The effects of voluntary front-of-pack nutrition labels on volume shares of products: the case of the Dutch Choices

Trends (2014-2018) in the healthiness of packaged food purchases of Australian consumers before and after the introduction of voluntary Health Star Rating nutrition labels

OBJECTIVE

To evaluate the trends in the healthiness of packaged food purchases of Australian consumers before and after the introduction of the Health Star Rating (HSR) nutrition labels.

DESIGN

Panel data analysis and difference-in-differences analysis.

SETTING

The Australian Government endorsed HSR nutrition labels for voluntary implementation on packaged foods in June 2014. We analyse the packaged food purchases of households across all major supermarkets before (January 2014 to June 2014) and after (June 2014-Dec 2018) the introduction of HSR.

PARTICIPANTS

6284 members of a panel of households across Australia reporting their grocery purchases to a market research company (Nielsen Homescan panel).

RESULTS

The healthiness of household food purchases exhibited a U-shaped trend - decreasing from 2014 to 2017, and then increasing from 2018, corresponding to the time when a higher proportion of products were HSR-labelled. Households that purchased a higher proportion of HSR-labelled products had healthier household purchases overall. Further, the healthiness of households' category-specific food purchases was positively associated with the proportion of HSR-labelled products in categories where HSR was adopted, relative to control categories where HSR was not adopted.

CONCLUSIONS

In Australia, once a substantial number of packaged food products adopted the voluntary HSR summary indicator, we observed an increasing trend in the healthiness of household food purchases. Widespread adoption of a nutrition summary indicator, such as HSR, on packaged food is likely to be beneficial for population health.

Front-of-pack labels: "Directive" versus "informative" approaches

Front-of-pack labels (FOPLs) aim at communicating to consumers the health value of food items in support of public health policies. Two main types can be discerned: directive and semidirective FOPLs using color schemes (e.g., Nutri-Score) and informative FOPLs (e.g., Nutrinform Battery). Directive approaches tend to show a "wear-out effect" and, additionally, they tend to have various underlying conceptual problems. Usually, their nutritional scores are calculated using changing, arbitrary algorithms and involve a reductionist set of parameters of debatable validity. Thus, they overstate the effects of selected nutritional factors, such as saturated fat and energy, while overlooking the food matrix and the more holistic aspects of nourishment. Moreover, they do not reflect the portion that is consumed, ignore the preparation steps at home, and fail to serve as a useful basis for composing a healthy diet. Also, so long as the nutritional formulations match the algorithmic standards, they tend to allow ultra-processed products. Thus, this might confuse and mislead consumers. Overconfidence in green-colored labels could even result in unbalanced dietary choices, whereas avoidance of red products may eliminate certain foods from the diet that are rich in essential nutrients (e.g., cheese), leading to opposite results than aimed for. The latter is particularly relevant to vulnerable populations, such as the young, pregnant women, and older adults, or for individuals with specific needs. Taken together, directive FOPLs such as Nutri-Score contradict the declared intent of the European Commission to empower consumers to undertake healthy and balanced diets based on easily accessible and robust information. Although informative systems usually also keep the focus on a few selected nutritional parameters, they have are less paternalizing and obviate the need to classify foods as healthy or unhealthy. They also focus attention on the individual portions that are consumed (even if the definition of portion size remains contentious). Given the importance of dietary patterns, rather than individual foods or nutrients, directiveFOPLs of the Nutri-Score type represent a regretful case of nutritionism. Finally, attempts to associate the adoption of a FOPL with an improvement in the health status are few and mainly applied in virtual settings; none of which are longitudinal, nor have they been able to identify a causal link.

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.

