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Childhood obesity is a major public health issue. The increase in the consumption of foods with poor nutritional value, such as processed foods, contributes to this. Breakfast cereals are often advertised as a healthy way to start the day, but the healthiness of these products varies greatly.
Our main objective was to gather information about the nutritional characteristics of ready-to-eat breakfast cereals in Sweden and to investigate the healthiness of products targeted at children compared to other cereals by use of the FoodSwitch platform. A secondary objective was to evaluate the alignment between the Keyhole symbol and the Health Star Rating.
The FoodSwitch app is a mobile health (mHealth) tool used to present nutrition data and healthier alternative products to consumers. Ready-to-eat breakfast cereals from the largest Swedish grocery retailers were collected using the FoodSwitch platform. Products were defined as targeting children if they presented features addressing children on the package.
Overall, information on 261 ready-to-eat cereals was examined. Of this total, 8% (n=21) were targeted at children. Child-targeted cereals were higher in sugar (22.3 g/100 g vs 12.8 g/100 g,
Ready-to-eat breakfast cereals targeted at children were less healthy in terms of sugar and fiber content compared to products not targeted at children. There is a need to improve the nutritional quality of child-targeted cereals.
Childhood obesity is a major public health issue. Over 40 million children under 5 years of age are overweight worldwide with a majority living in low- or middle-income countries [
Ready-to-eat breakfast cereals include a large range of products from unprocessed to ultraprocessed. This large diversity in products and the omnipresence of nutritional claims on the packages of breakfast cereals make it hard for the consumer to identify actual healthy options. In addition, there are data suggesting that highly advertised products targeted at children may be less healthy [
The use of mobile apps could be an innovative alternative way for consumers to access more information on the nutrients and healthiness of the foods they buy. Today, 88% of people in Sweden over the age of 12 years own a smartphone, which offers great potential for mobile health (mHealth) apps in all age groups [
In this study, we aim to use the FoodSwitch platform in the Swedish market to compare the healthiness and nutritional values of ready-to-eat breakfast cereals targeted at children to non–child-targeted, ready-to-eat cereals. Furthermore, we aim to assess the alignment of the Nordic Keyhole symbol and the HSR system for these products.
Ready-to-eat cereals from 4 supermarkets (ICA, Coop, Hemköp, and Lidl), representing 90% of the market share in Sweden, were analyzed [
The DataCollector app of the FoodSwitch platform (Android, version 2.7) from the George Institute for Global Health was used to collect information from packages. First, the bar codes were scanned using a smartphone camera. Then, numerous pictures of the front of the pack, the Nutrition Information Panel (NIP), and the ingredients were taken to collect all relevant information.
All products were manually entered in the system by 1 researcher (AM). The NIP, the gluten status and the Keyhole symbol, if present, were recorded. All child-targeted information on the package was identified. The criteria were as follows: the presence of cartoons, games, toys, children’s movie references, or text addressed to children on the package. A second researcher (V-ML) reviewed all the information entered and confirmed the presence of marketing targeted at children.
Finally, products were categorized and an HSR was generated. HSR scores of 0.5 to 5 stars in 10 half-star increments were assigned to all scanned products, where a higher number of stars represents healthier products. In the HSR system, each packaged food item is categorized into 1 of 6 categories depending on food type. All breakfast cereals were assigned to category 2. The HSR score was calculated via baseline and modifying points using the following formula: HSR score = baseline points – modifying points. Baseline points depended on energy content, saturated fat, sugar, and salt, and modifying points were based on protein, fiber, fruit, and vegetable content. The final assignment of the HSR score depended on which category the product was assigned to [
Categorical variables were summarized as the number of products and corresponding percentages, and continuous variables were summarized as mean (SD) and median (IQR). A Kolmogorov-Smirnov test was used to determine whether the data were normally distributed or not. A Mann-Whitney
This was a study of packaged food supplies in supermarkets in Sweden and did not involve study participants or animal testing. Therefore, no ethical permission was sought.
By use of the data collection application of the FoodSwitch platform, we collected information on a total of 261 ready-to-eat breakfast cereals, of which 21 (8%) were targeted at children and 240 (92%) were not.
Nutritional overview of ready-to-eat breakfast cereals targeted at children (n=21) compared to those not targeted at children (n=240) and their estimated healthiness. The mean fiber amount in child-targeted cereals was based on 20 products since 1 product did not display its fiber content.
