A comparison of the healthiness of packaged foods and beverages from 12 countries using the Health Star Rating nutrient profiling system, 2013-2018

Energy, nutrient and overall healthiness of processed packaged foods in Fiji, a comparison between 2018 and 2020

In Fiji, packaged foods are becoming increasingly available. However, it is unknown if nutrition composition of these foods has changed. This study aims to assess changes in energy, nutrient content and healthiness of packaged foods by comparing data from five major supermarkets in Fiji in 2018 and 2020. Foods were categorised into 14 groups; nutrient composition information was extracted and healthiness assessed using Health Star Rating (HSR). Descriptive statistics and a separate matched products analysis was conducted summarising differences in nutrient content and HSR. There was limited evidence of change in the nutrient content of included products however, there was a small reduction in mean saturated fat in the snack food category (-1.0 g/100 g, 95% CI -1.6 to -0.4 g/100 g). The proportion of products considered healthy based on HSR, increased in the convenience foods category (28.4%, 95% CI 8.3 to 48.5) and decreased in non-alcoholic beverages (-35.2%, 95% CI -43.6 to -26.9). The mean HSR score increased in the fruit and vegetables category (0.1 (95% CI 0.1, 0.2)) and decreased for non-alcoholic beverages (-1.1 (-1.3, -0.9)) and the sauces, dressings, spreads, and dips category (-0.3 (-0.3, -0.2)). Strengthened monitoring of the food supply is needed to improve the healthiness of foods available.

Evaluation of the Nutritional Quality of Chinese Processed Meat Products: Comparison of Two Nutrient Profile Models

Processed meat products are one of the most consumed pre-packaged foods in China. They are also group-1 carcinogens, whose consumption has proved to be positively associated with the risk of noncommunicable diseases (NCDs). The purpose of this study is to analyze the nutrient content on the food label of processed meat products based on the China Standardized Database for the Composition of Pre-packaged Food and the National Open Database of the UK and France. The Chilean front-of-pack warning label (FOPWL) and the Chinese Healthier Choice Logo were used to compare the nutrient content of processed meat products from the three countries. It was found that cured meat products have the highest median energy (483 kcal/100 g), total fat content (38.7 g/100 g), and sodium content (2076 mg/100 g) and dried meat products have the highest median protein content (30.2 g/100 g) and carbohydrate content (38.2 g/100 g). In addition, there were significant differences in energy content and contents of total fat, protein, and carbohydrate across different products of the three countries (p < 0.001). A large number of processed meat products currently collected did not meet the criteria of the Chilean FOPWL and the Chinese Healthier Choice Logo. This study provided information on the healthiness of Chinese processed meat products and provided data for improving food formulations for different categories of processed meat products.

Evaluating the Energy and Core Nutrients of Condiments in China

Condiments are a significant source of sodium in the diets of Chinese residents. This study aimed to analyze the nutrient content of China's major condiments and to provide support for setting the reference intake for condiments in order to take measures on salt reduction in China. Nutrition data for condiments were collected from the Database on Nutrition Labelling of Prepackaged Foods China in 2017-2022, and by online access to food composition databases from France, the UK, Belgium, and Japan. The analyses include 1510 condiments in China and 1565 related condiments in four countries, of which the descriptive indicators were examined such as median, IQR, and range. Cross-comparisons were made in terms of the difference between the content levels in five countries and the "WHO global sodium benchmarks". The results show that among the 15 types of condiments in China, sesame/peanut butter-based products have a relatively high content of energy, fat, and protein, namely, 2580 kJ/100 g, 50 g/100 g, and 22.2 g/100 g, respectively. In addition to salt, chicken extract/chicken powder, bouillon cubes, and soy sauce are also high in sodium. Furthermore, there were significant differences in the contents of energy and core nutrients across different products when benchmarking with similar condiments in the five countries (p < 0.001). The sodium content and fat content of some condiments are excessively high. Therefore, enhancing residents' consumption awareness and reducing the amount of condiments is of great significance for reducing China's per capita salt intake and promoting good health.

The Nutritional Quality of Gluten-Free versus Non-Gluten-Free Pre-Packaged Foods and Beverages Sold in Hong Kong

INTRODUCTION

The consumption of gluten-free foods has continued to increase in recent years. Given their higher intake among individuals both with and without a medically diagnosed gluten allergy or sensitivity, it is important to understand how the nutritional quality of these foods compares against non-gluten-free foods. As such, we aimed to compare the nutritional quality of gluten-free and non-gluten-free pre-packaged foods sold in Hong Kong.

METHODS

Data from 18,292 pre-packaged food and beverage items in the 2019 FoodSwitch Hong Kong database were used. These products were categorized as (1) "declared gluten-free"; (2) "gluten-free by ingredient or naturally gluten-free"; and (3) "non-gluten-free" according to information presented on the package. One-way ANOVA was used to compare the differences in the Australian Health Star Rating (HSR), energy, protein, fibre, total fat, saturated fat, trans-fat, carbohydrates, sugars, and sodium content between products in different gluten categories, overall and by major food category (e.g., bread and bakery products) and region of origin (e.g., America, Europe).

RESULTS

Products declared gluten-free (mean ± SD: 2.9 ± 1.3; n = 7%) had statistically significantly higher HSR than those gluten-free by ingredient or naturally gluten-free (2.7 ± 1.4; n = 51.9%) and non-gluten-free (2.2 ± 1.4; n = 41.2%) (all pairwise comparisons p < 0.001). Overall, non-gluten-free products have higher energy, protein, saturated fat, trans-fat, free sugar and sodium, and less fibre compared with products in the other two gluten categories. Similar differences were observed across major food groups and by region of origin.

