How Promising Are "Ultraprocessed" Front-of-Package Labels? A Formative Study with US Adults.

High levels of food processing can have detrimental health effects independent of nutrient content. Experts and advocates have proposed adding information about food processing status to front-of-package labeling schemes, which currently exclusively focus on nutrient content. How consumers would perceive "ultraprocessed" labels has not yet been examined. To address this gap, we conducted a within-subjects online experiment with a convenience sample of 600 US adults. Participants viewed a product under three labeling conditions (control, "ultraprocessed" label, and "ultraprocessed" plus "high in sugar" label) in random order for a single product. The "ultraprocessed" label led participants to report thinking more about the risks of eating the product and discouraging them from wanting to buy the product more than the control, despite not grabbing more attention than the control. The "ultraprocessed" plus "high in sugar" labels grabbed more attention, led participants to think more about the risks of eating the product, and discouraged them from wanting to buy the product more than the "ultraprocessed" label alone. "Ultraprocessed" labels may constitute promising messages that could work in tandem with nutrient labels, and further research should examine how they would influence consumers' actual intentions and behaviors.

A Qualitative Exploration of Spanish-Speaking Latina Women's Experiences Participating in WIC Before and During the COVID-19 Pandemic.

BACKGROUND: More than one-third of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants identify as Latino, but participation has been declining and individuals who speak predominantly Spanish face additional barriers to participation. During the COVID-19 pandemic, there were changes in WIC eligibility and benefits that may have been differentially accessible to Spanish-speaking Latina participants due to factors such as language barriers and lack of awareness of changes. Understanding Spanish-speaking Latinas' experiences with the WIC program generally and during the pandemic can inform efforts to equitably implement future emergency food response policies and improve the WIC program and Latina participant enrollment more broadly. OBJECTIVE: This study aimed to understand the perceptions and experiences of Spanish-speaking Latina WIC participants with the WIC program generally and with COVID-19 pandemic-related policy changes made to the WIC program. DESIGN: Qualitative in-depth interviews were conducted virtually in Spanish in August 2022 using a semi-structured guide. PARTICIPANTS/SETTING: Study participants were 18 Spanish-speaking Latina adult WIC participants living in North Carolina recruited using convenience sampling. ANALYSIS: All interviews were recorded, transcribed, and coded in Spanish. Thematic analysis with inductive coding was used to derive key themes. RESULTS: Perceptions about the WIC program in this sample were mixed. Participants felt positively about the healthfulness of foods included in the WIC food packages but expressed concern about the monthly benefit amounts being too low and the cultural appropriateness of food options. Pandemic policy changes, such as remote appointments and the Cash Value Benefit increase were perceived positively; however, barriers to using benefits during this time included limited communication from WIC agencies, food shortages, and concerns about not being granted US citizenship or permanent resident status due to use of WIC (ie, public charge rule). Social networks played an important role in learning about and enrolling in WIC and navigating food shortages during the pandemic. CONCLUSIONS: Concerns about the cultural appropriateness of foods provided, communication challenges, and the public charge rule emphasized the need for resources dedicated in the WIC program to improving Spanish-speaking Latina women's experiences with WIC.

Special Supplemental Nutrition Program for Women, Infants, and Children Participant Grocery Store Purchases during the COVID-19 Pandemic in North Carolina.

Background: Families participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) experienced barriers to accessing healthy food during the COVID-19 pandemic, but we do not yet understand how WIC participant food purchases shifted during the pandemic. Objectives: We aimed to describe the association between the initial shock of the pandemic in March 2020 and WIC shoppers' food purchases and changes in purchases before and during the pandemic at a top grocery chain and examine differences in these relationships by duration of WIC use. Methods: We used longitudinal food transaction data from WIC shoppers (n = 2,989,116 shopper-month observations from 175,081 unique WIC shoppers) from 496 stores in a top grocery store chain in North Carolina between October 2019 and May 2021. We used an interrupted time series design to describe the following: 1) the relationship between the initial shock of the pandemic and WIC shopper food purchases and 2) differences in purchases before and during the pandemic. To assess differences in purchases between shoppers consistently using WIC electronic benefit transfer (EBT) cards and shoppers starting or stopping WIC EBT use during the pandemic, we used models stratified by WIC group. Primary outcomes were share (%) of total calories purchased from fruits, vegetables, nuts, and legumes (FV), processed foods, and sugar-sweetened beverages (SSBs). Results: We observed small decreases in the share of total calories from FV (-0.4%) and small increases in the share of calories from processed food (1.1%) and SSBs (0.5%) purchased at this retailer when comparing the pre and post March 2020 periods. Compared with shoppers that started or stopped using WIC benefits during the pandemic, shoppers that used WIC benefits consistently had slightly higher FV and lower processed food and SSB purchases at this retailer. Conclusions: Future studies should examine whether additional supports for nutrient-dense food choices may be needed for families with low incomes in public health emergencies.

