Efecto del etiquetado frontal de advertencia de alimentos y bebidas. La experiencia de otros países de América Latina / Effect of food and drink warning front labeling. The experience of other Latin American countries

Introducción: En México se ha propuesto una serie de estrategias para la prevención y control de la obesidad, como el etiquetado frontal de advertencia, aprobado con la modificación a la NOM 051. Algunos países de América Latina como Chile y Ecuador ya han implementado etiquetados resumidos y simplificados sobre nutrientes relevantes para la salud. Objetivo: Describir la información disponible acerca de los efectos en la elección, compra y consumo de alimentos y bebidas procesadas, posterior a la implementación de un etiquetado nutrimental de advertencia en Chile y Ecuador.Material y métodos: Revisión sistémica en las bases de datos Medline, Pubmed, NCBI, Crossref, Scielo, Redalyc, buscador web y Google Académico. Las palabras claves fueron: etiquetado nutrimental, etiquetado de advertencia y semaforización de alimentos. La búsqueda se realizó en español e inglés.Resultados: Se encontró que existe buena comprensión y aceptabilidad de los sistemas de etiquetado de advertencia, sin embargo, los individuos con mayor nivel socioeconómico y educativo tienen una mayor predisposición a elegir productos más saludables, de igual manera en la elección de un alimento interfieren otros factores como la edad, las preferencias y el precio del producto. Por otro lado, el etiquetado de advertencia octogonal de Chile brinda resultados más favorables en comparación con el etiquetado de semáforo de Ecuador.Conclusiones: Este estudio permite describir un ligero panorama de las expectativas para México, posterior a la entrada en vigor de la modificación de la NOM 051 y muestra que, a pesar de brindar resultados favorables, requerirá estrategias adicionales para reforzar su efecto, esto evitaría resultados negativos.(AU)

In Mexico, a series of strategies for the prevention and control of obesity have been proposed, such as the frontal warning labeling, approved with the amendment to NOM 051. Some Latin American countries such as Chile and Ecuador have already implemented simplified and summary labels. on nutrients relevant to health.Aim: Describe the available information about the effects on the choice, purchase and consumption of processed foods and beverages, after the implementation of a nutritional warning label in Chile and Ecuador.Material and methods: Systemic review in the Medline, Pubmed, NCBI, Crossref, Scielo, Redalyc, web search and Google Scholar databases. The key words were: nutritional labeling, warning labeling and food traffic lights. The search was conducted in Spanish and English.Results: It was found that there is a good understanding and acceptability of warning labeling systems, however, individuals with a higher socioeconomic and educational level have a greater predisposition to choose healthier products, in the same way in the choice of a food other factors interfere, such as the age, preferences and price of the product. On the other hand, Chile's octagonal warning labeling provides more favorable results compared to Ecuador's traffic light labeling.Conclusions: This study allows describing a slight overview of expectations for Mexico, after the entry into force of the modification of NOM 051 and shows that, despite providing favorable results, it will require additional strategies to reinforce its effect, this would avoid negative results.(AU)

Un etiquetado alimentario efectivo: mucho más que salud pública / Effective food labeling - Much more than just public health

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Reformulation of Packaged Foods and Beverages in the Colombian Food Supply.

Public discussion, advocacy, and legislative consideration of policies aimed at reducing consumption of processed foods, such as sugar-sweetened beverage (SSB) taxes and mandatory front-of-package (FOP) warning labels, may stimulate product reformulation as a strategy to prevent regulation. In Colombia, there have been major legislative pushes for SSB taxes and FOP labels, although neither has passed to date. In light of the ongoing policy debate and successful implementation of similar policies in Peru and Chile, we explored manufacturer reformulation in the Colombian food supply. We compared the quantities of nutrients of concern (including sugar, sodium, and saturated fat) from the nutrition facts panels of the same 102 packaged foods and 36 beverages from the top-selling brands in Colombia between 2016 and 2018. Our analyses showed a substantial decrease in median sugar content of beverages, from 9.2 g per 100 mL to 5.2 g per 100 mL, and an increase in the percentage of beverages containing non-nutritive sweeteners (NNS), from 33% to 64% (p = 0.003). No meaningful changes in the quantities of nutrients of concern among foods were observed. Our findings suggest little reformulation has occurred in Colombia in the absence of mandatory policies, except for the substitution of sugar with NNS among beverages.

Characteristics of Allergen Labelling and Precautionary Allergen Labelling in Packaged Food Products Available in Latin America.

