Influence of Label Design on Children's Perception of 2 Snack Foods

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.

The Potential Effectiveness of Nutrient Declarations and Nutrition and Health Claims for Improving Population Diets

Nutrition labeling supports healthier diets by aiding purchase decisions and stimulating reformulation. This systematic literature review applied Cochrane methods to synthesize and appraise evidence on the effectiveness of nutrient declarations and nutrition and health claims on diet-related outcomes. The search spanned 11 academic databases, from inception to July 2022. Evidence was synthesized using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) and vote counting. Data were available from 170 studies. Randomized controlled trials (RCTs) suggest that nutrient declarations likely improved consumer understanding of the nutritional quality/content of foods (moderate certainty) and may have improved the healthfulness of choices (low certainty) versus no label. RCT evidence also suggests that claims likely increased consumer perceptions of food healthfulness and increased choice and purchases of labeled foods (both moderate certainty), irrespective of nutritional quality. To improve label understanding and avoid misinterpretation, nutrient declarations may incorporate interpretive elements and claims can apply disqualifying conditions for their usage, on the basis of overall nutritional quality.

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.

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.

A five-country study of front- and back-of-package nutrition label awareness and use: patterns and correlates from the 2018 International Food Policy Study

OBJECTIVE

This study aimed to identify correlates of nutrition label awareness and use, particularly subgroup differences among consumers. Two label types were assessed: (1) nutrition facts tables (NFt) in Australia, Canada, Mexico, UK, and USA and (2) front-of-package (FOP) labels, including mandatory Guideline Daily Amounts (Mexico), voluntary Health Star Ratings (Australia) and voluntary Traffic Lights (UK).

DESIGN

Respondents were recruited using Nielsen Consumer Insights Global Panel (n 21 586) and completed online surveys in November-December 2018. Linear regression and generalised linear mixed models examined differences in label use and awareness between countries and label type based on sociodemographic, knowledge-related and dietary characteristics.

SETTING

Australia, Canada, Mexico, UK and USA.

PARTICIPANTS

Adults (≥18 years).

RESULTS

Respondents from the USA, Canada and Australia reported significantly higher NFt use and awareness than those in Mexico and the UK. Mexican respondents reported the highest level of FOP label awareness, whereas UK respondents reported the highest FOP label use. NFt use was higher among females, 'minority' ethnic groups, those with higher nutrition knowledge and respondents with 'adequate literacy' compared with those with 'high likelihood of limited literacy'. FOP label use was higher among those with a 'high likelihood of limited literacy' compared with 'adequate literacy' across countries.

CONCLUSIONS

Lower use of mandatory Guideline Daily Amount labels compared with voluntary FOP labelling systems provides support for Mexico's decision to switch to mandatory 'high-in' warning symbols. The patterns of consumer label use and awareness across sociodemographic and knowledge-related characteristics suggest that simple FOP labels may encourage broader use across countries.

The effect of food packaging elements on children's food choices and intake: A systematic review

Little can be added about the worldwide concern over the exponential increase in obesity and child overweight problems. Much of the unhealthy eating habits occur at the time of food choice. The enormous influence of marketing strategies in general, and packaging in particular, has been highlighted here. In this respect, public policies that tend to direct choices toward healthier options have been developed. However, the usefulness of such policies will depend on evidence of how different packaging elements can influence children. This systematic review (SR) aims to compile the knowledge available to date on the influence of packaging on food choices and eating behaviours in children. Methodologically, the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines have been followed to select papers. We also assessed the risk of bias in the studies analysed using the Newcastle-Ottawa Quality Assessment Scale (NOS). The initial search strategy found 2,627 articles, although only 20 of them met the eligibility criteria. Data from the studies were extracted, categorised, and analysed. The results indicate that most of the packaging elements have some effect on children's food choices or food intake. The use of Cartoon is the element with the most consistent evidence of influence. Despite the number of studies and public initiatives developed to promote this informative and persuasive element, less consistency has been found regarding the effect of Nutrition Labelling. Therefore, the results found should be considered by both governments and organisations when promoting public policies that work for the wellbeing of children.