CONCLUSIONS

Non-gluten-free products sold in Hong Kong were generally less healthy than gluten-free products (regardless of the presence of gluten-free declaration). Consumers should be better educated on how to identify gluten-free foods, given that many gluten-free foods do not declare this information on the label.

Comparison of Nutri-Score and Health Star Rating Nutrient Profiling Models Using Large Branded Foods Composition Database and Sales Data

Front-of-package nutrition labelling (FOPNL) is known as an effective tool that can encourage healthier food choices and food reformulation. A very interesting type of FOPNL is grading schemes. Our objective was to compare two market-implemented grading schemes-European Nutri-Score (NS) and Australian Health Star Rating (HSR), using large Slovenian branded foods database. NS and HSR were used for profiling 17,226 pre-packed foods and drinks, available in Slovenian food supply dataset (2020). Alignment between models was evaluated with agreement (% of agreement and Cohen's Kappa) and correlation (Spearman rho). The 12-month nationwide sales-data were used for sale-weighing, to address market-share differences. Study results indicated that both models have good discriminatory ability between products based on their nutritional composition. NS and HSR ranked 22% and 33% of Slovenian food supply as healthy, respectively. Agreement between NS and HSR was strong (70%, κ = 0.62) with a very strong correlation (rho = 0.87). Observed profiling models were most aligned within food categories Beverages and Bread and bakery products, while less aligned for Dairy and imitates and Edible oils and emulsions. Notable disagreements were particularly observed in subcategories of Cheese and processed cheeses (8%, κ = 0.01, rho = 0.38) and Cooking oils (27%, κ = 0.11, rho = 0.40). Further analysis showed that the main differences in Cooking oils were due to olive oil and walnut oil, which are favoured by NS and grapeseed, flaxseed and sunflower oil that are favoured by HSR. For Cheeses and cheese products, we observed that HSR graded products across the whole scale, with majority (63%) being classified as healthy (≥3.5 *), while NS mostly graded lower scores. Sale-weighting analyses showed that offer in the food supply does not always reflect the sales. Sale-weighting increased overall agreement between profiles from 70% to 81%, with notable differences between food categories. In conclusion, NS and HSR were shown as highly compliant FOPNLs with few divergences in some subcategories. Even these models do not always grade products equally high, very similar ranking trends were observed. However, the observed differences highlight the challenges of FOPNL ranking schemes, which are tailored to address somewhat different public health priorities in different countries. International harmonization can support further development of grading type nutrient profiling models for the use in FOPNL, and make those acceptable for more stake-holders, which will be crucial for their successful regulatory implementation.

Snacking Behavior and Association with Metabolic Risk Factors in Adults from North and South India

BACKGROUND

Snacks are increasingly contributing to daily diets around the world. Studies from high-income countries have demonstrated the link between snack consumption and metabolic risk factors, but there are very few studies from low- and middle-income countries.

OBJECTIVES

The objective of this study was to assess snack behavior and its associations with metabolic risk factors in Indian adults.

METHODS

Adults from the UDAY study (October 2018-February 2019, n = 8762) from rural and urban Sonipat (North) and Vizag (South) India were studied for snack consumption (food frequency questionnaire), demographic factors, including age, sex, etc. and metabolic risk factors, including BMI, waist circumference, fat percentage, plasma glucose, and blood pressure. We compared snack consumption by categories of sociodemographic factors (Mann-Whitney U test, Kruskal-Wallis test) and studied the likelihood for metabolic risk (logistic regression analysis).

RESULTS

Half of the study participants were women and resided in rural locations. Savory snacks were the most preferred; 50% of the participants consumed them 3-5 times/wk. Participants preferred to purchase out-of-home prepared snacks and eat them at home (86.6%) while watching television (69.4%) or with family/friends (49.3%). The reasons for snacking were hunger, craving, liking, and availability. Snack consumption was higher in Vizag (56.6%) than in Sonipat (43.4%), among women (55.5%) than men (44.5%), and the wealthiest; it was similar in rural-urban locations. Frequent consumers of snacks had 2 times higher likelihood for having obesity (OR: 2.22; 95% CI: 1.51, 3.27) central obesity (OR: 2.35; 95% CI: 1.60, 3.45), and higher fat percentage (OR: 1.92; 95% CI: 1.31, 2.82) and higher fasting glucose levels (r=0.12 (0.07-0.18) than consumers who consumed snacks rarely (all P ≤ 0.05).

CONCLUSIONS

Snack (savory and sweet) consumption was high among adults from sexes in both urban and rural locations of north and south India. This was associated with higher risk of obesity. There is a need to improve the food environment by promoting policies for ensuring healthier food options to reduce snacking and associated metabolic risk.

Consumers' Perceptions of the Design of Front-of-Package Warning Labels-A Qualitative Study in China

The warning label is identified as a simple front-of-package labeling format that assists consumers in making healthier food choices at the point of purchase. The color and/or shape of the design elements of the packaging labels can influence the understanding and purchase intention outcomes. This study aimed to explore the perceptions of consumers regarding differently designed warning labels (WLs) to identify a possibly suitable warning label design in the Chinese context. Using a qualitative approach, we collected data through 12 focus group discussions consisting of 116 participants residing in 6 provinces. Participants were selected by purposive sampling. Data were coded following inductive thematic analysis and summarized into three themes: (1) perceived preference for the appearance of the WLs, (2) perceived benefits of the WLs, and (3) suggestions for promoting the WLs. Participants preferred the black shield label showing a high content of the nutrients of concern (e.g., sodium, added sugar, and saturated fat) in both Chinese and English. Consumers generally agreed that the WLs were easy to understand and offered a simple method for choosing healthier foods. They anticipated that WLs could encourage the food industry to reformulate their products. Our study results will support the design and facilitate the use of WLs in China.

