The estimated dietary and health impact of implementing the recently approved ‘high in’ front-of-package nutrition symbol in Canada: a food substitution scenario modeling study

Flexner, Nadia; Ahmed, Mavra; Mulligan, Christine; Bernstein, Jodi T.; Christoforou, Anthea K.; Lee, Jennifer J.; Khandpur, Neha; L’Abbe, Mary R.

doi:10.3389/fnut.2023.1158498

Cited by 5 publications

(8 citation statements)

References 48 publications

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“…Therefore, it is expected that implementation of FOPL will result in greater health and healthcare cost benefits, as it also targets other nutrients-of-concern (i.e., sugars and saturated fats) not accounted for in our estimates. For instance, a recent study from our research group estimated that 15% of diet related NCD deaths that could be averted or delayed due to implementation of FOPL in Canada were attributed to sodium (21).…”

Section: Discussionmentioning

confidence: 99%

“…CCHS-Nutrition 2015 is a nationally representative, cross-sectional health and nutrition survey that utilized 24-hour (24h) dietary recalls to collect data on food and beverage intake across the 10 Provinces of Canada (aged 1y or older) (35). We used both available days of 24h dietary recalls to estimate usual dietary sodium intakes for adults by Dietary Reference Intakes (DRI)(36) age/sex groups (i.e., males and females ages 19-30, 31-50, 51-70, 71+), methods that have been previously published by our research group (10,20,21).…”

Section: Dietary Sodium Intakementioning

confidence: 99%

“…All FOPL counterfactual scenarios tested in this study are based on 'high in' FOPL evidence, which is the FOPL system recently approved in Canada. We have previously published methods for all FOPL policy scenarios (20,21). For this study, we used potential impacts of implementing FOPL only for changes in sodium intakes.…”

Section: Implementing 'High In' Front-of-pack Labeling Regulations (S...mentioning

confidence: 99%

“…Studies in the Canadian context have estimated the economic and health impact of reducing sodium intake to recommended levels when compared to previous sodium intake levels (i.e., 3,800 mg/day) using data from CCHS-Nutrition 2004 (19). More recently, using data from CCHS-Nutrition 2015, we previously estimated the number of CVDs deaths that could be averted or delayed if Canadians were to reduce their sodium intake to recommended levels (10,19), and as a result of implementing 'high in' FOPL regulations (20,21). However, to the best of our knowledge, no study in Canada has previously estimated the health impact and healthcare cost savings from 'real world' policy scenario options to reduce population level dietary sodium intakes (i.e., food reformulation and mandatory 'high in' FOPL symbol).…”

Section: Introductionmentioning

confidence: 99%

“…The potential health impacts were estimated using the PRIMEtime model (24), with inputs described in Table 1. Full details of each counterfactual scenario have been published elsewhere (10,20,21). Sodium intake goal scenarios were based on the AI recommendations of 1,500 mg/day (S1) and the WHO sodium intake recommendations of The potential health gains and healthcare cost savings were estimated using the PRIMEtime model (24), with inputs described in Table 1.…”

mentioning

confidence: 99%

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The potential health impact and healthcare cost savings of different sodium reduction strategies in Canada

Flexner,

Jones,

Amies-Cull

et al. 2023

Preprint

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BackgroundHigh dietary sodium is the main dietary risk factor for non-communicable diseases due to its impact on cardiovascular diseases, the leading cause of death globally. The Government of Canada has taken measures to reduce average dietary sodium intakes, such as setting voluntary sodium reduction targets for packaged foods and recently approving regulations mandating ‘high in’ front-of-pack labeling (FOPL) symbols.ObjectivesTo estimate the number of avoidable ischemic heart disease (IHD) and stroke incidence cases, and their associated healthcare cost and Quality-Adjusted Life Year (QALY) savings resulting from different sodium reduction strategies and recommendations in Canada.MethodsWe used the PRIMEtime model, a proportional multi-state lifetable model. Outcomes were modeled over the lifetime of the population alive in 2019, at a 1.5% discount rate, and from the public healthcare system perspective. Nationally representative data were used as inputs for the model.ResultsFully meeting Health Canada’s sodium reduction targets was estimated to prevent 219,490 (95% UI, 73,409–408,630) cases of IHD, and 164,435 (95% UI, 56,121–305,770) strokes. This led to a gain of 276,185 (95% UI, 85,414–552,616) QALYs, and healthcare costs savings of CAD$ 4,212(95% UI, 1,303–8,206) million over the lifetime of the 2019 cohort. Sodium reduction intake through FOPL regulations has the potential to prevent between 35,930 (95% UI, 8,058– 80,528) and 124,744 (95% UI, 40,125–235,643) cases of IHD, and between 26,869 (95% UI, 5,235–61,621) and 93,129 (95% UI, 30,296–176,014) strokes. This results in QALY gains ranging from 45,492 (95% UI, 10,281–106,579) to 157,628 (95% UI, 46,701–320,622), and healthcare costs savings ranging from CAD$ 695 (95% UI, 160–1,580) to CAD$ 2,415 (95% UI, 722–4,746) million over the lifetime of the 2019 Canadian cohort. Greater health and healthcare costs gains were estimated if Canadians were to meet the population-level sodium intake recommendations of the World Health Organization (2,000 mg/day) and the Adequate Intake recommendation (1,500 mg/day). All sodium reduction strategies tested were cost saving.ConclusionsReducing population-level sodium intakes is feasible and has the potential to improve health outcomes and save healthcare costs in Canada. From interventions tested, most health and healthcare costs gains were attributed to fully meeting sodium reduction targets, which highlights the importance of changing the voluntary nature of these targets to mandatory. A combination of strategies, mandatory sodium reduction targets and implementation of the ‘high in’ FOPL symbol would provide the most benefit from a public health standpoint.

