Effects of front-of-package and shelf nutrition labeling systems on consumers

The impact of the Nutri-Score nutrition label on perceived healthiness and purchase intentions

Making healthier food choices easier at the time of purchase is a challenge for public policy makers. The Nutri-Score can be an effective tool for guiding and steering consumers toward more informed, healthier purchasing decisions. This research investigates the impact of the presence of the Nutri-Score and its five categories on consumers' perceived healthiness perceptions and purchase intentions. Consumers in the EU took part in two online experiments, in which they rated products from different categories, with or without Nutri-Scores, in terms of their perceived healthiness and purchase intentions. The presence of the Nutri-Score enabled respondents to assess the healthiness of products better; furthermore, it offers the potential to boost sales of healthy products, without affecting sales of unhealthy products. Perceived healthiness mediates the relationship between Nutri-Score categories and purchase intentions, and focusing on the healthiness of products can give producers a competitive advantage, regardless of whether it is a manufacturer brand or a private label. These findings offer actionable insights for public policy makers and manufacturers; they also suggest the need to embrace the Nutri-Score as the standard front-of-pack label to help fight the increasing obesity pandemic.

Proteomic profile of preeclampsia in the first trimester of pregnancy

OBJECTIVE

Preeclampsia (PE) is a leading cause of pregnancy-associated maternal and neonatal morbidity and mortality. Detection of patients at risk before the clinical onset of PE is a priority. Proteomics have become a valuable tool for the discovery of new biomarkers; however, the understanding of the underlying mechanism is necessary. The aim of the study was to determine differences between proteomic serum profiles of PE and normotensive pregnancies using quantitative and qualitative approaches.

STUDY DESIGN

Serum samples from pregnant women were taken at 10-12 weeks of gestation with follow-up to determine PE development. Samples were analyzed using nano 2-D liquid chromatography UPLC and qTOF-MS/MS.

RESULTS

A total of 136 women were recruited, of which eight (5.9%) developed PE, and eight normotensive were randomly selected as a control group for comparison. A different profile was obtained between groups. Nine proteins showed quantitative differences with fold-change over 1.5: PRRC2C (217.02), HEATR5A (179.46), ATP6 (162.38), PRRC2B (83.09), RBM25 (5.36), NUP205 (3.38), HLA-I (2.27), ZC3H13 (2.15), and SREK1 (1.66); and two under 0.66: Importin-4 (0.55) and Cytochrome b (0.26). Using bilateral Fisher's exact test for the qualitative approach, LRRK1 had statistical significance (p = .044), while PRRC2B (p = .121), PRRC2C (p = .134), and NUP205 (p = .134) showed a tendency to be present in PE.

CONCLUSION

The found proteins have plausibility with the early pathophysiological events that have been associated with this pathology. Further studies should be performed to confirm these findings and elucidate their specific roles.

Association between nutritional profiles of foods underlying Nutri-Score front-of-pack labels and mortality: EPIC cohort study in 10 European countries

OBJECTIVE

To determine if the Food Standards Agency nutrient profiling system (FSAm-NPS), which grades the nutritional quality of food products and is used to derive the Nutri-Score front-of-packet label to guide consumers towards healthier food choices, is associated with mortality.

DESIGN

Population based cohort study.

SETTING

European Prospective Investigation into Cancer and Nutrition (EPIC) cohort from 23 centres in 10 European countries.

PARTICIPANTS

521 324 adults; at recruitment, country specific and validated dietary questionnaires were used to assess their usual dietary intakes. A FSAm-NPS score was calculated for each food item per 100 g content of energy, sugars, saturated fatty acids, sodium, fibre, and protein, and of fruit, vegetables, legumes, and nuts. The FSAm-NPS dietary index was calculated for each participant as an energy weighted mean of the FSAm-NPS score of all foods consumed. The higher the score the lower the overall nutritional quality of the diet.

MAIN OUTCOME MEASURE

Associations between the FSAm-NPS dietary index score and mortality, assessed using multivariable adjusted Cox proportional hazards regression models.

RESULTS

After exclusions, 501 594 adults (median follow-up 17.2 years, 8 162 730 person years) were included in the analyses. Those with a higher FSAm-NPS dietary index score (highest versus lowest fifth) showed an increased risk of all cause mortality (n=53 112 events from non-external causes; hazard ratio 1.07, 95% confidence interval 1.03 to 1.10, P<0.001 for trend) and mortality from cancer (1.08, 1.03 to 1.13, P<0.001 for trend) and diseases of the circulatory (1.04, 0.98 to 1.11, P=0.06 for trend), respiratory (1.39, 1.22 to 1.59, P<0.001), and digestive (1.22, 1.02 to 1.45, P=0.03 for trend) systems. The age standardised absolute rates for all cause mortality per 10 000 persons over 10 years were 760 (men=1237; women=563) for those in the highest fifth of the FSAm-NPS dietary index score and 661 (men=1008; women=518) for those in the lowest fifth.

CONCLUSIONS

In this large multinational European cohort, consuming foods with a higher FSAm-NPS score (lower nutritional quality) was associated with a higher mortality for all causes and for cancer and diseases of the circulatory, respiratory, and digestive systems, supporting the relevance of FSAm-NPS to characterise healthier food choices in the context of public health policies (eg, the Nutri-Score) for European populations. This is important considering ongoing discussions about the potential implementation of a unique nutrition labelling system at the European Union level.

Low-Income Parents' Use of Front-of-Package Nutrition Labels in a Virtual Supermarket

OBJECTIVE

To examine the impact front-of-package nutrition labels (FOPLs) have on decision-making abilities among low-income parents in a virtual supermarket.

DESIGN

A 4-by-2 experimental design with 3 FOPLs (summary, nutrient-specific, hybrid) and a no-FOPL comparison. Within the FOPL condition, participants either shopped with a time limit (10 minutes) or with no time limit.

SETTING

A web-based, 3-dimensional virtual supermarket.

PARTICIPANTS

Parents (n = 1,452) from low-income households with at least 1 child aged 4-12 years.

MAIN OUTCOMES MEASURED

Index derived from the United Kingdom's Nutrient Profiling Model that summarized the overall nutrient profile of the participant's shopping basket.

ANALYSIS

Analysis of covariance with post hoc estimations (pairwise) of condition means adjusted for multiple comparisons.

RESULTS

All FOPLs led to healthier nutrient profiles than the no-FOPL condition (P < .001). Simple FOPLs (ie, summary, hybrid) led to healthier nutrient profiles than nutrient-specific FOPLs (P = .02 and P < .001, respectively). Among parents exposed to simple FOPLs, those under time pressure made less healthy choices than those who were not under time pressure (P = .05 and P = .03, respectively). Time pressure did not affect parents exposed to nutrient-specific FOPLs (P = .69).

