Special Supplemental Nutrition Program for Women, Infants, and Children Participant Grocery Store Purchases during the COVID-19 Pandemic in North Carolina.

Background: Families participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) experienced barriers to accessing healthy food during the COVID-19 pandemic, but we do not yet understand how WIC participant food purchases shifted during the pandemic. Objectives: We aimed to describe the association between the initial shock of the pandemic in March 2020 and WIC shoppers' food purchases and changes in purchases before and during the pandemic at a top grocery chain and examine differences in these relationships by duration of WIC use. Methods: We used longitudinal food transaction data from WIC shoppers (n = 2,989,116 shopper-month observations from 175,081 unique WIC shoppers) from 496 stores in a top grocery store chain in North Carolina between October 2019 and May 2021. We used an interrupted time series design to describe the following: 1) the relationship between the initial shock of the pandemic and WIC shopper food purchases and 2) differences in purchases before and during the pandemic. To assess differences in purchases between shoppers consistently using WIC electronic benefit transfer (EBT) cards and shoppers starting or stopping WIC EBT use during the pandemic, we used models stratified by WIC group. Primary outcomes were share (%) of total calories purchased from fruits, vegetables, nuts, and legumes (FV), processed foods, and sugar-sweetened beverages (SSBs). Results: We observed small decreases in the share of total calories from FV (-0.4%) and small increases in the share of calories from processed food (1.1%) and SSBs (0.5%) purchased at this retailer when comparing the pre and post March 2020 periods. Compared with shoppers that started or stopped using WIC benefits during the pandemic, shoppers that used WIC benefits consistently had slightly higher FV and lower processed food and SSB purchases at this retailer. Conclusions: Future studies should examine whether additional supports for nutrient-dense food choices may be needed for families with low incomes in public health emergencies.

Front-of-package claims & imagery on fruit-flavored drinks and exposure by household demographics.

Young children regularly consume sugary fruit drinks, in part because parents may falsely believe they are healthful due to front-of-package (FOP) claims and imagery. The goal of this study was to assess: 1) the prevalence of FOP claims/imagery on fruit-flavored beverages purchased by U.S. households with 0-5-year-olds, and 2) proportional differences in beverages purchased with FOP claims/imagery across household demographic groups. A content analysis of FOP claims/imagery (e.g., nutrient claims, fruit imagery) on beverages (n = 1365) purchased by households with 0-5-year-olds was conducted by linking beverage sales with FOP marketing data. Results were merged with purchasing data from a nationally representative sample of households (FoodAPS), and survey-weighted logistic regression was used to assess differences in the proportions of 100% juices and fruit drinks with specific FOP claims/imagery purchased by household race/ethnicity, income, and SNAP/WIC participation. The most common claims on fruit-flavored beverages included nutrient claims (fruit drinks: 73%; 100% juices: 68%; flavored waters: 95%), which most commonly highlighted vitamin C (35-41% across beverage categories) and the absence of sugar (31-48%). Most beverages also contained implied-natural claims (fruit drinks: 60%; 100% juices: 64%; flavored waters: 95%) and natural imagery (fruit drinks: 97%; 100% juices: 96%; flavored waters: 73%). A large proportion of fruit drinks and 100% juices purchased by households across all demographic groups contained FOP claims and imagery, with a few minor differences between racial/ethnic groups. In conclusion, most fruit drinks, 100% juices, and flavored waters purchased by households with 0-5-year-olds contained FOP claims and imagery that may lead consumers to believe the beverages are healthy and natural. FDA regulations should ensure parents are not misled by this marketing.

The Impact of Toddler Milk Claims on Beliefs and Misperceptions: A Randomized Experiment with Parents of Young Children.

