Purpose: Nutrient content and food processing level are two complementary but distinct concepts, and a large body of evidence shows that ultra-processed foods can have detrimental health effects independently from their nutrient content. In 2015, the Brazilian Ministry of Health published dietary guidelines recommending that Brazilians choose less processed foods and avoid ultra-processed products. In turn, in 2022, the Brazilian Regulatory Health Agency implemented a new front-of-package “high in” warning label system to inform consumers when products are high in nutrients of concern (i.e., sugar, saturated fat, and sodium). The potential additional impact of an “ultra-processed” warning to this labeling system remains unknown. Thus, we examined whether adding a warning label indicating an ultra-processed product to existing nutrient warnings could influence consumers’ product perceptions and purchase intentions.

Methods: In 2023, a sample of adults in Brazil (n=1,004) participated in an online experiment where they saw images of four different products carrying warning labels. Participants were randomly assigned to view either existing nutrient warnings or nutrient warnings with the addition of an “ultra-processed” warning. Participants then answered questions about their intentions to purchase the products, product perceptions, and perceived label effectiveness.

Results: The addition of an “ultra-processed” warning label led to a higher share of participants who correctly identified products that were ultra-processed (Cohen’s d=0.16, p=0.02). However, the addition of the “ultra-processed” warning label did not significantly influence purchase intentions, product healthfulness perceptions, or perceived label effectiveness compared to nutrient warnings alone (all p>0.05). In exploratory analyses, demographic characteristics (age, gender, education, health status) and level of understanding of the concept of ultra-processed did not significantly moderate the effect of the “ultra-processed” warning on purchase intentions or identification of ultra-processed products.

Conclusions: “Ultra-processed” warning labels may help consumers better identify which products are ultra-processed, but do not seem to influence their behavioral intentions and product perceptions beyond the influence already exerted by nutrient warnings. Future research should examine how “ultra-processed” warning labels would work in naturalistic store settings.

Purpose: Non-sugar sweeteners (NSS) are commonly found in beverages that children frequently consume, yet there is uncertainty about the health effects of NSS consumption. This is concerning, especially in countries like Brazil, where new front of package nutritional labeling (FOPNL) for products ‘high in sugar’ is likely to increase the use of NSS. This study investigated parents' perceptions and knowledge about NSS, terminology related to NSS, and how they would like to have information about NSS on packages.

Methods: Seven focus groups with parents and caregivers (hereafter parents) of children between 2-5 and 6-11 years old were conducted in a small- and a large municipality in São Paulo, Brazil. A socioeconomically diverse sample of parents was recruited at public and private schools/early education centers. Focus groups (3-8 participants/group, total n=40) were conducted by a nutritionist and research assistant using a semi-structured guide. We inquired about parents’ understanding of the Portuguese word for NSS (“edulcorantes”) and their perceptions regarding their children´s consumption of NSS. Finally, parents were probed to reflect on the healthfulness of NSS compared with added sugars and if and how they would like to have information about NSS on beverage packaging.

Results: The Portuguese term for NSS, “edulcorantes”, found in the list of ingredients, was not recognized by most parents, especially due to confusion with the term “corantes”, which translates to “food coloring.” Parents indicated having difficulty identifying NSS in beverages and presented divergent opinions about giving beverages with NSS to children and regarding the healthfulness of NSS compared with added sugars. Overall, parents agreed that FOPNL information calling attention to NSS would be helpful, in particularly with the statement “not recommended for children,” similar to what has been implemented in Mexico and Argentina.

Conclusions: The term “edulcorantes” was not recognizable to parents of young and school-aged children and they reported difficulties identifying NSS in beverages, suggesting that parents are not aware that the products they provide contain NSS. FOPNL information disclosing the presence of NSS along with the statement they are not recommended for children could help parents identify NSS and make more informed product choices.

Alcaire, F., Giménez, A., Ares, G.

Corresponding author and presenting author: Alcaire, F.

Purpose: The availability of ultra-processed foods has largely increased in the last decades across the globe. These products are frequently marketed to children, despite their unfavorable nutritional profile and the presence of food additives. In this context, the present research aimed to explore the nutritional composition and the prevalence of additives in processed and ultra-processed foods targeted at children commercialized in Uruguay, an emerging Latin American country.
Methods: A survey of products in 9 supermarkets in two cities was conducted using a cellphone app. A total of 7443 products from 75 different categories were classified as (not) targeted at children based on the information included in the labels. The nutritional composition and the ingredient lists were extracted from the labels. Notification of functional classes of additives was determined using a computer-assisted method. Results were summarized using descriptive statistics and products targeted at children were compared with those not targeted at children using t-tests and chi-square.
Results/findings: A total of 570 products (7.7%) from 35 categories were identified as products target at children. Categories with the higher number of products targeted at children corresponded to discretionary ultra-processed products: candies (n=111); cookies (n=105 products); breakfast cereals (n=44); cocoa and sweetened cocoa powder (n=37); vegetable, cereal, flour or starch based snacks (n=30); chocolates (n=25); decorations, coatings, and fillings (n=24); and powder mixes to prepare desserts (n=23). Most of the products targeted at children were high in nutrients associated with non-communicable diseases and contained at least one additive. On average, products targeted at children had a significantly higher content of sugar than those not targeted at children, as well as a higher frequency of notification of flavorings (86% vs 53%), colorings (53.9% vs 24.5%) and emulsifiers (31.6% vs 25.8%). Considering the emerging evidence about the negative effects of artificial colorings and emulsifiers on health, these results stress the need to discuss the risks associated with exposure to these substances from an early age, and highlight the need to broaden the scope of regulatory policies beyond nutritional composition.

