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

Can environmental traffic light warning labels reduce meat meal selection? A randomised experimental study with UK meat consumers

An important area for tackling climate change and health improvement is reducing population meat consumption. Traffic light labelling has successfully been implemented to reduce the consumption of unhealthy foods and sugary drinks. The present research extends this work to meat selection. We tested 1,300 adult UK meat consumers (with quotas for age and gender to approximate a nationally representative sample). Participants were randomised into one of four experimental groups: (1) a red traffic light label with the text 'High Climate Impact' displayed on meat meal options only; (2) a green traffic light label with the text 'Low Climate Impact' displayed on vegetarian and vegan meal options only; (3) red/orange/green (ROG) traffic light labels displayed on relevant meals; and (4) control (no label present). Participants made meal selections within their randomised group across 20 meal trials. A beta-regression was performed to ascertain the change in primary outcome (proportion of meat meals selected across the 20 trials) across the different groups. The red-only label and ROG labels significantly reduced the proportion of meat meals selected compared to the unlabelled control group, by 9.2% and 9.8% respectively. The green-only label did not differ from control. Negatively framed traffic light labels seem to be effective at discouraging meat selection. The labels appeared to be moderately acceptable to meat eaters, who did not think the labels impacted the appeal of the products. These encouraging findings require replication in real-life settings.

Comparing the impact of simple and educational point-of-decision messages on nutritional choice outcomes

Emerging evidence suggests that point-of-decision messages may be an effective way to promote healthy food choices. Previous studies show improvements in overall nutritional quality, as well as increases in underconsumed food categories, such as fruits and vegetables, and underconsumed nutrients of public health concern, like dietary fiber. However, there have been multiple approaches used for delivering point-of-decision messages, including very brief messages that remind individuals to consider health during choice, as well as longer messages providing educational information about health benefits. While both approaches have demonstrated positive impacts on outcomes, there is no comparative evidence of the messages' effectiveness. In this study, we examine the impact of four messages on two nutritional attributes of cereals selected in a two-round pre- and post-message breakfast cereal choice exercise with numerous (n = 33) breakfast cereals available. Data were collected via an online survey of adult US residents recruited from the Prolific consumer panel. Three of the messages were simple reminder messages (taste, health, fiber), while there was additionally a longer fiber-focused messaging detailing the health benefits of fiber. Findings show that the simple messages outperformed the longer educational message, though there were some trade-offs between general health and fiber messages. The simple dietary fiber-focused message resulted in significantly higher dietary fiber content in cereals chosen than in any other messaging condition, while the general health message did not result in significantly higher measures of nutritional quality than the simple fiber message. The results of the study suggest that simpler messages may be more effective at increasing the nutritional quality of food choices. Additionally, messages focused on specific nutrients lead to significantly greater increases in the content of those nutrients.

Potential consumer response to the healthy symbol proposed by the U.S. food and Drug Administration

The U.S. Food and Drug Administration (FDA) has proposed updates to the definition of "healthy," including distinctions between types of sugar and fats and limits on added sugar, saturated fat, and sodium. To communicate the updated standards, the FDA is developing a Healthy symbol to display on food packages, which could reduce knowledge gaps by assisting U.S. consumers in meeting recommended nutritional guidelines. This study aimed to explore the potential for the label to increase consumers' ability to correctly identify a food product that met the FDA's criteria for a healthy symbol. To complete the study objective, 1018 adults were recruited to represent the U.S. population regarding gender, age, income, and geographic region, and a randomized group experiment was used to determine the potential communication value of an FDA Healthy symbol. Respondents were randomized to a group shown either a healthy yogurt with the FDA symbol, a healthy yogurt without the symbol, or an unhealthy yogurt. Respondents were then asked whether they considered the yogurt shown to be healthy, a question examining the desired criteria for the Healthy symbol, willingness to accept various costs to implement the symbol, and questions to measure objective dietary knowledge. Adding the symbol to yogurt that already met the healthy criteria only yielded about a 4 percentage point increase in the proportion of respondents identifying it as healthy. However, 53 % of participants still identified a yogurt too high in added sugars as healthy. For the desired label criteria, 64 % of respondents selected limits on added sugars, 57 % selected limits on sodium, and 54 % selected limits on saturated fats, which all align with the proposed updates to the definition of healthy. Over half of the participants supported the implementation of the label, even at a cost of $40 annually, and 86 % supported implementation at no cost.