BACKGROUND: Toddler milk (ie, a nutrient-fortified milk-based drink marketed for children aged 12 to 36 months) has been marketed increasingly in the United States with structure/function claims on product packaging that are potentially misleading. OBJECTIVE: This study examined how structure/function claims impact parents' beliefs and perceptions about a toddler milk product. DESIGN: This was a 3-arm between-subjects randomized experiment. PARTICIPANTS: A diverse sample of 2,190 US parents of children aged 1 to 5 years were chosen to take an online survey. INTERVENTION: Participants were randomly assigned to view a toddler milk package with either an unrelated claim ("new and improved," ie, control condition), a "brain development" claim (ie, "brain" claim), or an "immunity-related" claim (ie, "immunity" claim). MAIN OUTCOME MEASURES: Outcomes included perceptions, intentions, and beliefs about the toddler milk product. STATISTICAL ANALYSES PERFORMED: Linear regression for continuous outcomes and logistic regression for dichotomous outcomes. RESULTS: Parents who were exposed to the "brain" claim or the "immunity" claim were more likely to incorrectly believe that the toddler milk was as healthy or healthier than cow's milk compared with those who saw the control claim (89% for brain claim, 87% for immunity claim, and 79% for control; P < .001 for both comparisons). Parents exposed to either the brain or immunity claim had higher intentions to give the toddler milk to their child, higher perceived product healthfulness, and stronger beliefs that pediatricians would recommend the product compared with parents exposed to the control (all, P < .001). CONCLUSIONS: These findings suggest that structure/function claims on toddler milk packaging may mislead parents and increase the appeal of toddler milk. Our findings support calls for public health policies to regulate marketing on toddler milk packaging.

Prevalence of Low-Calorie Sweeteners and Related Front-of-Package Claims in the Brazilian Packaged Food Supply.

BACKGROUND: Low-calorie sweeteners (LCSs) are increasingly being used worldwide, including in foods and beverages commonly consumed by children. OBJECTIVE: To examine the prevalence of LCSs in packaged foods and beverages sold in Brazil, whether LCSs are added to products with advertising directed to children, and whether foods and beverages with LCSs include front-of-package (FoP) LCS-related health and nutrition claims. DESIGN: Cross-sectional study. SETTING: A sample (n = 11,434) of packaged foods and beverages sold by the top 5 largest Brazilian food retailers was examined to identify LCSs and added sugars, and a subsample (n = 3491) was examined to determine the presence of advertising directed to children and FoP LCS-related claims in foods and beverages with LCSs. MAIN OUTCOME AND MEASURES: The prevalence of foods and beverages with different types of LCSs in the Brazilian food supply, among ultra-processed foods and beverages and among foods and beverages with added sugars, were measured. Foods and beverages with advertising directed to children were checked to see if these products had LCSs and how many products with LCSs had FoP labels with LCS-related claims. STATISTICAL ANALYSES: Mean and 95% CIs were used to determine the overall prevalence of foods and beverages with LCSs and in the different assessed stratifications. RESULTS: The prevalence of LCSs was 9.3% (95% CI 8.8-9.9) in Brazilian packaged foods and beverages, 14.6% (95% CI 13.8-15.4) in ultra-processed products alone, and 5.7% (95% CI 4.2-7.7) in foods and beverages with advertising directed to children. About 83% of food and beverage with LCSs were also sweetened with added sugars. LCSs were most frequently added to nonalcoholic sweetened beverages, breakfast cereals, and granola bars. Forty percent of foods and beverages with LCS did not present any FoP LCS-related claim. CONCLUSION: This study shows that LCSs are present in 15% of ultra-processed foods and beverages in Brazil, largely used in combination with added sugars, and are found in foods and beverages with advertising directed to children. Clearer FoP information regarding the presence of LCSs, in particular in products with advertising directed to children, can help consumers make more informed choices regarding LCS consumption.

Changes in the Use of Non-nutritive Sweeteners in the Chilean Food and Beverage Supply After the Implementation of the Food Labeling and Advertising Law.