Understanding and Use of Nutrition Labels of Prepackaged Food by University Students: A Cross-Sectional Study in Chongqing, China

Object: The correct use of nutrition labels for prepackaged food helps university students develop healthy eating habits and prevent the occurrence of chronic non-communicable diseases. This study evaluates the understanding and use of nutrition labels of prepackaged food by university students in four different fields of study in Chongqing, China. Methods: This cross-sectional study used an online survey platform conducted in July 2022 in colleges and universities in Chongqing, China. The convenience sampling method was used to select students in four different fields of study, including medicine, humanities, science and technology, and arts and sports. Ten questions were used to assess participants’ understanding of nutrition labels. A score of six or above (60%) indicates that the respondent has a basic understanding of the nutritional labels of prepackaged food. Descriptive statistics and generalized linear models (GLMs) were used to assess participants’ understanding and use of nutrition labels for prepackaged foods and their influencing factors. Results: A total of 1262 valid questionnaires was collected. The average age of the participants was 21.8 years (SD: 2.43), 50.1% were male, 80.8% were ethnic Han, and 50.9% were from rural areas. Only 21.3% of the university students in Chongqing had a good understanding of the nutrition labels of prepackaged food, where medical students were the highest (39.9%) and science and engineering students were the lowest (15.6%). Gender, ethnicity, grade, major, and whether received courses related to nutrition were influential factors in the understanding and use of nutrition labels of prepackaged food. Medical students also had more positive attitudes toward nutritional labels of prepackaged food. Conclusions: Understanding and use of nutrition labels for prepackaged food by university students in Chongqing are unsatisfactory. Student’s major was a significant influencing factor in nutrition label comprehension, with medical students having the greatest understanding. Based on these results, we suggest that nutrition and health courses should be popularized among non-medical students to narrow the differences between different fields of study. For university students in all fields of study, education and publicity of nutrition labels of prepackaged food are needed, not only in the classroom but also in daily life.

Effect of voluntary Health Star Rating labels on healthier food purchasing in New Zealand: longitudinal evidence using representative household purchase data

Front-of-pack labelling (FoPL) aims to promote healthier diets by altering consumer food purchasing behaviour. We quantify the impact of the voluntary Health Star Rating (HSR) FoPL adopted by New Zealand (NZ) in 2014, on (i) the quantity of foods purchased by HSR scores and food groups and (ii) the quantities of different nutrients purchased. We used Nielsen HomeScan household purchasing panel data over 2013-2019, linked to Nutritrack packaged food composition data. Fixed effects analyses were used to estimate the association of HSR with product and nutrient purchasing. We controlled for NZ-wide purchasing trends and potential confounding at the household and product level. In 2019, HSR-labelled products accounted for 24% (2890) of 12 040 products in the dataset and 32% of purchasing volume. Of HSR-labelled products, 1339 (46%) displayed a rating of 4.0-5.0 stars and 556 (19%) displayed a rating of 0.5-2.0 stars. We found little or no association between HSR labelling and the quantities of different foods purchased. Introduction of HSR was, however, associated with lower sodium (-9%, 95% CI -13% to -5%), lower protein (-3%, 95% CI -5% to 0%) and higher fibre (5%, 95% CI 2% to 7%) purchases when purchased products carrying an HSR were compared with the same products prior to introduction of the programme. Robust evidence of HSR labelling changing consumer purchasing behaviour was not observed. The positive effect on nutrient purchasing of HSR-labelled foods likely arises from reformulation of products to achieve a better HSR label.

Development of the Choices 5-Level Criteria to Support Multiple Food System Actions

In 2008, the Choices International Foundation developed its logo criteria, identifying best-in-class food products. More advanced, global and graded nutrient profiling systems (NPSs) are needed to substantiate different national nutrition policies. The objective of this work was to extend Choices NPS to identify five levels of the healthiness of food products, so that the Choices NPS can also be used to support other nutrition policies, next to front-of-pack labelling. Based on the same principles as the previous logo criteria, four sets of threshold criteria were determined using a combination of compliance levels, calculated from a large international food group-specific database, the Choices logo criteria, and WHO-NPSs developed to restrict marketing to children. Validation consisted of a comparison with indicator foods from food-based dietary guidelines from various countries. Some thresholds were adjusted after the validation, e.g., because intermediate thresholds were too lenient. This resulted in a new international NPS that can be applied to different contexts and to support a variety of health policies, to prevent both undernutrition and obesity. It can efficiently evaluate mixed food products and represents a flexible tool, applicable in various settings and populations.