Nutrients or processing? An analysis of food and drink items from the UK National Diet and Nutrition Survey based on nutrient content, the NOVA classification and front of package traffic light labelling

UK front of package labelling (FOPL) informs consumers on the nutrient content of food. However, FOPL does not consider food processing, and with the UK government being urged to act on ultra-processed food (UPF), whether UPF should be added to FOPL is unclear. This study compared food and drink in the UK National Diet and Nutrition Survey (NDNS) Intake24 database based on FOPL, nutrient content and NOVA classification, to understand whether UPF are covered by dietary recommendations for foods high in fat, salt and sugar. NDNS items were coded into minimally processed food (MPF), processed culinary ingredients, processed food and UPF according to the NOVA classification and FOPL traffic lights. UPF contained greater energy, fat, saturated fat (SF), total sugar (TS) and salt than MPF. UPF had a greater odds of containing red FOPL and an unhealthier overall FOPL score (OR:4·59 (95 % CI: 3·79, 5·57); OR:7·0 (95 % CI: 6·1, 8·2), respectively) and lower odds of containing green FOPL (OR:0·05 (95 % CI: 0·03, 0·10)), compared with MPFs. For items with no red FOPL, UPF still contained greater energy, fat, SF, TS and salt than MPF. However, several UPF have healthier FOPL scores. UPF had an unhealthier nutritional profile and FOPL score than MPF. For items with no red FOPL, UPF still had an unhealthier profile than MPF, with a higher energy density. Importantly, not all UPF were unhealthy according to FOPL. These results indicate partial overlap between FOPL, nutrient content and NOVA classification of UK food and drink products, with implications for UK food and drink labelling.

How Promising Are "Ultraprocessed" Front-of-Package Labels? A Formative Study with US Adults

High levels of food processing can have detrimental health effects independent of nutrient content. Experts and advocates have proposed adding information about food processing status to front-of-package labeling schemes, which currently exclusively focus on nutrient content. How consumers would perceive "ultraprocessed" labels has not yet been examined. To address this gap, we conducted a within-subjects online experiment with a convenience sample of 600 US adults. Participants viewed a product under three labeling conditions (control, "ultraprocessed" label, and "ultraprocessed" plus "high in sugar" label) in random order for a single product. The "ultraprocessed" label led participants to report thinking more about the risks of eating the product and discouraging them from wanting to buy the product more than the control, despite not grabbing more attention than the control. The "ultraprocessed" plus "high in sugar" labels grabbed more attention, led participants to think more about the risks of eating the product, and discouraged them from wanting to buy the product more than the "ultraprocessed" label alone. "Ultraprocessed" labels may constitute promising messages that could work in tandem with nutrient labels, and further research should examine how they would influence consumers' actual intentions and behaviors.

Understanding Whether Price Tag Messaging Can Amplify the Benefits of Taxes: An Online Experiment

INTRODUCTION

Excise taxes on unhealthy products like sugary drinks and tobacco can reduce purchases of these products. However, little research has investigated whether messages at the point of purchase, such as enhanced price tags, can increase the effects of taxes by heightening psychological reactions. This study aimed to examine whether including messages about taxes on price tags could amplify the benefits of excise taxes on unhealthy products.

METHODS

In 2022, an online study recruited 1,013 U.S. parents to view seven price tag messages (e.g., "includes a 19% sugary drink tax") and a control (i.e., standard price tag with the tax included in the price) displayed in random order alongside sugary drinks. Participants were randomly assigned to view a caution-symbol icon or no icon on price tags. Analyses were conducted in 2023.

RESULTS

All seven messages discouraged parents from buying sugary drinks for their children compared to control (average differential effects [ADEs] ranged from 0.28 to 0.48, all p<0.001). All messages led to greater attention to the price tag (ADEs ranged from 0.24 to 0.41, all p<0.001) and greater consideration of the cost of sugary drinks (ADEs ranged from 0.31 to 0.50, all p<0.001). Icons elicited higher cost consideration than text-only price tags (ADE=0.15, p<0.010), but not discouragement (p=0.061) or attention (p=0.079).

CONCLUSIONS

Messaging on price tags could make excise taxes more effective. Policymakers should consider requiring messaging on price tags when implementing taxes.

Front-of-Package-Label-Style Health Logos on Menus-Do Canadian Consumers Really Care about Menu Health Logos?

Public health policies have been widely utilized to improve population nutrition, such as the newly announced front-of-pack labels (FOPLs) that will be applied to Canadian prepackaged foods to help consumers make healthier selections. However, research on similar health logos in the food service sector has been limited. This study explores the potential application of FOPL-style health logos in the food service sector and its impact on consumer behaviors. A survey was conducted among 1070 Canadians to assess their awareness, perception, and support for health logos on restaurant menus. The results indicate that while participants value healthy food options when dining out, taste, price, and convenience remain the primary factors influencing their choices. Most participants were unaware of existing FOPL policies and demonstrated mixed responses regarding the influence of similar health logos on their restaurant selection. However, a majority expressed a desire to see FOPL-style health logos on menus, and nutrient profile ratings and logos indicating nutrient limitations or encouragements were listed as preferred health logos. Notably, females indicated higher supportiveness for FOPL-style health logos on menus and individuals with food allergies exhibited higher agreement in the likelihood of eating at a restaurant displaying labels. Additionally, findings revealed that FOPL-style health logos alone may not significantly deter consumers from purchasing labelled menu items, especially if price is affected. Overall, this study highlights the need for further understanding consumer perceptions to effectively develop and implement FOPL initiatives in the food service sector.

