Nutrition Label Viewing during a Food-Selection Task: Front-of-Package Labels vs Nutrition Facts Labels

The Potential Effectiveness of Front-of-Pack Nutrition Labeling for Improving Population Diets

Nutrition labeling on the front of food packages can support more healthful purchase decisions and encourage favorable reformulation. This systematic literature review applied Cochrane methods to synthesize and appraise the evidence on the effectiveness of front-of-pack labeling (FOPL) on diet-related outcomes and food reformulation to inform policy recommendations. The search was conducted on 11 academic and gray literature databases, from inception to July 2022. Evidence was synthesized using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation), vote counting, and meta-analyses, where appropriate. Overall, 221 articles were included in the review. The randomized controlled trial evidence suggested that, compared with when no FOPL was present, FOPL likely improved consumer understanding of the nutritional quality/content of foods (moderate certainty of evidence), and the healthfulness of food choices (moderate certainty) and purchases (moderate certainty). Interpretive FOPL had a greater effect on these outcomes compared with noninterpretive systems (moderate certainty). There was inconsistency in the best-performing interpretive FOPL system.

Front-of-Package Protein Labels on Cereal Create Health Halos

Front-of-package protein labels are frequently added to breakfast cereals, aimed at increasing purchases by consumers who believe they would benefit from eating more protein. However, the overall nutritional compositions of such products are often not significantly better than similar products without protein labels, and may contain more sugar, sodium, and calories to improve taste. We conducted an online survey with 1022 US adults to examine consumer perceptions of two cereals (Special K Original and Special K Protein). Participants perceived Special K Protein as healthier and more nutritious, though less tasty, than Special K Original. Special K Protein was perceived as providing greater health benefits, such as being more likely to help them build muscle, stay healthy, and live longer. Many participants perceived no differences in the amounts of certain nutrients between the cereals, such as sugar (54.5%), sodium (59.2%), and calories (49.1%). Yet, when serving sizes are equalized to one cup, Special K Protein has more sugar, sodium, and calories than Special K Original. Though most participants reported viewing the Facts Up Front label, only 21.3% correctly chose Special K Original as having the larger serving size. This pattern of results suggests the presence of a health halo surrounding the protein-labeled product.

Employees' Baseline Food Choices and the Effect of a Workplace Intervention to Promote Healthy Eating: Secondary Analysis of the ChooseWell 365 Randomized Controlled Trial

BACKGROUND

Little is known about whether the effectiveness of workplace wellness programs differs by employees' baseline health behaviors.

OBJECTIVE

This study examined the association of baseline cafeteria food choices with the effect of a workplace intervention on cafeteria food choices, dietary quality, and body mass index (BMI).

DESIGN

This was a secondary analysis of the ChooseWell 365 randomized controlled trial, testing a set of behavioral interventions to improve diet and prevent weight gain.

PARTICIPANTS/SETTING

Participants were 602 employees of a Boston, MA, hospital who had purchased food from cafeterias, which used traffic-light food labeling. Data were collected in 2016-2020.

INTERVENTION

The 12-month intervention (plus 12 months' follow-up) involved financial incentives and personalized feedback on cafeteria purchases. The control group received monthly letters with generic healthy eating and exercise tips.

MAIN OUTCOME MEASURES

Healthy purchasing scores (HPS) were calculated by weighting color categories (red = 0, yellow = 0.5, green = 1) and scaling from 0 to 100 (healthiest); employees were categorized into baseline (pre-intervention) HPS tertiles (T1 = least healthy, T3 = healthiest). Healthy eating index (HEI-2015) scores were calculated from two 24-hour dietary recalls. Intervention effects on 12- and 24-month changes in HPS (primary outcome), HEI-2015 score, and BMI were compared among tertiles. Subgroup analyses examined whether changes by tertile varied with financial rewards received.

STATISTICAL ANALYSES

Adjusting for baseline characteristics, multivariable linear regression assessed intervention effects across baseline HPS tertiles.

RESULTS

Compared with T3, T1 employees had lower education; higher obesity, hypertension, and pre-diabetes; and lower HEI-2015 scores. The intervention increased HPS, but no change was observed in HEI-2015 scores or BMI; the intervention effect did not differ among tertiles at 12 or 24 months. Financial incentives were associated with a larger effect on 12-month HPS changes for T1 than for T2/T3 (P-interaction < 0.001).

CONCLUSION

Compared with employees with healthier baseline food choices, employees with the least healthy food choices and highest cardiometabolic risk had similar improvements in the nutritional quality of cafeteria purchases as a result of the behavioral intervention, and they appeared to be more responsive to financial incentives.

Sociodemographic disparities in purchases of fruit drinks with policy relevant front-of-package nutrition claims

OBJECTIVE

Our objectives were to describe sociodemographic characteristics associated with the purchase of (1) any fruit drinks and (2) fruit drinks with specific front-of-package (FOP) nutrition claims.

