Impact of front-of-pack nutrition information and label design on children's choice of two snack foods: Comparison of warnings and the traffic-light system

Objective understanding of the Nutri-score front-of-pack label by European consumers and its effect on food choices: an online experimental study

Background

The effectiveness of Front-of-Pack nutrition Labels (FoPLs) may be influenced by national context. In light of the ongoing efforts to harmonize FoPLs across Europe, this study aimed to compare the effectiveness of five FoPLs (Health Star Rating system, Multiple Traffic Lights, Nutri-Score, Reference Intakes, Warning symbols) on consumer understanding and food choice in 12 European countries.

Methods

In 2018–2019, for three food categories, approximately 1000 participants per country were asked to select which food they would prefer to purchase between three products with distinct nutritional quality profiles, and then to rank the products by nutritional quality. Participants (N = 12,391 in total) completed these tasks first with no FoPL and then, after randomization to one of the five FoPLs, with a FoPL on the food packages. Associations between FoPLs and change in (i) nutritional quality of food choices and (ii) ability to correctly rank the products by nutritional quality were assessed with logistic regression models adjusted for sociodemographic and lifestyle characteristics of participants, conducted overall and by country.

Findings

Compared with the Reference Intakes, the Nutri-Score (OR = 3.23[2.75–3.81]; p < 0.0001), followed by the Multiple Traffic Lights (OR = 1.68[1.42–1.98]; p < 0.0001), was the most effective FoPL in helping consumers identify the foods’ nutritional quality, overall and in each of the 12 countries. Differences between FoPLs regarding food choice modifications were smaller, but the effect of the Nutri-Score seemed slightly higher in eliciting healthier food choices overall compared with the Reference Intakes, followed by the Warning symbols, the Multiple Traffic Lights and the Health Star Rating system.

Interpretation

In the context of FoPL harmonization in Europe, these findings from an online experiment provide insights into the Nutri-Score’s effectiveness on European consumers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-020-01053-z.

Food Marketing as a Special Ingredient in Consumer Choices: The Main Insights from Existing Literature

The choices and preferences of food consumers are influenced by several factors, from those related to the socioeconomic, cultural, and health dimensions to marketing strategies. In fact, marketing is a determinant ingredient in the choices related to food consumption. Nonetheless, for an effective implementation of any marketing approach, the brands play a crucial role. Creating new brands in the food sector is not always easy, considering the relevant amount of these goods produced within the agricultural sector and in small food industries. The small dimension of the production units in these sectors hinders both brand creation and respective branding. In this context, it would seem important to analyse the relationships between food marketing and consumer choice, highlighting the role of brands in these frameworks. For this purpose, a literature review was carried out considering 147 documents from Scopus database for the topics of search “food marketing” and “choices” (search performed on 16 October 2020). As main insights, it is worth highlighting that the main issues addressed by the literature, concerning food marketing and consumer choices, are the following: economic theory; label and packaging; marketing strategies; agriculture and food industry; market segments; social dimensions; brand and branding. In turn, food marketing heavily conditions consumer choices; however, these related instruments are better manipulated by larger companies. In addition, this review highlights that bigger companies have dominant positions in these markets which are not always beneficial to the consumers’ objectives.

Consumers' Implicit and Explicit Recall, Understanding and Perceptions of Products with Nutrition-Related Messages: An Online Survey

This study aimed to assess consumers' implicit and explicit recall, understanding and perceptions of products with a nutrition claim and a symbol depicting 'health,' and to determine whether these perceptions differed among Nutrition Facts table (NFt) users vs. nonusers. In an online survey, participants (n = 1997) were randomized to one of eight conditions in a 2 × 2 × 2 factorial design, consisting of a label with a claim (present/absent) a heart-shaped symbol depicting 'health' (present/absent) for a healthier or less healthy soup. Participants were shown a label for 10 s and asked whether they recalled seeing a claim. If participants answered yes, they were then asked to describe their response using open-ended questions. Participants also rated the product's perceived nutritional quality and purchase intentions using seven-point Likert scales. In the claim condition, most participants (75%) were able to recall the presence of a claim, while 12% incorrectly mentioned the presence of a claim when there was none. Claims likely attracted consumers' attention and increased perceived nutritional quality, although with limited influence among NFt users (23%). The symbol depicting 'health' did not enhance perceived nutritional quality or purchase intentions. Although most participants (77%) made their decisions implicitly using the front of labels, those who used the NFt had a better understanding of the nutritional quality of products.

Efficacy of "High in" Nutrient Specific Front of Package Labels-A Retail Experiment with Canadians of Varying Health Literacy Levels

BACKGROUND

In 2018, Health Canada, the Federal department responsible for public health, put forward a regulatory proposal to introduce regulations requiring a "High in" front-of-package label (FOPL) on foods that exceed predetermined thresholds for sodium, sugars, or saturated fat. This study evaluated the efficacy of the proposed FOPL as a quick and easy tool for making food choices that support reduction in the intakes of these nutrients.

METHODS

Consumers (n = 625) of varying health literacy levels (HL) were assigned to control (current labeling with no FOPL) or one of four FOPL designs. They completed six shopping tasks, designed to control for internal motivations. Efficacy was measured with correct product selection and response time (seconds) to make food choices using repeated measures statistical modeling, adjusting for HL, task type, and task order. Eye-tracking and structured interviews were used to gather additional insights about participants' choices.

RESULTS

Overall, FOPL was significantly more effective than current labeling at helping consumers of varying HL levels to identify foods high in nutrients of concern and make healthier food choices. All FOPL were equally effective.

CONCLUSIONS

"High in" FOPL can be effective at helping Canadians of varying HL levels make more informed food choices in relation to sugars, sodium, and saturated fat.

The efficacy of 'high in' warning labels, health star and traffic light front-of-package labelling: an online randomised control trial

OBJECTIVE

To examine the impact of front-of-package (FOP) labels on perceived healthfulness, purchasing intentions and understanding of common FOP systems.

DESIGN

A parallel, open-label design randomised participants to different FOP labelling conditions: 'high in' warning labels (WL), multiple traffic light labelling (TLL), health star ratings (HSR) (all displayed per serving) or control with no interpretive FOP labelling. Participants completed a brief educational session via a smartphone application and two experimental tasks. In Task 1, participants viewed healthy or unhealthy versions of four products and rated healthiness and purchasing intention on a seven-point Likert-type scale. In Task 2, participants ranked three sets of five products from healthiest to least healthy.

SETTING

Online commercial panel.

PARTICIPANTS

Canadian residents ≥ 18 years who were involved in household grocery shopping, owned a smartphone and met minimum screen requirements.

RESULTS

Data from 1997 participants (n 500/condition) were analysed. Task 1: across most product categories, the TLL and HSR increased perceived healthiness of healthier products. All FOP systems decreased perceived healthiness of less healthy products. Similar, albeit dampened, effects were seen regarding purchasing intentions. Task 2: participants performed best in the HSR, followed by the TLL, WL and control conditions. Lower health literacy was associated with higher perceived healthiness and purchasing intentions and poorer ranking task performance across all conditions.

