The most prevalent causes of mortality and morbidity in Chile relate to non-communicable diseases (NCD), with one third of the population classified as obese [1
]. The high consumption of energy and nutrients of concern based on foods high in sugars, sodium and saturated fats is the most important risk factor associated with diet-related NCD [2
]. Furthermore, 28.6% of total energy intake of the Chilean diet is derived from ultra-processed foods [3
International organizations, such as the World Health Organization (WHO), the Pan American Health Organization (PAHO) and the Organization for Economic Co-operation and Development (OECD) have encouraged countries to prioritize prevention of overweight and obesity in public health polices, calling for policies focused on market regulation and policies to revert tendencies of increased consumption of unhealthy foods. In addition, policies on the restriction of sales of processed foods, sugary drinks and the poor nutritional content of fast food and its relation to NCD are encouraged [4
In this context, Chile has implemented several strategies to decrease the burden of obesity and chronic diseases, including specific laws, plans, and programs [7
]. A pioneer in the region, one of the most important was the Food Labeling and Advertising Law (Law 20.606); An innovative policy that implemented a nutritional profile limit for energy and nutrients of concern (total sugars, saturated fats, sodium) for incorporating a front-of-package (FoP) “high in” warning label. Moreover, this same regulation restricts the marketing of “high in” foods to children under 14y and prohibited the sale of these products at schools. The implementation of the Law 20.606 occurred in three periods: 2016 (less restrictive limits), 2018 (more restrictive limits) and 2019 (final limits for energy and nutrients of concern). The primary focus of this regulation was to inform consumers about the high content of energy, total sugar, saturated fat and sodium in processed foods and to improve the food environment for children, restricting their exposure to excessive advertising and sales of unhealthy foods [8
]. Another objective of this regulation was to support the reformulation of processed foods, decreasing total sugars, saturated fats and sodium content or replacing ingredients that improve the nutrient profile.
The presence of FoP warning labels on products improve consumer comprehension of nutritional facts, help consumers identify products high in nutrients of concern, and discourage consumers from purchasing these products [10
]. An Australian study showed that FoP labels could reduce intended sugar-sweetened beverages purchases independent of type, with the magnitude of effect greatest for graphic warning labels (OR: 0.22; 95% CI: 0.14–0.35) [12
Researchers compared the Chilean FoP warning label with the traffic light system among children in grades 4 to 6, and showed a positive effect of the Chilean model in the choices of processed foods (wafer cookies and orange juice), demonstrating a possible impact on the consumption of nutrients of concern [13
]. The availability of unhealthy foods in school kiosks in the capital, Santiago, was analyzed in 2014 and six months before the law came into force in 2016. The authors found a reduction in availability of 75.4% of these products and a reduction in energy, total sugar, saturated fat and sodium in the nutrient content of solid products [14
], demonstrating an overall positive outcome of the Law, related to an improvement of the school food environment.
Few studies have established the relationship between FoP warning label implementation and product reformulation. In a simulation study, Ares and cols (2018) found that FoP warning labels could improve consumer intention to select more healthful foods, decreasing intake of nutrients of concern [15
]. Another simulation study investigated consumer willingness to pay for a reformulated product and found that this condition was affected by the brand type and sodium and fat reductions in sausages samples [16
]. These results demonstrate that implementation of a FoP warning label system could be followed by a reduction in consumption of unhealthy foods after reformulation, which, in turn, could reduce the exposure to this diet-related risk factor for NCD.
Kanter et al. (2016) demonstrated a minimal impact of product reformulation before Law 20.606 implementation in Chile, with few reductions in energy content and increases in some nutrients of concern by food groups [17
]. There have been no studies considering the latest implementation period (June 2019) of the law. Thus, the purpose of this study was to evaluate the impact of Law 20.606 in energy, total sugar, saturated fat and sodium declaration of packaged foods commercialized in Chile, comparing nutrient content information prior to the law implementation (2013) and after the last implementation stage (2019). We hypothesized that companies reformulated products to adapt to the new regulation, reducing energy and the content of nutrients of concern.
