Quotation: Contreras-Manzano A, Cruz-Casarrubias C, Munguía A, Jáuregui A, Vargas-Meza J, Nieto C, et al. (2022) Analysis of the Mexican warning label nutrient profile on meals merchandise marketed in Mexico in 2016 and 2017: A cross-sectional evaluation. PLoS Med 19(4):
e1003968.
https://doi.org/10.1371/journal.pmed.1003968
Tutorial Editor: Carmen Piernas, College of Oxford, UNITED KINGDOM
Obtained: June 2, 2021; Accepted: March 16, 2022; Printed: April 20, 2022
Copyright: © 2022 Contreras-Manzano et al. That is an open entry article distributed beneath the phrases of the Creative Commons Attribution License, which allows unrestricted use, distribution, and copy in any medium, offered the unique writer and supply are credited.
Knowledge Availability: All related information are throughout the manuscript and its Supporting information recordsdata.
Funding: This work was funded by Bloomberg philantrophies [grant number #43003]. (S.B). The funders had no position in examine design, information assortment and evaluation, resolution to publish, or preparation of the manuscript.
Competing pursuits: The authors have declared that no competing pursuits exist.
Abbreviations:
FoPL,
front-of-package labeling; NCD,
noncommunicable illness; NP,
nutrient profile; PAHO,
Pan American Well being Group; WHO,
World Well being Group
Introduction
A nutrient profile (NP) is a software that classifies meals and drinks in line with their dietary composition, e.g., whether or not merchandise include extreme quantities of vitamins of concern (sugar, sodium, and saturated and trans fat) and energy [1,2]. This software permits the formulation and utility of methods associated to the prevention and management of weight problems and chubby [3,4], similar to the usage of front-of-package labels on processed meals, laws for well being or diet claims, regulation of unhealthy meals advertising to kids, meals taxes, and restrictions on the meals and drinks obtainable or bought in and outdoors colleges [5,6].
Entrance-of-package labeling (FoPL) is an economical technique to advertise wholesome buy decision-making within the inhabitants [3]. Just lately, as a response to the rising epidemic of chubby and weight problems within the Latin American area [7], a number of nations have adopted warning label programs. These are typically carried out in progressive phases to offer the meals and beverage trade the chance to reformulate their merchandise as a way to design new ones that don’t exceed established thresholds for vitamins of concern [8]. For instance, in 2016, Chile carried out warning labels for the primary time in a 3-phase scheme (2016, 2018, and 2019) [9–11]. Chilean warning labels encompass black octagons with the legend “Excessive in…” displayed on the entrance of the bundle for merchandise with unhealthy ranges of sugar, sodium, saturated fat, and/or energy [10]. Related warning label programs have been adopted or are being thought-about in Peru (sugar, saturated fats, trans fats, and sodium), Uruguay (sugar, complete fats, saturated fats, and sodium), Argentina (sugar, saturated fats, trans fats, sodium, energy, non-nutritive sweeteners, and caffeine), and Brazil (sugar, saturated fats, and sodium) [12–15]. In 2014, Ecuador used its personal NP to implement a site visitors gentle system indicating whether or not a product comprises comparatively low (inexperienced), common (yellow), or excessive (purple) ranges of vitamins of concern (sugar, saturated fats, and sodium) [16]. In 2020, Mexico adopted new necessary FoPL with warning octagons with the legend “Extra of…” for substances of concern (i.e., energy, sugar, sodium, saturated fat, and trans fat) and warning rectangles for merchandise that embrace caffeine and non-nutritive sweeteners, together with the assertion “keep away from/not advisable in kids” [17]. These nationwide FoPL programs are carried out together with their very own NP fashions, typically involving a 2- or 3-phase progressive implementation scheme, and a few of them are primarily based on the Pan American Well being Group (PAHO) NP mannequin [17].
The PAHO mannequin gives regional standards for acceptable quantities of vitamins of concern (salt, sugar, saturated fat, and trans fat) in Latin America. Nonetheless, NP fashions underpinning FoPL programs ought to be related for the nationwide or regional meals provide [18]. Subsequently, regional standards proposed by the PAHO mannequin ought to be rigorously tailored to make sure that the FoPL system is delicate sufficient to categorise merchandise in line with their healthfulness [18]. Classifications produced by the tailored NP fashions must also align with nationwide dietary tips. In Mexico, sugar-sweetened drinks, significantly cola drinks, are partly answerable for the excessive prevalence of weight problems and diabetes [19]; these drinks are consumed at excessive ranges by the inhabitants, together with kids [20]. Subsequently, variations of the PAHO mannequin to be used in Mexico included extra thresholds for energy and a warning for added caffeine, consumption of which isn’t advisable amongst kids [21]. Different variations included eradicating the entire fats threshold of the PAHO mannequin, since complete fats consists of wholesome fatty acids, which aren’t widespread within the Mexican weight loss plan and whose consumption must be promoted. The sodium threshold proposed by PAHO was additionally tailored contemplating the nationwide market share in Mexico. In accordance with the Mexican FoPL regulation, which includes 3 implementation phases (2020, 2023, and 2025), 3 NPs had been proposed, with stricter nutrient standards for every progressive section [8,17].