CONCLUSIONS

All FOP labelling systems, after a brief educational session, improved task performance across a wide spectrum of foods. This effect differed depending on the nutritional quality of the products and the information communicated on labels.Trial Registration: NCT03290118.

Changes in Nutrient Declaration after the Food Labeling and Advertising Law in Chile: A Longitudinal Approach

Chile has implemented several strategies to decrease the burden of obesity and chronic diseases. The Food Labeling and Advertising Law (Law 20.606) requires a front-of-package "high in" warning label when energy and nutrients of concern (ENC) (total sugar, saturated fats, sodium) exceed established limits. This study aims to evaluate the impact of Law 20.606 on the ENC declaration of packaged foods in Chile, before and after the law implementation. We analyzed food nutritional labeling declarations from 70% of the most consumed packaged foods in Chile. Data collection was conducted in 2013 and 2019 in Santiago. Pictures from all sides of the package were taken from 476 products, classified into 16 food groups. All food groups had changes in the ENC declaration during the study period. Total sugar content showed the highest reduction (-15.0%; p = 0.001). Dairy, confitures and similar and sugary beverages had the greatest reduction in energy and total sugar content (p < 0.01). Energy, total sugar and sodium front of package "high in" simulation was significantly reduced in dairy, sugary beverages, flour-based foods, confitures and similar, fish and seafoods, fats and oils, spices, condiments and sauces and sugars (p < 0.05). We observed that companies reformulated products to adapt to the new regulation.

Measuring the Power of Food Marketing to Children: a Review of Recent Literature

PURPOSE OF REVIEW

This scoping review examines literature from the past 5 years (June 2014 to June 2019) across three databases (PubMed, MEDLINE, and Scopus) to detail how the persuasive power of child-targeted food marketing content is addressed and evaluated in current research, to document trends and gaps in research, and to identify opportunities for future focus.

RECENT FINDINGS

Eighty relevant studies were identified, with varied approaches related to examining food marketing techniques to children (i.e., experimental, survey, meta-analyses, mixed methods, content analyses, focus groups). Few studies specifically defined power, and studies differed in terms of techniques examined. Spokes-characters were the predominant marketing technique measured; television was the platform most analyzed; and dominant messages focused on health/nutrition, taste appeals, and appeals to fun/pleasure. Mapping the current landscape when it comes to the power of food marketing to children reveals concrete details about particular platforms, methods, and strategies, as well as opportunities for future research-particularly with respect to definitions and techniques monitored, digital platforms, qualitative research, and tracking changes in targeted marketing techniques over time.

An Experimental Comparison of the Impact of 'Warning' and 'Health Star Rating' FoP Labels on Adolescents' Choice of Breakfast Cereals in New Zealand

This research investigated the performance of the red, octagonal Vienna Convention traffic ‘STOP’ sign as a front of pack (FoP) warning nutritional label. While the Vienna Convention traffic light system is an established FoP label, the potential of the ‘STOP’ sign in the role has not been investigated. The performance of the ‘STOP’ label was compared with that of a single star (low nutritional value) Australasian Health Star Rating (HSR) label using a fractionally replicated Latin square design. The labels were presented on choice diads of cold breakfast cereal packets. The sample of 240 adolescents aged 16–18 was drawn from a secondary school in the South Island of New Zealand. A large and significant main effect was observed at the p < 0.01 level for the difference between the ’STOP’ sign and the control condition (no nutritional FoP label), and at p < 0.05 for the difference between the HSR and the ‘STOP’ label. There was no significant difference between the HSR FoP and the control condition. A significant non-additivity (interaction) (p < 0.01) was also observed via the fractional replication. The results indicate that the Vienna Convention ‘STOP’ sign is worthy of further research with regard to its potential as an FoP nutritional label.

Sugary drink warnings: A meta-analysis of experimental studies

BACKGROUND

Policymakers worldwide are considering requiring warnings for sugary drinks. A growing number of experimental studies have examined sugary drink warnings' impacts, but no research to our knowledge has synthesized this literature. To inform ongoing policy debates, this study aimed to identify the effects of sugary drink warnings compared with control conditions.

METHODS AND FINDINGS

We systematically searched 7 databases on June 21, 2019, and October 25, 2019. We also searched reference lists of relevant articles. Two investigators independently screened titles, abstracts, and full texts to identify peer-reviewed articles that used an experimental protocol to examine the effects of sugary drink warnings compared to a control condition. Two investigators independently extracted study characteristics and effect sizes from all relevant full-text articles. We meta-analyzed any outcome assessed in at least 2 studies, combining effect sizes using random effects meta-analytic procedures. Twenty-three experiments with data on 16,241 individuals (mean proportion female, 58%) were included in the meta-analysis. Most studies took place in Latin America (35%) or the US or Canada (46%); 32% included children. Relative to control conditions, sugary drink warnings caused stronger negative emotional reactions (d = 0.69; 95% CI: 0.25, 1.13; p = 0.002) and elicited more thinking about the health effects of sugary drinks (d = 0.65; 95% CI: 0.29, 1.01; p < 0.001). Sugary drink warnings also led to lower healthfulness perceptions (d = -0.22; 95% CI: -0.27, -0.17; p < 0.001) and stronger disease likelihood perceptions (d = 0.15; 95% CI: 0.06, 0.24; p = 0.001). Moreover, sugary drink warnings reduced both hypothetical (d = -0.32; 95% CI: -0.44, -0.21; p < 0.001) and actual consumption and purchasing behavior (d = -0.17; 95% CI: -0.30, -0.04; p = 0.012). Statistically significant effects were not observed for perceptions of added sugar or positive sugary drink attitudes (p's > 0.10). Moderation analyses revealed that health warnings (e.g., "Beverages with added sugar contribute to obesity") led to greater reductions in hypothetical sugary drink purchases than did nutrient warnings (e.g., "High in sugar"; d = -0.35 versus -0.18; Qb = 4.04; p = 0.04). Limitations of this study include that we did not review grey literature and that we were unable to conduct moderation analyses for several prespecified moderators due to an insufficient number of studies.

CONCLUSIONS

This international body of experimental literature supports sugary drink warnings as a population-level strategy for changing behavior, as well as emotions, perceptions, and intentions.

PROTOCOL REGISTRY

PROSPERO ID 146405.

