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BackgroundThe app-based salt reduction intervention program in school children and their families (AppSalt) is a multicomponent mobile health (mHealth) intervention program, which involves multiple stakeholders, including students, parents, teachers, school heads, and local health and education authorities. The complexity of the AppSalt program highlights the need for process evaluation to investigate how the implementation will be achieved at different sites. ObjectiveThis paper presents a process evaluation protocol of the AppSalt program, which aims to monitor the implementation of the program, explain its causal mechanisms, and provide evidence for scaling up the program nationwide. MethodsA mixed methods approach will be used to collect data relating to five process evaluation dimensions: fidelity, dose delivered, dose received, reach, and context. Quantitative data, including app use logs, activity logs, and routine monitoring data, will be collected alongside the intervention process to evaluate the quantity and quality of intervention activities. The quantitative data will be summarized as medians, means, and proportions as appropriate. Qualitative data will be collected through semistructured interviews of purposely selected intervention participants and key stakeholders from local health and education authorities. The thematic analysis technique will be used for analyzing the qualitative data with the support of NVivo 12. The qualitative data will be triangulated with the quantitative data during the interpretation phase to explain the 5 process evaluation dimensions. ResultsThe intervention activities of the AppSalt program were initiated at 27 primary schools in three cities since October 2018. We have completed the 1-year intervention of this program. The quantitative data for this study, including app use log, activity logs, and the routine monitoring data, were collected and organized during the intervention process. After completing the intervention, we conducted semistructured interviews with 32 students, 32 parents, 9 teachers, 9 school heads, and 8 stakeholders from local health and education departments. Data analysis is currently underway. ConclusionsUsing mHealth technology for salt reduction among primary school students is an innovation in China. The findings of this study will help researchers understand the implementation of the AppSalt program and similar mHealth interventions in real-world settings. Furthermore, this process evaluation will be informative for other researchers and policy makers interested in replicating the AppSalt program and designing their salt reduction intervention. International Registered Report Identifier (IRRID)DERR1-10.2196/19430

Poor diets are the major cause of death and disease globally, driving high levels of obesity and noncommunicable diseases. Cheap, heavily marketed, ultra-processed, energy-dense and nutrient-poor food and drinks that are high in fat, sugar and salt play a major role. The high-sugar content of these products leads to consumption levels much higher than recommended. The World Health Organization recommends that sugar intake should be reduced to just 5% of energy intake by using fiscal policies and food and drink reformulation strategies. Over the previous decade, the government of the United Kingdom of Great Britain and Northern Ireland has implemented several policies aimed at reducing sugar intake. We compare the soft drinks industry levy and the sugar reduction programme, examining how differences in policy design and process may have influenced the outcomes. Success has been mixed: the mandatory levy achieved a reduction in total sugar sales of 34.3%, and the voluntary reduction programme only achieved a 3.5% reduction in sugar levels of key contributors to sugar intake (despite a target of 20%). Both policies can be improved to enhance their impact, for example, by increasing the levy and reducing the sugar content threshold in the soft drinks industry levy, and by setting more stringent subcategory specific targets in the sugar reduction programme. We also recommend that policy-makers should consider applying a similar levy to other discretionary products that are key contributors to sugar intake. Both approaches provide valuable learnings