This impact evaluation of the Chilean Food Labeling and Advertising Law on nutrient declaration showed an extensive decrease in energy, total sugar and sodium content for the most consumed packaged food products (period 2013–2019). The highest reduction was observed in total sugar content, while few changes were observed in saturated fat content. This could indicate an industry reformulation on some products groups during these period. Our analysis was based on food labels declaration and in Chile, compliance with food label regulation is around 70% to 80% [19
An important effect found in our study was that the FoP “high in” labeling implemented in Chile has induced a change in nutrient declarations of products, in food groups highly consumed by the population and especially among children, such as cereals, dairy and sugary beverages. On the other hand, very little changes were observed in pastry and desserts and ice creams products, in which reformulation is more complex. These changes represent positive advances in creating a healthier food environment. In addition, it is important to remember that the most relevant objective of FoP “high in” labels is to provide clear, simple and truthful information regarding the nutritional quality of food, so that consumers can make informed purchases [20
The first evaluations of the impact of the Law 20.606 (2018) showed that the population recognizes, supports, and understands the regulation and around 50% are using FoP “high in” labels when purchasing foods. Moreover, according to food-producing companies, food reformulation has occurred in about 18% of package foods [21
]. Kanter et al. (2019) analyzed changes in ENC declaration of packaged food in Chile in 2015 and 2016 (n
= 5241 and n
= 5479) and found few changes (less than 5%), reinforcing that there was minimal reformulation prior to the implementation of the Law [17
]. Nonetheless and considering this minimal reformulation, these changes in nutrient content are reflected in the fact that many products that would have had a FoP “high in” label for energy and nutrients of concern, when food law came into effect (June 2016) did not have one.
With the implementation of the law occurring in stages and the final change happening in 2019, the results of our study imply that consumers can now find products with fewer FoP “high in” warning labels and, as a result, be exposed to lower levels of energy, total sugar, saturated fat and sodium in some food groups such as, dairy, sugary beverages, and flour-based foods. It is important to mention that food producers that decrease the content of nutrients of concern can avoid marketing restrictions and continue with sales in school environments, making reformulation very attractive for food industry.
A review of experimental studies of FoP warning labels on sugary beverages and processed food conclude that the strategy was easy to understand and allowed consumers to identify and purchase foods with a lower content of energy and nutrients of concern, which, in turn, helps consumers to rank healthier products [11
]. Other models of FoP warning labels implemented in Holland (“Choices”) and in New Zealand (“Health Star Rating”) have been associated with a decrease in sodium content, saturated fat, added sugar, energy and an increase in fiber content on reformulated and in new products [22
According to our data, dairy presented a high decrease in total sugars (liquid and solid) and energy (liquid). These results could impact the intake of energy and nutrients of concern among children, considering that these products are highly consumed among this age group [18
]. One limitation in the dairy group is that each food producer is allowed to define the consistency of the product as either a solid or liquid [8
] and indeed this could mask compliance with the regulation. Massri et al. (2018), observed that in the period after implementation of Law 20.606 this food group increased in availability, with respect to total products, in school kiosks of Santiago (1.7% in 2014 to 5.4% in 2016) [14
]. This could be mainly due to a reformulation process that was going on in this period and changes in its food matrix, principally focused on decreasing total sugar content and replacing sugars to non-caloric sweeteners. With this strategy, products could be sold at school kiosks since they did not have any FoP “high in” labels. Dairy are widely consumed by preschool and schoolchildren in Chile (e.g., milk, cheese, yogurt, and milk-based desserts) complying with 68.8% (preschool) and 37.8% (school children) of the dairy recommendations intake of the Food Based Dietary Guidelines according to ENCA [18
The consumption of flour-based foods is widespread in the Chilean population. According to ENCA, 100% of Chileans consume bread daily (median 151 g/per day) [18
], with this product being the principal source of sodium intake in the population (9.5 g per day) [1
]. Evaluation of sodium content of the most consumed bread in Chile results in an average of 630.2 ± 112.0 mg/100 g [24
]. Since 2010, the Chilean government has encouraged a voluntary reduction in the sodium content of bread, following international recommendations [25
]. The positive results of this reformulation process [24
] could influence the results of sodium content in flour-based foods in our baseline assessment (2013), however, over the study period, we observed a significant decrease in energy and sodium content in this food group.