The characteristics of food allergen labelling are relevant for avoiding accidental exposure to the allergens of interest but no Latin American country has evaluated these characteristics. Our aim was to evaluate the characteristics of food allergen labelling and precautionary allergen labelling (PAL) in six Latin American countries. All data were collected directly from the supermarkets surveyed. A total of 10,254 packaged food products were analyzed, of which 63.3% (n = 6494) and 33.2% (n = 3405) featured allergen labelling and/or PAL, respectively. Most products complied with local regulations (≥87.4% for both locally produced and imported). Thirty-three types of PAL statements were detected; the most frequent was "may contain traces of…" (35.1%). Countries without regulations on the characteristics of allergen labelling had two-fold more products that contained allergens in their ingredients lists but no food allergen labelling. The use of PAL in countries that regulate it (38.2%) was as high as that in countries without PAL regulations (19.2%-44.7%). The findings suggest that the lack of regulations for the characteristics of allergen labeling increases the risk of accidental exposure to allergens of interest. Our findings also suggest that beyond regulations, a scientific approach is required for minimizing and standardizing the use of PAL.

Mexico Adopts Food Warning Labels, Why Now?

Mexico recently voted to implement front-of-pack warning labels on food and beverage products deemed high in calories, sugar, saturated fat, trans fat, and sodium, and those containing non-caloric sweeteners. Research shows that warning labels allow consumers to quickly identify healthy and unhealthy products. Supporters claim these labels can help people make healthier decisions and combat growing rates of obesity and diet-related diseases. Warning labels will replace the Guideline Daily Amount (GDA) nutrition labels, which were implemented in 2014 against the guidance of public health leaders who argued the GDA was hard to understand and ineffective at conveying health risks. Conflicting interests between public health, government, and food industry slowed efforts to adopt a new nutrition label. Actions by academia and civil society to change the GDA were met with common strategies used to interfere in public health policies. However, in 2019, several factors came together to create favorable conditions for the approval of warning labels. The new leftist government's public promises to fight corruption fit well with labeling advocates' calls for transparency. Civil society and academia developed a highly coordinated response thanks to international funding, which propelled extensive marketing campaigns around the country and supported research efforts. These actions helped make the topic visible and place it strategically in the political and public agendas. Despite this legislative victory, the opposition has been strong and there are struggles ahead. Only time will reveal how effectively the law is implemented and to what extent it is upheld and defended.

Implementing a Food Labeling and Marketing Law in Chile.

In 2012, Chile passed a law intended to reduce obesity in the country. It included several novel features, such as a front-of-package label, limitations to marketing and advertising, and policies targeting schools. The law required the creation of a regulation to address its implementation. Between 2012 and 2015, a process was carried out to generate this regulation that finally came into force in June 2016. This process confronted several difficulties: the involvement of multiple actors, political changes in national government, and endless negotiations to define the operational details of the regulation. The end result was one of the most discussed health policies of recent years in Chile. This article tells the story of the process defining this regulation, carried out between 2012 and 2015. It describes its evolution from a legal perspective but also reveals the trade-offs faced by the team in charge of providing the operational definitions for the implementation of the law. The article presents the main challenges as well the strategies used by the team at the Ministry of Health to overcome the many difficulties that arose during the process of implementing Chile's food labeling and marketing law. The experience of the Chilean reform may provide practical information and lessons for other countries and policy makers embarking on the task of preventing and reducing obesity. Although the Chilean experience has its own particularities, it also suggests common difficulties for similar reform processes in terms of technical challenges-such as the definition of concepts and the scope of regulation-and political challenges-like the opposition of the food industry and conflicts of interest among governmental institutions.

Barriers and facilitators to implementation of menu labelling interventions from a food service industry perspective: a mixed methods systematic review.

