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

Exploring Children's Knowledge of Healthy Eating, Digital Media Use, and Caregivers' Perspectives to Inform Design and Contextual Considerations for Game-Based Interventions in Schools for Low-Income Families in Lima, Peru: Survey Study

BACKGROUND

The prevalence of overweight and obesity in schoolchildren is increasing in Peru. Given the increased use of digital media, there is potential to develop effective digital health interventions to promote healthy eating practices at schools. This study investigates the needs of schoolchildren in relation to healthy eating and the potential role of digital media to inform the design of game-based nutritional interventions.

OBJECTIVE

This study aims to explore schoolchildren's knowledge about healthy eating and use of and preferences for digital media to inform the future development of a serious game to promote healthy eating.

METHODS

A survey was conducted in 17 schools in metropolitan Lima, Peru. The information was collected virtually with specific questions for the schoolchild and their caregiver during October 2021 and November 2021 and following the COVID-19 public health restrictions. Questions on nutritional knowledge and preferences for and use of digital media were included. In the descriptive analysis, the percentages of the variables of interest were calculated.

RESULTS

We received 3937 validated responses from caregivers and schoolchildren. The schoolchildren were aged between 8 years and 15 years (2030/3937, 55.8% girls). Of the caregivers, 83% (3267/3937) were mothers, and 56.5% (2223/3937) had a secondary education. Only 5.2% (203/3937) of schoolchildren's homes did not have internet access; such access was through WiFi (2151/3937, 54.6%) and mobile internet (1314/3937, 33.4%). In addition, 95.3% (3753/3937) of schoolchildren's homes had a mobile phone; 31.3% (1233/3937) had computers. In relation to children's knowledge on healthy eating, 42.2% (1663/3937) of schoolchildren did not know the recommendation to consume at least 5 servings of fruits and vegetables daily, 46.7% (1837/3937) of schoolchildren did not identify front-of-package warning labels (FOPWLs), and 63.9% (2514/3937) did not relate the presence of an FOPWL with dietary risk. Most schoolchildren (3100/3937, 78.7%) preferred to use a mobile phone. Only 38.3% (1509/3937) indicated they preferred a computer. In addition, 47.9% (1885/3937) of caregivers considered that the internet helps in the education of schoolchildren, 82.7% (3254/3937) of caregivers gave permission for schoolchildren to play games with digital devices, and 38% (1495/3937) of caregivers considered that traditional digital games for children are inadequate.

CONCLUSIONS

The results suggest that knowledge about nutrition in Peruvian schoolchildren has limitations. Most schoolchildren have access to the internet, with mobile phones being the device type with the greatest availability and preference for use. Caregivers' perspectives on games and schoolchildren, including a greater interest in using digital games, provide opportunities for the design and development of serious games to improve schoolchildren's nutritional knowledge in Peru. Future research is needed to explore the potential of serious games that are tailored to the needs and preferences of both schoolchildren and their caregivers in Peru in order to promote healthy eating.

Incidence of traffic light labelling on noncommunicable diseases: a roadmap for achieving sustainable development

The production and diversity of the supply of food products has grown exponentially in recent decades, along with the increase in cardiovascular diseases associated with poor diet. Among the factors, one of the most important is the lack of information for the consumer when purchasing. The present work evaluates the impact of implementing the traffic light labelling of foods in reducing deaths due to Noncommunicable Diseases (NCD). Econometric techniques of two-way effects panel data from 21 Ecuadorian provinces taken from official sources for the analysis period 2010-2019. For Ecuador, a favourable impact was found in the reduction of the NCD mortality rate, especially in the last three years; in 2017, it was reduced by 0.129%, in 2018 by 0.305%, and in 2019 by 0.289%. An implication of economic policy is the advertising regulation of products that may affect health, strengthening surveillance and sanctioning companies that fail to comply with the regulation.

How Interdisciplinary Interventions Can Improve the Educational Process of Children Regarding the Nutritional Labeling of Foods

This research aimed to evaluate the effect of interdisciplinary educational interventions on children's attitudes, knowledge, preferences, and perceptions about different nutrition labels. Four hundred and ten elementary school children, aged between seven and ten years, participated in the research. The children completed questionnaires on attitudes, knowledge, and preferences about nutrition labeling and on perceived healthiness of a food product considering different types of nutrition labels (Pre-Intervention). They then participated in educational interventions as a strategy to address nutrition labeling of foods (Intervention). Finally, the Pre-Intervention questionnaires were reapplied (Post-Intervention). The intervention improved children's attitudes and knowledge about nutrition labeling. It also showed that this public has a greater preference for labels printed on the front of the food package. The label in the form of a warning was considered the most favorable for comparing the healthiness of the food product among children, while the table was the least preferred. It is concluded that interdisciplinary educational interventions are effective in improving children's attitudes, knowledge, preferences, and perceptions about different nutrition labels on a food product. The front label model is the most suitable for food packaging aimed at children.