Visual communication design: a neglected factor in nutrition promotion via packaged food labels

Packaging design is a communication device and a critical component in branding strategy, and has relevance for food policy. Presently, packaging-related nutrition policy initiatives focus on the role of regulated claims, nutrition information panels and front-of-pack nutrition labels to help guide consumer food choices and address high prevalences of discretionary and ultra-processed food consumption in many countries. However, these nutrition labelling systems are not optimized as public health policy tools as many consumers do not use them to inform their food choices. Visual communication design theory posits that a designer orders the elements and principles of design into hierarchies that prioritize certain elements over others, and that some of these elements are more dominant and given more emphasis than others. The overall design of the package thereby directs consumer attention to some aspects of pack design (e.g., characters, contents of the package) and away from others (e.g., nutrition details). Dual processing frameworks propose that food decisions are made with the interplay between automatic and rational thinking processes. Packaging designs affect whether consumers rely predominantly on automatic or rational thinking to select a food. This narrative review outlines the role of food packaging design and how it impacts the clear communication of nutrition aspects of food products and how the use of nutrition information by consumers to make decisions may depend upon design structures in packaging. This article attests that nutrition scientists and policy makers should incorporate visual communication design into research on the food packaging as a public health promotion tool. A stronger focus on the communication of regulated front-of-pack nutrition information can be made with a re-evaluation of the hierarchy of elements in the front-of-pack design enabling consumers to make healthier decisions.

The Ability of Nutrition Warning Labels to Improve Understanding and Choice Outcomes Among Consumers Demonstrating Preferences for Unhealthy Foods

BACKGROUND

Given growing interest in warning labels as a form of front-of-pack nutrition label, it is important to better understand the mechanisms via which these labels may exert their effects, especially among those making suboptimal food choices.

OBJECTIVE

The study aim was to assess the extent to which consumers with the weakest outcomes for objective understanding and choice in no-label conditions were able to improve their understanding and choices after exposure to warning labels on food product options.

DESIGN

Post-hoc analyses of the cross-sectional FOP-ICE (Front-of-Pack International Comparative Experimental) study data generated from an online survey that included simulated food choice and nutritional quality ranking scenarios.

PARTICIPANTS/SETTING

Participants included 3,680 adults from the following 18 countries: Argentina, Australia, Belgium, Bulgaria, Canada, Denmark, France, Germany, Italy, Mexico, Netherlands, Poland, Portugal, Singapore, Spain, Switzerland, United Kingdom, and United States.

INTERVENTION

Survey respondents selected their preferred product options and ranked foods according to their healthiness before and after exposure to mock breakfast cereal, cake, and pizza products displaying warning labels.

MAIN OUTCOME MEASURES

Objective understanding and food choice were measured.

STATISTICAL ANALYSES PERFORMED

Within each product category, analyses were conducted on respondents who initially incorrectly identified the healthiest option and/or selected the unhealthiest option as their preferred choice. Significant differences between proportions selecting each understanding and choice response option were assessed using 2-sample z tests for proportions.

RESULTS

Salience of the warning labels was low; 46% reported noticing the labels while completing the survey. Just over one-third of those aware of the presence of warning labels were able to identify the least healthy option in the post-exposure condition. Approximately one-half reselected the least healthy option post exposure and just over one-fourth switched to the healthiest option.

CONCLUSIONS

The results indicated that warning labels can assist some consumers to improve their food quality assessments and choices. However, design improvements could enhance the salience and interpretability of this label format.

Harnessing the power on our plates: sustainable dietary patterns for public and planetary health

Globally, diet quality is poor, with populations failing to achieve national dietary guidelines. Such failure has been consistently linked with malnutrition and poorer health outcomes. In addition to the impact of diet on health outcomes, it is now accepted that what we eat, and the resulting food system, has significant environmental or planetary health impacts. Changes are required to our food systems to reduce these impacts and mitigate the impact of climate change on our food supply. Given the complexity of the interactions between climate change, food and health, and the different actors and drivers that influence these, a systems-thinking approach to capture such complexity is essential. Such an approach will help address the challenges set by the UN 2030 Agenda for sustainable development in the form of the sustainable development goals (SDG). Progress against SDG has been challenging, with an ultimate target of 2030. While the scientific uncertainties regarding diet and public and planetary health need to be addressed, equal attention needs to be paid to the structures and systems, as there is a need for multi-level, coherent and sustained structural interventions and policies across the full food system/supply chain to effect behaviour change. Such systems-level change must always keep nutritional status, including impact on micronutrient status, in mind. However, benefits to both population and environmental health could be expected from achieving dietary behaviour change towards more sustainable diets.

