Regulated nutrition claims increase perceived healthiness of an ultra-processed, discretionary toddler snack food and ultra-processed toddler milks: A discrete choice experiment

The Evolving Landscape of Discrete Choice Experiments in Health Economics: A Systematic Review

INTRODUCTION

Stakeholder preference evaluations are increasingly emphasized in healthcare policy and health technology assessment. Discrete choice experiments (DCEs) are the most common method for quantifying preferences among patients, the public, and healthcare professionals. While prior reviews (1990-2017) have examined DCE trends, no comprehensive synthesis exists for studies published since 2018. This updated review (2018-2023) provides critical insights into evolving methodologies and global trends in health-related DCEs.

METHODS

A systematic search (2018-2023) of Medline, Embase, and Web of Science identified relevant studies. Studies were screened for inclusion and data were extracted, including details on DCE design and analysis. To enable trend comparisons, the search strategy and extraction items aligned with previous reviews.

RESULTS

Of 2663 identified papers, 1279 met the inclusion criteria, reflecting a significant rise in published DCEs over time. DCEs were conducted globally, with a remarkable increase in publications from Asia and Africa compared with previous reviews. Experimental designs and econometric models have advanced, continuing prior trends. Notably, most recent DCEs were administered online.

DISCUSSION

The rapid growth of DCE applications underscores their importance in health research. While the methodology is advancing rapidly, it is crucial that researchers provide full transparency in reporting their methods, particularly in detailing experimental designs and validity tests, which are too often overlooked. Key recommendations include improving reporting of experimental designs, applying validity tests, following good practices for presenting benefit-risk attributes, and adopting open science practices. Ensuring methodological rigor will maximize the impact and reproducibility of DCE research in health economics.

Parents' Perceptions of Claims on Packaged Commercial Toddler Foods: A Qualitative Study

Commercial toddler foods (CTFs) are widely used. Many are nutritionally poor despite displaying health, nutrition or marketing claims implying healthiness. This study aimed to: (i) explore how claims on CTFs influence parents' product perceptions and preferences, and gauge support for regulatory reform to ensure CTFs are marketed responsibly; (ii) identify other factors influencing parent's and toddlers' perceptions and preferences towards CTFs and toddler feeding in general. Six moderator-led online focus groups (N = 47) were conducted with parents of toddlers (aged 12 to < 36 months) in Victoria, Australia, using a discussion guide and mock CTFs to elicit discourse. Discussions were audio-recorded, transcribed, and analysed using exploratory content and thematic analysis. Parents found CTFs displaying claims more appealing, despite awareness and scepticism of claims. Parents expressed frustration over industry's use of claims and supported stronger regulation of claims. Some doubted the effectiveness of regulations, concerned that industry would find ways to circumvent rules. Parents perceive visual features (especially cartoon characters) on CTFs as highly influential for toddlers. Parents support honest labelling of CTFs, reflecting a product's actual ingredients and nutritional profile, especially signposting of sugar content. Parents evaluate CTFs based on perceived healthiness and convenience, often relying on social media and brand reputation for guidance on what to feed their toddlers. While parents are aware of, and sceptical about claims on CTFs, these claims still influence their perceptions. Findings highlight the need for stronger regulations to ensure that claims on CTFs do not create inaccurate perceptions of their healthiness.

How different goals drive attention: An interview study on how parental feeding goals influence the assessment of child-targeted food packaging cues

