Public Health Nutrition

ObjectiveThis study aimed to monitor the initial 12 months of the implementation of the updated nutrition labeling regulations in Brazil approved in 2020, focusing on the presence and readability of the front-of-package nutrition labeling (FOPNL) on food packages and the presence of added sugars information in the nutrition facts panel. MethodsWe used data on nutrition information and FOPNL of 6,829 products launched at Brazilian food retail between November 2022 and October 2023, available at the Mintel - Global New Products Database. We applied eligibility criteria stipulated by regulations to identify products eligible for FOPNL. We classified the foods according to the NOVA classification, identified the products with added sugars information in the nutrition facts panel and those with FOPNL for added sugar, saturated fat or sodium. Moreover, we analyzed the temporal trends in FOPNL presence. Last, a subsample of 202 product labels was analyzed to identify non-compliance with FOPNL readability standards. ResultsIn the first year of implementation 63.9% of the products analyzed were eligible for at least one critical nutrients FOPNL; however, only 12.9% already featured FOPNL by the end of the 12-month implementation period. Among ultra-processed products, 65.1% were supposed to have FOPNL, but only 14.4% did. Less than 30% of sweet cookies, ice cream, tabletop sweeteners, and candies with added sugar in the list of ingredients declared this information in the nutritional facts panel. Analysis of label images revealed non-compliance with FOPNL readability regarding its location on the packaging, FOPNL in removable parts of the packaging or hidden positions, and inadequate color pattern and format. ConclusionThe implementation of the nutrition labeling regulations in Brazil within the first 12 months reached less than 15% of eligible foods and beverages, indicating non-compliance by the food industry. Such inadequacies undermine the expected impact of promoting healthier choices at the point of food purchase.

Background and objectivesThe consumption of unprocessed or minimally processed whole plant foods and of ultra-processed foods, as defined by the Nova food classification system, are associated in opposite ways with diet quality and risk of diseases. However, it can be difficult to evaluate and monitor the consumption of these foods in some contexts due to lack of resources and time constraints for data collection. This study aimed to describe two simple and easily derived diet quality scores and evaluate their performance in reflecting the dietary share of unprocessed or minimally processed whole plant foods and ultra-processed foods. MethodsA total of 812 adults (18 years old or older) answered the Nova24h screener, a 2-minute self-administered questionnaire that measures the consumption of a set of foods on the day before the interview. Food items included in this tool belong to two main groups of Nova classification: unprocessed or minimally processed whole plant foods (WPF, 33 food items) and ultra-processed foods (UPF, 23 food items). Two scores are obtained from this tool by summing the number of items checked - the Nova-WPF and the Nova-UPF. We compared the Nova-WPF and the Nova-UPF scores with the dietary intake (% of total energy) of all unprocessed or minimally processed whole plant foods and all ultra-processed foods, respectively, obtained through a full self-administered web-based 24-hour recall, applied on the same day. We evaluated the relationship between the approximate quintiles or intervals of each score and the corresponding % of energy intake by linear regression, and the agreement between the intervals of each score with the intervals of the corresponding % of energy intake, using the Prevalence-Adjusted and Bias-Adjusted Kappa (PABAK). ResultsApproximate quintiles of each score presented a direct and linear relationship with the corresponding % of energy intake (p-value for linear trend <0.001). We found a substantial agreement between the intervals of each score and of the corresponding % of energy intake (PABAK 0.72, 95% CI 0.64-0.81 for the Nova-WPF score and PABAK 0.79, 95% CI 0.69-0.88, for the Nova-UPF score). ConclusionsThese two scores performed well against the dietary share of unprocessed or minimally processed whole plant foods and ultra-processed foods in Brazil and can thus be used to evaluate and monitor diet quality.

ObjectiveTo assess the energy contribution of ultra-processed foods (UPF) and its association to sociodemographic and anthropometric factors in 6-35 months old children in the databases of national surveys carried out in 2008-2010, 2015-2016 and 2019. MethodsAll surveys were stratified multi-stage random samples. Sub-samples had 24-hr food recall on a random day for each child, using a modified multiple step method with visual aids and scales. UPF were defined based on the Nova 4 classification system. Factors were evaluated with two generalized linear models (binomial for the percentage of UPF consumers and normal for the mean UPF energy contribution among UPF consumers only). Estimations and models were adjusted by the sampling design. Results2887 children were included. UPF contributed 29% [CI95 27 to 31] of the total energy intake. UPF contributed 31% [30 to 33%] of energy intake among UPF consumers, decreasing with age, increasing with height-for-age and showing seasonal variation. UPF were consumed by 86% [84 to 89%] of children, increasing with age and height-for-age, slightly increasing over the years and decreasing with poverty. UPF energy contribution comes mainly from milk and derivatives 19% [17 to 20] and cereals 5% [4 to 6]. ConclusionsThe mean UPF energy contribution and the percentage of UPF consumers vary with age, height, poverty and survey year in 6-35 months old children in Peru.

