Exploring Parental Perspectives on Added Sugar Labeling in a Low-Income, Minoritized Patient Population

Exploring Parental Perspectives on Added Sugar Labeling in a Low-Income, Minoritized Patient Population | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring Parental Perspectives on Added Sugar Labeling in a Low-Income, Minoritized Patient Population Hadar K. Shimshon, Michael Lynch, Paul Fried, Samuel Sabzanov, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9499668/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 2 You are reading this latest preprint version Abstract Added sugar labeling is conceived as an intervention to support healthy food choices, but data is inconsistent on how parents use labeling based on label location. In particular, it is not clear how effective this labeling is at reaching communities of interest, such as minoritized urban populations, at high risk of metabolic disease. To assess this, conducted a cross-sectional survey of 82 parents of pediatric patients at SUNY Downstate outpatient clinics in Brooklyn, New York. Participants completed a 12-item questionnaire assessing nutrition label use, attention to added sugar information, purchasing behaviors, and attitudes toward front-of-package warning labels. Because most variables were ordinal (Likert-type scales), associations were assessed using Kendall’s tau-b and the Mantel-Haenszel chi-square test for linear trend (1 df). Fisher’s exact test was used for cross-tabulations with sparse expected cell counts. Cramér’s V was reported as the effect size. A Spearman rank correlation matrix was computed across all 11 survey variables to identify behavioral clusters. Significance was set at P < .05. Of 82 parents surveyed, all rated healthy eating as important; 61 (74.4%) rated it very or extremely important. However, only 32 (39.0%) read nutrition labels most of the time or always, and 8 (9.8%) never read them. Parents who rated healthy eating as very or extremely important read labels significantly more frequently than those who did not (τ-b = 0.290, P = .007; 49.2% vs 9.5% reading most of the time/always). Health motivation was also significantly associated with sugar-label-driven item avoidance (τ-b = 0.315, P = .004) and endorsement of warning labels (τ-b = 0.296, P = .006). Education level was not associated with any labeling behavior. A Spearman correlation matrix revealed a tightly correlated cluster of label-engagement behaviors (label reading, checking added sugar, front-of-package icon use; ρ = 0.57–0.66). These findings suggest that current added sugar labeling primarily reaches parents who are already health-conscious, while those who might benefit most remain less engaged. Nutrition Labeling Added Sugars Health Literacy African Americans Figures Figure 1 Figure 2 INTRODUCTION In recent years, consumption of added sugars has risen significantly across a range of food and beverage products. 1 Added sugars, referring to sugars added into food during processing, provide negligible nutritional value yet drive excess caloric intake and elevate the glycemic index of processed foods. Excessive consumption has been linked to weight gain and obesity, 1 hypertension, 2 dyslipidemia, 3 and cardiovascular disease mortality. 4 Among children, sugar-sweetened beverages represent a leading contributor to total added sugar intake, and their consumption is associated with increased risk of childhood obesity and metabolic dysregulation. 5 , 6 In May 2016, the FDA finalized updates to the Nutrition Facts label, requiring a dedicated line item for added sugars alongside a corresponding percent Daily Value (%DV). 7 The mandate, which became effective in January 2020 for large manufacturers and in January 2021 for smaller ones, was designed to help consumers distinguish naturally occurring sugars from those introduced during processing. Some products high in added sugars, like sweetened beverages and baked goods, are easily recognized; others, including yogurts, tomato sauces, and condiments, contain substantial hidden sugars that the new label was intended to make visible. Whether this labeling change has reached its intended audience remains uncertain. Nutrition warning labels have been shown to improve consumers’ understanding of food healthfulness and to promote healthier choice behaviors, even among individuals who initially prefer unhealthy options. 8 Randomized trial data demonstrate that front-of-package scoring systems can meaningfully shift purchasing toward healthier products, 9 and broader evidence links nutrition label use to improved dietary decision-making. 10 Yet national data consistently show that label use is lower among individuals with less education, lower household income, and minority racial or ethnic backgrounds, the very populations bearing the greatest burden of sugar-related chronic disease. 11 Few studies have examined the added sugar label specifically, and fewer still have done so in clinical populations serving predominantly low-income, minoritized communities. We conducted this study to assess parental awareness, understanding, and use of added sugar labeling among African-descent parents at an urban pediatric clinic, to examine associations with both perceived importance of healthy eating and educational attainment, and to explore parental attitudes toward front-of-package warning labels as a potentially more accessible alternative. METHODS Study Design and Setting We conducted a cross-sectional survey of parents of patients seen at SUNY Downstate Health Sciences University Outpatient Pediatric Clinics in Brooklyn, New York, between October and December 2023. This clinic serves a predominantly low-income, African-descent patient population in central Brooklyn. Participants and Recruitment Parents or legal guardians of children aged 0 to 18 years presenting for outpatient pediatric visits were eligible. The sole exclusion criterion was the absence of dependent children currently residing in the participant’s household. Study forms were distributed in the waiting room by research staff rather than treating physicians to prevent any perception of coercion. Participation was voluntary and anonymous. The SUNY Downstate Institutional Review Board approved this study, and a waiver of written informed consent was granted, given the anonymous, minimal-risk design. Survey Instrument We developed a 12-item questionnaire comprising 1 demographic item (highest education level; 5 categories) and 11 attitudinal and behavioral items (Supplementary Material). Nine items used 5-point Likert-type response scales (e.g., “Never” to “Always” or “Definitely not” to “Definitely yes”), 1 used a 5-point ease-of-use scale, and 1 was a multi-select with 7 options for information sources. Domains assessed included perceived importance of healthy eating, accessibility of healthy food, frequency of reading Nutrition Facts labels, frequency of checking added sugar information, response to high %DV for added sugars, perceived helpfulness of added sugar information, avoidance behavior driven by added sugar content, use of front-of-package nutrition icons, and attitudes toward warning labels. Variables and Recoding Education was categorized as primary (elementary school), secondary (high school), or post-secondary (college degree or higher). The primary predictor, perceived importance of healthy eating, was dichotomized as slightly or moderately important versus very or extremely important; no participant selected “not at all important.” Frequency-based outcomes were collapsed into 3 ordered categories: Never, Sometimes/About half the time, and Most of the time/Always. The multi-select information sources item was decomposed into 7 binary indicators. Responses coded as 0 in the original dataset were treated as missing data per the coding protocol (0 = no answer) and excluded from denominators for affected variables. Statistical Analysis Descriptive statistics were calculated as frequencies and percentages for all categorical variables. Because the majority of study variables are ordinal, associations between ordered predictors and outcomes were assessed using Kendall’s tau-b correlation coefficient, which quantifies the strength and direction of monotonic association while appropriately handling tied ranks inherent to categorical data. The Mantel-Haenszel (MH) chi-square test for linear trend (1 degree of freedom) was used as a confirmatory test of ordinal trends. For cross-tabulations with expected cell counts below 5 in more than 20% of cells (a common occurrence given the sample size), Fisher’s exact test with Monte Carlo simulation (10,000 replicates) was used. Cramér’s V was reported as the effect size for all associations (Table 2 ). Education level was tested against all survey parameters; the perceived importance of healthy eating was tested against all behavioral outcomes. All tests were 2-sided with significance set at α = .05. Post hoc power analysis indicated approximately 88% power to detect a medium effect (w = 0.30) in 2 × 3 tables at α = .05 with N = 82. To characterize the overall correlation structure among all 11 survey variables and identify clusters of related labeling behaviors, a Spearman rank correlation matrix was computed using complete-observation pairs, with significance assessed at P < .05. Analyses were performed in R version 4.5.3 (R Foundation for Statistical Computing, Vienna, Austria) using the DescTools and pwr packages. Table 2 Bivariate Association Test Results Predictor Outcome N τ-b τ-b P MH P Fisher P Cramér’s V Education (3-cat) Health importance 78 0.276 .012 .010 .039 0.32 Education (3-cat) Label reading freq 78 0.069 .519 .495 .848 0.13 Education (3-cat) Check added sugar 78 0.148 .160 .133 .341 0.20 Education (3-cat) Sugar avoidance 76 0.185 .085 .038 .089 0.28 Education (3-cat) Warning helpful 77 0.172 .108 .076 .338 0.21 Health imp. (2-cat) Label reading freq 82 0.290 .007 .015 .002 0.37 Health imp. (2-cat) Check added sugar 82 0.185 .082 .096 .187 0.20 Health imp. (2-cat) Buy high %DV 81 0.206 .052 .060 .144 0.23 Health imp. (2-cat) Sugar understanding 82 0.244 .024 .029 .051 0.25 Health imp. (2-cat) Sugar avoidance 80 0.315 .004 .003 .009 0.33 Health imp. (2-cat) FOP icons 81 0.148 .172 .210 .322 0.17 Health imp. (2-cat) Warning helpful 81 0.296 .006 .008 .018 0.31 Label reading (3-cat) Check added sugar 82 0.589 < .001 < .001 < .001 0.59 Label reading (3-cat) Sugar understanding 82 0.361 < .001 < .001 .001 0.33 Label reading (3-cat) Sugar avoidance 80 0.384 < .001 < .001 < .001 0.38 Note. τ-b = Kendall’s tau-b; MH = Mantel-Haenszel chi-square test for linear trend (1 df). Full results for all 20 associations are available from the authors. RESULTS Participant Characteristics Eighty-two (82) parents completed the questionnaire anonymously. All respondents were of African descent. Most (47; 57.3%) had completed secondary education (high school), 25 (30.5%) had completed post-secondary education (including 1 with a master’s degree), 6 (7.3%) reported only primary education, and 4 (4.9%) did not report their education level. Full descriptive characteristics are presented in Table 1 . Table 1 Descriptive Characteristics of Study Participants (N = 82) Characteristic n % Education level Primary (Elementary School) 6 7.3 Secondary (High School) 47 57.3 Post-secondary (College+) 25 30.5 Missing 4 4.9 Education level (dichotomized) Elementary/HS 53 64.6 College or above 25 30.5 Missing 4 4.9 Importance of healthy eating Slightly/Moderately important 21 25.6 Very/Extremely important 61 74.4 Ease of finding healthy food Easy 34 41.5 Neither easy nor difficult 16 19.5 Difficult 32 39.0 Frequency of reading nutrition labels Never 8 9.8 Sometimes/About half the time 42 51.2 Most of the time/Always 32 39.0 Frequency of checking added sugar info Never 11 13.4 Sometimes/About half the time 30 36.6 Most of the time/Always 41 50.0 Would buy item with high %DV added sugar (n = 81) Definitely/Probably yes 17 20.7 Might or might not 28 34.1 Probably/Definitely not 36 43.9 Added sugar info helped understand healthiness Never 5 6.1 Sometimes/About half the time 40 48.8 Most of the time/Always 37 45.1 Added sugar info led to item avoidance (n = 80) Never 9 11.0 Sometimes/About half the time 46 56.1 Most of the time/Always 25 30.5 Frequency of checking FOP nutrition icons (n = 81) Never 7 8.5 Sometimes/About half the time 34 41.5 Most of the time/Always 40 48.8 Warning labels would help make healthy choices (n = 81) Definitely/Probably not 13 15.9 Might or might not 15 18.3 Probably/Definitely yes 53 64.6 Note. Percentages calculated using N = 82 as denominator except where valid n is indicated. FOP = front-of-package. Perceived Importance of Healthy Eating and Food Access All 82 parents rated eating healthy foods as at least slightly important, with 61 (74.4%) rating it very or extremely important (Fig. 1 A). Parents with higher education levels were significantly more likely to rate healthy eating as important (τ-b = 0.276, P = .012; MH P = .010). When asked about access to healthy food, parents were nearly evenly divided: 34 (41.5%) found it easy, 16 (19.5%) found it neither easy nor difficult, and 32 (39.0%) reported difficulty finding and purchasing healthy food. Sources of Nutrition Information Nutrition Facts panels were the most frequently cited information source, endorsed by 52 (63.4%) parents, followed by ingredient lists (43; 52.4%), recommendations from family or friends (28; 34.1%), recommendations from a dietician or nutritionist (28; 34.1%), social media (18; 22.0%), symbols and icons on the package (16; 19.5%), and nutrition claims on the package (16; 19.5%) (Fig. 1 C). Neither education level nor perceived importance of healthy eating was significantly associated with any specific information source. Nutrition Label Reading and Added Sugar Awareness About half the parents (42; 51.2%) reported reading Nutrition Facts on food packages sometimes or about half the time before purchasing a new item, 32 (39.0%) read them most of the time or always, and 8 (9.8%) never read them (Fig. 1 B). Parents who rated healthy eating as very or extremely important read labels significantly more frequently: 30 of 61 (49.2%) in this group read labels most of the time or always, compared with only 2 of 21 (9.5%) of those rating it slightly or moderately important (τ-b = 0.290, P = .007; MH P = .015; Cramér’s V = 0.37) (Fig. 1 D). When asked specifically about checking for added sugar information, 41 (50.0%) parents reported doing so most of the time or always, 30 (36.6%) sometimes or about half the time, and 11 (13.4%) never. Although parents who considered healthy eating important tended to check for added sugar more often, this association did not reach statistical significance (τ-b = 0.185, P = .082; MH P = .096). The largest proportion of respondents (36 of 81 valid responses; 43.9%) reported they would not buy a food item with a high %DV for added sugars, while 28 (34.1%) were undecided. Impact of Added Sugar Information on Understanding and Purchasing Only 5 (6.1%) parents reported that added sugar information on the Nutrition Facts label never helped them understand whether a food was healthy; 40 (48.8%) found it helpful sometimes or about half the time, and 37 (45.1%) found it helpful most of the time or always. Parents who rated healthy eating as very or extremely important were significantly more likely to report that the added sugar label aided their understanding (τ-b = 0.244, P = .024; MH P = .029). Regarding actual avoidance behavior, 46 (56.1%) parents reported that added sugar information prompted them to avoid an item sometimes or about half the time, and 25 (30.5%) reported avoiding it most of the time or always. Health-motivated parents were significantly more likely to report sugar-label-driven avoidance (τ-b = 0.315, P = .004; MH P = .003; Cramér’s V = 0.33). Front-of-Package Icons and Warning Labels The vast majority of parents (74 of 81 valid responses; 91.4%) reported checking front-of-package nutrition content icons at least sometimes. This behavior was consistent regardless of the perceived importance of healthy eating (MH P = .210), distinguishing it from the motivation-dependent back-of-package reading. When asked whether warning labels on foods high in sugar would help them make healthy choices, 53 of 81 (65.4%) responded probably or definitely yes, 15 (18.5%) were uncertain, and 13 (16.0%) responded probably or definitely not. Parents who considered healthy eating very or extremely important endorsed warning labels at significantly higher rates: 45 of 61 (73.8%) compared with 8 of 20 (40.0%) (τ-b = 0.296, P = .006; MH P = .008; Cramér’s V = 0.31) (Fig. 1 E). Education and Labeling Behaviors Apart from the significant association with perceived importance of healthy eating (τ-b = 0.276, P = .012), education level was not significantly associated with any labeling behavior, including label reading frequency (MH P = .495), checking for added sugar (MH P = .133), avoidance based on sugar content (MH P = .038, though τ-b = 0.185, P = .085), or endorsement of warning labels (MH P = .076) (Fig. 1 F). Effect sizes for all education-outcome associations were small (Cramér’s V range: 0.13 to 0.28). Correlation Structure Among Survey Variables A Spearman rank correlation matrix across all 11 survey variables revealed two distinct behavioral clusters and one notable disconnection (Fig. 2 ). The first and most prominent cluster linked label-engagement behaviors: frequency of reading Nutrition Facts correlated strongly with checking added sugar information (ρ = 0.66, P < .001), checking front-of-package icons (ρ = 0.60, P < .001), and sugar-label-driven avoidance (ρ = 0.47, P < .001). Checking added sugar information was likewise strongly correlated with front-of-package icon use (ρ = 0.57, P < .001) and with avoidance behavior (ρ = 0.44, P < .001). These variables also correlated with understanding health through sugar information (ρ = 0.29 to 0.40), suggesting that parents who engage with one form of nutrition labeling tend to engage across the board (Table 2 ). A second cluster centered on attitudinal responses: perceived importance of healthy eating correlated moderately with warning label endorsement (ρ = 0.35, P < .01), label reading (ρ = 0.30, P < .01), sugar understanding (ρ = 0.30, P < .01), and sugar avoidance (ρ = 0.28, P < .05). Education level showed a modest correlation with health importance (ρ = 0.29, P < .01) and warning label endorsement (ρ = 0.26, P < .05) but weak correlations with all other behavioral variables (ρ ≤ 0.21), consistent with the bivariate null findings reported above. Strikingly, the “buy if warning label present” item (Q12) was effectively uncorrelated with every other variable in the matrix (ρ range: −0.05 to 0.16), including warning label helpfulness (Q11; ρ = 0.01). Given that a respondent who believes warning labels are helpful should logically avoid purchasing warned products, this near-zero correlation provides quantitative confirmation that the inverted response scale on Q12 confused respondents, supporting our decision to interpret Q12 with caution. Ease of finding healthy food was similarly disconnected from all labeling behaviors (ρ range: −0.06 to 0.17), indicating that perceived food access operates independently of label engagement in this sample. DISCUSSION In this survey of low-income, African-descent parents at an urban pediatric clinic, nutrition label reading and awareness of added sugar tracked closely with pre-existing health motivation but not with educational attainment. Parents who already valued healthy eating were the ones reading labels, checking for added sugars, and letting that information guide their purchasing decisions. Those who placed less importance on healthy eating, precisely the group that might benefit most from accessible nutrition information, were far less engaged. This pattern, which amounts to labeling “preaching to the choir,” has been observed in national samples 11 but has rarely been documented in a clinical population serving predominantly low-income families of African-descent. Our data align with earlier work showing that health motivation, rather than demographics, is the primary driver of label engagement. Satia et al. (2005) found that, among African Americans in North Carolina, pre-existing health motivations predicted nutrition label use more strongly than education or income. 