Reductions on the sugars content of the food supply have been described after the initial implementation Chilean Labeling Law, but it is unclear if sugars were replaced by non-caloric sweeteners (NNS). We evaluated changes in the NNSs use in foods and beverages after the initial implementation of the labeling law. We used longitudinal data on packaged foods and beverages collected in six major supermarkets and three candy distributors in Santiago, Chile, in January-February 2015/2016 and in January-February 2017. We included in the analysis beverages, dairy-based beverages, yogurts, breakfast cereals, desserts and ice creams, candies and sweet confectioneries, and sweet spreads with a market share ≥1% of their food groups (n = 999). We compared the use of any NNS, the number of different NNSs used, and the combined use of NNSs and ingredients adding sugars using non-parametric tests for matched samples. We evaluated the association between a reduction in sugars and starting NNS use in the post-implementation period using negative binomial regression. The use of any NNS increased from 37.9 to 43.6% (p < 0.001) after the law's implementation, NNSs increased among beverages, dairy-based beverages, yogurts, and desserts and ice creams (p < 0.05), driven mostly by increases in sucralose and stevia use (p < 0.05). We found that reformulated products that reduced the amount of sugars below the law's cutoff were more likely to start using an NNS in the post-implementation period (prevalence ratio: 12.1; 95%CI: 7.2-20.2; p < 0.001). Our results suggest that NNSs likely replaced sugars after the initial implementation of the law. Further analyses should explore how these changes may impact NNS consumption.

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.

Nutrition Claims on Fruit Drinks Are Inconsistent Indicators of Nutritional Profile: A Content Analysis of Fruit Drinks Purchased by Households With Young Children.

BACKGROUND: Fruit drinks are the most commonly consumed sugar-sweetened beverage among young children. Fruit drinks carry many nutrition-related claims on the front of package (FOP). Nutrition-related claims affect individuals' perceptions of the healthfulness of products and purchase intentions, often creating a "health halo" effect. OBJECTIVE: The aims of this study were to describe the prevalence of FOP nutrition-related claims on fruit drinks purchased by households with young children and to examine the association between claims and the nutritional profile of fruit drinks. DESIGN: The sample included 2059 fruit drinks purchased by households with children 0 to 5 years old participating in Nielsen Homescan in 2017. FOP labels were obtained from 2 databases that contain bar code-level information on all printed material on product labels. A codebook was used to code for presence of FOP nutrition-related claims. The coded claims data were linked by bar code with Nutrition Facts label data. Claim type prevalence was calculated, and the association between claim types and median calories and total grams of sugar per 100 mL was analyzed using Wilcoxon rank-sum tests. The percentages of products containing noncaloric sweeteners (NCSs) with and without each claim type were also calculated and compared. RESULTS: Almost all (97%) fruit drinks sampled had at least 1 nutrition-related FOP claim. Implied natural claims such as "natural flavors" were the most common (55% of products), followed by claims about the presence of juice or nectar (49%). Claims about vitamin C (33%), sugar (29%), and calories (23%) were also common. Fruit drinks with vitamin C, juice or nectar, fruit or fruit flavor, and overt natural claims were higher in calories and sugar and less likely to contain NCSs compared with products without these claims. Fruit drinks with calorie, sugar, NCS, implied natural, and other claims were lower in calories and sugar and more likely to contain NCSs compared with products without these claims. CONCLUSIONS: Claims are prevalent on fruit drinks purchased by households with young children. This is concerning given prior research demonstrating that claims can mislead consumers. Regulatory actions such as requiring a warning or disclosure on drinks that contain added sugars or NCSs should be considered.

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.

Consumption of non-nutritive sweeteners by pre-schoolers of the food and environment Chilean cohort (FECHIC) before the implementation of the Chilean food labelling and advertising law.