DESIGN

Cross-sectional.

SETTING

USA.

PARTICIPANTS

We merged fruit drink purchasing data from 60 712 household-months from 5233 households with children 0-5 years participating in Nielsen Homescan in 2017 with nutrition claims data. We examined differences in predicted probabilities of purchasing any fruit drinks by race/ethnicity, income and education. We constructed inverse probability (IP) weights based on likelihood of purchasing any fruit drinks. We used IP-weighted multivariable logistic regression models to examine predicted probabilities of purchasing fruit drinks with specific FOP claims.

RESULTS

One-third of households with young children purchased any fruit drinks. Non-Hispanic (NH) Black (51·6 %), Hispanic (36·3 %), lower-income (39·3 %) and lower-educated households (40·9 %) were more likely to purchase any fruit drinks than NH White (31·3 %), higher-income (25·8 %) and higher-educated households (30·3 %) (all P < 0·001). In IP-weighted analyses, NH Black households were more likely to purchase fruit drinks with 'Natural' and fruit or fruit flavour claims (6·8 % and 3·7 %) than NH White households (4·5 % and 2·7 %) (both P < 0·01). Lower- and middle-income (15·0 % and 13·8 %) and lower- and middle-educated households (15·4 % and 14·5 %) were more likely to purchase fruit drinks with '100 % Vitamin C' claims than higher-income (10·8 %) and higher-educated households (12·9 %) (all P < 0·025).

CONCLUSIONS

We found a higher likelihood of fruit drink purchases in lower-income, lower-educated, NH Black and Hispanic households. Experimental studies should determine if nutrition claims may be contributing to disparities in fruit drink consumption.

Impact of front-of-pack nutrition labelling in consumer understanding and use across socio-economic status: A systematic review

An unhealthy diet is a leading contributor to the increasing burden of overweight and obesity. Front-of-pack labelling (FOPL) is being recognized as a policy strategy to promote healthier choices yet there is limited evaluation of FOPL to suggest if it is effective for all population subgroups. This systematic review aimed to assess the impact of FOPL on consumer understanding and usage across socio-economic gradients. Six electronic databases were searched through a systematic search process using key terms for FOPL and socioeconomic status (SES) from 2011 to March 2022 to include studies evaluating the effectiveness of FOPL. A narrative synthesis was conducted and the results were assessed according to the effects of FOPL on consumer awareness, understanding, and usage across SES. The review included 36 articles. In general, people of all SES groups were aware of and more likely to pay attention towards FOPL than the nutrition information panel provided on the back of the package. However, the understanding and usage were relatively poor, particularly in low SES groups. While studies conducted in low SES populations suggest FOPL increased the purchase intention of healthy products, the stratified analysis across SES showed less beneficial effects in low SES individuals. The findings highlight simplified and easy-to-understand FOPLs such as Nutri-score and traffic light labelling are likely to be effective for all populations including low SES groups. Overall, the review suggests FOPLs are more visible than the nutrition information panel and may guide healthier food choices for people of all SES backgrounds. It is unclear whether FOPL influences actual purchasing and food intake as there are insufficient studies comparing the effects among higher and lower SES populations.

Advantages of graphical nutrition facts label: faster attention capture and improved healthiness judgement

Consumers have to rely on the traditional back-of-package nutrition facts label (NFL) to obtain nutrition information in many countries. However, traditional NFLs have been criticised for their poor visualisation and low efficiency. This study redesigned back-of-package NFLs integrated with bar graphs (black or coloured) to visually indicate nutrient reference values (NRVs). Two eye movement studies were performed to evaluate the ergonomic advantages of the graphical NFLs. Our findings suggested that the newly designed NFLs led to faster and better healthiness evaluation performance. The newly designed graphical labels led to a shorter time to first fixation duration and offered a higher percentage of fixation time in the nutrient reference values region compared with that observed using traditional text labels. Nowadays, many chronic diseases are associated with poor eating habits, therefore, the importance of visualisation design to nudge healthier food choices could be paid more attention to by policymakers and food manufacturers.Practitioner summary: To improve the ergonomic design of traditional nutrition facts panel (NFL), this study assessed a newly designed graphical NFL. The results showed that graphical NFL captured consumers' attention faster and improved their healthiness judgement. Moreover, a brief nutrition education can improve consumers' attention and understanding of nutrition information.

