The estimated dietary and health impact of implementing the recently approved 'high in' front-of-package nutrition symbol in Canada: a food substitution scenario modeling study.

Background: Front-of-pack labeling (FOPL) has been identified as a cost-effective policy to promote healthy food environments and to help consumers make healthier food choices. Consumer surveys report that after implementation of mandatory 'high in' FOPL symbols between 30 and 70% of consumers choose or were willing to choose products with fewer 'high in' symbols. Health Canada has recently published FOPL regulations that will require prepackaged food and beverages that meet or exceed thresholds for sodium, total sugars, or saturated fat to display a 'high in' FOPL nutrition symbol. Objectives: The aims were to estimate the potential (1) dietary impact of substituting foods with similar foods that would display at least one less 'high in' symbol, and (2) the number of diet-related noncommunicable disease (NCD) deaths that could be averted or delayed due to estimated dietary changes. Methods: Baseline and counterfactual intakes of sodium, total sugars, saturated fats, and energy were estimated among Canadian adults (n = 11,992) using both available days of 24 h-recall data from the 2015 Canadian Community Health Survey-Nutrition (CCHS). Similar foods to those reported in CCHS that would display at least one less 'high in' symbol (n = 239) were identified using a Canadian branded food composition database. Based on current FOPL consumer research, identified foods were substituted for 30, 50, and 70% of randomly selected CCHS-Nutrition adult participants and for all adult participants. Potential health impacts were estimated using the Preventable Risk Integrated ModEl. Results: Mean dietary reductions of between 73 and 259 mg/day of sodium, 2.0 and 6.9 g/day of total sugars, 0.2 and 0.5 g/day of saturated fats, and 14 and 46 kcal/day of energy were estimated. Between 2,148 (95% UI 1,913-2,386) and 7,047 (95% UI 6,249-7,886) of deaths due to diet-related NCDs, primarily from cardiovascular diseases (70%), could potentially be averted or delayed if Canadians choose products with fewer 'high in' symbols. Conclusion: Results suggest that FOPL could significantly reduce sodium and total sugar intakes among Canadian adults, the consequences of which could avert or delay an important number of diet-related NCD deaths. These findings provide relevant data to support the importance of the impending FOPL regulations.

Canadian Free Sugar Intake and Modelling of a Reformulation Scenario.

Recommendations suggest limiting the intake of free sugar to under 10% or 5% of calories in order to reduce the risk of negative health outcomes. This study aimed to examine Canadian free sugar intake and model how intakes change following the implementation of a systematic reformulation of foods and beverages to be 20% lower in free sugar. Additionally, this study aimed to examine how calorie intake might be impacted by this reformulation scenario. Canadians' free sugar and calorie intakes were determined using free sugar and calorie data from the Food Label Information Program (FLIP) 2017, a Canadian branded food composition database, and applied to foods reported as being consumed in Canadian Community Health Survey-Nutrition (CCHS-Nutrition) 2015. A "counterfactual" scenario was modelled to examine changes in intake following the reformulation of foods to be 20% lower in free sugar. The overall mean free sugar intake was 12.1% of calories and was reduced to align with the intake recommendations at 10% of calories in the "counterfactual" scenario (p < 0.05). Calorie intake was reduced by 3.2% (60 calories) in the "counterfactual" scenario (p < 0.05). Although the overall average intake was aligned with the recommendations, many age/sex groups exceeded the recommended intake, even in the "counterfactual" scenario. The results demonstrate a need to reduce the intake of free sugar in Canada to align with dietary recommendations, potentially through reformulation. The results can be used to inform future program and policy decisions related to achieving the recommended intake levels of free sugar in Canada.

Estimating Canadian sodium intakes and the health impact of meeting national and WHO recommended sodium intake levels: A macrosimulation modelling study.