Impact of Obesogenic Environments on Sugar-Sweetened Beverage Consumption among Preschoolers: Findings from a Cross-Sectional Survey in Beijing

The excessive consumption of sugar-sweetened beverages (SSBs) has been proven to be critical for obesity among preschoolers. This study aimed to describe the SSB consumption rates among preschoolers in the Dongcheng District of Beijing, China, and to explore the association between obesogenic environmental determinants and consumption. We applied a stratified cluster sampling method and recruited 3057 primary caregivers of preschoolers in June 2019 to participate in the survey. The caregivers reported their children’s consumption rates of six categories of SSBs and their exposure rates to SSB-related obesogenic environments. The associations between them were tested using multivariate logistic regression models. The mean (SD) age of the children was 5.6 (0.6) years and nearly half (48.3%) were girls. About 84.5% of the children had consumed SSBs over the past three months, and sugar-sweetened milk beverages had the highest consumption rate. Higher exposure to advertisements for the corresponding SSB categories in children, higher frequency rates of consuming SSBs and of taking children to fast-food restaurants in caregivers, and lower frequency rates of reading the Nutrition Facts Panels by caregivers were associated with higher SSB consumption rates among children (p < 0.05 in all of the SSB categories investigated, except for the Nutrition Facts Panel reading behaviors for the sports and energy beverages). SSB consumption among preschoolers is of concern, and comprehensive policy actions and education are urgently needed.

Pathophysiology, phenotypes and management of type 2 diabetes mellitus in Indian and Chinese populations

Nearly half of all adults with type 2 diabetes mellitus (T2DM) live in India and China. These populations have an underlying predisposition to deficient insulin secretion, which has a key role in the pathogenesis of T2DM. Indian and Chinese people might be more susceptible to hepatic or skeletal muscle insulin resistance, respectively, than other populations, resulting in specific forms of insulin deficiency. Cluster-based phenotypic analyses demonstrate a higher frequency of severe insulin-deficient diabetes mellitus and younger ages at diagnosis, lower β-cell function, lower insulin resistance and lower BMI among Indian and Chinese people compared with European people. Individuals diagnosed earliest in life have the most aggressive course of disease and the highest risk of complications. These characteristics might contribute to distinctive responses to glucose-lowering medications. Incretin-based agents are particularly effective for lowering glucose levels in these populations; they enhance incretin-augmented insulin secretion and suppress glucagon secretion. Sodium-glucose cotransporter 2 inhibitors might also lower blood levels of glucose especially effectively among Asian people, while α-glucosidase inhibitors are better tolerated in east Asian populations versus other populations. Further research is needed to better characterize and address the pathophysiology and phenotypes of T2DM in Indian and Chinese populations, and to further develop individualized treatment strategies.

Nutritional Quality of Pre-Packaged Foods in China under Various Nutrient Profile Models

This study used various nutrient profile models (NPMs) to evaluate the nutritional quality of pre-packaged foods in China to inform future food policy development. Nutrition data for pre-packaged foods were collected through FoodSwitch China in 2017-2020. The analyses included 73,885 pre-packaged foods, including 8236 beverages and 65,649 foods. Processed foods (PFs) and ultra-processed foods (UPFs) accounted for 8222 (11.4%) and 47,003 (63.6%) of all products, respectively. Among the 55,425 PFs and UPFs, the overall proportion of products with an excessive quantity of at least one negative nutrient was 86.0% according to the Chilean NPM (2019), 83.3% for the Pan American Health Organization NPM (PAHO NPM), and 90.6% for the Western Pacific Region NPM for protecting children from food marketing (WPHO NPM), respectively. In all NPMs, 70.4% of PFs and UPFs were identified as containing an excessive quantity of at least one negative nutrient, with higher proportions of UPFs compared to PFs. Food groups exceeding nutrient thresholds in most NPMs included snack foods, meat and meat products, bread and bakery products, non-alcoholic beverages, confectionery, and convenience foods. In conclusion, PFs and UPFs accounted for three-fourths of pre-packaged foods in China, and the majority of PFs and UPFs exceeded the threshold for at least one negative nutrient under all three NPMs. Given the need to prevent obesity and other diet-related chronic diseases, efforts are warranted to improve the healthiness of foods in China through evidence-based food policy.

Types and Aspects of Front-of-Package Labeling Preferred by Parents: Insights for Policy Making in China

The WHO recommends front-of-package labeling (FOPL) to help parents make healthier food choices for their children. But which type of FOPL resonates with parents in China? We performed a cross-sectional study to investigate parental preferences for five widely used formats of FOPL. A multi-stage cluster sampling method was applied to selected parents of students in primary and secondary schools in six provinces and municipalities from July 2020 to March 2021. A close-ended questionnaire was used to collect demographic information, parents’ preferences for five FOPL in three dimensions, perceptions of the importance of nutrients labeled on FOPL, and prepackaged foods that need FOPL most. Chi-square tests were used to examine the characteristics among five groups. The results showed that multiple traffic lights (MTL) was preferred by parents, followed by warning labels. Parents thought the most needed nutrients to label were sugar, salt, and total fat. The top three prepackaged foods to label were “baked food”, “milk and dairy products” and “sugar-sweetened beverages”. Our findings indicate that nutrient-specific FOPL formats with interpretive aids were preferred by Chinese parents. These new findings can help inform the planning and implementation of FOPL in China and help Chinese parents make healthier food choices.

