Effects of red meat taxes and warning labels on food groups selected in a randomized controlled trial.

BACKGROUND: High consumption of red and processed meat contributes to both health and environmental harms. Warning labels and taxes for red meat reduce selection of red meat overall, but little is known about how these potential policies affect purchases of subcategories of red meat (e.g., processed versus unprocessed) or of non-red-meat foods (e.g., cheese, pulses) relevant to health and environmental outcomes. This study examined consumer responses to warning labels and taxes for red meat in a randomized controlled trial. METHODS: In October 2021, we recruited 3,518 US adults to complete a shopping task in a naturalistic online grocery store. Participants were randomly assigned to one of four arms: control (no warning labels or tax), warning labels only (health and environmental warning labels appeared next to products containing red meat), tax only (prices of products containing red meat were increased 30%) or combined warning labels + tax. Participants selected items to hypothetically purchase, which we categorized into food groups based on the presence of animal- and plant-source ingredients (e.g., beef, eggs, pulses), meat processing level (e.g., processed pork versus unprocessed pork), and meat species (e.g., beef versus pork). We assessed the effects of the warning labels and tax on selections from each food group. RESULTS: Compared to control, all three interventions led participants to select fewer items with processed meat (driven by reductions in processed pork) and (for the tax and warning labels + tax interventions only) fewer items with unprocessed meat (driven by reductions in unprocessed beef). All three interventions also led participants to select more items containing cheese, while only the combined warning labels + tax intervention led participants to select more items containing processed poultry. Except for an increase in selection of pulses in the tax arm, the interventions did not affect selections of fish or seafood (processed or unprocessed), eggs, or plant-based items (pulses, nuts & seeds, tofu, meat mimics, grains & potatoes, vegetables). CONCLUSIONS: Policies to reduce red meat consumption are also likely to affect consumption of other types of foods that are relevant to both health and environmental outcomes. TRIAL REGISTRATION: NCT04716010 on www. CLINICALTRIALS: gov .

Dietary quality and dietary greenhouse gas emissions in the USA: a comparison of the planetary health diet index, healthy eating index-2015, and dietary approaches to stop hypertension.

BACKGROUND: The Planetary Health Diet Index (PHDI) measures adherence to the dietary pattern presented by the EAT-Lancet Commission, which aligns health and sustainability targets. There is a need to understand how PHDI scores correlate with dietary greenhouse gas emissions (GHGE) and how this differs from the carbon footprints of scores on established dietary recommendations. The objectives of this study were to compare how the PHDI, Healthy Eating Index-2015 (HEI-2015) and Dietary Approaches to Stop Hypertension (DASH) relate to (a) dietary GHGE and (b) to examine the influence of PHDI food components on dietary GHGE. METHODS: We used life cycle assessment data from the Database of Food Recall Impacts on the Environment for Nutrition and Dietary Studies to calculate the mean dietary GHGE of 8,128 adult participants in the 2015-2016 and 2017-2018 cycles of the National Health and Nutrition Examination Survey (NHANES). Poisson regression was used to estimate the association of (a) quintiles of diet score and (b) standardized dietary index Z-scores with dietary GHGE for PHDI, HEI-2015, and DASH scores. In secondary analyses, we used Poisson regression to assess the influence of individual PHDI component scores on dietary GHGE. RESULTS: We found that higher dietary quality on all three indices was correlated with lower dietary GHGE. The magnitude of the dietary quality-dietary GHGE relationship was larger for PHDI [-0.4, 95% CI (-0.5, -0.3) kg CO2 equivalents per one standard deviation change] and for DASH [-0.5, (-0.4, -0.6) kg CO2-equivalents] than for HEI-2015 [-0.2, (-0.2, -0.3) kg CO2-equivalents]. When examining PHDI component scores, we found that diet-related GHGE were driven largely by red and processed meat intake. CONCLUSIONS: Improved dietary quality has the potential to lower the emissions impacts of US diets. Future efforts to promote healthy, sustainable diets could apply the recommendations of the established DASH guidelines as well as the new guidance provided by the PHDI to increase their environmental benefits.