BACKGROUND: Cardiovascular diseases (CVDs) are the second leading cause of total deaths in Canada. High blood pressure is the main metabolic risk factor for developing CVDs. It has been well established that excess consumption of sodium adversely affects blood pressure. Canadians' mean sodium intakes are well above recommended levels. Reducing dietary sodium intake through food reformulation has been identified as a cost-effective intervention, however, dietary sodium intake and the potential health impact of meeting recommended sodium intake levels due to food reformulation have not been determined in Canada. OBJECTIVE: This study aimed to 1) obtain robust estimates of Canadians' usual sodium intakes, 2) model sodium intakes had foods been reformulated to align with Health Canada's sodium reduction targets, and 3) estimate the number of CVD deaths that could be averted or delayed if Canadian adults were to reduce their mean sodium intake to recommended levels under three scenarios: A) 2,300 mg/d-driven by a reduction of sodium levels in packaged foods to meet Health Canada targets (reformulation); B) 2,000 mg/d to meet the World Health Organization (WHO) recommendation; and C) 1,500 mg/d to meet the Adequate Intake recommendation. METHODS: Foods in the University of Toronto's Food Label Information Program 2017, a Canadian branded food composition database, were linked to nationally representative food intake data from the 2015 Canadian Community Health Survey-Nutrition to estimate sodium intakes (and intakes had Health Canada's reformulation strategy been fully implemented). The Preventable Risk Integrated ModEl (PRIME) was used to estimate potential health impact. RESULTS: Overall, mean sodium intake was 2758 mg/day, varying by age and sex group. Based on 'reformulation' scenario A, mean sodium intakes were reduced by 459 mg/day, to 2299 mg/day. Reducing Canadians' sodium intake to recommended levels under scenarios A, B and C could have averted or delayed 2,176 (95% UI 869-3,687), 3,252 (95% UI 1,380-5,321), and 5,296 (95% UI 2,190-8,311) deaths due to CVDs, respectively, mainly from ischaemic heart disease, stroke, and hypertensive disease. This represents 3.7%, 5.6%, and 9.1%, respectively, of the total number of CVDs deaths observed in Canada in 2019. CONCLUSION: Results suggest that reducing sodium intake to recommended levels could prevent or postpone a substantial number of CVD deaths in Canada. Reduced sodium intakes could be achieved through reformulation of the Canadian food supply. However, it will require higher compliance from the food industry to achieve Health Canada's voluntary benchmark sodium reduction targets.

How Many Diet-Related Non-Communicable Disease Deaths Could Be Averted or Delayed If Canadians Reduced Their Consumption of Calories Derived from Free Sugars Intake? A Macrosimulation Modeling Study.

Free sugars are a major source of calories in diets and contribute to the burden of many non-communicable diseases (NCDs). The World Health Organization (WHO) recommends reducing free sugars intake to less than 10% of total energy. This study aimed to estimate the number of diet-related NCD deaths which could be averted or delayed if Canadian adults were to reduce their calorie intake due to a systematic 20% reduction in the free sugars content in foods and beverages in Canada. We used the Preventable Risk Integrated ModEl (PRIME) to estimate the potential health impact. An estimated 6770 (95% UI 6184-7333) deaths due to diet-related NCDs could be averted or delayed, mostly from cardiovascular diseases (66.3%). This estimation would represent 7.5% of diet-related NCD deaths observed in 2019 in Canada. A 20% reduction in the free sugars content in foods and beverages would lead to a 3.2% reduction in calorie intake, yet an important number of diet-related NCD deaths could be averted or delayed through this strategy. Our findings can inform future policy decisions to support Canadians' free sugars intake reduction, such as proposing target levels for the free sugars content in key food categories.

Comparing the nutritional composition of foods and beverages in the Canadian Nutrient File to a large representative database of Canadian prepackaged foods and beverages.