In accordance with the World Well being Group (WHO), the calibration of a NP “considers completely different strategies aimed toward answering the query of whether or not the nutrient profile mannequin classifies meals accurately” [1]. Calibration can also be wanted to extend the proof supporting the mannequin, and therefore enhance confidence within the mannequin [1]. There are completely different approaches to evaluating a NP mannequin, involving calibration, assemble validity, evaluation of predictive validity in opposition to well being outcomes in people, and experimental research [22–24]. The calibration method includes evaluating the classifications produced by a NP mannequin in opposition to these from one other designed for comparable functions. At the moment, there isn’t a gold commonplace for classifying the dietary profile of a meals product. Nonetheless, the PAHO mannequin has been adopted as a reference for evaluating new NPs in numerous Latin American research [10–13]. Thus, for Latin American nations, the PAHO mannequin may go as a reference NP mannequin [1]. The PAHO mannequin was developed with out meals and beverage trade interference, and was the results of rigorous work by an Skilled Session Group primarily based on scientific proof [4]. It is usually primarily based on the WHO inhabitants nutrient consumption targets to stop weight problems and associated continual noncommunicable ailments (NCDs) [25], and considers the up to date targets of the WHO professional consultations on most advisable consumption of vitamins of concern: sugar, fat, and sodium [26].
The target of this examine was to judge the Mexican NP by evaluating the proportion of merchandise categorized as “wholesome” and “much less wholesome” (i.e., when product had 1 or extra warnings), in addition to the quantity and kind of warnings assigned to meals merchandise, in opposition to the PAHO mannequin utilizing the calibration technique. We additionally in contrast the classifications produced by the PAHO mannequin in opposition to these from the NP fashions of Chile, Ecuador, Peru, Uruguay, and Brazil.
The Mexican NP mannequin
The Mexican NP mannequin (Table 1) was developed primarily based on the PAHO mannequin and the Chilean NP, in addition to on a feasibility evaluation in additional than 38,000 merchandise retailed in Mexico. A short description of the foundations of the Mexican NP is offered beneath.
The PAHO mannequin proposes thresholds for six vitamins or substances of concern (i.e., sugar, complete fats, saturated fats, trans fats, sodium, and non-nutritive sweeteners), primarily based on the inhabitants nutrient consumption targets for stopping diet-related continual ailments. These targets don’t embrace a threshold for energy however are primarily based on the power contribution of every nutrient of concern. The PAHO mannequin considers particular thresholds for every nutrient of concern primarily based on its proportional contribution to the power of the product, nevertheless it doesn’t have a threshold for total energy [17,25,26]. Therefore, the Chilean NP mannequin threshold for “excessive in energy” was used for drinks and solids within the Mexican NP mannequin. The Chilean threshold for energy was decided in line with the power content material in pure meals and drinks. For solids, the calorie threshold corresponds to the ninetieth–ninety fifth percentile worth of the power distribution for 100 g of pure meals, primarily based on a meals composition database [27]; this worth has additionally been used to find out energy-dense meals [28]. For drinks, the Chilean mannequin considers the power content material of plain milk per 100 mL (70 kcal) because the reference [11,29]. However, in line with this threshold some dairy drinks are categorized as “excessive in energy” and “excessive in sugars,” whereas mushy drinks are solely labeled as “excessive in sugars,” indicating that mushy drinks are more healthy than dairy drinks [30]. That is controversial since all energy in mushy drinks come from added sugar, whereas for sweetened dairy drinks, different vitamins additionally account for complete energy (e.g., lactose, proteins, and fats). Certainly, mushy drinks have been instantly linked with the event of some NCDs, similar to weight problems and diabetes [26,31]. To resolve this limitation, the Mexican NP mannequin proposes a brand new cutoff level for the “extra energy” threshold in drinks. This criterion was developed contemplating 2 inhabitants scientific bases. The primary scientific base was the WHO advice to cut back every day consumption of free sugars to lower than 10% of complete power consumption (equal to 50 g of sugar per day) [32,33]. The second scientific base was the every day common beverage consumption of two,520 mL/day; this quantity was established by the Beverage Consumption Suggestions for the Mexican Inhabitants, contemplating a weight loss plan that gives 2,200 energy and an sufficient consumption of all important vitamins [34]. By dividing the WHO advisable every day consumption of free sugars by the every day common beverage consumption advice in Mexico, a standardized fee of 1.98 g of sugar per 100 mL was obtained. For ease of calculations, this determine was rounded up into 2 g/100 mL, equal to eight kcal per 100 mL (or roughly 5 g of sugar [1 teaspoon] per 250 mL), and set as the ultimate threshold for “extra energy” for the Mexican NP mannequin. Nonetheless, for the primary implementation section of the Mexican FoPL system, a restrict of <10 kcal per 100 mL was established (i.e., merchandise with ≥10 kcal/100 mL obtain the label “extra energy”). This threshold was established by the Mexican authorities as a way to present producers sufficient time to reformulate their merchandise.