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.

A policy approach to identifying food and beverage products that are ultra-processed and high in added salt, sugar and saturated fat in the United States: a cross-sectional analysis of packaged foods.

Background: Governments globally aim to reduce the intake of unhealthy foods. Many policies exist that aim to address foods high in saturated fat, salt and sugar (HFSS) but the identification of ultra-processed foods (UPF) have presented a greater challenge due to the lack of an appropriate policy definition. To support policymakers, we provide approaches that can support governments to identify both HFSS foods and UPFs. Methods: Four approaches combining elements of UPF definitions (i.e., presence of additives) and HFSS definitions were compared attempting to simplify and standardize the identification of less healthy products. Nationally representative food purchase data from NielsenIQ linked with nutrition facts label data were used to examine the mean proportion of product volume purchased by US households to be targeted. Differences between approaches were examined using Student t test; Bonferroni adjusted P value < 0.0001 was considered significant. Findings: In 2020, 50% of 33,054,687 products purchased by US households were considered UPFs (65% of foods and 38% of beverages) and 43% HFSS (65% of foods and 26% of beverages), however there was not 100% agreement between the two definitions (P < 0.0001). By starting with HFSS criteria and adding elements of UPF (colors and flavors), we were able to provide a method with 100% agreement between the identification of UPFs and HFSS products. Interpretation: Results demonstrated how combining HFSS criteria with UPF criteria can be used to identify less healthy foods and ensure policymakers have both a simple and accurate method to target products for policy intervention. Funding: Bloomberg Philanthropies and the Global Food Research Program of UNC-Chapel Hill provided funds.

Adherence to the Planetary Health Diet Index and correlation with nutrients of public health concern: an analysis of NHANES 2003-2018.

BACKGROUND: The Planetary Health Diet Index (PHDI) is a novel measure adapted to quantify alignment with the dietary evidence presented by the EAT-Lancet Commission on Food, Planet, Health. OBJECTIVES: To examine how population-level health and sustainability of diet as measured by the PHDI changed from 2003 to 2018, and to assess how PHDI correlated with inadequacy for nutrients of public health concern (iron, calcium, potassium, and fiber) in the United States. METHODS: We estimated survey-weighted trends in PHDI scores and median intake of PHDI components in a nationally representative sample of 33,859 adults aged 20+ y from 8 cycles (2003-2018) of the National Health and Nutrition Examination Survey with 2 d of dietary recall data. We used the National Cancer Institute method to examine how PHDI correlated with inadequate intake of iron, calcium, potassium, and fiber. RESULTS: Out of a theoretical range of 0-140, the median PHDI value increased by 4.2 points over the study period, from 62.7 (95% confidence interval [CI]: 62.0, 63.4) points in 2003-2004 to 66.9 (66.2, 67.7) points in 2017-2018 (P-trend < 0.001), although most of this change occurred before 2011-2012 and plateaued thereafter. For adequacy components that are encouraged for consumption, nonstarchy vegetable intake significantly decreased over time, whereas whole grains, nuts and seeds, and unsaturated oils increased. For moderation components with recommended limits for consumption, poultry and egg intake increased, but red and processed meat, added sugars, saturated fats, and starchy vegetables decreased over time. Higher PHDI values were associated with a lower probability of iron, fiber, and potassium inadequacy. CONCLUSIONS: Although there have been positive changes over the past 20 y, there is substantial room for improving the health and sustainability of the United States diet. Shifting diets toward EAT-Lancet recommendations would improve nutrient adequacy for iron, fiber, and potassium. Policy action is needed to support healthier, more sustainable diets in the United States and globally.

Dietary quality and cardiometabolic indicators in the USA: A comparison of the Planetary Health Diet Index, Healthy Eating Index-2015, and Dietary Approaches to Stop Hypertension.