The contribution of Australian fathers in getting food on the table among families with young children

OBJECTIVE

To explore how fathers with young children contributed to healthy home food provisioning and the factors enabling or inhibiting their involvement in family food tasks.

DESIGN

Cross-sectional study using purpose-designed online survey. The survey assessed the level of responsibilities and practices in family food tasks, food agency (Cooking and Food Provisioning Action Scale), and use of resources to support involvement in family food tasks. Data collection took place over 3 weeks in November-December 2020 when various COVID-19-related restrictions were in place. Descriptive and regression analyses were used to assess psychosocial factors influencing responsibilities in family food tasks and food agency.

SETTING

Online survey.

PARTICIPANTS

Included in the analysis were 435 Australian fathers with children aged under 5 years.

RESULTS

Between 75 and 77 % of fathers in this study reported having at least half of the responsibilities in meal planning, shopping, and cooking. Health was frequently considered when deciding what to eat, but few used nutrition or food labels when shopping, tried new recipes or modified recipes to make them healthier. Involvement in family food tasks was promoted by a higher food agency, but time spent in employment was a significant barrier to reported food agency and greater involvement in food tasks. There was a high interest in resources to support healthy home food provisioning.

CONCLUSIONS

The findings suggest the need to consider father-specific strategies to overcome time barriers and opportunities to enhance their capabilities for healthy home food provisioning.

Expert views on high fat, salt and sugar food marketing policies to tackle obesity and improve dietary behaviours in the UK: a qualitative study

BACKGROUND

There has been a lack of progress in reducing obesity in the United Kingdom (UK) despite Government strategies released over the last 30 years. These strategies, including the most recent publication from July 2020, have focused on childhood obesity and high fat, sugar and/or salt (HFSS) marketing restrictions, particularly broadcast advertising. In this study, we aimed to examine a range of expert views on the potential impact and the relative importance of such policies.

METHODS

Semi-structured interviews were conducted with 42 experts in policy (n = 19), industry (n = 10), and advocacy (n = 13) with an interest in obesity. The UK Government's 2020 obesity strategy was used as a prompt to guide discussion on policy options. Qualitative thematic analysis was employed to answer the three research questions and themes were inductively coded within each research question. Data were also cross compared using matrix coding and a form of framework analysis to examine the views expressed by the different types of stakeholders.

RESULTS

Reactions to the July 2020 proposal were mixed among policy and advocacy stakeholders, while commercial stakeholders expressed disappointment. A main theme emerging in all groups was frustration with the policy process and wishing to see more clarity regarding restrictions and their implementation. There was an overall lack of trust that the government would carry out their proposed plan and agreement that a more comprehensive, multi-sector approach aimed at the underlying drivers of obesity would be most effective, with some stakeholders indicating that some of the proposed policies could make a difference if implemented robustly. On the theme of promoting healthier options, some stakeholders suggested lowering the prices of 'healthy' products and making them more accessible to combat regressivity. There was a potentially surprising level of agreement between policy/advocacy stakeholders and commercial stakeholders, although commercial stakeholders were more likely to advocate for collaboration between government and industry as well as voluntary industry measures.

CONCLUSION

While HFSS marketing restrictions have a role to play and send a strong signal - provided they are implemented comprehensively - investment in these policies needs to be part of wider efforts to tackle the underlying drivers of obesity.

Do Brazilian consumers intend to use food labels to make healthy food choices? An assessment before the front-of-package labelling policy

Front-of-package labelling is a measure that can facilitate consumption of healthier foods. This study examined the predictors of consumers' intentions to use food labelling to make healthy food choices and prevent non-communicable diseases before the implementation of the front-of-package labelling policy in Brazil. An extended theory of planned behaviour incorporating knowledge and food literacy served as the theoretical foundation. First, experts (n = 6) and the target population (n = 30) validated the questionnaire, and the validation data were analysed using content validity coefficients (CVC). An online questionnaire was administered to 783 participants, and data were collected between May and October 2022. Partial least squares structural equation modelling (PLS-SEM) was used to test the prediction hypothesis. The questionnaire showed adequate content validity, with all indicators of CVC ≥ 0.75. In the PLS-SEM attitudes (p < 0.001), subjective norms (p < 0.001), knowledge (p < 0.001), and food literacy (p < 0.001) positively predicted the intention to use food labels to make healthy food choices, confirming the main hypothesis. Also, Food literacy and knowledge predicted all constructs of the theory of planned behaviour (p < 0.001). The results highlight the importance of providing nutritional knowledge and food literacy, developing nutritional skills and abilities to encourage consumers to make healthy food choices, and to strengthen other policies such as front-of-package labelling.

