Unhealthy Products Research Articles

Labels Affect Food Choices, but in What Ways?

To reduce obesity and thus promote healthy food choices, front-of-pack (FOP) labels have been introduced. Though FOP labels help identify healthy foods, their impact on actual food choices is rather small. A newly developed so-called swipe task was used to investigate whether the type of label used (summary vs. nutrient-specific) had differential effects on different operationalizations of the “healthier choice” measure (e.g., calories and sugar). After learning about the product offerings of a small online store, observers (N = 354) could, by means of a swipe gesture, purchase the products they needed for a weekend with six people. Observers were randomly assigned to one of five conditions, two summary label conditions (Nutri-Score and HFL), two nutrient (sugar)-specific label conditions (manga and comic), or a control condition without a label. Unexpectedly, more products (+7.3 products)—albeit mostly healthy ones—and thus more calories (+1732 kcal) were purchased in the label conditions than in the control condition. Furthermore, the tested labels had different effects with respect to the different operationalizations (e.g., manga reduced sugar purchase). We argue that the additional green-labeled healthy products purchased (in label conditions) “compensate” for the purchase of red-labeled unhealthy products (see averaging bias and licensing effect).

Food and beverage advertising expenditures in Canada in 2016 and 2019 across media

BackgroundFood and beverage advertising has been identified as a powerful determinant of dietary intake and weight. Available evidence suggests that the preponderance of food and beverage advertising expenditures are devoted to the promotion of unhealthy products. The purpose of this study is to estimate food advertising expenditures in Canada in 2019 overall, by media and by food category, determine how much was spent on promoting healthier versus less healthy products and assess whether changes in these expenditures occurred between 2016 and 2019.MethodsEstimates of net advertising expenditures for 57 selected food categories promoted on television, radio, out-of-home media, print media and popular websites, were licensed from Numerator. The nutrient content of promoted products or brands were collected, and related expenditures were then categorized as “healthy” or “unhealthy” according to a Nutrient Profile Model (NPM) proposed by Health Canada. Expenditures were described using frequencies and relative frequencies and percent changes in expenditures between 2016 and 2019 were computed.ResultsAn estimated $628.6 million was spent on examined food and beverage advertising in Canada in 2019, with television accounting for 67.7%, followed by digital media (11.8%). In 2019, most spending (55.7%) was devoted to restaurants, followed by dairy and alternatives (11%), and $492.9 million (87.2% of classified spending) was spent advertising products and brands classified as “unhealthy”. Fruit and vegetables and water accounted for only 2.1 and 0.8% of expenditures, respectively, in 2019. In 2019 compared to 2016, advertising expenditures decreased by 14.1% across all media (excluding digital media), with the largest decreases noted for print media (− 63.0%) and television (− 14.6%). Overall, expenditures increased the most in relative terms for fruit and vegetables (+ 19.5%) and miscellaneous products (+ 5%), while decreasing the most for water (− 55.6%) and beverages (− 47.5%).ConclusionsDespite a slight drop in national food and beverage advertising spending between 2016 and 2019, examined expenditures remain high, and most products or brands being advertised are unhealthy. Expenditures across all media should continue to be monitored to assess Canada’s nutrition environment and track changes in food advertising over time.

“Expert persuasion” can decrease willingness to pay for sugar-containing food

Recent studies have revealed types of eating nudges that can steer consumers toward choosing healthier options. However, most of the previously studied interventions target individual decisions and are not directed to changing consumers’ underlying perception of unhealthy food. Here, we investigate how a healthy eating call—first-person narrative by a health expert—affects individuals’ willingness to pay (WTP) for sugar-free and sugar-containing food products. Participants performed two blocks of a bidding task, in which they had to bid on sweets labeled either as “sugar- free” or as “sugar-containing.” In-between the two blocks, half of the participants listened to a narrative by a dietary specialist emphasizing the health risks of sugar consumption, whereas the remaining participants listened to a control narrative irrelevant to food choices. We demonstrate that the health expert’s narrative decreased individuals’ WTP for sugar-containing food, but did not modulate their WTP for sugar- free food. Overall, our findings confirm that consumers may conform to healthy eating calls by rather devaluating unhealthy food products than by increasing the value of healthy ones. This paves the way for an avenue of innovative marketing strategies to support individuals in their food choices.