CONCLUSIONS AND IMPLICATIONS

Front-of-package nutrition labels can aid parents in selecting healthier products. Simple FOPLs provide greater utility for selecting healthier products than FOPLs that present an array of nutrient information. Time pressure can influence how parents interact with different types of label information.

Consumers' reactions to nutrition and ingredient labelling for wine - A cross-country discrete choice experiment

The purpose of this study is to examine consumers' reactions to the introduction of nutrition and ingredient labelling for wine, a product that is so far still exempt from mandatory nutrition and ingredient labelling. It also analyses the effect of positive and negative information about the use of ingredients in wine on consumers' choice. Representative samples for wine consumers from three distinctly different countries representing old and new wine markets (Australia, n = 745; Germany, n = 716; Italy, n = 715) completed a discrete choice experiment (DCE) with graphically simulated wine back labels. For each country, respondents were randomly allocated to a reference group and two different treatment conditions where they received newspaper-like information (positive, negative) before making choices. Results for the reference condition show that consumers across all three countries have a significant positive utility for detailed nutrition information. Instead, ingredient information only receives a positive utility in Italy, whereas German and Australian respondents do not receive utility from ingredient labelling. When consumers in the treatment group are confronted with negative media information the attribute importance of ingredients significantly increases across all three countries, clean labelled products without ingredients are preferred, and a significantly higher share of consumers in Germany and Italy prefer not to buy any wine. The treatment effect of positive media information on consumers' wine choice is lower than that of negative information. The results of the study have implications for the pending new regulation of wine labelling and for communication strategies of the wine industry that should actively inform consumers about the necessity of ingredients in wine production.

Effects on consumers' subjective understanding of a new front-of-pack nutritional label: a study on Italian consumers

Front-of-pack nutritional label (FOPL) systems have been developed worldwide to amplify and simplify nutritional information and induce healthier choices. This study explores consumers' internal reactions - in terms of subjective understanding and liking - to a new FOPL: the NutrInform Battery. The investigation aims to assess the clear comprehension by consumers of the information provided by the NutrInform Battery FOPL scheme, based on a sample of 200 Italian respondents, in a real-life setting, with products representative of the most widely consumed food categories, using a between-subject design. Participants were randomly assigned to one of the two conditions: products marked with NutrInform Battery or Nutri-Score labels. The results provided evidence of the effectiveness of NutrInform Battery in being perceived by consumers as an informative FOPL scheme. Specifically, consumers found NutrInform Battery more informative and helpful than Nutri-Score in terms of their understanding of the product composition.

Effectiveness of Different Front-of-Pack Nutrition Labels among Italian Consumers: Results from an Online Randomized Controlled Trial

In Italy, discussions are currently ongoing to implement a front-of-pack nutrition label (FoPL) while a growing number of European countries are adopting the Nutri-Score. The effectiveness of the Nutri-Score among Italian consumers requires further investigation. This study compared five FoPLs among Italian participants (Health Star Rating system, multiple traffic lights, Nutri-Score, reference intakes, warning symbol) in terms of food choices and understanding of the labels by consumers. In 2019, 1032 Italian consumers completed an online survey in which they were asked to select one product they would likely purchase from a set of three foods with different nutrient profiles and then classify the products within the set according to their nutritional quality, first with no label and then with one of the five FoPLs on the pack. While no significant difference across labels was observed for food choices, the Nutri-Score demonstrated the highest overall performance in helping consumers to correctly rank the products according to their nutritional quality compared to the reference intakes (OR = 2.18 (1.50–3.17), p-value < 0.0001). Our results provide new insights on the effectiveness of the Nutri-Score, which would be a relevant tool to inform Italian consumers on the nutritional quality of food products.

The Effect of Dynamic Food Labels with Real-Time Feedback on Diet Quality: Results from a Randomized Controlled Trial

The rising prevalence of non-communicable diseases has brought attention to the importance of consuming a healthy diet. One strategy to improve diet quality is through front-of-pack (FOP) nutrition labels. Taking advantage of an online grocery store, we allowed consumers to choose the FOP labels they preferred, and combined this information with real-time feedback on the overall nutritional quality of the shopping basket. We hypothesized that these dynamic food labels with real-time feedback (DFLF) would improve nutritional quality of food purchases. This trial followed a two-arm (no-label control and DFLF) crossover design with 125 participants exposed to each condition once in random order via an online grocery store. A first difference regression model allowed for estimating the unbiased effect of the DFLF on diet quality, measured by the weighted average Nutri-Score (ranging 1 to 5) per serving (primary) and changes in select nutrients and calories. The mean weighted Nutri-Score was 0.4 (12.6%) higher in the DFLF arm (CI: [0.2, 0.6]) relative to the control. The DFLF also decreased the amount of sugar per serving by 0.9 g (CI: [−1.7, −0.0]) and total sugar per shop by 169.5 g (CI: [−284.5, −54.5]). The DFLF features significantly improved nutrition quality relative to no labelling, as measured by average Nutri-Score values. These results shed light on the considerable potential of the online shopping environment to improve diet quality through customization and real time feedback.

Impact of sugar taxes and front-of-package nutrition labels on purchases of protein, calcium and fibre

Taxes and front-of-package (FOP) labels can be effective interventions for reducing consumption of sugar, saturated fat, and sodium; however, few studies have examined their impact on intake of 'positive' nutrients. The current study explored the impact of sugar taxes and FOP labels on the protein, calcium and fibre density of snack food purchases. A total of 3584 Canadians aged 13 years and older participated in an experimental marketplace using a 3 × 8 between-within group experiment. Participants received $5 and viewed images of 20 snack food products available for purchase. Participants were randomized to one of five FOP label conditions (no label, high in, multiple traffic light, health star rating, or nutrition grade) and completed three within-subject purchasing tasks with different sugar tax conditions (no tax, 20%, tiered). Upon conclusion, participants received the product and any change from one of the purchasing tasks. The results indicate that participants purchased snack foods with higher fibre density when either sugar tax was applied (+0.1 g/100 kcal) compared to no tax, and when they were assigned to see the multiple traffic light (+0.4 g/100 kcal) or health star rating (+0.3 g/100 kcal) FOP labels, compared to no FOP label. There were no significant differences in the protein or calcium density of snack foods purchased across the tax or FOP labelling conditions. Overall, the findings suggest that as consumers respond to tax or labelling policies by moving away from sugars, sodium, and saturated fat, there may be no downside-or even an increase-in 'positive' nutrient density.