Thresholds for extra sodium in stable and liquid merchandise had been additionally established. Based mostly on obtainable PAHO suggestions on the time [4], a threshold of >1 mg of sodium per 1 kcal was initially established for stable and liquid merchandise [35]. Nonetheless, the proposed threshold had the limitation that it categorized some low-calorie drinks with minimal quantities of added sodium (e.g., weight loss plan soda) as “excessive in sodium.” For instance, a low-calorie beverage with 5 kcal and 10 mg of sodium would exceed this threshold. Subsequently, we developed a brand new threshold for non-caloric drinks primarily based on the utmost content material of sodium in drinks obtainable within the Mexican market. First, all drinks not exceeding the sodium threshold (>1 mg/kcal) proposed by PAHO had been chosen (n = 425, 85% had been carbonated drinks). Then, we analyzed the sodium content material per 100 mL of those drinks, discovering that the utmost content material was of 45 mg [31]. We established this threshold (45 mg of sodium per 100 mL) because the criterion for the “extra sodium” label for non-caloric drinks. This threshold is much like the 2020 PAHO threshold for sodium for ultra-processed and processed drinks that present no power (40 mg/100 mL) that was printed in a while [35]. Based mostly on the up to date PAHO thresholds, we determined to moreover think about 300 mg of sodium per 100 g or 100 mL because the sodium threshold for the remainder of meals merchandise [35]. This threshold would permit a extra stringent identification of merchandise with extra of sodium, particularly desserts, snacks, and sauces/condiments.
Strategies
Meals merchandise retailed within the Mexican market
Public databases containing data on nutrient composition and ingredient data for branded meals and drinks in Mexico weren’t obtainable on the time of the examine. Subsequently, nutrient composition information on 38,872 packaged meals merchandise retailed within the Mexican market had been collected from 23 January 2016 to fifteen December 2017 following standardized procedures for measuring packaged meals and drinks in line with Kanter et al., consisting of photographing chosen product packaging at factors of sale, adopted by data obtain and information entry on the workplace utilizing the software program Analysis Digital Knowledge Seize (REDCap, Vanderbilt College, Nashville, TN, US) (see S1 Text) [36].
The protocol of this examine was authorised by the analysis, ethics, and biosafety committees of the Mexican Nationwide Institute of Public Well being (approval quantity: 1530). This examine was a part of the examine INFORMAS, monitoring and benchmarking meals environments globally [37].
Fieldworkers had been skilled nutritionists who attended a 1-month workshop [38] that consisted of coaching and experiential studying on meals composition, meals labeling, and meals promotion of packaged meals. As well as, fieldworkers obtained a 1-day images workshop led by an expert photographer, and half-week fieldwork coaching in an actual grocery store. To standardize information assortment processes, fieldworkers had been supplied with 50 merchandise from completely different classes and of various sizes and styles. Merchandise had been positioned on a desk in a big classroom and fieldworkers had been instructed to {photograph} the merchandise, obtain pictures to their computer systems, and seize information utilizing REDCap [39]. Knowledge captures had been in contrast, and fieldworkers had been thought-about skilled when inter-rater reliability was >80%.
Knowledge had been collected in 8 cities purposively chosen to seize the range of meals obtainable in city areas within the nation and to check completely different areas of Mexico (e.g., the northern a part of the nation has all kinds of imported meals merchandise from america of America). These cities included the 4 cities with the very best inhabitants density and financial relevance within the nation (Mexico Metropolis, Guadalajara, Monterrey, and Queretaro) in addition to different smaller cities (Cuernavaca, Baja California, Saltillo, and Ciudad Juárez). The examine is reported in line with STROBE (https://www.strobe-statement.org) (see S2 Text) [40].
We chosen a comfort pattern of 127 and 136 retail shops in 2016 and 2017, respectively. Retail shops had been geographically situated in areas with excessive inhabitants densities. First, the Nationwide Statistical Listing of Financial Models [41] was used to establish all financial items categorized as “retail commerce in supermarkets” inside every metropolis. Of those, all hypermarkets, supermarkets, and comfort shops had been initially chosen. Then, a 1,000-m buffer round every institution was drawn, and the entire inhabitants throughout the buffer in line with the 2010 census was calculated [42]. Subsequently, the gap to the closest retail retailer was calculated. All retail shops with a inhabitants density of >20,000 inhabitants throughout the 1,000-m buffer and with a distance of >1,500 m to the closest retail retailer had been included. Whatever the above standards, all membership meals shops from the highest grocery retailers in Mexico had been included as a result of these institutions market choose model merchandise which are obtainable solely in these shops. The included meals retailers altogether symbolize greater than 70% of the market share within the nation [43]. The ultimate variety of shops visited in every metropolis diverse from 3 in Cuernavaca to 65 in Mexico Metropolis.