Food industry perspectives on potential policies targeting unhealthy food and beverage price promotions in Australian supermarkets

Current supermarket price promotions are likely to encourage unhealthy diets, leading some governments to recently endorse restrictions on price promotions for unhealthy food and beverages. However, little is known about the likely industry response to policy action in this area. The aim of this study was to understand how potential government policies targeting food and beverage price promotions in supermarkets are perceived by food industry stakeholders in Australia. Twelve semi-structured in-depth interviews were conducted with current and former employees of major food manufacturers and food retailers as well as other industry experts with experience related to price promotion practices in the Australian supermarket setting. Data were analysed deductively based on Lewin’s organisational change theories and inductively to highlight forces that might drive or restrain change.From an industry perspective, forces likely to create industry opposition to implementation of price promotion policy included: fear of losing competitive advantage; potential financial loss for food retailers and their suppliers; a perception that restrictions on price promotions for unhealthy products will not impact health; and a perception of increased financial cost to consumers. Forces perceived to drive implementation of a policy that would benefit public health included: mandatory regulation; extensive compliance monitoring; support for promoting healthy products; consumer education; and sufficient lead time and support from retailers for implementation. These forces, and the way in which they interact, need to be actively considered as part of efforts to change the healthiness of food and beverage price promotions in supermarkets.

Objective understanding of front of pack warning labels among Mexican children of public elementary schools. A randomized experiment

BackgroundWarning Labels (WL) highlight excessive amounts of critical nutrients in order to discourage consumption of unhealthful packaged food products. This study aimed to evaluate among Mexican school children, the objective understanding of traditional and numeric WL (aimed at small products) considered by the Mexican regulation, and whether cartoon characters influenced the understanding of WL. We also tested some communication strategies to facilitate the correct use of the WL.MethodsWe carried out a randomized experiment in July 2019 in public elementary schools from Morelos, Mexico. Participants aged 6–13 years, were randomly assigned to one of four groups: 1) Nutrient Facts Panel (NF) (n = 120), 2) Nutrient Facts Panel with cartoon characters (NF + C) (n = 83), considered the control groups, 3) Warning Labels (WL) (n = 109), and 4) Warning Labels with cartoon characters (WL + C) (n = 96). After allocation, children assigned to both WL groups (WL or WL + C), were randomly required to watch two posters simultaneously or a video explaining how to correctly interpret WLs. Logistic regression models adjusted by sex, age and cluster (school) were fitted.ResultsThe percentage of children correctly choosing the healthiest or the unhealthiest option was higher for WL groups (56.8, 95%CI; 40.8–72.8) compared to NF groups (24.3, 95%CI; 20.4–28.3, p < 0.05). The understanding of traditional WL was higher (28.7, 95%CI: 22.8–35.4) than the numeric WL (19, 95%CI: 14.2–25.0, p < 0.05). But, correct answers for identifying healthy and unhealthy products were higher for numeric WL than for NF groups. Cartoon characters reduced the percentage of correct answers for choosing unhealthiest products (WL + C: 48.9, 95%CI: 25.6–72.4 vs WL: 58.7, 95%CI: 36.4–81.1, p < 0.05). The video was 2.23 times more helpful than the posters to the correct interpretation of the WL (p < 0.05).ConclusionsIn scholar Mexican children, traditional and numeric WL were useful to identify healthier and unhealthier packaged products in comparison to NF, suggesting that both WL formats may effectively communicate the excessive content of nutrients of concern among children. Cartoon characters may reduce the objective understanding of the WL, underscoring the need to regulate advertising directed to children along with the implementation of front-of-pack labeling.