Can sodium warnings modify preferences? A case study with white bread

Several studies have shown that the inclusion of front of pack nutritional warnings is a potentially effective strategy to encourage consumers to avoid products with high content of nutrients associated with non-communicable diseases. In this context, the present work aimed at exploring consumers' reaction towards sodium reduction in the context of the implementation of warnings in three scenarios: package evaluation, tasting and intention to re-purchase the product after tasting, using white bread as case study. A total of 171 consumers participated in the study that encompassed four parts. Firstly, consumers received two bread samples with different salt content (2.00% and 1.38% salt) under blind conditions and were asked to rate their overall liking and to indicate the one they preferred. Then, they were asked to look at four bread packages differing in graphic design and the presence of warnings. They had to rate their expected liking and to indicate the one they would purchase. Finally, consumers were asked to try the bread they had previously chosen, to assess their overall liking and to indicate their willingness to purchase it again. Salt content significantly affected consumer hedonic reaction towards the breads. Two consumer segments with different preference for the salt content in bread were identified: 58% of consumers preferred the bread with 2.00% salt while 42% preferred breads with 1.38% salt. However, when looking at the packages the majority of consumers in both groups selected bread packages that did not feature warnings. In addition, after having tried the bread, most consumers were willing to buy the bread they had previously chosen again, which is promising in terms of reaching sustainable changes towards lower salt levels. Results from the present work suggest that, in the case of bread, nutritional warnings have potential to shift consumers' preferences to lower sodium content, even after trying the products.

The impact of calorie and physical activity labelling on consumer's emo-sensory perceptions and food choices

Providing labelling information is one of the strategies used to help consumers make healthier choices. However, although the type of information has the potential to assist consumers, it is important to evaluate their sensory and emotional perceptions. Therefore, the objective of this study was to evaluate the effect of different labelling information on consumers' sensory and emotional perceptions and their choices, for three different products (potato chips, juice and yogurt). A total of 480 participants were randomly assigned to one of four information conditions (no information (blind), kilocalorie (kcal) information, physical activity (PA) information [duration of walking required to burn the kcal in the product], kcal + PA information). For each information condition, participants were provided with higher kcal and lower kcal equivalent food pairs and were required to choose one. The participants evaluated their overall liking using a 9-point hedonic scale and answered rate-all-that-apply (RATA) questions related to the sensory and emotional characteristics of the products. The results showed no significant impact of calorie and physical activity labelling on consumers' overall liking for juice and yogurt samples and no impact of PA information for chips. Significant differences in overall liking were found when comparing the blind condition with kcal and kcal + PA information, with lower acceptance of the chips samples when this information was presented. Although providing calorie and physical activity labelling had little impact on consumers' sensory and emotional perceptions, consumers perceived unhealthy attributes and negative emotions, such as fatty and guilty, when information was presented. The present work suggests that, although nutrition labelling may be presented as an important strategy to assist consumers, it is important to evaluate consumers' lifestyles, considering that non-dieters and those low and moderate in dietary restraint may not be impacted by this information.

Compared to other front-of-pack nutrition labels, the Nutri-Score emerged as the most efficient to inform Swiss consumers on the nutritional quality of food products

Background

Switzerland, like other high-income countries, is facing a major public health challenge with the increasing burden of non-communicable diseases. Discussions are currently on-going in Switzerland regarding the implementation of a Front-of-Pack nutrition label (FoPL) as a public health measure to guide consumers towards healthier food choices, and the Nutri-Score represents an alternative supported by multiple actors. To date, no studies have investigated the performance of the Nutri-Score among Swiss consumers. This study aimed to compare the response of Swiss consumers to five FoPLs (Health Star Rating system, Multiple Traffic Lights, Nutri-Score, Reference Intakes and Warning symbol) in terms of perception and understanding of these labels and effects on food choices.

Methods

In 2019, 1,088 Swiss consumers were recruited and asked to select one product from among a set of three foods with different nutritional profiles and then classify the products within the sets according to their nutritional quality. Tasks were performed in situations without a label and then with one of the five FoPLs–depending on the group in which they were randomized–on the pack. Finally, participants were questioned on their perceptions regarding the label to which they were exposed.

Results

All FoPLs were favorably perceived, with marginal differences between FoPLs. The Nutri-Score demonstrated the highest percentage of improvement in food choices and the highest overall performance in helping consumers rank the products according to their nutritional quality.

Conclusion

Overall, the Nutri-Score was the most efficient FoPL in informing Swiss consumers of the nutritional quality of food products, and as such could be a useful tool to improve food choices and reduce the burden of chronic diseases in Switzerland.

Experimental Studies of Front-of-Package Nutrient Warning Labels on Sugar-Sweetened Beverages and Ultra-Processed Foods: A Scoping Review

Policies that require front-of-package (FoP) nutrient warnings are becoming increasingly common across the globe as a strategy to discourage excess consumption of sugary drinks and ultra-processed food. However, a better understanding of the pathway through which FoP nutrient warnings work, as well as a review of how outcomes being measured in recent studies map onto this pathway, are needed in order to inform policy on the most effective FoP label design for reducing purchases of ultra-processed foods. This scoping review describes a conceptual model for how FoP nutrient warnings affect consumer behavior, examines which of these outcomes are currently being measured, and summarizes evidence from randomized controlled experiments. Twenty-two studies which experimentally tested nutrient warnings against a control label or other labeling systems were included for full-text review. Our conceptual model includes attention; comprehension, cognitive elaboration, and message acceptance; negative affect and risk perception; behavioral intentions, and behavioral response, along with other elements such as external factors and interpersonal communications. We found that many studies focused on outcomes such as attention, comprehension, and behavioral intentions, but considerable gaps in the evidence remain, particularly for intermediary steps on the pathway to behavioral change, such as negative affect and social interactions. FoP nutrient warnings were visually attended to by consumers, easy to understand, helped consumers identify products high in nutrients of concern, and discouraged them from purchasing these products, although other labeling systems were perceived as containing more information and performed better at helping consumers rank the healthfulness of products. More research is needed to understand whether and how nutrient warnings work in the real world to discourage consumer purchases of sugary drinks and ultra-processed food.

A randomized controlled trial examining consumers' perceptions and opinions on using different versions of a FoodFlip© smartphone application for delivery of nutrition information

Background

Food labelling is a common intervention to improve diets, where the back-of-pack Nutrition Information Panel (or Nutrition Facts table (NFt)) provides comprehensive nutrition information on food packages. However, many consumers find it difficult and time-consuming to identify healthier foods using the NFt. As a result, different interpretative nutrition rating systems (INRS) may enable healthier food choices and it is essential that consumers have the tools to allow for easily accessible nutrition information. The objective of this study was to examine consumers’ perceptions of different (INRS) for delivery of nutrition information using different versions of a smartphone app, FoodFlip©.

Methods

This study was part of a larger randomized controlled trial examining consumer perceptions of different INRS on food products. A nationally representative commercial sample of 2008 Canadians were randomized to one of four INRS intervention groups: 1) traffic light, 2) health star rating, 3) ‘high-in’ warning labels or 4) no INRS (NFt only; control) and asked to scan or enter 20 products into FoodFlip© from a list of food products provided to them with varying levels of healthfulness. After completing the app task, participants were asked a series of 7-point Likert-scale and open-ended questions to provide opinions on the usability and functionality of the app.