Marketing techniques, health, and nutritional claims on processed foods and beverages before and after the implementation of mandatory front-of-package warning labels in Peru

In June 2019, mandatory front-of-package warning labels (FOPL) were implemented in Peru. The aim of the study was to describe changes in marketing strategies on packaging: marketing techniques (MT), health claims (HC), and nutritional claims (NC) on the packaging of products frequently consumed by children before and after the FOPL implementation. Product photos were taken pre- (March 2019) and post-implementation (March-October 2020) in three supermarkets in Lima, Peru. Following INFORMAS protocols and Peruvian Technical Norms, the presence of MT, HC, and NC was assessed on all package sides. Products were classified as "high-in" and "not high-in" based on the regulation threshold for critical nutrients. Differences in the proportion of products with each strategy in both periods were evaluated. Also, a subsample of products was matched according to the barcode and exact McNemar test was used to compare proportions of strategies pre/post-implementation. We included 883 and 1,035 products in pre- and post-implementation, respectively. In both periods, MT appeared on almost 70% of all products. The presence of HC increased significantly only for beverages (24.5-38.1%, p < 0.001). In both phases, NC were commonly used on beverages (>80%). Overall, the prevalence of "high-in" products using MT increased (73.6-82.1%, p = 0.007), while use of HC increased among "not high-in" products (32.9-41.6%, p < 0.001). There is a high frequency of MT on all products and NC on beverages. The increase in MT in "high-in" products may be an industry response to minimize the impact of the FOPL on food choices and sales. New regulatory aspects regarding labeling should be implemented to strengthen the current policy.

Efficacy of different front-of-package labeling systems in changing purchase intention and product healthfulness perception for food products in Argentina

Objectives.

To identify the front-of-package scheme—Multiple Traffic Light (MTL), Nutri-Score (NS), and black octagon Warning System (WS)—most effective in reducing purchase intention and perceived product healthfulness of drinking yogurts, cookies and cheese spreads, and to assess the joint influence of nutrient claims on the effects.

Methods.

Randomized-controlled experiment. A within-subjects factorial design was used to evaluate the influence of three independent factors on perceived product healthfulness and purchase intention. A total of 704 adults in Argentina were shown three mock-up products and asked to indicate which product they would buy choosing between pairs of products from different categories and to rate product healthfulness on a 7-point Likert scale.

Results.

The WS was the most effective in reducing purchase intention in drinking yogurts (OR:0.16, 95%CI: 0.09;0.28), cookies (OR:0.10, 95%CI: 0.05;0.18) and cheese spreads (OR:0.10, 95%CI: 0.05;0.18), and the perception of healthfulness (WS Mean score 3,63 vs No label 4,24, p<0.001), regardless of the participants’ gender, age, and level of education. NS was inefficacious in reducing product healthfulness perception, while MTL had significantly increased how healthful the product was perceived (p<0.001). Nutrient claims increased purchase intention and perception of healthfulness, thus reducing the effectiveness of front-of-package labels (p<0.001).

Conclusions.

In line with growing evidence, our findings support that WS perform better than NS and MTL in reducing purchase intention and healthfulness perception of products with excessive amounts of critical nutrients associated with the greatest burden of diseases. Front-of-package WS are expected to facilitate the population in Argentina to make healthier decisions.

Packaging Weight, Filling Ratio and Filling Efficiency of Yogurt and Relevant Packagings Depending on Commercial Packaging Design, Material, Packaging Type and Filling Quantity

Yogurt is a diverse dairy product category. It is available in different packaging designs made of different materials. To identify potential for improvement for these packagings, a better understanding about used materials and packaging efficiencies is necessary. For this study, 150 dairy products and some yogurt relevant desserts were bought from various supermarkets, street markets and discounters in the Munich region (Germany) in spring 2022. Commercial types of packaging are cups, buckets, pouches, bottles, glass packagings and bricks. The filling ratio of most packagings is above 70%, the rest of the volume is headspace. Poly(1-methylethylene) (PP) and poly(1-phenylethene) (PS) dominate as main materials for the different types of packaging. For bottle packagings, poly(ethylene terephthalate) (PET) and polyethene high-density (PE-HD) are used. Interestingly, poly(lactic acid) (PLA) is not found. Closures (caps) are responsible for 5 to 30% of the total packaging weight. Typical filling efficiencies are 20 to 40 g food product packaged in one gram of packaging material. For glass packagings, the values are 1.5 to 2 g food product packaged in one gram of packaging material. Therefore, plastic packaging results in an at least ten-times lower packaging use per unit of food, at single use packagings. With increasing product weights, we observe a tendency towards higher packaging efficiencies. By using paper/carton wrapping at cups, plastic use is reduced for the whole packaging.

