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.

A high density of ultra-processed food, alcohol & tobacco retail stores, and social inequalities are associated with higher mortality rates of non-communicable diseases in Mexican adults: 2005 to 2021.

BACKGROUND: Non-communicable diseases (NCDs) are the leading causes of mortality in Mexico. Factors contributing to NCDs-related deaths may vary across small geographic areas such as municipalities. We aimed to predict municipal-level factors associated with NCD mortality in Mexican adults from 2005 to 2021 using the small-area analysis (SSA) approach. METHODS: We gathered data on population sociodemographic, access to healthcare services, and mortality records at the municipal-level from census and public institutions from 2005 to 2021. We identified municipal predictors of NCDs mortality rates (MR) using negative binomial regression models. RESULTS: A total of 584,052 observations of Mexican adults were analyzed. The national expected NCDs MR per 100,000 inhabitants was 210.7 (95%CI: 196.1-226.7) in 2005 and increased to 322.4 (95%CI: 300.3-346.4) by 2021. Predictors of NCDs mortality (quintile 5 vs. quintile 1) included; indigeneity (IRR = 1.15, 95%CI: 1.12-1.19), poverty (IRR = 1.14, 95%CI: 1.13-1.15), affiliation with Mexican Social Security Institute (IRR = 1.11, 95%CI: 1.09-1.14), households with television (IRR = 1.14, 95%CI: 1.11-1.17), and high density of ultra-processed food, alcohol & tobacco retail stores (IRR = 1.15, 95%CI: 1.13-1.17). The greatest increases in MR were observed in municipalities from Oaxaca (>200% increments). CONCLUSION: There was an overall increase in NCDs MR from 2005 to 2021, with a significant geographic variation among Mexican municipalities. The results of this study highlight the importance of identifying priority areas in the country that urgently require public policies focused on local factors associated with deaths from NCDs, such as the regulation of the ultra-processed food, alcohol & tobacco retail stores, and efforts to reduce social inequalities.

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.

Depression, Anxiety, and Stress Scale: Factor validation during the first COVID-19 lockdown in Mexico

Introduction: Globally, mental health problems have affected nearly 1 billion people and approximately 1 in 10 Mexicans. The detection and surveillance of depression, anxiety, and stress in Mexico requires more reliable and valid instruments. Objective: To determine the factor validity and internal consistency of the Depression, Anxiety, and Stress Scale-21 items (DASS-21) in a non-probabilistic national sample of Mexican adults. Method: Cross-sectional study by means of an online survey of 1 613 Mexican adults aged 18 years and older. The Spanish version of the DASS-21 was used, which evaluates the presence of depressive symptoms, anxiety, and stress. Factor validity was determined by comparing different confirmatory factor analysis models: one-dimensional, three factors (correlated and non-correlated), second order, and bifactor. Results: The application of the bifactor model to the DASS 21, supports its validity for identifying the presence of symptoms of depression, anxiety, and stress, as well as an altered general emotional state in a sample of Mexican adults. Conclusions: The DASS-21 is a theoretically robust instrument useful for research and clinical practice.

Introducción: A nivel global los problemas de salud mental han alcanzado a cerca de 1 billón de personas y aproximadamente a uno de cada diez mexicanos. La detección y vigilancia de depresión, ansiedad y estrés en México demandan instrumentos más confiables y válidos. Objetivo: Determinar la validez factorial y consistencia interna de la Escala de Depresión, Ansiedad y Estrés (DASS-21) en una muestra nacional no probabilística de adultos mexicanos. Método: Estudio transversal por medio de una encuesta en línea entre 1 613 adultos me-xicanos de 18 años o más. Se utilizó la versión en español del DASS-21 que evalúa la presencia de síntomas depresivos, ansiedad y estrés. La validez factorial se determinó mediante la comparación de distintos modelos del análisis factorial confirmatorio: unidimensional; tres factores (correlacionados y no), de segundo orden, y bifactor. Resultados: La aplicación del modelo bifactor al DASS-21 sustenta su validez para identificar la presencia de síntomas de depresión, ansiedad y estrés, así como de un estado general emocional alterado en una muestra de adultos mexicanos. Conclusiones: El DASS-21 es un instrumento teóricamente robusto útil para la investigación y la práctica clínica.

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.

Hacia el diseño de Vida Saludable, un nuevo programa de estudios para la educación básica en México.