14 The Health Belief Model helps explain this dynamic: information-based interventions, such as nutrition labels, tend to be most effective when recipients already perceive dietary risks as personally relevant. Parents who view healthy eating as peripheral to their daily concerns may not attend to Nutrition Facts panels regardless of content or format. The Spearman correlation matrix reinforces and extends these bivariate findings. The tight clustering of label-engagement behaviors (ρ = 0.57 to 0.66 among label reading, checking added sugar, and front-of-package icon use) indicates that nutrition label use is not a collection of independent acts but a coherent behavioral pattern: parents who read back-of-package labels also check added sugar information and attend to front-of-package icons. This clustering suggests that interventions targeting any single point of label engagement may have spillover effects on related behaviors. The disconnection of the “buy if warning label present” item from all other variables (ρ ≤ 0.16), including its conceptual counterpart “warning labels helpfulness” (ρ = 0.01), provides quantitative evidence for the response-scale confusion noted in the Limitations section. One finding, however, stands apart. Unlike back-of-package label reading, which was strongly motivation-dependent, front-of-package icon checking was nearly universal (91.4%) and did not vary by perceived importance of healthy eating (MH P = .210). This dissociation is clinically meaningful. It suggests that the barrier to reaching less health-motivated parents lies not in their willingness to look at packaging but in where the nutritional information is placed. Added sugar content is currently buried on the back of the package in fine print; front-of-package real estate, which consumers scan almost reflexively, contains little actionable health data. Closing this gap by relocating or duplicating added sugar information on the front of packaging could extend the reach of dietary guidance to the very consumers who currently bypass it. Chile’s experience offers the most compelling evidence that simplified front-of-package labeling can work across socioeconomic lines. Since implementing black octagonal “high in” warning labels in 2016, Chile has observed a nearly 24% reduction in sugar-sweetened beverage purchases, 12,13 alongside food industry reformulation to reduce sugar and salt content. It should be noted that Chile’s policy package also included marketing restrictions and school-based bans, making it difficult to isolate the label’s independent contribution. Israel’s 2020 adoption of red front-of-package warning labels yielded similarly promising results: 92% consumer awareness, 69% regular use, and 50% reporting reduced purchases of labeled products. 15 In France, the Nutri-Score system improved the nutritional quality of purchasing selections among adults with cardiometabolic conditions in a large randomized clinical trial. 16 , 17 These international experiences reinforce the importance of label visibility, interpretive simplicity, and contextual placement, qualities that the current U.S. Nutrition Facts label, with its back-of-package location and dense numerical format, lacks. The significant associations we observed between health motivation and label reading (τ-b = 0.290, P = .007), sugar-label avoidance (τ-b = 0.315, P = .004), and warning-label endorsement (τ-b = 0.296, P = .006) support a consistent narrative: current labeling reinforces behaviors among the already motivated. Among parents who rated healthy eating as very or extremely important, 49% reported reading nutrition labels most of the time or always, compared with just 10% among those who were less motivated (Fig. 1 D). Similarly, 74% of highly motivated parents believed that warning labels would help them make healthier choices, compared with 40% among those with lower health motivation (Fig. 1 E). That nearly two-thirds of all parents endorsed warning labels, however, suggests broad receptivity to this approach even among those who do not currently engage with back-of-package information. One might expect parents with more education to demonstrate greater label use, and some national studies have reported such associations. 11 However, we found that education predicted perceived importance of healthy eating (τ-b = 0.276, P = .012) but did not independently predict any labeling behavior. Within a population that is relatively homogeneous in income and racial composition, education may play a less differentiating role than in nationally representative samples, where it often serves as a proxy for broader socioeconomic stratification. Financial and access-related constraints may also attenuate the translation of motivation into action: nearly 40% of our participants reported difficulty finding and buying healthy food, a structural barrier that labeling alone cannot overcome. Several limitations should inform interpretation. The convenience sample of 82 parents from a single pediatric clinic, all of African descent, limits generalizability to other populations and settings, though the homogeneity of our sample provides a focused examination of labeling behaviors within a community bearing a disproportionate burden of cardiometabolic disease. Self-reported label reading may overstate actual behavior due to social desirability bias; studies using objective measures such as eye-tracking have found lower engagement rates than self-report suggests. 18 The cross-sectional design precludes causal inference; we cannot determine whether health motivation drives label reading or whether reading labels reinforces health-conscious attitudes. With 82 participants, we had adequate power (> 80%) to detect medium effects in 2 × 3 tables but could not detect small effects, which may explain the null findings for the education-outcome relationship. This study also did not assess household income, time constraints, or competing priorities, any of which may independently influence food purchasing and confound observed associations. Finally, the survey included an item pair (Questions 11 and 12) with inverted response scales. Because this inversion likely confused some respondents (as confirmed by the near-zero Spearman correlation between Q11 and Q12, ρ = 0.01), we report Question 12 results but urge caution in their interpretation. In summary, this study highlights both the potential and the limitations of nutrition labeling as a tool for improving dietary behavior in low-income, minoritized communities. Health motivation, not education, drove back-of-package label engagement, yet front-of-package icon checking was nearly universal and independent of motivation. This dissociation suggests a clear policy path: including added sugar warnings on the front of packaging, where all consumers already look, could extend the reach of dietary information beyond the already health conscious. Pediatric clinical encounters, where parents are already engaged in their children’s health, represent an underused setting for brief, targeted nutrition education that teaches parents how to interpret added-sugar labels and translate that knowledge into purchasing decisions. Future research should evaluate the impact of front-of-package sugar warning labels on actual purchasing behavior in this population using prospective intervention designs, ideally across multiple sites and with objective measures of food selection. Declarations Funding: No funding to disclose. Conflicts of Interest: No conflicts to disclose. References Bleich SN, Vercammen KA, Koma JW, Li Z. Trends in beverage consumption among children and adults, 2003–2014. Obes (Silver Spring). 2018;26(2):432–41. 10.1002/oby.22056 . Te Morenga LA, Howatson AJ, Jones RM, Mann J. Dietary sugars and cardiometabolic risk: systematic review and meta-analyses of randomized controlled trials of the effects on blood pressure and lipids. Am J Clin Nutr. 2014;100(1):65–79. 10.3945/ajcn.113.081521 . Haslam D, Peloso GM, Herman MA, et al. Beverage consumption and longitudinal changes in lipoprotein concentrations and incident dyslipidemia in US adults: the Framingham Heart Study. J Am Heart Assoc. 2020;9(5):e014083. 10.1161/JAHA.119.014083 . Yang Q, Zhang Z, Gregg EW, Flanders WD, Merritt R, Hu FB. Added sugar intake and cardiovascular diseases mortality among US adults. JAMA Intern Med. 2014;174(4):516–24. 10.1001/jamainternmed.2013.13563 . Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98(4):1084–102. 10.3945/ajcn.113.058362 . Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomized controlled trials and cohort studies. BMJ. 2013;346:e7492. 10.1136/bmj.e7492 . US Food and Drug Administration. Changes to the Nutrition Facts label. Updated March 2022. Accessed. January 2024. https://www.fda.gov/food/food-labeling-nutrition/changes-nutrition-facts-label Pettigrew S, Jongenelis M, Maganja D, Hercberg S, Julia C. The ability of nutrition warning labels to improve understanding and choice outcomes among consumers demonstrating preferences for unhealthy foods. JAMA Netw Open. 2023;6(12):e2346700. Fan B, Fuller K, Sharib JR, et al. Food Compass Score vs FDA healthy labeling and consumer purchases: a randomized clinical trial. JAMA Netw Open. 2025;8(12):e2546526. 10.1001/jamanetworkopen.2025.46526 . Giró-Candanedo M, Claret A, Fulladosa E, Guerrero L. Use and understanding of nutrition labels: impact of diet attachment. Foods. 2022;11(13):1918. 10.3390/foods11131918 . Campos S, Doxey J, Hammond D. Nutrition labels on pre-packaged foods: a systematic review. Public Health Nutr. 2011;14(8):1496–506. 10.1017/S1368980010003290 . Taillie LS, Hall MG, Popkin BM, Ng SW, Murukutla N. Experimental studies of front-of-package nutrient warning labels on sugar-sweetened beverages and ultra-processed foods: a scoping review. Nutrients. 