Evaluation of a state-wide intervention on salt intake in primary schoolchildren living in Victoria, Australia.

OBJECTIVE: In 2015, the Victorian Salt Reduction Partnership launched a 4-year multifaceted salt reduction intervention designed to reduce salt intake by 1 g/d in children and adults living in Victoria, Australia. Child-relevant intervention strategies included a consumer awareness campaign targeting parents and food industry engagement seeking to reduce salt levels in processed foods. This study aimed to assess trends in salt intake, dietary sources of salt and discretionary salt use in primary schoolchildren pre- and post-delivery of the intervention. DESIGN: Repeated cross-sectional surveys were completed at baseline (2010-2013) and follow-up (2018-2019). Salt intake was measured via 24-h urinary Na excretion, discretionary salt use behaviours by self-report and sources of salt by 24-h dietary recall. Data were analysed with multivariable-adjusted regression models. SETTING: Victoria, Australia. PARTICIPANTS: Children aged 4-12 years. RESULTS: Complete 24-h urine samples were collected from 666 children at baseline and 161 at follow-up. Mean salt intake remained unchanged from baseline (6·0; se 0·1 g/d) to follow-up (6·1; 0·4 g/d) (P = 0·36), and there were no clear differences in the food sources of salt and at both time points approximately 70 % of children exceeded Na intake recommendations. At follow-up, 14 % more parents (P = 0·001) reported adding salt during cooking, but child use of table salt and inclusion of a saltshaker on the table remained unchanged. CONCLUSION: These findings show no beneficial effect of the Victorian Salt Reduction Partnership intervention on children's salt intake. More intensive, sustained and coordinated efforts between state and federal stakeholders are required.

Junk Food Intake Among Adults in the United States.

BACKGROUND: There is no consensus on how to define "junk food." In 2016, Chile implemented the most comprehensive set of obesity-preventive regulations in the world, including criteria to define unhealthy foods. OBJECTIVES: The objective of this study was to examine the amount of energy, sodium, sugar, and saturated fat consumed by US adults defined as junk food using the Chilean criteria. METHODS: We used 2 nationally representative surveys of food intake in 10,001 US adults: NHANES 2015-2016 and NHANES 2017-2018. The main outcome measures were the contributions of energy, total sugars, saturated fat, and sodium deriving from junk food sources. Mean intake and proportion of energy, sugar, saturated fat, and sodium for junk food overall and each food category were calculated. RESULTS: Overall, 47% of energy, 75% of total sugar, 46% of sodium, and 48% of saturated fat consumed by US adults derived from junk food sources. Sugar-sweetened beverages (SSBs) were responsible for more than 40% of total sugar intake deriving from junk foods. Non-Hispanic black adults had the highest mean energy, total sugar, and sodium intake deriving from junk foods, with non-Hispanic white adults having the highest saturated fat intake. Non-Hispanic black adults had the highest intake of total sugar deriving from junk food sources of SSBs (26.7 g/d), with SSBs representing >40% of total sugar intake deriving from junk food sources for all race/ethnic groups. CONCLUSIONS: Foods that meet the Chilean criteria for junk food provide approximately half or more daily energy and food components to limit in the diet of US adults, with important differences observed between race/ethnic groups. Policy efforts to reduce junk food intake, particularly the intake of SSBs, must be expanded to improve the cardiometabolic health equitably in the United States.

Whole Grain and Refined Grains: An Examination of US Household Grocery Store Purchases.

BACKGROUND: The health benefits related to intake of whole grain foods are well established. Consumption of whole grains in the US population is low, and whole grain content can vary greatly depending upon the specific products that are purchased. OBJECTIVES: To examine the proportion of products purchased by US households containing whole grain and refined grain ingredients using time-specific food composition data, and examine whether purchases differ between income, race or ethnicity, and household make-up. METHODS: Nationally representative Nielsen Homescan 2018 data were used. Each barcoded product captured in Nielsen Homescan 2018 was linked with ingredient information using commercial nutrition databases in a time-relevant manner. Packaged food products containing whole grain ingredients, refined grain ingredients, neither, or both were identified. The percentage of packaged food products containing whole grain and refined grain ingredients purchased by US households was determined overall, by demographic subgroup, and by food category. RESULTS: The proportion of packaged food purchases containing refined grain ingredients was significantly higher than whole grain ingredients (30.9% compared with 7.9%; P < 0.0001). Lower income households and households with children purchased a significantly higher proportion of products containing refined grain ingredients, with no nutritionally meaningful racial or ethnic differences observed. Concerningly, across all demographic subgroups >90% of bread purchases contained refined grain ingredients, and the 5 categories with the largest proportion of whole grain ingredients contributed to <20% of overall US household packaged food purchases. CONCLUSIONS: US households are purchasing a significantly higher proportion of packaged food products containing refined grain ingredients than whole grain ingredients. Future policy changes are needed to provide incentives and information (e.g., front-of-pack labels) to aid in encouraging manufacturers to increase whole grain product offerings while decreasing refined grain offerings, and to encourage consumers to substitute away from refined grain products toward whole grain products.