Salient nutrition labels shift peoples' attention to healthy foods and exert more influence on their choices

Nutrition labels are the most commonly used tools to promote healthy choices. Research has shown that color-coded traffic light (TL) labels are more effective than purely numerical Guideline Daily Amount (GDA) labels at promoting healthy eating. While these effects of TL labels on food choice are hypothesized to rely on attention, how this occurs remains unknown. Based on previous eye-tracking research we hypothesized that TL labels compared to GDA labels will attract more attention, will induce shifts in attention allocation to healthy food items, and will increase the influence of attention to the labels on food choice. To test our hypotheses, we conducted an eye-tracking experiment where participants chose between healthy and unhealthy food items accompanied either by TL or GDA labels. We found that TL labels biased choices towards healthier items because their presence caused participants to allocate more attention to healthy items and less to unhealthy items. Moreover, our data indicated that TL labels were more likely to be looked at, and had a larger effect on choice, despite attracting less dwell time. These results reveal that TL labels increase healthy food choice, relative to GDA labels, by shifting attention and the effects of attention on choice.

Front of pack nutritional labelling schemes: a systematic review and meta-analysis of recent evidence relating to objectively measured consumption and purchasing

BACKGROUND

Front of pack labelling (FOPL) provides visible nutritional information and appears to influence knowledge and reformulation. However, a recent Cochrane review found limited and inconsistent evidence for behaviour change. The present review aimed to examine studies published subsequent the Cochrane review, focusing on prepackaged foods, examining the impact of FOPL on purchasing and consumption.

METHODS

Controlled experimental/intervention and interrupted time series (ITS) studies were included, with no age/geography restrictions. Exposures were FOPL with objectively measured consumption/purchasing outcomes. Thirteen databases were searched (January 2017 to April 2019) and forward citation searching was undertaken on the included studies. Purchasing data from experimental studies were meta-analysed. Two series of meta-analyses were undertaken; combined FOPL versus no-FOPL and specific FOPL scheme versus no-FOPL. Outcomes were sugar (g 100 g^-1 ), calories (kcal 100 g^-1 ), saturated fat (g 100 g^-1 ) and sodium (mg 100 g^-1 ).

RESULTS

We identified 14 studies, reporting consumption (experimental; n = 3) and purchasing (n = 8, experimental; n = 3, ITS). Meta-analysis of experimental studies showed sugar and sodium content of purchases was lower for combined FOPL versus no-FOPL (-0.40 g sugar 100 g^-1 , P < 0.01; -24.482 mg sodium 100 g^-1 , P = 0.012), with a trend for lower energy and saturated fat (-2.03 kcal 100 g^-1 , P = 0.08; -0.154 g saturated fat 100 g^-1 , P = 0.091). For specific FOPL, products purchased by 'high in' FOPL groups had lower sugar (-0.67 g sugar 100 g^-1 , P ≤ 0.01), calories (-4.43 kcal 100 g^-1 , P < 0.05), sodium (-33.78 mg 100 g^-1 , P = 0.01) versus no-FOPL; Multiple Traffic Light had lower sodium (-34.94 mg 100 g^-1 , P < 0.01) versus no-FOPL. Findings regarding consumption were limited and inconsistent. FOPL resulted in healthier purchasing in ITS studies.

CONCLUSIONS

This review provides evidence from experimental and 'real-life' studies indicating that FOPL encourages healthier food purchasing. PROSPERO CRD42019135743.

Performance of the Front-of-Pack Nutrition Label Nutri-Score to Discriminate the Nutritional Quality of Foods Products: A Comparative Study across 8 European Countries

Abstract: In Europe, discussions are currently ongoing to harmonize front-of-pack nutritional labelling, while some countries have adopted or are considering implementing the Nutri-Score. However, its adaptability to multiple nutritional contexts in Europe requires further investigation. This study aimed to evaluate the applicability of the Nutri-Score in various European countries, regarding its ability to discriminate the nutritional quality of foods and its consistency with national dietary recommendations. The European Food Information Resource (EUROFIR) nutritional composition databases from eight European countries (Finland, France, Norway, Poland, Portugal, Slovakia, Sweden, and Switzerland) were used. The distribution of foods across the Nutri-Score classes within food groups was assessed, as well as the discriminating performance of the label, and the adequacy of nutritional recommendations. The Nutri-Score demonstrated high discriminating ability for all food groups, with similar trends in the eight countries, and consistency with nutritional recommendations. For instance, fruit and vegetable products were mainly classified in the two healthiest Nutri-Score categories, while sugar and animal fat products were mainly classified in the two less healthy categories of the Nutri-Score. Our results support the fact that the Nutri-Score would be a relevant tool to discriminate the nutritional quality of products within and across relevant food groups in different European countries, with consistency with nutritional recommendations.

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.

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).

Strategies used by the Canadian food and beverage industry to influence food and nutrition policies

BACKGROUND

Unhealthy food environments contribute to the rising rates of obesity and diet-related diseases. To improve the Canadian nutritional landscape, Health Canada launched the Healthy Eating Strategy in October 2016 which involved several initiatives including the restriction of unhealthy food marketing to children, the reduction of sodium in the food supply and the introduction of front-of-package labelling. Subsequently, various stakeholders engaged in discussions with Health Canada. This study sought to describe the interactions between Health Canada and industry and non-industry stakeholders and to identify the strategies used by industry to influence food and nutrition policy in Canada.

METHODS

Documents such as correspondences and presentations exchanged in interactions between Health Canada and stakeholders regarding the Healthy Eating Strategy were obtained from Health Canada's Openness and Transparency website. The participating stakeholders of each interaction and the topics discussed were determined and described quantitatively. A directed content analysis was then conducted to identify the strategies employed by industry to influence policy. This was guided by a previously developed coding framework that was adapted during analysis.

RESULTS

A total of 208 interactions concerning the Healthy Eating Strategy occurred between October 2016 and June 2018. Of the interactions for which documents were received (n = 202), 56% involved industry stakeholders, 42% involved non-industry stakeholders and 2% involved both. Industry stakeholders were more likely to initiate interactions with Health Canada (94% of their interactions) than non-industry stakeholders (49%). Front-of-package labelling was the most frequently discussed topic by industry stakeholders (discussed in 49% interactions involving industry) while non-industry stakeholders most frequently discussed the Healthy Eating Strategy as a whole (discussed in 37% of interactions involving non-industry). A wide variety of strategies were used by industry in their attempts to influence policy. Those most frequently identified included: "framing the debate on diet- and public health-related issues", "promoting deregulation", "shaping the evidence base", "stressing the economic importance of industry", and "developing and promoting alternatives to proposed policies".