The impact of "pinkwashed" alcohol advertisements on attitudes and beliefs: A randomized experiment with US adults.

OBJECTIVE: To examine the impact of alcohol advertisements related to breast cancer awareness or charities (i.e., pinkwashed ads) on attitudes and beliefs. METHODS: In 2023, an online experiment randomized 602 US adults to view three pinkwashed ads for beer, wine, and liquor, or three standard ads for the same products. RESULTS: Breast cancer risk perceptions (average differential effect [ADE] = 0.03; p = 0.58)) and intentions to purchase the advertised product (ADE = -0.01, p = 0.95) did not differ by ad type. When informed about the link between alcohol and breast cancer, participants who viewed pinkwashed ads reported the ads were more misleading (ADE = 0.51, p < 0.001) and had stronger support for requiring alcohol breast cancer warnings (ADE = 0.23, p < 0.001). The pinkwashed ads for beer (but not for wine or liquor) led to greater: perceived product healthfulness (ADE = 0.16, p = 0.03), perceived social responsibility of the company (ADE = 0.18, p = 0.02), and favorable brand attitudes (ADE = 0.14, p = 0.03). CONCLUSIONS: Informing the public about pinkwashing increases perceptions of misleadingness and support for alcohol policies. POLICY IMPLICATIONS: Exposing the industry practice of pinkwashing could be a promising theme for campaigns to reduce alcohol consumption and increase support for alcohol policies.

Understanding Whether Price Tag Messaging Can Amplify the Benefits of Taxes: An Online Experiment.

INTRODUCTION: Excise taxes on unhealthy products like sugary drinks and tobacco can reduce purchases of these products. However, little research has investigated whether messages at the point of purchase, such as enhanced price tags, can increase the effects of taxes by heightening psychological reactions. This study aimed to examine whether including messages about taxes on price tags could amplify the benefits of excise taxes on unhealthy products. METHODS: In 2022, an online study recruited 1,013 U.S. parents to view seven price tag messages (e.g., "includes a 19% sugary drink tax") and a control (i.e., standard price tag with the tax included in the price) displayed in random order alongside sugary drinks. Participants were randomly assigned to view a caution-symbol icon or no icon on price tags. Analyses were conducted in 2023. RESULTS: All seven messages discouraged parents from buying sugary drinks for their children compared to control (average differential effects [ADEs] ranged from 0.28 to 0.48, all p<0.001). All messages led to greater attention to the price tag (ADEs ranged from 0.24 to 0.41, all p<0.001) and greater consideration of the cost of sugary drinks (ADEs ranged from 0.31 to 0.50, all p<0.001). Icons elicited higher cost consideration than text-only price tags (ADE=0.15, p<0.010), but not discouragement (p=0.061) or attention (p=0.079). CONCLUSIONS: Messaging on price tags could make excise taxes more effective. Policymakers should consider requiring messaging on price tags when implementing taxes.

Toddler milk: a scoping review of research on consumption, perceptions, and marketing practices.

Toddler milk is an ultra-processed beverage consisting primarily of powdered milk, caloric sweeteners, and vegetable oil. Pediatric health authorities do not support the use of toddler milk, and emerging evidence suggests that toddler-milk marketing practices may mislead consumers. However, studies have not synthesized the extent of toddler-milk marketing practices or how these practices affect parents' decisions about whether to serve toddler milk. We aimed to summarize the literature about toddler milk to identify what is known about: (1) parents' toddler-milk purchasing and feeding behaviors, (2) toddler-milk marketing, and (3) how marketing practices influence parents' beliefs and perceptions about toddler milk. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we systematically searched 8 databases (PubMed, APA PsycINFO, Scopus, Cochrane Central, Embase, CINAHL, Communication & Mass Media Complete, and Business Source Premier). We identified 45 articles about toddler milk. Studies were conducted in 25 countries across 6 continents. Five types of findings emerged: (1) consumption and feeding behaviors, (2) demographic correlates of toddler-milk purchasing and consumption, (3) misperceptions and beliefs, (4) increased sales, and (5) increased marketing and responses to marketing. The included articles suggested that toddler-milk sales are growing rapidly worldwide. Findings also revealed that toddler-milk packages (eg, labels, branding) resemble infant formula packages and that toddler-milk marketing practices may indirectly advertise infant formula. Purchasing, serving, and consumption of toddler milk were higher in Black and Hispanic populations than in non-Hispanic White populations, and parents with higher educational attainment and income were more likely to offer toddler milk to their children. Findings suggest a need for policies to prevent cross-marketing of toddler milk and infant formula, reduce provision of toddler milk to infants and toddlers, and prevent caregivers from being misled about toddler-milk healthfulness.