Availability, healthiness, and price of packaged and unpackaged foods in India: A cross-sectional study.

Background: Vulnerable populations are the most prone to diet-related disease. The availability, healthiness, and price of foods have established associations with diet-related disease in communities. However, data describing this in India are sparse, particularly in urban slums and rural areas. Aim: To quantify and compare availability, healthiness, and price of packaged and unpackaged foods and beverages in India, and to identify opportunities to improve diets and health of vulnerable populations. Methods: Nutrition data and price were collected on foods and beverages available at 44 stores in urban, urban slum, and rural areas in four states in India between May and August 2018. Healthiness was assessed using the Australasian Health Star Rating system and product retail prices were examined. Comparisons in the findings were made across state, community area type, and adherence to current and draft Indian food labeling regulations. Results: Packaged foods and beverages (n = 1443, 89%) were more prevalent than unpackaged (n = 172, 11%). Unpackaged products were healthier than packaged (mean Health Star Rating = 3.5 vs 2.0; p < 0.001) and lower in price (median price per 100 g/ml: 13.42 Indian rupees vs 25.70 Indian rupees; p < 0.001), a pattern observed across most community area types and states. 96% of packaged products were compliant with current Indian labeling regulations but only 23% were compliant with proposed labeling regulations. Conclusions: Unpackaged products were on average much healthier and lower in price than packaged foods and beverages. Food policies that support greater availability, accessibility and consumption of unpackaged foods, while limiting consumption of packaged foods, have enormous potential for sustaining the health of the Indian population.

Estimating the potential impact of the Australian government's reformulation targets on household sugar purchases.

BACKGROUND: Countries around the world are putting in place sugar reformulation targets for packaged foods to reduce excess sugar consumption. The Australian government released its voluntary sugar reformulation targets for nine food categories in 2020. We estimated the potential impact of these targets on household sugar purchases and examined differences by income. For comparison, we also modelled the potential impact of the UK sugar reduction targets on per capita sugar purchases as the UK has one of the most comprehensive sugar reduction strategies in the world. METHODS: Grocery purchase data from a nationally representative consumer panel (n=7,188) in Australia was linked with a large database (FoodSwitch) with product-specific sugar content information for packaged foods (n=25,261); both datasets were collected in 2018. Potential reductions in per capita sugar purchases were calculated overall and by food category. Differences in sugar reduction across income level were assessed by analysis of variance. RESULTS: In 2018, the total sugar acquired from packaged food and beverage purchases consumed at-home was 56.1 g/day per capita. Australia's voluntary reformulation targets for sugar covered 2,471/25,261 (9.8%) unique products in the FoodSwitch dataset. Under the scenario that all food companies adhered to the voluntary targets, sugar purchases were estimated to be reduced by 0.9 g/day per capita, which represents a 1.5% reduction in sugar purchased from packaged foods. However, if Australia adopted the UK targets, over twice as many products would be covered (n=4,667), and this would result in a more than four times greater reduction in sugar purchases (4.1 g/day per capita). It was also estimated that if all food companies complied with Australia's voluntary sugar targets, reductions to sugar would be slightly greater in low-income households compared with high-income households by 0.3 g/day (95%CI 0.2 - 0.4 g/day, p<0.001). CONCLUSIONS: Sugar-reduction policies have the potential to substantially reduce population sugar consumption and may help to reduce health inequalities related to excess sugar consumption. However, the current reformulation targets in Australia are estimated to achieve only a small reduction to sugar intakes, particularly in comparison to the UK's sugar reduction program.

Correction to: Contribution of major food companies and their products to household dietary sodium purchases in Australia.

An amendment to this paper has been published and can be accessed via the original article.

Contribution of major food companies and their products to household dietary sodium purchases in Australia.