BACKGROUND: Nutrient information used to code dietary intakes in the Canadian Community Health Survey (CCHS) may not be reflective of the current Canadian food supply and could result in inaccurate evaluations of nutrient exposures. OBJECTIVE: To compare the nutritional compositions of foods in the CCHS 2015 Food and Ingredient Details (FID) file (n = 2,785) to a large representative Canadian database of branded food and beverage products (Food Label Information Program, FLIP) collected in 2017 (n = 20,625). METHOD: Food products in the FLIP database were matched to equivalent generic foods from the FID file to create new aggregate food profiles based on FLIP nutrient data. Mann Whitney U tests were used to compare nutrient compositions between the FID and FLIP food profiles. RESULTS: In most food categories and nutrients there were no statistically significant differences between the FLIP and FID food profiles. Nutrients with the largest differences included: saturated fats (n = 9 of 21 categories), fiber (n = 7), cholesterol (n = 6), and total fats (n = 4). The meats and alternatives category had the most nutrients with significant differences. CONCLUSION: These results can be used to prioritize future updates and collections of food composition databases, while also providing insights for interpreting CCHS 2015 nutrient intakes.

Quantifying Child-Appeal: The Development and Mixed-Methods Validation of a Methodology for Evaluating Child-Appealing Marketing on Product Packaging.

There is no standardized or validated definition or measure of "child-appeal" used in food and beverage marketing policy or research, which can result in heterogeneous outcomes. Therefore, this pilot study aimed to develop and validate the child-appealing packaging (CAP) coding tool, which measures the presence, type, and power of child-appealing marketing on food packaging based on the marketing techniques displayed. Children (n = 15) participated in a mixed-methods validation study comprising a binary classification (child-appealing packaging? Yes/No) and ranking (order of preference/marketing power) activity using mock breakfast cereal packages (quantitative) and focus group discussions (qualitative). The percent agreement, Cohen's Kappa statistic, Spearman's Rank correlation, and cross-classification analyses tested the agreement between children's and the CAP tool's evaluation of packages' child-appeal and marketing power (criterion validity) and the content analysis tested the relevance of the CAP marketing techniques (content validity). There was an 80% agreement, and "moderate" pairwise agreement (κ [95% CI]: 0.54 [0.35, 0.73]) between children/CAP binary classifications and "strong" correlation (rs [95% CI]: 0.78 [0.63, 0.89]) between children/CAP rankings of packages, with 71.1% of packages ranked in the exact agreement. The marketing techniques included in the CAP tool corresponded to those children found pertinent. Pilot results suggest the criterion/content validity of the CAP tool for measuring child-appealing marketing on packaging in accordance with children's preferences.

Inventory of marketing techniques used in child-appealing food and beverage research: a rapid review.

OBJECTIVES: Restrictions on child-appealing food and beverage marketing have been prioritized globally. However, the concept of "child-appealing marketing" has not been consistently defined, leading to variability in policies and research. The objective of this review was therefore to generate an inventory of the marketing techniques that have been used in research to identify child-appealing marketing. METHODS: Based on WHO guidelines, this review identified primary research that analyzed child-appealing marketing techniques, using the OVID Medline database and hand searches in Google Scholar and PubMed. All marketing techniques were extracted, counted, and synthesized into an inventory, organized thematically and by popularity. RESULTS: From 133 publications, 1421 marketing techniques were extracted (mean 10.7/publication; range: 1-66). The final inventory included 117 techniques; the "use of characters, children, and actors" was the most popular theme. CONCLUSIONS: The inventory and categorization generated by this research can be used for informing future research and for alerting policy-makers globally to the breadth of child-appealing food and beverage marketing techniques, helping move toward a consistent and comprehensive definition of child-appealing marketing in regulations aimed at restricting this type of marketing.

Reformulation of sugar contents in Canadian prepackaged foods and beverages between 2013 and 2017 and resultant changes in nutritional composition of products with sugar reductions.