BACKGROUND: Consumption of non-nutritive sweeteners (NNS) is becoming increasingly more frequent, particularly in the context of obesity prevention policies. The aim of this study was to describe the consumption of NNS in an ongoing cohort of pre-schoolers (4-6-year-old) before the implementation of the Chilean Food Labelling and Advertising Law, identify sociodemographic and anthropometric characteristics associated with their consumption, and describe the main dietary sources of each NNS sub-type. METHODS: In 959 low-medium income pre-schoolers from the Food and Environment Chilean Cohort (FECHIC), dietary data from a single 24-h recall was linked to NNS content information obtained from packaged foods (n = 12,233). The prevalence of NNS consumption was estimated by food source and characterized by child and maternal sociodemographic and anthropometric variables. Intakes and main dietary sources were described for the six most prevalent NNS in Chile: Sodium Cyclamate, Saccharin, Aspartame, Acesulfame Potassium, Sucralose, and Steviol glycosides. RESULTS: Sixty-eight percent of the pre-schoolers consumed at least one source of NNS on the day of the dietary recall; most of them consumed NNS from foods and beverages (n = 532), while only 12% (n = 119) also consumed table-top sweeteners. The prevalence of NNS consumption was significantly higher among children whose mothers had a high educational level compared to children whose mothers did not complete high school (p < 0.05); however, it did not differ by any other variable studied. The highest intakes of NNS were observed for Aspartame [2.5 (1.4-3.7) mg/kg per consumer], followed by Sodium Cyclamate [1.6 (1.3-2.6) mg/kg per consumer] and Steviol glycosides [1.2 (0.2-2.1) mg/kg per consumer]. Beverages were the only food group that contributed to the intake of the six NNS studied, accounting for 22% of the overall intake of Saccharine and up to 99% of Aspartame intake. CONCLUSIONS: Before the implementation of the Food Labelling and Advertising Law, NNS consumption was highly prevalent among a cohort of low-middle income Chilean pre-schoolers. Continuous monitoring of NNS consumption is essential given potential food reformulation associated with the implementation of this set of obesity-prevention policies.

Prevalence of Child-Directed Marketing on Breakfast Cereal Packages before and after Chile's Food Marketing Law: A Pre- and Post-Quantitative Content Analysis.

Food marketing has been identified as a contributing factor in childhood obesity, prompting global health organizations to recommend restrictions on unhealthy food marketing to children. Chile has responded to this recommendation with a restriction on child-directed marketing for products that exceed certain regulation-defined thresholds in sugars, saturated fats, sodium, or calories. Child-directed strategies are allowed for products that do not exceed these thresholds. To evaluate changes in marketing due to this restriction, we examined differences in the use of child-directed strategies on breakfast cereal packages that exceeded the defined thresholds vs. those that did not exceed the thresholds before (n = 168) and after (n = 153) the restriction was implemented. Photographs of cereal packages were taken from top supermarket chains in Santiago. Photographed cereals were classified as "high-in" if they exceeded any nutrient threshold described in the regulation. We found that the percentage of all cereal packages using child-directed strategies before implementation (36%) was significantly lower after implementation (21%), p < 0.05. This overall decrease is due to the decrease we found in the percentage of "high-in" cereals using child-directed strategies after implementation (43% before implementation, 15% after implementation), p < 0.05. In contrast, a greater percentage of packages that did not qualify as "high-in" used child-directed strategies after implementation (30%) compared with before implementation (8%), p < 0.05. The results suggest that the Chilean food marketing regulation can be effective at reducing the use of child-directed marketing for unhealthy food products.

Dietary Intake by Food Source and Eating Location in Low- and Middle-Income Chilean Preschool Children and Adolescents from Southeast Santiago.

BACKGROUND: Food source and eating location are important factors associated with the quality of dietary intake. In Chile the main food sources and eating locations of preschool children and adolescents and how these relate to dietary quality are unknown. METHODS: We analyzed 24 h dietary recalls collected in 2016 from low- and middle-income Chilean preschool children (3-6 years, n = 839) and adolescents (12-14 years, n = 643) from southeastern Santiago. Surveys collected the food source and eating location for each food reported during the recall. We estimated the mean intake of calories and key nutrients of concern, such as saturated fats, total sugars, and sodium, by food source and eating location. RESULTS: Foods obtained and eaten at home contributed the greatest proportion of total calories and the key nutrients of concern. Foods obtained at home tended to have lower caloric densities but higher sugar and sodium densities than foods obtained away from home in both age groups. With regard to location, for preschool children foods consumed at home had lower caloric and sugar densities than foods eaten at school, while for adolescents foods consumed at home had lower caloric, saturated fat, and sugar densities than foods eaten at school. For both children and adolescents, home was the primary source of sugar-sweetened beverages (SSBs) calories. SSBs were important calorie contributors among foods across all settings, but the highest absolute amount of calories from these beverages was consumed at home. CONCLUSIONS: While most of Chilean youths' calories and key nutrients of concern are obtained and consumed at home, these foods tended to have lower caloric densities than foods obtained and consumed away from home. Home was the main food source for SSBs, but the relative consumption of these beverages was high in all eating locations. More research will be needed to inform and evaluate policies and interventions to improve children's dietary quality across settings.