Results

Of the survey sample of 1997 participants, 95% (n = 1907) completed the app task, with similar number of participants in each treatment group. The mean age was 40 ± 12 years with no differences in sociodemographic characteristics between treatment groups. The health star rating ranked significantly lower in comparison to the other treatment groups in terms of usefulness (OR, 95% CI -0.67, 0.52–0.85), believability (0.59, 0.46–0.75), and understanding (0.55, 0.44–0.71) (p < 0.001). The health star rating (1.20, 0.94–1.53) and control (NFt) (1,1,1) ranked significantly lower than the traffic light or the ‘high-in’ warning labels for their ability to compare the healthfulness of products (p < 0.001).

Conclusion

This study demonstrated Canadian consumers’ preference for a nutrient-specific system (i.e. traffic light or ‘high-in’ warning labels). The app, which was liked by majority of the participants for its functionality and usability, has the potential to support healthy dietary decision making and may also encourage reformulation.

Trial registration

NCT03290118 (Clinicaltrials.gov).

An evaluation of Chile's Law of Food Labeling and Advertising on sugar-sweetened beverage purchases from 2015 to 2017: A before-and-after study

BACKGROUND

Chile's Law of Food Labeling and Advertising, implemented in 2016, was the first national regulation to jointly mandate front-of-package warning labels, restrict child-directed marketing, and ban sales in schools of all foods and beverages containing added sugars, sodium, or saturated fats that exceed set nutrient or calorie thresholds. The objective of this study is to evaluate the impact of this package of policies on household beverage purchases.

METHOD AND FINDINGS

In this observational study, monthly longitudinal data on packaged beverage purchases were collected from urban-dwelling households (n = 2,383) participating in the Kantar WordPanel Chile Survey from January 1, 2015, to December 31, 2017. Beverage purchases were linked to nutritional information at the product level, reviewed by a team of nutritionists, and categorized as "high-in" or "not high-in" according to whether they contained high levels of nutrients of concern (i.e., sugars, sodium, saturated fat, or energy) according to Chilean nutrient thresholds and were thus subject to the law's warning label, marketing restriction, and school sales ban policies. The majority of high-in beverages were categorized as such because of high sugar content. We used fixed-effects models to compare the observed volume as well as calorie and sugar content of postregulation beverage purchases to a counterfactual based on preregulation trends, overall and by household-head educational attainment. Of households included in the study, 37% of household heads had low education (less than high school), 40% had medium education (graduated high school), and 23% had high education (graduated college), with the sample becoming more educated over the study period. Compared to the counterfactual, the volume of high-in beverage purchases decreased 22.8 mL/capita/day, postregulation (95% confidence interval [CI] -22.9 to -22.7; p < 0.001), or 23.7% (95% CI -23.8% to -23.7%). High-educated and low-educated households showed similar absolute reductions in high-in beverage purchases (approximately 27 mL/capita/day; p < 0.001), but for high-educated households this amounted to a larger relative decline (-28.7%, 95% CI -28.8% to -28.6%) compared to low-educated households (-21.5%, 95% CI -21.6% to -21.4%), likely because of the high-educated households' lower level of high-in beverage purchases in the preregulation period. Calories from high-in beverage purchases decreased 11.9 kcal/capita/day (95% CI -12.0 to -11.9; p < 0.001) or 27.5% (95% CI -27.6% to -27.5%). Calories purchased from beverages classified as "not high-in" increased 5.7 kcal/capita/day (95% CI 5.7-5.7; p < 0.001), or 10.8% (10.8%-10.8%). Calories from total beverage purchases decreased 7.4 kcal/capita/day (95% CI -7.4 to -7.3; p < 0.001), or 7.5% (95% CI -7.6% to -7.5%). A key limitation of this study is the inability to assess causality because of its observational nature. We also cannot determine whether observed changes in purchases are due to reformulation or consumer behavioral change, nor can we parse out the effects of the labeling, marketing, and school sales ban policies.

CONCLUSIONS

Purchases of high-in beverages significantly declined following implementation of Chile's Law of Food Labeling and Advertising; these reductions were larger than those observed from single, standalone policies, including sugar-sweetened-beverage taxes previously implemented in Latin America. Future research should evaluate the effects of Chile's policies on purchases of high-in foods, dietary intake, and long-term purchasing changes.

Acceptability and understanding of front-of-pack nutritional labels: an experimental study in Mexican consumers

BACKGROUND

Front-of-package labelling is a cost-effective strategy to help consumers make healthier choices and informed food purchases. The effect of labels is mediated by consumer understanding and acceptability of the label. We compared the acceptability and understanding of labels used in Latin-America among low- and middle-income Mexican adults.

METHODS

Participants (n = 2105) were randomly assigned to one of three labels: Mexican Guideline Daily Allowances (GDA), Ecuador's Multiple Traffic Lights (MTL), or Chile's Warning Labels (WL) in red. Label acceptability was evaluated through items regarding likeability, attractiveness and perceived cognitive workload. Objective understanding was evaluated by asking participants to select the product with the lowest nutritional quality among three products. We measured the time participants took to choose the product. Differences in label acceptability, understanding and time required to choose a product across labels were tested.

RESULTS

Compared to the GDA, a higher proportion of participants liked the MTL and WL, considered them attractive, and with a lower perceived cognitive workload (p < 0.05). Participants had 4.00 (2.86-5.59) times the odds of correctly identifying the product with the lowest nutritional quality when using the MTL label and 4.52 (3.24-6.29) times the odds when using the WL, in comparison to the GDA. Time required to choose the product was lower for the MTL (Median: 11.25 s; IQR = 8.00-16.09) and the WL (Median = 11.94 s, IQR = 8.56-16.52) compared to the GDA (Median: 15.31 s; IQR = 10.81-20.21; p < 0.05). No differences were observed between the MTL and the WL.

CONCLUSIONS

GDA had the lowest acceptability and understanding among the labels tested. The MTL and the WL were more accepted and understood, and allowed low- and middle-income consumers to make nutrition-quality related decisions more quickly. WL or MTL may foster healthier food choices in the most vulnerable groups in Mexico compared to the current labelling format.

Conflicting Messages on Food and Beverage Packages: Front-of-Package Nutritional Labeling, Health and Nutrition Claims in Brazil

We assessed the prevalence of front-of-package (FoP) claims in the Brazilian packaged food supply and examined whether foods with claims were more likely to be high in critical nutrients. Using data from a random 30% subsample of 11,434 foods and beverages collected in the five largest food retailers in Brazil in 2017 (n = 3491), we classified claims into nutrition, health, and environment. We examined whether foods with claims were more likely to be high in critical nutrients using 95% confidence intervals. Claims were found in 41.2% of the products. Nutrition claims were the most prevalent (28.5%), followed by health (22.1%), and environment-related claims (5.2%). More than 85% of the breakfast cereals, granola bars, and nectars contained claims, which were found in 51% of the dairy beverages. Foods with nutrition claims were more likely to be high in critical nutrients (65.3%; 95% CI 62.3, 68.2% vs. 54.1% 95% CI 52.1, 56.0). Products with health (52.9%; 95% CI 49.3, 56.4% vs. 58.5%; 95% CI 56.6, 60.3) and environment-related claims (33.5%; 95% CI 27.0, 40.8% vs. 58.6%; 95% CI 56.9, 60.2%) were less likely to be high in critical nutrients. FoP claims are prevalent in Brazil, and nutrition claims are more likely to have a poorer nutritional profile. Policymakers should consider restricting the presence of claims on unhealthy products.