CONCLUSION

Industry stakeholders are highly active in their attempts to influence Canadian nutritional policies. Policymakers and public health advocates should be aware of these strategies so that balanced and effective food and nutrition policies can be developed.

Improving Nutrition Information in the Eastern Mediterranean Region: Implementation of Front-Of-Pack Nutrition Labelling

The provision of simplified nutrition information, in a prominent place on the front of food packages, is recommended as an important element of comprehensive strategies to tackle the burden of death and disease caused by unhealthy diets. There is growing evidence that front-of-pack nutrition labels are preferred by consumers, are more likely to be looked at or noticed than nutrition labelling on the back or side of packages and can help consumers to better identify healthier and less healthy products. This review summarizes current implementation of front-of-pack nutrition labelling policies in the countries of the WHO Eastern Mediterranean Region. Implementation of front-of-pack nutrition labelling in the Eastern Mediterranean Region remains limited, but three types of scheme were identified as having been implemented or at an advanced stage of development by governments in six countries. Through a review of reviews of existing research and evidence from country implementation, the authors suggest some pointers for implementation for other countries in the Region deciding to implement front-of-pack nutrition labelling policies.

High proportions of children under 3 years of age consume commercially produced snack foods and sugar-sweetened beverages in Bandung City, Indonesia

Child undernutrition continues to be a national concern in Indonesia, whereas childhood overweight/obesity rises. Economic development has led to wide availability of highly processed foods and beverages, with growing evidence that children are consuming commercial snack products during the critical complementary feeding period. This study assessed the prevalence and patterns of consumption of commercially produced snack foods and sugar‐sweetened beverages among Indonesian children. A cross‐sectional survey was conducted with 495 mothers of children aged 6–35 months living in Bandung City, Indonesia. Among all children, 81.6% consumed a commercial snack food and 40.0% consumed a sugar‐sweetened beverage in the day preceding the interview. At 6–11 months, 46.5% of children consumed a snack food and 2.0% consumed a sugar‐sweetened beverage. Snack foods were consumed 3 or more times a day by 60.0% of children 24–35 months of age. Sweet biscuits and savory snacks were the most commonly consumed snack foods; sweetened milks and sweetened teas were the most common beverages. Maternal education, child age, and consumption of a commercially produced complementary food were associated with snack food consumption. Factors associated with sugar‐sweetened beverage consumption were child age and consumption of a commercially produced complementary food or breastmilk substitute. These findings reflect a high presence of processed, high‐sugar/salt commercial snack products in the diets of children 6–35 months. National attention should focus on interventions to reduce reliance on processed snack products and increase consumption of nutrient‐rich, locally available foods during the complementary feeding period.

Red for "Stop": "Traffic-Light" Nutrition Labels Decrease Unhealthy Food Choices by Increasing Activity and Connectivity in the Frontal Lobe

Food labels comprise a national health-intervention policy that informs consumers of food-product nutritional value. Previous evidence has indicated that, compared to a purely numeric guideline-daily-amount label, a traffic-light-inspired, color-coded label more effectively conveys the nutritional level and increases the selection of healthier products. Therefore, we used functional magnetic resonance imaging to assess the mechanism whereby traffic-light and guideline-daily-amount labels influence food-related decision-making. Forty-four female dieters (age, mean = 20.0, standard deviation = 1.45 years) were recruited to participate in a food-choice task; healthy or unhealthy food options were presented with color-coded traffic-light or purely numeric guideline-daily-amount labels, and the participants were asked to state their preference. We found that, compared with the guideline-daily-amount label, a salient, red traffic-light label potentially reduced unhealthy food-related decision-making and activated the superior medial frontal gyrus and the supplementary motor area, which are implicated in the execution of responses and motor inhibition. For the same stimulus contrast, we also found increased activation in the anterior cingulate cortex, which is associated with salient information monitoring. Finally, we found stronger functional connectivity between the anterior cingulate cortex and inhibitory regions (inferior and middle frontal gyri) under red-traffic-light than under guideline-daily-amount label conditions. These results suggest that traffic-light-inspired labels may be a more effective means of public-policy intervention than are numeric labels conveying guideline daily amounts.

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.

Effects of physical activity calorie equivalent food labelling to reduce food selection and consumption: systematic review and meta-analysis of randomised controlled studies

Background

There is limited evidence that nutritional labelling on food/drinks is changing eating behaviours. Physical activity calorie equivalent (PACE) food labelling aims to provide the public with information about the amount of physical activity required to expend the number of kilocalories in food/drinks (eg, calories in this pizza requires 45 min of running to burn), to encourage healthier food choices and reduce disease.

Objective

We aimed to systematically search for randomised controlled trials and experimental studies of the effects of PACE food labelling on the selection, purchase or consumption of food/drinks.

Methods

PACE food labelling was compared with any other type of food labelling or no labelling (comparator). Reports were identified by searching electronic databases, websites and social media platforms. Inverse variance meta-analysis was used to summarise evidence. Weighted mean differences (WMD) and 95% CIs were used to describe between-group differences using a random effects model.

Results

15 studies were eligible for inclusion. When PACE labelling was displayed on food/drinks and menus, significantly fewer calories were selected, relative to comparator labelling (WMD=−64.9 kcal, 95% CI −103.2 to −26.6, p=0.009, n=4606). Presenting participants with PACE food labelling results in the consumption of significantly fewer calories (WMD=−80.4 kcal, 95% CI−136.7 to −24.2, p=0.005, n=486) relative to comparator food labelling.

Conclusion

Based on current evidence PACE food labelling may reduce the number of kilocalories selected from menus and decrease the number of kilocalories/grams of food consumed by the public, compared with other types of food labelling/no labelling.

Trial registration number

CRD42018088567.

Does point-of-sale nutrition information improve the nutritional quality of food choices?

Point-of-sale nutrition information has been adopted by numerous grocery stores to respond to the demand for easy-to-understand nutrition labeling by consumers. Although there is conflicting evidence regarding the effectiveness of providing nutrition information, previous research indicates simplified shelf nutrition labels may lead to healthier choices. However, these studies have not examined how different consumer segments respond to these labels, nor the differential impacts across foods. Using household purchase data from a store that voluntarily adopted the (now defunct) NuVal shelf nutrition labels (a 1-100 numeric score derived from a nutrition-profiling algorithm), we assess NuVal impacts across different consumers and foods. NuVal scores potentially influence not only purchase quantity but also likelihood of buying. Thus, the effect of NuVal was measured by estimating a two-part model and predicting consumers' unconditional purchase responses. We found evidence of heterogeneous impacts of NuVal across consumers and foods. High-income households and households with children shifted their yogurt and frozen dinner purchases to more healthful items. In contrast, households with children and households headed by heads with college education slightly shifted their canned soup purchases to less healthful options. Our findings suggest that specific foods and consumer segments are influenced by simplified shelf nutrition information and further research is necessary to better understand its effect on consumer dietary quality.