OBJETIVO: Describir el proceso de diseño de Vida Saludable, un nuevo programa de estudios para la educación básica en México. Material y métodos. Se conformó un equipo de trabajo entre especialistas en salud y la Secretaría de Educación Pública. Se establecieron las bases científicas de Vida Saludable, se seleccionaron y evaluaron materiales para Vida Saludable, y se revisaron contenidos vigentes de salud incluidos en otras asignaturas. RESULTADOS: Alimentación, actividad física e higiene y limpieza fueron definidos como los tres ejes temáticos para Vida Saludable. Se aprobaron 3 de 228 insumos para usarse en Vida Saludable y 71.7% de los con-tenidos vigentes en educación básica sobre salud requieren ediciones. CONCLUSIONES: Vida Saludable es un parteaguas hacia la alfabetización en materia de salud en educación básica en México, que se alinea con la agenda global para preservar la salud humana y planetaria.

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.

Perception and Understanding of Guideline Daily Amount and Warning Labeling among Mexican Adults during the Law Modification Period.

Front-of-pack labeling (FOPL) is a tool that enables consumers to compare foods and select healthier options. Due to low understanding of the Guideline Daily Amount (GDA) labeling among Mexicans, a law was implemented in October 2020 that modified the FOPL to a warning labeling (WL) system. The purpose of this study was to compare the perception and understanding of GDA and WL during the law modification period. We conducted a panel design with two measurements: (1) using GDA label (September 2020) and (2) using WL (October-November). We estimated differences in GDA vs. WL through multinomial logistic regression models and changes were measured through predictive margin contrasts and Wald tests. When comparing the same products with different labels, the participants reported that it would be unlikely/very unlikely that they would consume products packaged with the WL (81.5%; 95%CI: 79.2, 83.8) compared to those with GDA (24.2%; 95%CI: 21.7, 26.7). Consumers' perception was that the quantities of packaged products they should consume was small or very small when they used the WL (93.8%; 95%CI: 92.4, 95.5) compared to GDA (41.6%; 95%CI: 39.7, 44.6). When comparing food groups, participants were more confident about choosing healthy products when using the WL compared to the GDA. During the implementation of WL in Mexico, the studied population had a better perception and understanding of less healthy packaged foods when using WL, compared to the GDA label.

Objective understanding of front of pack warning labels among Mexican children of public elementary schools. A randomized experiment.

BACKGROUND: Warning Labels (WL) highlight excessive amounts of critical nutrients in order to discourage consumption of unhealthful packaged food products. This study aimed to evaluate among Mexican school children, the objective understanding of traditional and numeric WL (aimed at small products) considered by the Mexican regulation, and whether cartoon characters influenced the understanding of WL. We also tested some communication strategies to facilitate the correct use of the WL. METHODS: We carried out a randomized experiment in July 2019 in public elementary schools from Morelos, Mexico. Participants aged 6-13 years, were randomly assigned to one of four groups: 1) Nutrient Facts Panel (NF) (n = 120), 2) Nutrient Facts Panel with cartoon characters (NF + C) (n = 83), considered the control groups, 3) Warning Labels (WL) (n = 109), and 4) Warning Labels with cartoon characters (WL + C) (n = 96). After allocation, children assigned to both WL groups (WL or WL + C), were randomly required to watch two posters simultaneously or a video explaining how to correctly interpret WLs. Logistic regression models adjusted by sex, age and cluster (school) were fitted. RESULTS: The percentage of children correctly choosing the healthiest or the unhealthiest option was higher for WL groups (56.8, 95%CI; 40.8-72.8) compared to NF groups (24.3, 95%CI; 20.4-28.3, p < 0.05). The understanding of traditional WL was higher (28.7, 95%CI: 22.8-35.4) than the numeric WL (19, 95%CI: 14.2-25.0, p < 0.05). But, correct answers for identifying healthy and unhealthy products were higher for numeric WL than for NF groups. Cartoon characters reduced the percentage of correct answers for choosing unhealthiest products (WL + C: 48.9, 95%CI: 25.6-72.4 vs WL: 58.7, 95%CI: 36.4-81.1, p < 0.05). The video was 2.23 times more helpful than the posters to the correct interpretation of the WL (p < 0.05). CONCLUSIONS: In scholar Mexican children, traditional and numeric WL were useful to identify healthier and unhealthier packaged products in comparison to NF, suggesting that both WL formats may effectively communicate the excessive content of nutrients of concern among children. Cartoon characters may reduce the objective understanding of the WL, underscoring the need to regulate advertising directed to children along with the implementation of front-of-pack labeling.

Reduction in the Treatment Gap for Breast Cancer in Mexico under Seguro Popular, 2007 to 2016.