Key Stakeholder Perspectives on Introducing a Front-of-Pack Labelling Scheme on Packaged Foods in China: A Qualitative Study

Front-of-pack (FoP) labelling on foods is recommended by the World Health Organization (WHO) to address the growing global burden of diet-related noncommunicable diseases (NCDs), but this policy has not yet been implemented in China. The aim of this study was to ascertain key stakeholders’ views on barriers and facilitators to developing a feasible and acceptable FoP labelling policy in the Chinese context. Semistructured interviews were used to elicit opinions from diverse representatives in roles of FoP labelling policy influence. Participants were identified by purposive and snowball sampling. The Consolidated Framework for Implementation Research (CFIR) was adopted to facilitate data collection and analysis. Themes and subthemes were generated using deductive and inductive approaches. Thirty participants were interviewed. The major barriers were the absence of national contextual analysis, perceived complexity of the process of policy development, disagreement on a preferred FoP labelling format, cost for the food industry, low priority compared to food safety policies, lack of existing regulatory framework or authorised nutrient profiling system, limited knowledge of FoP labelling, and the lack of planning and engagement with stakeholders. Facilitators included existing prerequisites, experiences and lessons from the pilot, policy coherence with Healthy China 2030, and support from external agents (e.g., WHO). Further efforts are required to develop and collate evidence to demonstrate the scientific, legal, and political feasibility of introducing effective FoP labelling.

Use of Branded Food Composition Databases for the Exploitation of Food Fortification Practices: A Case Study on Vitamin D in the Slovenian Food Supply

Vitamin D deficiency is a worldwide public health concern, which can be addressed with voluntary or mandatory food fortification. The aim of this study was to determine if branded food composition databases can be used to investigate voluntary fortification practices. A case study was conducted using two nationally representative cross-sectional datasets of branded foods in Slovenia, collected in 2017 and 2020, and yearly sales data. Using food labeling data we investigated prevalence of fortification and average vitamin D content, while nutrient profiling was used to investigate overall nutritional quality of the foods. In both datasets, the highest prevalence of vitamin D fortification was observed in meal replacements (78% in 2017; 100% in 2020) and in margarine, corresponding to high market share. Other food categories commonly fortified with vitamin D are breakfast cereals (5% in 2017; 6% in 2020), yogurts and their imitates (5% in 2017; 4% in 2020), and baby foods (18% in both years). The highest declared average content of vitamin D was observed in margarine and foods for specific dietary use (7-8 μg/100g), followed by breakfast cereals (4 μg/100g), while the average content in other foods was below 2 μg/100g. Only minor differences were observed between 2017 and 2020. Major food-category differences were also observed in comparison of the overall nutritional quality of the fortified foods; higher overall nutritional quality was only observed in fortified margarine. Our study showed that branded food composition databases are extremely useful resources for the investigation and monitoring of fortification practices, particularly if sales data can also be used. In the absence of mandatory or recommended fortification in Slovenia, very few manufacturers decide to add vitamin D, and even when this is the case, such products are commonly niche foods with lower market shares. We observed exceptions in imported foods, which can be subject to fortification policies introduced in other countries.

Branded Foods Databases as a Tool to Support Nutrition Research and Monitoring of the Food Supply: Insights From the Slovenian Composition and Labeling Information System

Branded foods databases are becoming very valuable not only in nutrition research but also for clinical practice, policymakers, businesses, and general population. In contrast to generic foods, branded foods are marked by rapid changes in the food supply because of reformulations, the introduction of new foods, and the removal of existing ones from the market. Also, different branded foods are available in different countries. This not only complicates the compilation of branded foods datasets but also causes such datasets to become out of date quickly. In this review, we present different approaches to the compilation of branded foods datasets, describe the history and progress of building and updating such datasets in Slovenia, and present data to support nutrition research and monitoring of the food supply. Manufacturers are key sources of information for the compilation of branded foods databases, most commonly through food labels. In Slovenia, the branded food dataset is compiled using standard food monitoring studies conducted at all major retailers. Cross-sectional studies are conducted every few years, in which the food labels of all available branded foods are photographed. Studies are conducted using the Composition and Labeling Information System (CLAS) infrastructure, composed of a smartphone application for data collection and online data extraction and management tool. We reviewed various uses of branded foods datasets. Datasets can be used to assess the nutritional composition of food in the food supply (i.e., salt, sugar content), the use of specific ingredients, for example, food additives, for nutrient profiling, and assessment of marketing techniques on food labels. Such datasets are also valuable for other studies, for example, assessing nutrient intakes in dietary surveys. Additional approaches are also being tested to keep datasets updated between food monitoring studies. A promising approach is the exploitation of crowdsourcing through the mobile application VešKajJeš, which was launched in Slovenia to support consumers in making healthier dietary choices.

Benchmarking as a Public Health Strategy for Creating Healthy Food Environments: An Evaluation of the INFORMAS Initiative (2012-2020)

Diet-related noncommunicable diseases (NCDs) and obesity are the leading contributors to poor health worldwide. Efforts to improve population diets need to focus on creating healthy food environments. INFORMAS, established in 2012, is an international network that monitors and benchmarks food environments and related policies. By 2020, INFORMAS was active in 58 countries; national government policies were the most frequent aspect benchmarked. INFORMAS has resulted in the development and widespread application of standardized methods for assessing the characteristics of food environments. The activities of INFORMAS have contributed substantially to capacity building, advocacy, stakeholder engagement, and policy evaluation in relation to creating healthy food environments. Future efforts to benchmark food environments need to incorporate measurements related to environmental sustainability. For sustained impact, INFORMAS activities will need to be embedded within other existing monitoring initiatives. The most value will come from repeated assessments that help drive increased accountability for improving food environments.

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.