How Can We Motivate People to Use Nutritional Warnings in Decision Making? Citizen Co-Created Insights for the Development of Communication Campaigns

Nutritional warnings are intended to enable citizens to make informed choice by clearly identifying food products with excessive content of nutrients associated with noncommunicable diseases. The efficacy of this public policy is expected to improve if accompanied by communication campaigns that raise awareness of the existence of nutritional warnings, as well as encourage citizens to take them into account in decision making. Because ordinary citizens have been shown to generate significantly more creative and valuable ideas than advanced users and professional developers, the aim of the present work was to obtain qualitative, citizen co-created insights for the design of a communication campaign. An online study was conducted with 518 Uruguayan citizens, recruited using a Facebook advertisement. Participants were asked to answer a series of open-ended questions about how they would encourage other people to use the warnings for making their food choices, as well as the key contents of a communication campaign. Responses were analyzed using content analysis. Results showed that, according to the participants’ accounts, an effective public awareness campaign aimed at promoting the use of nutritional warnings in decision making should include three main concepts: (a) position warnings as a cue to action for improving eating habits by enabling informed choices; (b) emphasize the benefits of using the warnings for avoiding consumption of unhealthy food and, consequently, achieving a healthier diet and an improvement in health status and quality of life; and (c) increase the perceived susceptibility and severity of the negative consequences of consumption of foods with excessive content of sugar, fat, and sodium. A communication campaign based on these key concepts could contribute to increasing the efficacy of nutritional warnings.

Front-of-pack nutritional labels: Understanding by low- and middle-income Mexican consumers

Front-of-pack labeling is a cost-effective strategy to decrease population consumption of sodium, sugar, saturated fat, total fat, and trans-fatty acids, considered critical nutrients for chronic disease. Our main objective was to explore the subjective understanding of labels that are currently used internationally among low- and middle-income Mexican consumers. We performed two phases of 10 focus groups with adolescents (13–15 y), young adults (21–23 y), mothers of children 3–12 y, fathers of children 3–12 y and older adults (55–70 y). Seven FOPL were evaluated: Guideline Daily Amounts, Multiple Traffic Light, Chilean Warning labels, Warning labels in Red, 5-Color Nutrition Label, Health Star Rating, and Healthy Choice label. Data was analyzed with a triangulation of researchers using a content analysis, based on three codes: 1) awareness and use of the Guideline Daily Amounts, 2) acceptability, and 3) subjective understanding of labels. Most participants were aware of the Guideline Daily Amounts, however they rarely used it because interpreting the information displayed on the label was too complicated. Health Star Rating, Warning labels, Multiple Traffic Light and the Healthy Choice logo labels were the most understandable, however the acceptability of the The Healthy Choice logo decreased as it did not provide information on specific ingredients. The Warning labels was the only label able to warn about critical nutrients that could represent a health risk. The Warning labels in red was more accepted compared to Warning labels in black. Results show that directive and semi-directive labels, such as Warning labels, Health Star Rating or Multiple Traffic Light, may be better at helping population of low- and middle income make healthier food choices, than non-directive FOPL such as the Guideline Daily Amounts implemented in México. The study results highlight the potential of Warning labels to support decreases in the consumption of critical ingredients in low- and middle-income Mexican consumers.

Prevalence of Child-Directed Marketing on Breakfast Cereal Packages before and after Chile's Food Marketing Law: A Pre- and Post-Quantitative Content Analysis

Food marketing has been identified as a contributing factor in childhood obesity, prompting global health organizations to recommend restrictions on unhealthy food marketing to children. Chile has responded to this recommendation with a restriction on child-directed marketing for products that exceed certain regulation-defined thresholds in sugars, saturated fats, sodium, or calories. Child-directed strategies are allowed for products that do not exceed these thresholds. To evaluate changes in marketing due to this restriction, we examined differences in the use of child-directed strategies on breakfast cereal packages that exceeded the defined thresholds vs. those that did not exceed the thresholds before (n = 168) and after (n = 153) the restriction was implemented. Photographs of cereal packages were taken from top supermarket chains in Santiago. Photographed cereals were classified as “high-in” if they exceeded any nutrient threshold described in the regulation. We found that the percentage of all cereal packages using child-directed strategies before implementation (36%) was significantly lower after implementation (21%), p < 0.05. This overall decrease is due to the decrease we found in the percentage of “high-in” cereals using child-directed strategies after implementation (43% before implementation, 15% after implementation), p < 0.05. In contrast, a greater percentage of packages that did not qualify as “high-in” used child-directed strategies after implementation (30%) compared with before implementation (8%), p < 0.05. The results suggest that the Chilean food marketing regulation can be effective at reducing the use of child-directed marketing for unhealthy food products.

The effect of 'Traffic-Light' nutritional labelling in carbonated soft drink purchases in Ecuador

Overweight and obesity have become global concerns in developed and developing countries due to their rise in recent years and their association with the prevalence of non-communicable diseases including diabetes, hypertension and cardiovascular diseases. In fact, it is estimated that roughly 39% of adults worldwide are overweight and 13% are obese. Ecuador is an example of a developing country concerned with the overweight and obesity problem, where it is estimated that 30% of children, 26% of teenagers and 63% of adults are either overweight or obese and where 1 in 4 deaths are attributed to chronic diseases. To address the overweight and obesity problem via the promotion of healthy eating habits, in 2013 the country approved technical regulation for the labelling of packed processed food products. The regulation included a mandatory traffic-light (TL) supplemental nutritional information labelling system to be displayed on the package of all processed foods for sale in the country. This new labelling system displays a traffic light panel for the product content of sugar, fat and salt in addition to the traditional nutrient declaration label. The objective of this paper was to evaluate the effect of the TL supplemental nutritional information on consumers’ buying behavior in Ecuador. More specifically, we concentrated on the purchasing behavior of carbonated soft drinks. For our analysis, we used monthly aggregated purchase data (total expenditures, quantities and average prices) of carbonated soft drinks from January 2013 to December 2015 obtained from Kantar World Panel—Ecuador. We estimated a non-linear Almost Ideal Demand System where we model the demand for high sugar and low sugar carbonated soft drinks. We found that the introduction of the traffic light supplemental nutrition labelling did not have the expected effect of reducing purchases of carbonated soft drinks during its first year of implementation, especially those high in sugar. Additionally, we found that lower income-status households tend to spend more on and consume more calories from CSD than households with higher socio-economic status. Finally, we identified that over time purchases of high sugar soft drinks decreased while purchases of low and no sugar soft drinks increased. Beyond our contribution of evaluating the effect of the traffic light on the purchases of carbonated soft drinks, we also estimated price and income elasticities of carbonated soft drinks which can be useful in the evaluation of fiscal policies.