BACKGROUND: Eating outside the home contributes to poor dietary habits worldwide and is associated with increased body fat and weight gain. Evidence shows menu labelling is effective in promoting healthier food choices; however, implementation issues have arisen. The purpose of this systematic review was to synthesise the evidence on the perceived barriers and facilitators to implementation of menu labelling interventions from the perspective of the food service industry. METHODS: Peer-reviewed and grey literature were searched using databases, specialised search engines and public health organisation websites. Screening reference lists, citation chaining and contacting authors of all included studies were undertaken. Primary research studies relevant to direct supply-side stakeholders were eligible for inclusion. There were no restrictions on menu labelling scheme or format, study methods, publication year or language. At least two independent reviewers performed study selection, data extraction and quality appraisal. The results were synthesised using the 'best fit' framework synthesis approach, with reference to the Consolidated Framework for Implementation Research (CFIR). RESULTS: Seventeen studies met the eligibility criteria, with the majority rated as average quality (n = 10). The most frequently cited barriers were coded to the CFIR constructs 'Consumer Needs & Resources' (e.g. lack of customer demand for/interest in menu labelling, risk of overwhelmed/confused customers) and 'Compatibility' with organisation work processes (e.g. lack of standardised recipes, limited space on menus). Frequently cited facilitators were coded to the CFIR constructs 'Relative Advantage' of menu labelling (e.g. improved business image/reputation) and 'Consumer Needs & Resources' (e.g. customer demand for/interest in menu labelling, providing nutrition information to customers). An adapted framework consisting of a priori and new constructs was developed, which illustrates the relationships between domains. CONCLUSION: This review generates an adapted CFIR framework for understanding implementation of menu labelling interventions. It highlights that implementation is influenced by multiple interdependent factors, particularly related to the external and internal context of food businesses, and features of the menu labelling intervention. The findings can be used by researchers and practitioners to develop or select strategies to address barriers that impede implementation and to leverage facilitators that assist with implementation effort. TRIAL REGISTRATION: Systematic review registration: PROSPERO CRD42017083306.

Trends in the Nutrition Profile of Menu Items at Large Burger Chain Restaurants.

INTRODUCTION: Fast food restaurants, including top burger chains, have reduced calorie content of some menu items in recent years. However, the extent to which the nutrition profile of restaurant menus is changing over time is unknown. METHODS: Data from 2,472 food items on the menus of 14 top-earning burger fast food chain restaurants in the U.S., available from 2012 to 2016, were obtained from the MenuStat project and analyzed in 2019. Nutrition Profile Index scores were estimated and used to categorize foods as healthy (≥64 of 100). Generalized linear models examined mean scores and the proportion of healthy menu items among items offered in all years (2012-2016) and items offered in 2012 only compared with items newly introduced in subsequent years. RESULTS: Overall, <20% of menu items were classified as healthy with no change from 2012 to 2016 (p=0.91). Mean Nutrition Profile Index score was relatively constant across the study period among all food items (≈50 points, p=0.58) and children's menu items (≈56 points, p=0.73). The only notable change in Nutrition Profile Index score or in proportion of healthy items was in the direction of menu items becoming less healthy. CONCLUSIONS: At large chain burger restaurants, most items were unhealthy, and the overall nutrition profile of menus remained unchanged from 2012 to 2016. Future research should examine the nutrition profile of restaurant menus in a larger, more diverse sample of restaurants over a longer timeframe and examine whether results are robust when other measures of nutritional quality are used.

Percepción del etiquetado nutricional en población con obesidad y sobrepeso / Perception of the nutritional labels by population in risk of being obese or overweight

FUNDAMENTOS: El etiquetado nutricional representa una valiosa herramienta para ayudar a los consumidores a tomar decisiones informadas acerca de su dieta y estilo de vida. Son escasos los estudios realizados en España sobre la percepción de la información alimentaria por el consumidor y ninguno considera la población con obesidad y sobrepeso como objetivo principal. Por ello el objetivo de este trabajo es evaluar la percepción de esta población frente a la información que le proporciona el etiquetado de los alimentos, su comprensión, utilidad y uso. MÉTODOS: Se realiza 133 encuestas en personas de la Comunidad Valenciana con obesidad (27,8%) y sobrepeso (72,2%) sobre la lectura, hábitos de compra, comprensión y uso de la información alimentaria. RESULTADOS: Se observa que a pesar del interés por seguir una dieta saludable (27,8%) y la valoración positiva del etiquetado de los alimentos (91%), se lee poco (35,3%) y resulta difícil de comprender (35,6%). El precio es el condicionante que más influye a la hora de la compra (72,9%). El 72,9% no sigue una dieta especial. El semáforo nutricional es el etiquetado frontal mejor comprendido. CONCLUSIONES: La población con obesidad y sobrepeso tiene dificultad para interpretar y comprender el etiquetado de los alimentos