The Sharp Rise in the Use of Low- and No-Calorie Sweeteners in Non-Alcoholic Beverages in Slovenia: An Update Based on 2020 Data

Reducing added sugars in non-alcoholic beverages is an important public health goal, which can result in increased use of low- and no-calorie sweeteners (LNCS). The aim of this study was to investigate recent changes in the use of LNCS in non-alcoholic beverages in the Slovenian food supply. The national branded foods dataset was updated with beverages available in 2020, and compared with previous datasets. The data were extracted from food labels. In 2020, N = 1,650 unique beverages were found in shops from five different retailers, covering the majority of the national market. The use of LNCS increased from 13.2% in 2017 and 15.5% in 2019 to 20.2% in 2020, with a major growth in soft drinks (16.8, 19.6, and 26.7%, respectively). We observed a significant growth of beverages containing both LNCS and added sugar. Results were also consistent with sales data, which showed that increased offer of beverages with LNCS also resulted in similarly increased sales of such beverages. The average energy and total sugar content in non-alcoholic beverages decreased, which reflects both the higher percentage of beverages with LNCS, and also the reduction of the sugar content in beverages with only added sugar. Analyses of product-specific reformulation practices highlighted reduced sugar content in 16.8% of products, and in 3.6% with the use of LNCS. The most commonly used LNCS are acesulfame K, sucralose, and aspartame. Typically, combinations are used, however steviol glycosides, sucralose and saccharin are also used alone, in most cases combined with added sugar. The results indicated rapid changes in the use of LNCS in non-alcoholic beverages in the Slovenian food supply, making further monitoring of this area highly relevant.

A Comparison of Diet Quality in a Sample of Rural and Urban Australian Adults

The diet quality of rural Australians is under researched. Characterising disparities in diet quality between rural and urban populations may inform targeted interventions in at- risk groups. A cross-sectional study aimed to determine the relationship between diet quality, rurality and sociodemographic characteristics in a sample of Australian adults. Participants were recruited at rural and regional events between 2017 and 2020, in New South Wales, Australia. Diet quality was measured using the Healthy Eating Quiz or Australian Eating Survey to generate an Australian Recommended Food Score (ARFS). ARFS was compared by rurality and sociodemographic characteristics using multivariate regression. Participants (n = 247; 53% female) had a mean ± SD ARFS of 34.5 ± 9.0. There was no significant effect of rurality on ARFS (β-coefficient = −0.4; 95%CI −3.0, 2.3). Compared to participants aged 18–30 years, higher ARFS was evident for those aged 31–50 (β = 5.4; 95%CI 0.3, 10.4), 51–70 (β = 4.4; 95%CI 0.3, 8.5) and >71 years (β = 6.5; 95% CI 1.6–11.4). Compared to those living alone, participants living with a partner (β = 5.2; 95%CI 2.0, 8.4) and families with children (β = 5.6; 95%CI 1.4, 9.8) had significantly higher ARFS. ARFS was significantly lower with each additional self-reported chronic health condition (β = −1.4; 95%CI −2.3, −0.4). Our results indicate that diet quality as defined by the ARFS was classified as ‘getting there’ and that age, living arrangements and chronic health conditions, but not rurality, influenced diet quality in a sample of Australian adults.

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.

The Contribution of Major Food Categories and Companies to Household Purchases of Added Sugar in Australia

BACKGROUND

The Australian Government will soon be releasing a series of sugar reformulation targets for packaged foods.

OBJECTIVE

To estimate the amount of added sugar purchased from packaged food and beverages and the relative contribution that food categories and food companies made to these purchases in 2018. The secondary objective was to examine differences in purchases of added sugar across income levels.

DESIGN

Cross-sectional study.

PARTICIPANTS/SETTING

We used 1 year of grocery purchase data from a nationally representative panel of Australian households (the NielsenIQ Homescan panel), combined with a packaged food and beverage database (FoodSwitch).

MAIN OUTCOME MEASURES

Added sugar purchases (grams per day per capita), purchase-weighted added sugar content (grams per 100 g) and total weight of products (with added sugar) purchased (grams per day per capita).

STATISTICAL ANALYSES PERFORMED

Food categories and food companies were ranked according to their contribution to added sugar purchases. Differences in added sugar purchases by income levels were assessed by 1-factor analysis of variance.

RESULTS

Added sugar information was available from 7188 households and across 26,291 unique foods and beverages. On average, the amount of added sugar acquired from packaged foods and beverages was (mean ± SE) 35.9 ± 0.01 g/d per capita. Low-income households purchased 11.0 g/d (95% CI: 10.9-11.0 g/d, P < .001) more added sugar from packaged products than high-income households per capita. The top 10 food categories accounted for 82.2% of added sugar purchased, largely due to purchases of chocolate and sweets, soft drinks, and ice cream and edible ices. Out of 994 food companies, the top 10 companies contributed to 62.1% of added sugar purchases.

CONCLUSIONS

The Australian Government can strengthen their proposed sugar reduction program by adding further category-specific targets, prioritizing engagement with key food companies and considering a broader range of policies to reduce added sugar intakes across the Australian population.

The WHO South-East Asia Region Nutrient Profile Model Is Quite Appropriate for India: An Exploration of 31,516 Food Products

The rapid rise in prevalence of overweight/obesity, as well as high prevalence of type 2 diabetes and other nutrition-related noncommunicable diseases, has led the Food Safety and Standards Authority of India (FSSAI) to propose a front-of-package labeling (FOPL) regulation. An effective FOPL system applies a nutrient profile model that identifies foods high in sugar, sodium, and saturated fat that would receive a warning label for consumers to effectively discern between more and less healthy foods. Previous Nutrition Alchemy data collected by the food industry (n = 1306 products) estimated that approximately 96% of foods in India would have at least one warning label based on the FSSAI proposed FOPL. This near universal coverage of warning labels may be inaccurate and misleading. To address this, the current study compared two nutrient profile models, the WHO South-East Asia Region Organization (SEARO) and the Chilean Warning Octagon (CWO) Phase 3, applied to food products available in the Indian market from 2015-2020, collected through Mintel Global New Products Database (n = 10,501 products). Results suggest that 68% of foods and beverages would have at least one ' high-in' level warning label. This study highlights the need to include a more comprehensive sample of food products for assessing the value of warning labels.