Price elasticity and affordability of aerated or sugar-sweetened beverages in India: implications for taxation

BackgroundThe sale of aerated or sugar-sweetened beverages (ASBs) has been consistently growing in India which has also experienced a major increase in non-communicable diseases. This study estimates the price elasticities of ASBs by different household-income groups in India and examine the trends in their affordability.MethodsThe price elasticity for ASBs were estimated using a nationally representative household sample survey on consumption of ASBs in India and with Deaton’s method which is robust to self-reported household expenditure surveys. Trends in affordability of ASBs were estimated using relative income price (RIP) which measured the proportion of per capita gross domestic product (GDP) required to purchase 100 L of ASBs in a given year. The elasticity parameters were used to estimate the incremental tax needed for a 10% reduction in ASB consumption.ResultsThe own-price elasticity of ASBs is − 0.94 in the overall sample and varied between − 1.04 to − 0.83 from low- to high-income households. There has been an annual average decline of about 6.8% in RIP of ASBs or an increase in their affordability over the last 13 years. Increasing the compensation cess on ASBs under the current Goods and Services Tax (GST) to 29%, will have the effect of decreasing ASB consumption by 10% and increasing the tax revenue by about 27%.ConclusionThe taxation policy on ASBs in India has largely been ineffective at increasing the real retail prices of ASBs as a result of which ASB consumption grew. ASBs should be classified along with other unhealthy products like tobacco and alcohol as demerit products for the purpose of taxation and their taxes should be regularly increased sufficiently enough to compensates for both general price inflation and income growth so as to decreases their affordability.

Lifestyle taxes in the presence of profit shifting

The consumption of unhealthy products generates significant externalities in terms of increased future health care costs to society. Lifestyle taxes are attracting increasing attention as a measure by which to discourage over-consumption and correct such externalities. This paper focuses on the trade-off that governments face in setting a lifestyle tax when the producer of the taxed good is a multinational which may engage in profit-shifting activities. In the absence of profit shifting, if governments do care about corporate tax revenue, the optimal lifestyle tax is always lower than the marginal health care cost. We show that, by shrinking the corporate tax base, profit shifting has the interesting side effect of helping to close the gap between the lifestyle tax and the marginal health care cost.

Use of environmental scan to assess density, content, and variation of predatory food and beverage marketing in New York City.

To explore the presence of predatory food and beverage marketing in different neighborhoods in New York City (NYC), this study describes the methodology of an outdoor environmental scan of the physical environment. The study was conducted in four NYC neighborhoods over a three-week period, in which pairs of trained researchers canvassed designated neighborhoods to document the presence of food and beverage marketing using photographs taken on digital smart phone devices. Commercial areas in the vicinity of NYC Public Schools and NYC Housing Authority campuses located in four neighborhoods with the highest and lowest nutrition related health indicators were studied: South Bronx, Pelham Throggs Neck, Upper West Side, Chelsea/Greenwich Village. Advertisements were coded against 50+ indicators to quantify pertinent variables including the frequency and content of food and beverages advertised and all forms of predatory marketing observed. Comparisons of prevalence and content of food and beverage advertisements and predatory marketing were made across neighborhoods with the highest and lowest health indicators, using chi-squared analysis, and a significance level of p<0.05. This article demonstrates a disproportionate presence of predatory marketing in low income NYC neighborhoods with negative health outcomes compared to wealthier neighborhoods. Further, this paper demonstrates the benefits and limitations of using an environmental scan methodology to assess predatory food and beverage marketing in a large urban area such as NYC.

Understanding of front of package nutrition labels: Guideline daily amount and warning labels in Mexicans with non-communicable diseases.