ObjectiveTo validate the telephone modality of the Latin American and Caribbean Food Security Scale (ELCSA) included in three waves of a phone survey to estimate the monthly household food insecurity (HFI) prevalence during the COVID-19 pandemic in Mexico. DesignWe examined the reliability and internal validity of the ELCSA scale in three repeated waves of a cross-sectional surveys with Rasch models. We estimated the monthly prevalence of food insecurity in the general population and in households with and without children, and compared them with a national 2018 survey. We tested concurrent validity by testing associations of HFI with socioeconomic status and anxiety. SettingENCOVID-19 is a monthly telephone cross-sectional survey collecting information on the well-being of Mexican households during the pandemic lockdown. Surveys used probabilistic samples and we used data from April (n=833), May (n=850), and June 2020 (n=1,674). ParticipantsMexicans 18 years or older who had a mobile telephone. ResultsELCSA had adequate model fit and HFI was associated, within each wave, with more poverty and anxiety. The COVID-19 lockdown was associated with an important reduction in food security; decreasing stepwise from 38.9% in 2018 to 24.9% in June 2020 in households with children. ConclusionsTelephone surveys are a feasible strategy to monitor food insecurity with ELCSA

BackgroundNutritional warnings are used as a public health strategy to prevent increases in obesity prevalence. 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 transfat. The complexity behind the implementation of this set of policies over six years provide unique learnings, essential to inform the obesity prevention context, especially when facing strong opposition from powerful stakeholders such as the food industry. AimsDescribe milestones and key stakeholders roles and stances during the nutritional warnings policy design in Peru; and identify and analyze the main drivers of policy change that explain its approval. MethodologyIn 2021, interviews were conducted with 25 key informants, advocates and opponents of the policy, closely involved in its design. Interviews were analyzed using the Kaleidoscope Model as a theoretical framework. Relevant policy documents and news were also analyzed. ResultsMilestones for this policy were the approval of the Law, Regulation, and Manual. Policy supporters were mainly from the Congress, civil society organizations, and Health Ministers; whereas opponents came from other parties in the 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 for 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. ConclusionsDespite the strong opposition faced and technical and political difficulties to define the best parameters and warnings design, Perus nutritional warnings policy was approved. Lessons learned are essential to inform similar and related prevention policies in Peru and elsewhere.

BackgroundThe COVID-19 pandemic has intensified economic hardships, with potential negative impacts on food insecurity and infant feeding beliefs and practices. The relationship between food insecurity and infant feeding beliefs and practices during the pandemic is not yet fully understood. Neither is how these relationships changed over the course of the waves of the pandemic. We examined these relationships in a cohort of infants born during the various waves of the COVID-19 pandemic in New York City (NYC). MethodsWe conducted a cross-sectional analysis of infants enrolled from birth into the COVID-19 Mother-Baby Outcomes (COMBO) study and born March 2020 to May 2024. We measured food insecurity in the prior 30 days with a 2-item survey adapted from Hunger Vital Sign, infant feeding confidence at hospital discharge, and current infant feeding practices. ResultsIn our sample, 40% of women had been exposed to prenatal SARS-CoV-2 infection and approximately 24% of mothers were food insecure. There was a significant association between food insecurity and prenatal SARS-CoV-2 infection, Spanish as ones preferred language, and self-identifying as Latina. In unadjusted models of the entire sample, food insecurity was associated with formula feeding, with 44% of food insecure mothers opting to formula feed vs. 28% of food secure mothers (p<0.001), but this relationship was no longer significant after adjusting for covariates (p=0.059). In comparing the first and second waves of the pandemic (March 2020-December 2021 vs. January 2022-May 2024), there was no significant difference in rate of food insecurity. When comparing different waves of the pandemic, food insecurity was associated with increased likelihood of formula feeding, even after adjusting for confounders. DiscussionFood insecurity was initially associated with feeding methods, but this relationship lost significance after adjusting for confounders. However, when analyzed separately, food insecurity was significantly linked to lower odds of exclusive breastfeeding during different waves of the pandemic, suggesting the influence of external factors like policy changes and social support variations. Other factors, such as maternal BMI, ethnicity, and delivery mode, were also significantly associated with breastfeeding practices, highlighting the need for targeted interventions to support breastfeeding, especially among food-insecure mothers.