for future policy in the United Kingdom and globally. La malnutrition est l'une des principales causes de deces et de pathologies dans le monde, entrainant des taux eleves d'obesite et un grand nombre de maladies non transmissibles. Massivement commercialises, les aliments et boissons bon marche, ultra-transformes, riches en energie et pauvres en nutriments, a forte teneur en graisse, en sucre et en sel jouent un role majeur. La quantite de sucre contenue dans ces produits engendre une consommation qui depasse largement les recommandations en la matiere. L'Organisation mondiale de la Sante conseille de reduire la proportion de sucre afin que ce dernier ne represente plus que 5% de l'apport energetique grace a des politiques fiscales et des strategies de revision de la composition des aliments et des boissons. Au cours des dix dernieres annees, le gouvernement du Royaume-Uni de Grande-Bretagne et d'Irlande du Nord a adopte plusieurs politiques visant a reduire la consommation de sucre. Dans le present document, nous comparons la taxe sur l'industrie des sodas avec le programme de reduction du sucre, en examinant comment les differences de conception et de mise en oeuvre des politiques pourraient avoir influence les resultats. Le succes s'est revele mitige: la taxe obligatoire a permis de faire chuter le total des ventes de sucre de 34,3%, alors que le programme de baisse volontaire n'a pas permis de faire diminuer ce taux de plus de 3,5% chez les acteurs cles de l'apport en sucre (bien loin des 20% cibles). Les deux politiques peuvent etre ameliorees pour renforcer leur impact, par exemple en augmentant la taxe et en reduisant la teneur en sucre maximale applicable a l'industrie des sodas, mais aussi en definissant des objectifs specifiques plus stricts dans les sous-categories du programme de reduction du sucre. Nous encourageons en outre les responsables politiques a instaurer une taxe similaire sur d'autres produits non essentiels qui contribuent eux aussi a la consommation de sucre. Les deux approches fournissent des renseignements precieux pour de futures mesures au Royaume-Uni et partout dans le monde. Las dietas inadecuadas son la principal causa de muerte y enfermedad en todo el mundo. Ademas, impulsan altos niveles de obesidad y enfermedades no transmisibles. Los alimentos y las bebidas baratos, muy comercializados, ultraprocesados, hipercaloricos y pobres en nutrientes, con un alto contenido en grasas, azucar y sal, desempenan una funcion importante. El alto contenido en azucar de estos productos conduce a niveles de consumo muy superiores a los recomendados. La Organizacion Mundial de la Salud recomienda reducir el consumo de azucar a solo el 5% de la ingesta energetica mediante politicas fiscales y estrategias de reformulacion de alimentos y bebidas. En la ultima decada, el gobierno del Reino Unido de Gran Bretana e Irlanda del Norte ha aplicado varias politicas encaminadas a reducir la ingesta de azucar. Comparamos el impuesto del sector de las bebidas no alcoholicas y el programa de reduccion del azucar, examinando como las diferencias en el diseno y el proceso de las politicas pueden haber influido en los resultados. El exito ha sido desigual: el impuesto obligatorio logro una reduccion de las ventas totales de azucar del 34,3%, y el programa de reduccion voluntaria solo consiguio una reduccion del 3,5% en los niveles de azucar de los principales contribuyentes a la ingesta de azucar (a pesar de un objetivo del 20%). Se pueden mejorar ambas politicas para aumentar su impacto, por ejemplo, aumentando el impuesto y reduciendo el umbral de contenido de azucar en el impuesto del sector de las bebidas no alcoholicas, y estableciendo objetivos especificos por subcategorias mas estrictos en el programa de reduccion de azucar. Tambien recomendamos a los responsables de formular las politicas que estudien la posibilidad de aplicar un impuesto similar a otros productos discrecionales que contribuyen decisivamente a la ingesta de azucar. Ambos enfoques aportan valiosas ensenanzas para las futuras politicas del Reino Unido y del resto del mundo. [phrase omitted], Introduction Excessive sugar consumption, increasing the risk of weight gain, is associated with an increased risk of type 2 diabetes, certain noncommunicable diseases and 13 types of cancer. (1,2) There [...]