One strategy for the prevention and treatment of non-communicable diseases (NCDs) is the implementation of the front-of-pack labeling (FoPL) in foods and beverages. In 2020, Mexico adopted the warning label system (WL) as a new public health policy, whose aim is to help consumers make healthier food choices. Previously, the Guideline Daily Amount (GDA) was the labelling used it. This paper aims to compare the understanding of two FoPL, the GDA and the WL, through the identification of unhealthy products in Mexicans with NCDs. We analyzed data from 14,880 Mexican adults older than 20 years old with NCDs (overweight-obesity (OW/O), self-reported diabetes mellitus 2 (DM2), or/and hypertension (HT), or/and dyslipidemia (Dys)). Participants were randomly assigned to one of two groups: the GDA labeling or WL. Each group had to respond to a survey and had to classify food products images as healthy or unhealthy according to the labelling system to which they were assigned. The correct classification was determined according to the criteria of Chile’s labeling nutrient profile stage 3. To evaluate the correct classification in each one of the groups we evaluated the differences in proportions. Logistic regression models were used to assess the likelihood to correctly classify the product according to participants’ number of diseases and WL information, taking GDA label as a reference. Participants who used the information contained in the GDA label misclassified food product labels in greater proportion (70%), mostly participants with three or more NCDs (participants with OW/O+ HT+ Dys, represent 42.3% of this group); compared with those who used WL (50%). The odds of correct classification of food products using WL image were two times greater compared to GDA image in participants with NCDs; being greater in participants with three or more NCDs. The study results highlight the usefulness of WL as it helps Mexicans with NCDs to classify unhealthy food products more adequately compared with GDA.

Marketing of Food and Beverages to Children in the Eastern Mediterranean Region: A Situational Analysis of the Regulatory Framework.

Marketing of food items high in added saturated and/or trans-fat, sugar, or sodium (HFSS) negatively affect consumption patterns of young children. The World Health Organization (WHO) advised countries to regulate the marketing of foods and non-alcoholic beverages to young populations. The aim of this manuscript is to provide a situational analysis of the regulatory framework of food marketing policies targeting children in the Eastern Mediterranean Region (EMR). A semi structured questionnaire was shared with the focal points of EMR member states inquiring about the reforms and monitoring initiatives in place. Electronic databases were searched for relevant publications between 2005 and 2021. Results revealed that even though 68% of countries discussed the recommendations, progress toward the WHO set goals has been slow with only 14% of countries implementing any kind of restrictions and none executing a comprehensive approach. Reforms have focused on local television and radio marketing and left out several loopholes related to marketing on the internet, mobile applications, and cross border marketing. Recent monitoring initiatives revealed a slight improvement in the content of advertised material. Yet, unhealthy products are the most promoted in the region. This review identified the need to intensify the efforts to legislate comprehensive food marketing policies within and across EMR countries.

Determination of Microbial and Heavy Metal Contamination of Popular Street Vended Foods in Faisalabad, Pakistan

Background: In developing countries, street vended foods continue to expand as an affordable food source which impacts the economy. However, the contamination of these foods leads to the outbreak of foodborne diseases and is considered a significant public health issue in Asian countries. This study assessed the microbial load and heavy metal contents in locally available street foods (shawarma, fruit chaat, and dahi baray) in different locations in Faisalabad city, Punjab province of Pakistan. Methods: A total of 60 food samples from five different locations in Faisalabad city were analyzed for microbial quality (Escherichia coli, Salmonella sp, and Staphylococcus aureus, and total viable count) and heavy metals levels (Zn, Cu, Pb, and Cd). A design was used to conduct questionnaires concerning vendors’ knowledge about food hygiene and sanitary practices. Data obtained were statistically analyzed by using the SPSS 21 Statistical Software. Results: The street foods were highly contaminated with Staphylococcus aureus (1.266×104 cfu g-1), Escherichia coli (0.370×104 cfu g-1), and Salmonella species (0.016×104 cfu g-1). The average heavy metal contamination of lead, zinc, copper, and cadmium were measured at 0.955 mg/kg, 3.712 mg/kg, 0.317 mg/kg, and 1.000 mg/kg, respectively. The survey questionnaire indicated the contamination of water and unhygienic conditions as significant sources of low-quality street foods. Conclusions: The results revealed that mostly the street foods sold in Faisalabad were contaminated with heavy metals and pathogenic bacteria. The unhygienic practices and contaminated water were the main factors for unhealthy street vended foods production. In this regard, food-safety practices, education, and regulations related to safe food production have been recognized as measures for ensuring the quality of vendor foods.

Understanding the Online Environment for the Delivery of Food, Alcohol and Tobacco: An Exploratory Analysis of 'Dark Kitchens' and Rapid Grocery Delivery Services.

