Guatemala is a lower middle income country struggling with the ?double-burden? of disease (malnutrition and obesity coexisting). It has the second highest prevalence of childhood stunting in the world (49%) and a rising prevalence of overweight and obesity, particularly among women (49%). This is concerning because obesity is a risk factor for numerous health problems, including type 2 diabetes, cardiovascular disease, and at least thirteen different types of cancers. Consumption of sugary drinks is strongly associated with obesity and related health problems. In Guatemala, sales of sugary drinks have increased 25% in the last decade (101.1 liters per capita) and Guatemala has one of the highest per capita intakes of sugary beverages worldwide (mean 2.69 servings per day, higher than Mexico (2.40) and the United States (1.89)). The World Health Organization, has identified research on global strategies to reduce sugary drink intake as a key need. Food labeling has become a popular policy approach to address high levels of sugary drink intake. Some countries are interested in placing health warning labels on sugary drinks, but there are no real-world studies testing the effects of such labels.
The first aim of the proposed research is to test the effect of repeated exposure to warning labels on mean fluid ounces of sugary drinks purchased by adolescents in Guatemala. This study will examine how repeated exposure to sugary drink warning labels influences 1500 adolescents' purchases at school stores over time. We will enroll six schools in the study (three private and three public). Each pair of matched private/public schools will be randomized to 1 of 3 labeling conditions: 1) kilocalorie (kcal) label (control); 2) text warning labels; or 3) graphic warning labels displaying amounts of sugar. In this six-week study, we will collect sales data during two weeks without labels, two weeks when labels are displayed, and two weeks after labels have been removed. We will also conduct surveys with 1500 students. Our hypotheses are: 1) graphic warning labels will be most effective at decreasing volume of sugary drinks purchased; 2) text warning labels will be less effective than graphic, but more effective than calorie labels; and 3) sales of sugary drinks will decline after label removal, but will remain lower than baseline levels.
The second aim of the proposed research is to systematically assess non-communicable disease (NCD) research capacity at the Cancer Institute in Guatemala (INCAN). We will conduct a formal assessment of NCD research capacity at INCAN using an established hierarchy of nine research capacity needs. Finally, our third aim is to catalyze NCD research capacity building in Guatemala by 1) working with faculty, trainees, and fellows on the proposed empirical research; and 2) offering a short course on NCD research for INCAN trainees and researchers. Our long-term goal is to build research capacity for studies that can evaluate policy interventions like food labels to address NCDs in Guatemala.

Public Health Relevance

Guatemala is a lower middle income country with a rising prevalence of overweight and obesity. Because consumption of sugary drinks is strongly associated with obesity, policy makers are interested in strategies to reduce consumption. The proposed research will evaluate the impact of different types of sugary drink warning labels on adolescents' purchases in Guatemalan schools and build capacity in non-communicable disease research in Guatemala.

National Institute of Health (NIH)
Fogarty International Center (FIC)
Exploratory/Developmental Grants (R21)
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Special Emphasis Panel (ZRG1)
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Levintova, Marya
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University of Pennsylvania
Social Sciences
Schools of Medicine
United States
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