Assessing the healthiness of UK food companies' product portfolios using food sales and nutrient composition data

Background

The provision and over-consumption of foods high in energy, saturated fat, free sugars or salt are important risk factors for poor diet and ill-health. In the UK, policies seek to drive improvement through voluntary reformulation of single nutrients in key food groups. There has been little consideration of the overall progress by individual companies. This study assesses recent changes in the nutrient profile of brands and products sold by the top 10 food and beverage companies in the UK.

Methods

The FSA/Ofcom nutrient profile model was applied to the nutrient composition data for all products manufactured by the top 10 food and beverage companies and weighted by volume sales. The mean nutrient profiling score, on a scale of 1–100 with thresholds for healthy products being 62 for foods and 68 for drinks, was used to rank companies and food categories between 2015 and 2018, and to calculate the proportion of individual products and sales that are considered by the UK Government to be healthy.

Results

Between 2015 and 2018 there was little change in the sales-weighted nutrient profiling score of the top 10 companies (49 to 51; p = 0.28) or the proportion of products classified as healthy (46% to 48%; p = 0.23). Of the top five brands sold by each of the ten companies, only six brands among ten companies improved their nutrient profiling score by 20% or more. The proportion of total volume sales classified as healthy increased from 44% to 51% (p = 0.07) driven by an increase in the volume sales of bottled water, low/no calorie carbonates and juices, but after removing soft drinks, the proportion of foods classified as healthy decreased from 7% to 6% (p = 33).

Conclusions

The UK voluntary reformulation policies, setting targets for reductions in calories, sugar and salt, do not appear to have led to significant changes in the nutritional quality of foods, though there has been progress in soft drinks where the soft drink industry levy also applies. Further policy action is needed to incentivise companies to make more substantive changes in product composition to support consumers to achieve a healthier diet.

Nutritional quality of beverages available in vending machines in health and social care institutions: do we really want such offers?

BACKGROUND

Vending machines represent one way of offering food, but they are overlooked in the efforts to improve people's eating habits. The aim of our study was to analyse the variety and nutritional values of beverages offered in vending machines in social and health care institution in Slovenia.

METHODS

The available beverages were quantitatively assessed using traffic light profiling and the model for nutrient profiling used by Food Standards Australia New Zealand. Vending machines in 188 institutions were surveyed, resulting in 3046 different beverages consisting of 162 unique product labels.

RESULTS

Between 51 and 54% of beverages were categorised as unhealthy with regard to sugar content. Water accounted for only 13.7% of all beverages in vending machines. About 82% of beverages in vending machines were devoted to sugar-sweetened beverages, the majority (58.9%) presented in 500-ml bottles. The average sugar content and average calories in beverages sold in vending machines are slightly lower than in beverages sold in food stores.

CONCLUSIONS

We suggest that regulatory guidelines should be included in the tender conditions for vending machines in health and social care institutions, to ensure healthy food and beverage choices.

Health policy and public health implications of obesity in China

China has experienced many drastic social and economic changes and shifts in people's lifestyles since the 1990s, in parallel with the fast rising prevalence of obesity. About half of adults and a fifth of children have overweight or obesity according to the Chinese criteria, making China the country with the highest number of people with overweight or obesity in the world. Assuming that observed time trends would continue in the future, we projected the prevalence of and the number of people affected by overweight and obesity by 2030, and the associated medical costs. The rising incidence of obesity and number of people affected, as well as the related health and economic consequences, place a huge burden on China's health-care system. China has made many efforts to tackle obesity, including the implementation of relevant national policies and programmes. However, these measures are inadequate for controlling the obesity epidemic. In the past decade, China has attached great importance to public health, and the Healthy China 2030 national strategy initiated in 2016 provides a historical opportunity to establish comprehensive national strategies for tackling obesity. China is well positioned to explore an effective model to overcome the obesity epidemic; however, strong commitment and leadership from central and local governments are needed, as well as active participation of all related society sectors and individual citizens. TRANSLATION: For the Chinese translation of the paper see Supplementary Materials section.

Epidemiology and determinants of obesity in China

Obesity has become a major public health issue in China. Overweight and obesity have increased rapidly in the past four decades, and the latest national prevalence estimates for 2015-19, based on Chinese criteria, were 6·8% for overweight and 3·6% for obesity in children younger than 6 years, 11·1% for overweight and 7·9% for obesity in children and adolescents aged 6-17 years, and 34·3% for overweight and 16·4% for obesity in adults (≥18 years). Prevalence differed by sex, age group, and geographical location, but was substantial in all subpopulations. Strong evidence from prospective cohort studies has linked overweight and obesity to increased risks of major non-communicable diseases and premature mortality in Chinese populations. The growing burden of overweight and obesity could be driven by economic developments, sociocultural norms, and policies that have shaped individual-level risk factors for obesity through urbanisation, urban planning and built environments, and food systems and environments. Substantial changes in dietary patterns have occurred in China, with increased consumption of animal-source foods, refined grains, and highly processed, high-sugar, and high-fat foods, while physical activity levels in all major domains have decreased with increasing sedentary behaviours. The effects of dietary factors and physical inactivity intersect with other individual-level risk factors such as genetic susceptibility, psychosocial factors, obesogens, and in-utero and early-life exposures. In view of the scarcity of research around the individual and collective roles of these upstream and downstream factors, multidisciplinary and transdisciplinary studies are urgently needed to identify systemic approaches that target both the population-level determinants and individual-level risk factors for obesity in China.