The prevalence and audience reach of food and beverage advertising on Chilean television according to marketing tactics and nutritional quality of products.

OBJECTIVE: In the light of Chile's comprehensive new restriction on unhealthy food marketing, we analyse food advertising on Chilean television prior to the first and final phases of implementation of the restriction. DESIGN: Content analysis of marketing strategies of 6976 advertisements, based on products' nutritional quality. Statistical analysis of total and child audience reached using television ratings data. SETTING: Advertising from television aired between 06.00 and 00.00 hours during two random composite weeks across April-May 2016 from the four broadcast and four cable channels with the largest youth audiences. RESULTS: Food ads represented 16 % of all advertising; 34 % of food ads featured a product high in energy, saturated fats, sugars and/or salt (HEFSS), as defined by the initial regulation. HEFSS ads were seen by more children and contained more child-directed marketing strategies than ads without HEFSS foods. If HEFSS advertising was restricted only in programmes where 20 % are children aged 4-12 years, 31 % of children's and 8 % of the general audience's HEFSS advertising exposure would be reduced. The newest 06.00-22.00 hours restriction captures 80 % of all audience exposure. CONCLUSIONS: HEFSS advertising was seen by a large proportion of children before Chile's regulation. Chile's first implementation based on audience composition should reduce a third of this exposure and its second restriction across the television day should eliminate most of the exposure. The current study is a crucial first step in evaluating how Chile's regulation efforts will impact children's diets and obesity prevalence.

Grocery Stores Are Not Associated with More Healthful Food for Participants in the Supplemental Nutrition Assistance Program.

BACKGROUND: Despite interventions to improve the nutrition of grocery store purchases, also referred to as at-home (AH) foods, by participants in the Supplemental Nutrition Program (SNAP), little is known about what proportion of participants' intake is from AH foods and how the dietary quality of AH food compares with participants' away-from-home (AFH) food. Although recent research indicates SNAP participants have dietary quality that is slightly worse than that of income-eligible nonparticipants, it is unknown whether this is attributable to AH or AFH consumption. OBJECTIVE: The objective of this study is to examine differences in self-reported dietary intake by food source for SNAP participants compared with income-eligible nonparticipants using 2011-2014 data from the National Health and Nutrition Examination Survey (NHANES). DESIGN: This study included data from the NHANES, a cross-sectional, nationally representative survey of the United States population. STUDY PARTICIPANTS: This study included 2,523 adults with low incomes (≤130% of the federal poverty level) in NHANES (2011-2014). MAIN OUTCOME MEASURES: Self-reported intake of calories, solid fats, added sugars, and servings of nonstarchy vegetables, whole fruits, and whole grains was assessed by food source in SNAP participants and income-eligible nonparticipants. STATISTICAL ANALYSIS: Multivariate linear regression was used for each outcome, controlling for relevant sociodemographic characteristics. Data were stratified by food source, including grocery stores, sit-down restaurants, and fast food. RESULTS: SNAP participants had a higher intake of solid fats and added sugar from AH foods than nonparticipants. Added sugar from AH food accounted for 15.3% of total calories consumed by SNAP participants, compared with 11.8% for nonparticipants (P<0.001). SNAP participants consumed fewer calories from sit-down restaurants, but both groups consumed similar amounts of calories from fast food. Consumption of nonstarchy vegetables, whole fruits, and whole grains was low for both groups. CONCLUSIONS: SNAP participants had poorer diet quality from consumption of AH food than did nonparticipants. Future research should focus on interventions to improve the healthfulness of grocery store purchases as a mechanism to improve dietary quality of SNAP participants.

Designing a food tax to impact food-related non-communicable diseases: the case of Chile.