Bringing down barriers to children's healthy eating: a critical review of opportunities, within a complex food system

This narrative review revises the scientific evidence of recent years on healthy eating in children and adolescents, making sense of promising avenues of action, from a food system perspective. A conceptual framework is provided to better understand how eating habits of children and adolescents are shaped to identify key multisectoral approaches that should be implemented to promote healthier diets. The following influencing factors are discussed: individual factors (physiological and psychological factors, food preferences and food literacy competencies), factors within the personal and socio-cultural food environments, external food environments, and the supply chain. In each section, the main barriers to healthy eating are briefly discussed focussing on how to overcome them. Finally, a discussion with recommendations of actions is provided, anchored in scientific knowledge, and transferable to the general public, industry, and policymakers. We highlight that multidisciplinary approaches are not enough, a systems approach, with a truly holistic view, is needed. Apart from introducing systemic changes, a variety of interventions can be implemented at different levels to foster healthier diets in children through fostering healthier and more sustainable food environments, facilitating pleasurable sensory experiences, increasing their food literacy, and enhancing their agency by empowering them to make better food related decisions. Acknowledging children as unique individuals is required, through interpersonal interactions, as well as their role in their environments. Actions should aim to enable children and adolescents as active participants within sustainable food systems, to support healthier dietary behaviours that can be sustained throughout life, impacting health at a societal level.

The Role of Front-of-Package Nutrition Labels with and without Explanatory Videos on Parent and Child Food Choices

The aim of this research was to determine whether parent/child pairs choosing products from a grocery aisle labeled with front-of-package (FOP) nutrition labels would make more healthful choices than pairs who viewed the same items without labels, and to determine the added value of viewing an explanatory video before choosing. In this experiment, 175 parent/child pairs chose USD 20 worth of packaged foods and beverages from a grocery aisle in a research laboratory and were randomly assigned to see products that either did or did not have 0-4-star FOP labels, with more stars indicating more healthful products. Among those participants with access to FOP labels, half were randomly assigned to view a 30 s video explaining the FOP labels before selecting foods. Participants who saw the explanatory video before selecting among products with FOP labels chose foods with significantly more stars than participants who saw the FOP-labeled products without the video; however, there was no significant difference in mean stars on selected products between the group that saw the videos and the control group that saw neither the video nor FOP labels. We conclude that explaining new FOP labels to consumers may be necessary for the labels to prompt more healthful choices.

Children's reaction to sugar reduced dairy desserts in the context of the implementation of nutritional warning labels: An exploratory study

The aim of the present work was to explore children's reaction to sugar reduction in the context of the implementation of nutritional warnings in Uruguay. The study was composed of two sessions involving three evaluation conditions: tasting without package information, package evaluation without tasting, and tasting with package information. A total of 122 children, ages ranging between 6 and 13 years old (47% girls) were involved in the study. In the first session, children's hedonic and emotional response to a regular and a sugar-reduced chocolate dairy dessert (without other sweeteners) was evaluated. In the second session, children first evaluated their expected liking, emotional associations and choice of packages differing in the presence of warning labels for excessive sugar content and cartoon character (2x2 design). Finally, they tasted the selected sample in the presence of the package and evaluated their liking, emotional associations, and intention to re-taste it. Although sugar reduction led to a significant reduction in overall liking, the dessert with 40% sugar reduction showed a mean overall score of 6.5 in a 9-point hedonic scale and was described using positive emoji (, , ). When the desserts were tasted with package information, no significant differences in the expected overall liking of the regular and sugar-reduced dessert were found. Regarding the effect of packaging elements, the presence of a warning label highlighting excessive content of sugar did not have a significant effect on children's choice. Instead, children's choices were defined by the presence of a cartoon character. Results from the present work provide additional evidence about the feasibility of reducing the sugar content and sweetness of dairy products targeted at children and stress the need to regulate the use of cartoon characters on products with an unfavorable nutritional profile. Methodological recommendations for sensory and consumer research with children are also discussed.