BackgroundConsumption of breast milk substitutes (BMS) by children aged under six months in low and middle income countries (LMICs) is directly driven by country income and family wealth. Multi-country investigations on the consumption of BMS by older children (6-23 months) are lacking. MethodsUsing data from 86 nationally representative surveys carried out in LMICs from 2010 onwards, we analyzed the prevalence of continued breastfeeding at one and two years, and frequency of consumption of formula and other non-human milk by age in months. Indicators were estimated through 24-hour dietary recall. Absolute and relative wealth indicators were used to describe within- and between-country socioeconomic inequalities. Results were stratified by country income groups. FindingsBreastfeeding declined sharply as children became older in all LMICs, especially in upper-middle income countries. Formula consumption peaked at six months of age in low and lower-middle income countries, and at around 12 months in upper-middle income countries. Consumption of formula at any age higher in children from wealthier families in all countries, while breastfeeding was more common among poor children. Multilevel linear regression analysis showed that consumption of formula was positively associated while breastfeeding was negatively associated with absolute national income. Factors at country level explained a substantial proportion of overall variability in formula use and breastfeeding. InterpretationInfant and young child feeding practices vary strongly according to wealth, both within and between countries. Breastfeeding falls sharply as children become older, especially in wealthier families living in upper-middle income countries; this is also the group with highest formula consumption at any age. Country-level factors play an important role in explaining BMS consumption by all family wealth groups in LMICs, suggesting that formula marketing at national level may be partly responsible for the observed differences. FundingThe Bill & Melinda Gates Foundation, through the WHO

ObjectiveTo characterize dietary habits, their temporal and spatial patterns, and associations with body mass index (BMI) in the 23andMe study population. DesignWe present a large-scale cross-sectional analysis of self-reported dietary intake data derived from the web-based NHANES 2009-2010 dietary screener. Survey-weighted estimates for each food item were characterized by age, sex, race/ethnicity, education, and BMI. Temporal patterns were plotted over a 2-year time period, and average consumption for select food items was mapped by state. Finally, dietary intake variables were tested for association with BMI. SettingU.S. based adults 20-85 years of age participating in the 23andMe research program. ParticipantsParticipants were 23andMe customers who consented to participate in research (n=526,774) and completed web-based surveys on demographic and dietary habits. ResultsSurvey-weighted estimates show very few participants met federal recommendations for fruit: 2.6%, vegetables: 5.9%, and dairy intake: 2.8%. Between 2017-2019, fruit, vegetables, and milk intake frequency declined, while total dairy remained stable and added sugars increased. Seasonal patterns in reporting were most pronounced for ice cream, chocolate, fruits, and vegetables. Dietary habits varied across the U.S., with higher intake of sugar and calorie dense foods characterizing areas with higher average BMI. In multivariate-adjusted models, BMI was directly associated with intake of processed meat, red meat, dairy, and inversely associated with consumption of fruit, vegetables, and whole grains. Conclusions23andMe research participants have created an opportunity for rapid, large scale, real time nutritional data collection, informing demographic, seasonal and spatial patterns with broad geographical coverage across the U.S.

BackgroundExposure to marketing for foods high in sugar, salt, and fat is considered a key risk factor for childhood obesity. To support efforts to limit such marketing, the World Health Organization Regional Office for Europe has developed a nutrient profile model (WHO NPM). Germanys Federal Ministry of Food and Agriculture plans to use this model in proposed new legislation on food marketing directed towards children, but the model has not yet been tested on products on the German market. Against this backdrop, the present paper aims to assess the feasibility and implications of implementing the WHO NPM in Germany. MethodsWe applied the WHO NPM to a random sample of 660 food and beverage products across 22 product categories on the German market drawn from Open Food Facts, a publicly available product database. We calculated the share of products permitted for marketing to children based on the WHO NPMs nutrient and ingredient criteria, both under current market conditions and for several hypothetical reformulation scenarios. We also assessed effects of adaptations to and practical challenges in applying the WHO NPM. ResultsThe median share of products permitted for marketing to children across the models 22 product categories was 20% (interquartile range (IQR) 3-59%) and increased to 38% (IQR 11-73%) with model adaptations for fruit juice and milk proposed by Germanys Federal Ministry of Food and Agriculture. With targeted reformulation (assuming a 30% reduction in fat, sugar, sodium and/or energy) the share of products permitted for marketing to children increased substantially (defined as a relative increase by at least 50%) in several product categories (including bread, processed meat, yogurt and cream, ready-made and convenience foods, and savoury plant-based foods), but changed less in the remaining categories. Practical challenges in applying the model included the ascertainment of the trans-fatty acid content of products, and the classification of products not required to carry nutrient declarations, such as fresh meats, fish, and similar products. DiscussionThe application of the WHO NPM to a random sample of food and beverage products on the German market was found to be feasible. Its use in the proposed new legislation on food marketing in Germany seems likely to serve its intended public health objective of limiting marketing in a targeted manner specifically for less healthy products. It seems plausible that it may incentivise reformulation in some product categories. Practical challenges in applying the model could be addressed with appropriate adaptations and procedural provisions.