The global shift towards diets high in sugar-sweetened beverages (SSBs) and energy dense ultra-processed foods is linked to higher prevalence of obesity, diabetes and most other noncommunicable diseases (NCDs), causing significant health costs. Chile has the highest SSB consumption in the world, very high junk food intake and very rapid increases in these poor components of the diet plus obesity prevalence. This study's purpose is to compare the effect of different tax schemes for SSBs and ultra-processed foods on nutrient availability, utilizing price-elasticities, which are estimated from a Quadratic Almost Ideal Demand System model, using the 2011-2012 Income and Expenditure survey. We take into account the high proportion of households not purchasing various food and beverage groups (censored nature of data). The food groups considered were: sweets and desserts; salty snacks and chips; meat products and fats; fruits, vegetables and seafood; cereals and cereal products; SSB ready-to-drink; SSB from concentrate; plain water, coffee and tea; and milk, which together represent 90% of food expenditures. The simulated taxes were: (1) 40% price tax on SSBs(22% above the current tax level); (2) a 5 cents per gram of sugar tax on products with added sugar; and (3) 30% price tax on all foods(27% above current tax levels) and beverages (12% above the current tax level) exceeding thresholds on sodium, saturated fat, and added sugar and for which marketing is restricted (based on a Chilean law, effective June 16 2016). Unhealthy foods are price-elastic (-1.99 for salty snacks and chips, -1.06 for SSBs ready-to-drink, and -1.27 for SSBs from concentrate), meaning that the change in consumption is proportionally larger with respect to a change in price. Results are robust to different model specification, and consistent among different socioeconomic sub-populations. Overall, the tax on marketing controlled foods and beverages is associated with the largest reduction in household purchases of sodium, added sugar, saturated fat and calorie purchases. Chile is unique in currently having instituted a small current SSB tax as well as marketing controls and front-of-package labeling of unhealthy foods and beverages. The design of a larger, more comprehensive tax to enhance the overall effect of these policies on healthier diets is a next critical step. This study shows that a large tax on the same foods and beverages already delineated as unhealthy by the marketing controls and front-of-pack labeling should prove to be more effective for promoting a healthier diet.

Added Sugars Intake Across the Distribution of US Children and Adult Consumers: 1977-2012.

BACKGROUND: Public health organizations in the United States have recently increased focus on reducing population consumption of added sugars. OBJECTIVE: The objective of this study is to provide in-depth information on national trends in added sugars consumption and to examine both the mean and distribution of added sugars intake from 1977 to 2012. DESIGN: We conducted a descriptive study using six cross-sectional nationally representative surveys of food intake in the United States: the 1977-1978 National Food Consumption Survey (n=29,668), the 1989-1991 Continuing Survey of Food Intake by Individuals (n=14,827), the 1994-1998 Continuing Survey of Food Intake by Individuals (n=19,027), the 2003-2004 National Health and Nutrition Examination Survey (NHANES; n=8,273), the 2009-2010 NHANES (n=9,042), and the 2011-2012 NHANES (n=16,451). STATISTICAL ANALYSIS: We examined the key dependent variables, calories from added sugars and percentage of total energy intake from added sugars, at the mean and by quintiles of added sugars consumption for children (2 to 18 years) and adults (19 years and older) across the survey years. We also examined trends in added sugars intakes from foods and beverages. We used ordinary least squares regression to examine linear trends between survey years and multinomial logistic regressions to examine sociodemographic characteristics by quintile of added sugars consumption. We adjusted estimates by race, income, sex, and education. RESULTS: The US mean adjusted intake of added sugars remains high. In 2011-2012, children and adults consumed 326 kcal/day and 308 kcal/day, respectively, of added sugars, or 14% and 17%, respectively, of total their energy. For both children and adults, there was a considerable increase in calories from added sugars from 1977 to 2003, followed by a substantial decline from 2003 to 2012. There was no decline in the percentage of total energy intake from added sugars from 2003 to 2012. Changes over time were consistent across each quintile of added sugars consumption. The highest quintile of consumption was more likely to be male and in children was more likely to be non-Hispanic white. CONCLUSIONS: Despite a decline in consumption of added sugars since 2003 in the United States, mean adjusted added sugars intakes continue to be above the recommended level of 10% of the total energy intake. Changes in added sugars consumption from 1977 through 2012 occurred evenly across the distribution of added sugars intakes.