A review of nutrition labeling and food choice in the United States

A proliferation of processed food and labeling claims motivated the Nutrition Labeling and Education Act of 1990, which mandated the Nutrition Facts Label. Providing nutrition information is often put forth as a way to change food choice; however, despite efforts to provide dietary information using nutrition labeling, more than a third of the US has obesity and portions of the population continue to under consume vital nutrients. There has been progress beyond the Nutrition Facts Label in recent years with front-of-package labeling and menu labeling, which is crucial given changes in consumption trends for food-away-from-home. Additionally, changes were recently made to the Nutrition Facts Label due to lack of awareness, understanding, and ability to effectively improve diet quality. This paper explores the literature to track the evolution of knowledge about attention to nutrition information and how nutrition information affects dietary choices.

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.

The Influence of Taste Liking on the Consumption of Nutrient Rich and Nutrient Poor Foods

Repeated consumption of high-energy nutrient poor foods can lead to undesirable health outcomes such as obesity. Taste plays an important role in food choice, and a better understanding of the links between the taste of foods, individual taste preferences, food choices, and intakes will aid in our understanding of why some people might select and consume unhealthy foods. The present review focuses on three main questions: (1) do nutrient poor and nutrient rich foods significantly differ in taste profile? (2) are humans predisposed toward developing a liking or preference for certain taste profiles? (3) how are individual variations in liking of the basic taste qualities related to long term food intake and adverse health outcomes such as obesity? Results indicated that nutrient poor foods were likely to be sweet, salty and fatty mouthfeel, while the taste profiles of nutrient rich foods were diverse. Although humans are born with a universal liking for sweet and aversion for bitter taste, large individual differences exist in liking of all the basic taste qualities. These individual differences partly explain differences in short term intakes of foods varying in taste profiles. However they fail to sufficiently explain long term food choices and negative health outcomes such as obesity. Future studies should focus on how the full sensory profile of food which includes taste, smell and texture interacts with individual characteristics (e.g., taste or health motivations, taste preferences) to affect consumption of nutrient rich and nutrient poor foods.

Food Choice Under Five Front-of-Package Nutrition Label Conditions: An Experimental Study Across 12 Countries

Objectives. To determine which front-of-package label (out of 5 formats) is most effective at guiding consumers toward healthier food choices.Methods. Respondents from Argentina, Australia, Bulgaria, Canada, Denmark, France, Germany, Mexico, Singapore, Spain, the United Kingdom, and the United States took part in the Front-of-Pack International Comparative Experiment between April and July 2018. Respondents were shown foods of varying nutritional quality (with no label on package) and selected which they would be most likely to purchase. The same choice sets were then shown again with 1 of 5 randomly allocated labels on package (Health Star Rating (HSR), Multiple Traffic Lights (MTL), Nutri-Score, Reference Intakes, or Warning Label). We calculated an improvement score (from 11 100 valid responses) to identify the extent to which the labels produced healthier choices.Results. The most effective labels were the Nutri-Score and the MTL (mean improvement score = 0.09; 95% confidence interval [CI] = 0.07, 0.11), then the Warning Label (0.06; 95% CI = 0.04, 0.08), the HSR (0.05; 95% CI = 0.03, 0.07), and lastly the Reference Intakes (0.04; 95% CI = 0.02, 0.04).Conclusions. Well-designed, salient, and intuitive front-of-package labels can be effective on a global scale. Their impact is not bound to the country from which they originate.

Understanding and use of food labeling systems among Whites and Latinos in the United States and among Mexicans: Results from the International Food Policy Study, 2017

BACKGROUND

Obesity and chronic diseases could be prevented through improved diet. Most governments require at least one type of food labeling system on packaged foods to communicate nutrition information and promote healthy eating. This study evaluated adult consumer understanding and use of nutrition labeling systems in the US and Mexico, the most obese countries in the world.

METHODS

Adults from online consumer panels in the US (Whites n = 2959; Latinos n = 667) and in Mexico (n = 3533) were shown five food labeling systems: 1. Nutrition Facts Table (NFT) that shows nutrients of concern per serving; 2. Guideline Daily Amounts (GDA) that shows levels of nutrients of concern; 3. Multiple Traffic-Light (MTL) that color codes each GDA nutrient (green = healthy; yellow = moderately unhealthy; red = unhealthy); 4. Health Star Rating System (HSR) that rates foods on a single dimension of healthiness; 5. Warning Label (WL) with a stop sign for nutrients present in unhealthy levels. Participants rated each label on understanding ("easy"/"very easy to understand" vs "difficult"/"very difficult to understand"), and, for NFTs and GDAs, frequency of use ("sometimes"/"often" vs "never"). Mixed logistic models regressed understanding and frequency of use on indicators of labeling systems (NFT = ref), testing for interactions by ethnicity (US Latinos, US Whites, Mexicans), while controlling for sociodemographic and obesity-related factors.

RESULTS

Compared to the NFT, participants reported greater understanding of the WL (OR = 4.8; 95% CI = 4.4-5.3) and lower understanding of the HSR (OR = 0.34, 95% CI = 0.31-0.37) and the MTL (OR = 0.56, 95% CI = 0.52-0.61), with similar patterns across ethnic subgroups. Participants used GDAs less often than NFTs (OR = 0.48; 95%CI = 0.41-0.55), with the greatest difference among US Whites (OR = 0.10; 95%CI = 0.07-0.14).

CONCLUSIONS

Understanding and use of the GDA was similar to that of the NFT. Whites, Latinos, and Mexicans consistently reported the best understanding for WLs, a FOPL that highlights unhealthfulness of a product. Therefore, a FOPL summary indicator, such as WLs, may be more effective in both the US and Mexico for guiding consumers towards informed food choices.

Consumer beliefs about healthy foods and diets

Background

The U.S. Food and Drug Administration has begun a public process to redefine how companies are allowed to use the term “healthy” on food packages. Although the definition is formulated based on the latest consensus in nutrition and epidemiological research, it is also important to understand how consumers define and understand the term if it is to be behaviorally relevant. This research is an exploratory study designed to provide a descriptive account of consumers’ perceptions of and beliefs about the meaning of “healthy” food.