Impact of taxes and warning labels on red meat purchases among US consumers: A randomized controlled trial.

BACKGROUND: Policies to reduce red meat intake are important for mitigating climate change and improving public health. We tested the impact of taxes and warning labels on red meat purchases in the United States. The main study question was, will taxes and warning labels reduce red meat purchases? METHODS AND FINDINGS: We recruited 3,518 US adults to participate in a shopping task in a naturalistic online grocery store from October 18, 2021 to October 28, 2021. Participants were randomized to one of 4 conditions: control (no tax or warning labels, n = 887), warning labels (health and environmental warning labels appeared next to products containing red meat, n = 891), tax (products containing red meat were subject to a 30% price increase, n = 874), or combined warning labels + tax (n = 866). We used fractional probit and Poisson regression models to assess the co-primary outcomes, percent, and count of red meat purchases, and linear regression to assess the secondary outcomes of nutrients purchased. Most participants identified as women, consumed red meat 2 or more times per week, and reported doing all of their household's grocery shopping. The warning, tax, and combined conditions led to lower percent of red meat-containing items purchased, with 39% (95% confidence interval (CI) [38%, 40%]) of control participants' purchases containing red meat, compared to 36% (95% CI [35%, 37%], p = 0.001) of warning participants, 34% (95% CI [33%, 35%], p < 0.001) of tax participants, and 31% (95% CI [30%, 32%], p < 0.001) of combined participants. A similar pattern was observed for count of red meat items. Compared to the control, the combined condition reduced calories purchased (-312.0 kcals, 95% CI [-590.3 kcals, -33.6 kcals], p = 0.027), while the tax (-10.4 g, 95% CI [-18.2 g, -2.5 g], p = 0.01) and combined (-12.8 g, 95% CI [-20.7 g, -4.9 g], p = 0.001) conditions reduced saturated fat purchases; no condition affected sodium purchases. Warning labels decreased the perceived healthfulness and environmental sustainability of red meat, while taxes increased perceived cost. The main limitations were that the study differed in sociodemographic characteristics from the US population, and only about 30% to 40% of the US population shops for groceries online. CONCLUSIONS: Warning labels and taxes reduced red meat purchases in a naturalistic online grocery store. Trial Registration: http://www.clinicaltrials.gov/ NCT04716010.

Implementation costs of sugary drink policies in the United States.

To support implementation of important public health policies, policymakers need information about implementation costs over time and across stakeholder groups. We assessed implementation costs of two federal sugar-sweetened beverage (SSB) policies of current policy interest and with evidence to support their effects: excise taxes and health warning labels. Our analysis encompassed the entire policy life cycle using the Exploration, Preparation, Implementation, and Sustainment framework. We identified implementation actions using key informant interviews and developed quantitative estimates of implementation costs using published literature and government documents. Results show that implementation costs vary over time and among stakeholders. Explicitly integrating implementation science theory and using mixed methods improved the comprehensiveness of our results. Although this work is specific to federal SSB policies, the process can inform how we understand the costs of many public health policies, providing crucial information for public health policy making.

Designing Effective Alcohol Warnings: Consumer Reactions to Icons and Health Topics.