BackgroundSalt intake in China is over twice the maximum recommendation of the World Health Organization. Unlike most developed countries where salt intake is mainly derived from prepackaged foods, around 80% of the salt consumed in China is added during cooking. ObjectiveAction on Salt China (ASC), initiated in 2017, aims to develop, implement, and evaluate a comprehensive and tailored salt reduction program for national scaling-up. MethodsASC consists of six programs working in synergy to increase salt awareness and to reduce the amount of salt used during cooking at home and in restaurants, as well as in processed foods. Since September 2018, two health campaigns on health education and processed foods have respectively started, in parallel with four open-label cluster randomized controlled trials (RCTs) in six provinces across China: (1) app-based intervention study (AIS), in which a mobile app is used to achieve and sustain salt reduction in school children and their families; (2) home cook-based intervention study (HIS), in which family cooks receive support in using less salt; (3) restaurant-based intervention study (RIS) targeting restaurant consumers, cooks, and managers; and (4) comprehensive intervention study (CIS), which is a real-world implementation and evaluation of all available interventions in the three other RCTs. To explore the barriers, facilitators, and effectiveness of delivering a comprehensive salt reduction intervention, these RCTs will last for 1 year (stage 1), followed by nationwide implementation (stage 2). In AIS, HIS, and CIS, the primary outcome of salt reduction will be evaluated by 24-hour urinary sodium excretion in 6030 participants, including 5436 adults and 594 school children around 8-9 years old. In RIS, the salt content of meals will be measured by laboratory food analysis of the 5 best-selling dishes from 192 restaurants. Secondary outcomes will include process evaluation; changes in knowledge, attitude, and practice on salt intake; and economic evaluation. ResultsAll RCTs have been approved by Queen Mary Research Ethics Committee and the Institutional Review Boards of leading institutes in China. The research started in June 2017 and is expected to be completed around March 2021. The baseline investigations of the four RCTs were completed in May 2019. ConclusionsThe ASC project is progressing smoothly. The intervention packages and tailored components will be promoted for salt reduction in China, and could be adopted by other countries. Trial RegistrationChinese Clinical Trial Registry. AIS: ChiCTR1800017553; https://tinyurl.com/vdr8rpr. HIS: ChiCTR1800016804; https://tinyurl.com/w8c7x3w. RIS: ChiCTR1800019694; https://tinyurl.com/uqkjgfw. CIS: ChiCTR1800018119; https://tinyurl.com/s3ajldw. International Registered Report Identifier (IRRID)DERR1-10.2196/15933

Objective To evaluate the changes in sugar and energy labelling of carbonated sugar-sweetened soft drinks after the implementation of a tax on sugar-sweetened drinks in the United Kingdom of Great Britain and Northern Ireland. Methods We visited nine main supermarkets before (May 2014) and after (April 2018) the tax came into effect and obtained data from product packaging and nutrition information panels of carbonated sugar-sweetened soft drinks. We used the paired f-test to assess differences in sugar and energy content of the same products between 2014 and 2018. Findings We obtained data from 166 products in 2014 and 464 products in 2018, of which 83 products were the same in both years. Large variations in stated sugar content were found between the different carbonated sugar-sweetened soft drinks in both 2014 and 2018 for all products and for the 83 products. The mean sugar content of the 83 products decreased by 42% between 2014 and 2018, from 9.1 g/100 mL (standard deviation, SD: 3.3) to 5.3 g/100 mL (SD: 3.5; P < 0.001). The mean energy content decreased by 40%, from 38 kcal/100 mL (SD: 13) in 2014 to 23 kcal/100 mL (SD: 15) in 2018 (P < 0.001). Conclusion The significant decreases in the labelling of sugar and energy content of carbonated sugar-sweetened soft drinks after the levy came into effect suggest this tax has been effective. The sugar content of drinks still varied considerably in 2018, suggesting