Online spaces are increasingly important in the sale of food, alcohol and tobacco. This analysis focuses on two developments in online food delivery: delivery-only ‘dark kitchens’ and rapid grocery delivery services (RGDS), with the aim to understand and assess the availability of health harming and health promoting products through these services. Data was collected for one metropolitan local authority in London, UK, using publicly available online sources. Being explorative in nature, the analysis includes descriptive statistics and qualitative assessment. Three dark kitchens (renting kitchens to 116 food businesses), three grocery delivery apps, and 76 grocery businesses available through online delivery platforms were identified. Most businesses renting dark kitchen space were ‘virtual restaurants’ (52%) selling fast food (47%) or dessert (21%) through online delivery platforms. RGDS sold a variety of items, with a focus on pre-packaged foods high in fat, salt and sugar, alcoholic beverages and tobacco. These items were also most likely to be promoted through offers and promotional language. Fruits and vegetables were less commonly available and mainly on grocery delivery apps. Online delivery services increase the temporal and geographic availability and promotion of many unhealthy products. Research expanding on the geographic area of interest is needed.

Socioeconomic disparities in outdoor branded advertising in San Francisco and Oakland, California

Advertising exerts a powerful influence over consumer decision-making, and disproportionate marketing for unhealthy products may contribute to health inequities. The objective of this study was to examine socioeconomic and racial and ethnic disparities in outdoor branded advertising for products harmful to health in San Francisco and Oakland, CA. We collected cross-sectional data on outdoor advertising from 372 blocks with ≥ 1 residential or mixed-residential parcel in SF and Oakland in 2018–2019. Blocks were randomly sampled by city, land use, majority vs. non-majority Black and/or Hispanic composition, and upper and lower tertiles of household income. Advertisements were coded by product, healthfulness, and branding. Exposure variables were neighborhood household median income and percent of residents who were Hispanic of any race, non-Hispanic Asian, non-Hispanic Black, and non-Hispanic White. The primary outcome variable was block-level dichotomous presence of any unhealthy branded advertisement for food, beverage, alcohol, or tobacco. Analyses were unadjusted and adjusted for land use and number of total advertisements on each block. Each additional $10,000 in neighborhood household median income was associated with an 11% lower adjusted odds of having any unhealthy branded advertisements on the block (95%CI: 0.80–0.99; P = 0.03). There were no significant associations between neighborhood racial and ethnic composition and presence of unhealthy branded advertisements, but with each 10% higher neighborhood composition of Hispanic residents, there was a borderline significant higher presence of unhealthy branded advertisements (OR = 1.23; 95%CI: 1.00–1.51; P = 0.05). Results indicate that low-income neighborhoods were disproportionately exposed to outdoor branded advertisements for unhealthy products.

Time Domain (TD) Proton NMR Analysis of the Oxidative Safety and Quality of Lipid-Rich Foods

Food safety monitoring is highly important due to the generation of unhealthy components within many food products during harvesting, processing, storage, transportation and cooking. Current technologies for food safety analysis often require sample extraction and the modification of the complex chemical and morphological structures of foods, and are either time consuming, have insufficient component resolution or require costly and complex instrumentation. In addition to the detection of unhealthy chemical toxins and microbes, food safety needs further developments in (a) monitoring the optimal nutritional compositions in many different food categories and (b) minimizing the potential chemical changes of food components into unhealthy products at different stages from food production until digestion. Here, we review an efficient methodology for overcoming the present analytical limitations of monitoring a food’s composition, with an emphasis on oxidized food components, such as polyunsaturated fatty acids, in complex structures, including food emulsions, using compact instruments for simple real-time analysis. An intelligent low-field proton NMR as a time domain (TD) NMR relaxation sensor technology for the monitoring of T2 (spin-spin) and T1 (spin-lattice) energy relaxation times is reviewed to support decision-making by producers, retailers and consumers in regard to food safety and nutritional value during production, shipping, storage and consumption.