When making snack choices for children, parents are exposed to many child-targeted food packaging cues. This study aims to understand how different parental feeding goals (e.g. health versus fun versus taste) drive attention to these cues and how these cues help parents to make different snack choices. Qualitative interviews were conducted with 20 parents with at least one child between the ages of 3 and 12 years old. During the interviews, parents were primed with different feeding goals and asked to rank seven snack packages based on these goals. The interviews revealed three key takeaways regarding how parents consider snack packaging from a goal perspective. Firstly, packaging cues are interpreted (and thus used) differently when different feeding goals are salient. Secondly, cues are ignored when they do not offer valuable information for making goal-based assessments. Thirdly, when combining goals, parents either look for a combination of cues that fit their multiple goals, assess packaging based on a stepwise implementation of goals, or choose one dominant goal and rely on relevant packaging cues to rank snack packaging. This study widens the knowledge on how parental feeding goals can influence the food packaging choices parents make and the way in which they interpret packaging cues. The study can inspire policymakers by providing strategies to stimulate marketers to make the food environment healthier by steering consumers towards healthy food options and making these options more salient within environments where snacks are bought (e.g. supermarkets).

Factors influencing perceptions of processed baby foods and feeding practices among Indian mothers: a qualitative investigation

OBJECTIVE

To explore how professionally qualified, working Indian mothers conceptualize healthy foods in general, perceive processed infant and baby foods available commercially and what feeding practices they actually follow with their children at home.

DESIGN

Five focus groups with 8-12 participants were conducted around the participants' conceptualization of healthy food, their perceptions about commercially available processed baby and infant foods and their actual feeding practices that they routinely follow with their children. Discussion transcripts were analyzed using an inductive coding approach.

SETTING

India.

PARTICIPANTS

Fifty-one professionally qualified, working women with at least one child under 5 years of age.

RESULTS

Participants agreed that fresh food is healthiest. They also had favorable opinions about processed infant and baby foods with regards to healthfulness, hygiene and safety. Healthy foods were largely conceptualized in relation to nutrient claims, ingredients and discernible health outcomes. They use cues, such as health claims, brand, price, package design and others to determine healthfulness of the product. Perception was heavily influenced by these extrinsic cues rather than by participants' own nutrition knowledge. Despite having the knowledge, most participants admitted to using these foods on account of factors such as their own inability to lactate, social pressure, lack of time and convenience.

CONCLUSIONS

Most educated and well off people continue to use these products. While they rue the lack of stringent regulatory measures in India, they feel there is an urgent need to address this huge policy gap by way of legislation and regulation.

Market survey of food product indicators and their credibility as a healthy food product in Klang Valley, Malaysia

INTRODUCTION

The presence of food product indicators may facilitate consumers in making informed healthy choices. However, it may also mislead consumers. This study aims to determine the prevalence of food products carrying food product indicators; the compliance of products bearing Malaysia's Healthier Choice Logo (HCL) and nutrition and health claims (NHC) towards the local regulations; and the credibility of the aforementioned products as healthy food products based on the international regulation in the Malaysian market.

METHOD

This is a cross-sectional market survey conducted from February to May 2023 on 3428 products sold in Malaysian supermarkets. Product information including the brand, name, nutrition information panel, food product indicator (front-of-pack nutrition labelling, NHC, other claims), ingredients list and manufacturer or importer were collected. Compliance of products carrying NHC and HCL is evaluated against local guidelines. Credibility as a healthy product is evaluated against the WHO Nutrient Profile Model for the Western Pacific Region on a subsample (products with HCL and/or NHC).

RESULTS

53% of food products surveyed had food product indicators (n=1809). A total of 32% carried at least one NHC (n=1101), of which 47% had excellent overall compliance (n=522). Only 4% carried Malaysia's HCL (n=138), of which 48% had excellent nutrient compliance (n=66). Only 13% of the products carrying Malaysia's HCL and NHC could be identified as absolute healthy food products as defined by the WHO standard (n=147).

CONCLUSION

Although half of the products surveyed had food product indicators, merely half of them had excellent compliance towards the standards. Only 13% of the subsample qualified as healthy food products. Voluntary application of the local HCL was low among food industries. Ensuring high standards of compliance and credibility of food products in the Malaysian market is crucial for food companies and government authorities.