Front-of-package nutrition labeling as a driver for healthier food choices: Lessons learned and future perspectives

This work aims to provide a comprehensive overview of the use of front-of-package nutritional labeling (FOPL), identify and characterize the major existing FOPL systems, examine the impact of FOPL systems on consumer behavior, and discuss future perspectives. The searched databases were PubMed, Scopus, and Web of Science, and papers in English, Portuguese, Spanish, and French were considered. The integrative review method was used, comprising 68 papers. The FOPL system from more than 47 countries from North America, South America, Africa, Europe, Australia, and Asia was included in this study. The two main ways to characterize FOPL are the level of interpretation and the type of information provided. Interpretive schemes (such as warning labels, multiple traffic lights, and Nutri-Score) appear to lead to better consumer understanding and support healthier food purchases. However, due to the differences among the results and the specificity of the contexts in which they are used, it is impossible to define one FOPL interpretation scheme superior to the others. Some potential factors that influence the effectiveness of FOPL on consumer attitudes have been identified, such as food taste, as a major intrinsic factor. Extrinsic factors, such as price, food category, cultural diversity, politics, and economics, were also relevant. The lack of availability of similar alternatives, lack of understanding of the importance of FOPL, and lower levels of income and education were also some cognitive and social aspects impairing FOPL effectiveness. Prospects for the United States, Europe, Brazil, Colombia, and Argentina were discussed.

Emotional responses to taste and smell stimuli: Self-reports, physiological measures, and a potential role for individual and genetic factors

Taste and olfaction elicit conscious feelings by direct connection with the neural circuits of emotions that affects physiological responses in the body (e.g., heart rate and skin conductance). While sensory attributes are strong determinants of food liking, other factors such as emotional reactions to foods may be better predictors of consumer choices even for products that are equally-liked. Thus, important insights can be gained for understanding the full spectrum of emotional reactions to foods that inform the activities of product developers and marketers, eating psychologist and nutritionists, and policy makers. Today, self-reported questionnaires and physiological measures are the most common tools applied to study variations in emotional perception. The present review discusses these methodological approaches, underlining their different strengths and weaknesses. We also discuss a small, emerging literature suggesting that individual differences and genetic variations in taste and smell perception, like the genetic ability to perceive the bitter compound PROP, may also play a role in emotional reactions to aromas and foods.

Objective understanding of front of pack warning labels among Mexican children of public elementary schools. A randomized experiment

Background

Warning Labels (WL) highlight excessive amounts of critical nutrients in order to discourage consumption of unhealthful packaged food products. This study aimed to evaluate among Mexican school children, the objective understanding of traditional and numeric WL (aimed at small products) considered by the Mexican regulation, and whether cartoon characters influenced the understanding of WL. We also tested some communication strategies to facilitate the correct use of the WL.

Methods

We carried out a randomized experiment in July 2019 in public elementary schools from Morelos, Mexico. Participants aged 6–13 years, were randomly assigned to one of four groups: 1) Nutrient Facts Panel (NF) (n = 120), 2) Nutrient Facts Panel with cartoon characters (NF + C) (n = 83), considered the control groups, 3) Warning Labels (WL) (n = 109), and 4) Warning Labels with cartoon characters (WL + C) (n = 96). After allocation, children assigned to both WL groups (WL or WL + C), were randomly required to watch two posters simultaneously or a video explaining how to correctly interpret WLs. Logistic regression models adjusted by sex, age and cluster (school) were fitted.

Results

The percentage of children correctly choosing the healthiest or the unhealthiest option was higher for WL groups (56.8, 95%CI; 40.8–72.8) compared to NF groups (24.3, 95%CI; 20.4–28.3, p < 0.05). The understanding of traditional WL was higher (28.7, 95%CI: 22.8–35.4) than the numeric WL (19, 95%CI: 14.2–25.0, p < 0.05). But, correct answers for identifying healthy and unhealthy products were higher for numeric WL than for NF groups. Cartoon characters reduced the percentage of correct answers for choosing unhealthiest products (WL + C: 48.9, 95%CI: 25.6–72.4 vs WL: 58.7, 95%CI: 36.4–81.1, p < 0.05). The video was 2.23 times more helpful than the posters to the correct interpretation of the WL (p < 0.05).

Conclusions

In scholar Mexican children, traditional and numeric WL were useful to identify healthier and unhealthier packaged products in comparison to NF, suggesting that both WL formats may effectively communicate the excessive content of nutrients of concern among children. Cartoon characters may reduce the objective understanding of the WL, underscoring the need to regulate advertising directed to children along with the implementation of front-of-pack labeling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-022-00791-z.