Association of Food and Nonalcoholic Beverage Marketing With Children and Adolescents' Eating Behaviors and Health: A Systematic Review and Meta-analysis

IMPORTANCE

There is widespread interest in the effect of food marketing on children; however, the comprehensive global evidence reviews are now dated.

OBJECTIVE

To quantify the association of food and nonalcoholic beverage marketing with behavioral and health outcomes in children and adolescents to inform updated World Health Organization guidelines.

DATA SOURCES

Twenty-two databases were searched (including MEDLINE, CINAHL, Web of Science, Embase, and The Cochrane Library) with a publication date limit from January 2009 through March 2020.

STUDY SELECTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines were followed. Inclusion criteria were primary studies assessing the association of food marketing with specified outcomes in children and adolescents (aged 0-19 years). Exclusion criteria were qualitative studies or those on advertising of infant formula. Of 31 063 articles identified, 96 articles were eligible for inclusion in the systematic review, and 80 articles in the meta-analysis (19 372 participants).

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data. Random-effects models were used for meta-analyses; meta-regressions, sensitivity analyses, and P curve analyses were also performed. Where appropriate, pooling was conducted using combining P values and vote counting by direction of effect. Grading of Recommendations Assessment, Development, and Evaluation was used to judge certainty of evidence.

MAIN OUTCOMES AND MEASURES

Critical outcomes were intake, choice, preference, and purchasing. Important outcomes were purchase requests, dental caries, body weight, and diet-related noncommunicable diseases.

RESULTS

Participants totaled 19 372 from 80 included articles. Food marketing was associated with significant increases in intake (standardized mean difference [SMD], 0.25; 95% CI, 0.15-0.35; P < .001), choice (odds ratio, 1.77; 95% CI, 1.26-2.50; P < .001), and preference (SMD, 0.30; 95% CI, 0.12-0.49; P = .001). Substantial heterogeneity (all >76%) was unexplained by sensitivity or moderator analyses. The combination of P values for purchase requests was significant but no clear evidence was found for an association of marketing with purchasing. Data on dental health and body weight outcomes were scarce. The certainty of evidence was graded as very low to moderate for intake and choice, and very low for preference and purchasing.

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, food marketing was associated with increased intake, choice, preference, and purchase requests in children and adolescents. Implementation of policies to restrict children's exposure is expected to benefit child health.

Association of Food and Nonalcoholic Beverage Marketing With Children and Adolescents' Eating Behaviors and Health: A Systematic Review and Meta-analysis

IMPORTANCE

There is widespread interest in the effect of food marketing on children; however, the comprehensive global evidence reviews are now dated.

OBJECTIVE

To quantify the association of food and nonalcoholic beverage marketing with behavioral and health outcomes in children and adolescents to inform updated World Health Organization guidelines.

DATA SOURCES

Twenty-two databases were searched (including MEDLINE, CINAHL, Web of Science, Embase, and The Cochrane Library) with a publication date limit from January 2009 through March 2020.

STUDY SELECTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines were followed. Inclusion criteria were primary studies assessing the association of food marketing with specified outcomes in children and adolescents (aged 0-19 years). Exclusion criteria were qualitative studies or those on advertising of infant formula. Of 31 063 articles identified, 96 articles were eligible for inclusion in the systematic review, and 80 articles in the meta-analysis (19 372 participants).

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data. Random-effects models were used for meta-analyses; meta-regressions, sensitivity analyses, and P curve analyses were also performed. Where appropriate, pooling was conducted using combining P values and vote counting by direction of effect. Grading of Recommendations Assessment, Development, and Evaluation was used to judge certainty of evidence.

MAIN OUTCOMES AND MEASURES

Critical outcomes were intake, choice, preference, and purchasing. Important outcomes were purchase requests, dental caries, body weight, and diet-related noncommunicable diseases.

RESULTS

Participants totaled 19 372 from 80 included articles. Food marketing was associated with significant increases in intake (standardized mean difference [SMD], 0.25; 95% CI, 0.15-0.35; P < .001), choice (odds ratio, 1.77; 95% CI, 1.26-2.50; P < .001), and preference (SMD, 0.30; 95% CI, 0.12-0.49; P = .001). Substantial heterogeneity (all >76%) was unexplained by sensitivity or moderator analyses. The combination of P values for purchase requests was significant but no clear evidence was found for an association of marketing with purchasing. Data on dental health and body weight outcomes were scarce. The certainty of evidence was graded as very low to moderate for intake and choice, and very low for preference and purchasing.