Research on commercial milk formulas for young children: A scoping review

A scoping review of publications about commercial milk formulas intended for or consumed by children 12-36 months (CMF 12-36) was conducted. This review aimed to comprehensively map the existing literature, identify key concepts in the field and understand its evolution through time. A total of 3329 articles were screened and 220 were included, published between 1986 and 2024. Most works were published after 2016 (70.0%) and in high-income countries (71.8%). Original studies were the vast majority (81.8%) of publications. Most publications dealt with feeding practices or analysed the composition and/or contamination of specific products (44.1% and 35.9%), but since the late 2000s, publications about marketing, policy, legislation, and consumer perception started to appear. Most published works (65.5%) did not focus exclusively on CMF 12-36 and included formulas for other demographics or other foods. About half of the works (55.5%) did not consider CMF 12-36 to be a breast milk substitute. We found 81 distinct product denominations used to refer to CMF 12-36, Growing Up Milk was the most common (25.9%). CMF industry was involved in 41.8% of all analysed works, and industry participation and funding were not always clearly informed (22.5% lacked a conflict of interest statement, and 25.5% did not present any information about funding). In the last decade, publications about CMF 12-36 have increased in volume and diversified in scope and subject matter. CMF-industry participation has always been and still is present in the field, so possible vested interests should be taken into account when appreciating the literature.

Characterising Parent-Appeal Marketing on Foods for Children: A Scoping Review

PURPOSE OF REVIEW

This scoping review examines current evidence on parent-appeal marketing on the front-of-pack of food products for children and the impacts on parents' perceptions, intentions, and behaviours.

RECENT FINDINGS

Thirteen relevant studies were identified. Marketing features on packages of foods for children that appealed to parents include health claims, nutrition claims, non-nutrient claims such as 'natural', healthy-looking product images, images of healthy ingredients, and celebrity endorsements. At the same time, parents were wary of front-of-pack marketing and find it confusing, deceptive, and misleading. Child-appeal marketing features such as cartoon characters and bright colours gave parents the perception that products were unhealthy. Overall, this scoping review offers important insights into the types of front-of-pack marketing that appeal to parents and offers an inventory of parent-appeal marketing features. These findings support the design and implementation of policies that aim to reduce commercial influences on children's diets through stronger regulation of marketing of foods for children.

An Evaluation of the Nutritional and Promotional Profile of Commercial Foods for Infants and Toddlers in the United States

Despite growing concerns over the increasing popularity and health impact of commercial foods for infants and toddlers, no nutrition or promotional guidelines currently exist for the United States. In 2022, the WHO Regional Office for Europe published a nutrient and promotion profile model (NPPM) to provide guidance and regulation for commercially produced infant and toddler foods. This study assessed the nutritional and promotional profile of infant and toddler foods (6-36 months of age) collected from the top 10 grocery chains in 2023. Products were assessed against the WHO NPPM nutritional and promotional requirements. The type and number of claims across packaging type were also assessed. Of the 651 products examined, 60% failed to meet the nutritional requirements of the NPPM, and 0% met the promotional requirements. Almost 100% of products had at least 1 claim on-pack that was prohibited under the NPPM, with some products displaying up to 11 prohibited claims. Snack-size packages had the lowest compliance with nutrient requirements. These findings highlight that urgent work is needed to improve the nutritional quality of commercially produced infant and toddler foods in the United States. The high use of prohibited claims also suggests the need to regulate the type and number of claims allowed on-pack.

Compliance of Australian commercial foods for young children (<36 months) with an international nutrient and promotion profile model

OBJECTIVE

To assess how Australian infant and toddler foods compare to a nutrient and promotion profile model (NPPM) developed by the World Health Organization to support the appropriate promotion of commercial food products for children aged 6-36 months.

METHODS

A cross-sectional audit of infant and toddler foods found at three major Australian supermarkets was conducted in September/October 2022. Using nutrition and promotional data extracted from the packaging, products were classified according to NPPM categories and assessed against relevant compositional, front-of-pack labelling and promotional requirements.