2020;12(2):569. 10.3390/nu12020569 . Reyes M, Taillie LS, Popkin B, et al. Changes in the amount of nutrients in packaged foods and beverages after the initial implementation of the Chilean Law of Food Labelling and Advertising: a nonexperimental prospective study. PLoS Med. 2020;17(7):e1003220. 10.1371/journal.pmed.1003220 . Satia JA, Galanko JA, Neuhouser ML. Food nutrition label use is associated with demographic, behavioral, and psychosocial factors and dietary intake among African Americans in North Carolina. J Am Diet Assoc. 2005;105(3):392–402. 10.1016/j.jada.2004.12.006 . Samuel H, Katz E, Maoz Breuer R. Food Consumption Habits and Public Attitudes Toward the Front-of-Package Nutritional Labeling Program. Myers-JDC-Brookdale Institute; 2024. Special publication S-230-24. Egnell M, et al. Impact of the Nutri-Score front-of-pack nutrition label on the nutritional quality of purchasing intentions among individuals with cardiometabolic chronic diseases: a randomized clinical trial. BMJ Open. 2022;12:e058139. 10.1136/bmjopen-2021-058139 . Paraje G, Montes de Oca D, Corvalán C, et al. Evolution of food and beverage prices after the front-of-package labelling regulations in Chile. BMJ Glob Health. 2023;8:e011312. 10.1136/bmjgh-2022-011312 . Graham DJ, Jeffery RW. Predictors of nutrition label reading among adult consumers: results from the Heart Disease and Environment Study. Am J Health Promot. 2012;26(6):e164–70. 10.4278/ajhp.110217-QUAN-75 . Cite Share Download PDF Status: Under Review Version 1 posted Editor assigned by journal 30 Apr, 2026 First submitted to journal 30 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9499668","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":632598307,"identity":"42dc0767-9ade-4e9f-87b3-c14abf333e16","order_by":0,"name":"Hadar K. Shimshon","email":"","orcid":"","institution":"SUNY Downstate Medical Center College of Medicine: SUNY Downstate Health Sciences University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hadar","middleName":"K.","lastName":"Shimshon","suffix":""},{"id":632598308,"identity":"a44ce392-3a8e-495e-bef8-e036e77f852e","order_by":1,"name":"Michael Lynch","email":"","orcid":"","institution":"SUNY Downstate Medical Center College of Medicine: SUNY Downstate Health Sciences University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Lynch","suffix":""},{"id":632598309,"identity":"06046811-f731-4c94-b5ba-82244e7dbcc9","order_by":2,"name":"Paul Fried","email":"","orcid":"","institution":"Westchester County Medical Center: Westchester Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Fried","suffix":""},{"id":632598310,"identity":"b41e9478-cb47-4203-8eb2-83739684cec0","order_by":3,"name":"Samuel Sabzanov","email":"","orcid":"","institution":"SUNY Downstate: SUNY Downstate Health Sciences University","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Sabzanov","suffix":""},{"id":632598311,"identity":"88ac3f9c-78be-4f3c-a39a-602033bd61f8","order_by":4,"name":"Cassandra Charles","email":"","orcid":"","institution":"RF SUNY: Research Foundation of SUNY","correspondingAuthor":false,"prefix":"","firstName":"Cassandra","middleName":"","lastName":"Charles","suffix":""},{"id":632598312,"identity":"9159b874-9979-4f3f-b63a-ba666a15f788","order_by":5,"name":"Olumide Arigbede","email":"","orcid":"","institution":"SUNY Downstate Medical Center School of Public Health: SUNY Downstate Health Sciences University School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Olumide","middleName":"","lastName":"Arigbede","suffix":""},{"id":632598313,"identity":"4c392070-bfc3-4d8c-88b8-9cc2037745b8","order_by":6,"name":"Thomas Wallach","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0001-6207-1363","institution":"SUNY Downstate: SUNY Downstate Health Sciences University","correspondingAuthor":true,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Wallach","suffix":""}],"badges":[],"createdAt":"2026-04-22 18:52:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9499668/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9499668/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108972251,"identity":"0f6de8b3-797b-49c7-be13-f592cac56aa5","added_by":"auto","created_at":"2026-05-11 10:35:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2102873,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHealthy eating attitudes, use of nutrition information, and perceived utility of warning labels among African-descent parents.\u003c/strong\u003e\u003cbr\u003e\nPanels show \u003cstrong\u003e(A)\u003c/strong\u003e perceived importance of eating healthy foods, \u003cstrong\u003e(B)\u003c/strong\u003e frequency of reading the Nutrition Facts label before buying, \u003cstrong\u003e(C)\u003c/strong\u003e sources used to assess food healthiness, \u003cstrong\u003e(D)\u003c/strong\u003e nutrition label reading frequency by perceived importance of healthy eating, \u003cstrong\u003e(E)\u003c/strong\u003e perceived helpfulness of warning labels by perceived importance of healthy eating, and \u003cstrong\u003e(F)\u003c/strong\u003e nutrition label reading frequency by education level. Multiple responses were permitted for panel C. Subgroup percentages in panels D-F are calculated within group among participants with valid data.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9499668/v1/3093d9be3b53c33fb116894b.png"},{"id":108972252,"identity":"fed63177-903d-49a9-b7eb-8049e8cc882b","added_by":"auto","created_at":"2026-05-11 10:35:23","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":549671,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorrelation of Responses \u003c/strong\u003eSpearman Rank Correlation Matrix across all 11 survey variables (N = 82). Values represent Spearman’s ρ. Significance: *P \u0026lt; .05, **P \u0026lt; .01, ***P \u0026lt; .001.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9499668/v1/9f691bab656293de8f1ea58b.jpeg"},{"id":108978121,"identity":"8db5d7f3-44b8-4eef-bd3d-cb3f2a9475e0","added_by":"auto","created_at":"2026-05-11 11:34:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2993546,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9499668/v1/06a74b10-a843-4152-aec4-8405d60675cd.pdf"}],"financialInterests":"","formattedTitle":"Exploring Parental Perspectives on Added Sugar Labeling in a Low-Income, Minoritized Patient Population","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIn recent years, consumption of added sugars has risen significantly across a range of food and beverage products.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Added sugars, referring to sugars added into food during processing, provide negligible nutritional value yet drive excess caloric intake and elevate the glycemic index of processed foods. Excessive consumption has been linked to weight gain and obesity,\u003csup\u003e1\u003c/sup\u003e hypertension,\u003csup\u003e2\u003c/sup\u003e dyslipidemia,\u003csup\u003e3\u003c/sup\u003e and cardiovascular disease mortality.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Among children, sugar-sweetened beverages represent a leading contributor to total added sugar intake, and their consumption is associated with increased risk of childhood obesity and metabolic dysregulation.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn May 2016, the FDA finalized updates to the Nutrition Facts label, requiring a dedicated line item for added sugars alongside a corresponding percent Daily Value (%DV).\u003csup\u003e7\u003c/sup\u003e The mandate, which became effective in January 2020 for large manufacturers and in January 2021 for smaller ones, was designed to help consumers distinguish naturally occurring sugars from those introduced during processing. Some products high in added sugars, like sweetened beverages and baked goods, are easily recognized; others, including yogurts, tomato sauces, and condiments, contain substantial hidden sugars that the new label was intended to make visible.\u003c/p\u003e \u003cp\u003eWhether this labeling change has reached its intended audience remains uncertain. Nutrition warning labels have been shown to improve consumers\u0026rsquo; understanding of food healthfulness and to promote healthier choice behaviors, even among individuals who initially prefer unhealthy options.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Randomized trial data demonstrate that front-of-package scoring systems can meaningfully shift purchasing toward healthier products,\u003csup\u003e9\u003c/sup\u003e and broader evidence links nutrition label use to improved dietary decision-making.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Yet national data consistently show that label use is lower among individuals with less education, lower household income, and minority racial or ethnic backgrounds, the very populations bearing the greatest burden of sugar-related chronic disease.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFew studies have examined the added sugar label specifically, and fewer still have done so in clinical populations serving predominantly low-income, minoritized communities. We conducted this study to assess parental awareness, understanding, and use of added sugar labeling among African-descent parents at an urban pediatric clinic, to examine associations with both perceived importance of healthy eating and educational attainment, and to explore parental attitudes toward front-of-package warning labels as a potentially more accessible alternative.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003e We conducted a cross-sectional survey of parents of patients seen at SUNY Downstate Health Sciences University Outpatient Pediatric Clinics in Brooklyn, New York, between October and December 2023. This clinic serves a predominantly low-income, African-descent patient population in central Brooklyn.