BACKGROUND: The Planetary Health Diet Index (PHDI) measures adherence to the sustainable dietary guidance proposed by the EAT-Lancet Commission on Food, Planet, Health. To justify incorporating sustainable dietary guidance such as the PHDI in the US, the index needs to be compared to health-focused dietary recommendations already in use. The objectives of this study were to compare the how the Planetary Health Diet Index (PHDI), the Healthy Eating Index-2015 (HEI-2015) and Dietary Approaches to Stop Hypertension (DASH) relate to cardiometabolic risk factors. METHODS AND FINDINGS: Participants from the National Health and Nutrition Examination Survey (2015-2018) were assigned a score for each dietary index. We examined disparities in dietary quality for each index. We used linear and logistic regression to assess the association of standardized dietary index values with waist circumference, blood pressure, HDL-C, fasting plasma glucose (FPG) and triglycerides (TG). We also dichotomized the cardiometabolic indicators using the cutoffs for the Metabolic Syndrome and used logistic regression to assess the relationship of the standardized dietary index values with binary cardiometabolic risk factors. We observed diet quality disparities for populations that were Black, Hispanic, low-income, and low-education. Higher diet quality was associated with improved continuous and binary cardiometabolic risk factors, although higher PHDI was not associated with high FPG and was the only index associated with lower TG. These patterns remained consistent in sensitivity analyses. CONCLUSIONS: Sustainability-focused dietary recommendations such as the PHDI have similar cross-sectional associations with cardiometabolic risk as HEI-2015 or DASH. Health-focused dietary guidelines such as the forthcoming 2025-2030 Dietary Guidelines for Americans can consider the environmental impact of diet and still promote cardiometabolic health.

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.

Beverage industry TV advertising shifts after a stepwise mandatory food marketing restriction: achievements and challenges with regulating the food marketing environment.

OBJECTIVE: Sugar-sweetened beverages (SSB) are heavily advertised globally, and SSB consumption is linked to increased health risk. To reduce unhealthy food marketing, Chile implemented a regulation for products classified as high in energies, sugar, saturated fat or sodium, starting with a 2016 ban on child-targeted advertising of these products and adding a 06.00-22.00 daytime advertising ban in 2019. This study assesses changes in television advertising prevalence of ready-to-drink beverages, including and beyond SSB, to analyse how the beverage industry shifted its marketing strategies across Chile's implementation phases. DESIGN: Beverage advertisements were recorded during two randomly constructed weeks in April-May of 2016 (pre-implementation) through 2019 (daytime ban). Ad products were classified as 'high-in' or 'non-high-in' according to regulation nutrient thresholds. Ads were analysed for their programme placement and marketing content. SETTING: Chile. RESULTS: From pre-regulation to daytime ban, child-targeted, daytime and total ads decreased by 51·8 percentage points (p.p.), 51·5 p.p. and 61·8 p.p. for high-in products and increased by 62·9 p.p., 54·9 p.p. and 61·8 p.p. for non-high-in products (Ps < 0·001). Additionally, total ready-to-drink beverage ads increased by 5·4 p.p. and brand-only ads (no product shown) by 7 p.p. CONCLUSIONS: After the regulation implementation, 'high-in' ads fell significantly, but 'non-high-in' ads rose and continued using strategies targeting children and being aired during daytime. Given research showing that advertising one product can increase preferences for a different product from that same brand and product categories, broader food marketing regulation approaches may be needed to protect children from the harmful effects of food marketing.

More than a Nuisance: Implications of Food Marketing for Public Health Efforts to Curb Childhood Obesity.

Fifteen years ago, public health experts urged industry, governments, and advocates to take action to dramatically improve the unhealthy food-marketing environment surrounding children in order to address the global childhood obesity crisis. Since then, research has confirmed that food marketing to children has far-reaching negative effects on their diets and health, takes advantage of adolescent vulnerabilities, and contributes to health disparities. In addition, digital marketing has profoundly changed young people's engagement with brands. Moreover, reliance on industry self-regulation as a solution has proven ineffective. Government-led policies have been more successful, but they remain limited in scope and challenging to adopt and implement. New approaches are necessary to increase public and policy maker awareness that food marketing is more than a nuisance, that it threatens the long-term health of children and adolescents worldwide, and that meaningful governmental action is urgently required to curtail industry's negative impact on young people's well-being. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Trends in Sugar from Packaged Foods and Beverages Purchased by US Households Between 2002 and 2020.