BACKGROUND: Nutritional food label represents a valuable tool to help consumers to make informed decisions about their diets and lifestyle. There are few studies carried out in Spain about the perception of the consumer and none of them has obese or overweight population as their main target. Consequently the high interest to conduct this research in order to assess the perception of this population to food label, their understanding, utility and use. METHODS: 133 surveys are conducted in Comunidad Valenciana on obese (27.8%) and overweight (72.2%) people regarding their reading, shopping habits, use and understanding of food information. RESULTS: It is observed that despite their interest to follow a healthy diet (27.8%) and the positive assessment of the food label (91.0%) little is read (35.3%) and it is difficult to understand (35.6%). Price is the most determining factor regarding purchase (72.9%). 72.9% of the population don't follow a special diet. Traffic light colours used on the front packaging is the best understood food label. CONCLUSIONS: Obese and overweight population has difficulty in interpreting and understanding food labels

Calorie and nutrient trends in large U.S. chain restaurants, 2012-2018.

INTRODUCTION: Large chain restaurants reduced calories in their newly-introduced menu items from 2012 to 2015. The objective of this study was to provide updated calorie trends through 2018 and examine trends in the macronutrient composition of menu items across this time period. METHODS AND FINDINGS: Data were obtained from the MenuStat project and include 66 of the 100 largest revenue generating U.S. chain restaurants (N = 28,238 items) that had data available in all years from 2012 to 2018. Generalized linear models were used to examine per-item calorie and nutrient changes (saturated fat, trans fat, unsaturated fat, sugar, non-sugar carbohydrates, protein, sodium) among (1) items on the menu in all years (common items) and (2) newly introduced items (2013-2018). Overall, there were no significant changes in calories or nutrients among common items from 2012 to 2018. Among all newly introduced items, calories (-120 kcals, -25%, p = 0.01; p-for-trend = 0.02), saturated fat (-3.4g, -41%, p<0.01, p-for-trend = 0.06), unsaturated fat (-4.5g, -37%, p = 0.02; p-for-trend = 0.04), non-sugar carbohydrates (-10.3g, -40%, p = 0.02, p-for-trend = 0.69), and protein (-4.3g, -25%, p = 0.04, p-for-trend = 0.02) declined. CONCLUSION: Newly introduced menu items in large chain restaurants have continued to decline in calories through 2018, which may help to reduce calorie intake. Other changes in macronutrient content were sporadic and not clearly toward improved dietary quality.

Growing the Business of Whole Grain in the Australian Market: A 6-Year Impact Assessment.

The Australia New Zealand Food Standards Code does not regulate on-pack claims describing the amount of whole grain in foods. In July 2013, The Grains & Legumes Nutrition CouncilTM (GLNC) established a voluntary Code of Practice for Whole Grain Ingredient Content Claims (the Code) providing guidance for whole grain claims, with cut-off values and suggested wording ≥8 g, ≥16 g, and ≥24 g per manufacturer serve (contains; high and very high in whole grain), based on a 48 g whole grain daily target intake. The aim of this impact assessment was to report the uptake of the Code by manufacturers, changes in numbers of whole grain products, and claims on-pack since 2013, including compliance. The impact assessment was undertaken in August 2019, comparing current registered manufacturers ("users") and their products to the total number of products in the market deemed eligible for registration through GLNC product audits since 2013. Reporting included breakfast cereals, bread products, crispbreads, crackers, rice/corn cakes, rice, pasta, noodles, couscous, other grains (e.g., quinoa, buckwheat, freekeh), and grain-based muesli bars. As of 30 June 2019, there were 33 registered users and 531 registered products in Australia and New Zealand representing 43% of the eligible manufacturers and 65% of the eligible whole grain foods. Three-quarters (78% and 74%) of the eligible breakfast cereals and bread products were registered with the Code in 2019, followed by 62% of grain-based muesli bars. Only 39% of crispbread, crackers, rice/corn cakes, and rice, pasta, noodles, couscous, and other grains were registered. From 2013 there has been a 71% increase in the number of whole grain foods making claims, demonstrating strong uptake by industry, with clearer, more consistent, and compliant on-pack communication regarding whole grain content.

A New Age of Evolution: Protecting the Consumer's Moral and Legal Right to Know through the Clear and Transparent Labeling of All Genetically Modified Foods.

The United States government, until recently, did not require the labeling of genetically modified organisms (GMOs). On July 29, 2016, President Barack Obama signed into law the National Bioengineered Food Disclosure Standard (NBFDS). This law directs the United States Department of Agriculture (USDA) to create regulations that require manufacturers to disclose certain bioengineered products on food labels. On December 20, 2018, the USDA released the final regulations for the NBFDS, which requires food manufactures, importers, and certain retailers to ensure bioengineered foods are appropriately disclosed. The final regulations include provisions that will leave the majority of GMO derived foods unlabeled. The final regulations also restrict approximately 100 million Americans from accessing GMO information by allowing QR codes to replace clear and transparent labeling, an issue that will be discussed in further detail later in this Note. This Note explores why you, as a consumer, may want to know whether your food contains GM products, and furthermore, why you as a consumer have a moral and legal right to know.