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, food marketing was associated with increased intake, choice, preference, and purchase requests in children and adolescents. Implementation of policies to restrict children's exposure is expected to benefit child health.

A cross-country experimental study on consumers' subjective understanding and liking on front-of-pack nutrition labels

Different Front-of-Pack (FOP) nutritional labels have been implemented in order to increase consumers' awareness of food nutritional quality and encourage healthier choices. However, few studies have analysed the effects of FOPLs on consumers' subjective understanding and liking across different socio-cultural contexts. This study tests the effect that the new enriched informative label NutrInform Battery and the summary label Nutri-Score have on subjective comprehension and liking across 2776 respondents of seven European countries (France, Germany, Greece, Italy, Portugal, Romania and Spain). Main effects regarding socio-demographic differences are also explored according to extant literature and highlighting significant effects of education and income. This study therefore extends the current research on subjective understanding and liking with a cross-country analysis. Findings suggest that NutrInform Battery can help consumers in understanding information in a relevant way, obtaining the highest performance across countries and showing limited impact of socio-cultural differences.

The Power of Packaging: A Scoping Review and Assessment of Child-Targeted Food Packaging

Child-targeted food marketing is a significant public health concern, prompting calls for its regulation. Product packaging is a powerful form of food marketing aimed at children, yet no published studies examine the range of literature on the topic or the “power” of its marketing techniques. This study attempts such a task. Providing a systematic scoping review of the literature on child-targeted food packaging, we assesses the nutritional profile of these foods, the types of foods examined, and the creative strategies used to attract children. Fifty-seven full text articles were reviewed. Results identify high level trends in methodological approaches (content analysis, 38%), outcomes measured (exposure, 44%) and with respect to age. Studies examining the nutritional profile of child-targeted packaged foods use various models, classifying from anywhere from 41% to 97% of products as unhealthy. Content analyses track the prevalence of child-targeted techniques (cartoon characters as the most frequently measured), while other studies assess their effectiveness. Overall, this scoping review offers important insights into the differences between techniques tracked and those measured for effectiveness in existing literature, and identifies gaps for future research around the question of persuasive power—particularly when it comes to children’s age and the specific types of techniques examined.

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

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

Nutritional Content According to the Presence of Front of Package Marketing Strategies: The Case of Ultra-Processed Snack Food Products Purchased in Costa Rica

The industry uses nutrition and health claims, premium offers, and promotional characters as marketing strategies (MS). The inclusion of these MS on ultra-processed products may influence child and adolescent purchase behavior. This study determined the proportion of foods carrying claims and marketing strategies, also the proportion of products with critical nutrients declaration, and nutritional profile differences between products that carry or not claims and MS on the front-of-package (FoP) of ultra-processed food products sold in Costa Rica. Data were obtained from 2423 photographs of seven food groups consumed as snacks that were sold in one of the most widespread and popular hypermarket chains in Costa Rica in 2015. Ten percent of products lacked a nutrition facts panel. Sodium was the least reported critical nutrient. Energy and critical nutrients were significantly highest in products that did not include any nutrition or health claim and in products that included at least one MS. Forty-four percent and 10% of all products displayed at least one nutrition or at least one health claim, respectively, and 23% displayed at least one MS. In conclusion, regulations are needed to restrict claims and marketing on ultra-processed food packages to generate healthier food environments and contribute to the prevention of childhood and adolescent obesity in Costa Rica.

Food Marketing Influences Children's Attitudes, Preferences and Consumption: A Systematic Critical Review

Exposure to the marketing of unhealthy foods and beverages is a widely acknowledged risk factor for the development of childhood obesity and noncommunicable diseases. Food marketing involves the use of numerous persuasive techniques to influence children's food attitudes, preferences and consumption. This systematic review provides a comprehensive contemporary account of the impact of these marketing techniques on children aged 0-18 years and critically evaluates the methodologies used. Five electronic academic databases were searched using key terms for primary studies (both quantitative and qualitative) published up to September 2018; 71 eligible articles were identified. Significant detrimental effects of food marketing, including enhanced attitudes, preferences and increased consumption of marketed foods were documented for a wide range of marketing techniques, particularly those used in television/movies and product packaging. Together, these studies contribute strong evidence to support the restriction of food marketing to children. However, the review also signposted distinct gaps: Firstly, there is a lack of use of qualitative and physiological methodologies. Secondly, contemporary and sophisticated marketing techniques used in new media warrant increased research attention. Finally, more research is needed to evaluate the longer-term effects of food marketing on children's weight.