Introduction: New warning labels for alcohol could reduce alcohol-related health harms. This study examined consumer responses to alcohol warnings with different designs. Methods: A national sample of 3,051 U.S. adults completed an online survey in August 2021. Participants were randomized to 1 of 4 warning topics (addiction, liver damage, early death, or colon cancer). Participants viewed 3 labels, presented in random order: 2 types of warning labels (text-only and icon) showing a newly developed warning message about their assigned topic and a text-only control label showing a neutral message. Participants rated each label on effectiveness at discouraging alcohol consumption (primary outcome) and attention (secondary outcome) using 1 to 5 Likert-type scales. Participants also rated warnings with different causal language variants (e.g., "increases risk of," "contributes to") and marker words (e.g., "WARNING," "SURGEON GENERAL WARNING"). Results: Both the text-only and icon warnings were perceived as more effective (Average Differential Effects [ADEs]=0.79 and 0.86, respectively) and more attention-grabbing (ADEs=0.43 and 0.69, respectively) than control labels (all ps<0.001). The icon warnings were rated as more effective and attention-grabbing than the text-only warnings (ADEs=0.07 and 0.27, respectively, both ps<0.001). Although all warning topics outperformed the control messages, warnings about addiction were rated as less effective and attention-grabbing than the other topics. A majority (60%) of participants selected "increases risk of" as the most discouraging causal variant and a plurality (47%) selected "SURGEON GENERAL WARNING" as the most discouraging marker word. Conclusions: New alcohol warnings could discourage alcohol consumption, especially if warnings include icons.

Natural Claims on Sugary Fruit Drinks: A Randomized Experiment With U.S. Parents.

INTRODUCTION: Natural claims on food are largely unregulated in the U.S. This study examined the effects of natural claims on a fruit-flavored drink with added sugar (i.e., fruit drink). METHODS: In 2019, U.S. parents of children aged 2-12 years (N=1,078) recruited from an online survey panel were randomized to one of three arms: natural claim on a fruit drink, 100% all-natural claim, or a no-claim control. Parents reported their intentions and perceptions regarding fruit drinks using 1-5 response scales. Analysis occurred in 2022-2023. RESULTS: Both natural claims led parents to have higher intentions to purchase a fruit drink for their child than the control (average differential effect=0.20-0.24, both p<0.05). The natural claim (but not the 100% all-natural claim) also led parents to think that the fruit drink was healthier for their children (average differential effect=0.22, p=0.024). Claims made parents less likely to think that the drink contained added sugar (average differential effect= -0.08 to -0.12, both p<0.05) and led to lower estimated amounts of added sugar in teaspoons (average differential effect= -1.77 to -2.09, both p<0.05). Mediation analyses revealed that the claims led to higher intentions to purchase the fruit drink by increasing perceived healthfulness of the fruit drink and by leading parents to believe that there was no added sugar in the fruit drink. CONCLUSIONS: Natural claims could increase interest in and perceived healthfulness of fruit drinks. Misperceptions about the nutritional content caused by claims appear to be driving greater purchase intentions. These findings suggest a need for stronger regulation around natural claims to prevent consumer misunderstanding.

Institutional Reform to Promote Antiracism: A Tool for Developing an Organizational Equity Action and Accountability Plan.

Racism is a public health problem. Systems, structures, policies, and practices perpetuate a culture built on racism. Institutional reform is needed to promote antiracism. This article describes 1) a tool used to develop an equity action and accountability plan (EAAP) that promotes antiracism in the Department of Health Behavior at the University of North Carolina at Chapel Hill's Gillings School of Global Public Health, 2) strategies that were developed, and 3) short-term outcomes and lessons learned. A study coordinator, not affiliated with the Department of Health Behavior, was hired to collect qualitative data that documented the lived experiences of students and alumni of color (ie, racial and ethnic minority students) over time in the department. Seeking action from faculty and departmental leadership, students engaged in collective organizing covered the department chair's office door with notes describing microaggressions, and visited faculty one-on-one to demand action. In response, 6 faculty members volunteered to form the Equity Task Force (ETF) to explicitly address students' concerns. The ETF identified priority areas for action based on 2 student-led reports, gathered resources from other institutions and the public health literature, and examined departmental policies and procedures. The ETF drafted the EAAP, solicited feedback, and revised it according to 6 priority strategies with actionable steps: 1) transform culture and climate, 2) enhance teaching, mentoring, and training, 3) revisit performance and evaluation of faculty and staff, 4) strengthen recruitment and retention of faculty of color, 5) increase transparency in student hiring practices and financial resources, and 6) improve equity-oriented research practices. This planning tool and process can be used by other institutions to achieve antiracist reform.

Examining the Longitudinal Relationship Between Perceived and Actual Message Effectiveness: A Randomized Trial.