Purpose: Sugar-sweetened and other unhealthier (i.e., non-sugar-sweetened) beverages have long been recognized as key contributors to poor population health with inequitable impacts. Over the past two decades, multiple US initiatives have attempted to address the issue through public awareness campaigns and policy levers (e.g., sugar-sweetened beverage [SSB] taxes, default beverages in kids’ meals) with varied success. Yet, recent indicators, such as stalling declines of SSB sales, increasing shifts to low-calorie alternatives, and limited growth in enacted SSB policies suggest more needs to be done to accelerate progress. This study presents the approach and results of a systems-oriented modeling process to inform new thinking and actions towards addressing unhealthy beverages in the US.

Methods: A participatory group model building workshop series was conducted in 2023 to develop a causal loop diagram, depicting key mechanisms underlying the high and inequitable persistence of unhealthy beverage promotion, availability, and consumption in the US. Five facilitated, structured group exercises were used to identify variables, their connections, and review and refine the model. Twenty-four public health experts and advocates from across the US representing perspectives from government (n=6), academia (n=7), advocacy organizations (n=7), and community-led groups (e.g., food policy councils) (n=4) participated. Perspectives from industry were also integrated into the model.

Results: The resulting model identified six feedback loops describing the causal effects of Corporatocracy and the beverage industry, Environmental impacts, Water infrastructure and norms, Public health advocacy, Voter suppression, and Civic engagement in health issues. Of the 27 variables included in the model political will for public health played a prominent role in several feedback loops. For instance, political will for health was key to generating action to improve safe drinking water and its associated acceptance, supporting public health funding for healthy beverage campaigns, and limiting industry power and its associated marketing, retail, manufacturing, and lobbying influence.

Conclusions: Gaining traction on addressing unhealthy beverages is a complex, dynamic problem. Participatory, systems-oriented approaches are a promising tool and, in this iteration, led to renewed thinking about the actions and strategies necessary to achieve higher levels of effectiveness and reignite traction in the US.

Purpose: Ultra-processed foods (UPFs) comprise >50% of United States (US) adults’ energy intake, with the proportion of calories from UPFs increasing over time. Overall, dietary quality of US adults is poor, and foods consumed at home are, on average, healthier than those consumed away from home. However, less is known about whether UPFs are primarily consumed at home or away from home. In this study we examine trends in consumption of UPFs as well as unprocessed/minimally processed foods (MPFs) at home and away from home among US adults overall and among socio-demographic subgroups.
Methods: We analyzed data from a nationally representative sample of 34,661 adults (aged ≥20 years) with two 24-hour dietary recalls from the 2003-2018 waves of the National Health and Nutrition Examination Survey (NHANES). We calculated intake from MPFs and UPFs as a proportion of total energy intake and as a proportion of home energy intake and away from home energy intake. We examined trends over time using generalized linear models adjusted for sex, age, race/ethnicity, education, and household income. We examined differences in trends by socio-demographic groups using interaction terms and stratified models.
Results: Overall, and for most demographic subgroups, UPFs comprised >50% of at home energy intake and >50% of away from home energy intake, with UPFs increasing over time and MPFs decreasing over time as a proportion of energy intake at home and away from home. The proportion of total energy intake from UPFs increased for food consumed at home (33.6% to 37.1%, p-trend<0.001), but not for UPFs consumed away from home (19.5% to 18.8%, p-trend=0.88). From 2003-2004 to 2017-2018, the proportion of total energy intake from MPFs declined for foods consumed at home (23.6% to 20.8%, p-trend<0.001) and away from home (9.7% to 7.5%, p-trend<0.001). Stratified models revealed different levels of MPF and UPF at home and away from home by socio-demographic subgroups though trends over time were similar and interaction terms were generally not significant.
Conclusions: Findings highlight the ubiquity of UPFs in US adults’ diets regardless of whether foods are being consumed at home or away from home.

Purpose: Ultra-processed food (UPF) intake in pregnancy is linked to poor maternal health outcomes. Financial circumstances, time scarcity, and social support often correlate with eating behavior but remain unexplored concerning UPF intake during pregnancy. Identifying the role of these factors on maternal UPF intake would guide interventions and policy.

Methods: We analyzed data from the SUPER pregnancy cohort in a cross-sectional structural equation model (SEM). Independent variables included: number of adults and children at home; weekly hours spent working; perceived time scarcity; perceived social support from friends and family; income (having enough, not enough, or more than enough to get by); and 4 subscales that comprise financial scarcity (shortage of money, worry, short-term focus, and lack of control). For our dependent variable, UPF, we used two 24-hour recalls from each participant to categorize foods and beverages using NOVA and calculate the contribution of UPF to total grams of dietary intake.

Results: In the analytic sample (n=94, 54% Hispanic/Latina), 30.6%±16.6 of participants’ dietary intake in grams were UPF. In a fully saturated SEM (R-squared=0.20; p=0.006), consuming a greater proportion of UPF in the diet was associated with a lack of financial control (βstandardized=0.605, p=0.004) and with income (βstandardized=0.238, p=0.04). There were also multiple significant relationships among the independent variables. Income and social support were inversely associated; income and social support were both associated with each of the four financial scarcity subscales, and time scarcity was positively associated with the financial scarcity subscales (all p<0.001). Children at home was positively associated with 3 of 4 financial scarcity subscales and inversely associated with income (all p<0.05).

Conclusions: Among a diverse cohort of pregnant women, we found that those who felt a lack of control over their finances as well as those who reported more sufficient income both had higher UPF intakes. This seemingly contradictory finding may be explained by the heterogeneity of UPF, which includes cheap, convenient products marketed to people experiencing financial scarcity and products with health halos targeted to consumers with higher incomes. Further research should explore the nuanced relationship between financial experiences and the heterogeneity of UPF intake.