Consumer Interaction with Sustainability Labelling on Food Products: A Narrative Literature Review

Sustainability labelling on food products can help consumers make informed purchasing decisions and support the urgent transition to sustainable food systems. While there is a relatively robust body of evidence on health and nutrition labelling, less is known about the effectiveness of sustainability labelling in facilitating sustainable food choices. This paper investigates the impact of sustainability labelling on consumer understanding, attitudes, and behaviour to support a more nuanced, detailed, and holistic understanding of the evidence. Using a narrative literature review methodology, the paper assesses studies covering environmental, social, and/or animal welfare aspects of sustainability labelling on food products. We found that consumer understanding of sustainability information is often limited, which could hinder behaviour change. While sustainability labelling can influence consumer attitudes and purchasing behaviours, evidence from real consumer settings tends to show small effect sizes. Consumers are generally willing to pay more for sustainability-labelled products, and organic labelling often leads to the highest reported willingness to pay. The review emphasises the importance of trust, suggesting a preference for labelling backed by governments or public authorities. Sustainability labelling that uses intuitively understandable cues has an increased impact, with visual aids such as traffic light colours showing promise. We conclude that further research is needed in real-world settings, using representative populations and exploring the influence of demographic factors, values, and attitudes.

Study on knowledge of front-of-pack labeling and food group-based dietary intake among chronic gastritis patients

Introduction

Chronic gastritis is one of the most prevalent disorders affecting individuals, which affects hundreds of millions of people in different ways around the world. The significant incidence of poor dietary quality and diet-related illnesses may be addressed by orienting customers toward healthier food options. The objective of the study was to estimate the knowledge of front-of-package labels (FoPLs) and food group-based dietary intake of nutrients among patients with chronic gastritis.

Materials and Methods

The study design was a hospital-based cross-sectional study that was done in Guntur district of Andhra Pradesh. The study population included 208 chronic gastritis patients between 20 to 60 years of age selected by systematic sampling. Detailed information on sociodemographic and lifestyle factors was collected using a questionnaire and 24-h dietary recall was done. The objective assessment of Knowledge of FoPLs was assessed mock package images representing a fictional brand to prevent other factors from interfering with product evaluation.

Results

A total of 208 patients were studied with a near-equal proportion of males and females. Among participants, more than half (57.2%) can interpret FoPL, more than three-fourths (77.4%) have a belief that they eat a healthy diet mostly and only half (52.4%) of participants are somewhat knowledgeable about nutrition, and finally almost half (46.6%) of participants are not seeing the FoP label during food purchase. The mean score of knowledge of FoP labeling was 0.92 ± 1.135. Knowledge of FOPL was positively associated with the age of study participants OR 0.178 (95% CI: 0.178 to 0.856) with P value = 0.02. Grains have the maximum intake among all the food groups with a mean intake of 123.21 g/day.

Conclusion

The majority of participants do not know the food labeling, thus methods of education that focus on dietary interventions are urgently needed to raise awareness among the people.

Investment case for the prevention and reduction of childhood and adolescent overweight and obesity in Mexico

Despite efforts to curb the rise in Mexico's child and adolescent overweight and obesity rates, prevalence in Mexico has grown by 120% since 1990 to 43.3% in 2022. This investment case identifies policies that will produce the largest returns for Mexico. The investment case model builds beyond a cost-of-illness analysis by predicting the health and societal economic impact of implementing child and adolescent overweight and obesity interventions in a cohort aged 0-19 from 2025 to 2090. The Markov model's impacts include healthcare expenditures, years of life lost, and reduced wages and productivity. We projected and compared costs in a status quo scenario to an intervention scenario to estimate cost savings and calculate return-on-investment (ROI). Total lifetime health and economic costs amount to USD 1.8 trillion-USD 30 billion on average per year. Implementing five interventions can reduce lifetime costs by approximately 7%. Each intervention has a low cost per disability-adjusted life year averted over 30-year, 50-year, and lifetime horizons. The findings demonstrate that a package of interventions mitigating child and adolescent overweight and obesity offers a strong ROI. The novel investment case methods should be applied to other countries, particularly low- and middle-income countries.

Do Pictograms on Medication Packages Cause People to Consult Package Inserts Less Often? If so, With What Consequences?

Overall, pharmaceutical pictograms seem to improve medication adherence. However, little is known about how warning pictograms (e.g., "do not drive after taking") on medication packages influence patients' information-seeking strategies such as consulting the package insert (PI) to determine other features such as the correct dosage. In this online study, participants (358 students) were presented with three fictitious scenarios (e.g., headache after alcohol consumption; factor scenario) in which medication use would be contraindicated. Each scenario was accompanied by a visual presentation of a medication package that could contain three possible pictogram selections or arrangements (factor warning); some arrangements contained pictograms relevant to the situation represented by the scenario, while others did not. Participants had to decide which dosage of the represented medication they were allowed to take in the given scenario. In making this decision, they could consult the PI or not. Overall, in two out of the three scenarios (driving and pregnancy), medication packages with relevant pictograms resulted in fewer PI consultations but led to more correct dosage decisions ("no pill") than packages with irrelevant pictograms. Pictograms generally played no role in either the review of the PI consultation or dosage decisions in the alcohol scenario. Providing warning-relevant pictograms on medication packages can help people know when they should not take medication even without reading the PI.