BACKGROUND: Excess sugar consumption is a public health concern in the United States. How sugar purchases have changed over time, whether there are disparities across subpopulations, and the contribution of various food groups are unclear. OBJECTIVE: To assess trends in sugar from packaged foods and beverages purchased by US households between 2002 and 2020. DESIGN: This is an open cohort study. PARTICIPANTS/SETTING: We obtained data from the NielsenIQ U.S. Homescan Consumer Panel, which collects data on household purchases of all consumer packaged goods in 52 metropolitan and 24 non-metropolitan markets across the United States. We assessed data on food and beverage purchases for 1,163,447 household-years. MAIN OUTCOME MEASURES: The primary outcomes are the total sugar in grams purchased per capita per day and percentage of calories from sugar, by sociodemographic group. STATISTICAL ANALYSES PERFORMED: We used linear regression to estimate trends in total grams of sugar per capita per day, percentage of calories from sugar, and percentage of total sugar purchases by food or beverage group. We estimated means for select years and tested for significance compared with 2002 and with the previous timepoint and calculated the overall P-value for the linear trend using time series regression. RESULTS: Total sugar purchases decreased over the study period, both in absolute terms (-37.2 g/capita/day; 95% confidence interval [CI], -38.7, -35.6) and as a percentage of total calories purchased (-5.3 percentage points; 95% CI, -5.5, -5.2). Sugar purchases declined for all sociodemographic groups, but disparities have persisted or widened, particularly among individuals who are non-Hispanic Black, low-income, and with lower educational attainment. Beverages' contributions to sugar purchases decreased 8.1 percentage points (95% CI, -8.4, -7.8). CONCLUSION: In the United States, purchases of sugar declined, but disparities by socioeconomic status and race or ethnicity persisted or widened. Policies to further reduce sugar consumption and the burden of diet-related disparities are needed.

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.

Cultural and Contextual Drivers of Triple Burden of Malnutrition among Children in India.

This study examines malnutrition's triple burden, including anaemia, overweight, and stunting, among children aged 6-59 months. Using data from the National Family Health Survey-5 (2019-2021), the study identifies risk factors and assesses their contribution at different levels to existing malnutrition burden. A random intercept multilevel logistic regression model and spatial analysis are employed to identify child, maternal, and household level risk factors for stunting, overweight, and anaemia. The study finds that 34% of children were stunted, 4% were overweight, and 66% were anaemic. Stunting and anaemia prevalence were higher in central and eastern regions, while overweight was more prevalent in the north-eastern and northern regions. At the macro-level, the coexistence of stunting, overweight, and anaemia circumstantiates the triple burden of childhood malnutrition with substantial spatial variation (Moran's I: stunting-0.53, overweight-0.41, and anaemia-0.53). Multilevel analysis reveals that child, maternal, and household variables play a substantial role in determining malnutrition burden in India. The nutritional health is significantly influenced by a wide range of determinants, necessitating multilevel treatments targeting households to address this diverse group of coexisting factors. Given the intra-country spatial heterogeneity, the treatment also needs to be tailor-made for various disaggregated levels.

Food for thought or food for emotions? An analysis of marketing strategies in television food advertising seen by children in Colombia.

OBJECTIVE: To establish the relationship between the marketing strategies and nutritional quality of foods and beverages promoted in television food advertisements (TV ads) seen by Colombian child audiences overall and based on child gender and socio-economic strata (SES). DESIGN: A quantitative content analysis of marketing appeals was combined with nutritional data of the food products advertised and matched with TV audience ratings data for each food and beverage ads for Colombian children between 4 and 11 years. SETTING: All beverages and foods TV ads cable or over-the-air channels in Colombia in 2017. PARTICIPANTS: N/A. RESULTS: Compared with rational appeals (e.g. freshness, health or nutrition messages), emotional appeals (referencing or depicting human senses or emotions, e.g. using cartoons to suggest fun) were more frequently used in the TV ads most viewed by Colombian children. Female children and children in lower SES tended to be more exposed to emotional appeals in TV ads than their male or higher SES counterparts. Furthermore, TV ads using more emotional appeals tended to be for products high in problematic nutrients. CONCLUSION: The findings of this study highlight the need to implement statutory measures to reduce the deleterious effect of food marketing on children.