Estimating the potential impact of Australia's reformulation programme on households' sodium purchases

Background

On average, Australian adults consume 3500 mg sodium per day, almost twice the recommended maximum level of intake. The Australian government through the Healthy Food Partnership initiative has developed a voluntary reformulation programme with sodium targets for 27 food categories. We estimated the potential impact of this programme on household sodium purchases (mg/day per capita) and examined potential differences by income level. We also modelled and compared the effects of applying the existing UK reformulation programme targets in Australia.

Methods

This study used 1 year of grocery purchase data (2018) from a nationally representative consumer panel of Australian households (Nielsen Homescan) that was linked with a packaged food and beverage database (FoodSwitch) that contains product-specific sodium information. Potential reductions in per capita sodium purchases were calculated and differences across income level were assessed by analysis of variance. All analyses were modelled to the Australian population in 2018.

Results

A total of 7188 households were included in the analyses. The Healthy Food Partnership targets covered 4307/26 728 (16.1%) unique products, which represented 22.3% of all packaged foods purchased by Australian households in 2018. Under the scenario that food manufacturers complied completely with the targets, sodium purchases will be reduced by 50 mg/day per capita, equivalent to 3.5% of sodium currently purchased from packaged foods. Reductions will be greater in low-income households compared with high-income households (mean difference -7 mg/day, 95% CI -4 to -11 mg/day, p<0.001). If Australia had adopted the UK sodium targets, this would have covered 9927 unique products, resulting in a reduction in per capita sodium purchases by 110 mg/day.

Conclusion

The Healthy Food Partnership reformulation programme is estimated to result in a very small reduction to sodium purchases. There are opportunities to improve the programme considerably through greater coverage and more stringent targets.

The role of colour and summary indicators in influencing front-of-pack food label effectiveness across seven countries

OBJECTIVE

Many countries are considering the implementation of front-of-pack nutrition labels as a strategy to address high and increasing levels of overweight and obesity. A growing body of work demonstrates the superiority of labels that use colour and/or provide a summary indicator of product healthiness to enhance comprehension. However, previous studies have been confounded in determining the relative effectiveness of these two attributes by comparing labels that also differ in other ways. The present study tested labels that varied only on use of colour and/or reliance on a summary indicator across an international sample to provide unique insights into the relative importance of these attributes.

DESIGN

Participants were randomised to see one of four variations of the Health Star Rating label that differed on the basis of use of colour and sole provision of a summary indicator.

SETTING

Australia, Canada, China, India, New Zealand, the UK and the USA.

PARTICIPANTS

Adults (n 7545) in seven countries were exposed to online choice tasks requiring them to select a preferred breakfast cereal and then nominate the healthiest cereal.

RESULTS

Overall, the coloured versions, and particularly the one with just a summary indicator, outperformed the monochrome version that included nutrient-specific information. However, there were some differences by country, with results from Canada and China indicating superior outcomes for monochrome labels and those providing nutrient-specific information.

CONCLUSIONS

The results highlight the importance of colour, but suggest that the introduction of front-of-pack nutrition labels should be preceded by country-specific formative testing to identify potential differences in outcomes.

Reformulation of Packaged Foods and Beverages in the Colombian Food Supply

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

Changes in the amount of nutrient of packaged foods and beverages after the initial implementation of the Chilean Law of Food Labelling and Advertising: A nonexperimental prospective study

BACKGROUND

In June 2016, the first phase of the Chilean Food Labelling and Advertising Law that mandated front-of-package warning labels and marketing restrictions for unhealthy foods and beverages was implemented. We assess foods and beverages reformulation after this initial implementation.

METHODS AND FINDINGS

A data set with the 2015 to 2017 nutritional information was developed collecting the information at 2 time periods: preimplementation (T0: January-February 2015 or 2016; n = 4,055) and postimplementation (T1: January-February 2017; n = 3,025). Quartiles of energy and nutrients of concern (total sugars, saturated fats, and sodium, per 100 g/100 mL) and the proportion of products with energy and nutrients exceeding the cutoffs of the law (i.e., products "high in") were compared pre- and postimplementation of the law in cross-sectional samples of products with sales >1% of their specific food or beverage groups, according to the Euromonitor International Database; a longitudinal subsample (i.e., products collected in both the pre- and postimplementation periods, n = 1,915) was also analyzed. Chi-squared, McNemar tests, and quantile regressions (simple and multilevel) were used for comparing T0 and T1. Cross-sectional analysis showed a significant decrease (T0 versus T1) in the proportion of product with any "high in" (from 51% [95% confidence interval (CI) 49-52] to 44% [95% CI 42-45]), mostly in food and beverage groups in which regulatory cutoffs were below the 75th percentile of the nutrient or energy distribution. Most frequent reductions were in the proportion of "high in" sugars products (in beverages, milks and milk-based drinks, breakfast cereals, sweet baked products, and sweet and savory spreads; from 80% [95% CI 73-86] to 60% [95% CI 51-69]) and in "high in sodium" products (in savory spreads, cheeses, ready-to-eat meals, soups, and sausages; from 74% [95% CI 69-78] to 27% [95% CI 20-35]). Conversely, the proportion of products "high in" saturated fats only decreased in savory spreads (p < 0.01), and the proportion of "high in" energy products significantly decreased among breakfast cereals and savory spreads (both p < 0.01). Quantile analyses showed that most of the changes took place close to the cutoff values, with only few exceptions of overall left shifts in distribution. Longitudinal analyses showed similar results. However, it is important to note that the nonexperimental nature of this study does not allow to imply causality of these findings.