Methods

A nationwide U.S. sample of 1,290 food consumers was surveyed in December 2018. Respondents answered 15 questions designed to gauge perceptions of healthy food and to elicit preference for policies surrounding healthy food definitions. Responses are weighted to demographically match the population. Categorical variables have a sampling error of ±2.7%. Exploratory factor analysis is used to determine latent dimensions of health perceptions related to food type.

Results

Consumers were about evenly split on whether a food can be deemed healthy based solely on the foods’ nutritional content (52.1% believing as such) or whether there were other factors that affect whether a food is healthy (47.9% believing as such). Consumers were also about evenly split on whether an individual food can be considered healthy (believed by 47.9%) or whether this healthiness is instead a characteristic of one’s overall diet (believed by 52.1%). Ratings of individual food products revealed that “healthy” perceptions are comprised of at least three underlying latent dimensions related to animal origin, preservation, and freshness/processing. Focusing on individual macronutrients, perceived healthiness was generally decreasing in a food’s fat, sodium, and carbohydrate content and increasing in protein content. About 40% of consumers thought a healthy label implied they should increase consumption of the type of food bearing the label and about 15% thought the label meant they could eat all they wanted.

Conclusions

Results suggest consumer’s perceptions of “healthy,” which is primarily based on fat content, partially aligns with the FDA definition but also suggest consumers perceive the word as a broader and more nuanced concept that defies easy, uniform definition. Results highlight areas where nutrition education may be needed and suggest disclosures may need to accompany health claims so that consumers know what, precisely, is being communicated.

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.

Nutrition Label Use Is Related to Chronic Conditions among Mexicans: Data from the Mexican National Health and Nutrition Survey 2016

BACKGROUND

Non-communicable diseases, such as obesity, diabetes, and hypertension, can be prevented and treated through a balanced nutrient-rich diet. Nutrition labels have been recognized as crucial to preventing obesity and non-communicable diseases through a healthier diet.

OBJECTIVE

Our aim was to examine the association between nutrition label use and chronic conditions (overweight, obesity, previously diagnosed diabetes, and hypertension) among an adult Mexican population.

DESIGN

This was a cross-sectional study that used data from the Mexican National Health and Nutrition Survey of 2016 (ENSANUT MC 2016).

PARTICIPANTS/SETTING

The participants were 5,013 adults aged 20 to 70 years old. Older adults (>70 years), illiterate participants, pregnant women, and participants with implausible blood pressure data were excluded from the sample. The survey was conducted from May to August 2016 in the participants' households.

MAIN OUTCOME MEASURES

We measured chronic conditions (overweight, obesity, previously diagnosed diabetes, and hypertension).

STATISTICAL ANALYSES PERFORMED

Pearson χ² test was used to examine the associations among the use of nutrition labels and sociodemographic characteristics and chronic conditions. Multiple logistic regression was used to determine the association between nutrition label use and chronic conditions adjusting for the effect of confounding variables like sex, age, body mass index, education level, marital status, ethnicity, residence area, region, and socioeconomic status.

RESULTS

From the total sample, 40.9% (95% CI 38.4% to 43.8%) reported using nutrition labeling. Respondents with overweight or obesity were less likely to use nutrition labels (odds ratio 0.74; P<0.05). Participants who self-reported diabetes had significantly lower odds of nutrition label use than participants who did not report to have diabetes (odds ratio 0.66; P<0.05). Participants having 3 chronic conditions had lower odds of nutrition label use (odds ratio 0.34; P<0.01) relative to having zero chronic conditions.

CONCLUSIONS

This study suggests an association between nutrition label use and chronic conditions (obesity and diabetes). These findings demonstrate that people with obesity, diabetes, and a combination of chronic conditions were less likely to use nutrition labels than people without these conditions.

Kebiasaan Membaca Label Gizi Berhubungan Dengan Asupan Natrium Pada Wanita Dewasa

Background: Sodium is one of the nutrients which is mandatory to be displayed in food packaging. High intake of sodium can increase the risk blood pressure elevation and hypertension. The habit of reading the nutrition label can affect in dietary intake, one of them is sodium.Objective: The purpose of this study was to analyze the association between the habit of reading the nutrition label and sodium intake in female adolescents.Methods: This study was a cross sectional study with citizens of  Modong Village, Tulangan Sub-district, Sidoarjo District with 70 participants. Sample collection used a simple random sampling method. Sodium intake data was collected through interview using Semi Quantitative Food Frequency Questionnaire (SQ-FFQ). Data of habit of reading the nutrition label were obtained through interview in reading nutrition label frequency. Statistical test performed was chi square test.Result: The results showed that there was a significant relationship between reading habit of nutrition fact with sodium intake among adult woman (p=0.023). Most respondents rarely read nutrition label (40%) and inadequate sodium intake (30%).Conclusion: The habit of reading nutrition label is significantly associated with sodium intake in female adolescents in Modong Village, Tulangan Sub-district, Sidoarjo District.ABSTRAK Latar Belakang: Natrium adalah salah satu zat gizi yang wajib ditampilkan di label pangan kemasan. Asupan tinggi natrium meningkatkan resiko peningkatan tekanan darah dan hipertensi. Kebiasaan membaca label gizi dapat berpengaruh terhadap asupan zat gizi, salah satunya natrium.Tujuan: Tujuan dari penelitian ini adalah untuk menganalisis hubungan kebiasaan membaca label gizi dengan asupan natrium pada wanita dewasa.Metode: Penelitian cross sectional ini dilakukan pada populasi wanita dewasa di Desa Modong, Kecamatan Tulangan, Kabupaten Sidoarjo dengan 70 orang responden. Teknik pengumpulan sampel menggunakan simple random sampling. Data asupan natrium didapatkan melalui wawancara menggunakan Semi Quantitative Food Frequency Questionnaire (SQ-FFQ). Data kebiasaan membaca label gizi didapatkan melalui wawancara frekuensi membaca label gizi. Hubungan antara kebiasaan membaca label gizi dengan asupan natrium dianalisis menggunakan uji statistic uji chi square.Hasil: Hasil penelitian menunjukkan terdapat hubungan yang bermakna antara kebiasaan membaca label gizi dengan asupan natrium (p=0,023). Sebagian besar responden jarang membaca label gizi (40%) dan mengonsumsi natrium yang berlebih (30%).Kesimpulan: Kebiasaan membaca label gizi memiliki hubungan yang bermakna dengan asupan natrium wanita dewasa di Desa Modong, Kecamatan Tulangan, Kabupaten Sidoarjo.

[Effects of front-of-package nutritional labeling of food and beverages: synopsis of systematic reviewsEfeitos da rotulagem nutricional frontal de alimentos e bebidas: sumário de estudos de revisão sistemática]

Objetivos.