Fats and oils presented a strong reduction in sodium content, but no changes were observed in saturated fat. This food group has a median consumption of 12.7 g-mL/day and 14.0 g-mL/day among adolescents and young adults, respectively, according to ENCA [18
]. Decreasing the amount of saturated fat in this food group and others (e.g., confectionary and similar or desserts and ice creams) require changes in technological process and/or the use of other ingredients capable of maintaining sensorial aspects and food matrix structure, considering that increasing the amount of trans-saturated fatty acids in processed foods is not possible, as it is regulated in Chile since 2010 [8
Sugary drinks presented a strong reduction in energy and total sugar content and these results could relate to two important Chilean regulations recently implemented: one that increased taxation of sugary drinks (2014) [27
] and the Law 20.606 (2016) [8
]. A recent study analyzed sugar-sweetened beverages purchased before implementation of Law 20.606 (2015) and after the first limit of implementation (2017), the authors found a decrease in the volume purchased of beverages with FoP “high in” label of 22.8 mL/capita/day (95% CI: −22.9 to −22.7; p
< 0.001) and a consequent decline in calories purchased from these products of 11.9 kcal/capita/day (95%CI: −12.0 to −11.9; p
< 0.001) [28
Recent meta-analysis support warning labels on sugary drinks as a population-level strategy for reducing sugary drink purchases. Based on simulation studies, authors conclude that reducing sugary drink intake by as little as 15–30 calories per day could reduce obesity prevalence by 1.5% to 7.8% and type 2 diabetes prevalence by up to 6.8%, with effects on behavioral outcomes of smaller magnitude [29
Interestingly, in some food groups, the absence of different product brands in 2019 compared with 2013 was pronounced (more than 20%). In the meat and derivatives group, this non-presence reached 41.4%, especially due to the absence of processed turkey meat products. The most important change in this food group was the decrease in sodium content in 13.0%. The meat food group is highly accepted by children and includes products like ham and sausages (hot-dog). While product reformulation supports a reduction in sodium intake, no decrease in saturated fat content was observed for this food group.
Although it is important to consider the significant changes in the nutrient content in the food groups, the presence or absence of FoP labels between the analyzed period becomes more relevant. For example, there was a reduction of products with FoP “high in”total sugar labels canned foods, dairy (liquid) and in sugary beverages groups in different proportions (−45.0%, −32.1%, −15.4% and −49.3%, respectively). These reductions suggest important changes in the availability of products and could impact in the population choices and consumption.
There are still many questions to be answered in terms of the effects of the Law 20.606. For example: how has reformulation affected the number of ingredients per product? has food consumption and nutritional status changed in Chile? are Chileans eating more natural foods since the implementation of the law? [20
]. Some of these questions will take time to answer. For now, studies such as ours show that the food environment has changed and today there are fewer foods with FoP warning labels in some food groups like dairy (especially liquid products) and, as a result, consumers have more alternatives to purchase products with a lower levels of energy and nutrients of concern. On the other hand, these same products may be higher in artificial sweeteners and additives used to improve the sensorial characteristics of the products.
To date, Chile has conducted only one National Food Consumption Survey, which was carried out in 2009-2010 [18
]. The behavior of purchasing and consuming food of the population can change and can be influenced by many factors like the food environment and advertising. Updated and representative data from population, considering this new scenario is necessary to further evaluate the impact of market changes in patterns of consumption.
During the initial implementation of the food law, no massive campaigns to discourage the consumption of foods with a FoP “high in” label was carried out. It is important to mention that healthy eating messages, based on Dietary Food Guidelines, that recommend increasing the consumption of fruits, vegetables, legumes, fish and low fat dairy products (in their natural state) and reducing the consumption of salt, sugar, and products with FoP “high in” warning labels, are part of counselling strategy used permanently in the primary health care system to promote healthy eating and discourage the consumption of products with FoP “high in” labels [30
These results should be evaluated while considering the limitations of this study. One of these relates to the limited number of products evaluated, as we included only the most consumed products according to ENCA [18
]. However, consumption patterns could have changed and it is possible that the selected and analyzed products in this study do not represent the same proportion of products currently consumed. Some food groups presented low sample, which may have negatively influenced statistical power to show changes. It is important to reinforce that our study design did not consider the replacement of the brand products, only the replacement of product type of the same brand. Another limitation refers to the fact that we simulated the presence or absence of FoP “high in” warning labels, without confirming the real presence of the label on the products.
The findings of this study could stimulate food industry to work on product reformulation and to develop more healthy products by decreasing the content of total sugar, saturated fat and sodium without the addition of chemical replacements. Understanding the impact of Law 20.606 can help in the planning and development of new policies to protect and improve healthy food environments [32
]. Future studies should further analyze ingredient modifications of the most consumed products in the country.