Estimating the dietary and health impact of implementing front-of-pack nutrition labeling in Canada: A macrosimulation modeling study

{"Background": "In Canada, over 80% of all deaths are due to non-communicable diseases (NCDs), and intakes of sodium, sugars, and saturated fat exceed recommended levels. Front-of-pack labeling (FOPL) has been recognized by the WHO as a 'Best Buy' cost-effective policy for preventing diet-related NCDs. Health Canada published FOPL regulations in July 2022 requiring a 'high in' symbol on prepackaged foods exceeding thresholds for saturated fat, sodium, and sugars, to take effect by January 2026. Although FOPL has shown promise in other countries (e.g., Chile), its potential dietary and health impacts had not been estimated for Canada prior to this study.", "Methods": "The study used both available days of 24-hour dietary recalls from the nationally representative 2015 Canadian Community Health Survey-Nutrition (n=11,992 adults \u226519 years after exclusions). The National Cancer Institute (NCI) method was used to estimate usual intakes of sodium, total sugars, saturated fat, and calories, adjusted for age, sex, misreporting status, weekend/weekday, and recall sequence. Four counterfactual scenarios were modeled: Scenario 1 (S1) and Scenario 2 (S2) were based on early evaluations of the Chilean Food Labeling and Marketing Law (Taillie et al., 2020), with S1 applying overall reductions (\u22124.7% sodium, \u221210.2% sugars, \u22123.9% saturated fat, \u22123.5% calories) and S2 applying reductions disaggregated by foods and beverages. Scenario 3 (S3) was based on a Canadian randomized experimental marketplace study (Acton et al., 2018) applying reductions only to snack foods and beverages. Scenario 4 (S4) was based on a meta-analysis of nutrient warning labels (Song et al., 2021) applying overall reductions (\u22127.8% sodium, \u22127.3% sugars, \u221216.3% saturated fat, \u221212.9% calories). The Preventable Risk Integrated ModEl (PRIME), a cross-sectional NCD scenario model endorsed by the WHO Regional Office for Europe, was used to estimate the number of diet-related NCD deaths that could be averted or delayed. Inputs included 2019 Canadian population demographics and mortality data for CVDs, diabetes, cancers, chronic renal failure, and liver disease. Monte Carlo analysis at 10,000 iterations was used to estimate 95% uncertainty intervals.", "Key Results": "Baseline mean usual intakes were: calories 1,889\u00b120 kcal/day, sodium 2,729\u00b133 mg/day, sugars 86.4\u00b10.9 g/day, saturated fat 22.8\u00b10.6 g/day, and saturated fat 10.6\u00b10.18% of total energy/day. Estimated mean dietary reductions across scenarios ranged from 31 to 212 mg/day for sodium, 2.3 to 8.7 g/day for total sugars, 0.8 to 3.7 g/day for saturated fat, and 16 to 59 kcal/day for calories. The estimated number of diet-related NCD deaths that could be averted or delayed ranged from 2,183 (95% UI 2,008\u20132,361) under S3 to 8,907 (95% UI 8,095\u20139,667) under S4. Across all scenarios, approximately 68\u201370% of averted deaths were from cardiovascular diseases, followed by diabetes (13\u201314%), cancers (9\u201310%), liver disease (5\u20135.5%), and chronic renal failure (2.7\u20132.8%). Between 35\u201338% of averted deaths would occur in individuals under 75 years. More deaths were averted in men than women across all scenarios. These estimates represent 2.4% (S3) to 9.6% (S4) of total diet-related NCD deaths in Canada (92,845 in 2019). Most health gains (87\u201392%) were attributable to changes in energy intake, with 5\u20139% from sodium reductions and 1\u20136% from saturated fat reductions. Sensitivity analyses using overall calorie changes (rather than only calories from sugar and saturated fat) yielded larger estimates, with deaths averted increasing by 35% (S1), 22% (S2), 94% (S3), and 252% (S4).", "Clinical Implications": "These findings suggest that implementing a 'high in' FOPL symbol in Canada could produce meaningful population-level reductions in intakes of sodium, sugars, and saturated fat, potentially preventing or delaying thousands of diet-related NCD deaths annually, predominantly from cardiovascular disease. Even modest per-person dietary reductions could translate to substantial health gains at the population level. The results support the recently published Canadian FOPL regulations and provide critical evidence for policymakers. The authors note that combining FOPL with other cost-effective policies (e.g., mandatory sodium reduction targets, SSB taxes) could yield even greater health benefits. They also emphasize the need for robust monitoring systems to detect unintended consequences, such as reformulation that replaces sugars with fats or starches without reducing calories, or increased use of non-nutritive sweeteners, as observed in Chile."}