further reductions in sugar content of these drinks is possible. The levy thresholds should be reduced and the tax increased to drive further reformulation of soft drinks to reduce their sugar content. Objectif Evaluer les changements dans l'etiquetage des boissons gazeuses sucrees non alcoolisees, sur le plan de la teneur en sucre et de la valeur energetique, apres l'instauration d'une taxe sur les boissons sucrees au Royaume-Uni de Grande-Bretagne et d'lrlande du Nord. Methodes Nous nous sommes rendus dans neuf grands supermarches avant (mai 2014) et apres (avril 2018) l'entree en vigueur de la taxe et avons recueilli des donnees sur les emballages et les encadres d'information nutritionnelle de boissons gazeuses sucrees non alcoolisees. Nous avons eu recours a un test t d'echantillons apparies pour evaluer les differences au niveau de la teneur en sucre et de la valeur energetique des memes produits entre 2014 et 2018. Resultats Nous avons obtenu des donnees sur 166 produits en 2014 et sur 464 produits en 2018, parmi lesquels 83 produits identiques sur ces deux annees. S'agissant de la teneur en sucre indiquee, de gros ecarts ont ete observes entre les differentes boissons gazeuses sucrees non alcoolisees, aussi bien en 2014 qu'en 2018, pour l'ensemble des produits et pour les 83 produits semblables. La teneur en sucre moyenne des 83 produits a diminue de 42% entre 2014 et 2018, passant de 9,1 g/100 mL (ecart type, ET: 3,3) a 5,3 g/100 mL (ET: 3,5; P < 0,001). La valeur energetique moyenne a diminue de 40%, passant de 38 kcal/100 mL (ET: 13) en 2014 a 23 kcal/100 mL (ET: 15) en 2018 (P < 0,001). Conclusion La diminution notable, sur les etiquettes, de la teneur en sucre et de la valeur energetique des boissons gazeuses sucrees non alcoolisees apres l'entree en vigueur de la taxe laisse penser que celle-ci a ete efficace. La teneur en sucre des boissons variait encore considerablement en 2018, ce qui laisse penser qu'il est possible de la reduire encore davantage. Les seuils d'application de la taxe devraient etre abaisses et cette derniere augmentee afin d'encourager la reformulation des boissons non alcoolisees dans le but de reduire leur teneur en sucre. Objetivo Evaluar los cambios en el etiquetado sobre el azucar y la energia de las bebidas gaseosas endulzadas con azucar despues de la aplicacion de un impuesto sobre las bebidas endulzadas con azucar en el Reino Unido de Gran Bretana e Irlanda del Norte. Metodos Se visitaron nueve supermercados principales antes (mayo de 2014) y despues (abril de 2018) de que el impuesto entrara en vigor y se obtuvieron datos de los envases de los productos y de los paneles de informacion nutricional de las bebidas gaseosas endulzadas con azucar. Se utilizo la prueba t pareada para evaluar las diferencias en el contenido de azucar y energia de los mismos productos entre 2014 y 2018. Resultados Se obtuvieron datos de 166 productos de 2014 y 464 de 2018, de los cuales 83 productos fueron los mismos en ambos anos. Se encontraron grandes variaciones en el contenido de azucar declarado entre las diferentes bebidas gaseosas endulzadas con azucar en 2014 y 2018 para todos los productos y para los 83 productos. El contenido promedio de azucar de los 83 productos disminuyo en un 42 % entre 2014 y 2018, de 9,1 g/100 ml (desviacion estandar, DE: 3,3) a 5,3 g/100 ml (DE: 3,5; P < 0,001). El contenido promedio de energia disminuyo en un 40 %, de 38 kcal/100 ml (SD: 13) en 2014 a 23 kcal/100 ml (SD: 15) en 2018 (P < 0,001). Conclusion Las importantes reducciones en el etiquetado sobre el contenido de azucar y de energia de las bebidas gaseosas endulzadas con azucar despues de que la tasa entrara en vigor sugieren que este impuesto ha sido efectivo. El contenido de azucar en las bebidas todavia varia considerablemente en 2018, lo que sugiere que es posible reducir aun mas el contenido de azucar de dichas bebidas. Los umbrales de la tasa deben reducirse y el impuesto debe aumentarse para impulsar una nueva reformulacion de las bebidas gaseosas a fin de reducir su contenido de azucar., Introduction In July 2015, the Scientific Advisory Committee on Nutrition of the United Kingdom of Great Britain and Northern Ireland recommended that average free sugars (sugar) intake across the country's [...]