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants and Recruitment\u003c/h3\u003e\n\u003cp\u003e Parents or legal guardians of children aged 0 to 18 years presenting for outpatient pediatric visits were eligible. The sole exclusion criterion was the absence of dependent children currently residing in the participant\u0026rsquo;s household. Study forms were distributed in the waiting room by research staff rather than treating physicians to prevent any perception of coercion. Participation was voluntary and anonymous. The SUNY Downstate Institutional Review Board approved this study, and a waiver of written informed consent was granted, given the anonymous, minimal-risk design.\u003c/p\u003e\n\u003ch3\u003eSurvey Instrument\u003c/h3\u003e\n\u003cp\u003eWe developed a 12-item questionnaire comprising 1 demographic item (highest education level; 5 categories) and 11 attitudinal and behavioral items (Supplementary Material). Nine items used 5-point Likert-type response scales (e.g., \u0026ldquo;Never\u0026rdquo; to \u0026ldquo;Always\u0026rdquo; or \u0026ldquo;Definitely not\u0026rdquo; to \u0026ldquo;Definitely yes\u0026rdquo;), 1 used a 5-point ease-of-use scale, and 1 was a multi-select with 7 options for information sources. Domains assessed included perceived importance of healthy eating, accessibility of healthy food, frequency of reading Nutrition Facts labels, frequency of checking added sugar information, response to high %DV for added sugars, perceived helpfulness of added sugar information, avoidance behavior driven by added sugar content, use of front-of-package nutrition icons, and attitudes toward warning labels.\u003c/p\u003e\n\u003ch3\u003eVariables and Recoding\u003c/h3\u003e\n\u003cp\u003eEducation was categorized as primary (elementary school), secondary (high school), or post-secondary (college degree or higher). The primary predictor, perceived importance of healthy eating, was dichotomized as slightly or moderately important versus very or extremely important; no participant selected \u0026ldquo;not at all important.\u0026rdquo; Frequency-based outcomes were collapsed into 3 ordered categories: Never, Sometimes/About half the time, and Most of the time/Always. The multi-select information sources item was decomposed into 7 binary indicators. Responses coded as 0 in the original dataset were treated as missing data per the coding protocol (0\u0026thinsp;=\u0026thinsp;no answer) and excluded from denominators for affected variables.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were calculated as frequencies and percentages for all categorical variables. Because the majority of study variables are ordinal, associations between ordered predictors and outcomes were assessed using Kendall\u0026rsquo;s tau-b correlation coefficient, which quantifies the strength and direction of monotonic association while appropriately handling tied ranks inherent to categorical data. The Mantel-Haenszel (MH) chi-square test for linear trend (1 degree of freedom) was used as a confirmatory test of ordinal trends. For cross-tabulations with expected cell counts below 5 in more than 20% of cells (a common occurrence given the sample size), Fisher\u0026rsquo;s exact test with Monte Carlo simulation (10,000 replicates) was used. Cram\u0026eacute;r\u0026rsquo;s V was reported as the effect size for all associations (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Education level was tested against all survey parameters; the perceived importance of healthy eating was tested against all behavioral outcomes. All tests were 2-sided with significance set at α\u0026thinsp;=\u0026thinsp;.05. Post hoc power analysis indicated approximately 88% power to detect a medium effect (w\u0026thinsp;=\u0026thinsp;0.30) in 2 \u0026times; 3 tables at α\u0026thinsp;=\u0026thinsp;.05 with N\u0026thinsp;=\u0026thinsp;82. To characterize the overall correlation structure among all 11 survey variables and identify clusters of related labeling behaviors, a Spearman rank correlation matrix was computed using complete-observation pairs, with significance assessed at P \u0026lt; .05. Analyses were performed in R version 4.5.3 (R Foundation for Statistical Computing, Vienna, Austria) using the DescTools and pwr packages.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBivariate Association Test Results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eτ-b\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eτ-b P\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMH P\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFisher P\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCram\u0026eacute;r\u0026rsquo;s V\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation (3-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth importance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.276\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation (3-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLabel reading freq\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.069\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.519\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.495\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.848\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation (3-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCheck added sugar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation (3-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSugar avoidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.085\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation (3-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWarning helpful\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.076\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.338\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth imp. (2-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLabel reading freq\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.290\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth imp. (2-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCheck added sugar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.082\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.096\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth imp. (2-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBuy high %DV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.060\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth imp. (2-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSugar understanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.051\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth imp. (2-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSugar avoidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth imp. (2-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFOP icons\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.322\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth imp. (2-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWarning helpful\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLabel reading (3-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCheck added sugar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.589\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLabel reading (3-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSugar understanding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.361\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLabel reading (3-cat)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSugar avoidance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003eNote.\u003c/em\u003e τ-b\u0026thinsp;=\u0026thinsp;Kendall\u0026rsquo;s tau-b; MH\u0026thinsp;=\u0026thinsp;Mantel-Haenszel chi-square test for linear trend (1 df). Full results for all 20 associations are available from the authors.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Characteristics\u003c/h2\u003e \u003cp\u003e Eighty-two (82) parents completed the questionnaire anonymously. All respondents were of African descent. Most (47; 57.3%) had completed secondary education (high school), 25 (30.5%) had completed post-secondary education (including 1 with a master\u0026rsquo;s degree), 6 (7.3%) reported only primary education, and 4 (4.9%) did not report their education level. Full descriptive characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Characteristics of Study Participants (N\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEducation level\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary (Elementary School)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary (High School)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-secondary (College+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMissing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level (dichotomized)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary/HS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMissing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImportance of healthy eating\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlightly/Moderately important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery/Extremely important\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEase of finding healthy food\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEasy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeither easy nor difficult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFrequency of reading nutrition labels\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes/About half the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost of the time/Always\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFrequency of checking added sugar info\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes/About half the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost of the time/Always\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWould buy item with high %DV added sugar (n\u0026thinsp;=\u0026thinsp;81)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDefinitely/Probably yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMight or might not\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProbably/Definitely not\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdded sugar info helped understand healthiness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes/About half the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost of the time/Always\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdded sugar info led to item avoidance (n\u0026thinsp;=\u0026thinsp;80)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes/About half the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost of the time/Always\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFrequency of checking FOP nutrition icons (n\u0026thinsp;=\u0026thinsp;81)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes/About half the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost of the time/Always\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWarning labels would help make healthy choices (n\u0026thinsp;=\u0026thinsp;81)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDefinitely/Probably not\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMight or might not\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProbably/Definitely yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eNote.