Inside every retailer chosen, fieldworkers photographed all packaged meals merchandise obtainable on the time, together with all meals classes and all manufacturers. This technique was adopted as a result of we had been serious about evaluating variations within the availability of merchandise in line with the socioeconomic standing of the neighborhoods through which shops had been situated. Subsequently, duplicate merchandise had been eliminated. The info collected by the fieldworkers included product data (e.g., firm, model), web content material, value, nutrient info panel data, substances listing, well being and diet claims, and FoPL, from images of all sides of the packaging. Vitamin data was recorded and within the case of reconstituted merchandise, the “as consumed” data was retrieved from the pictures of the merchandise. Subject supervisors revised the completeness and accuracy of the captured information.
The database was then transferred to Stata (model 14, StataCorp, School Station, TX, US) format to be reviewed and cleaned. Meals and drinks had been categorized into 23 teams that generally embrace processed or ultra-processed merchandise and have been beforehand used for the dialogue of meals diet insurance policies: eggs, legumes, soups, potatoes/yams, marine merchandise, packaged salads, cereal/grains, mixture dishes, sugars/sweets, nuts/seeds, greens, meat/poultry, desserts, sauces/condiments, bakery merchandise, dessert toppings/fillings, snacks, miscellaneous gadgets, fat/oils, fruit/fruit juices, dairy drinks, and non-dairy drinks (S1 Table) [44].
Latin American NPs
This examine didn’t have a prespecified evaluation plan. Meals and drinks had been categorized in line with completely different NPs from 6 nations (Mexico, Chile, Uruguay, Brazil, Peru, and Ecuador) contemplating completely different phases of implementation, from the primary, or most permissive, to the final, or definitive, one, in addition to the PAHO NP mannequin (Table 1). Thus, a complete of 12 NPs had been included within the examine. Of those, 9 corresponded to authorised NP fashions for octagon warning labeling programs (Mexico [n = 3] [17], Chile [n = 3] [9,45,46], Peru [n = 2] [12,47], and Uruguay [n = 1] [13]), 1 to the multiple-traffic-light system in Ecuador (n = 1) [46,48,49], and 1 to the proposed NP in Brazil as a part of a labeling system comparable that carried out in Canada (n = 1) [50]. Specs for every NP had been retrieved from official information of the Ministry of Well being of every nation. Table 1 summarizes the NP fashions examined and the vitamins and substances of concern evaluated. The traits of the Latin American NP fashions and their detailed cutoff factors are proven in S2 and S3 Tables, respectively.
As recommended by the PAHO mannequin, meals and drinks had been categorized in line with the NOVA meals classification [4,44]. Of the 38,872 merchandise included within the dataset, a complete of two,028 had been excluded from the evaluation as a result of data was not obtainable for power or a few of the vitamins of concern evaluated or as a result of they had been child meals. For all of the assessed NP fashions, unprocessed or uncooked merchandise had been categorized as compliant with the NP standards.
The NPs of processed meals had been independently calculated by 2 researchers utilizing algorithms generated in Stata. The outcomes obtained by every researcher had been in contrast. Any disagreements had been mentioned and resolved till consensus was reached. Then, the NPs of a random pattern of 30 merchandise had been manually calculated and in contrast in opposition to these calculated by Stata algorithms. This course of was repeated for every NP till outcomes (i.e., Stata algorithms versus guide calculations) matched 100%.
Calibration of NP fashions
The three Mexican NPs (implementation phases 1–3), in addition to the NP fashions from Uruguay, Ecuador, Brazil, Peru (section 1 and a couple of), and Chile (phases 1–3), had been assessed utilizing the calibration technique in opposition to the PAHO mannequin. For this goal, we used the next indicators.
Outcomes
Settlement within the proportion of merchandise categorized as “wholesome” and “much less wholesome”
Fig 1 reveals the proportion of meals categorized as wholesome (i.e., with no warnings) and fewer wholesome (i.e., with 1 or extra warnings) by every NP mannequin, in addition to the settlement between the PAHO mannequin and the remainder of the NP fashions. Total, 19.9% of merchandise had been categorized as wholesome in line with the PAHO mannequin. The Mexican Part 1 (19.4%), Part 2 (20.4%), and Part 3 (24%) NPs categorized the same proportion of packaged meals as having no warnings, having a excessive settlement with the PAHO mannequin (okay > 91.9%, substantial to close excellent). Equally, the Ecuador (89.8%, okay = 0.707), Uruguay (82.5%, okay = 0.572), Chile Part 3 (82.3%, okay = 0.557), and Peru Part 2 (84.2%, okay = 0.604) NPs confirmed reasonable to excessive settlement with the PAHO mannequin. In distinction, the Chile Part 1, Brazil, and Peru Part 1 NP fashions had the very best proportion of meals categorized as wholesome (46.5%, 47.1%, and 49.2%, respectively) and the bottom settlement with the PAHO mannequin (<70%, okay < 0.432, reasonable) (Fig 1). All comparisons had been statistically important (p < 0.05).
