A five-country evaluation of nutrition labelling policies: consumer use, understanding, and knowledge of processed foods

Background: Poor dietary intake is a critical risk factor for non-communicable diseases – the world’s leading cause of premature death and disability. Globally, consumption of highly processed foods has increased in recent decades. Population-health interventions, such as nutrition labelling, have the potential to promote healthy eating behaviours. Nutrition Facts tables (NFts) and front-of-package (FOP) labelling systems provide consumers with essential nutrition information at the point-of-purchase to aid healthy decision-making and encourage healthier product reformulation. An increasing number of countries are implementing FOP labelling systems, ranging from ‘high in’ labels in Chile to Health Star Ratings in Australia. There is a need to examine consumers’ knowledge of levels of food processing, as well as awareness, understanding, and use of nutrition labels to better understand the impact of labelling policies. Objectives: This dissertation explored patterns and correlates of nutrition label awareness, understanding, and use, as well as functional nutrition knowledge across five countries with different nutrition labeling systems. Canada and the US currently have NFts only, which were compared to NFt and FOP labelling systems in Australia (voluntary Health Star Rating FOP labels), the UK (voluntary multiple Traffic Light FOP labels) and Mexico (mandatory Guideline Daily Amount FOP labels). The four primary aims of this study were to: 1) assess face and content validity of a new functional nutrition knowledge measure based on level of food processing – the Food Processing Knowledge (FoodProK) score; 2) determine functional nutrition knowledge levels (FoodProK scores) and associated correlates; 3) identify and compare patterns and correlates of self-reported versus functional label understanding; and 4) explore patterns and correlates of label awareness and use across countries. Methods: This dissertation consisted of four sub-studies: Study 1 developed and tested a new functional measure of nutrition knowledge which was based on respondents' ability to understand and apply the concept of food processing in a functional task; Study 2 examined patterns and correlates of functional nutrition knowledge across countries; Study 3 explored self-reported (NFt, FOP label) and functional (NFt) label understanding across countries; and Study 4 examined patterns of NFt and FOP label use and awareness across countries. Cross-sectional data from the 2018 International Food Policy Study were used. Respondents aged ≥18 years (n = 22,824) from Australia (n = 4103), Canada (n = 4397), Mexico (n = 4135), the UK (n = 5549), and the US (n = 4640) were recruited through Nielsen Consumer Insights Global Panel and their partners’ panels. Respondents completed web-based surveys answering questions about food policies, dietary behaviours, health literacy, and other factors related to food environment. The primary outcomes were functional nutrition knowledge; self-reported label (NFt, FOP) awareness, understanding, and use; and functional NFt understanding. Sociodemographic factors (age, sex, ethnicity, country, education level, income adequacy), body mass index, dietary behaviours (dietary practices, diet modification efforts, food shopping role), and knowledge-related characteristics (health literacy, FoodProK score) were included in all analyses. In Study 1, content validity of the newly developed FoodProK score was examined by surveying Registered Dietitians in Canada (n = 64). Dietitians completed the FoodProK measure, which required rating the healthiness of three food products in four categories (fruit, dairy, grain, meat). Thereafter, dietitians answered several open-ended survey questions about the measure. One-way repeated-measure ANOVA models tested whether dietitians’ product ratings were significantly different between products and food categories. Multiple linear regression models were fitted to examine between-country differences in functional nutrition knowledge in Study 2. Studies 3 and 4 also used multiple linear regression models to assess correlates of label understanding and use/awareness, respectively. All analyses adjusted for sociodemographic, dietary behaviours, and knowledge-related characteristics. Interaction terms with country and sociodemographic characteristics were tested to examine how patterns differed across countries. Results: Study 1 – Overall, 70.3% of dietitians scored 