ObjectiveTo examine associations between sociodemographic and mental health characteristics with household food insecurity as a result of the COVID-19 outbreak. DesignCross-sectional online survey analyzed using univariable tests and a multivariable logistic regression model. SettingThe United States during the week of March 30, 2020. ParticipantsConvenience sample of 1,965 American adults using Amazons Mechanical Turk (MTurk) platform. Participants reporting household food insecurity prior to the pandemic were excluded from analyses. Results1,517 participants reported household food security before the COVID-19 outbreak. Among this subset, 30% reported food insecurity after the COVID-19 outbreak, 53% were women and 72% were white. On multivariable analysis, race, income, relationship status, anxiety, and depression were significantly associated with incident household food insecurity. Black respondents, Hispanic/Latino respondents, and respondents with annual income less than $100,000 were significantly more likely to experience incident household food insecurity. Individuals experiencing incident household food insecurity were 2.09 (95% CI 1.58-2.83) times more likely to screen positively for anxiety and 1.88 (95% CI 1.37-2.52) times more likely to screen positively for depression. ConclusionsFood insecurity due to the COVID-19 pandemic is common, and certain populations are particularly vulnerable. There are strong associations between food insecurity and anxiety/depression. Public health interventions to increase the accessibility of healthful foods, especially for Black and Hispanic/Latino communities, are crucial to relieving the economic stress of this pandemic.

BackgroundWhile dietary guidelines recommend limiting foods high in added sugars, saturated fat, refined grains, and sodium, there is no criteria for identifying foods high in these components. ObjectiveTo evaluate a novel nutrient-based method to classify moderation foods and compare with two alternative methods. DesignFace validity was assessed by examining the proportion of recommended and non-recommended foods classified as moderation using the 2017-2018 Food and Nutrient Database for Dietary Studies (FNDDS, n=6909). Convergent validity was evaluated by comparing nutrient density in moderation vs. non-moderation foods in FNDDS, and investigating correlations of moderation food intake with diet quality from 2-day dietary recalls. Results were compared with the hyperpalatable food and NOVA ultra-processed food classifications. ParticipantsNational Health and Nutrition Examination Survey (2017-2018) non-pregnant participants aged 2+ years (n=6136) were included. Main outcome measuresThe Nutrient Rich Foods 9.3 index (NRF) measured nutrient density; Healthy Eating Index-2020 scores (HEI-2020) measured diet quality. Statistical AnalysesT-tests and ANOVA evaluated differences in NRF by moderation, hyperpalatable, and ultra-processed classifications. Fishers z-transformation compared associations of HEI-2020 with intake (%kcal) from moderation, hyperpalatable, and ultra-processed foods. ResultsMore non-recommended (e.g., 97% of snacks) than recommended (e.g., 18% of vegetables) food groups were classified as moderation. NRF was significantly lower in moderation foods than non-moderation foods (mean diff: -74.8, 95%CI:-70.6 --78.9). The difference in NRF between moderation vs. non-moderation foods was larger than that between ultra-processed vs. non-ultra-processed (mean diff=-29.7, 95%CI:-25.1--34.2) and hyperpalatable vs. non-hyperpalatable foods (mean diff=-53.2, 95%CI:-49.3--57.1)(p-diff<0.001). Moderation food intake (% kcal) was correlated with HEI-2020 (r=-0.72), and associations were stronger than those with hyperpalatable (r=-0.40) or ultra-processed food intake (r=-0.49). ConclusionsThe moderation food classification method demonstrated strong face and convergent validity, and may improve diet quality assessment and public health interventions.