\u003c/em\u003e Percentages calculated using N\u0026thinsp;=\u0026thinsp;82 as denominator except where valid n is indicated. FOP\u0026thinsp;=\u0026thinsp;front-of-package.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePerceived Importance of Healthy Eating and Food Access\u003c/h3\u003e\n\u003cp\u003eAll 82 parents rated eating healthy foods as at least slightly important, with 61 (74.4%) rating it very or extremely important (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Parents with higher education levels were significantly more likely to rate healthy eating as important (τ-b\u0026thinsp;=\u0026thinsp;0.276, P = .012; MH P = .010). When asked about access to healthy food, parents were nearly evenly divided: 34 (41.5%) found it easy, 16 (19.5%) found it neither easy nor difficult, and 32 (39.0%) reported difficulty finding and purchasing healthy food.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSources of Nutrition Information\u003c/h2\u003e \u003cp\u003eNutrition Facts panels were the most frequently cited information source, endorsed by 52 (63.4%) parents, followed by ingredient lists (43; 52.4%), recommendations from family or friends (28; 34.1%), recommendations from a dietician or nutritionist (28; 34.1%), social media (18; 22.0%), symbols and icons on the package (16; 19.5%), and nutrition claims on the package (16; 19.5%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). Neither education level nor perceived importance of healthy eating was significantly associated with any specific information source.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eNutrition Label Reading and Added Sugar Awareness\u003c/h2\u003e \u003cp\u003eAbout half the parents (42; 51.2%) reported reading Nutrition Facts on food packages sometimes or about half the time before purchasing a new item, 32 (39.0%) read them most of the time or always, and 8 (9.8%) never read them (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Parents who rated healthy eating as very or extremely important read labels significantly more frequently: 30 of 61 (49.2%) in this group read labels most of the time or always, compared with only 2 of 21 (9.5%) of those rating it slightly or moderately important (τ-b\u0026thinsp;=\u0026thinsp;0.290, P = .007; MH P = .015; Cram\u0026eacute;r\u0026rsquo;s V\u0026thinsp;=\u0026thinsp;0.37) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD).\u003c/p\u003e \u003cp\u003eWhen asked specifically about checking for added sugar information, 41 (50.0%) parents reported doing so most of the time or always, 30 (36.6%) sometimes or about half the time, and 11 (13.4%) never. Although parents who considered healthy eating important tended to check for added sugar more often, this association did not reach statistical significance (τ-b\u0026thinsp;=\u0026thinsp;0.185, P = .082; MH P = .096). The largest proportion of respondents (36 of 81 valid responses; 43.9%) reported they would not buy a food item with a high %DV for added sugars, while 28 (34.1%) were undecided.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImpact of Added Sugar Information on Understanding and Purchasing\u003c/h2\u003e \u003cp\u003eOnly 5 (6.1%) parents reported that added sugar information on the Nutrition Facts label never helped them understand whether a food was healthy; 40 (48.8%) found it helpful sometimes or about half the time, and 37 (45.1%) found it helpful most of the time or always. Parents who rated healthy eating as very or extremely important were significantly more likely to report that the added sugar label aided their understanding (τ-b\u0026thinsp;=\u0026thinsp;0.244, P = .024; MH P = .029). Regarding actual avoidance behavior, 46 (56.1%) parents reported that added sugar information prompted them to avoid an item sometimes or about half the time, and 25 (30.5%) reported avoiding it most of the time or always. Health-motivated parents were significantly more likely to report sugar-label-driven avoidance (τ-b\u0026thinsp;=\u0026thinsp;0.315, P = .004; MH P = .003; Cram\u0026eacute;r\u0026rsquo;s V\u0026thinsp;=\u0026thinsp;0.33).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eFront-of-Package Icons and Warning Labels\u003c/h2\u003e \u003cp\u003eThe vast majority of parents (74 of 81 valid responses; 91.4%) reported checking front-of-package nutrition content icons at least sometimes. This behavior was consistent regardless of the perceived importance of healthy eating (MH P = .210), distinguishing it from the motivation-dependent back-of-package reading. When asked whether warning labels on foods high in sugar would help them make healthy choices, 53 of 81 (65.4%) responded probably or definitely yes, 15 (18.5%) were uncertain, and 13 (16.0%) responded probably or definitely not. Parents who considered healthy eating very or extremely important endorsed warning labels at significantly higher rates: 45 of 61 (73.8%) compared with 8 of 20 (40.0%) (τ-b\u0026thinsp;=\u0026thinsp;0.296, P = .006; MH P = .008; Cram\u0026eacute;r\u0026rsquo;s V\u0026thinsp;=\u0026thinsp;0.31) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEducation and Labeling Behaviors\u003c/h2\u003e \u003cp\u003eApart from the significant association with perceived importance of healthy eating (τ-b\u0026thinsp;=\u0026thinsp;0.276, P = .012), education level was not significantly associated with any labeling behavior, including label reading frequency (MH P = .495), checking for added sugar (MH P = .133), avoidance based on sugar content (MH P = .038, though τ-b\u0026thinsp;=\u0026thinsp;0.185, P = .085), or endorsement of warning labels (MH P = .076) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eF). Effect sizes for all education-outcome associations were small (Cram\u0026eacute;r\u0026rsquo;s V range: 0.13 to 0.28).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation Structure Among Survey Variables\u003c/h2\u003e \u003cp\u003eA Spearman rank correlation matrix across all 11 survey variables revealed two distinct behavioral clusters and one notable disconnection (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The first and most prominent cluster linked label-engagement behaviors: frequency of reading Nutrition Facts correlated strongly with checking added sugar information (ρ\u0026thinsp;=\u0026thinsp;0.66, P \u0026lt; .001), checking front-of-package icons (ρ\u0026thinsp;=\u0026thinsp;0.60, P \u0026lt; .001), and sugar-label-driven avoidance (ρ\u0026thinsp;=\u0026thinsp;0.47, P \u0026lt; .001). Checking added sugar information was likewise strongly correlated with front-of-package icon use (ρ\u0026thinsp;=\u0026thinsp;0.57, P \u0026lt; .001) and with avoidance behavior (ρ\u0026thinsp;=\u0026thinsp;0.44, P \u0026lt; .001). These variables also correlated with understanding health through sugar information (ρ\u0026thinsp;=\u0026thinsp;0.29 to 0.40), suggesting that parents who engage with one form of nutrition labeling tend to engage across the board (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA second cluster centered on attitudinal responses: perceived importance of healthy eating correlated moderately with warning label endorsement (ρ\u0026thinsp;=\u0026thinsp;0.35, P \u0026lt; .01), label reading (ρ\u0026thinsp;=\u0026thinsp;0.30, P \u0026lt; .01), sugar understanding (ρ\u0026thinsp;=\u0026thinsp;0.30, P \u0026lt; .01), and sugar avoidance (ρ\u0026thinsp;=\u0026thinsp;0.28, P \u0026lt; .05). Education level showed a modest correlation with health importance (ρ\u0026thinsp;=\u0026thinsp;0.29, P \u0026lt; .01) and warning label endorsement (ρ\u0026thinsp;=\u0026thinsp;0.26, P \u0026lt; .05) but weak correlations with all other behavioral variables (ρ\u0026thinsp;\u0026le;\u0026thinsp;0.21), consistent with the bivariate null findings reported above.\u003c/p\u003e \u003cp\u003eStrikingly, the \u0026ldquo;buy if warning label present\u0026rdquo; item (Q12) was effectively uncorrelated with every other variable in the matrix (ρ range: \u0026minus;0.05 to 0.16), including warning label helpfulness (Q11; ρ\u0026thinsp;=\u0026thinsp;0.01). Given that a respondent who believes warning labels are helpful should logically avoid purchasing warned products, this near-zero correlation provides quantitative confirmation that the inverted response scale on Q12 confused respondents, supporting our decision to interpret Q12 with caution. Ease of finding healthy food was similarly disconnected from all labeling behaviors (ρ range: \u0026minus;0.06 to 0.17), indicating that perceived food access operates independently of label engagement in this sample.