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Section: Discussionmentioning

confidence: 99%

Section: Dietary Sodium Intakementioning

confidence: 99%

Section: Implementing 'High In' Front-of-pack Labeling Regulations (S...mentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

mentioning

confidence: 99%

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The potential health impact and healthcare cost savings of different sodium reduction strategies in Canada

Flexner,

Jones,

Amies-Cull

et al. 2023

Preprint

Self Cite

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Recognizing the ethical complexity of food policies and the role of the food industry

Abdool Karim,

Alvarado,

Johnson

et al. 2024

Health Promotion International

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Restrictive food policies are often contentious and controversial. Supporters of these policies view them as imperative for achieving public health aims while some opponents view them as overly paternalistic, infringing on consumer choice and potentially inequitable. As a consequence, their ethical status and permissibility are both contested and of importance in decision-making for policy. Traditional ethical analysis of these interventions has examined the ethical implications of the policies according to a direct, linear view of the relationships between government and consumer and the impact of government policy on the consumer. However, this approach to ethical analysis fails to take into account the role of the food industry as the subjects of the policies and intermediaries between government and consumers in the implementation and effectiveness of the policies. The actions of the food industry in response to a policy substantially determine how the policy translates to changes in the food supply and thus, the effect of the policy on consumers. This has significant implications for the ethical status of the policy. As a result, this article calls for complicating the common ethical approach to restrictive food policies by adopting a framing that recognizes the role of the food industry in the implementation of these policies. We then discuss three implications this framing has for ethical analysis: first that ethical analysis must be more nuanced and recognize the potentially complex outcomes of a policy, second that it must be dynamic and ongoing and third that underlying assumptions about policies’ effects on choice, effectiveness and equity need to be reconsidered.

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Comparing the Canadian front-of-pack labeling regulations with other mandatory approaches in the Americas and their ability to identify ultra-processed products

Flexner,

Gomes,

Mulligan

et al. 2024

Preprint

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Background Front-of-pack labeling (FOPL) has been implemented in several countries in the Americas, with Chile being the first to introduce a mandatory ‘high in’ warning FOPL in 2016. The Pan American Health Organization (PAHO) food classification criteria, considered a best practice for FOPL regulations, has been adopted by Mexico, Argentina, and Colombia. Canada’s FOPL regulations were recently approved and will take effect in January 2026, but it is unknown how these regulations compare to FOPL regulations that have already been implemented in other parts of the region. Objectives To compare the Canadian criteria for FOPL regulations with other FOPL criteria implemented in the Americas, and to determine their ability to identify ultra-processed products (UPPs). Methods Packaged foods and beverages (n=17,094) from the University of Toronto’s Food Label Information and Price (FLIP) 2017 database were analyzed using three FOPL criteria (Canadian, Chilean and PAHO criteria) and the NOVA classification system. The proportions of products that would be subject to displaying a ‘high in/excess’ FOPL and UPPs that would not be subject to FOPL regulations were examined under each system’s criteria. Agreement patterns were modeled using a nested sequence of hierarchical Poisson log-linear models. The Wald statistics for homogeneity were used to test whether proportional distributions differ significantly. Results Under the Canadian, Chilean and PAHO criteria, 54.4%, 68.4%, and 81.3% of packaged products would be required to display a ‘high in/excess’ FOPL, respectively. Disagreements between the Chilean and the Canadian criteria with PAHO’s were significant, but the greatest disagreement was between the Canadian and PAHO criteria. According to the Canadian, Chilean, and PAHO criteria, 33.4%, 18.4%, 2.3% of UPPs would not be subject to FOPL regulations, respectively. Conclusions A significant proportion of products that should be subject to FOPL regulations according to the PAHO criteria would not be regulated under Chilean and Canadian criteria, resulting in high proportion of UPPs that would not be subject to FOPL regulations. The Canadian FOPL criteria are the most lenient, with the highest proportion of UPPs that would not display a FOPL. Results can inform improvements for FOPL regulations in Canada, Chile and other countries.

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The estimated dietary and health impact of implementing the recently approved ‘high in’ front-of-package nutrition symbol in Canada: a food substitution scenario modeling study

Cited by 5 publications

References 48 publications

The potential health impact and healthcare cost savings of different sodium reduction strategies in Canada

The potential health impact and healthcare cost savings of different sodium reduction strategies in Canada

Recognizing the ethical complexity of food policies and the role of the food industry

Comparing the Canadian front-of-pack labeling regulations with other mandatory approaches in the Americas and their ability to identify ultra-processed products

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