Tracking Kids' Food: Comparing the Nutritional Value and Marketing Appeals of Child-Targeted Supermarket Products Over Time.

Marketing unhealthy foods negatively impacts children's food preferences, dietary habits and health, prompting calls for regulations that will help to create an "enabling" food environment for children. One powerful food marketing technique is product packaging, but little is known about the nature or quality of child-targeted food products over time. This study assesses how child-targeted supermarket foods in Canada have transformed with respect to nutritional profile and types of marketing appeals (that is, the power of such marketing). Products from 2009 (n = 354) and from 2017 (n = 374) were first evaluated and compared in light of two established nutritional criteria, and then compared in terms of marketing techniques on packages. Overall, child-targeted supermarket foods did not improve nutritionally over time: 88% of child-targeted products (across both datasets) would not be permitted to be marketed to children, according to the World Health Organization (WHO) criteria, and sugar levels remained consistently high. Despite this poor nutritional quality, the use of nutrition claims increased significantly over time, as did the use of cartoon characters and appealing fonts to attract children's attention. Character licensing-using characters from entertainment companies-remained consistent. The findings reveal the critical need to consider packaging as part of the strategy for protecting children from unhealthy food marketing. Given the poor nutritional quality and appealing nature of child-oriented supermarket foods, food product packaging needs to be included in the WHO's call to improve the restrictions on unhealthy food marketing to children.

Trends in Calories and Nutrients of Beverages in U.S. Chain Restaurants, 2012-2017.

INTRODUCTION: Although beverages comprise one third of all menu items at large chain restaurants, no prior research has examined trends in their calorie and nutrient content. METHODS: Beverages (n=13,879) on the menus of 63 U.S. chain restaurants were the final analytic sample obtained from a restaurant nutrition database (MenuStat, 2012-2017). For each beverage type, cluster-bootstrapped mixed-effects regressions estimated changes in mean calories, sugar, and saturated fat for beverages available on menus in all years and for newly introduced beverages. Data were analyzed in 2018. RESULTS: Traditional sugar-sweetened beverages, sweetened teas, and blended milk-based beverages (e.g., milkshakes) were significantly higher in calories from 2012 to 2017 for newly introduced beverages (p-value for trend <0.004). For all newly introduced sweetened beverages, sugar increased significantly (2015, +7.9 g; 2016, +8.2 g; p<0.004) whereas saturated fat declined (2016, -2.3 g; 2017, -1.6 g; p<0.004). For beverages on menus in all years, saturated fat declined significantly (p<0.001), whereas mean calories and sugar remained relatively constant. Significant declines were observed for sweetened coffees (-10 kcal, -0.5 g saturated fat, p<0.001), teas (-2.6 g sugar, p=0.001), and blended milk-based beverages (-28 kcal, -4.2 g sugar, -0.8 g saturated fat, p<0.001). From 2012 to 2017, the total number of beverage offerings increased by 155%, with 82% of this change driven by sweetened beverages. CONCLUSIONS: Sweetened beverages available in large chain restaurants were consistently high in calories, sugar, and saturated fat and substantially increased in quantity and variety from 2012 to 2017.

Smart food policy for healthy food labeling: Leading with taste, not healthiness, to shift consumption and enjoyment of healthy foods.

Smart food policy models for improving dietary intake recommend tailoring interventions to people's food preferences. Yet, despite people citing tastiness as their leading concern when making food choices, healthy food labels overwhelmingly emphasize health attributes (e.g., low caloric content, reductions in fat or sugar) rather than tastiness. Here we compared the effects of this traditional health-focused labeling approach to a taste-focused labeling approach on adults' selection and enjoyment of healthy foods. Four field studies (total N = 4273) across several dining settings in northern California in 2016-2017 tested whether changing healthy food labels to emphasize taste and satisfaction rather than nutritional properties would encourage more people to choose them (Studies 1-2), sustain healthy purchases over the long-term (Study 3), and improve both the perceived taste of and mindsets about healthy foods (Study 4). Compared to health-focused labeling, taste-focused labeling increased choice of vegetables (OR = 1.73, 95% CI: 1.32, 2.26), salads (OR = 2.06, 95% CI: 1.06, 4.06), and vegetable wraps (OR = 3.09, 95% CI: 1.73, 5.65) in Studies 1-2. In Study 3, taste-focused labeling sustained vegetarian entrée purchases over a two-month period, while health-focused labeling led to a 45.1% decrease. In Study 4, taste-focused labeling significantly enhanced post-consumption ratings of vegetable deliciousness and improved mindsets about the deliciousness of healthy foods compared to health-focused labeling. These studies demonstrate that taste-focused labeling is a low-cost strategy that increased healthy food selection by 38% and outperforms health-focused labeling on multiple smart food policy mechanisms.