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this survey of low-income, African-descent parents at an urban pediatric clinic, nutrition label reading and awareness of added sugar tracked closely with pre-existing health motivation but not with educational attainment. Parents who already valued healthy eating were the ones reading labels, checking for added sugars, and letting that information guide their purchasing decisions. Those who placed less importance on healthy eating, precisely the group that might benefit most from accessible nutrition information, were far less engaged. This pattern, which amounts to labeling \u0026ldquo;preaching to the choir,\u0026rdquo; has been observed in national samples\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e but has rarely been documented in a clinical population serving predominantly low-income families of African-descent.\u003c/p\u003e \u003cp\u003eOur data align with earlier work showing that health motivation, rather than demographics, is the primary driver of label engagement. Satia et al. (2005) found that, among African Americans in North Carolina, pre-existing health motivations predicted nutrition label use more strongly than education or income.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e The Health Belief Model helps explain this dynamic: information-based interventions, such as nutrition labels, tend to be most effective when recipients already perceive dietary risks as personally relevant. Parents who view healthy eating as peripheral to their daily concerns may not attend to Nutrition Facts panels regardless of content or format.\u003c/p\u003e \u003cp\u003eThe Spearman correlation matrix reinforces and extends these bivariate findings. The tight clustering of label-engagement behaviors (ρ\u0026thinsp;=\u0026thinsp;0.57 to 0.66 among label reading, checking added sugar, and front-of-package icon use) indicates that nutrition label use is not a collection of independent acts but a coherent behavioral pattern: parents who read back-of-package labels also check added sugar information and attend to front-of-package icons. This clustering suggests that interventions targeting any single point of label engagement may have spillover effects on related behaviors. The disconnection of the \u0026ldquo;buy if warning label present\u0026rdquo; item from all other variables (ρ\u0026thinsp;\u0026le;\u0026thinsp;0.16), including its conceptual counterpart \u0026ldquo;warning labels helpfulness\u0026rdquo; (ρ\u0026thinsp;=\u0026thinsp;0.01), provides quantitative evidence for the response-scale confusion noted in the Limitations section.\u003c/p\u003e \u003cp\u003eOne finding, however, stands apart. Unlike back-of-package label reading, which was strongly motivation-dependent, front-of-package icon checking was nearly universal (91.4%) and did not vary by perceived importance of healthy eating (MH P = .210). This dissociation is clinically meaningful. It suggests that the barrier to reaching less health-motivated parents lies not in their willingness to look at packaging but in where the nutritional information is placed. Added sugar content is currently buried on the back of the package in fine print; front-of-package real estate, which consumers scan almost reflexively, contains little actionable health data. Closing this gap by relocating or duplicating added sugar information on the front of packaging could extend the reach of dietary guidance to the very consumers who currently bypass it.\u003c/p\u003e \u003cp\u003eChile\u0026rsquo;s experience offers the most compelling evidence that simplified front-of-package labeling can work across socioeconomic lines. Since implementing black octagonal \u0026ldquo;high in\u0026rdquo; warning labels in 2016, Chile has observed a nearly 24% reduction in sugar-sweetened beverage purchases,\u003csup\u003e12,13\u003c/sup\u003e alongside food industry reformulation to reduce sugar and salt content. It should be noted that Chile\u0026rsquo;s policy package also included marketing restrictions and school-based bans, making it difficult to isolate the label\u0026rsquo;s independent contribution. Israel\u0026rsquo;s 2020 adoption of red front-of-package warning labels yielded similarly promising results: 92% consumer awareness, 69% regular use, and 50% reporting reduced purchases of labeled products.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e In France, the Nutri-Score system improved the nutritional quality of purchasing selections among adults with cardiometabolic conditions in a large randomized clinical trial.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e These international experiences reinforce the importance of label visibility, interpretive simplicity, and contextual placement, qualities that the current U.S. Nutrition Facts label, with its back-of-package location and dense numerical format, lacks.\u003c/p\u003e \u003cp\u003eThe significant associations we observed between health motivation and label reading (τ-b\u0026thinsp;=\u0026thinsp;0.290, P = .007), sugar-label avoidance (τ-b\u0026thinsp;=\u0026thinsp;0.315, P = .004), and warning-label endorsement (τ-b\u0026thinsp;=\u0026thinsp;0.296, P = .006) support a consistent narrative: current labeling reinforces behaviors among the already motivated. Among parents who rated healthy eating as very or extremely important, 49% reported reading nutrition labels most of the time or always, compared with just 10% among those who were less motivated (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). Similarly, 74% of highly motivated parents believed that warning labels would help them make healthier choices, compared with 40% among those with lower health motivation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE). That nearly two-thirds of all parents endorsed warning labels, however, suggests broad receptivity to this approach even among those who do not currently engage with back-of-package information.\u003c/p\u003e \u003cp\u003eOne might expect parents with more education to demonstrate greater label use, and some national studies have reported such associations.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e However, we found that education predicted perceived importance of healthy eating (τ-b\u0026thinsp;=\u0026thinsp;0.276, P = .012) but did not independently predict any labeling behavior. Within a population that is relatively homogeneous in income and racial composition, education may play a less differentiating role than in nationally representative samples, where it often serves as a proxy for broader socioeconomic stratification. Financial and access-related constraints may also attenuate the translation of motivation into action: nearly 40% of our participants reported difficulty finding and buying healthy food, a structural barrier that labeling alone cannot overcome.\u003c/p\u003e \u003cp\u003eSeveral limitations should inform interpretation. The convenience sample of 82 parents from a single pediatric clinic, all of African descent, limits generalizability to other populations and settings, though the homogeneity of our sample provides a focused examination of labeling behaviors within a community bearing a disproportionate burden of cardiometabolic disease. Self-reported label reading may overstate actual behavior due to social desirability bias; studies using objective measures such as eye-tracking have found lower engagement rates than self-report suggests.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e The cross-sectional design precludes causal inference; we cannot determine whether health motivation drives label reading or whether reading labels reinforces health-conscious attitudes. With 82 participants, we had adequate power (\u0026gt;\u0026thinsp;80%) to detect medium effects in 2 \u0026times; 3 tables but could not detect small effects, which may explain the null findings for the education-outcome relationship. This study also did not assess household income, time constraints, or competing priorities, any of which may independently influence food purchasing and confound observed associations. Finally, the survey included an item pair (Questions 11 and 12) with inverted response scales. Because this inversion likely confused some respondents (as confirmed by the near-zero Spearman correlation between Q11 and Q12, ρ\u0026thinsp;=\u0026thinsp;0.01), we report Question 12 results but urge caution in their interpretation.\u003c/p\u003e \u003cp\u003eIn summary, this study highlights both the potential and the limitations of nutrition labeling as a tool for improving dietary behavior in low-income, minoritized communities. Health motivation, not education, drove back-of-package label engagement, yet front-of-package icon checking was nearly universal and independent of motivation. This dissociation suggests a clear policy path: including added sugar warnings on the front of packaging, where all consumers already look, could extend the reach of dietary information beyond the already health conscious. Pediatric clinical encounters, where parents are already engaged in their children\u0026rsquo;s health, represent an underused setting for brief, targeted nutrition education that teaches parents how to interpret added-sugar labels and translate that knowledge into purchasing decisions. Future research should evaluate the impact of front-of-package sugar warning labels on actual purchasing behavior in this population using prospective intervention designs, ideally across multiple sites and with objective measures of food selection.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo funding to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u0026nbsp;\u003c/strong\u003eNo conflicts to disclose.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBleich SN, Vercammen KA, Koma JW, Li Z. Trends in beverage consumption among children and adults, 2003\u0026ndash;2014. Obes (Silver Spring). 2018;26(2):432\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/oby.22056\u003c/span\u003e\u003cspan address=\"10.1002/oby.22056\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTe Morenga LA, Howatson AJ, Jones RM, Mann J. Dietary sugars and cardiometabolic risk: systematic review and meta-analyses of randomized controlled trials of the effects on blood pressure and lipids. Am J Clin Nutr. 2014;100(1):65\u0026ndash;79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3945/ajcn.113.081521\u003c/span\u003e\u003cspan address=\"10.3945/ajcn.113.081521\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaslam D, Peloso GM, Herman MA, et al. Beverage consumption and longitudinal changes in lipoprotein concentrations and incident dyslipidemia in US adults: the Framingham Heart Study. J Am Heart Assoc. 