We sought to examine the relationship between perceived message effectiveness (PME) and actual message effectiveness (AME) in a 3-week randomized trial of vaping prevention advertisements. Participants were US adolescents (n = 1,514) recruited in 2021. We randomly assigned them to view The Real Cost vaping prevention ads or control videos online. Participants viewed three videos at Visit 1, again at Visits 2 and 3, and completed a survey at each visit that assessed AME (susceptibility to vaping) and two types of PME - effects perceptions (potential for behavioral impact) and message perceptions (potential for message processing). At Visit 4, AME was measured. Compared to control, The Real Cost ads led to improved AME (lower susceptibility to vaping at Visit 4, p < .001). This was anticipated by The Real Cost ads eliciting higher PME ratings (higher effects and message perceptions at Visit 1, both p < .001). Furthermore, PME (both effects and message perceptions) at Visit 1 predicted susceptibility to vaping at Visits 1, 2, 3, and 4 (all p < .001). Finally, effects perceptions fully mediated the impact of The Real Cost ads on susceptibility to vaping (ß = -.30; p < .001), while message perceptions only partially mediated the effect (ß = -.04; p = .001). Our findings indicate a relationship between PME and AME, especially effects perceptions, and suggest that PME may be useful in message pre-testing to select messages with greater behavior change potential.

Online RCT of Icon Added-Sugar Warning Labels for Restaurant Menus.

INTRODUCTION: To reduce added-sugar consumption, jurisdictions are considering requiring restaurant menu labels to identify high-added-sugar items. This study examined the impacts of added-sugar warning labels on hypothetical choices, knowledge of items' added-sugar content, and perceptions of high-added-sugar items. STUDY DESIGN: The design was an online RCT. SETTING/PARTICIPANTS: National sample of adults (N=15,496) was recruited to approximate the U.S. distribution of sex, age, race, ethnicity, and education. INTERVENTION: Participants viewed fast-food and full-service restaurant menus displaying no warning labels (control) or icon-only added-sugar warning labels next to high-added-sugar items (containing >50% of the daily recommended limit). MAIN OUTCOME MEASURES: The main outcome measures were hypothetical ordering of ≥1 high-added-sugar item, grams of added sugar ordered, and knowledge of items' added-sugar content assessed in 2021 and analyzed in 2021-2022. RESULTS: Warning labels reduced the relative probability of ordering ≥1 high-added-sugar item by 2.2% (probability ratio=0.978, 95% CI=0.964, 0.992; p=0.002); improved knowledge of added-sugar content (p<0.001); and led to a nonstatistically significant reduction of 1.5 grams of added sugar ordered, averaged across menus (p=0.07). The label modestly reduced the appeal of high-added-sugar items, increased perceptions that consuming such items often will increase Type 2 diabetes risk, increased perceived control over eating decisions, and increased injunctive norms about limiting consumption of high-added-sugar items (ps<0.001). However, in the warning condition, only 47% noticed nutrition labels, and 21% recalled seeing added-sugar labels. When restricting the warning condition to those who noticed the label, the result for grams of added sugar ordered was significant, with the warning condition ordering 4.9 fewer grams than the controls (95% CI= -7.3, -2.5; p<0.001). CONCLUSIONS: Added-sugar warning labels reduced the probability of ordering a high-added-sugar menu item and increased participants' knowledge of whether items contained >50% of the daily value for added sugar. The modest magnitudes of effects may be due to low label noticeability. Menu warning labels should be designed for noticeability. REGISTRATION: This study was registered at AsPredicted.org #65655.

Optimising messages and images for e-cigarette warnings.

BACKGROUND: The US Food and Drug Administration (FDA) requires electronic cigarettes (e-cigarettes) to have a single addiction warning, but many other health harms are associated with vaping and warnings grow stale over time. We aimed to develop new warning messages and images to discourage e-cigarette use. METHODS: Participants were 1629 US adults who vaped or smoked. We randomised each participant to evaluate 7 of 28 messages on newly developed warning themes (metals exposure, DNA mutation, cardiovascular problems, chemical exposure, lung damage, impaired immunity, addiction), and the current FDA-required warning (total of 8 messages). Then, participants evaluated images of hazards (eg, metal), internal harms (eg, organ damage) or people experiencing harms. RESULTS: Regarding intended effects, new warning themes all discouraged vaping more than the current FDA-required warning (all p<0.001), led to greater negative affect (all p<0.001) and led to more anticipated social interactions (all p<0.001). The most discouraging warnings were about toxic metals exposure. Regarding unintended effects, the new themes led to more stigma against people who vape (6 of 7 themes, p<0.001) and led to a greater likelihood of thinking vaping is more harmful than smoking (all 7 themes, p<0.001), although unintended effects were smaller than intended effects. Images of harms (internal or people experiencing) discouraged vaping more than images of hazards (all p<0.001). DISCUSSION: Vaping warning policies should communicate a broader range of hazards and harms, beyond addiction, to potentially increase awareness of health harms. Images of internal harm or people experiencing harms may be particularly effective at discouraging vaping.