Farm-to-hospital programs and public health: Leveraging local food for organizational and behavioral change

Farm-to-hospital (FTH) programs have emerged over the last decade as an approach for hospitals to leverage their buying power and growing influence in the food system to support healthier eating hab­its, as well as stimulate local economic develop­ment and community wealth building, often within a broader set of policy, systems, and environmental (PSE) interventions. While FTH programs have increased in prominence over the last decade, sev­eral challenges prevent widespread adoption. These include distributor contracts that limit outside pur­chases, logistical challenges receiving products from local vendors, and a lack of buy-in from key decision-makers. These challenges frequently reflect foodservice operations organized to maxim­ize revenue, which lends itself to an approach that sources cheap and unhealthy food products. In this paper, we present findings from a case study of two hospitals part of the University of Wisconsin Health system in their efforts to develop a farm-to-hospital program from 2008 to 2017. Specifically, we study the organizational strategies used by the We Are Health Committee (WAHC) and its infor­mal predecessors to create the conditions to facili­tate and encourage local food procurement. We find that stakeholders reorganized their foodservice operations around the value of supporting public health, leveraging their clinics’ mission as a public health institution. This resulted in the creation of new organizational structures and roles, including merging their nutritional and foodservice depart­ments, creating the infrastructure for institution-wide change. Local food procurement was per­ceived as a means to develop nutritional interven­tions targeting the availability of healthier food items without creating the perception of paternal­ism among visitors. Finally, as stakeholders observed the local economic impact of their pur­chasing decisions, the values of their foodservice evolved to explicitly include supporting local eco­nomic development, resulting in an evolution of their relationship with their broadline distributor to facilitate increased local food purchases.

The influence of unhealthy food and beverage marketing through social media and advergaming on diet-related outcomes in children-A systematic review.

SummaryChildren are increasingly exposed to food and beverage marketing, but little is known about the specific effects of marketing through media most used by children. This study aims to systematically review the influence of unhealthy food and beverage marketing through social media and advergaming on diet‐related outcomes in children. Seven databases were systematically searched for English peer‐reviewed quantitative and qualitative scientific studies on the effects of marketing of unhealthy products through social media or advergaming on a range of diet‐related outcomes in children. Risk of bias was assessed with tools specific for the different study designs. Twenty‐six studies were included, of which 20 examined the effect of food and beverage marketing through advergaming and six through social media. Most studies had a high risk of bias. The results suggested that unhealthy food and beverage marketing through social media and advergaming has a significant effect on pester behaviors, food choice, and food intake of children. The studies demonstrate that unhealthy food and beverage marketing through media popular with children significantly impacts different diet‐related outcomes. Combined with existing evidence on this effect in other settings, this review provides clear evidence of the need for policies targeting screen‐based marketing.

"It's All Just Marketing", a Qualitative Analysis of Consumer Perceptions and Understandings of Nutrition Content and Health Claims in New Zealand.

Nutrition content and health claims are widely used globally on both food labels and in food advertising. This study explored how New Zealand consumers understand, perceive, and use nutrition content and health claims on food labels. A qualitative approach was used with semi-structured in-depth online interviews and in-person focus groups including 49 participants, aged ≥25 years responsible for household food shopping. Transcripts were analysed using reflexive thematic analysis using inductive coding, with development of five themes—(1) aware of claims but did not use, (2) mistrust and scepticism, (3) confusion and misinterpretation, (4) using claims to guide food choice, and (5) not all claims are equal. For theme 1, price and habit were found to be the most influential in driving food choice. Underlying theme 2 was the perception by most of nutrition and health claims as marketing. Scepticism was exacerbated when nutrient claims were displayed on inherently unhealthy products. However participants with specific dietary requirements did find claims helpful. Restricting nutrient claims to foods meeting a healthy nutrient profile aligned to the existing Health Star Rating system, education about regulation and supporting claims with more contextual information may increase trust, the perceived value of claims and therefore their utility.