2020;9(5):e014083. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1161/JAHA.119.014083\u003c/span\u003e\u003cspan address=\"10.1161/JAHA.119.014083\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang Q, Zhang Z, Gregg EW, Flanders WD, Merritt R, Hu FB. Added sugar intake and cardiovascular diseases mortality among US adults. JAMA Intern Med. 2014;174(4):516\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamainternmed.2013.13563\u003c/span\u003e\u003cspan address=\"10.1001/jamainternmed.2013.13563\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98(4):1084\u0026ndash;102. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3945/ajcn.113.058362\u003c/span\u003e\u003cspan address=\"10.3945/ajcn.113.058362\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTe Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomized controlled trials and cohort studies. BMJ. 2013;346:e7492. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmj.e7492\u003c/span\u003e\u003cspan address=\"10.1136/bmj.e7492\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUS Food and Drug Administration. Changes to the Nutrition Facts label. Updated March 2022. Accessed. January 2024. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.fda.gov/food/food-labeling-nutrition/changes-nutrition-facts-label\u003c/span\u003e\u003cspan address=\"https://www.fda.gov/food/food-labeling-nutrition/changes-nutrition-facts-label\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePettigrew S, Jongenelis M, Maganja D, Hercberg S, Julia C. The ability of nutrition warning labels to improve understanding and choice outcomes among consumers demonstrating preferences for unhealthy foods. JAMA Netw Open. 2023;6(12):e2346700.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFan B, Fuller K, Sharib JR, et al. Food Compass Score vs FDA healthy labeling and consumer purchases: a randomized clinical trial. JAMA Netw Open. 2025;8(12):e2546526. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jamanetworkopen.2025.46526\u003c/span\u003e\u003cspan address=\"10.1001/jamanetworkopen.2025.46526\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGir\u0026oacute;-Candanedo M, Claret A, Fulladosa E, Guerrero L. Use and understanding of nutrition labels: impact of diet attachment. Foods. 2022;11(13):1918. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/foods11131918\u003c/span\u003e\u003cspan address=\"10.3390/foods11131918\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampos S, Doxey J, Hammond D. Nutrition labels on pre-packaged foods: a systematic review. Public Health Nutr. 2011;14(8):1496\u0026ndash;506. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1017/S1368980010003290\u003c/span\u003e\u003cspan address=\"10.1017/S1368980010003290\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaillie LS, Hall MG, Popkin BM, Ng SW, Murukutla N. Experimental studies of front-of-package nutrient warning labels on sugar-sweetened beverages and ultra-processed foods: a scoping review. Nutrients. 2020;12(2):569. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/nu12020569\u003c/span\u003e\u003cspan address=\"10.3390/nu12020569\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReyes M, Taillie LS, Popkin B, et al. Changes in the amount of nutrients in packaged foods and beverages after the initial implementation of the Chilean Law of Food Labelling and Advertising: a nonexperimental prospective study. PLoS Med. 2020;17(7):e1003220. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pmed.1003220\u003c/span\u003e\u003cspan address=\"10.1371/journal.pmed.1003220\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSatia JA, Galanko JA, Neuhouser ML. Food nutrition label use is associated with demographic, behavioral, and psychosocial factors and dietary intake among African Americans in North Carolina. J Am Diet Assoc. 2005;105(3):392\u0026ndash;402. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jada.2004.12.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jada.2004.12.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSamuel H, Katz E, Maoz Breuer R. Food Consumption Habits and Public Attitudes Toward the Front-of-Package Nutritional Labeling Program. Myers-JDC-Brookdale Institute; 2024. Special publication S-230-24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEgnell M, et al. Impact of the Nutri-Score front-of-pack nutrition label on the nutritional quality of purchasing intentions among individuals with cardiometabolic chronic diseases: a randomized clinical trial. BMJ Open. 2022;12:e058139. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2021-058139\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2021-058139\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParaje G, Montes de Oca D, Corval\u0026aacute;n C, et al. Evolution of food and beverage prices after the front-of-package labelling regulations in Chile. BMJ Glob Health. 2023;8:e011312. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjgh-2022-011312\u003c/span\u003e\u003cspan address=\"10.1136/bmjgh-2022-011312\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGraham DJ, Jeffery RW. Predictors of nutrition label reading among adult consumers: results from the Heart Disease and Environment Study. Am J Health Promot. 2012;26(6):e164\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4278/ajhp.110217-QUAN-75\u003c/span\u003e\u003cspan address=\"10.4278/ajhp.110217-QUAN-75\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-urban-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jurh","sideBox":"Learn more about [Journal of Urban Health](https://www.springer.com/journal/11524)","snPcode":"11524","submissionUrl":"https://www.editorialmanager.com/jurh","title":"Journal of Urban Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Nutrition Labeling, Added Sugars, Health Literacy, African Americans","lastPublishedDoi":"10.21203/rs.3.rs-9499668/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9499668/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAdded sugar labeling is conceived as an intervention to support healthy food choices, but data is inconsistent on how parents use labeling based on label location. In particular, it is not clear how effective this labeling is at reaching communities of interest, such as minoritized urban populations, at high risk of metabolic disease. To assess this, conducted a cross-sectional survey of 82 parents of pediatric patients at SUNY Downstate outpatient clinics in Brooklyn, New York. Participants completed a 12-item questionnaire assessing nutrition label use, attention to added sugar information, purchasing behaviors, and attitudes toward front-of-package warning labels. Because most variables were ordinal (Likert-type scales), associations were assessed using Kendall\u0026rsquo;s tau-b and the Mantel-Haenszel chi-square test for linear trend (1 df). Fisher\u0026rsquo;s exact test was used for cross-tabulations with sparse expected cell counts. Cram\u0026eacute;r\u0026rsquo;s V was reported as the effect size. A Spearman rank correlation matrix was computed across all 11 survey variables to identify behavioral clusters. Significance was set at P \u0026lt; .05. Of 82 parents surveyed, all rated healthy eating as important; 61 (74.4%) rated it very or extremely important. However, only 32 (39.0%) read nutrition labels most of the time or always, and 8 (9.8%) never read them. Parents who rated healthy eating as very or extremely important read labels significantly more frequently than those who did not (τ-b\u0026thinsp;=\u0026thinsp;0.290, P = .007; 49.2% vs 9.5% reading most of the time/always). Health motivation was also significantly associated with sugar-label-driven item avoidance (τ-b\u0026thinsp;=\u0026thinsp;0.315, P = .004) and endorsement of warning labels (τ-b\u0026thinsp;=\u0026thinsp;0.296, P = .006). Education level was not associated with any labeling behavior. A Spearman correlation matrix revealed a tightly correlated cluster of label-engagement behaviors (label reading, checking added sugar, front-of-package icon use; ρ\u0026thinsp;=\u0026thinsp;0.57\u0026ndash;0.66). These findings suggest that current added sugar labeling primarily reaches parents who are already health-conscious, while those who might benefit most remain less engaged.\u003c/p\u003e","manuscriptTitle":"Exploring Parental Perspectives on Added Sugar Labeling in a Low-Income, Minoritized Patient Population","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-11 10:35:14","doi":"10.21203/rs.3.rs-9499668/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorAssigned","content":"","date":"2026-04-30T16:35:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Urban Health","date":"2026-04-30T09:30:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-urban-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jurh","sideBox":"Learn more about [Journal of Urban Health](https://www.springer.com/journal/11524)","snPcode":"11524","submissionUrl":"https://www.editorialmanager.com/jurh","title":"Journal of Urban Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0dccb1a1-a2e7-445a-a54f-98ae79d38d57","owner":[],"postedDate":"May 11th, 2026","published":true,"recentEditorialEvents":[{"type":"editorAssigned","content":"","date":"2026-04-30T16:35:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Urban Health","date":"2026-04-30T09:30:49+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T10:35:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-11 10:35:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9499668","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9499668","identity":"rs-9499668","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}