An Experimental Study Evaluating the Influence of Front-of-Package Warning Labels on Adolescent’s Purchase Intention of Processed Food Products

Front-of-package warning labels (WLs) are among the public health policies adopted by some countries, mainly in Latin-America, to tackle childhood obesity; however, their impact is still under review. The aim of this study was to assess, using an experimental design, whether WLs influence purchase intention of processed foods and identification of the healthiest products among adolescents in Peru, in May 2019, just before WLs mandatory implementation. Four hundred forty-nine adolescents from two public schools were randomly assigned to an experimental group (received three different processed products with either zero, one or two WLs, informing if they were high in sugar, sodium and/or saturated fats) or a control group (received the same products but unlabeled). Participants chose which product they would buy, and which they considered to be the healthiest. No differences between groups were found neither in purchase intention (p = 0.386) nor in the identification of the healthiest product (p = 0.322). In both groups, the most-selected product was always the healthiest of the triad (>40% in purchase intention and >80% in identification of the healthiest). Front-of-package WLs did not influence purchase intention, or identification of healthier products among adolescents from public schools in Peru. Mass media and educational campaigns should accompany the WLs implementation to help achieve the policy objective.

Adherence to the new policy framework of the World Cancer Research Fund International in developing a policy package for the prevention of gastrointestinal cancers in Iran: a Delphi study

BACKGROUND

Gastrointestinal cancers in Iran are among the major non-communicable diseases with a considerable burden on the health system. Changes in lifestyles as well as environmental factors have resulted in the emergence of these cancers.

OBJECTIVE

To elicit and quantitatively verify experts' opinions regarding the potential public health impact, feasibility, economic impact, and budgetary impact of gastrointestinal cancer prevention policies in Iran.

METHODS

Sixteen experts from Iran were recruited in an email-based, two-round Delphi study. In each round, a questionnaire of policy options for preventing gastrointestinal cancers, which adhered to the new policy framework of the World Cancer Research Fund International, was given to participants. In the first round, experts were asked to provide opinions for and against the policy options. The second round evaluated the policy options for their public health impact, feasibility, economic impact, and budgetary impact.

RESULTS

A total of 32 policy options were organized based on three domains: health-enhancing environments, system changes, and behavior change communications. Of the 32 policy options, there were consensus in 31 (96%) and 30 (93%) options for public health impact and feasibility, respectively. On study completion, experts reached a consensus in 29 of 32 (90%) policy options for economic impact; only on 26 (81%) of these policy options did participants reached consensus for budgetary impact.

CONCLUSION

Findings indicated that although nearly all policy options reached a consensus for their public health impact, some options are not feasible or do not appear to have an economic rationale for being implemented. Moreover, it is crucial to take into account the inter-sectoral collaboration between health and non-health sectors. Findings from this study can be helpful for health policymakers in identifying support for evidence-informed approaches regarding gastrointestinal cancer prevention.

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.

Health beliefs towards kefir correlate with emotion and attitude: A study using an emoji scale in Brazil

Emojis can be used to explore food-evoked emotions in order to provide information that can support the product development and marketing decisions. This study aimed to evaluate consumers' acceptance, purchase intent and emotional responses to milk beverages, with and without kefir added, before and after these consumers were informed about the products' composition (0%, 15%, 30% and 50% m/v) and health claims toward kefir (blind and informed tests, respectively). Emotional responses were assessed by emoji use within a RATA questionnaire in order quantify the perceived significance of the emojis chosen. In the informed test, the consumers' perception of the sensory attributes of the milk beverages, such as their perception of an acid taste in added kefir beverages was shown to have changed. Overall, participants attributed significantly higher acceptance and purchase intent scores to added kefir beverages after they had been informed on its health benefits. In addition, expressions of positive emotion increased when participants were exposed to stimuli related to health benefits of kefir (15%, 30% and 50% m/v), while negative expressions of emotion decreased. The provided information of kefir modified valence and arousal in subjects, and it can be said that to 30% of kefir can be added to yogurt without compromising its sensory acceptability. Thus, health benefits alone cannot improve product acceptance, since participants found a 50% addition of kefir to be unpleasant when tasted during a blind test. Mixed beverages may present a probiotic beverage alternative for consumers who dislike kefir milk, but want to include it in their diets. The implications of liking and purchase intent and how they are linked to emotions are discussed in this paper as well.

A Systematic Review of Emoji: Current Research and Future Perspectives

A growing body of research explores emoji, which are visual symbols in computer mediated communication (CMC). In the 20 years since the first set of emoji was released, research on it has been on the increase, albeit in a variety of directions. We reviewed the extant body of research on emoji and noted the development, usage, function, and application of emoji. In this review article, we provide a systematic review of the extant body of work on emoji, reviewing how they have developed, how they are used differently, what functions they have and what research has been conducted on them in different domains. Furthermore, we summarize directions for future research on this topic.