Sintetizar la información disponible sobre el efecto del etiquetado nutricional frontal en la elección, compra y consumo de alimentos y bebidas, y el estado nutricional de los consumidores, e identificar los factores que influyen en su efectividad.

Métodos.

Se realizó una sinopsis de revisiones sistemáticas (RS) conforme a las recomendaciones PRISMA. La búsqueda bibliográfica se realizó en Medline (Pubmed), The Cochrane Library, LILACS, EBSCOhost y Scopus, limitada a estudios publicados en español o inglés sin restricción por fecha de publicación. La calidad metodológica se evaluó utilizando la herramienta AMSTAR 2.

Resultados.

Se incluyeron siete RS. El etiquetado frontal facilitó la elección de alimentos saludables y tuvo un efecto variable sobre las dimensiones de consumo y compra. Ninguna RS evaluó el efecto sobre el estado nutricional. El costo y sabor, los hábitos alimentarios, el nivel educativo y los sistemas dominantes de procesamiento de información en el consumidor influyeron en su efectividad. La mayoría de RS mostraron limitaciones metodológicas y un nivel de confianza críticamente bajo.

Conclusiones.

El etiquetado frontal tuvo efecto positivo en la elección de alimentos saludables, con resultados variables en las dimensiones de compra y consumo. Se necesitan estudios locales con una adecuada calidad metodológica para identificar el formato de etiquetado más efectivo en cada país. Su implementación como política de salud pública debe acompañarse de estrategias para mejorar el acceso a alimentos saludables, promover la actividad física y brindar educación nutricional a los consumidores.

Impact of a front-of-pack nutritional traffic-light label on the nutritional quality and the hedonic value of mid-afternoon snacks chosen by mother-child dyads

The aim of this study was to assess the impact of a nutritional traffic-light label, the Nutri-Score, on snack choices in mother-child dyads and to assess a potential hedonic cost associated with a change in favour of healthier choices. French mothers and children (n = 95; children's age: 7-11 years) who participated were asked to choose, for themselves and for the other dyad member, a snack composed of one beverage and two food items selected among several products with different nutritional quality. In the first step, the products were presented without any information. In the second step, the products were labelled with the Nutri-Score. Mothers and children were asked to rate their liking for all proposed products before being informed of their nutritional quality. The nutritional quality, the hedonic score, and the estimated budget of the selected snacks were compared before and after labelling. As hypothesized, the Nutri-Score label led to a significant increase in the nutritional quality of the chosen snacks. The budget for the chosen snacks was unchanged or decreased after the nutritional labelling was applied. Children and mothers had significantly lower liking for the snacks after nutritional labelling than before nutritional labelling, suggesting a hedonic cost associated with a change in favour of healthier snack choices. This raises the question of the sustainability of the behavioural change induced by the Nutri-Score label.

Consumers' Perceptions of Five Front-of-Package Nutrition Labels: An Experimental Study Across 12 Countries

Consumers’ perceptions of five front-of-pack nutrition label formats (health star rating (HSR), multiple traffic lights (MTL), Nutri-Score, reference intakes (RI) and warning label) were assessed across 12 countries (Argentina, Australia, Bulgaria, Canada, Denmark, France, Germany, Mexico, Singapore, Spain, the UK and the USA). Perceptions assessed included liking, trust, comprehensibility, salience and desire for the label to be mandatory. A sample of 12,015 respondents completed an online survey in which they rated one of the five (randomly allocated) front-of-pack labels (FoPLs) along the perception dimensions described above. Respondents viewing the MTL provided the most favourable ratings. Perceptions of the other FoPLs were mixed or neutral. No meaningful or consistent patterns were observed in the interactions between country and FoPL type, indicating that culture was not a strong predictor of general perceptions. The overall ranking of the FoPLs differed somewhat from previous research assessing their objective performance in terms of enhancing understanding of product healthiness, in which the Nutri-Score was the clear front-runner. Respondents showed a strong preference for mandatory labelling, regardless of label condition, which is consistent with past research showing that the application of labels across all products leads to healthier choices.

Consumers' Responses to Front-of-Pack Nutrition Labelling: Results from a Sample from The Netherlands

Front-of-pack labels (FoPLs) are efficient tools for helping consumers identify healthier food products. Although discussions on nutritional labelling are currently ongoing in Europe, few studies have compared the effectiveness of FoPLs in European countries, including the Netherlands. This study aimed to compare five FoPLs among Dutch participants (the Health Star Rating (HSR) system, Multiple Traffic Lights (MTL), Nutri-Score, Reference Intakes (RIs), and Warning symbols) in terms of perception and understanding of the labels and food choices. In 2019, 1032 Dutch consumers were recruited and asked to select one product from among a set of three foods with different nutritional profiles, and then rank the products within the sets according to their nutritional quality. These tasks were performed with no label and then with one of the five FoPLs on the package, depending on the randomization arm. Finally, participants were questioned on their perceptions regarding the label to which they were exposed. Regarding perceptions, all FoPLs were favorably perceived but with only marginal differences between FoPLs. While no significant difference across labels was observed for food choices, the Nutri-Score demonstrated the highest overall performance in helping consumers rank the products according to their nutritional quality.

Modelling the impact of different front-of-package nutrition labels on mortality from non-communicable chronic disease

Background

Front-of-Package nutrition labels (FoPLs) are intended to help reduce the incidence of nutrition-related non-communicable diseases through an improvement in diet quality. FoPLs have been shown to improve the nutritional quality of purchases and have been associated with improved diet quality, which is in turn associated with reduced risk of non-communicable diseases. However, the potential impact of FoPLs on reducing mortality from chronic diseases has never been estimated.

Methods

Data from a laboratory experimental economics test were used to investigate the effects of five different FoPLs (Nutri-Score, Health Star Rating system, Multiple Traffic lights, Reference intakes and SENS (Système d’Etiquetage Nutritionnel Simplifié)) on the nutritional quality of household purchases. The relative differences in nutrient content and composition of food purchases were then applied to dietary intakes using data from an observational study, thus yielding estimates for ‘reference’ and ‘labelled’ diets. A macro-simulation study using the PRIME model was then conducted to estimate the impact of the modification in dietary intake as a result of FoPL use on mortality from diet-related non-communicable diseases.

Results

The use of FoPLs led to a substantial reduction in mortality from chronic diseases. Approximately 3.4% of all deaths from diet-related non-communicable diseases was estimated to be avoidable when the Nutri-Score FoPL was used. The remaining FoPLs likewise resulted in mortality reduction, although to a lesser extent: Health Star Rating system (2.8%), Reference Intakes (1.9%), Multiple Traffic Lights (1.6%), and SENS (1.1%).