7 and above on the 8-point FoodProK measure. The majority of dietitians rated food products in congruence with level of processing (85.9% of dietitians correctly ordered products in the fruit and dairy categories; 73.4% correctly ordered grain products). The meat category was an exception, with approximately half of dietitians (54.7%) rating meat products in accordance with level of processing. Open-ended responses showed dietitians did not perceive meaningful differences between the processed meat products. Overall, 80% of dietitians reported level of processing as an important indicator of the healthiness of foods. Preliminary content validity evidence suggests knowledge of food processing levels as one indicator of general nutrition knowledge. Study 2 –The highest FoodProK scores were reported in Canada (mean: 5.1) and Australia (5.0), followed by the UK (4.8), Mexico (4.7), and the US (4.6). Health literacy and self-rated nutrition knowledge were positively associated with FoodProK scores (p<.0001). FoodProK scores were higher among those who reported specific dietary practices such as vegetarianism (p<.0001); made efforts to consume less sodium, trans fats, sugars, processed foods, or calories (p<.0001); respondents classified as having ‘adequate health literacy’ (p<.0001); respondents who self-reported being ‘very knowledgeable’ or ‘somewhat knowledgeable’ about nutrition (p<.0001); those who were 60+ years old (p=0.0023), women (p<.0001), and respondents who belonged to the ‘majority’ ethnic group in their respective countries (p<.0001). Education, income adequacy, and food shopping role were not significantly associated with FoodProK scores. Study 3 – Self-reported and functional NFt understanding was highest in the US and Canada, followed by Australia, the UK, and Mexico. Functional and self-reported NFt understanding were weakly correlated (rs=0.18, p<.0001). In adjusted analyses, functional NFt understanding was higher among women (p<.0001), ‘majority’ ethnic groups (p<0.0001), respondents with higher education levels (p<.0001), and those making efforts to consume less sodium, sugar, fat, calories or processed food (p<.0001). Similar correlates were significant for self-reported NFt and FOP label understanding, with some differences in diet behaviour correlates between self-reported and functional NFt understanding. Self-reported FOP label understanding was higher for interpretative labelling systems in Australia (Health Star Ratings) and the UK (Traffic Lights) compared with Mexico’s Guideline Daily Amounts (p<.0001). Mean self-reported FOP label understanding was higher than NFt understanding, with the exception of Mexico where self-reported NFt understanding was higher. Study 4 - Respondents from the US, Canada, and Australia reported significantly higher NFt use and awareness than respondents in Mexico and the UK. Mexican respondents reported the highest level of FOP label awareness, followed by the UK and Australia, whereas UK respondents reported the highest FOP label use followed by Mexico and Australia. In countries with both NFt and FOP labelling systems, use and awareness was higher for NFts in Australia and Mexico, with UK respondents reporting higher FOP label than NFt use and awareness. Correlates of NFt and FOP label use were similar, with the exception of health literacy where NFt use was higher among respondents with ‘adequate literacy,’ but FOP use was lower among this group compared to those with a ‘high likelihood of limited literacy.’ Food processing knowledge, sex, and ethnicity were only significantly associated with NFt use. Conclusions: Cross-country differences in labelling outcomes provide an opportunity to examine differences in nutrition labelling policies across countries. Nutrition labels requiring greater numerical skills (i.e., NFt, GDA) were more difficult for consumers to understand than interpretive FOP labels, and mandatory labelling policies (NFt, GDA) had the highest levels of awareness. These findings highlight the importance of mandatory FOP labelling policies to maximize reach, particularly among consumers with lower literacy, nutrition knowledge, and education who reported using nutrition labels less. This study also provides further evidence for the use of functional measures of knowledge and label understanding for multi-country, population-based studies. Overall, these findings support the need for mandatory labelling policies and national health promotion efforts that are accessible to all populations to minimize nutrition-related health disparities