Nutrition Education to Reduce Metabolic Dysfunction for Spinal Cord Injury: A Module-Based Nutrition Education Guide for Healthcare Providers and Consumers

Spinal cord injury (SCI) results in a high prevalence of neurogenic obesity and metabolic dysfunction. The increased risk for neurogenic obesity and metabolic dysfunction is mainly due to the loss of energy balance because of significantly reduced energy expenditure following SCI. Consequently, excessive energy intake (positive energy balance) leads to adipose tissue accumulation at a rapid rate, resulting in neurogenic obesity, systemic inflammation, and metabolic dysfunction. The purpose of this article is to review the existing literature on nutrition, dietary intake, and nutrition education in persons with SCI as it relates to metabolic dysfunction. The review will highlight the poor dietary intakes of persons with SCI according to authoritative guidelines and the need for nutrition education for health care professionals and consumers. Nutrition education topics are presented in a module-based format with supporting literature. The authors emphasize the role of a diet consisting of low-energy, nutrient-dense, anti-inflammatory foods consistent with the Dietary Guidelines for Americans' MyPlate to effectively achieve energy balance and reduce the risk for neurogenic obesity and metabolic dysfunction in individuals with SCI.

Health Literacy, Numeracy, and Health Promotion: A Secondary Analysis of the Choosewell 365 Workplace Trial

INTRODUCTION

Health literacy and numeracy are linked to obesity and dietary behaviors. This study investigates whether the effect of a workplace behavioral intervention to prevent weight gain and improve diet differed by employee health literacy and numeracy.

METHODS

ChooseWell 365 was an RCT of hospital employees testing a 12-month intervention using nudges and feedback to promote healthier choices, building on existing cafeteria traffic light labels (e.g., green=healthy, red=unhealthy). Health literacy and numeracy were measured with the Newest Vital Sign (range=0-6) and General Numeracy Scale (range=0-3). Mixed-effects linear models examined if intervention effects on cafeteria purchases, diet quality (Healthy Eating Index 2015, range=0-100), and weight change over 24 months differed by higher versus lower health literacy or numeracy. Data were collected in 2016-2020 and analyzed in 2020-2021.

RESULTS

In 12 months, 510 participants completed the Newest Vital Sign and General Numerancy Scale; 36.7% had Newest Vital Sign<6 (lower health literacy) and 31.6% had General Numerancy Scale<2 (lower numeracy). Intervention participants increased healthy purchases over 24 months compared with controls in both higher and lower health literacy and numeracy groups. At 12 months, Healthy Eating Index 2015 scores increased in intervention versus control participants with lower health literacy (5.5 points, 95% CI=1.51, 9.54) but not in those with higher health literacy (p-interaction=0.040). BMI did not differ by health literacy or numeracy.

CONCLUSIONS

A behavioral intervention improved cafeteria food choices of hospital employees of varying health literacy and numeracy levels and improved diet quality among employees with lower health literacy, suggesting this group also improved food choices outside of work.

Effects of food nutrition labels on the health awareness of school-age children

BACKGROUND

Overweight and obesity have been described as a global epidemic that seriously affects the health of adults and children. Front of Package (FOP) Nutrition Labeling can increase consumers' awareness of unhealthy foods. The purpose of this study is to find effective deterrence and improve children's health awareness via the FOP.

METHODS

This study examined children's health awareness of snack packaging using the four labels: guideline daily amounts (GDA), traffic light system (TLS), Apple label (designed in this study), and Warning label. This study recruited 343 children in the sixth grade, including 223 children living in cities and 120 children living in rural areas. First, 30 children in grades 3 to 6 selected 8 snacks that they often buy. Then, each snack was synthesized into these four labels according to their nutritional content for a total of 32 samples. Finally, a questionnaire was used to evaluate the health of snack packaging and the visibility of nutrition labels.

RESULTS

Four results can be drawn: (1) GDA, Apple label and TLS can help children determine healthier snack choices, (2) black Warning label cannot induce children to make healthier choices, (3) children who often buy snacks have low health awareness, and (4) rural children have weak health awareness of snack packaging.

CONCLUSIONS

These results can provide a packaging label design, which can effectively improve children's health awareness.

Identifying over-the-counter information to prioritize for the purpose of reducing adverse drug reactions in older adults: a national survey of pharmacists

BACKGROUND

Over-the-counter (OTC) medication use is associated with risks of adverse drug reactions (ADRs), particularly among older adults. The Drug Facts Label (DFL) is supposed to provide consumers with information that would avoid ADRs, yet research suggests that consumers frequently fail to interact with this critical information. We postulate that emphasizing critical information by placing it on the front of the package may increase its usage. Before doing so, the most critical information from the DFL needs to be identified.

OBJECTIVES

This study aimed to determine which information from the DFL is most critical in reducing ADRs at the time of purchase or use by older adults.

METHODS

A national survey of practicing pharmacists knowledgeable about OTC medication use by older adults asked participants to rank order the importance of the DFL sections to reduce ADRs in older adults. Open-ended questions focused on identifying ways of improving OTC medication labeling. Quantitative rankings were used to calculate the content validity ratio and analyzed using Wilcoxon signed rank tests. Qualitative results were categorized into themes.

RESULTS

A total of 318 responses (12% response rate) were analyzed. There was high consensus that uses and purpose, active ingredient, warnings, and directions for use were the most important sections of the DFL. Within the warning section, 2 specific warnings, "Do not use" and "Ask a doctor or pharmacist," were deemed most important. Similarly, qualitative themes focused on seeking health care provider assistance or were specific to age-related precautions.