'Feta is obviously very dangerous stuff looking at all those reds': Can nutrition labelling help people living with type 2 diabetes to self-manage their condition?

BACKGROUND

The consumption of a healthy balanced diet is the cornerstone of treatment for people living with type 2 diabetes (PLWT2DM). The United Kingdom recommends a standardised voluntary front-of-pack food labelling system which uses the green-amber-red colour coding to indicate the presence of nutrients in a food item. Research with PLWT2DM suggests that they may find it challenging to interpret the information on food labels. This paper draws from a larger study exploring nutrition information practices for PLWT2DM. The aim of this paper is to explore the experiences of using nutrition information found on food labels among PLWT2DM and their partners/carers.

METHODS

This study used a qualitative and mixed methods design, using a solicited 4-week unstructured diary followed by a qualitative interview with each participant. The theoretical framework drew on practice theory. Data were analysed using thematic analysis.

RESULTS

Nineteen PLWT2DM and one partner took part. Data consisted of 19 diaries and interviews. Almost all participants used food labels to help manage their condition; however, the colour-coding link with traffic lights appeared to overemphasise the need to avoid foods with red labels. Participants' beliefs about sugar influenced their food choices which in turn could impact on their nutritional intake. Highly developed mathematical skills were needed to interpret information about portion sizes.

CONCLUSIONS

Healthcare professionals and patient support groups should focus more on educating PLWT2DM about how to interpret food labels so that they are able to apply these to their own food choices. Future research and development of subsequent versions of the food labelling system should include PLWT2DM to ensure that labels are both clear and relevant to them.

Examining the diet quality of Canadian adults and the alignment of Canadian front-of-pack labelling regulations with other front-of-pack labelling systems and dietary guidelines

Introduction

Canada promulgated mandatory front-of-pack labelling (FOPL) regulations in 2022, requiring pre-packaged foods meeting and/or exceeding recommended thresholds for nutrients-of-concern (i.e., saturated fat, sodium, sugars) to display a "high-in" nutrition symbol. However, there is limited evidence on how Canadian FOPL (CAN-FOPL) regulations compare to other FOPL systems and dietary guidelines. Therefore, the objectives of the study were to examine the diet quality of Canadians using the CAN-FOPL dietary index system and its alignment with other FOPL systems and dietary guidelines.

Methods

Nationally representative dietary data from the 2015 Canadian Community Health Survey-Nutrition survey (n = 13,495) was assigned dietary index scores that underpin CAN-FOPL, Diabetes Canada Clinical Practice (DCCP) Guidelines, Nutri-score, Dietary Approaches to Stop Hypertension (DASH) and Canada's Food Guide (Healthy Eating Food Index-2019 [HEFI-2019]). Diet quality was examined by assessing linear trends of nutrient intakes across quintile groups of CAN-FOPL dietary index scores. The alignment of CAN-FOPL dietary index system compared with other dietary index systems, with HEFI as the reference standard, was examined using Pearson's correlations and к statistics.

Results

The mean [95% CI] dietary index scores (range: 0-100) for CAN-FOPL, DCCP, Nutri-score, DASH, and HEFI-2019 were 73.0 [72.8, 73.2], 64.2 [64.0, 64.3], 54.9 [54.7, 55.1], 51.7 [51.4, 51.9], and 54.3 [54.1, 54.6], respectively. Moving from the "least healthy" to the "most healthy" quintile in the CAN-FOPL dietary index system, intakes of protein, fiber, vitamin A, vitamin C, and potassium increased, while intakes of energy, saturated fat, total and free sugars, and sodium decreased. CAN-FOPL showed moderate association with DCCP (r = 0.545, p < 0.001), Nutri-score (r = 0.444, p < 0.001),  and HEFI-2019 (r = 0.401, p < 0.001), but poor association with DASH (r = 0.242, p < 0.001). Slight to fair agreement was seen between quintile combinations of CAN-FOPL and all dietary index scores (к = 0.05-0.38).

Discussion

Our findings show that CAN-FOPL rates the dietary quality of Canadian adults to be healthier than other systems. The disagreement between CAN-FOPL with other systems suggest a need to provide additional guidance to help Canadians select and consume 'healthier' options among foods that would not display a front-of-pack nutrition symbol.