Fig 1. Share of merchandise categorized as “wholesome” and “much less wholesome” by the PAHO mannequin and Latin American NPs (n = 36,844 distinctive packaged merchandise).
Merchandise with no warning labels had been categorized as wholesome; merchandise with 1 or extra “excessive in…” warnings had been categorized as much less wholesome. For the Ecuador NP mannequin, merchandise with 1 or extra warnings of reasonable (yellow) or excessive (purple) content material of vitamins of concern had been categorized as much less wholesome. P.c settlement (A) was assessed utilizing kappa statistics (okay): 0.01–0.20, slight; 0.21–0.40, honest; 0.41–0.60, reasonable; 0.61–0.80, substantial; 0.81–0.99, close to excellent. PAHO (reference); Mexico Part 3 (okay = 0.861; A: 95.6%); Mexico Part 2 (okay = 0.764; A: 95.3%); Mexico Part 1 (okay = 0.764; A: 91.9%); Ecuador (okay = 0.764; A: 89.8%); Uruguay (okay = 0.572; A: 82.5%); Chile Part 3 (okay = 0.557; A: 82.3%); Peru Part 2 (okay = 0.604; A: 84.2%); Chile Part 2 (okay = 0.479; A: 77.7%); Chile Part 1 (okay = 0.372; A: 69.9%); Brazil (okay = 0.431; A: 73%), Peru Part 1 (okay = 0.379; A: 69.3%). All comparisons had been statistically important (p < 0.05). NP, nutrient profile; PAHO, Pan American Well being Group.
Settlement within the sorts of warnings
Table 2 reveals the settlement within the sorts of warning labels assigned to meals merchandise between the PAHO mannequin and the opposite NP fashions. The best proportion of merchandise with “excessive in sugar” warnings was discovered for the PAHO mannequin and Mexico Part 2 and Part 3 NP fashions (40.4% for the three fashions). The settlement between the PAHO mannequin and these Mexican NP fashions was close to excellent. The Peru Part 1 and Chile Part 1 NP fashions had the bottom proportion of merchandise with warnings for sugar (roughly 28%); the Peru Part 1 NP had the bottom settlement with the PAHO mannequin for this nutrient (okay = 0.643, 83.6%).
Desk 2. Settlement of Latin American NP fashions with the PAHO mannequin for the proportion of merchandise with warnings for vitamins and substances of concern, and with the Chilean mannequin for the proportion of merchandise with warnings for “excessive in energy,” by nutrient or ingredient (n = 36,844 distinctive packaged merchandise).
The PAHO mannequin categorized 40.1% of merchandise as excessive in sodium. The Ecuador (47.3%) and Mexico Part 3 (43.4%) NP fashions had a barely larger proportion of merchandise labeled with this warning. The settlement between the NP fashions the PAHO mannequin was reasonable (78.7%, okay = 0.519) for the Ecuador NP mannequin and close to excellent for the Mexico Part 3 NP mannequin (91.2%, okay = 0.819). The Peru Part 1 and Chile Part 1 NP fashions had the bottom proportion of warnings for sodium (13.9% and 15.1%, respectively).
The PAHO (34.7%) and Mexico Part 3 NP (33.9%) fashions had the very best proportion of merchandise with “excessive in saturated fats” warnings; their settlement was close to excellent (98.9%, okay = 0.977). The Chile Part 1 NP mannequin had the bottom settlement with the PAHO mannequin for this nutrient (83.4%, okay = 0.588, reasonable), with 18.6% of merchandise categorized as excessive in saturated fats.
For energy, the Chile Part 3 NP was the reference mannequin, and categorized 38.9% of merchandise as excessive in energy. The Mexico Part 1 NP mannequin had the very best settlement (92.6%) with the Chile Part 3 NP, classifying 44.3% of the merchandise with this warning. In the meantime the Mexico Part 3 NP categorized 48.4% of the merchandise as excessive in energy, in close to excellent settlement with the Chile Part 3 NP (87.6%, okay = 0.750). No different NP fashions thought-about this criterion.
For complete fats, the Ecuador and Uruguay NP fashions had substantial settlement with the PAHO mannequin (okay = 0.606 and 0.639, respectively). Lastly, close to excellent settlement (okay = 0.999) between the Mexico NP fashions and the PAHO mannequin was noticed for trans fats (1.0%) and non-nutritive sweeteners (12.7%) (Table 2). The Peru NP had substantial settlement (okay = 0.706) with the PAHO mannequin for trans fats. Added caffeine was solely evaluated for the Mexico NP fashions (Table 2). All comparisons had been statistically important (p < 0.05).