Toddler Milk Perceptions and Responses to Front-of-Package Claims and Product Warnings: A Qualitative Study of Caregivers of Toddlers.

BACKGROUND: Toddler milk products are ultraprocessed milk-based beverages promoted for children aged 9 through 36 months. They often contain added sugars, which may contribute to unhealthy dietary habits. Aggressive promotion of toddler milk, particularly to the Latinx population, has likely led to rapid rises in sales. OBJECTIVE: The study aims were to qualitatively explore caregivers' experiences with, beliefs about, and attitudes toward toddler milk; to explore caregivers' reactions to health claims and product warnings on toddler milk packaging; and explore whether perceptions of toddler milk differ by Latinx ethnicity. DESIGN: Focus group discussions and in-depth interviews were conducted. PARTICIPANTS: Fifteen online in-depth interviews and 4 online focus groups with US caregivers of children aged 9 through 36 months who reported serving toddler milk to their children were conducted in 2021. STATISTICAL ANALYSES PERFORMED: Audio files were transcribed, coded, and analyzed in NVivo. A thematic analysis with a hybrid analytical approach of deductive and inductive coding was conducted. RESULTS: Caregivers struggled to discern toddler milk from infant formula and perceived formula as a larger term that included toddler milk. Participants described offering toddler milk to their children for its convenience, nutritional profile, and perceived benefits tied to health claims present on the labels. Participants reported that health claims on toddler milk packaging attracted their attention; most participants did not express skepticism about the veracity of the claims. An "added sugar" warning increased understanding of the presence of added sugar in a toddler milk product. Latinx and non-Latinx participants largely reported similar perceptions, beliefs, and patterns of provision of toddler milk. CONCLUSIONS: Health claims may lead caregivers to perceive toddler milk as a nutritionally adequate product. Research is needed to investigate caregiver-directed interventions for informing caregivers about the distinction between infant formula and toddler milk.

How pictorial warnings change parents' purchases of sugar-sweetened beverage for their children: mechanisms of impact.

BACKGROUND: Pictorial health warnings on sugar-sweetened beverages (SSBs) are a promising policy for preventing diet-related disease in children. A recent study found that pictorial warnings reduced parents' purchases of SSBs for their children by 17%. However, the psychological mechanisms through which warnings affect parental behavior remain unknown. We aimed to identify the mechanisms that explain how pictorial warnings affect parents' SSB purchasing behavior for their children using secondary data from a randomized trial. METHODS: In 2020-2021, parents of children ages 2 to 12 years (n = 325) completed a shopping task in a convenience store laboratory in North Carolina, USA. Participants were randomly assigned to a pictorial warnings arm (SSBs displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (SSBs displayed a barcode label). Parents then bought a beverage for their child and took a survey measuring 11 potential psychological mediators, selected based on health behavior theories and a model explaining the impact of tobacco warnings. We conducted simple mediation analyses to identify which of the 11 mechanisms mediated the impact of exposure to pictorial warnings on purchasing any SSBs for their children. RESULTS: Two of the 11 constructs were statistically significant mediators. First, the impact of pictorial warnings on the likelihood of purchasing any SSB was mediated by parents' perceptions that SSBs were healthier for their child (mediated effect= -0.17; 95% CI = - 0.33, - 0.05). Second, parents' intentions to serve SSBs to their children also mediated the effect of warnings on likelihood of purchasing any SSB (mediated effect= -0.07, 95% CI=-0.21, - 0.003). CONCLUSIONS: Pictorial warnings reduced parents' purchases of SSBs for their children by making parents think SSBs are less healthful for their children and reducing their intentions to serve SSBs to their children. Communication approaches that target healthfulness perceptions and intentions to serve SSBs may motivate parents to buy fewer SSBs for their children.

