingly prominent. The World Health Organization (WHO) recently developed a proposed tool to support member states in preventing and managing COI in nutrition policy. We analysed responses to an online consultation to explore how actors from across sectors understand COI and the ways in which they use this concept to frame the terms of commercial sector engagement in health governance. METHODS: Submissions from 44 Member States, international organisations, non-governmental organizations (NGOs), academic institutions and commercial sector actors were coded using a thematic framework informed by framing theory. Respondents' orientation to the tool aligned with two broad frames, ie, a 'collaboration and partnership' frame that endorsed multi-stakeholder approaches and a 'restricted engagement' frame that highlighted core tensions between public health and food industry actors. RESULTS: Responses to the WHO tool reflected contrasting conceptualisations of COI and implications for health governance. While most Member States, NGOs, and academic institutions strongly supported the tool, commercial sector organisations depicted it as inappropriate, unworkable and incompatible with the Sustainable Development Goals (SGDs). Commercial sector respondents advanced a narrow, individual-level understanding of COI, seen as adequately addressed by existing mechanisms for disclosure, and viewed the WHO tool as unduly restricting scope for private sector engagement in nutrition policy. In contrast, health-focused NGOs and several Member States drew on a more expansive understanding of COI that recognised scope for wider tensions between public health goals and commercial interests and associated governance challenges. These submissions mostly welcomed the tool as an innovative approach to preventing and managing such conflicts, although some NGOs sought broader exclusion of corporate actors from policy engagement. CONCLUSION: Submissions on the WHO tool illustrate how contrasting positions on COI are central to understanding broader debates in nutrition policy and across global health governance. Effective health governance requires greater understanding of how COI can be conceptualised and managed amid high levels of contestation on policy engagement with commercial sector actors. This requires both ongoing innovation in governance tools and more extensive conceptual and empirical research.

Effects of Menu Labeling Policies on Transnational Restaurant Chains to Promote a Healthy Diet: A Scoping Review to Inform Policy and Research.

There is insufficient evidence that restaurant menu labeling policies are cost-effective strategies to reduce obesity and diet-related non-communicable diseases (NCDs). Evidence suggests that menu labeling has a modest effect on calories purchased and consumed. No review has been published on the effect of menu labeling policies on transnational restaurant chains globally. This study conducted a two-step scoping review to map and describe the effect of restaurant menu labeling policies on menu reformulation. First, we identified national, state, and municipal menu labeling policies in countries from global databases. Second, we searched four databases (i.e., PubMed, CINHAL/EBSCO, Web of Science, and Google Scholar) for peer-reviewed studies and gray-literature sources in English and Spanish (2000-2020). Step 1 identified three voluntary and eight mandatory menu labeling policies primarily for energy disclosures for 11 upper-middle and high-income countries, but none for low- or middle-income countries. Step 2 identified 15 of 577 studies that met the inclusion criteria. The analysis showed reductions in energy for newly introduced menu items only in the United States. We suggesr actions for governments, civil society organizations, and the restaurant businesses to develop, implement, and evaluate comprehensive menu labeling policies to determine whether these may reduce obesity and NCD risks worldwide.

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.