Settlement within the variety of warnings
Fig 2 and S4 Table present the proportion of merchandise with 0 to five or extra warning labels, and the settlement and correlation between the PAHO mannequin and the Mexico Part 3 NP within the variety of warning labels assigned to merchandise, total and by meals group. Total, 57.4% of the merchandise had been categorized as having the identical variety of warnings by the two NP fashions, and the correlation between them was of 0.813. Throughout meals teams, the settlement between these 2 NP fashions was highest (i.e., okay was close to excellent) for fruit/juices (95.8%), adopted by miscellaneous gadgets (91.1%) and soups (81.9%). For toppings/fillings, fat/oils, greens, and snacks, settlement between the PAHO mannequin and the Mexico Part 3 NP was between 74.5% and 77.3%. The meals teams with the bottom settlement (i.e., beneath 70%) between these 2 fashions had been non-dairy drinks (31.9%), bakery merchandise (32.1%), and mixture dishes (37.5%): The Mexican NP recognized the next proportion of drinks and bakery merchandise as having excessive content material of vitamins of concern, whereas the PAHO NP mannequin recognized the next proportion of mixture dishes as being excessive in vitamins of concern (Fig 2; S4 Table).
Fig 2. Share of merchandise with 0 to five or extra warning labels assigned by the PAHO mannequin and the Mexico Part 3 nutrient profile, total and by meals group (n = 36,844 distinctive packaged merchandise).
All comparisons had been statistically important (p < 0.05). PAHO, Pan American Well being Group.
S1 Fig summarizes the general distribution of merchandise in line with the variety of warning labels assigned to meals merchandise by all of the included NP fashions. The Mexico Part 3 NP mannequin had the very best proportion of meals merchandise categorized with 3 (26.8%) and 4 or extra warnings (5.5%), whereas the Peru Part 1 NP mannequin had the bottom proportion of merchandise with 2 (14.1%) and three warnings (0.9%).
S5 Table summarizes the Pearson correlation coefficients and kappa statistics throughout all of the included NP fashions. Correlations between all NP fashions diverse broadly. The best correlation for the variety of warnings assigned to meals merchandise was discovered between the Brazil and Ecuador NP fashions (r = 0.930), and the bottom correlation was discovered between the PAHO mannequin and the Chile Part 1 NP mannequin (r = 0.486). Equally, the NP mannequin with the very best settlement with the PAHO mannequin concerning the classification of merchandise as wholesome and fewer wholesome was the Mexico Part 3 NP mannequin (95.6%, okay = 0.861), whereas the bottom settlement was noticed for the Peru Part 1 (69.3%, okay = 0.379) and Chile Part 1 NP fashions (69.6%, okay = 0.372). All comparisons had been statistically important (p < 0.05).
Dialogue
On this examine the Mexican NP mannequin was evaluated by means of the calibration technique in opposition to the PAHO mannequin utilizing a big pattern of Mexican packaged meals and drinks. Outcomes point out excessive settlement and correlation in examine outcomes between the three implementation phases of the Mexican NP mannequin and the PAHO mannequin. Additional, outcomes additionally present data on the comparability of different NP fashions proposed or utilized in Latin America because the underlying standards for FoPL schemes, displaying a large variability of their capability to establish merchandise with excessive quantities of vitamins of concern, regardless of most of them being primarily based on the PAHO mannequin. These outcomes underscore the relevance of selecting and adapting a NP mannequin to native diet insurance policies.
Settlement within the classification of wholesome versus much less wholesome merchandise
Thus far, scarce proof is obtainable concerning calibration of Latin American NP fashions. In a examine performed in a pattern of merchandise from Brazil, Duran et al. [51] categorized 38% of the merchandise as wholesome in line with the PAHO mannequin, whereas greater than half of the merchandise had been categorized as wholesome by the Chile Part 3 (58%) and Brazil (55%) NP fashions. In our examine, the PAHO mannequin and the three phases of the Mexican NP mannequin categorized the bottom proportion of merchandise as wholesome (round 20%), whereas virtually half of the merchandise had been categorized as wholesome by the Brazil mannequin, and round a 3rd had been categorized as wholesome by the Chile Part 3 mannequin. It is very important be aware that the profile utilized by Duran et al. for Brazil was a extra stringent model [52] than the lately authorised NP utilized in our examine. Therefore, one would anticipate the next proportion of merchandise to be categorized as wholesome in line with the much less stringent model utilized in our examine than the one utilized by Duran et al. [51]. Nonetheless, this inconsistency could also be defined by variations within the total healthiness of merchandise included within the 2 research. Merchandise in our database had been much less wholesome than those included in Duran et al.’s examine, as recommended by the decrease proportion of wholesome merchandise in our examine in comparison with Duran et al.’s examine in line with each the PAHO (38% versus 20%) and the Chile Part 3 fashions (58% versus 33%) [51].