ObjectiveHousehold Consumption and Expenditure Surveys (HCES) are increasingly used to assess diets in low- and middle-income countries, but their validity compared to individual-level dietary data remains uncertain. We assessed the strengths and limitations of HCES data for informing strategies to improve diets and nutrition in Tanzania. DesignExploratory analysis of food group consumption from HCES (individualized using the adult female equivalent approach) and 24-hour dietary recall (24hR). We examined concordance and trends by socioeconomic characteristics between methods for 10 food groups and fortifiable food vehicles. SettingRural Arusha and Kilimanjaro regions, and national data from the Tanzania National Panel Survey Wave 5. ParticipantsThe analysis included 2,599 adult women who completed a 24hR and lived in 2,604 households contributing to HCES data in Arusha and Kilimanjaro. Nationally, 4,469 households were included, with a regional subsample of 370 households from Arusha and Kilimanjaro. ResultsDietary patterns were similar using HCES and 24hR data, including low consumption of nutrient-dense foods, while HCES were effective at capturing usual intake of food items eaten episodically. However, compared to 24hR data, energy intakes were substantially lower using HCES data, particularly in large households (42% difference), while there was poor concordance between methods for fruit and meat consumption and for wealth-related trends in cereal and vegetable intake. ConclusionHCES data can provide valuable insights for nutrition policy and planning, however, careful communication and interpretation of evidence is required, given limitations such as assumptions on within-household allocation of foods. Methods development could reduce measurement error.

Context and objectiveWhen considering the health-related impact of foods, nutrient profile (content in salt, sugar, fibre, etc.) and (ultra-)processing are two complementary dimensions. The Nutri-Score, a summary graded front-of-pack label, already used in seven European countries, informs on the nutrient profile dimension, i.e. the one with the strongest evidence. Recently, mounting evidence linked ultra-processed food consumption to various adverse health outcomes, independently of their nutrient profile. To inform consumers about each of these two health-related dimensions of food (i.e., nutrient profile and ultra-processing), we aimed to test, in a randomised controlled trial, if a graphically modified version "Nutri-Score 2.0", including a black "ultra-processed" banner, would improve the capacity of consumers to rank products according to their nutrient profile but also to detect those ultra-processed, compared to a no-label situation. MethodsA total of 21,159 participants included in the NutriNet-Sante web-cohort were randomly assigned to a control arm (no front-of-pack label) or an experimental arm (Nutri-Score 2.0), and were presented an online interactive questionnaire with 3 sets of food products (8 cookies, 7 breakfast cereals, and 7 ready-to-eat meals) to rank according to their nutrient profile, and to identify ultra-processed foods. The primary outcome was the objective understanding of nutrient profile and ultra-processing, represented by a score of correct answers. Secondary outcomes were purchasing intentions and the healthiest-perceived product. Multinomial logistic regressions were performed. ResultsThe Nutri-Score 2.0 increased significantly the objective understanding of both the nutrient profile dimension of food products from 0.9% to 24.2% (OR = 29.0 (23.4 - 35.9), p<0.001), and the ultra-processing dimension from 4.4% to 77.7% (OR = 174.3 (151.4 - 200.5), p<0.001), compared with no front-of-pack label. The results followed similar trends for cookies, breakfast cereals, and ready-to-eat meals. The Nutri-Score 2.0 also had a positive impact on purchasing intentions and on the products perceived as the healthiest, guiding consumers towards a better nutrient profile and non-ultra-processed products. ConclusionThis randomised controlled trial demonstrates the interest of a front-of-pack label combining the Nutri-Score (informing on the nutrient profile dimension) with an additional graphic mention indicating when the food is ultra-processed, compared to a no-label situation. Our results show that participants were able to independently identify and understand these two complementary dimensions of foods. Trial registration numberNCT05610930

The COVID-19 pandemic has had profound impacts on the global food system, supply chain, and employment, which, in turn, has created numerous challenges to food access and food security. Early exploratory studies suggest significant increases in food insecurity in the United States. Comprehensive longitudinal research across multiple locations is needed to understand the range of impacts and responses at the household level and to improve preparedness for future events. This protocol paper outlines the formation of the National Food Access and COVID research Team (NFACT), a collaborative, interdisciplinary, multi-state research effort that will utilize common measurement tools, codebooks, code, data aggregation tools, and outreach materials to collectively examine and communicate the effect of COVID-19 on household food access and security. NFACT is led by an executive committee of researchers from four institutions, with additional NFACT collaborating institutions across more than a dozen states. A survey was developed by the NFACT executive team in March 2020, with additional refinements in May 2020, using both existing validated questions and new original questions, which were piloted and validated in Vermont. The project provides suggestive guidance for recruitment, and is designed to allow each study site to adopt recruitment strategies that meet their budget and needs. Primary outcomes of interest include food security status, employment status, food access challenges and concerns, dietary intake, and use of food assistance programs. Additional outcomes assess emotional eating, stigma, COVID-19 perceptions and experiences, and pro-environmental purchasing behaviors. This protocol and the establishment of NFACT provide important advancements in COVID-19 and food security research by generating harmonized data and assessing comparable outcomes across geographies and time. The collaborative, open-source approach makes research tools available to teams who might not have the resources to design their own tools, and can enable streamlined data collection, large-scale comparative analyses, and cost savings through reduced administrative tasks. The project has contributed to building new networks between and within states. Enabling facilitation and implementation of instruments in study sites has provided flexibility and meaningful opportunity for local stakeholder engagement and relevant outreach for informed public health decision-making.