BACKGROUND: The Australian federal government will soon release voluntary sodium reduction targets for 30 packaged food categories through the Healthy Food Partnership. Previous assessments of voluntary targets show variable industry engagement, and little is known about the extent that major food companies and their products contribute to dietary sodium purchases among Australian households. METHODS: The aim of this cross-sectional study was to identify the relative contribution that food companies and their products made to Australian household sodium purchases in 2018, and to examine differences in sodium purchases by household income level. We used 1 year of grocery purchase data from a nationally representative consumer panel of Australian households who reported their grocery purchases (the Nielsen Homescan panel), combined with database that contains product-specific sodium content for packaged foods and beverages (FoodSwitch). The top food companies and food categories were ranked according to their contribution to household sodium purchases. Differences in per capita sodium purchases by income levels were assessed by 1-factor ANOVA. All analyses were modelled to the Australian population in 2018 using sample weights. RESULTS: Sodium data were available from 7188 households who purchased 26,728 unique products and purchased just under 7.5 million food product units. Out of 1329 food companies, the top 10 accounted for 35% of unique products and contributed to 58% of all sodium purchased from packaged foods and beverages. The top three companies were grocery food retailers each contributing 12-15% of sodium purchases from sales of their private label products, particularly processed meat, cheese and bread. Out of the 67 food categories, the top 10 accounted for 73% of sodium purchased, particularly driven by purchases of processed meat (14%), bread (12%) and sauces (11%). Low-income Australian households purchased significantly more sodium from packaged products than high-income households per capita (452 mg/d, 95%CI: 363-540 mg/d, P < 0.001). CONCLUSIONS: A small number of food companies and food categories account for most of the dietary sodium purchased by Australian households. Prioritizing government engagement with these groups could deliver a large reduction in population sodium intake.

Sources of dietary sodium and implications for a statewide salt reduction initiative in Victoria, Australia.

In Victoria, Australia, a statewide salt reduction partnership was launched in 2015. The aim was to measure Na intake, food sources of Na (level of processing, purchase origin) and discretionary salt use in a cross-section of Victorian adults prior to a salt reduction initiative. In 2016/2017, participants completed a 24-h urine collection (n 338) and a subsample completed a 24-h dietary recall (n 142). Participants were aged 41·2 (sd 13·9) years, and 56 % were females. Mean 24-h urinary excretion was 138 (95 % CI 127, 149) mmol/d for Na. Salt equivalent was 8·1 (95 % CI 7·4, 8·7) g/d, equating to about 8·9 (95 % CI 8·1, 9·6) g/d after 10 % adjustment for non-urinary losses. Mean 24-h intake estimated by diet recall was 118 (95 % CI 103, 133) mmol/d for Na (salt 6·9 (95 % CI 6·0, 7·8 g/d)). Leading dietary sources of Na were cereal-based mixed dishes (12 %), English muffins, flat/savoury/sweet breads (9 %), regular breads/rolls (9 %), gravies and savoury sauces (7 %) and processed meats (7 %). Over one-third (38 %) of Na consumed was derived from discretionary foods. Half of all Na consumed came from ultra-processed foods. Dietary Na derived from foods was obtained from retail stores (51 %), restaurants and fast-food/takeaway outlets (28 %) and fresh food markets (9 %). One-third (32 %) of participants reported adding salt at the table and 61 % added salt whilst cooking. This study revealed that salt intake was above recommended levels with diverse sources of intake. Results from this study suggest a multi-faceted salt reduction strategy focusing on the retail sector, and food reformulation would most likely benefit Victorians and has been used to inform the ongoing statewide salt reduction initiative.

Simulating the impact of sodium reduction from packaged foods on population sodium intake in US adults and children.

OBJECTIVE: To simulate the impact that Na reductions in food categories that are the largest contributors to dietary Na intake would have on population Na intake from packaged foods among US adults and children. DESIGN: 24 h Dietary recall data were used. For each store-bought packaged food product reported by participants, we generated sales-weighted Na content at the median and 25th percentile using Nutrition Facts Panel data from 193 195 products purchased by US households. The impact that Na reductions would have on population Na intake, overall and by sociodemographic subgroup, was examined. SETTINGS: US households. PARTICIPANTS: Children aged 2-18 years (n 2948) and adults aged >18 years (n 4878), 2011-2012 National Health and Nutrition Examination Survey. RESULTS: Na intake from packaged foods was 1258 (se 21) mg for adults and 1215 (se 35) mg for children. Top-ten packaged food group sources contributed 67 % of Na intake. For adults and children, there was a decrease of 8·7 % (109 mg) and 8·0 % (97 mg), respectively, in Na intake if the top-ten sources reduced Na from the median to the 25th percentile. Although absolute reduction in intake varied between sociodemographic subgroups, significant differences were not observed. CONCLUSIONS: The study demonstrated that if Na reduction shifted the top-ten packaged food group sources of dietary Na intake from the median to 25th percentile, population Na intake would be reduced by 9 % in US adults and children. These findings will help inform the US government's Na reduction targets, as well as policy makers' understanding of differences in intake of critical sub-populations in the USA.