CONCLUSIONS

Our results show that, after initial implementation of the Chilean Law of Food Labelling and Advertising, there was a significant decrease in the amount of sugars and sodium in several groups of packaged foods and beverages. Further studies should clarify how food reformulation will impact dietary quality of the population.

Facilitating Consumers Choice of Healthier Foods: A Comparison of Different Front-of-Package Labelling Schemes Using Slovenian Food Supply Database

Summary indicator front-of-package nutrition labelling schemes are gaining momentum. In Europe, an example of such a scheme is Nutri-Score, which was first introduced in France. Supported by additional research, the scheme has the potential to expand into other countries. Such a scenario opens a series of questions related to the use of Nutri-Score in the territories with pre-existing food labelling schemes. A key question is whether different nutrition labelling schemes would provide conflicting information for consumers when applied to same foods. The goal of our study was, therefore, to evaluate the alignment of different front-of-package nutrition labelling schemes. The study was conducted using cross-sectional data on the composition of selected categories of prepacked foods with high penetration nutrition/health claims and symbols in the Slovenian food supply. We evaluated a variety of existing front-of-package nutrition labelling schemes: three interpretive nutrition rating systems (Nutri-Score, Health Star Rating (HSR), Traffic light system), four health symbols (Protective Food symbol, Choices, Finnish heart, and Keyhole symbol), and also three nutrient profile models developed for other purposes (Office of Communications (United Kingdom, Ofcom), World Health Organization Regional office for Europe (WHOE) and Food Standards Australia New Zealand (FSANZ)). Overall, our results indicate that interpretive nutrition rating systems (i.e., Nutri-Score) are mostly less strict than the nutrient profiles of tested health symbols. A risk of conflicting information would happen in a scenario where food is eligible to carry a health symbol, but is at the same time rated to have lower nutritional quality by an accompanying interpretive nutrition rating system. When Protective Food symbol and Nutri-Score are used together, this would occur for 5% of foods in our sample. To avoid such risks, schemes for health symbols could be adapted to be stricter than interpretive nutrition rating systems used in the same territory/market, but such adaptations are challenging and should be well planned. While our study showed that, in most cases, Nutri-Score is a less strict model than tested health symbols, the rating-system approach might offer useful support and incentive for food producers towards gradual food reformulation.

Pyrraline Formation Modulated by Sodium Chloride and Controlled by Encapsulation with Different Coating Materials in the Maillard Reaction

Advanced glycation end products (AGEs), which are present in heat-processed foods, have been associated with several chronic diseases. Sodium chloride (NaCl) modulates the formation of furfurals and acrylamide in the Maillard reaction; however, the effects of NaCl on AGE formation are inconsistent. In this study, we investigated the effects of NaCl on pyrraline formation using glucose-lysine model systems. NaCl, especially at 0.50%, promoted Maillard browning and pyrraline formation, with a simultaneous increase in the 3-deoxyglucosone concentration. To reduce the rate of pyrraline formation, NaCl coated with different gums and starches were used. The results showed that NaCl encapsulation is an effective approach to mitigate pyrraline and 3-deoxyglucosone formation. The content of NaCl in the microparticles were 284 ± 12, 269 ± 6, 258 ± 8, 247 ± 10, 273 ± 16, and 288 ± 15 mg/g (coated with waxy maize starch, normal maize starch, HYLON VII high amylose maize starch, gelatinized resistant starch, xanthan gum, and gum arabic, respectively). The heat resistance of the coating material was negatively correlated with the pyrraline and 3-deoxyglucosone formation, whereas the solubility of the coating material had the opposite results. Coating the material with gum had little effects on the reduction of pyrraline and 3-deoxyglucosone.

Understanding the rise of cardiometabolic diseases in low- and middle-income countries

Increases in the prevalence of noncommunicable diseases (NCDs), particularly cardiometabolic diseases such as cardiovascular disease, stroke and diabetes, and their major risk factors have not been uniform across settings: for example, cardiovascular disease mortality has declined over recent decades in high-income countries but increased in low- and middle-income countries (LMICs). The factors contributing to this rise are varied and are influenced by environmental, social, political and commercial determinants of health, among other factors. This Review focuses on understanding the rise of cardiometabolic diseases in LMICs, with particular emphasis on obesity and its drivers, together with broader environmental and macro determinants of health, as well as LMIC-based responses to counteract cardiometabolic diseases.

Free Sugar Content in Pre-Packaged Products: Does Voluntary Product Reformulation Work in Practice?

Ultra-processed, pre-packaged foods are becoming a growing part of our diet, while displacing whole and minimally processed foods. This results in an increased intake of free sugar, salt, and saturated fats, that have a profoundly negative effect on health. We aimed to assess the trend in free sugar content in pre-packaged foods in Slovenia and evaluate the efficacy of industry self-regulations designed to combat the excess consumption of free sugar. A nation-wide data collection of the Slovenian food supply was performed in 2015 and repeated in 2017. In 2017, 54.5% of all products (n = 21,115) contained free sugars (median: 0.26 g free sugar/100 g). Soft drinks became the main free sugar source among pre-packaged goods (28% of all free sugar sold on the market) in place of chocolates and sweets, of which relative share decreased by 4.4%. In the categories with the highest free sugar share, market-leading brands were often sweeter than the average free sugar value of the category. This indicates that changes in on-shelf availability towards a greater number of healthier, less sweet products are not necessarily reflected in healthier consumers’ choices. Relying solely on voluntary industrial commitments to reduce free sugar consumption will likely not be sufficient to considerably improve public health. While some further improvements might be expected over the longer term, voluntarily commitments are more successful in increasing the availability of healthier alternatives, rather than improving the nutritional composition of the market-leading products. Additional activities are, therefore, needed to stimulate reformulation of the existing market-leading foods and drinks, and to stimulate the consumption of healthier alternatives.