BackgroundUnhealthy diets are a major public health concern. However, a lack of available and up-to-date quantitative dietary intake data, accurate low-burden data collection methods, and valid and interpretable metrics across contexts has hindered frequent monitoring of diets globally. MethodsIn this multi-country validation study, we compared the relationships between low-burden metrics of a healthy diet, identified by the FAO, UNICEF, and WHO Healthy Diets Monitoring Initiative, and a suite of reference metrics of dietary intake. To this end, we used harmonized open access quantitative 24-hour recall and food record data collected from 77,118 adolescent and adult females across 27 countries. FindingsOn any given day, non-consumption of sweet foods or sweet beverages was associated with greater population-level adherence to <10% energy from free sugars in available upper-middle income countries [odds ratio (95% CI): 5.35 (5.05, 5.66)]. Food group diversity score (FGDS) was positively associated with mean adequacy ratio of micronutrients [{beta} of 1-SD change (95% CI): [~]11 percentage points (9, 12)], while NCD-Protect score best predicted consumption of [&ge;]400 g/day of fruits and vegetables [range odds ratio of 1-SD changes (95% CI): 2.56 to 3.01 (2.40 to 3.13) in lower-middle and high income countries, respectively]. FGDS and Global Diet Quality Score Positive were associated with achieving [&ge;]25 g/day of fibre and [&ge;]3,510 mg/day of potassium across contexts. No indicator accurately predicted adherence to WHO guidelines for sodium intake or energy intake ranges for carbohydrates, lipids, and proteins. InterpretationAccurate low-burden dietary assessment methods can provide valid metrics that enable timely monitoring of key characteristics of healthy diets globally. Specifically, avoiding sweet foods or sweet beverages serves as an indicator for population-level adherence to the WHO guideline for free sugar intake, while metrics reflecting nutritious food group diversity are strongly predictive of better micronutrient adequacy and adherence to WHO guidelines for fruits and vegetables, fibre, and potassium intakes across settings. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSUnhealthy diets are a common cause of all forms of malnutrition and are the major risk factor for non-communicable diseases. However, a lack of up-to-date nationally representative quantitative dietary intake data, and a lack of consensus on fit-for-purpose lower-burden data collection methods and metrics, based on comparative epidemiological evidence, has hindered monitoring of healthy diets globally. Added value of this studyUsing open access quantitative 24-hour recall and food record data collected in 27 countries, our validation analyses compared the relationships between measures of a healthy diet, deemed most promising for global surveillance by the FAO, UNICEF, and WHO Healthy Diets Monitoring Initiative, and a suite of reference metrics of dietary intake, both within and across countries. Implications of all the available evidenceNationally representative quantitative dietary intake assessments remain the reference for nutrition. Nevertheless, complementary low-burden methods can yield metrics that are suitable for high-frequency monitoring of healthy diets. Specifically, on any given day, avoiding sweet foods or sweet beverages is an accurate population-level indicator for achieving the WHO guideline of <10% kcal/day from free sugars, while metrics capturing nutritious food group diversity are associated with better micronutrient adequacy, as well as, higher probabilities of reaching WHO guidelines of [&ge;]400 and [&ge;]25 g/day for fruits and vegetables and fibre, respectively, and [&ge;]3,510 mg/day of potassium across contexts.