As Mexico's government restructures the health system, a comprehensive assessment of Seguro Popular's Fund for Protection against Catastrophic Expenses (FPGC) can help inform decision makers to improve breast cancer outcomes and health system performance. This study aimed to estimate the treatment gap for breast cancer patients treated under FPGC and assess changes in this gap between 2007 (when coverage started for breast cancer treatment) and 2016. We used a nationwide administrative claims database for patients whose breast cancer treatment was financed by FPGC in this period (56,847 women), Global Burden of Disease breast cancer incidence estimates, and other databases to estimate the population not covered by social security. We compared the observed number of patients who received treatment under FPGC to the expected number of breast cancer cases among women not covered by social security to estimate the treatment gap. Nationwide, the treatment gap was reduced by more than half: from 0.71, 95% CI (0.69, 0.73) in 2007 to 0.15, 95%CI (0.09, 0.22) in 2016. Reductions were observed across all states . This is the first study to assess the treatment gap for breast cancer patients covered under Seguro Popular. Expanded financing through FPGC sharply increased access to treatment for breast cancer. This was an important step toward improving breast cancer care, but high mortality remains a problem in Mexico. Increased access to treatment needs to be coupled with effective interventions to assure earlier cancer diagnosis and earlier initiation of high-quality treatment.

Perceived Availability of Healthy and Unhealthy Foods in the Community, Work, and Higher Education Settings across Five Countries: Findings from the International Food Policy Study 2018.

BACKGROUND: Food environments play a key role in dietary behavior and vary due to different contexts, regulations, and policies. OBJECTIVES: This study aimed to characterize the perceived availability of healthy and unhealthy foods in 3 different settings in 5 countries. METHODS: We analyzed data from the 2018 International Food Policy Study, a cross-sectional survey of adults (18-100 y, n = 22,824) from Australia, Canada, Mexico, the United Kingdom (UK), and the USA. Perceived availability of unhealthy (junk food and sugary drinks) and healthy foods (fruit or vegetables, healthy snacks, and water) in the community, workplace, and university settings were measured (i.e. not available, available for purchase, or available for free). Differences in perceived availability across countries were tested using adjusted multinomial logistic regression models. RESULTS: Across countries, unhealthy foods were perceived as highly available in all settings; in university and work settings unhealthy foods were perceived as more available than healthy foods. Australia and Canada had the highest perceived availability of unhealthy foods (range 87.5-90.6% between categories), and the UK had the highest perceived availability of fruits and vegetables for purchase (89.3%) in the community. In university and work settings, Mexico had the highest perceived availability for purchase of unhealthy foods (range 69.9-84.9%). The USA and the UK had the highest perceived availability of fruits and vegetables for purchase (65.3-66.3%) or for free (21.2-22.8%) in the university. In the workplace, the UK had high perceived availability of fruits and vegetables for purchase (40.2%) or for free (18.5%), and the USA had the highest perceived availability of junk food for free (17.3%). CONCLUSIONS: Across countries, unhealthy foods were perceived as highly available in all settings. Variability between countries may reflect differences in policies and regulations. Results underscore the need for the continuation and improvement of policy efforts to generate healthier food environments.

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.

Evaluation of the Mexican warning label nutrient profile on food products marketed in Mexico in 2016 and 2017: A cross-sectional analysis.

BACKGROUND: Different nutrient profiles (NPs) have been developed in Latin America to assess the nutritional quality of packaged food products. Recently, the Mexican NP was developed as part of the new warning label regulation implemented in 2020, considering 5 warning octagons (calories, sugar, sodium, saturated fats, and trans fats) and 2 warning rectangles (caffeine and non-nutritive sweeteners). The objective of this cross-sectional study was to evaluate the Mexican NP and other NPs proposed or used in Latin America against the Pan American Health Organization (PAHO) model. METHODS AND FINDINGS: Nutrition content data of 38,872 packaged food products available in the Mexican market were collected in 2016 and 2017. The evaluation of the Mexican NP, including its 3 implementation phases of increasing stringency (2020, 2023, and 2025), was conducted by comparing the percentage of products classified as "healthy" (without warnings) or "less healthy" (with 1 or more warnings), as well as the number and type of warnings assigned to food products, against the PAHO NP. Using the calibration method, we compared the classifications produced by the PAHO model against those produced by the NP models of Ecuador, Chile (3 phases), Peru (2 phases), Uruguay, and Brazil. Kappa coefficients and Pearson correlations were estimated, and proportion tests were performed. We found that the 3 implementation phases of the Mexican NP had near to perfect agreement in the classification of healthy foods (Mexico NP models: 19.1% to 23.8%; PAHO model: 19.7%) and a strong correlation (>91.9%) with the PAHO model. Other NPs with high agreement with the PAHO model were the Ecuador (89.8%), Uruguay (82.5%), Chile Phase 3 (82.3%), and Peru Phase 2 (84.2%) NPs. In contrast, the Peru Phase 1, Brazil, and Chile Phase 1 NP models had the highest percentage of foods classified as healthy (49.2%, 47.1%, and 46.5%, respectively) and the lowest agreement with the PAHO model (69.9%, 69.3%, and 73%, respectively). Study limitations include that warnings considered by the Mexican NP models were evaluated as if all the warnings were octagon seals, while 2 out of the 7 were rectangular warnings (caffeine and non-nutritive sweeteners), and that our data are limited by the quality of the information reported in the list of ingredients and the nutrition facts table of the products. CONCLUSIONS: The 3 implementation phases of the Mexican NP were useful to identify healthy food products. In contrast, the Peru Phase 1, Brazil, and Chile Phase 1 NP models may have limited usefulness for the classification of foods according to the content of ingredients of concern. The results of this study may inform countries seeking to adapt and evaluate existing NP models for use in population-specific applications.

