Alignment with front-of-package labeling policy and risk of hospitalization: evidence from Canadian National Nutrition Survey linked to routinely collected health administrative databases

Alisha Buttar; Nicole Hu; Boris Sobolev; Lisa Kuramoto; Mahsa Jessri

doi:10.1016/j.ajcnut.2025.101191

Alignment with front-of-package labeling policy and risk of hospitalization: evidence from Canadian National Nutrition Survey linked to routinely collected health administrative databases

Am J Clin Nutr. 2026 Jan 8;123(3):101191. doi: 10.1016/j.ajcnut.2025.101191. Online ahead of print.

Authors

Alisha Buttar¹, Nicole Hu², Boris Sobolev³, Lisa Kuramoto², Mahsa Jessri⁴

Affiliations

¹ Food, Nutrition and Health Program, Faculty of Land and Food Systems, The University of British Columbia, Vancouver, BC, Canada.
² Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, Vancouver, British Columbia, Canada.
³ Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, Vancouver, British Columbia, Canada; School of Populationa and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada.
⁴ Food, Nutrition and Health Program, Faculty of Land and Food Systems, The University of British Columbia, Vancouver, BC, Canada; Centre for Health Services and Policy Research, The University of British Columbia, Vancouver, BC, Canada. Electronic address: mahsa.jessri@ubc.ca.

PMID: 41519302
DOI: 10.1016/j.ajcnut.2025.101191

Abstract

Background: Nutrient-specific front-of-package (FOP) schemes are expanding internationally, but no validated, population-level measures exist to monitor adherence or link adherence to healthcare burden. Leveraging Canada's FOP thresholds, we introduce reproducible alignment indexes designed for surveillance and evaluate their predictive validity using hospital bed-day outcomes.

Objectives: This study aims to construct a priori dietary indexes reflecting alignment with Canadian FOP thresholds and assess their ability to predict all-cause hospital bed-day rates over 5 and 10 y among Canadian adults aged 20-79.

Methods: Data from the Canadian Community Health Survey-Nutrition linked longitudinally with individual hospital records (n = 14,249 after exclusions) were used. Food items were classified according to FOP nutrition labeling regulations to create the FOP-compliance index (FOP-CI) dietary index. A 10-y follow-up sensitivity analysis and 2 policy scenarios were included: 1 removing exemptions (FOP-compliance index without policy exemptions) and 1 including fast food and restaurant items (FOP-compliance index including fast food and restaurant items). The Dietary Approaches to Stop Hypertension index served as a reference. Weighted multivariable zero-inflated negative binomial models estimated the relative rate (RR) of hospital bed-days across alignment quintiles.

Results: Quintile 5 (lower FOP-CI alignment) had a higher rate of all-cause hospital bed-days than quintile 1 [RR: 1.52; 90% confidence interval (CI): 1.05, 2.19] over 5 y. After accounting for the probability of hospitalization across the entire cohort, this corresponds to an estimated difference of 500,108 annual bed-days. The increased bed-day rate for nonalignment held across policy scenarios and a 10-y follow-up (RR: 1.34; 90% CI: 1.02,1.77). Sex-stratified models showed consistent directions, with stronger and significant associations for males at 10 y of follow-up (FOP-CI, RR: 1.50; 90% CI: 1.00, 2.25).

Conclusions: In this exploratory analysis, greater alignment with FOP policy was associated with a lower hospital bed-day rate over5 and 10 y. Sex-tailored risk-reduction strategies may be warranted with the strongest association in males. These findings reinforce the value of the "high-in" symbol; however, the nutrient-specific focus may still miss broader dimensions of diet quality. Complementary, whole-diet guidance remains essential to maximize population-level benefits and health-system savings.

Keywords: Canadian Community Health Survey—Nutrition; diet-related hospitalizations; front-of-pack label; healthcare burden; hospital bed-days; nutrient profiling; nutrient-specific labeling policy.