Association of body image (dis)satisfaction and perception with food consumption according to the NOVA classification: Pró-Saúde Study

The literature on body image and food consumption has generally focused on isolated food items, while overlooking the growing role of ultra-processed foods in the overall diet. The objective of this study was to assess the association of body image (dis)satisfaction and perception with food consumption, according to the NOVA classification, which takes into account the extent and purpose of industrial food processing. A silhouette scale developed considering the Brazilian adults' Body Mass Index was used to assess body image (dis)satisfaction and perception. Food consumption was evaluated using a Food Frequency Questionnaire, and its items were categorized into three groups: unprocessed or minimally-processed foods and culinary preparations; processed foods; ultra-processed foods. The association was assessed using linear regression models. A total of 514 of Brazilian university employees were evaluated. Women dissatisfied due to excess weight consumed less unprocessed or minimally-processed foods and culinary preparations (-6.6, 95% CI: -10.7; -2.5) and more ultra-processed foods (3.7, 95% CI: 0.1; 7.2) compared to satisfied. Women that overestimated their body size consumed less unprocessed or minimally-processed food and culinary preparations (-4.2, 95% CI: -7.3; -1.1), compared to those who had not distorted body image. Food consumption appears to be more strongly associated with body image (dis)satisfaction than with perception. An association was established between body image dissatisfaction and unhealthy eating habits. This relation deserves public health attention since it may contribute to the development of chronic diseases and reduce the quality of life and body image assessment could be adopted by nutritionists and other health professionals in their practice.

The double burden of malnutrition among youth: Trajectories and inequalities in four emerging economies

As part of the nutritional transition, undernutrition is globally declining while changes brought by economic development have ushered in increases in overweight and its related economic costs and health consequences around the world. We examine trajectories in stunting and overweight from age one year to mid-adolescence and from mid-childhood to early adulthood among two cohorts from Ethiopia, India, Peru and Vietnam using data from the Young Lives study. We examine descriptive data and then model trajectories in stunting and overweight status over age. Group-based trajectory analysis with five ages of overweight and stunting for each country-cohort reveals (1) trajectories of catch-up growth for a subset of study children between the ages of 12 and 19 in the older cohort in Ethiopia (20.1% of the cohort), India (20.5%), Peru (16.9%), and Vietnam (14.0%); (2) trajectories of increasing probabilities of stunting as children age from 12 to 22 in the older cohort in India (22.2%) and Peru (30.7%); (3) trajectories of early (childhood) increases in overweight probabilities (younger cohort: India, 3.4%, Peru, 19.4%, and Vietnam, 8.1%), and of later (adolescence) increases in overweight probabilities (older cohort: Ethiopia, 0.5%, India, 6.3%, Peru, 40.9%, and Vietnam, 9.4%). Multinomial logit prediction of membership in trajectory categories reveals that higher wealth quartiles and maternal schooling are protective against high stunting probability trajectory group membership, but higher wealth and urban residence predict high overweight probability trajectory group membership. This evidence suggests a window of opportunity for interventions to reduce stunting and to avert overweight development in adolescence, in addition to the often-emphasized first 1000 days after conception. A life-course approach to policies and programs to target both undernutrition and overweight should be considered.

Development of the Chilean front-of-package food warning label

BACKGROUND

Front-of package (FoP) nutrition labels are an option to guide consumer's decision at the point of food purchase. Chile was the first country worldwide to implement a FoP warning label and thereafter several countries have followed this model. The objective of this study is to describe the process of development of the Chilean FoP warning label.

METHODS

A stepwise study was conducted including literature review, qualitative phase (lay audience & expert group meetings) and quantitative phase in women/adolescents from low-middle-socioeconomic status neighborhoods, Santiago, Chile (2 sub-studies, using point-of-sale questionnaires). Outcomes were prototype visualization, ease of understanding, and ability to modify purchase behavior.

RESULTS

The literature review and qualitative phase provided information on general text (e.g. short wording) and design characteristics (e.g. use of a logo, use of red or black colors); based on these characteristics 15 prototypes were created and quantitatively tested. In the first survey, a black-&-white stop sign and a black-&-white hand were preselected; in the second survey, the stop sign stating 'Excess of ' had significantly better performance than the hand in terms of visualization, intention to purchase, and ability to modify intended purchase. Due to legal reasons the "excess of" was replaced by "high-in" in the final implementation of the law.

CONCLUSIONS

A simple black-&-white stop sign warning label was the best option to flag pre-packaged foods with an excess of energy or nutrients of concern for non-communicable diseases; this FoP warning label was implemented in Chile in June 2016 as part of the Chilean Food Labeling and Marketing Law.

Relative Impact of Nutritional Warnings and Other Label Features on Cereal Bar Healthfulness Evaluations

OBJECTIVE

To investigate the relative influence of nutritional warnings and 2 marketing strategies commonly used in food labels, nutrient claims, and fruit images on consumers' healthfulness judgments.

DESIGN

Labels of cereal bars were designed according to a full factorial design with 3 2-level variables: images of fruit (with vs without), nutrient claims about the fiber content (with vs without), and nutritional warnings about excessive content of sugar and saturated fat (with vs without).

SETTING

Experiment conducted in Montevideo, Uruguay.

PARTICIPANTS

One hundred Uruguayan people, 75% female, aged 18-56 years.

MAIN OUTCOME MEASURES

Healthfulness perception and eye-tracking variables.

ANALYSIS

The researchers used ANOVA to evaluate the influence of the experimental design's variables on perceived healthfulness and eye-tracking measures.

RESULTS

Nutritional warnings caught participants' attention and reduced the amount of visual attention needed to evaluate healthfulness. Participants mainly relied on nutritional warnings to make healthfulness judgments.

CONCLUSIONS AND IMPLICATIONS

Findings of the current work confirm the potential of nutritional warnings to influence consumers' healthfulness perception, overriding the effect of other label cues used by the food industry to convey the concept of healthfulness.

Consumers' opinions on warning labels on food packages: A qualitative study in Brazil

This study aimed to assess consumers’ uses of and opinions on the current Brazilian food label and their reaction to the introduction of a front-of-package warning label. We conducted 12 focus groups among a diverse sample of adult consumers, to broadly assess: (1) uses of and perceptions about the current food label, and (2) opinions about implementing a front-of-package warning label to guide food purchases. Data was analyzed with a triangulation of researchers using an exploratory content analysis, which allowed codes to emerge from the data. The frequency of codes across focus groups was compared by gender and socioeconomic status to explore differences by these sociodemographic factors. Codes were divided into six main themes: (1) “Reasons for using food labels”; (2) “Barriers to using food labels”; (3) “Requirements for a new label”; (4) “Perceived influence on consumption behaviors”; (5) “Perceived influence on child behaviors”; and (6) “Perceptions of the food manufacturers using of warning labels”. Participants used food labels to check nutrient content and ingredient information but the format of these labels and the technicality of the content displayed often made the information inaccessible, particularly for those with low socioeconomic status. Most participants were supportive of the display of front-of-package warning labels on products and considered them useful to inform purchases. Women believed that they and their children would reduce the consumption of foods with front-of-package warning labels, while men reported more polarity in their intentions. For men and their children, front-of-package warning labels would result in either stopping food intake entirely or continued consumption without changes to the amount. The study results highlight the potential of front-of-package warning labels to support healthier behaviors in both consumers and their children.