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.

Design and approval of the nutritional warnings' policy in Peru: Milestones, key stakeholders, and policy drivers for its approval.

Nutritional warnings are used as a public health strategy to address obesity. Peru approved in 2013 and implemented in 2019 a law requiring nutritional warnings on the marketing and packaging of processed foods high in sugar, sodium, saturated fat, and containing trans-fat. The complexity behind the design and approval of these policies over six years provides unique learnings, that inform the obesity prevention context, especially when proposed policies face strong opposition from powerful stakeholders. Our study aims to describe the milestones and key stakeholders' roles and stances during the nutritional warnings policy design in Peru, and to identify and analyze the main drivers of policy change that explain its approval. In 2021, interviews were conducted with 25 key informants closely involved in its design. Interviews were analyzed using the Kaleidoscope Model as a theoretical framework. Relevant policy documents and news were also analyzed. Milestones for this policy included the approval of the Law, Regulation, and Manual. Policy supporters were mainly from Congress, civil society advocates, and Health Ministers. Opponents came from Congress, ministries linked to the economic sector, the food industry, and media. Across the years, warnings evolved from a single text, to traffic lights, to the approved black octagons. Main challenges included the strong opposition of powerful stakeholders, the lack of agreement for defining the appropriate evidence supporting nutritional warning parameters and design, and the political instability of the country. Based on the Kaleidoscope Model, the policy successfully targeted a relevant problem (unhealthy eating decisions) and had powerful advocates who effectively used focusing events to reposition the warnings in the policy agenda across the years. Negotiations weakened the policy but led to its approval. Importantly, government veto players were mostly in favor of the policy, which enabled its final approval despite the strong opposition.

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.

Sweetener Purchases in Chile before and after Implementing a Policy for Food Labeling, Marketing, and Sales in Schools.

Background: Chile's landmark food labeling and advertising policy led to major reductions in sugar purchases. However, it is unclear whether this led to increases in the purchases of nonnutritive sweeteners (NNS). Objectives: The objective of this study was to assess the changes in NNS and caloric-sweetened (CS) products purchased after the law's first phase. Methods: Longitudinal data on food and beverage purchases from 2,381 households collected from January 1, 2015 to December 31, 2017, were linked to nutritional information and categorized into added sweetener groups (unsweetened, NNS-only, CS-only, or NNS with CS). Logistic random-effects models and fixed-effects models were used to compare the percentage of households purchasing products and the mean volume purchased by sweetener category to a counterfactual based on pre-regulation trends. Results: Compared with the counterfactual, the percentage of households purchasing any NNS beverages (NNS-only or NNS with CS) increased by 4.2 percentage points (pp) (95% CI: 2.8, 5.7; P < 0.01). This increase was driven by households purchasing NNS-only beverages (12.1 pp, 95% CI: 10.0, 14.2; P < 0.01). The purchased volume of beverages with any NNS increased by 25.4 mL/person/d (95% CI: 20.1, 30.7; P < 0.01) or 26.5%. Relative to the counterfactual, there were declines of -5.9 pp in households purchasing CS-only beverages (95% CI: -7.0, -4.7; P < 0.01). Regarding the types of sweeteners purchased, we found significant increases in the amounts of sucralose, aspartame, acesulfame K, and steviol glycosides purchased from beverages. Among foods, differences were minimal. Conclusions: The first phase of Chile's law was associated with an increase in the purchases of beverages containing NNS and decreases in beverages containing CS, but virtually no changes in foods.

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.