Business and health: A research agenda post‐Covid‐19

Despite some work dealing with occupational health and marketing unhealthy products, the business and society largely ignores the impacts of business on health. Focusing on employees and consumers, the literature does not take into account the impacts of business on the health of community members in general. Given work in such fields as public health, geography, and history, there is an ample basis upon which to construct a new line of research for business and society scholars—business and health. This essay develops ideas on how such a line of inquiry might proceed.

The interaction of social influence and message framing on children’s food choice

PurposeObesity leads to increased mortality and morbidity among children, as well as when they turn adults. Melding marketing theories in social influence and message framing, this study aims to examine how compliance versus conformance social influence, each framed either prescriptively or proscriptively, may guide children’s choice of healthy versus unhealthy food.Design/methodology/approachThis study conducted two experiments in a Pakistani junior school. Experiment 1 exposed children to either a prescriptive or a proscriptive compliance influence. Experiment 2 involved a 2 (prescriptive vs proscriptive compliance influence) × 2 (supportive vs conflicting conformance-influence) between-subjects design. Participants in both studies answered an online survey after being exposed to the social-influence messages.FindingsExperiment 1 showed proscriptive was stronger than prescriptive compliance influence in nudging children to pick fruits (healthy) over candies (unhealthy). However, frequency of fruits dropped as susceptibility to compliance strengthened. Experiment 2 found that a proscriptive compliance influence reinforced by a supportive conformance-influence led to most children picking fruits. However, a conflicting conformance influence was able to sway some children away from fruits to candies. This signalled the importance of harmful peer influence, particularly with children who were more likely to conform.Research limitations/implicationsChildhood is a critical stage for inculcating good eating habits. Besides formal education about food and health, social influence within classrooms can be effective in shaping children’s food choice. While compliance and conformance influence can co-exist, one influence can reinforce or negate the other depending on message framing.Practical implicationsIn developing countries like Pakistan, institutional support to tackle childhood obesity may be weak. Teachers can take on official, yet informal, responsibility to encourage healthy eating. Governments can incentivise schools to organise informal activities to develop children’s understanding of healthy consumption. Schools should prevent children from bringing unhealthy food to school, so that harmful peer behaviours are not observable, and even impose high tax on unhealthy products or subsidise healthy products sold in schools.Originality/valueThis study adopts a marketing lens and draws on social influence and message framing theory to shed light on children’s food choice behaviour within a classroom environment. The context was an underexplored developing country, Pakistan, where childhood obesity is a public health concern.

Eligibility and Prevalence of the American Heart Association Heart Check Certification Program in the US Packaged Food and Beverage Supply: A Cross-Sectional Study.

Objective: Consumers in the US make choices within a food supply dominated by processed packaged foods and beverage products. Front-of-package nutrition labels (FOPL) equip consumers to make healthier choices, but further evaluation and regulation regarding FOPL format, scope, and display have been recommended by the World Health Organization. As a leader in consumer FOPL guidance, the American Heart Association's (AHA) Heart Check programme certifies food companies seeking to add an AHA Heart Check logo as a FOPL for qualifying heart healthy products. A cross-sectional assessment of the AHA Heart Check Standard Certification was conducted within the US packaged food and beverage supply to assess the eligibility and prevalence of the programme as a FOPL. Methods: Data were derived from Label Insight's Open Data initiative, which is the largest publicly-available US branded food composition database. The proportions of products that were certified and eligible to be certified for the Standard Certification were reported by nutrient attributes, grocery aisles and food brands. Results: Among 153,453 products examined, fewer than 1% exhibited the Heart Check certification on their label. Among products that were not Heart Check certified,13.8% were eligible for Standard Certification. The most common reason for ineligibility was the saturated fat content (52%), followed by total fat content (47%) and sodium content (47%). Heart Check certification and eligibility differed substantially across grocery aisle categories. Conclusions: The abundance of unhealthy products in the US packaged food and beverage supply and absence of harmonized FOPL policies suggest the need for FOPL like the Heart Check label to promote adherence to healthy diets. There are opportunities for food manufacturers and the AHA to certify more heart healthy foods and beverages. However, more consistent criteria and transparent labelling could enhance Heart Check certification to facilitate consumers' ability to make more informed and healthful purchases.