Nutrition Quality of Packaged Foods in Bogotá, Colombia: A Comparison of Two Nutrient Profile Models

BACKGROUND

Front-of-package warning labels are an increasingly common policy and have been implemented to inform consumers of the nutritional quality of ultra-processed foods. This study examined the proportion of Colombian products that could be subjected to such regulations.

METHODS

Two nutrition profile models were compared: the Pan American Health Organization (PAHO) model, and the nutrient profile established under the Chilean food labeling and advertising law (Chilean model). Products (n = 6708) exceeding nutrient criteria based on each model were identified as subject to regulation.

RESULTS

A total of 80.2% (PAHO model) to 66.4% (Chilean model) of foods met the criteria for regulation. The categories with the highest proportion of regulated products were meats (97.3% PAHO model; 87.5% Chilean model), sweets (95.6% PAHO) and snacks (Chilean model). The category with the lowest proportions of regulated products were cereals (47.3% PAHO model) and miscellaneous foods and fish/seafood (39.0% and 39.5%, respectively, Chilean model).

CONCLUSIONS

Under both the PAHO and Chilean nutrient profile models, the majority of packaged foods available in Bogotá would be eligible to receive front-of-package warning labels. These results suggest a warning label law could have a major impact on the Colombian food supply, especially in the context of the growing prevalence of diet-related chronic diseases in Colombia.

Structural responses to the obesity and non-communicable diseases epidemic: Update on the Chilean law of food labelling and advertising

Chile approved the law of food labelling and advertising in 2012; this law aims to address the obesity epidemic, particularly in children. The implementation details were published in 2015, and the law was implemented finally in 2016, as described in the current article. Regulated foods were defined based on a specially developed nutrient profiling, which considered natural foods as gold standard. For liquid foods, amounts of energy, sugars, saturated fats, and sodium in 100 mL of cow's milk were used as cut-offs. For solid foods, values within the 90th - 99th percentile range for energy and critical nutrients were selected as cut-off within a list of natural foods. A stop sign stating "High in <nutrient>" was chosen as warning label for packaged regulated foods. Regulated foods were also forbidden to be sold or offered for free at kiosks, cafeterias, and feeding programme at schools and nurseries. Besides, regulated foods cannot be promoted to children under 14 years. A staggered implementation of the regulation was decided, with nutrients cut-offs becoming increasingly stricter over a 3-year period. These regulatory efforts are in the right direction but will have to be sustained and complemented with other actions to achieve their ultimate impact of halting the obesity epidemic.

Can front-of-pack nutrition labeling influence children's emotional associations with unhealthy food products? An experiment using emoji

Food products targeted at children are usually marketed using persuasive elements aimed at creating positive hedonic and emotional associations. For this reason, changes in children's emotional associations with unhealthy food products can discourage their consumption. In this context, the aim of the present study was to compare children's emotional associations with food products featuring different front-of-pack (FOP) nutrition labelling schemes. A total of 492 children (6-12 years old) were randomly divided into three groups, each of which evaluated a series of packages featuring different FOP nutrition labelling schemes: guidelines daily amount (GDA), traffic light system (TLS) and nutritional warnings. For each of the six packages and three unpackaged products, children were asked to select all the emoji from a list that described how they would feel eating the product. Data were analyzed using generalized linear models. FOP nutrition labelling significantly influenced the frequency of use five of the 16 emoji. In general, children who evaluated packages with directive and semi-directive schemes used emoji associated with positive emotions less frequently than those who evaluated packages with the GDA system. The effect of FOP nutrition labelling scheme on emotional associations was moderated by age and type of school. The effect of directive and semi-directive FOP nutritional schemes, in special nutritional warnings, tended to be higher for younger children and children from public schools. These results suggest that FOP nutrition labelling may contribute to discouraging consumption of products with high content of nutrients associated with non-communicable diseases among children.

Nutrient-Based Warning Labels May Help in the Pursuit of Healthy Diets

In this commentary we argue that the newest paradigm of front-of-package labels, represented by the characteristics found in the Chilean warning label, has the greatest potential to promote healthy diets compared with the Keyhole symbol, the multiple traffic light label, the Health Star Ratings system, and the 5-Color Nutrition label. Warning labels: (1) are consistent in the information they communicate; (2) discourage the purchase and consumption of noncore foods that characterize unhealthy diets; (3) are more likely to reinforce other regulatory measures; and (4) are more likely to encourage reformulation and are less likely to be used as a marketing tool by the food industry. Ongoing empirical evaluation of the impact of warning labels on consumer behavior and product reformulation is essential.

Do manufacturer ‘nutrient claims’ influence the efficacy of mandated front-of-package labels?

Objective

To examine consumers’ ability to correctly interpret front-of-package (FOP) ‘high in’ warnings in the presence of a voluntary claim for the same or a different nutrient.

Design

A between-group experimental task assigned respondents to view food products labelled as ‘high in sodium’, with a ‘reduced sodium’ claim positioned next to the warning, away from the warning or absent. A second experiment assigned participants to view a food product labelled as ‘high in sugar’, with a ‘reduced fat’ claim positioned next to the warning, away from the warning or absent. For both tasks, respondents were asked to identify whether the products were high in the indicated nutrient.

Setting

Online survey (2016).

Subjects

Canadians aged 16–32 years (n 1000) were recruited in person from five major cities in Canada.

Results

Respondents were less likely to correctly identify a product as ‘high in sodium’ when packages also featured a voluntary ‘reduced sodium’ claim, with a stronger effect when the claim was positioned away from the FOP symbol (P<0·001). The number of correct responses was similar across conditions when the nutrient claim was for a different nutrient than the one featured in the FOP ‘high in’ warning.

Conclusions

The findings demonstrate that the presence of a voluntary nutrient claim can undermine the efficacy of mandated FOP labels for the same nutrient. Countries considering nutrient-specific FOP warnings, including Canada, should consider regulations that would prohibit claims for nutrients that exceed the threshold for nutrient-specific FOP warnings.