Sociodemographic disparities in purchases of fruit drinks with policy relevant front-of-package nutrition claims.

OBJECTIVE: Our objectives were to describe sociodemographic characteristics associated with the purchase of (1) any fruit drinks and (2) fruit drinks with specific front-of-package (FOP) nutrition claims. DESIGN: Cross-sectional. SETTING: USA. PARTICIPANTS: We merged fruit drink purchasing data from 60 712 household-months from 5233 households with children 0-5 years participating in Nielsen Homescan in 2017 with nutrition claims data. We examined differences in predicted probabilities of purchasing any fruit drinks by race/ethnicity, income and education. We constructed inverse probability (IP) weights based on likelihood of purchasing any fruit drinks. We used IP-weighted multivariable logistic regression models to examine predicted probabilities of purchasing fruit drinks with specific FOP claims. RESULTS: One-third of households with young children purchased any fruit drinks. Non-Hispanic (NH) Black (51·6 %), Hispanic (36·3 %), lower-income (39·3 %) and lower-educated households (40·9 %) were more likely to purchase any fruit drinks than NH White (31·3 %), higher-income (25·8 %) and higher-educated households (30·3 %) (all P < 0·001). In IP-weighted analyses, NH Black households were more likely to purchase fruit drinks with 'Natural' and fruit or fruit flavour claims (6·8 % and 3·7 %) than NH White households (4·5 % and 2·7 %) (both P < 0·01). Lower- and middle-income (15·0 % and 13·8 %) and lower- and middle-educated households (15·4 % and 14·5 %) were more likely to purchase fruit drinks with '100 % Vitamin C' claims than higher-income (10·8 %) and higher-educated households (12·9 %) (all P < 0·025). CONCLUSIONS: We found a higher likelihood of fruit drink purchases in lower-income, lower-educated, NH Black and Hispanic households. Experimental studies should determine if nutrition claims may be contributing to disparities in fruit drink consumption.

Consumer behaviour and experiences in a naturalistic online grocery store: implications for nutrition research.

Naturalistic online grocery stores could provide a novel setting for evaluating nutrition interventions. In 2021-2022, we recruited US adults (n 144, 59% low-income) to complete two weekly study visits: one in a naturalistic ('mock') online grocery store developed for research and one in a real online grocery store. Participants selected groceries and responded to survey questions. Analyses examined survey responses and expenditures on fifteen food categories (e.g., bread, sugar-sweetened beverages). Nearly all enrolled participants completed both visits (98% retention). Moreover, nearly participants all reported that their selections in the naturalistic store were similar to their usual purchases (95%) and that the naturalistic store felt like a real store (92%). Participants' spending on food categories in the naturalistic store were moderately-to-strongly correlated with their spending in the real store (range of correlation coefficients: 0⋅36-0⋅67, all P-values < 0⋅001). Naturalistic online grocery stores may offer a promising platform for conducting nutrition research.

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.

Effects of pictorial warnings on parents' purchases and perceptions of sugar-sweetened beverage categories.

BACKGROUND: Sugar-sweetened beverage (SSB) consumption remains high among US children. Warning labels on SSBs hold promise for reducing consumption, but their impact may differ by SSB category. OBJECTIVES: This study examined the effects of pictorial warnings on parents' beverage purchases and perceptions across SSB categories. METHODS: Parents of children ages 2-12 (n = 326) visited a convenience store laboratory in North Carolina. Participants were randomly assigned to see SSBs carrying either pictorial warning labels or control labels. Parents purchased a beverage for their child and completed a survey. RESULTS: Responses from parents in the control arm suggest underlying perceptions of flavoured milk (2.8 on scale ranging from 1 to 5), flavoured water (2.6), and fruit-flavoured drinks (2.5) as the most healthful SSB categories. Compared to the control, pictorial warnings led to the largest reductions in purchases of fruit drinks (-61%), soda (-36%) and flavoured milk (-32%). Warnings also lowered the perceived healthfulness of flavoured water (d = -0.34), flavoured milk (d = -0.28), sports drinks (d = -0.25), and a reduction in intentions to give one's child sports drinks (d = -0.30), flavoured water (d = -0.24) and sweet tea (d = -0.22, all p < 0.05). CONCLUSIONS: Warning labels may have heterogeneous effects across SSB categories. Future research should assess the psychological mechanisms underlying these heterogeneous effects.