Total, our outcomes point out that the three implementation phases of the Mexican NP are helpful to categorise meals merchandise in line with their dietary high quality, when in comparison with the PAHO mannequin. Nonetheless, the Mexican NP was stricter than different Latin American NPs, and, for some meals and beverage teams, it was even stricter than the PAHO mannequin. Variations could also be defined by the extra threshold for energy within the Mexican NP. As a result of alarming epidemic of weight problems and diabetes in Latin American nations, a warning label system with a stringent NP just like the PAHO mannequin or the Mexican NP is taken into account supreme to tell shoppers in a transparent and easy method, particularly as a result of packaged processed meals normally have excessive quantities of energy, added sugars, fat, and sodium that the final inhabitants is unaware of. On this context, it has been proposed {that a} NP mannequin classifying greater than half of merchandise as wholesome might have a diminished capability to enhance shoppers’ dietary behaviors [53] and to advertise product reformulation [54] aimed toward decreasing the content material of vitamins of concern. In accordance with our examine, the Peru Part 1, Brazil, and Chile Part 1 and Part 2 NP fashions categorized round half of the merchandise as wholesome. However, most of those fashions had been transitional, apart from the Brazil NP, which was the ultimate one. The truth that Brazil’s NP mannequin confirmed the bottom settlement with the PAHO mannequin among the many NPs studied might have essential implications for the flexibility of shoppers within the Brazilian inhabitants to accurately classify the dietary high quality of meals merchandise.
Settlement in the kind of warnings
Our outcomes are in keeping with the outcomes of the examine by Duran et al. indicating excessive settlement between the PAHO mannequin and the Chilean Part 3 NP within the proportion of meals merchandise exceeding the thresholds for sugar, sodium, and saturated fats [51]. As for the sugar threshold, Duran et al. categorized 51.8% of merchandise as excessive in sugar with the PAHO mannequin, 34.5% with Brazil’s mannequin, and 38.1% with the Chile Part 3 mannequin. Related percentages had been noticed in our examine for these fashions (PAHO, 40.9%; Brazil, 28.1%; Chile Part 3, 37.3%) in addition to for the Mexico Part 3 NP. Equally, and in keeping with Duran et al. [51], between 30% and 40% of meals merchandise exceeded the sodium threshold in line with the PAHO mannequin, Chile NP fashions, and Mexico Part 3 mannequin. Lastly, in line with Duran et al. [51], 35.4% of the merchandise had been categorized as excessive in saturated fat with PAHO NP mannequin, 29% with the Brazilian mannequin, and 20.4% with the Chilean mannequin. In concordance with our examine, the PAHO mannequin and the Mexican Part 3 NP categorized round 30% of merchandise as having extra saturated fats, whereas the Chile and Brazil NP fashions categorized round 20%.
The Mexican NP mannequin considers a threshold for energy, which isn’t included within the PAHO mannequin. Our outcomes point out that this threshold is very correlated with that of the Chile NP mannequin. That is related data for the Mexican context since sugar-sweetened drinks symbolize the “much less wholesome” meals group with the very best every day consumption amongst Mexicans throughout age teams (ENSANUT 2020) [20]; moreover, 40,842 deaths per yr in Mexico are attributable to the consumption of those drinks [19].
Non-nutritive sweeteners are essential substances to be warned about, since their consumption has been related to the recurring use of candy flavors (sugar-based or not), dysbiosis of the intestine microbiome, weight acquire, and better danger for sort 2 diabetes [55–58]. This criterion is evaluated by the PAHO mannequin and the Mexico NP, primarily based on the potential dangerous results of non-nutritive sweeteners amongst kids [58], and our examine reveals excessive settlement between the fashions. Even if the unique NP proposals in Chile, Peru [59], and Uruguay [60] additionally included a threshold for this ingredient, the ultimate laws dropped it because of meals trade interference. In consequence, product reformulation in these nations consisted partly in changing added sugar with non-nutritive sweeteners [61]. As compared, product reformulation in Mexico has been achieved by decreasing the quantity of added sugar and together with different novel substances, similar to lactase for dairy drinks and allulose for breakfast cereals. The well being results of those meals trade responses are to be studied in future analysis.
The warning for caffeine focusing on kids was included within the Mexican NP mannequin primarily based on the argument that caffeinated merchandise might trigger hyperactivity, insomnia, habit, and will increase in blood strain amongst shoppers [21,62]. In accordance with our outcomes, lower than 1% of merchandise have this warning, inflicting little impression on the classification settlement between this mannequin and the PAHO and Chile NP fashions. Nonetheless, by together with particular thresholds focusing on kids, the impression of the brand new warning labels could also be maximized since research in Chile recommend that younger populations had been the primary drivers for change amongst Chilean households [63].
Lastly, complete fats is taken into account by just some NP fashions, as a result of complete fats consists of wholesome (i.e., monounsaturated and polyunsaturated fatty acids) and unhealthy (i.e., saturated or trans) fatty acids. Our outcomes point out excessive settlement within the proportion of merchandise exceeding this threshold for the PAHO, Ecuador, and Uruguay NP fashions.
