Madam

Regarding our article, ‘A qualitative study of perceptions and use of traffic light food labelling in Ecuador’⁽ Reference Freire, Waters and Rivas-Mariño ^{1 )}, published in Public Health Nutrition (PHN), we are extremely concerned that our work has been construed a duplication of our manuscript ‘Semáforo nutricional de alimentos procesados: estudio cualitativo sobre conocimientos, comprensión, actitudes y prácticas en Ecuador’ (‘Nutritional traffic light system for processed foods: qualitative study of awareness, understanding, attitudes, and practices in Ecuador’)⁽ Reference Freire, Waters and Rivas-Mariño ^{2 )}, which was published afterwards in Revista Peruana de Medicina Experimental y Salud Publica (RPMESP). Please excuse this extensive reply, which has been reviewed by all authors; we wish to make our position as clear and complete as possible. We would like to make two points. First, it was – and continues to be – our contention that the two manuscripts are not duplicative or repetitive and that the manuscript published in RPMESP is not a simple translation from English to Spanish of the article published in PHN. Second, regarding ethics, we never intended that the affirmation that I signed as corresponding author (to the effect that the manuscript submitted to PHN had not been submitted elsewhere) be deceptive or constitute a breach of ethics or professional malfeasance. As chair of the Institutional Review Board of the Universidad San Francisco for nearly 10 years, I am particularly sensitive to issues related to research ethics, including those having to do with conflict of interests and publishing.

Regarding the first point, we acknowledge and would even emphasize that the two manuscripts report on the same research project, which used qualitative methods to collect data on perceptions and practices related to the visual ‘traffic light’ nutrition label that has been used on packages of processed and ultra-processed food products in Ecuador since 2014. Consequently, the sections on methodology and basic results in the two manuscripts are similar, but they are not simple translations. Moreover, some elements are not found in both; for example, Table 2 in PHN is not presented in RPMESP. There are other important differences throughout the text, and the reference sections are not the same. Moreover, since the editors of the two journals requested different modifications and clarifications in the respective submissions, additional differences were necessarily introduced.

We would emphasize that the most significant difference in the two manuscripts (and the substance of our reply) is that we designed the two manuscripts to address different issues and to reach different audiences. The focus of the PHN manuscript was that our research demonstrated that the Ecuadorian nutrition label was recognized and understood by different groups of respondents (distinguished by age group, sex and place of residence throughout the country) although, in practice, food purchase and consumption patterns varied. We thought that given overweight and obesity are public health concerns worldwide – at the same time that consumption of processed and ultra-processed foods appears to be increasingly prevalent – this point would be of interest to PHN readers in general, and we were grateful the editors agreed.

In contrast, the RPMESP manuscript emphasizes a different point, particularly in the much more extensive discussion section: that given opposition and resistance to visual nutritional labelling by the processed food industry and, consequently, considerable political pressure for weakening or eliminating visual labels like Ecuador’s, it is essential that decision makers, public health authorities and academics recognize and understand the situation and respond accordingly based on evidence to counter claims that consumers ignore or are not interested in visual nutritional labelling. The three authors of the PHN article attended the 18th meeting of the Latin American Nutrition Society (SLAN) in Guadalajara, Mexico on 11–15 November 2018, and this issue was extensively discussed, including variations in visual nutritional labelling. The label implemented in Chile and recently adopted in Peru contrasts with the Ecuadorian ‘traffic light’ label as well as the Guideline Daily Amount label used in Europe and favoured by the processed food industry in Latin America. Thus, our motivation to publish in a Latin American journal published in Spanish was to reach a broader Spanish-speaking audience that may not have access to PHN, and with a different emphasis and direction.

Finally, we would like to mention that the two manuscripts are consistent with two areas of particular interest of the Institute for Research in Health and Nutrition of the Universidad San Francisco de Quito, and hence with other articles published by the first two authors. In brief, much of our work is intended to contribute to an understanding of different aspects of nutrition epidemiology (with a certain focus on the epidemiological, demographic and nutrition transitions), while a second area addresses policy and political issues and community health and is, consequently, somewhat more polemical. From both perspectives, we have addressed the epidemic of overweight and obesity and related issues. For example, the first author was Principal Investigator and first author of the most recent national health and nutrition survey, which was published in Spanish and later discussed in English⁽ Reference Freire, Ramirez-Luzuriaga and Belmont ^{3 ,} Reference Freire, Silva and Ramirez ^{4 )}. This work showed for the first time the significance of overweight and obesity in all age groups, as well as the persistence of undernutrition. Similarly, we recently published a paper on trends in the double burden of chronic malnutrition and overweight and obesity in Ecuador using national survey data, and another article on overweight, obesity and food consumption in Galapagos, the Ecuadorian province with the highest rate of overweight and obesity⁽ Reference Freire, Waters and Rivas-Mariño ^{5 ,} Reference Freire, Waters and Román ^{6 )}. This work is consistent with the PHN manuscript, in our view. On the other hand, we have also published papers more consistent with the RPMESP manuscript, including one on local responses to globalization and another on the role of transnational corporations in food fortification⁽ Reference Waters ^{7 ,} Reference Freire and Waters ^{8 )}. An alternative community-based approach that we have explored was through a randomized controlled trial based on a food-based intervention⁽ Reference Iannotti, Lutter and Waters ^{9 ,} Reference Waters, Gallegos and Karp ^{10 )}. I mention these publications to indicate that the two papers in question are consistent with our two established lines of work. Parenthetically, we would like to mention that the first two authors are approaching retirement and have no need or interest in inflating their curriculums.

The process of preparing and submitting the two manuscripts overlapped, as suggested in your inquiry. But the PHN manuscript was under final revision by the authors when the initial draft of the RPMESP manuscript was being prepared, and revisions of the latter continued later.

In sum, it was – and remains – our sincere belief that for these reasons, the publication of the two manuscripts was justified. Nevertheless, we understand that the editors of PHN may disagree and may conclude that the two manuscripts are not sufficiently different as to have been published separately. I hope to have explained our thinking on this matter and to have made clear that we had no intention of contravening ethical academic norms and practices. Either way, we sincerely regret that we have caused this issue to be raised. We thank you for the opportunity to respond; if in your judgement we were mistaken in this endeavour, we will accept your determination.