BackgroundIn 2016, Chile implemented a multi-phase set of policies that mandated warning labels, restricted food marketing to children, and banned school sales of unhealthy foods and beverages. Chiles law, particularly the warning label component, set the precedent for a rapid global proliferation of similar policies. While our initial evaluation showed policy-linked decreases in purchases of products carrying the warning label, a longer-term evaluation is needed, particularly as later phases of Chiles law included stricter nutrient thresholds and introduced a daytime ban on advertising of labeled foods for all audiences. The objective is to evaluate changes in purchases of energy, sugar, sodium, and saturated fat purchased after Phase 2 implementation of the Chilean policies. Methods and FindingsThis before- and after-study used longitudinal data on monthly food and beverage purchases from 2,844 Chilean households (138,391 household-months) from July 1, 2013 until June 30, 2019. Nutrition facts panel data from food and beverage packages were linked at the product level and reviewed by nutritionists. Products were considered to carry the warning label if they contained added sugar, sodium, or saturated fat, and exceeded the final phase nutrient or calorie thresholds (thus would carry the warning label). Using correlated random-effects models and an interrupted time series design, we estimated the nutrient content of food and beverage purchases associated with Phase 1 and Phase 2 compared to a counterfactual scenario based on pre-policy trends. Compared to the counterfactual, we observed significant decreases in purchases of foods and beverages carrying the warning label during Phase 2, including a relative 36.8% reduction in sugar (-30.3 calories, 95% CI -34.5, -26.3), a 23.0% relative reduction in energy (-51.6 calories, 95% CI -60.7, -42.6), a 21.9% relative reduction in sodium (-85.8 mg, 95% CI -105.0, -66.7) and a 15.7% relative reduction in saturated fat (-6.4 calories, 95% CI -8.4, -4.3). Decreases were partially offset by increases in non-labeled purchases, but the net effect shows a significant decrease in total nutrients of concern purchased during Phase 2. Reductions in sugar and energy were driven by beverage purchases, whereas reductions in sodium and saturated fat were driven by foods. The pattern of declines in purchases was similar for households of lower vs. higher socioeconomic status. A key limitation of this study is that the data include only a portion of what Chilean households purchase that, while including important categories impacted by the law, do not cover an entire diet. ConclusionsThe Chilean policies on food labeling, marketing, and school food sales led to declines in nutrients of concern during a more complete phase of implementation, particularly from foods and drinks carrying the warning label.

BackgroundThe introduction of mandatory calorie labelling among large food businesses (chains) in England in 2022 has been found to have little impact on consumer behaviour, but overall calories on restaurant menus have decreased slightly. This study examined menu changes post policy implementation, and the population groups likely to have been affected most. MethodsMenu data from 169 chains in Great Britain were extracted from two online food delivery platforms in June 2022 and June 2023. We selected 10 categories (specific foods or chains) jointly with public and policy advisors. Menu changes over time were assessed with multilevel models accounting for whether an item was continuously on the menu and for the type of chain. Where changes were found, we assessed differences in purchasing frequency by consumer characteristics using 2022 OOH purchase data (Worldpanel by Numerator, GB OOH Panel). ResultsChanges were observed in two (out of 10) categories examined and were driven by changing items on the menu rather than reformulating continuous dishes. Chains that used a healthy tag on the delivery website increased the share of mains under 600 kcal by 3.7 percentage points (95% CI 0.2 to 7.2), while average calories did not change (-17.6 kcal/item, 95% CI -38.7 to 3.4). Men, people aged 35-44 years and with high SES were found to purchase more frequently from these chains. Across all chains, the share of lower-calorie coffees decreased by 10 pp (95% CI -18.0 to - 0.02), with purchasing more frequent among men and increasing with age. ConclusionsAlthough data were available for one year only post-policy implementation, menu changes among the investigated foods and chains were limited. While menu change may equitably improve population dietary health, dietary inequalities may exacerbate if only healthy chains already offering lower-calorie food change their menus.

IntroductionThe effects of front-of-package nutrition labels among Latino and Hispanic ("Latine") adults in the US, including those with limited English proficiency, remains largely unknown. We examined the impact of different types of labels among Latine consumers and whether effects differed by English proficiency. Study designOnline randomized trial. Setting/participants3,053 Latine US adults (49% limited English proficiency). InterventionParticipants viewed one of three labels: numerical labels displaying numerical information about sodium, saturated fat, and added sugar; text high-in labels stating when foods are high in these nutrients of concern; and icon high-in labels identical to the text labels plus a magnifying glass icon. Main outcome measuresParticipants viewed three frozen pies, three frozen pizzas, and three frozen meals displaying randomly assigned labels and identified the healthiest and least healthy product within each group (based on nutrient content). ResultsText high-in labels (49% correct) led to higher correct identification of the least healthy foods compared to the numerical labels (44%, p<.001) though the icon high-in labels did not (47%, p=.07). Neither the text high-in labels (46% correct) nor the icon high-in labels (46%) led to better identification of the healthiest food compared to the numerical labels (45%, all p>=.71). Neither type of high-in label led to more correct identification of foods high in nutrients of concern or higher selection of the healthiest food for purchase compared to the numerical labels (all p>=.09). English proficiency moderated the impact of label type on correct identification of the least healthy food (p-interaction=.003) such that the benefit of high-in labels was only present for participants with high English proficiency. ConclusionsHigh-in labels helped Latine consumers identify unhealthy foods more than numerical labels, but only among those with high English proficiency. Future food labeling research should include participants with limited English proficiency. Trial registrationNCT06293963.