Changes Among Mexican Adults in Physical Activity and Screen Time During the COVID-19 Lockdown Period and Association With Symptoms of Depression, Anxiety, and Stress, May 29-July 31, 2020.

INTRODUCTION: We examined the association between changes in physical activity and leisure screen time and mental health outcomes during the early stages of the recommended COVID-19 stay-at-home period in a national sample of Mexican adults aged 18 years or older. METHODS: A cross-sectional online survey conducted from May 29 through July 31, 2020, among 1,148 participants, reported time spent in physical activity and leisure screen time during a typical week before (retrospectively) and a week during the COVID-19 stay-at-home period. Mental health outcomes during this period were measured with the Depression, Anxiety and Stress Scale (DASS-21). Linear regression models were used to estimate the associations between changes in physical activity and leisure screen time and mental health outcomes by socioeconomic status (SES), adjusting for potential confounders. RESULTS: Compared with maintaining high levels of physical activity or increasing them, decreasing physical activity was associated with higher stress scores overall, and among people of high SES, with higher scores for DASS-21, depression, and anxiety. Among participants of low and medium SES only, increasing screen time was associated with higher DASS-21, depression, anxiety, and stress scores compared with maintaining low or decreasing leisure screen time. CONCLUSION: Results highlight the potential protective effect of physical activity and limited leisure screen time on mental health in the context of COVID-19 stay-at-home restrictions.

Impact of front-of-pack labels on the perceived healthfulness of a sweetened fruit drink: a randomised experiment in five countries.

OBJECTIVE: Front-of-pack (FOP) nutrition labelling is a globally recommended strategy to encourage healthier food choices. We evaluated the effect of FOP labels on the perceived healthfulness of a sweetened fruit drink in an international sample of adult consumers. DESIGN: Six-arm randomised controlled experiment to examine the impact of FOP labels (no label control, Guideline Daily Amounts (GDA), Multiple Traffic Lights, the Health Star Ratings (HSR), Health Warning Labels, and 'High-in' Warning Labels (HIWL)) on the perceived healthfulness of the drink. Linear regression models by country examined healthfulness perceptions on FOP nutrition labels, testing for interactions by demographic characteristics. SETTING: Online survey in 2018 among participants from Australia, Canada, Mexico, United Kingdom (UK) and United States. PARTICIPANTS: Adults (≥18 years, n 22 140). RESULTS: Compared with control, HIWL had the greatest impact in lowering perceived healthfulness (ß from -0·62 to -1·71) across all countries. The HIWL and the HSR had a similar effect in Australia. Other labels were effective in decreasing the perceived healthfulness of the drink within some countries only, but to a lower extent. The GDA did not reduce perceived healthfulness in most countries. In the UK, the effect of HIWL differed by age group, with greater impact among older participants (> 40 years). There were no other variations across key demographic characteristics. CONCLUSIONS: HIWL, which communicates clear, non-quantitative messages about high levels of nutrients of concern, demonstrated the greatest efficacy to decrease the perceived healthfulness of a sweetened fruit drink across countries. This effect was similar across demographic characteristics.

Municipality-Level Predictors of COVID-19 Mortality in Mexico: A Cautionary Tale.