Conclusions

FoPLs have the potential to help decrease mortality from diet-related non-communicable diseases, and the Nutri-Score appears to be the most efficient among the five formats tested.

Electronic supplementary material

The online version of this article (10.1186/s12966-019-0817-2) contains supplementary material, which is available to authorized users.

Assessment of an e-training tool for college students to improve accuracy and reduce effort associated with reading nutrition labels

Objective: Nutrition labels are often underutilized due to the time and effort required to read them. We investigated the impact of label-reading training on effort, as well as accuracy and motivation. Participants: Eighty college students (21 men and 59 women). Methods: The training consisted of a background tutorial on nutrition followed by three blocks of practice reading labels to decide which of two foods was the relatively better choice. Label-reading effort was assessed using an eye tracker and motivation was assessed using a 6-item scale of healthy food-choice empowerment. Results: Students showed increases in label-reading accuracy, decreases in label-reading effort, and increases in empowerment. Conclusions: The nutrition label e-training tool presented here, whether used alone or as part of other wellness and health programs, may be an effective way to boost students' label-reading skills and healthy food choices, before they settle into grocery shopping habits.

Front-of-Pack Labeling and the Nutritional Quality of Students' Food Purchases: A 3-Arm Randomized Controlled Trial

Objectives. To assess the effects of the Nutri-Score label (relative to the Reference Intakes label or no label) on the nutritional quality of students' food purchases. Methods. A 3-arm randomized controlled trial was conducted in France in 2017; 2907 participants were randomized into 1 of the 3 study arms (Nutri-Score, Reference Intakes, no label) and invited to purchase groceries from an experimental Web-based supermarket. The main outcome was the overall nutritional quality of purchases, measured according to a modified version of the Food Standards Agency Nutrient Profiling System (FSAm-NPS/HCSP) score. Results. The mean (±SD) FSAm-NPS/HCSP score was lower in the Nutri-Score group (2.02 ±3.56) than in the Reference Intakes group (2.69 ±3.44), reflecting higher nutritional quality; however, there was no significant difference between the Nutri-Score and no-label (2.45 ±3.28) groups or between the Reference Intakes and no-label groups. Shopping cart content was lower in calories and saturated fatty acids and higher in fruits and vegetables in the Nutri-Score arm than in the other arms. Conclusions. The Nutri-Score label appeared to improve the nutritional composition of students' food purchases relative to the Reference Intakes label or no label.

Packaged food consumption and understanding of front-of-pack labels in urban Thailand

OBJECTIVES

We assessed the use of current guideline daily amount (GDA) label and consumers' ability to read GDA, compared with GDA-plus labels (green colour-coded GDA [GGDA], GDA label with text [GDAT] and green colour-coded GDA label with text [GGDAT]) in Thailand.

STUDY DESIGN

This is a cross-sectional study.

METHODS

We interviewed individuals at 23 major supermarkets across the country in March 2015. We used a mixed multivariate logistic regression model to identify factors associated with the ability to make healthier choices when reading front-of-pack (FoP) labels.

RESULTS

Of 1364 participants, only 11% claimed to read the GDA label every time; those who did not read the main reason was that it was not understandable or attractive. In total, 65%, 62%, 61% and 39% were able to read GDAT, GGDAT, GGDA and GDA labels, respectively. When reading GGDA, GDAT and GGDAT labels, participants were 2.91 (95% confidence interval [CI]: 2.45, 3.45), 3.59 (95% CI: 3.01, 4.28) and 3.13 (95% CI: 2.63, 3.72) times more likely to choose healthier food choices compared with having read an ordinary GDA label. Participants who were exposed to food selection guidelines were more likely to make healthier food choices when reading FoP labels with different odds depending on sources of information. Participants who recognized the link between diet and non-communicable diseases were 1.21 (95% CI: 1.02, 1.44) times more likely to choose healthier food choices. No sociodemographic characteristics were significantly statistically associated with the ability to choose healthier food choices when adjusted for diet-related knowledge and FoP formats.

CONCLUSIONS

Use and understanding of GDA are still low, mainly because GDA is incomprehensible and unattractive. Interpretive FoP formats tend to be more understandable and need less complementary public campaigns compared with non-interpretive formats.

Taxes and front-of-package labels improve the healthiness of beverage and snack purchases: a randomized experimental marketplace

BACKGROUND

Sugar taxes and front-of-package (FOP) nutrition labelling systems are strategies to address diet-related non-communicable diseases. However, there is relatively little experimental data on how these strategies influence consumer behavior and how they may interact. This study examined the relative impact of different sugar taxes and FOP labelling systems on beverage and snack food purchases.

METHODS

A total of 3584 Canadians 13 years and older participated in an experimental marketplace study using a 5 (FOP label condition) × 8 (tax condition) between-within group experiment. Participants received $5 and were presented with images of 20 beverages and 20 snack foods available for purchase. Participants were randomized to one of five FOP label conditions (no label; 'high in' warning; multiple traffic light; health star rating; nutrition grade) and completed eight within-subject purchasing tasks with different taxation conditions (beverages: no tax, 20% tax on sugar-sweetened beverages (SSBs), 20% tax on sugary drinks, tiered tax on SSBs, tiered tax on sugary drinks; snack foods: no tax, 20% tax on high-sugar foods, tiered tax on high-sugar foods). Upon conclusion, one of eight selections was randomly chosen for purchase, and participants received the product and any change.

RESULTS

Compared to those who saw no FOP label, participants who viewed the 'high in' symbol purchased less sugar (- 2.5 g), saturated fat (- 0.09 g), and calories (- 12.6 kcal) in the beverage purchasing tasks, and less sodium (- 13.5 mg) and calories (- 8.9 kcal) in the food tasks. All taxes resulted in substantial reductions in mean sugars (- 1.4 to - 4.7 g) and calories (- 5.3 to - 19.8 kcal) purchased, and in some cases, reductions in sodium (- 2.5 to - 6.6 mg) and saturated fat (- 0.03 to - 0.08 g). Taxes that included 100% fruit juice ('sugary drink' taxes) produced greater reductions in sugars and calories than those that did not.

CONCLUSIONS

This study expands the evidence indicating the effectiveness of sugar taxation and FOP labelling strategies in promoting healthy food and beverage choices. The results emphasize the importance of applying taxes to 100% fruit juice to maximize policy impact, and suggest that nutrient-specific FOP 'high in' labels may be more effective than other common labelling systems at reducing consumption of targeted nutrients.