RESULTS

Of 330 eligible products identified, just 28% met all NPPM compositional requirements. Toddler foods were less compliant than infant foods overall (18% vs. 31%; p=0.021), and for specific nutrients such as sodium (75% vs. 89%; p=0.003). No products met all NPPM front-of-pack labelling/promotional requirements. Only two-thirds and two-fifths of products were compliant with product name and ingredient list requirements, respectively.

CONCLUSION

Australian infant and toddler foods do not fully comply with the NPPM requirements. While toddler foods performed comparatively worse in terms of their nutritional adequacy, there is considerable scope to improve the nutrient profile of both infant and toddler foods.

IMPLICATIONS FOR PUBLIC HEALTH

To better support young children's health and development, the introduction of mandatory nutrition standards for Australian toddler foods, and the improvement of nutrition standards for Australian infant foods, in line with the NPPM, is needed. To be most effective, these should be combined with regulations for the labelling and promotion of these foods in line with the NPPM.

Market-driven fortification of vitamins and minerals in packaged foods targeted at children in Brazil

This study aimed to characterise the market-driven fortification of vitamins and minerals in packaged foods targeted at children in Brazil. We analysed 535 food labels using data collected in a census-type method (n = 5620) of food labels in a Brazilian supermarket in 2013. Micronutrients declared in nutrition claims and the ingredients list (synthetic compounds) were considered to be added for commercial purposes. Analysis of the ingredients list and nutrition claims showed that market-driven fortification of vitamins and minerals was present in 27.1% of foods. The main vitamins and minerals were vitamins A, B complex, C, D, calcium, iron and zinc. The food groups 'Milk and dairy products' and 'Sugars, sugary foods and snacks' had the highest frequencies of micronutrients declared in the ingredients list. Calcium, iron, phosphorus, zinc and all vitamins, except B7, were found to be added for commercial purposes. Micronutrients were found to be commonly added to packaged foods as a marketing strategy directed at parents and their children. Future studies should assess the amount of vitamins and minerals added to packaged foods targeted at children and whether intakes of vitamins and minerals in children are potentially excessive.

Effects of marketing claims on toddler food products on parents' product preferences, perceptions and purchasing intentions: an online experiment

BACKGROUND

The retail market for toddler-specific packaged foods is growing. Many of these products are ultra-processed and high in nutrients of concern for health, yet marketed in ways that may make them appear wholesome. This study aims to assess parents' responses to claims on unhealthy, ultra-processed toddler food products and test whether removing such claims promotes more accurate product perceptions and healthier product preferences.

METHODS

Parents of toddlers aged 12 to < 36 months (N = 838) were recruited for an online experiment testing four on-pack claim conditions: control (no claim); 'contains "good" ingredient'; 'free from "bad" ingredient'; and unregulated 'child-related' claim. Participants were randomly assigned to one condition, then viewed images of toddler food products that varied in nutrition content and the claims displayed. Participants completed tasks assessing product preferences (unhealthy product displaying claim vs. a healthier option with no claim, across four food categories (banana bars, strawberry snacks, blueberry yogurt snacks and veggie snacks)), purchase intentions and product perceptions. Poisson regression (count variable) and linear regression (continuous outcomes) analyses were employed to test for mean differences by marketing claim conditions.

RESULTS

For the overall sample, brief exposure to 'free from "bad" ingredient' claims increased participant's intentions to purchase unhealthy food products for their toddlers, but there was no clear evidence that 'contains "good" ingredient' claims and 'child-related' claims significantly impacted parent's preferences, purchase intentions and perceptions of toddler foods. However, certain claims influenced particular parent subgroups. Notably, parents with three or more children chose more unhealthy products when these products displayed 'contains "good" ingredient' or 'free from "bad" ingredient' claims; the latter claims also promoted stronger purchase intentions and enhanced product perceptions among this subgroup.