How Does the Healthfulness of the US Food Supply Compare to International Guidelines for Marketing to Children and Adolescents?

Objectives Food marketing to children is pervasive and linked to increased preference and intake of unhealthy foods. The World Health Organization (WHO) developed the only multi-country nutrient criteria, and Chile recently released the world's most comprehensive regulation to identify foods that should not be marketed to children. Our objective was to examine the proportion of US packaged food and beverage products eligible for marketing to children under the WHO Europe Nutrient Profile Model (NPM) and the 2019 Chilean regulation. Methods Data for this study are from Label Insight's 2017 Open Access branded food database. Each product was assigned to one of 13 food categories, and nutritional content compared to both the NPM and Chilean criteria. The proportion of US products meeting criteria for marketing to children using both schemes was examined overall and by category. Agreement between the two criteria was examined using Cohen's Kappa. Results Of 17,740 US products, 21% were eligible to be marketed to children using the WHO criteria and 26% using the Chilean criteria. 'Egg and egg products' and 'Seafood' had the highest proportion of products eligible for marketing to children under both schemes. 'Confectionery' and 'Snack foods' had the lowest proportion eligible. Conclusions for practice The WHO NPM and Chilean criteria both restrict less healthy items from being marketed to children. Regulatory agencies in the US developing policies should consider the implementation of nutrient criteria to restrict the marketing of less healthy foods and beverages to children and adolescents.

Monitoring the changes to the nutrient composition of fast foods following the introduction of menu labelling in New South Wales, Australia: an observational study.

OBJECTIVE: The present study examined the energy (kilojoule) content of Australian fast-food menu items over seven years, before and after introduction of menu board labelling, to determine the impact of the introduction of the legislation. DESIGN: Analysis of the median energy contents per serving and per 100g of fast-food menu items. Change in energy content of menu items across the years surveyed and differences in energy content of standard and limited-time only menu items were analysed. SETTING: Five of Australia's largest fast food chains: Hungry Jack's, KFC, McDonald's, Oporto and Red Rooster. SUBJECTS: All standard and limited-time only menu items available at each fast-food chain, collected annually for seven years, 2009-2015. RESULTS: Although some fast-food chains/menu item categories had significant increases in the energy contents of their menus at some time points during the 7-year period, overall there were no significant or systematic decreases in energy following the introduction of menu labelling (P=0·19 by +17 kJ/100 g, P=0·83 by +8 kJ/serving). Limited-time only items were significantly higher in median energy content per 100 g than standard menu items (+74 kJ/100 g, P=0·002). CONCLUSIONS: While reformulation across the entire Australian fast-food supply has the potential to positively influence population nutrient intake, the introduction of menu labelling legislation in New South Wales, Australia did not lead to reduced energy contents across the five fast-food chains. To encourage widespread reformulation by the fast-food industry and enhance the impact of labelling legislation, the government should work with industry to set targets for reformulation of nutrient content.

Differences in the sodium content of bread products in the USA and UK: implications for policy.

OBJECTIVE: Americans consume Na in excess of daily recommendations. Most dietary Na comes from packaged foods, and bread is a major contributor. In the UK, national Na reduction strategies contributed to lower Na levels in packaged foods and lower population Na intake. Similar initiatives are emerging in the USA and require surveillance to assess effectiveness. We aimed to examine Na levels in bread products in the USA and compare levels with similar UK products. DESIGN: Na data for bread products were obtained from the US Label Insight Open Data Initiative (n 4466) and the FoodSwitch UK database (n 1651). Mean, median and range of Na content, and proportion of products meeting Na targets established by the National Salt Reduction Initiative (NSRI) and the UK Department of Health (DH) were calculated overall, by bread type and by country. RESULTS: Mean (sd) Na content in bread was 455 (170) mg/100 g in the USA and 406 (179) mg/100 g in the UK. In both countries, savoury bread had the highest mean Na (USA=584 mg/100 g, UK=543 mg/100 g) and fruit bread the lowest mean Na (USA=345 mg/100 g, UK=277 mg/100 g). Na content of US bread products was 12 % higher than in the UK, with 21 % of US bread products and 31 % of UK bread products meeting the NSRI and DH targets, respectively. CONCLUSIONS: US bread products have, on average, 12 % more Na than similar products in the UK. Variation in Na content within product categories, and between countries, suggests the feasibility of manufacturing products with lower Na to lower dietary Na intake.