CONCLUSIONS

Prioritizing warnings that highlight the importance of possible drug-drug and drug-disease precautions and the need to seek medical advice before taking OTC medications were deemed most critical. Moving this type of information to the front of the package may help reduce ADRs among older adults.

Using change detection to objectively evaluate whether novel over-the-counter drug labels can increase attention to critical health information among older adults

Over-the-counter (OTC) drugs have many benefits but also carry risks, such as adverse drug reactions, which are more prevalent in older adults. Because these products do not require the oversight of a physician or pharmacist, labeling plays a key role in communicating information required for their safe and effective use. Research suggests that current labels are not terribly effective at communicating potential risk. One reason for their lack of effectiveness is that few consumers attend to critical information (active ingredients and warnings) when making purchases. In two experiments, we used a change detection task to objectively evaluate how novel label designs that employ highlighting and a warning label placed on the package’s front impact attention to critical information among older participants (65 and older). The change detection task is a unique form of visual search which allowed us to assess the attentional priority of critical information among participants who were not explicitly instructed to search for this critical information. This unique aspect of the task is important given research suggesting that consumers rarely have the explicit goal of seeking out warnings and active ingredients when making OTC selections. Our results provide empirical support that both highlighting critical information and positioning it on the package’s front increase its attentional prioritization relative to current, commercial practice. Given that attending to the critical information is prerequisite to utilizing that information, strategies that elicit attention in this way are likely to reduce medication errors.

Food Labeling Use by Consumers in Arab countries: A Scoping Review

Non-communicable diseases (NCD) related to inadequate nutrition are prevalent in economically transitioning countries such as the Arab region. The westernized diet is recognized as a leading trend and the UN General Assembly is focused on the prevention and control of NCD. Due to the rapid transitions in diet and physical inactivity occurring in the Arab region, revising public health dietary strategies, guidelines, and policies to reduce the burden of NCD is needed. This article presents existing literature on food label use in the Arab region as a response to the problem. The primary objective was to locate, review, and summarize peer-reviewed studies on how and why consumers use food labels in Arab countries. An integrative review of the related literature was conducted with no delimiting time frames. The authors applied search strategies to eight academic databases which produced 32 peer-reviewed articles. Seventeen were removed due to inconsistent scope and focus. Awareness of and nutrition knowledge about food labeling emerged as a primary theme. Education, household income, and age were secondary themes and predictor variables. Nutrition food labels as a population-based strategy can influence individual behavior change and potentially improve population health. These outcomes depend on the consumer's ability to understand nutrition labels and properly apply information. Themed recommendations included standardization of food labeling policies, consumer education on food labeling, and public health efforts to develop a detailed understanding of regional populations prior to health promotion strategy development. Enabling informed food selection and reinforcing healthy dietary intake can help prevent NCD and support individual and population health.

Nutrition label processing in the past 10 years: Contributions from eye tracking approach

Healthy eating plays a critical role in preventing diet-related chronic diseases. To promote healthy eating, nutrition labels have been mandated to certain foods in many countries. To test how different designs of nutrition labels affect consumer behavior, eye tracking technique has been increasingly used to overcome the limitations of subjective report which are susceptible to different biases and a poor indicator of nutrition label use in reality. In this review, we reviewed 45 eye-tracking studies on nutrition label processing. Besides a summary of eye tracking methodology, we found three emerged topics from these studies: attention capture, nutrition label comprehension and food choice. Overall, updated designs of nutrition labels improve attention capture and nutrition label comprehension, but it does not necessarily lead to healthier food choices. The discrepancy between attention capture and food choice also indicate potential limitation in promoting healthy food choice via the indirect attention route (exposure - attention - nutrition label processing - food choice). Instead, actual food choice may be a consequence of a direct heuristic route and modulated by person-, product- and context-related factors. These findings can not only guide future studies, but also have implications on making nutrition label policy and improving human health in eastern developing countries.

Who Reads Food Labels? Selected Predictors of Consumer Interest in Front-of-Package and Back-of-Package Labels during and after the Purchase

The paper aims to identify selected predictors of food label use to extend our knowledge about consumer behavior related to food purchases. Two types of information were examined: front-of-package (FOP) and back-of-package (BOP), and two contexts of reading labels were distinguished: during shopping and at home. Various types of potential predictors were tested, including demographic (e.g., age, gender, household size, place of living), socioeconomic (e.g., education, professional activity, income), behavioral (e.g., purchasing certain types of products), and psychographic (e.g., importance attached to various types of information) criteria. The survey was conducted with the use of the CAWI (Computer-Assisted Web Interviews) methodology in a sample of 1051 Polish consumers. Quota sampling was applied based on sex, age, education, place of living (urban vs. rural), and region. Descriptive statistics, t-tests, ANOVAs, Pearson correlation coefficients, and multiple and retrograde step regressions were applied. In retrograde step regression models, only one predictor (self-rated knowledge about nutrition healthiness) turned out to be significant for all four measures of label reading. The remaining predictors were specific to selected measures of reading labels. The importance of the information about the content of fat and that about the health effects of consuming a food product were significant predictors of three types of food label use. This study confirms the necessity to investigate reading labels in fine-grained models, adapted to different types of labels and different contexts of reading. Our results show that demographic or socioeconomic variables are not significant predictors of reading food labels for a large group of Polish consumers.