CONCLUSIONS

Findings indicate that 'free from "bad" ingredient' claims on unhealthy toddler foods are of most concern, as they boost the appeal of these products to parents. 'Contains "good" ingredient' claims and 'child-related' claims showed limited effects in this study. Considering available evidence, we recommend claims should not be permitted on child-oriented foods, as they may promote inaccurate product perceptions and unhealthy product choices by parents, that can detract from their children's diets and health.

Front-of-pack marketing on infant and toddler foods: Targeting children and their caregivers

OBJECTIVE

To identify and quantify child- and caregiver-appeal on front-of-pack marketing on infant and toddler foods in the Australian food supply.

METHODS

Content analysis of the presence and type of front-of-pack marketing techniques displayed on the front-of-pack of infant and toddler foods (for children aged up to 36 months) available in Australia's two major supermarkets' online stores.

RESULTS

Infant and toddler foods are promoted by up to 15 unique marketing techniques on the front-of-pack with an average of eight unique features per pack. A majority of food packages included marketing techniques targeting children, and all food packages included marketing techniques targeting caregivers, most commonly promoting health and nutrition.

CONCLUSIONS

Infant and toddler food packages are saturated with front-of-pack marketing features that target children and caregivers. To adequately protect young children's diets from the harmful influence of food marketing, and to promote the development of optimal feeding behaviours, government-led controls of all marketing intended to influence children's diets are required. In the context of marketing infant and toddler foods, this includes regulation of front-of-pack marketing techniques targeted to children and their caregivers.

IMPLICATIONS FOR PUBLIC HEALTH

Comprehensive government-led food marketing controls are required to protect children's diets from the harmful influence of marketing. The scope of these controls must include all unhealthy food marketing that children are exposed to and all other forms of unhealthy food marketing intended to influence children's diets.

Benchmarking the nutrient composition and labelling practices of finger foods and snacks for older infants and young children across seven Southeast Asian countries

Ensuring consumption of nutrient-dense, safe and appropriate complementary foods among older infants and young children (IYC) 6-36 months of age is critical for enabling optimal growth and development. The ubiquitous availability of and high demand for commercially packaged snack foods has culminated in a growing trend of snack food products specifically produced and promoted for older IYC. Commercially produced complementary foods (CPCF) that are finger foods/snacks often contain added sugars, excessive sodium content and high total sugar content, making them inappropriate for this young population. This study benchmarked the nutrient composition and labelling practices of CPCF finger foods/snacks available for purchase in seven countries in Southeast Asia. The study adapted a nutrient profiling model from the WHO Regional Office for Europe to determine the proportion of products suitable for promotion for older IYC. Of the total 606 products identified, 8.2% were automatically categorized as not suitable because they were confectionery items. Of the remaining 556 products assessed, over 85% failed to meet all nutrient composition requirements, with the presence of added sugars/sweeteners and excessive sodium and total sugar contents the primary reasons for failure. Products also demonstrated concerning labelling practices, with all of the products (98.6%) displaying an inappropriate claim on the label. These findings reveal major concerns with the nutrient composition and labelling practices of CPCF finger foods/snacks in the SEA region and should serve as an alarm bell for regulatory action. National binding legal measures, such as mandatory standards for composition and labelling are urgently needed.

Accuracy of declared nutrient content on labels of commercial complementary food products in Cambodia, Indonesia and Senegal