Efficacy of front-of-pack warning label system versus guideline for daily amount on healthfulness perception, purchase intention and objective understanding of nutrient content of food products in Guatemala: a cross-over cluster randomized controlled experiment

BACKGROUND

Front-of-package warning labels (FOPWL) have been adopted in many countries aiming at reducing the consumption of unhealthy food and drink products and have also been considered in Guatemala. The aim of the study is to evaluate the efficacy of FOPWL versus Guidelines for Daily Amount (GDA) on products' healthfulness perception (HP), purchase intention (PI) and the objective understanding of the nutrient content (UNC) in Guatemala.

METHODS

Participants (children and adults) (n = 356) were randomly assigned to evaluate either FOPWL or GDA during a crossover cluster randomized experiment in rural and urban areas across 3 phases of exposure. During phase 1, participants evaluated mock-up images of single products (single task) and compared pairs of products within the same food category (comparison task) without any label. In phase 2, participants evaluated labels only (without any product), and during phase 3, they evaluated the same products and questions from phase 1, now depicting the assigned front-of-package label. We generated indicators for single-task questions and scores for comparison tasks, one for each HP, PI and UNC questions. We used intention-to-treat, difference-in-difference regression analysis to test whether exposure to FOPWL was associated with HP, PI and UNC, compared to GDA. We also tested models for children and adults and by area (rural/urban) separately adjusting for sociodemographic variables.

RESULTS

In single tasks, FOPWL significantly decreased the PI (β -18.1, 95%CI -23.3, -12.8; p < 0.001) and the HP (β -13.2, 95%CI -18.4, -7.9; p < 0.001) of unhealthy food products compared to GDA. In the comparison task, FOPWL significantly increased the UNC (β 20.4, 95%CI 17.0, 23.9; p < 0.001), improved PI towards healthier choices (OR 4.5, 95%CI 2.9, 7.0 p < 0.001) and HP (OR 5.6, 95%CI 2.8, 11.1; p < 0.001) compared to GDA. Similar results were found in children and adults and in urban and rural settings.

CONCLUSIONS

FOPWL reduces products' healthfulness perception and purchase intention, and increases understanding of products' nutrient content compared to GDA.

Food Front-of-Pack Labelling and the Nutri-Score Nutrition Label-Poland-Wide Cross-Sectional Expert Opinion Study

Front-of-pack labelling (FOPL) systems, such as the Nutri-Score, play a crucial role in promoting healthy diets and raising consumer awareness. Our study aimed to gather the opinions of Polish experts on the Nutri-Score and its relation to an ideal information system. We conducted a Poland-wide expert opinion study using a cross-sectional design survey with 75 participants, who had an average of 18 ± 13 years of experience and were mainly employed at medical and agricultural universities. The data were collected with the CAWI method. The results showed that the most important features of an FOPL system were clarity, simplicity, consistency with healthy eating recommendations, and the ability to objectively compare products within the same group. While more than half of the respondents believed that the Nutri-Score provides an overall assessment of a product's nutritional value and facilitates quick purchasing decisions, it falls short in helping consumers compose a balanced diet and cannot be applied to all product groups. The experts also expressed concerns about the system's ability to account for a product's degree of processing, full nutritional value and carbon footprint. In conclusion, Poland's current labelling system needs expansion, but the Nutri-Score requires significant and detailed changes and validation against national guidelines and expert expectations before implementation.

Front-of-Package Nutrition Labeling and Its Impact on Food Industry Practices: A Systematic Review of the Evidence

The obesity epidemic has become a major public health concern globally, and the food supply is a significant driver of this trend. Front-of-package (FOP) labels have been implemented in many countries to encourage healthier food choices. This systematic review aimed to examine the effect of FOP label implementation on food manufacturers' practices. A comprehensive search of multiple databases was conducted following PRISMA guidelines, identifying 39 relevant articles from 1990 to 2021. The studies indicated that FOP labels conveying intuitive information influenced product reformulation, whereas those with numerical information without specific guidance had no impact on reducing unhealthy nutrients. The most common outcomes were sodium, sugar, and calorie reduction. Mandatory policies reported higher and more consistent effects on product reformulation compared to voluntary approaches. Voluntary FOP labeling resulted in low uptake and tended to be applied to healthier products. Food manufacturers responded to FOP labeling heterogeneously, depending on the label design and type of enforcement. FOP label implementation can reduce nutrients of concern but food manufacturers behave strategically by labeling healthier choices. This review provides recommendations for maximizing the benefits of using FOP labels to prevent obesity, and findings can inform future public health research and policymaking.