The Color Nutrition Information Paradox: Effects of Suggested Sugar Content on Food Cue Reactivity in Healthy Young Women

Color nutrition information (CNI) based on a traffic light system conveys information about food quality with a glance. The color red typically indicates detrimental food characteristics (e.g., very high sugar content) and aims at inhibiting food shopping and consumption. Red may, however, also elicit cross-modal associations with sweet taste, which is a preferable food characteristic. We conducted two experiments. An eye-tracking study investigated whether CNI has an effect on cue reactivity (dwell time, saccadic latency, wanting/liking) for sweet foods. The participants were presented with images depicting sweets (e.g., cake). Each image was preceded by a colored circle that informed about the sugar content of the food (red = high, green = low, gray = unknown). It was tested whether the red circle would help the participants to direct their gaze away from the 'high sugar' item. A second experiment investigated whether colored prime circles (red, green, gray) without nutrition information would influence the assumed sweetness of a food. In Experiment 1, CNI had the opposite of the intended effect. Dwell time and saccadic latency were higher for food items preceded by a red compared to a green circle. This unintended response was positively associated with participants' liking of sweet foods. CNI did not change the wanting/liking of the displayed foods. In Experiment 2, we found no evidence for color priming on the assumed sweetness of food. Our results question whether CNI is helpful to influence initial cue reactivity toward sweet foods.

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.

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.

Nutrition Facts Panels: Who Uses Them, What Do They Use, and How Does Use Relate to Dietary Intake?

BACKGROUND

Nutrition labels are a low-cost tool with the potential to encourage healthy eating habits.

OBJECTIVE

To investigate correlates of frequent Nutrition Facts label use, describe the types of label information most often used, and measure how label use relates to dietary intake in young adults.

DESIGN

Cross-sectional population-based study of young adults participating in Project Eating and Activity in Teens and Young Adults-IV.

PARTICIPANTS/SETTING

Surveys and food frequency questionnaires were completed during 2015-2016 by young adults (N=1,817; weighted sample=49% women) aged 25 to 36 years.

MAIN OUTCOME MEASURES

Nutrition Facts label use, frequency of using specific information on labels, and dietary intake.

STATISTICAL ANALYSES PERFORMED

Relative risks and adjusted means were used to examine how demographic, behavior, and weight-related factors were associated with Nutrition Facts panel use, and how label use related to dietary outcomes. Associations with P values <0.05 were considered statistically significant.

RESULTS

Approximately one-third (31.4%) of participants used Nutrition Facts labels "frequently." Use was significantly higher for women; for participants with high education and income; among those who prepared food regularly; among those who were physically active; among those with a weight status classified as overweight; and among those who were trying to lose, gain, or maintain weight. Label components used most often included sugars (74.1%), total calories (72.9%), serving size (67.9%), and the ingredient list (65.8%). Nutrition Facts label users consumed significantly more fruits, vegetables, and whole grains and fewer sugar-sweetened beverages, compared with nonusers. Nutrition Facts label users ate significantly more frequently at sit-down restaurants but less frequently at fast-food restaurants compared with nonusers.

CONCLUSIONS

Although Nutrition Facts label use was associated with markers of better dietary quality in a population-based sample of young adults, only one-third of participants used labels frequently. Methods to improve label use should be studied, particularly through leveraging weight- or health-related goals (eg, interest in making healthier food choices), and meeting consumer preferences concerning label content.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Consumers' Views on the Importance of Specific Front-of-Pack Nutrition Information: A Latent Profile Analysis

Nutrition labelling can influence consumers’ assessments of food healthiness and their food choices. However, there is a lack of consensus about the optimal type and amount of nutrition information to provide on food packages. This study analysed consumers’ preferences for front-of-pack information relating to energy and various nutrients (sugar, saturated fat, sodium, fibre, carbohydrate, and protein). The aim was to identify discrete preference segments within the Australian market where the current Health Star Rating front-of-pack labelling system can be displayed with different levels of nutrition information. Adults (n = 1558) completed a survey assessing socio-demographics, self-reported nutrition knowledge, diet healthiness, special dietary requirements, and perceived importance of the provision of energy and nutrient information on the front of food packs. Latent profile analysis identified five consumer segments within the sample that ranged from groups exhibiting high levels of interest in various forms of nutrition information to one with very low interest and one with divergent scores according to whether nutrients were perceived as positive or negative for health. The results indicate that different forms of front-of-pack labelling featuring varying degrees of information about energy and specific nutrients are likely to be of interest and use to different market segments.