Settlement within the variety of warning labels
In our examine, classifications diverse broadly when evaluating the variety of warnings throughout Latin American NP fashions. Outcomes exhibit that even small variations within the collection of vitamins of concern included in a NP mannequin might trigger huge variations within the classification of the merchandise. Variations throughout NPs and the PAHO mannequin are largely because of the variety of vitamins and substances of concern evaluated by every. The Mexico NP had the very best variety of thresholds established (n = 7), adopted by the PAHO mannequin (n = 6). In distinction, the Ecuador and Brazil NPs have the bottom quantity (n = 3). However, overestimation of the proportion of wholesome merchandise was larger for Brazil than for Ecuador as a result of Brazil’s thresholds are extra versatile. Variations within the variety of warning labels may additionally be brought on by the kind of ingredient. For instance, for the Mexico NP and the PAHO mannequin, the sugar threshold considers the content material of free sugars, whereas for the remainder of the NPs, complete sugars are thought-about. Free sugars are extra helpful than complete sugars to establish sugars added to the merchandise, since sugars apart from monosaccharides or disaccharides are current in merchandise in a pure method, similar to lactose and fructose. [58]. Equally, the PAHO mannequin and the Mexico NP fashions consider trans fats content material in processed meals utilizing a threshold primarily based on the proportion of power derived from trans fat (>1%), whereas Peru NP classifies merchandise with a “excessive in trans fat” warning when any of this nutrient is added to the product.
Outcomes point out that the Mexico Part 3 NP had excessive settlement with the PAHO mannequin for many meals teams. Nonetheless, disagreement (<40% settlement) was noticed inside particular meals teams, together with non-dairy drinks, mixture dishes, and bakery merchandise. Disagreement between these 2 NP fashions was noticed within the proportion of merchandise with 1 or extra warnings, which can be defined by the “extra energy” warning of the Mexican NP mannequin and the “excessive in complete fats” warning of the PAHO mannequin. For bakery merchandise, the “extra energy” warning of the Mexican NP mannequin accounts for 1 extra warning in 77.4% of the merchandise on this meals group; equally, the entire fats criterion of the PAHO mannequin accounts for 1 extra warning in 17% of those merchandise. For mixture dishes, a complete of 23% of the merchandise on this meals group had been labeled as having extra energy in line with the Mexican NP mannequin, whereas 75% had been categorized as excessive in complete fats by the PAHO mannequin. Lastly, for non-dairy drinks, 55% of the merchandise had been labeled as having extra energy by the Mexican NP, whereas solely 3% had been labeled as excessive in complete fats by the PAHO mannequin. Regardless of disagreements between the fashions, it have to be famous that for each fashions round 10% of the merchandise had been categorized as having 0 warnings (i.e., wholesome).
Strengths and limitations
This examine thought-about a big pattern of packaged merchandise retailed in Mexico collected in 2016 and 2017, earlier than the implementation of the warning labels. Additionally, to our data that is the primary examine evaluating all NP fashions utilized in Latin America, filling the data hole concerning the comparability of those NPs.
Nonetheless, outcomes ought to be interpreted contemplating some limitations. First, warning rectangles (caffeine and non-nutritive sweeteners) thought-about by the Mexican NP mannequin had been evaluated as if all the warnings had been octagonal seals. Therefore, the utmost variety of warnings for the Mexican NP mannequin was 7 (5 octagons and a couple of rectangles). An identical method was used when evaluating Ecuador’s NP, by giving the same interpretation to each the yellow and the purple site visitors lights. These choices might have overestimated the strictness of the Mexico and Ecuador NP fashions. However, rectangles and yellow warnings might have equal significance to octagons and purple warnings, since they can be utilized to control promoting directed to kids or to control the usage of well being and diet claims [64]. Second, our information had been restricted by the standard of the knowledge reported within the listing of substances and the diet info desk of the merchandise. The regulation enforced throughout the information assortment interval allowed 0 values to be reported for power and vitamins when their content material was very small (i.e., small merchandise similar to candies reported servings of 1 g of sugar per portion). This was extra widespread in merchandise with small portion sizes, opening the likelihood for underreporting. However, the Federal Fee for the Safety in opposition to Sanitary Dangers (COFEPRIS by its acronym in Spanish) displays and assesses the diet composition and labeling of packaged meals and drinks, stopping producers from reporting incorrect data on the labels. Moreover, meals producers are required to submit a bromatology evaluation of their product earlier than it reaches the Mexican market. On account of that course of, we reckon that the content material declared is correct typically. Nonetheless, no nationwide evaluation of the accuracy of packaged meals data has been printed. As with all meals composition databases, there’s a danger of error. Beneath this assumption, our outcomes are conservative, and the variety of meals and drinks categorized as much less wholesome might be larger.
