Introduction
diabetes, cardiovascular diseases, cancer, deaths
CANCER, DISEASES
The epidemic of non-communicable diseases (NCDs) is a growing concern worldwide. NCDs, including but not limited to diabetes, cardiovascular diseases, and cancer, account for 41 million deaths annually, which is equivalent to 71% of global deaths [Singapore is no exception to the global trend of poor diet quality and rising NCDs. The 2018 National Nutrition Survey showed that Singaporean adults consumed an average of 60 g of sugar daily (10 grams above the daily recommended intake), more than half of which came from SSBs [NG grades freshly-prepared and pre-packaged beverages on a four-point scale, in terms of Nutri-Grade label D for a beverage (Left); Nutri-Score label E for a food or beverage (Right)This study aims to evaluate the impact of the NG label on 1) beverage product selection (measured by weighted (by the number of servings) average NG score of beverages purchased, where A = 4, ..., D = 1) and 2) nutritional quality (average sugar, saturated fat, and calories per serving) of beverages purchased using an online grocery platform and shoppers in Singapore. Although NG will be mandatory only for Grade C or D beverages, in this study the full range of grades was displayed as the HCS experience suggests that manufacturers are likely to display the labels on their healthier products.Although the label is soon to be implemented, the use of the experimental online grocery store allows us to quantify the effects of the label independent of real-world confounders. This includes not only other food policies, including an SSB advertisement prohibition that will be implemented simultaneously with Nutri-Grade, but also other confounders, such as changes in retail prices and employment rates. By using randomization and a control condition, our estimates of the causal effects of the label will inform policymakers of any potential intended and unintended consequences of the labels on food purchases.Beyond the local relevance, this study contributes to the growing literature on FOP nutrition labelling in general and specifically with regards to color-coded graded labels. The Singapore HPB chose to focus on these labels because they are generally well understood by consumers, effective at promoting healthier food choices [As specified in the Trial Registry (ClinicalTrials.gov), we expect that the labels are likely to shift beverage demand towards healthier beverages, 