Comparing five front-of-pack nutrition labels' influence on consumers' perceptions and purchase intentions

In 2011, a National Academy of Medicine report recommended that packaged food in the U.S. display a uniform front-of-package nutrition label, using a system such as a 0-3 star ranking. Few studies have directly compared this to other labels to determine which best informs consumers and encourages healthier purchases. In 2013, we randomized adult participants (N=1247) in an Internet-based survey to one of six conditions: no label control; single traffic light; multiple traffic light; Facts Up Front; NuVal; or 0-3 star ranking. We compared groups on purchase intentions and accuracy of participants' interpretation of food labels. There were no differences in the nutritional quality of hypothetical shopping baskets across conditions (p=0.845). All labels improved consumers' abilities to judge the nutritional quality of foods relative to no label, but the best designs varied by outcomes. NuVal and multiple traffic light labels led to the greatest accuracy identifying the healthier of two products (p<0.001), while the multiple traffic light also led to the most accurate estimates of saturated fat, sugar, and sodium (p<0.001). The single traffic light outperformed other labels when participants compared nutrient levels between similar products (p<0.03). Single/multiple traffic light and Facts Up Front labels led to the most accurate calories per serving estimations (p<0.001). Although front-of-package labels helped participants more accurately assess products' nutrition information relative to no label, no conditions shifted adults' purchase intentions. Results did not point to a clearly superior label design, but they suggest that a 3-star label might not be best for educating consumers.

The impact of interpretive and reductive front-of-pack labels on food choice and willingness to pay

BACKGROUND

This study examined how front-of-pack labels and product healthfulness affect choice and willingness to pay across a range of foods. It was hypothesized that: (i) product choice and (ii) willingness to pay would be more aligned with product healthfulness when healthfulness was expressed through the Health Star Rating, followed by the Multiple Traffic Light, then the Daily Intake Guide, and (iii) the Nutrition Facts Panel would be viewed infrequently.

METHODS

Adults and children aged 10+ years (n = 2069) completed an online discrete choice task involving mock food packages. A 4 food type (cookies, corn flakes, pizza, yoghurt) × 2 front-of-pack label presence (present, absent) × 3 front-of-pack label type (Daily Intake Guide, Multiple Traffic Light, Health Star Rating) × 3 price (cheap, moderate, expensive) × 3 healthfulness (less healthy, moderately healthy, healthier) design was used. A 30 s time limit was imposed for each choice.

RESULTS

Of the three front-of-pack labels tested, the Health Star Rating produced the largest differences in choices, with 40% (95% CIs: 38%-42%) of respondents selecting the healthier variant, 33% selecting the moderately healthy variant (95% CIs: 31%-35%), and 23% (95% CIs: 21%-24%) selecting the less healthy variant of the four products included in the study. The Multiple Traffic Light led to significant differences in choices between healthier (35%, 95% CIs: 33%-37%) and less healthy products (29%, 95% CIs: 27%-31%), but not moderately healthy products (32%, 95% CIs: 30%-34%). No significant differences in choices were observed by product healthfulness when the Daily Intake Guide was present. Only the Health Star Rating resulted in a significantly greater willingness to pay for healthier versus less healthy products. The Nutrition Facts Panel was viewed for only 7% of all mock packages.

CONCLUSIONS

Front-of-pack labels that are more interpretive, such as the Health Star Rating, can be more effective at directing consumers towards healthier choices than reductive front-of-pack labels such as the Daily Intake Guide. The study results provide policy makers with clear guidance on the types of front-of-pack labels that are most likely to achieve positive health outcomes at a population level.

Consumers' responses to health claims in the context of other on-pack nutrition information: a systematic review

Context

The presence of health claims on food packaging can positively bias consumers' evaluations of foods. This review examined whether cognitive biases endure when other sources of nutrition information [the nutrition facts panel (NFP) and front-of-pack labels] appear on-pack with health claims. The following databases were searched: Web of Science, Ovid, Google Scholar, ScienceDirect, Scopus, ProQuest, and Wiley Online Library. The search terms ("health claim*" OR "nutri* claim") AND ("food label*" OR "front of pack") were used to identify studies. Twenty-four studies that examined health claims and front-of-pack labels or the NFP were included. The NFP can reduce bias, but only if consumers view it and interpret it correctly, which often does not occur. Front-of-pack labels show greater promise in reducing bias created by health claims. These findings are relevant to policymakers who are considering the effectiveness of mandating an NFP and/or a front-of-pack label alongside health claims.