ObjectiveTo investigate mothers experiences during the 2022 infant formula shortage in the United States and its perceived impacts on infants diet and health. MethodsMothers of infants under 8 months old were recruited from Washington D.C. using social media and neighborhood listservs and invited to participate in a virtual study meeting between June 22 and July 14, 2022. Mothers completed a brief survey with questions about their demographic characteristics, infants anthropometric characteristics, and infant feeding practices, and participated in an in-depth, qualitative interview about their experiences during the infant formula shortage. Survey data were analyzed using means and frequencies, as appropriate. Qualitative interviews were recorded, transcribed verbatim, coded, and thematically analyzed. ResultsThe sample (n=28) was predominantly White and highly educated. Five overarching themes were identified, including the shortage had: 1) adverse impacts on mothers mental and emotional health; 2) significant financial and intangible costs; and 3) led to changes in infant feeding practices; and, 4) social and family networks were helpful in navigating the shortage; and 5) mothers felt fortunate to have resources to breastfeed and/or obtain formula. Most mothers reported the shortage had not yet detrimentally impacted their infants health. ConclusionsEven among highly educated women with access to financial, social, structural resources, the infant formula shortage adversely impacted mothers mental and emotional health, and has been costly, in terms of financial and intangible costs. Findings demonstrate the urgent need to develop strategies to support mothers in feeding their infants, especially mothers who may lack the resources to locate and obtain formula.

IMPORTANCEAn unhealthy diet is a key risk factor for chronic diseases including obesity, diabetes, and heart disease. Limited access to healthy food options may contribute to unhealthy diets. However, previous studies of food environment have led to mixed results, potentially due to methodological limitations of small sample size, single location, and non-uniform design across studies. OBJECTIVETo quantify the independent impact of fast food and grocery access, income and education on food consumption and weight status. DESIGN, SETTING AND PARTICIPANTSRetrospective cohort study of 1,164,926 participants across 9,822 U.S. zip codes logging 2.3 billion consumed foods. Participants were users of the My-FitnessPal smartphone application and used the app to monitor their caloric intake for an average of 197 days each (min 10, max 1,825 days, STD=242). MAIN OUTCOMES AND MEASURESThe primary outcomes were relative change in consumption of fresh fruits and vegetables, fast food, and soda, as well as relative change in likelihood of overweight/obese body mass index (BMI), based on food consumption logs. Food access measures for each zip code were computed from USDA Food Access Research Atlas and Yelp.com, and demographic, income and education measures were based on Census data. Genetic Matching-based approaches were used to create matched pairs of zip codes. RESULTSAccess to grocery stores, non-fast food restaurants, income, and education were independently associated with healthier food consumption and lower prevalence of overweight/obese BMI levels. Substantial differences were observed between predominantly Black, Hispanic, and White zip codes. For instance, within predominantly Black zip codes we found that high income was associated with a decrease in healthful food consumption patterns across fresh fruits and vegetables and fast food. Further, high grocery access had a significantly larger association with increased fruit and vegetable consumption in predominantly Hispanic (7.4% increase) and Black (10.2% increase) zip codes in contrast to predominantly White zip codes (1.7% increase). CONCLUSIONS AND RELEVANCEPolicy targeted at improving access to grocery stores, access to non-fast food restaurants, income and education may significantly increase healthy eating, but interventions may need to be adapted to specific subpopulations for optimal effectiveness. NoteWe will release all data aggregated at a zipcode level in order to enable validation, follow-up research, and use by policy makers. Key PointsO_ST_ABSQuestionC_ST_ABSHow does food consumption and weight status vary with food access, income and education in the United States? FindingsIn this country-wide observational study of 1,164,926 participants and 2.3 billion food entries, higher access to grocery stores, lower access to fast food, higher income and education were independently associated with higher consumption of fresh fruits and vegetables, lower consumption of fast food and soda, and lower likelihood of being overweight/obese, but these associations varied significantly across Black, Hispanic, and White subpopulations. MeaningPolicy targeted at improving food access, income and education may increase healthy eating, but interventions may need to be targeted to specific subpopulations for optimal effectiveness.