The major types of added sugars and non-nutritive sweeteners in a sample of Australian packaged foods.

OBJECTIVE: Limiting the intake of added sugars in the diet remains a key focus of global dietary recommendations. To date there has been no systematic monitoring of the major types of added sugars used in the Australian food supply. The present study aimed to identify the most common added sugars and non-nutritive sweeteners in the Australian packaged food supply. DESIGN: Secondary analysis of data from the Australian FoodSwitch database was undertaken. Forty-six added sugars and eight non-nutritive sweetener types were extracted from the ingredient lists of 5744 foods across seventeen food categories. SETTING: Australia. SUBJECTS: Not applicable. RESULTS: Added sugar ingredients were found in 61 % of the sample of foods examined and non-nutritive sweetener ingredients were found in 69 %. Only 31 % of foods contained no added sugar or non-nutritive sweetener. Sugar (as an ingredient), glucose syrup, maple syrup, maltodextrin and glucose/dextrose were the most common sugar ingredient types identified. Most Australian packaged food products had at least one added sugar ingredient, the most common being 'sugar'. CONCLUSIONS: The study provides insight into the most common types of added sugars and non-nutritive sweeteners used in the Australian food supply and is a useful baseline to monitor changes in how added sugars are used in Australian packaged foods over time.

A comparison of the Health Star Rating system when used for restaurant fast foods and packaged foods.

BACKGROUND: In June 2014, the Australian government agreed to the voluntary implementation of an interpretive 'Health Star Rating' (HSR) front-of-pack labelling system for packaged foods. The aim of the system is to make it easier for consumers to compare the healthiness of products based on number of stars. With many Australians consuming fast food there is a strong rationale for extending the HSR system to include fast food items. OBJECTIVE: To examine the performance of the HSR system when applied to fast foods. DESIGN: Nutrient content data for fast food menu items were collected from the websites of 13 large Australian fast-food chains. The HSR was calculated for each menu item. Statistics describing HSR values for fast foods were calculated and compared to results for comparable packaged foods. RESULTS: Data for 1529 fast food products were compared to data for 3810 packaged food products across 16 of 17 fast food product categories. The mean HSR for the fast foods was 2.5 and ranged from 0.5 to 5.0 and corresponding values for the comparator packaged foods were 2.6 and 0.5 to 5.0. Visual inspection of the data showed broadly comparable distributions of HSR values across the fast food and the packaged food categories, although statistically significant differences were apparent for seven categories (all p < 0.04). In some cases these differences reflected the large sample size and the power to detect small variations across fast foods and packaged food, and in others it appeared to reflect primarily differences in the mix of product types within a category. CONCLUSIONS: These data support the idea that the HSR system could be extended to Australian fast foods. There are likely to be significant benefits to the community from the use of a single standardised signposting system for healthiness across all fresh, packaged and restaurant foods.

A nutrient profiling assessment of packaged foods using two star-based front-of-pack labels.

OBJECTIVE: To compare two front-of-pack nutrition labelling systems for the assessment of packaged foods and drinks with Australian Dietary Guidelines. DESIGN: A cross-sectional nutrient profiling assessment. Food and drink products (n 20 225) were categorised into scoring levels using criteria for the Institute of Medicine (IOM) three-star system and the five-star Australian Health Star Rating (HSR). The effectiveness of these systems to categorise foods in accordance with Australian Dietary Guidelines was explored. SETTING: The study was conducted in Australia, using a comprehensive food database. SUBJECTS: Packaged food and drink products (n 20 225) available in Australia. RESULTS: Using the IOM three-star system, the majority (55 %) of products scored the minimum 0 points and 25·5 % scored the maximum 3 points. Using HSR criteria, the greatest proportion of products (15·2 %) scored three-and-a-half stars from a possible five and 12·5 % received the lowest rating of a half-star. Very few products (4·1 %) scored five stars. Products considered core foods and drinks in Australian Dietary Guidelines received higher scores than discretionary foods in all food categories for both labelling systems (all P<0·05; Mann-Whitney U test), with the exception of fish products using IOM three-star criteria (P=0·603). The largest discrepancies in median score between the two systems were for the food categories edible oils, convenience foods and dairy. CONCLUSIONS: Both the IOM three-star and Australian HSR front-of-pack labelling systems rated packaged foods and drinks broadly in line with Australian Dietary Guidelines by assigning core foods higher ratings and discretionary foods lower ratings.