Effects on Consumers' Subjective Understanding and Liking of Front-of-Pack Nutrition Labels: A Study on Slovenian and Dutch Consumers

In the context of the ongoing debate on front-of-pack labels (FOPL), extant research highlights a lack of clear indications on which label is most effective in increasing consumers' knowledge of food nutritional quality, and in favoring informed food choices. In this study, we have compared the effects of two different labels, one nutrient-specific label (i.e., NutrInform Battery) and one summary label (i.e., Nutri-Score), in terms of consumers' "subjective understanding" and "liking". Our work advances prior research on FOPL performance by focusing on two different countries-which have different socio-political contexts and which, from previous studies, present limited evidence on the topic-Slovenia, currently utilizing the Protective Food logo, and the Netherlands, who has recently adopted the Nutri-Score. The study also confirms, in line with previous research, a higher effectiveness of the nutrient-specific label, NutrInform Battery, on all analyzed dimensions in tested countries, when compared to the summary label, Nutri-Score.

Analysis of Factors Influencing Food Nutritional Labels Use in Nanjing, China

A correct use of food nutrition la bels benefits consumers in pursuing balanced diets. As a result, we conducted interviews in Nanjing, China and randomly sampled 427 respondents. Further, we used both descriptive statistics and binary logistic regression to assess their perception of food nutrition label use. The results indicated that the current situation is not ideal in Nanjing. Only 7.26% of respondents use labeling consistently. Data on purchasing experience, comprehension, nutritional value, work sector, chronic disease, diet awareness, nutritional knowledge, and age were statistically significant. Conversely, taste and primary shopper categories negatively influenced food nutrition label use. In light of the above results, we propose policy recommendations to promote consumers' use of food nutrition labels. These are also beneficial in improving diet and relieving chronic diseases.

The Effect of Front-of-Pack Nutritional Labels and Back-of-Pack Tables on Dietary Quality

A healthy diet is important to prevent lifestyle diseases. Food labels have been proposed as a policy tool to improve the healthiness of food choices, as they provide information about nutritional content and health attributes which may otherwise have been unknown to the consumer. This study investigates the effect of food labels with different formats on dietary quality by using home-scan panel data and difference-in-difference methods to compare the change in dietary quality over time for households that start to use food labels with households that do not use labels. I find that the use of front-of-pack (FOP) nutritional labels increases overall dietary quality, which is driven by reduced intake of added sugar and increased intake of fiber. The use of back-of-pack (BOP) nutritional tables does not influence dietary quality. There is no additional benefit to overall dietary quality by using both labels. However, the results indicate that there could be a benefit of using both labels on certain nutrients. The results imply that additional policies are needed to supplement food labels in order to improve dietary quality.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

That's My Cue to Eat: A Systematic Review of the Persuasiveness of Front-of-Pack Cues on Food Packages for Children vs. Adults

Packaging is increasingly recognized as an essential component of any marketing strategy. Visual and informational front-of-pack cues constitute salient elements of the environment that may influence what and how much someone eats. Considering their overwhelming presence on packaging of non-core foods, front-of-pack cues may contribute to the growing rates of overweight and obesity in children and adults. We conducted a systematic review to summarize the evidence concerning the impact of front-of-pack cues on choices and eating behaviors. Four electronic databases were searched for experimental studies (2009-present). This resulted in the inclusion of 57 studies (in 43 articles). We identified studies on children (3-12 years) and adults (≥ 18 years), but no studies on adolescents (12-18 years). The results suggest that children and adults are susceptible to packaging cues, with most evidence supporting the impact of visual cues. More specifically, children more often choose products with a licensed endorser and eat more from packages portraying the product with an exaggerated portion size. Adults' eating behaviors are influenced by a range of other visual cues, mainly, package size and shape, and less so by informational cues such as labels.

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

Background

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

Methods

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

Results

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

Conclusion

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