Influence of nutritional warnings and other label features on consumers' choice: Results from an eye-tracking study

Nutritional warnings highlighting products with high content of nutrients associated with non-communicable diseases have emerged as a potentially efficient alternative to discourage consumption of unhealthful products. However, the relative influence of this front-of-pack nutrition information scheme compared to other label features is still under researched. In this context, the aim of the present work was to study the influence of nutritional warnings and other information commonly displayed on food labels to convey health associations on consumers' choice and visual attention. A choice-conjoint study using labels of cookies and crackers was implemented considering the following three variables: front-of-pack nutrition information (nutritional warnings vs. facts up front panel), nutrient claim (present vs. absent) and type of product (conveying health vs. hedonic associations). A total of 124 people completed the task using the monitor of an eye-tracker. Participants were asked to select the label they would prefer to buy if they were in a supermarket. Nutritional warnings were efficient in attracting consumers' attention and required less time and fewer fixations to process than the facts up front panel. In addition, their inclusion on the labels significantly discouraged consumers' choice of labels. However, type of product was the most important variable influencing the choice of both cookies and crackers. Results from the present work confirm the potential of nutritional warnings as directive front-of-pack nutrition labelling scheme and stress that they cannot be expected to cause radical changes in consumers' eating habits due to their competition with other product features. Instead, they are expected to encourage consumers to select the most healthful option within a product category.

A citizen perspective on nutritional warnings as front-of-pack labels: insights for the design of accompanying policy measures

Objective

Nutritional warnings have recently been suggested as a simplified front-of-pack nutrition labelling scheme to facilitate citizens’ ability to identify unhealthful products and discourage their consumption. However, citizens’ perspective on this policy is still under-researched. The objective of the present work was to study how citizens perceive nutritional warnings and to evaluate public support of this policy, with the goal of deriving recommendations for the design of policy measures accompanying the introduction of nutritional warnings.

Design

An online survey with 1416 Uruguayan citizens, aged 18–75 years, 61 % female, was conducted. Participants had to answer a series of questions (open-ended and multiple-choice) related to their perception of warnings as a front-of-package nutrition labelling scheme.

Results

Participants showed a positive attitude towards nutritional warnings, which were regarded as easy to understand and to identify on food packages. The majority of respondents emphasized that they would take nutritional warnings into account when making their food choices, stating that they would allow them to make informed choices and, consequently, to increase the quality of their diet and their health status. Health motivation appeared as a crucial driver for taking nutritional warnings into consideration.

Conclusions

A high level of public support for nutritional warnings was observed. Responses can be used to derive a range of recommendations for a policy mix that should synergistically support the introduction of nutritional warnings and encourage citizens to take them into account when making their food purchases.

The Impact of the Australasian 'Health Star Rating', Front-of-Pack Nutritional Label, on Consumer Choice: A Longitudinal Study

Front-of-pack (FoP) nutrition labels are a widely deployed tool in public good marketing. This article reports on a field experimental test of the impact of one of these systems, the Australasian Health Star Rating system (HSR), on consumer choice in the breakfast cereals category in New Zealand. This study forms part of a time-series replication stream of research on this topic. The research applied a 2 × 2 factorial design with multiple replications to retail food consumers exiting from supermarkets in New Zealand. The first part of the time series, undertaken shortly after the HSR’s initiation in 2014, indicated that the HSR was ineffective. Between 2014 and 2016, commercial brands in the category within New Zealand massively promoted the HSR as a basis for consumer choice. The research presented in this article forms part of the second part of the series, undertaken in 2016, using an identical experimental methodology to the 2014 study. The results indicate that the HSR may be beginning to influence consumer choice as it was predicted to, but the impact of the system is still small, and statistically sub-significant, relative to other consumer decision inputs presented on the package.

Traffic Light System Can Increase Healthfulness Perception: Implications for Policy Making

OBJECTIVE

To evaluate how information about low nutrient content included in the traffic light labeling system influences consumers' perception of the healthfulness of products with high content of 1 key nutrient, and to compare the traffic light system with warnings in terms of the perception of healthfulness.

DESIGN

Images of front-of-pack (FOP) nutrition labels (the traffic light labeling system with different numbers of nutrients with low content, and warnings) were evaluated in study 1, whereas product labels featuring the different FOP nutrition labels were evaluated in study 2.

SETTING

Online studies conducted in Montevideo, Uruguay.

PARTICIPANTS

A total of 1,228 Uruguayan Facebook users.

MAIN OUTCOME MEASURES

Perception of healthfulness.

ANALYSIS

The researchers used ANOVA to evaluate the influence of FOP nutrition labels on perceived healthfulness.

RESULTS

The inclusion of information about low nutrient content in the traffic light system statistically significantly increased the perception of the healthfulness of products with high nutrient content. Nutritional warnings showed healthfulness ratings similar to those of the simplified version of the traffic light system.

CONCLUSIONS AND IMPLICATIONS

Information about low nutrient content in the traffic light system might be used to infer health, and thus could raise the perception of healthfulness and decrease the traffic light system's efficacy in discouraging the consumption of unhealthful products. A simplified version of the traffic light highlighting only high-nutrient content or nutritional warnings seems to overcome this problem.

Comparative Analysis of the Classification of Food Products in the Mexican Market According to Seven Different Nutrient Profiling Systems

Nutrient profiling systems (NPS) are used around the world. In some countries, the food industry participates in the design of these systems. We aimed to compare the ability of various NPS to identify processed and ultra-processed Mexican products containing excessive amounts of critical nutrients. A sample of 2544 foods and beverages available in the Mexican market were classified as compliant and non-compliant according to seven NPS: the Pan American Health Organization (PAHO) model, which served as our reference, the Nutrient Profiling Scoring Criterion (NPSC), the Mexican Committee of Nutrition Experts (MCNE), the Health Star Rating (HSR), the Mexican Nutritional Seal (MNS), the Chilean Warning Octagons (CWO) 2016, 2018 and 2019 criteria, and Ecuador's Multiple Traffic Light (MTL). Overall, the proportion of foods classified as compliant by the HSR, MTL and MCNE models was similar to the PAHO model. In contrast, the NPSC, the MNS and the CWO-2016 classified a higher amount of foods as compliant. Larger differences between NPS classification were observed across food categories. Results support the notion that models developed with the involvement of food manufacturers are more permissive than those based on scientific evidence. Results highlight the importance of thoroughly evaluating the underlying criteria of a model.

Obesity Prevention: Strategies and Challenges in Latin America

PURPOSE OF REVIEW

The purpose of this study is to present changes of policies and norms aimed to reduce obesity levels that have been adopted in some Latin American countries.

RECENT FINDINGS

The global increase of the excess weight within the population has been demanding governmental actions aimed at preventing health impacts generated by obesity. Over recent years, many Latin American countries have established a number of regulations aimed at reducing weight in the population using interventions that could effectively prevent childhood obesity, including the taxation of sugar-sweetened beverages (SSBs), increasing physical activity in open spaces, and, especially, front-of-package labeling. Some strategies are part of the Action Plan for Prevention of Child and Adolescence Obesity signed by all countries in Latin America, which currently have among the highest prevalence of childhood obesity in the world. Among them are the implementation of fiscal policies on energy-dense and nutrient-poor foods and taxes on SSBs; improvements in nutrition labeling, highlighting the front-of-package (FOP) labeling to promote the choice of healthier products at the time of purchase; and promotion of an active lifestyle, such as encouraging the use of bicycle paths or physical activity programs at school. The real impact of these prevention strategies implemented in Latin America on the prevalence of obesity is still unknown.