The Impact of Food Insecurity and Diet on Obesity among Métis and Off-Reserve First Nations Children in Canada

Objective: Aboriginal children are disproportionately affected by obesity, as they are twice as likely to be classified as obese compared to their non-Aboriginal Canadian counterparts. Research indicates that income, food insecurity, and diet quality are important predictors of weight status, however these factors are not well explored among Aboriginal children living off reserve. This study aims to identify associations between food insecurity and diet on obesity status among off-reserve First Nations and Métis children. Methods: This study used both quantitative and qualitative research methods. Data from the 2006 Aboriginal Peoples Survey (APS) – Children and Youth component were analyzed using binary logistic regression and the proportional odds model to assess relationships between food insecurity, diet, and body mass index (BMI). Fruit and vegetable intake, as well as junk food consumption, were used as proxy measures for children’s diet quality. Additional analyses involving income instead of food insecurity, as well as food insecurity interaction terms, were also explored. Focus groups were conducted with caregivers of Métis and off-reserve First Nations children in Midland-Penetanguishene and London, Ontario, respectively. The focus groups were planned and carried out in partnership with the Métis Nation of Ontario (MNO) and the Southwest Ontario Aboriginal Health Access Centre (SOAHAC). A thematic analysis was conducted with the qualitative data, and the focus group discussions provided important contextual information to complement the statistical results. Results: Approximately 11% of First Nations and 6.8% of Métis children were food insecure according to the 2006 APS. The quantitative analysis did not find a significant association between food insecurity and diet, or food insecurity and BMI for First Nations or Métis children. Income was a better predictor of weight status than food insecurity. For First Nations children, having a household income higher than $60,000 decreased the risk of being overweight/obese. For Métis children, a household income of less than$20,000 increased the risk of overweight/obesity. Food insecurity was only significant as an interaction with parental education for First Nations children, and with parental education and number of people living in the household for Métis children. The proportional odds model produced similar results to the binary logistic regression procedure, and food insecurity remained insignificant in the analyses. Contrary to the quantitative findings, the focus group discussions indicated that caregivers perceived a positive relationship between low income and food insecurity, as well as adverse impacts on their children’s diets. While caregivers did not use the term “food insecurity” explicitly, conversations about not having enough food or money for food, as well as coping strategies for when these situations occurred, suggested that food insecurity manifests itself in different ways. Caregivers mentioned decreased variety of foods, compromised fruit and vegetable intake, as well as decreased traditional food consumption as examples of how families’ food consumption and purchasing patterns changed when food insecure. Food insecurity negatively impacted children’s diets, and many caregivers attributed the rise in overweight and obesity to poor diet quality. Some of the key barriers to children eating healthfully were unaffordability and limited access to healthy foods. Caregivers also discussed the role of various programs for improving child health within their communities. Conclusions: While food insecurity was not significantly associated with obesity in the quantitative analyses, discussions with caregivers of First Nations and Métis children identified food insecurity and low income as important predictors of poor diet, and consequently decreased well-being. Several limitations associated with the 2006 APS design may have prevented food insecurity from being significantly associated with obesity risk; however, it is clear from both the quantitative and qualitative components of this study that income consistently affects diet and child obesity risk. Findings from this study can inform necessary improvements to existing programs, interventions, and policies targeting obesity and health of Aboriginal children

The association of household food security, household characteristics and school environment with obesity status among off-reserve first nations and métis children and youth in Canada: Results from the 2012 aboriginal peoples survey

Introduction: Indigenous children are twice as likely to be classified as obese and three times as likely to experience household food insecurity when compared with non-Indigenous Canadian children. The purpose of this study was to explore the relationship between food insecurity and weight status among Métis and off-reserve First Nations children and youth across Canada. Methods: We obtained data on children and youth aged 6 to 17 years (n = 6900) from the 2012 Aboriginal Peoples Survey. We tested bivariate relationships using Pearson chi-square tests and used nested binary logistic regressions to examine the food insecurity−weight status relationship, after controlling for geography, household and school characteristics and cultural factors. Results: Approximately 22% of Métis and First Nations children and youth were overweight, and 15% were classified as obese. Over 80% of the sample was reported as food secure, 9% experienced low food security and 7% were severely food insecure. Off-reserve Indigenous children and youth from households with very low food security were at higher risk of overweight or obese status; however, this excess risk was not independent of household socioeconomic status, and was reduced by controlling for household income, adjusted for household size. Negative school environment was also a significant predictor of obesity risk, independent of demographic, household and geographic factors. Conclusion: Both food insecurity and obesity were prevalent among the Indigenous groups studied, and our results suggest that a large proportion of children and youth who are food insecure are also overweight or obese. This study reinforces the importance of including social determinants of health, such as income, school environment and geography, in programs or policies targeting child obesity

Community perspectives on food insecurity and obesity: Focus groups with caregivers of metis and Off-reserve first nations children