OBJECTIVE: Local characteristics of populations have been associated with coronavirus disease 2019 (COVID-19) outcomes. We analyze the municipality-level factors associated with a high COVID-19 mortality rate (MR) of in Mexico. METHODS: We retrieved information from cumulative confirmed symptomatic cases and deaths from COVID-19 as of June 20, 2020, and data from most recent census and surveys of Mexico. A negative binomial regression model was adjusted, the dependent variable was the number of COVID-19 deaths, and the independent variables were the quintiles of the distribution of sociodemographic and health characteristics among the 2457 municipalities of Mexico. RESULTS: Factors associated with high MRs from COVID-19, relative to quintile 1, were diabetes and obesity prevalence, diabetes mortality rate, indigenous population, economically active population, density of economic units that operate essential activities, and population density. Among factors inversely associated with lower MRs from COVID-19 were high hypertension prevalence and houses without sewage drainage. We identified 1351 municipalities without confirmed COVID-19 deaths, of which, 202 had high and 82 very high expected COVID-19 mortality (mean = 8 and 13.8 deaths per 100,000, respectively). CONCLUSION: This study identified municipalities of Mexico that could lead to a high mortality scenario later in the epidemic and warns against premature easing of mobility restrictions and to reinforce strategies of prevention and control of outbreaks in communities vulnerable to COVID-19.

Association between Predictors of Vitamin D Serum Levels and Risk of Retinoblastoma in Children: A Case-Control Study.

BACKGROUND: vitamin D (VD) may be a protective factor for retinoblastoma, though no temporal association has been reported during pregnancy or the child's first year of life. Serum VD concentrations are determined by both distal (DF) and proximal factors (PF). OBJECTIVE: To identify if DF and PF can predict VD insufficiency (VDI) and VD deficiency (VDD) in women of childbearing age; and to test whether maternal exposure to DF and PF during pregnancy and a child's exposure during the first 11.9 months postpartum are associated with sporadic retinoblastoma (SRb) in children. METHODS: This is a secondary analysis of data from the Epidemiology of SRb in Mexico (EpiRbMx) study and the National Health and Nutrition Survey 2018-2019 (ENSANUT 2018-2019, for its acronym in Spanish). The association of DF and PF with VDD or VDI was estimated using ENSANUT 2018-2019, and the association of DF and PF with SRb using EpiRbMx. All were estimated using logistic regression, with comparable samples selected from ENSANUT 2018-2019 and EpiRbMx. RESULTS: Altitude, latitude and obesity predicted VDI and VDD in ENSANUT women. In EpiRbMx, residence in a rural location during pregnancy increased the risk of SRb. For children, rural residence and latitude increased the risk of SRb, while the number of days exposed to the spring-summer season during months 6 to 11.9 of life was protective. CONCLUSIONS: risk of VDI and VDD in women (ENSANUT 2018-2019) increased with altitude, urban dwelling, overweight and obesity. The child and mother's place of residence, including altitude, latitude and rural classification were important predictors of SRb in EpiRbMx.

Dietary patterns in Mexican preschool children are associated with stunting and overweight.

OBJECTIVE: To evaluate the association between dietary patterns, stunting, and overweight among Mexican preschoolers. METHODS: This study was conducted with anthropometric (weight, height/length), sociodemographic (age, gender, education level of household head, socioeconomic status, country region and area, ethnicity, and beneficiary of social programs), and dietary data (Semiquantitative-food frequency questionnaire) on children aged from 1 to 4 years collected from the Mexican National Health and Nutrition Survey-2012. Dietary patterns were derived by principal components analysis. The association between dietary patterns, stunting, and overweight was assessed by prevalence ratios (PR), estimated by Poisson regression. RESULTS: In total, 1,112 preschoolers (mean age 3.06 years, SD = 1.08 years; 48.8% females) were included in the study; 11.9% of whom presented stunting, and 6.7% overweight. We identified four dietary patterns: Fruits and Vegetables [F&V], Western [W], Traditional [T], and Milk and Liquids [M&L]. Considering the lowest tertile of each dietary pattern as reference, the prevalence of stunting was 2.04 times higher [95%CI: 1.17-3.56] among children in the highest tertile of the "F&V" pattern. The prevalence of stunting was lower among children in the highest tertile of the "W" pattern [PR = 0.48; 95%CI: 0.27-0.85]. Overweight was negatively associated with the "F&V" dietary pattern [PR = 0.37; 95%CI: 0.16-0.85 for its highest tertile], and children whose consumption was mostly equivalent to the "T" pattern showed higher prevalence of stunting [PR = 1.74; 95%CI: 1.01-3.00]. CONCLUSIONS: The prevalence of stunting and overweight in a nationwide sample of Mexican preschoolers was associated with dietary patterns.