Background Suboptimal diets are a leading risk factor for death and disability. Nutrition labelling is a potential method to encourage consumers to improve dietary behaviour. This systematic review and network meta-analysis (NMA) summarises evidence on the impact of colour-coded interpretive labels and warning labels on changing consumers' purchasing behaviour. Methods and findings We conducted a literature review of peer-reviewed articles published between 1 January 1990 and 24 May 2021 in PubMed, Embase via Ovid, Cochrane Central Register of Controlled Trials, and SCOPUS. Randomised controlled trials (RCTs) and quasi-experimental studies were included for the primary outcomes (measures of changes in consumers' purchasing and consuming behaviour). A frequentist NMA method was applied to pool the results. A total of 156 studies (including 101 RCTs and 55 non-RCTs) nested in 138 articles were incorporated into the systematic review, of which 134 studies in 120 articles were eligible for meta-analysis. We found that the traffic light labelling system (TLS), nutrient warning (NW), and health warning (HW) were associated with an increased probability of selecting more healthful products (odds ratios [ORs] and 95% confidence intervals [CIs]: TLS, 1.5 [1.2, 1.87]; NW, 3.61 [2.82, 4.63]; HW, 1.65 [1.32, 2.06]). Nutri-Score (NS) and warning labels appeared effective in reducing consumers' probability of selecting less healthful products (NS, 0.66 [0.53, 0.82]; NW,0.65 [0.54, 0.77]; HW,0.64 [0.53, 0.76]). NS and NW were associated with an increased overall healthfulness (healthfulness ratings of products purchased using models such as FSAm-NPS/HCSP) by 7.9% and 26%, respectively. TLS, NS, and NW were associated with a reduced energy (total energy: TLS, -6.5%; NS, -6%; NW, -12.9%; energy per 100 g/ml: TLS, -3%; NS, -3.5%; NW, -3.8%), sodium (total sodium/salt: TLS, -6.4%; sodium/salt per 100 g/ml: NS: -7.8%), fat (total fat: NS, -15.7%; fat per 100 g/ml: TLS: -2.6%; NS: -3.2%), and total saturated fat (TLS, -12.9%; NS: -17.1%; NW: -16.3%) content of purchases. The impact of TLS, NS, and NW on purchasing behaviour could be explained by improved understanding of the nutrition information, which further elicits negative perception towards unhealthful products or positive attitudes towards healthful foods. Comparisons across label types suggested that colour-coded labels performed better in nudging consumers towards the purchase of more healthful products (NS versus NW: 1.51 [1.08, 2.11]), while warning labels have the advantage in discouraging unhealthful purchasing behaviour (NW versus TLS: 0.81 [0.67, 0.98]; HW versus TLS: 0.8 [0.63, 1]). Study limitations included high heterogeneity and inconsistency in the comparisons across different label types, limited number of real-world studies (95% were laboratory studies), and lack of long-term impact assessments. Conclusions Our systematic review provided comprehensive evidence for the impact of colour-coded labels and warnings in nudging consumers' purchasing behaviour towards more healthful products and the underlying psychological mechanism of behavioural change. Each type of label had different attributes, which should be taken into consideration when making front-of-package nutrition labelling (FOPL) policies according to local contexts. Our study supported mandatory front-of-pack labelling policies in directing consumers' choice and encouraging the food industry to reformulate their products. Protocol registry PROSPERO (CRD42020161877)., Author(s): Jing Song 1, Mhairi K. Brown 1, Monique Tan 1, Graham A. MacGregor 1, Jacqui Webster 2, Norm R. C. Campbell 3, Kathy Trieu 2, Cliona Ni Mhurchu 2,4, [...]