Introduction: Aboriginal children in Canada are at a higher risk for overweight and obesity than other Canadian children. In Northern and remote areas, this has been linked to a lack of affordable nutritious food. However, the majority of Aboriginal children live in urban areas where food choices are more plentiful. This study aimed to explore the experiences of food insecurity among Métis and First Nations parents living in urban areas, including the predictors and perceived connections between food insecurity and obesity among Aboriginal children. Methods: Factors influencing children\u27s diets, families\u27 experiences with food insecurity, and coping strategies were explored using focus group discussions with 32 parents and caregivers of Métis and off-reserve First Nations children from Midland-Penetanguishene and London, Ontario. Four focus groups were conducted and transcribed verbatim between July 2011 and March 2013. A thematic analysis was conducted using NVivo software, and second coders ensured reliability of the results. Results: Caregivers identified low income as an underlying cause of food insecurity within their communities and as contributing to poor nutrition among their children. Families reported a reliance on energy-dense, nutrient-poor foods, as these tended to be more affordable and lasted longer than more nutritious, fresh food options. A lack of transportation also compromised families\u27 ability to purchase healthful food. Aboriginal caregivers also mentioned a lack of access to traditional foods. Coping strategies such as food banks and community programming were not always seen as effective. In fact, some were reported as potentially exacerbating the problem of overweight and obesity among First Nations and Métis children. Conclusion: Food insecurity manifested itself in different ways, and coping strategies were often insufficient for addressing the lack of fruit and vegetable consumption in Aboriginal children\u27s diets. Results suggest that obesity prevention strategies should take a family-targeted approach that considers the unique barriers facing urban Aboriginal populations. This study also reinforces the importance of low income as an important risk factor for obesity among Aboriginal peoples

Community perspectives on food insecurity and obesity: Focus groups with caregivers of metis and Off-reserve first nations children

Introduction: Aboriginal children in Canada are at a higher risk for overweight and obesity than other Canadian children. In Northern and remote areas, this has been linked to a lack of affordable nutritious food. However, the majority of Aboriginal children live in urban areas where food choices are more plentiful. This study aimed to explore the experiences of food insecurity among Métis and First Nations parents living in urban areas, including the predictors and perceived connections between food insecurity and obesity among Aboriginal children. Methods: Factors influencing children\u27s diets, families\u27 experiences with food insecurity, and coping strategies were explored using focus group discussions with 32 parents and caregivers of Métis and off-reserve First Nations children from Midland-Penetanguishene and London, Ontario. Four focus groups were conducted and transcribed verbatim between July 2011 and March 2013. A thematic analysis was conducted using NVivo software, and second coders ensured reliability of the results. Results: Caregivers identified low income as an underlying cause of food insecurity within their communities and as contributing to poor nutrition among their children. Families reported a reliance on energy-dense, nutrient-poor foods, as these tended to be more affordable and lasted longer than more nutritious, fresh food options. A lack of transportation also compromised families\u27 ability to purchase healthful food. Aboriginal caregivers also mentioned a lack of access to traditional foods. Coping strategies such as food banks and community programming were not always seen as effective. In fact, some were reported as potentially exacerbating the problem of overweight and obesity among First Nations and Métis children. Conclusion: Food insecurity manifested itself in different ways, and coping strategies were often insufficient for addressing the lack of fruit and vegetable consumption in Aboriginal children\u27s diets. Results suggest that obesity prevention strategies should take a family-targeted approach that considers the unique barriers facing urban Aboriginal populations. This study also reinforces the importance of low income as an important risk factor for obesity among Aboriginal peoples

Global Matrix 3.0 Physical Activity Report Card Grades for Children and Youth: Results and Analysis From 49 Countries

Background: Accumulating sufficient moderate to vigorous physical activity is recognized as a key determinant of physical, physiological, developmental, mental, cognitive, and social health among children and youth (aged 5–17 y). The Global Matrix 3.0 of Report Card grades on physical activity was developed to achieve a better understanding of the global variation in child and youth physical activity and associated supports. Methods: Work groups from 49 countries followed harmonized procedures to develop their Report Cards by grading 10 common indicators using the best available data. The participating countries were divided into 3 categories using the United Nations’ human development index (HDI) classification (low or medium, high, and very high HDI). Results: A total of 490 grades, including 369 letter grades and 121 incomplete grades, were assigned by the 49 work groups. Overall, an average grade of “C-,” “D+,” and “C-” was obtained for the low and medium HDI countries, high HDI countries, and very high HDI countries, respectively. Conclusions: The present study provides rich new evidence showing that the situation regarding the physical activity of children and youth is a concern worldwide. Strategic public investments to implement effective interventions to increase physical activity opportunities are needed