Changes in the sodium content of leading Australian fast-food products between 2009 and 2012.

UNLABELLED: OBJECTIVE To define the changes in sodium levels of Australian fast foods between 2009 and 2012 overall, in major food subcategories and by company. DESIGN: A comparison of mean sodium content was made across 4 years using t tests and mixed models. SETTING: Nutrient content data for fast-food menu items collected from company websites of six large Australian fast-food chains. MAIN OUTCOME MEASURES: Mean sodium values in mg/100 g and mg/serve. RESULTS: There were between 302 and 381 products identified each year. Overall, the mean sodium content of fast-food products decreased between 2009 and 2012 by 43 mg/100 g (95% CI, - 66 to - 20 mg/100 g), from 514 mg/100 g in 2009 to 471 mg/100 g in 2012. Mean sodium content per serving was not significantly different at 654 mg in 2009 and 605 mg in 2012 (- 49 mg; 95% CI, - 108 to + 10 mg), reflecting wide variation in the serving sizes of items offered each year. There was a small decline in sodium content over the 4 years across most food categories and food companies. CONCLUSIONS: The observed reduction in the sodium content of fast foods during the 4-year study period is encouraging. However, the reductions are small, and fast-food companies should be encouraged to make further and larger reductions since many products still contain high levels of sodium.

The salt content of products from popular fast-food chains in Costa Rica.

Salt is a major determinant of population blood pressure levels. Salt intake in Costa Rica is above levels required for good health. With an increasing number of Costa Ricans visiting fast food restaurants, it is likely that fast-food is contributing to daily salt intake. Salt content data from seven popular fast food chains in Costa Rica were collected in January 2013. Products were classified into 10 categories. Mean salt content was compared between chains and categories. Statistical analysis was performed using Welch ANOVA and Tukey-Kramer HSD tests. Significant differences were found between companies; Subway products had lowest mean salt content (0.97 g/100 g; p < 0.05) while Popeye's and KFC had the highest (1.57 g/100 g; p < 0.05). Significant variations in mean salt content were observed between categories. Salads had a mean salt content of 0.45 g/100 g while sauces had 2.16 g/100 g (p < 0.05). Wide variation in salt content was also seen within food categories. Salt content in sandwiches ranged from 0.5 to 2.1 g/100 g. The high levels and wide variation in salt content of fast food products in Costa Rica suggest that salt reduction is likely to be technically feasible in many cases. With an increasing number of consumers purchasing fast foods, even small improvements in salt levels could produce important health gains.

Could Google Help Curb Online Advertising of Unhealthy Foods to U.S. Children?

INTRODUCTION: In 2020, Google took voluntary action to restrict food and beverage advertising through its online channels in the European Union/United Kingdom using Google's own nutrient profiling model to identify products eligible to be marketed to children through its Google Display Network. The objective of this study was to evaluate the potential impact of the Google policy, if applied to the U.S. market, on restricting online advertising of the top-selling packaged foods and beverages in the U.S. METHODS: The top 25 U.S. food and beverage manufacturers were identified. Nutrient data for products from these manufacturers were sourced from Label Insight (a Nielsen IQ company) in 2021. Each product was examined against four nutrient profiling models: the Google nutrient profiling model, the WHO Europe nutrient profiling model, the Pan American Health Organization nutrient profiling model, and the Chilean government nutrient profiling model. RESULTS: Under Google's nutrient profiling model, 18% of 14,188 products were eligible to be advertised to children, representing $44 billion in revenue for the top 25 U.S. manufacturers of the >$240 billion generated annually. The Google nutrient profiling model permitted the most products to be advertised to children of all four nutrient profiling models examined. CONCLUSIONS: U.S. children engage extensively with online media. In place of government regulation, the Google advertising policy and related nutrient profiling model would limit online advertising of the most unhealthful products to children, if the policy were to be applied to the U.S. market. The effectiveness of the policy would be strengthened by refining the Google nutrient profiling model to better align with nutrient profiling models developed by authoritative health agencies, including the WHO.

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.