OBJECTIVE: To quantify total sugar reformulation in Canadian prepackaged foods and beverages between 2013 and 2017 and identify changes in the nutritional composition of the foods and beverages reformulated to be lower in total sugar. DESIGN: Longitudinal examination of foods and beverages present in both 2013 and 2017 collections of the University of Toronto's Food Label Information Program database (n 6628 matched products). The proportion of products with changes in sugar levels was determined. Wilcoxon signed-rank test was used to examine changes in sugar levels overall for products lower or higher in sugar and changes in nutrient composition for products lower in sugar. SETTING: Largest grocery retailers by market share in Canada. PARTICIPANTS: Canadian prepackaged foods and beverages. RESULTS: The majority (76·6 %) of products had no change in total sugar content, 12·4 % were reformulated to be lower in sugar and 11·0 % were higher in sugar. A median sugar reduction of 19·0 % (1·6 g) was seen among products lower in sugar which was offset by a median 18·0 % (1·5 g) increase among products higher in sugar. Overall, median levels of energies and other nutrients stayed the same or decreased among products reformulated to be lower in sugar, the exception was for starch, which increased. CONCLUSIONS: Limited progress was made to reformulate foods and beverages to be lower in total sugar between 2013 and 2017. Results from this study identify areas in the food supply where attention may be needed to avoid unintended consequences of sugar-focused reformulation in terms of overall nutritional composition.

Evaluating the Canadian Packaged Food Supply Using Health Canada's Proposed Nutrient Criteria for Restricting Food and Beverage Marketing to Children.

Federally mandated restrictions on food and beverage marketing to kids (M2K) have been re-introduced as a national public health priority in Canada by the newly elected government, following the failure to implement a similar policy first proposed in 2016. This study examined the extent to which Canadian packaged foods, including products already displaying M2K on the packaging, would be permitted to be marketed, based on the nutrient criteria for marketing restrictions defined by Health Canada (in December 2018) as part of the previous policy proposal. Products from the University of Toronto Food Label Information Program 2013 database (n = 15,200) were evaluated using Health Canada's published criteria: thresholds for sodium, sugars and saturated fats that products cannot exceed in order to be M2K. The proportion of products exceeding no thresholds (i.e., permitted to be M2K), the number of thresholds exceeded, and the proportion exceeding each individual threshold were calculated overall and in the subsample of products displaying M2K on the packaging (n = 747). Overall, 18.0% of products would be permitted to be M2K, versus 2.7% of products displaying M2K. Sodium was the most exceeded threshold overall (57.5% of products), whereas sugars was the most exceeded by products displaying M2K (80.1%). Only 4.7% of all products versus 10.4% of products displaying M2K exceeded all three thresholds. These results highlight the importance of reintroducing federal regulations restricting M2K in Canada and including marketing on product packaging in the regulatory scope.

Examining the relationship between sugars contents of Canadian foods and beverages and child-appealing marketing.

OBJECTIVE: In 2016, legislation to restrict child-appealing marketing (M2K) of "unhealthy" foods and beverages ("foods") (i.e., foods that exceed roughly 5-10% of the Daily Value (DV) for total sugars, sodium, or saturated fats) was proposed in Canada. The objective of this study was to examine the relationship between foods with on-pack M2K and excessive free sugars contents (≥ 10% calories from free sugars) and the potential for a 5% total sugars DV threshold to restrict M2K on these products. METHODS: Cross-sectional analysis of the University of Toronto's Food Label Information Program (FLIP) 2013 database (n = 15,259, after exclusions). Odds ratios were used to determine the association between excess free sugars contents and presence of M2K, stratified by major food category. The proportion of products with excessive free sugars levels, or with M2K, that would be restricted from M2K if a 5% DV threshold for total sugars was implemented was also determined. RESULTS: 77.8% of foods with M2K had excess free sugars levels compared with 38.4% without M2K. M2K was more likely to be present on foods with excess free sugars levels in 8 of 14 food categories that contained products with M2K. A 5% DV threshold for total sugars would restrict M2K on 83% of foods with excess free sugars levels and on 75% of current foods that had M2K. CONCLUSION: Findings demonstrate that foods with M2K are less healthy, particularly in regard to free sugars levels. This highlights the importance of ensuring policies aimed at supporting healthy dietary habits among children carefully consider free sugars levels.