Global matrix 4.0 physical activity report card grades for children and adolescents : results and analyses from 57 countries

Background: The Global Matrix 4.0 on physical activity (PA) for children and adolescents was developed to achieve a comprehensive understanding of the global variation in children’s and adolescents’ (5–17 y) PA, related measures, and key sources of influence. The objectives of this article were (1) to summarize the findings from the Global Matrix 4.0 Report Cards, (2) to compare indicators across countries, and (3) to explore trends related to the Human Development Index and geo-cultural regions. Methods: A total of 57 Report Card teams followed a harmonized process to grade the 10 common PA indicators. An online survey was conducted to collect Report Card Leaders’ top 3 priorities for each PA indicator and their opinions on how the COVID-19 pandemic impacted child and adolescent PA indicators in their country. Results: Overall Physical Activity was the indicator with the lowest global average grade (D), while School and Community and Environment were the indicators with the highest global average grade (C+). An overview of the global situation in terms of surveillance and prevalence is provided for all 10 common PA indicators, followed by priorities and examples to support the development of strategies and policies internationally. Conclusions: The Global Matrix 4.0 represents the largest compilation of children’s and adolescents’ PA indicators to date. While variation in data sources informing the grades across countries was observed, this initiative highlighted low PA levels in children and adolescents globally. Measures to contain the COVID-19 pandemic, local/international conflicts, climate change, and economic change threaten to worsen this situation

Decolonizing Digital Citizen Science: Applying the Bridge Framework for Climate Change Preparedness and Adaptation

Research has historically exploited Indigenous communities, particularly in the medical and health sciences, due to the dominance of discriminatory colonial systems. In many regions across Canada and worldwide, historical and continued injustices have worsened health among Indigenous Peoples. Global health crises such as climate change are most adversely impacting Indigenous communities, as their strong connection to the land means that even subtle changes in the environment can disproportionately affect local food and health systems. As we explore strategies for climate change preparedness and adaptation, Indigenous Peoples have a wealth of Traditional Knowledge to tackle specific climate and related health issues. If combined with digital citizen science, data collection by citizens within a community could provide relevant and timely information about specific jurisdictions. Digital devices such as smartphones, which have widespread ownership, can enable equitable participation in citizen science projects to obtain big data for mitigating and managing climate change impacts. Informed by a Two-Eyed Seeing approach, a decolonized lens to digital citizen science can advance climate change adaptation and preparedness efforts. This paper describes the &lsquo;Bridge Framework&rsquo; for decolonizing digital citizen science using a case study with a subarctic Indigenous community in Saskatchewan, Canada

Inverting Innovation to Transform Health Systems Responses to Climate Change Impacts in the Global South

July 2023 was the hottest month in history, with the global south experiencing the disproportionate burden of adverse climate change impacts, ranging from heatwaves and wildfires to droughts and flooding. If there was ever an existential crisis that required systems thinking to address its complexity, it is climate change. Systems thinking aims to understand and solve complex problems that cut across sectors – an approach that requires accurate, timely, and multisectoral data. Citizen-driven big data can enable systems thinking, considering the widespread use of digital devices. Using tailored digital platforms, data from these devices can transform evidence-based decision-making to not only predict and prevent global health crises, but also to respond rapidly to emerging crises by providing citizens with near real-time support. In the context of climate change, digital health platforms can strengthen climate response by integrating systems (e.g., food, health, and social services) and ethically relaying citizen data for rapid decision-making – a paradigm-changing approach that can invert innovation by prioritizing community needs over big technology corporate profits. However, to foster inclusive digital health partnerships, it is critical to avoid top-down approaches that sometimes result when researchers in the global north and south collaborate – a systemic barrier to equitable partnerships. A systems integration approach can be operationalized by combining digital citizen science and community-based participatory research to ethically leverage multisectoral and citizen-driven big data for rapid responses across international jurisdictions. This approach can bring together diverse global south-north teams by prioritizing equity and inclusion of vulnerable populations