Innovative Techniques for Evaluating Behavioral Nutrition Interventions

Assessing outcomes and the impact from behavioral nutrition interventions has remained challenging because of the lack of methods available beyond traditional nutrition assessment tools and techniques. With the current high global obesity and related chronic disease rates, novel methods to evaluate the impact of behavioral nutrition-based interventions are much needed. The objective of this narrative review is to describe and review the current status of knowledge as it relates to 4 different innovative methods or tools to assess behavioral nutrition interventions. Methods reviewed include 1) the assessment of stress and stress responsiveness to enhance the evaluation of nutrition interventions, 2) eye-tracking technology in nutritional interventions, 3) smartphone biosensors to assess nutrition and health-related outcomes, and 4) skin carotenoid measurements to assess fruit and vegetable intake. Specifically, the novel use of functional magnetic resonance imaging, by characterizing the brain's responsiveness to an intervention, can help researchers develop programs with greater efficacy. Similarly, if eye-tracking technology can enable researchers to get a better sense as to how participants view materials, the materials may be better tailored to create an optimal impact. The latter 2 techniques reviewed, smartphone biosensors and methods to detect skin carotenoids, can provide the research community with portable, effective, nonbiased ways to assess dietary intake and quality and more in the field. The information gained from using these types of methodologies can improve the efficacy and assessment of behavior-based nutrition interventions.

Food Label Knowledge, Usage and Attitudes of Older Adults

Few recent studies have investigated food label practices in older adults. This cross-sectional study surveyed adults, 60 years and older in Delaware (n = 100, 82% female, 74% between 60 and 79 years, 49% Caucasian, 45% African Americans) to examine associations between food label knowledge, attitudes, and usage patterns. A 28-item questionnaire assessed knowledge, attitudes, usage, and demographic information. Bivariate analysis results showed food label knowledge was associated with education and monthly income. Those reporting a high school education or less incorrectly identified calorie (P < 0.05) and carbohydrate information (P < 0.03). Monthly income ≤$2000 was associated with incorrectly interpreting carbohydrate information (P < 0.03). Label usage was associated with being female (P < 0.001), having a high school education or less (P < 0.000), being 70 years or older (P < 0.05), and having a monthly income ≤$2000 (P < 0.001). Respondent's usage and perceived label comprehension was high; however less than half could correctly interpret label information. When shown samples of the US Food and Drug Administration's proposed new labels, subjects had a very favorable attitude toward the new changes. Increasing nutrition knowledge through education interventions appropriate for older adult consumers may improve comprehension of information on the food labels.

The types and aspects of front-of-pack food labelling schemes preferred by adults and children

There is strong interest in front-of-pack labels (FoPLs) as a potential mechanism for improving diets, and therefore health, at the population level. The present study examined Australian consumers' preferences for different types and attributes of FoPLs to provide additional insights into optimal methods of presenting nutrition information on the front of food packets. Much research to date has focused on two main types of FoPLs - those expressing daily intake values for specific nutrients and those utilising 'traffic light' colour coding. This study extends this work by: (i) including the new Health Star Rating system recently introduced in Australia and New Zealand; (ii) allowing a large sample of consumers to self-nominate the evaluation criteria they consider to be most important in choosing between FoPLs; (iii) oversampling consumers of lower socioeconomic status; and (iv) including children, who consume and purchase food in their own right and also influence their parents' food purchase decisions. A cross-sectional online survey of 2058 Australian consumers (1558 adults and 500 children) assessed preferences between a daily intake FoPL, a traffic light FoPL, and the Health Star Rating FoPL. Across the whole sample and among all respondent subgroups (males vs females; adults vs children; lower socioeconomic status vs medium-high socioeconomic status; normal weight vs overweight/obese), the Health Star Rating was the most preferred FoPL (44%) and the daily intake guide was the least preferred (20%). The reasons most commonly provided by respondents to explain their preference related to ease of use, interpretive content, and salience. The findings suggest that a simple to use, interpretive, star-based food label represents a population-based nutrition promotion strategy that is considered helpful by a broad range of consumers.

The effects of restaurant nutrition menu labelling on college students' healthy eating behaviours

OBJECTIVE

According to the US Affordable Care Act, restaurant chains are required to provide energy (calorie) and other nutrition information on their menu. The current study examined the impact of menu labelling containing calorie information and recommended daily calorie intake, along with subjective nutrition knowledge, on intention to select lower-calorie foods prior to the implementation of the Affordable Care Act.

DESIGN

Full factorial experimental design with participants exposed to four variants of a sample menu in a 2 (presence v. absence of calorie information) ×2 (presence v. absence of recommended daily calorie intake).

SETTING

Large, public university in the Southwest USA.

SUBJECTS

Primarily undergraduate college students.

RESULTS

Majority of participants were 19-23 years of age (mean 21·8 (sd 3·6) years). Menu information about calorie content and respondents' subjective nutrition knowledge had a significantly positive impact on students' intention to select lower-calorie foods (β=0·24, P<0·001 and β=0·33, P<0·001, respectively); however, recommended daily calorie intake information on the menu board did not influence students' intention to select lower-calorie foods (β=0·10, P=0·105). Gender played a significant role on purchase intent for lower-calorie menu items, with females more affected by the calorie information than males (β=0·37, P<0·001).