Barriers and facilitators to implementation of menu labelling interventions to support healthy food choices: a mixed methods systematic review protocol.

BACKGROUND: Menu labelling is continuing to gather public and legislative support as one of the potential environmental strategies for addressing the obesity pandemic. However, issues relating to implementation have been reported in countries where menu labelling has been introduced on a voluntary or mandatory basis. The aim of this mixed methods systematic review is to synthesise the empirical evidence on the barriers and facilitators to implementation of menu labelling interventions to support healthy food choices. METHODS: This review will use the 'best fit' framework synthesis approach to synthesise qualitative, quantitative and mixed methods evidence. Peer-reviewed publications will be accessed through PubMed, EMBASE, CINAHL, PsycINFO, Web of Science and Scopus. Grey literature will be accessed through Google Scholar, OpenGrey, RIAN, EThOS, ProQuest, WorldCat, Networked Digital Library of Theses and Dissertations, Open Access Theses and Dissertations, and public health organisation websites. Screening reference lists, citation chaining and contacting authors of all included studies will be undertaken. There will be no restriction on menu labelling scheme or format, publication year or language; however, only primary research studies relevant to supply-side stakeholders will be eligible for inclusion. Study quality will be assessed using the Mixed Methods Appraisal Tool. At least two independent reviewers will perform study selection, data extraction and quality appraisal; if consensus is required, another independent reviewer will be consulted. A combination of deductive coding, using the Consolidated Framework for Implementation Research as the a priori framework, and inductive analysis, using secondary thematic analysis, will be used. The overall process will assist in the construction of a new evidence-based conceptual model regarding the implementation of menu labelling interventions. The new model will be assessed for bias and a sensitivity analysis performed. DISCUSSION: Given the growing consensus that a systemic, sustained portfolio of obesity prevention strategies, delivered at scale, is needed to address the obesity epidemic, greater understanding of the practical issues relating to implementation of such strategies is required. Findings from this review will be used to develop a set of best-practice guidelines to enhance the adoption, implementation and sustainability of menu labelling interventions across countries worldwide. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017083306.

Changes in the nutritional quality of fast-food items marketed at restaurants, 2010 v. 2013.

OBJECTIVE: To examine the nutritional quality of menu items promoted in four (US) fast-food restaurant chains (McDonald's, Burger King, Wendy's, Taco Bell) in 2010 and 2013. DESIGN: Menu items pictured on signs and menu boards were recorded at 400 fast-food restaurants across the USA. The Nutrient Profile Index (NPI) was used to calculate overall nutrition scores for items (higher scores indicate greater nutritional quality) and was dichotomized to denote healthier v. less healthy items. Changes over time in NPI scores and energy of promoted foods and beverages were analysed using linear regression. SETTING: Four hundred fast-food restaurants (McDonald's, Burger King, Wendy's, Taco Bell; 100 locations per chain). SUBJECTS: NPI of fast-food items marketed at fast-food restaurants. RESULTS: Promoted foods and beverages on general menu boards and signs remained below the 'healthier' cut-off at both time points. On general menu boards, pictured items became modestly healthier from 2010 to 2013, increasing (mean (se)) by 3·08 (0·16) NPI score points (P<0·001) and decreasing (mean (se)) by 130 (15) kJ (31·1 (3·65) kcal; P<0·001). This pattern was evident in all chains except Taco Bell, where pictured items increased in energy. Foods and beverages pictured on the kids' section showed the greatest nutritional improvements. Although promoted foods on general menu boards and signs improved in nutritional quality, beverages remained the same or became worse. CONCLUSIONS: Foods, and to a lesser extent, beverages, promoted on menu boards and signs in fast-food restaurants showed limited improvements in nutritional quality in 2013 v. 2010.