Commercially produced complementary foods (CPCF) have the potential to fill nutritional gaps in the diets of older infants and young children. This study evaluated the accuracy of nutrient declarations on labels of 43 commonly available CPCF in three peri-urban/urban locations: Khsach Kandal district, Cambodia (n = 11); Bandung, Indonesia (n = 11) and Guédiawaye and Dakar departments, Senegal (n = 21). Label values (LV) from product nutrient declarations were compared to analytical values (AV) derived from laboratory nutrient analysis for macronutrients (carbohydrate, protein and total fat), nutrients of public health concern (saturated fat, total sugar and sodium), and micronutrients of interest (calcium, iron and zinc). European Union guidance for nutrition label accuracy was used to set tolerance ranges for each nutrient LV relative to AV. LV were missing for one or more nutrients in 88.4% (n = 38) of the CPCF products and no CPCF met EU tolerance thresholds for all nine nutrients assessed. Over half of products with LV for key micronutrients (55.6%, n = 10/18) and macronutrients (54.8%, n = 23/42) met tolerances for LV accuracy. Eighty-five percent (n = 11/13) of products with LV for nutrients of public health concern were determined to be accurate. Nutrient content claims for iron appeared on 19 (44.2%) of the 43 products. Of the products which made an iron content claim, 26.3% had inaccurate LV with the majority of these containing less iron than declared. Regulatory action is needed to ensure that CPCF labelling communicates complete and accurate nutrient content information that enables caregivers to make informed decisions for feeding older infants and young children.

Influence of nutrition claims on different models of front-of-package nutritional labeling in supposedly healthy foods: Impact on the understanding of nutritional information, healthfulness perception, and purchase intention of Brazilian consumers

Nutrition claims are positive information about foods, which are widely used as a marketing strategy on labels. On the contrary, front-of-package nutritional labeling (FoPNL) aims to make it easier for consumers to understand the nutritional composition of foods and favor healthy food choices. However, the concomitant presence of nutrition claims and FoPNL may hinder the understanding, judgment, and choices of consumers at the moment of purchase. Therefore, the objective of this study was to evaluate the influence of nutrition claims on the efficacy of FoPNL models in the understanding of nutritional information, healthfulness perception, and purchase intention of Brazilian consumers. It was an experimental cross-sectional study carried out using an online questionnaire, with a total of 720 participants randomly divided into four FoPNL conditions: control, octagon, triangle, and magnifying glass. Each participant looked at 12 food packages, which were produced following the factorial design: (i) food category (cereal bar, whole grain cookies, and snacks); (ii) product type (containing one critical nutrient × containing two critical nutrients); and (iii) nutrition claims (present × absent). The comprehension of nutritional information was evaluated through the identification of excessive nutrients, and the healthfulness perception and purchase intention were evaluated using a seven-point scale. The results indicated that the presence of FoPNL increased the understanding of the information and reduced healthfulness perception and purchase intention. The presence of nutrition claims influenced the three outcomes, decreasing the probability of understanding information about food composition by 32% (OR 0.68, 95% confidence interval 0.58–0.78, p &lt; 0.01) and significantly increasing (p &lt; 0.05) average health scores (1.95–2.02) and purchase intention (2.00–2.05). Nonetheless, the interaction “FoPNL × claims” was not significant, which indicated that claims act independently. All FoPNL models were more effective than the control. For the least healthful type of product (two nutrients in excess), the octagon and triangle models were superior to the magnifying glass, regarding the outcome of healthfulness perception. The results prove the efficacy of FoPNL in consumer understanding and judgment. Despite the positive effects of FoPNL, it did not cancel the positivity bias generated by the claims.

Kombucha: Perceptions and Future Prospects

Background: Kombucha is an increasingly consumed product classified as a nutraceutical. Legislative efforts about these products remain confusing and without global harmonization. This natural product has been developed to improve or promote physical and mental health. However, it needs regulatory guidelines to control the production and guarantee the product’s efficacy and safety. Aim: The study intends to draw attention to the need for regulatory guidelines and the potential of this product in the market and peoples’ health. Key findings and conclusions: The lack of regulation and the low level of literacy about this product can limit its development, marketing, and impact on health. Thus, it is essential to highlight the potential value of this product and invest in its development and marketing. Likewise, it is important to spread awareness among the population of these products and their impacts on people’s health. Thus, this study focuses on a pertinent theme and alerts to the need for legislation for these products, to draw attention to the inexistent legislative control and the consequent need for regulatory guidelines for better and safer production and consumption.