Nutritiona | Child-targeted cereals | Non–child-targeted cereals | ||
|
.18 | |||
|
Mean (SD) | 1628 (68) | 1699 (202) |
|
|
Median (IQR) | 1618 (49) | 1647 (225) |
|
|
<.001 | |||
|
Mean (SD) | 3.0 (2.8) | 10.5 (9.6) |
|
|
Median (IQR) | 2.3 (1.5) | 7.6 (12.8) |
|
|
<.001 | |||
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Mean (SD) | 0.8 (0.8) | 2.6 (3.0) |
|
|
Median (IQR) | 0.6 (0.6) | 1.8 (3.0) |
|
|
<.001 | |||
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Mean (SD) | 78.3 (5.3) | 62.0 (13.5) |
|
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Median (IQR) | 78.0 (6.1) | 62.0 (13.4) |
|
|
<.001 | |||
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Mean (SD) | 22.3 (7.5) | 12.8 (7.8) |
|
|
Median (IQR) | 23.5 (13.0) | 11.0 (12.1) |
|
|
.002 | |||
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Mean (SD) | 8.1 (1.7) | 10.5 (2.6) |
|
|
Median (IQR) | 8.2 (2.2 | 10.0 (3.2)) |
|
|
.01 | |||
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Mean (SD) | 6.2 (2.5) | 9.8 (5.0) |
|
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Median (IQR) | 6.8 (3.6) | 9.0 (4.8) |
|
|
.61 | |||
|
Mean (SD) | 0.5 (0.3) | 0.5 (0.4) |
|
|
Median (IQR) | 0.6 (0.6) | 0.4 (0.6) |
|
|
.07 | |||
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Mean (SD) | 3.5 (0.5) | 3.8 (0.9) |
|
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Median (IQR) | 3.8 (1.0) | 4.0 (1.5) |
|
Keyhole symbol, n (%) | 1 (5) | 53 (22) | .06 |
aData are n (%) for the categorical variable and mean (SD) and median (IQR) for continuous variables.
bComparison of child-targeted versus non–child-targeted breakfast cereals was analyzed with a Mann-Whitney
cHSR: Health Score Rating.
The calculated Health Star Rating (HSR) score of breakfast cereals in supermarkets in Sweden (light blue) and the HSR scores of packaged products displaying an on-pack Keyhole symbol (dark blue).
This study compared the healthiness of ready-to-eat breakfast cereals targeted at children to cereal products not specifically targeted at children across supermarkets in Sweden using the FoodSwitch platform. Despite lower levels of saturated fat, the child-targeted cereals were overall less healthy, according to the nutritional content. Child-targeted products had a greater amount of sugar, with a mean nearly 2 times higher than the cereals not branded toward children. Furthermore, they were lower in fiber and protein. Our results are in line with 3 similar studies conducted in Canada, Australia, New Zealand, Guatemala, and the United States [
In a context where childhood obesity is at the heart of public health concerns, our findings are highly relevant. The direct link between added sugar intake and obesity is well established [
Marketing toward children often depicts cartoon characters to influence their food preferences [
A substantial part of the foods sold and eaten in high-income countries is preprepared packaged foods, and processed foods are largely responsible for an excessive intake of saturated fat, energy, added sugars, and sodium in the diet [
Because of this, introducing the FoodSwitch app in Sweden could be of interest to Swedish consumers. First, it would allow a virtual front-of-pack labeling of all products (
Screenshots of the Australian version of the FoodSwitch app displaying the estimated healthiness of products using Health Star Ratings (panels A and C) and Traffic Lights ratings (panels B and D) for the scanned products Dorset Cereals Really Nutty Muesli (panels A and B) and Kellogg’s Special K Original (panels C and D), and suggestions for healthier options.
We consider the conclusions drawn from our primary investigation to be reliable for the Swedish market because we visited the largest grocery retailers, representing 90% of market shares [
Limitations include possible transcribing errors and, in some cases, minor discrepancies that can occur between the NIP information shown on the package and the real value [
A further research objective could be to expand this assessment of nutrition to all child-targeted products. Additionally, data collection of breakfast cereals can be redone to provide a longitudinal perspective.
In conclusion, we showed that the nutritional quality of ready-to-eat cereals targeted at children was overall not significantly unhealthier than ready-to-eat breakfast cereals not targeted at children. However, cereals targeted at children were high in sugar and low in fiber. Thus, we conclude that there is a need to improve the dietary quality of child-targeted breakfast cereals in Sweden.
Ready-to-eat breakfast cereals in Swedish supermarkets in 2019, categorized according to the FoodSwitch platform categories.
Health Star Rating
mobile health
Nutrition Information Panel
AM, CNM, BN, and KR contributed to the concept and rationale of the study. The data were collected and analyzed by AM. V-ML conducted the data review. AM and KR drafted the manuscript. All authors contributed to the interpretation of the results and the discussion, and reviewed and edited the manuscript.
None declared.