CONCLUSIONS

Findings support the role menu labelling can play in encouraging a healthier lifestyle for college students. College students who are Generation Y desire healthier menu options and accept nutritional labels on restaurant menus as a way to easily and expediently obtain nutrition information.

Impact of explained v. unexplained front-of-package nutrition labels on parent and child food choices: a randomized trial

Objective

The present study investigated whether parent/child pairs would select more healthful foods when: (i) products were labelled with front-of-package (FOP) nutrition labels relative to packages without labels; (ii) products were labelled with colour-coded Multiple Traffic Light (MTL) FOP labels relative to monochromatic Facts up Front (FuF) FOP labels; and (iii) FOP labels were explained via in-aisle signage v. unexplained.

Design

Participants were randomly assigned to one of five conditions: (i) FuF labels with in-aisle signs explaining the labels; (ii) FuF labels, no signage; (iii) MTL labels with in-aisle signage; (iv) MTL labels, no signage; (v) control group, no labels/signage. Saturated fat, sodium, sugar and energy (calorie) content were compared across conditions.

Setting

The study took place in a laboratory grocery aisle.

Subjects

Parent/child pairs (n 153) completed the study.

Results

Results did not support the hypothesis that MTL labels would lead to more healthful choices than FuF labels. The presence of FOP labels did little to improve the healthfulness of selected foods, with few exceptions (participants with v. without access to FOP labels selected lower-calorie cereals, participants with access to both FOP labels and in-aisle explanatory signage selected products with less saturated fat v. participants without explanatory signage).

Conclusions

Neither MTL nor FuF FOP labels led to food choices with significantly lower saturated fat, sodium or sugar. In-aisle signs explaining the FOP labels were somewhat helpful to consumers in making more healthful dietary decisions. New FOP labelling programmes could benefit from campaigns to increase consumer awareness and understanding of the labels.

Health literacy, literacy, numeracy and nutrition label understanding and use: a scoping review of the literature

BACKGROUND

Low health literacy, literacy and numeracy have been identified as barriers to consumer understanding and the interpretation of nutrition-related information. To inform policy and dietetic practice, we examined the extent, range and nature of research on empirical relationships between health literacy, literacy or numeracy and the understanding and use of nutrition labels.

METHODS

A scoping review of the literature was conducted. A search of eight databases on 15 April 2014 and 26 May 2016 returned 651 and 173 records, respectively. After de-duplication and two levels of relevance screening, 16 studies were deemed eligible for inclusion in the present review.

RESULTS

The majority of studies were conducted in the USA and focused primarily on the use of back-of-pack nutrition labels. Empirical relationships reported between health literacy and nutrition label use were inconsistent and, in some cases, contradictory. The findings from studies examining empirical relationships between literacy, numeracy and nutrition label use suggest that consumers with lower literacy and numeracy: (i) differ from those with higher levels in some of the judgements that they make about food and (ii) may benefit from interventions designed to improve their understanding and use of nutrition label information. Measurement-related issues were identified, such as a reliance on self-reports of nutrition label use, as well as a lack of independence between some measures of health literacy and nutrition label understanding and use.

CONCLUSIONS

The empirical relationships between health literacy, literacy, numeracy and nutrition label understanding and use have not been well-studied. Additional attention is needed regarding the measurement-related issues identified in the present review.

Evaluating the Impact of U.S. Food and Drug Administration–Proposed Nutrition Facts Label Changes on Young Adults’ Visual Attention and Purchase Intentions

Background. The U.S. Food and Drug Administration (FDA) has proposed modifying the Nutrition Facts Label (NFL) on food packages to increase consumer attention to this resource and to promote healthier dietary choices. Aims. The present study sought to determine whether the proposed NFL changes will affect consumer attention to the NFL or purchase intentions. Method. This study compared purchase intentions (yes/no responses to “would you purchase this food?” for 64 products) and attention to NFLs (measured via high-speed eye-tracking camera) among 155 young adults randomly assigned to view products with existing versus modified NFLs. Attention to all individual components of the NFL (e.g., calories, fats, sugars) were analyzed separately to assess the impact of each proposed NFL modification on attention to that region. Data were collected in 2014; analysis was conducted in 2015. Results. Modified NFLs did not elicit significantly more visual attention or lead to more healthful purchase intentions than did existing NFLs. Relocating the percent daily value component from the right side of the NFL to the left side, as proposed by the FDA, actually reduced participants’ attention to this information. The proposed “added sugars” component was viewed on at least one label by a majority (58%) of participants. Discussion. Results suggest that the proposed NFL changes may not achieve FDA’s goals. Changes to nutrition labeling may need to take a different form to meaningfully influence dietary behavior. Conclusion. Young adults’ visual attention and purchase intentions do not appear to be meaningfully affected by the proposed NFL modifications.