Modelling of perceived sweetness in biscuits based on sensory analysis as a new tool to evaluate reformulation performance in sugar reduction studies

Sugar reduction in foods is of global interest in food science and industry to limit excessive calorie intake for healthier nutrition. Therefore, a modified Weibull model-based approach is presented here to relate sweetness perception with sugar concentration for the first time. The model was tested by using sweetness perception data obtained from sensory analysis of biscuits (wholewheat flour, whey or hydrolysed pea protein, different sucrose forms, ethylvanillin, furaneol, phenylacetaldehyde) using a line scale and untrained panellists. Sweetness scores increased 56%, 59%, 41% by the addition of wholewheat flour, proteins, or aroma compounds at 17% sucrose containing biscuits, respectively. Wholewheat flour and proteins boosted Maillard reaction products imparting baked/caramel-like flavour. The Weibull model well fitted to the sweetness perception data with a sigmoidal curve and high predicting power. This approach allows to explain how much sugar reduction can be achieved to reach a targeted sweetness perception without performing further sensory analysis.

Nutrient intakes and top food categories contributing to intakes of energy and nutrients-of-concern consumed by Canadian adults that would require a 'high-in' front-of-pack symbol according to Canadian labelling regulations

Canada recently mandated front-of-pack (FOP) labelling regulations, where foods meeting and/or exceeding recommended thresholds for nutrients-of-concern (i.e., saturated fat, sodium, and sugars) must display a 'high-in' FOP nutrition symbol. However, there is limited research on the amounts and sources of foods consumed by Canadians that would require a FOP symbol. The objective was to examine the intakes of nutrients-of-concern from foods that would display a FOP symbol and to identify the top food categories contributing to intakes for each nutrient-of-concern. Using the first day 24-hour dietary recall from the nationally representative 2015 Canadian Community Health Survey-Nutrition (CCHS), Canadian adults' intakes of nutrients-of-concern from foods that would display a FOP symbol was examined. Foods were assigned to 1 of 62 categories to identify the top food categories contributing to intakes of energy and nutrient-of-concern that would display a FOP symbol for each nutrient-of-concern. Canadian adults (n = 13,495) consumed approximately 24% of total calories from foods that would display a FOP symbol. Foods that would display a FOP symbol for exceeding thresholds for nutrients-of-concern accounted for 16% of saturated fat, 30% of sodium, 25% of total sugar, and 39% of free sugar intakes among Canadian adults. The top food category contributing intakes of each nutrient-of-concern that would display a FOP symbol were nutrient-specific: Processed meat and meat substitutes for saturated fat; Breads for sodium; and Fruit juices & drinks for total and free sugars. Our findings show that Canadian FOP labelling regulations have the potential to influence the intakes of nutrients-of-concern for Canadian adults. Using the findings as baseline data, future studies are warranted to evaluate the impact of FOP labelling regulations.

Nutrient Profiles of Commercially Produced Complementary Foods Available in Burkina Faso, Cameroon, Ghana, Nigeria and Senegal

The nutritional quality of commercially produced complementary food (CPCF) varies widely, with CPCF in high-income settings often containing excessive levels of sugar and sodium. Little is known about the nutritional quality of CPCF available in the West Africa region, despite their potential to improve the nutrition of infants and young children (IYC). This study evaluated the nutritional quality of CPCF available in five West African countries using the WHO Europe nutrient profiling model (NPM) and assessed their suitability for IYC based on label information. The proportion that would necessitate a "high sugar" warning was also determined, and the micronutrient (iron, calcium, and zinc) content was assessed against IYC-recommended nutrient intakes. Of the 666 products assessed, only 15.9% were classified as nutritionally suitable for promotion for IYC. The presence of added sugar and excessive sodium levels were the most common reasons for a product to fail the nutrient profiling assessment. Dry/instant cereals contributed the highest percentage of recommended nutrient intake (RNI) per serving. This highlights the need for policies to improve the nutritional quality of CPCF in West Africa, including labeling standards and the use of front-of-pack warning signs to promote product reformulation and clearly communicate nutritional quality to caregivers.

Characteristics of successful government-led interventions to support healthier populations: a starting portfolio of positive outlier examples

Despite progress on the Millennium and Sustainable Development Goals, significant public health challenges remain to address communicable and non-communicable diseases and health inequities. The Healthier Societies for Healthy Populations initiative convened by WHO's Alliance for Health Policy and Systems Research; the Government of Sweden; and the Wellcome Trust aims to address these complex challenges. One starting point is to build understanding of the characteristics of successful government-led interventions to support healthier populations. To this end, this project explored five purposefully sampled, successful public health initiatives: front-of-package warnings on food labels containing high sugar, sodium or saturated fat (Chile); healthy food initiatives (trans fats, calorie labelling, cap on beverage size; New York); the alcohol sales and transport ban during COVID-19 (South Africa); the Vision Zero road safety initiative (Sweden) and establishment of the Thai Health Promotion Foundation. For each initiative a qualitative, semistructured one-on-one interview with a key leader was conducted, supplemented by a rapid literature scan with input from an information specialist. Thematic analysis of the five interviews and 169 relevant studies across the five examples identified facilitators of success including political leadership, public education, multifaceted approaches, stable funding and planning for opposition. Barriers included industry opposition, the complex nature of public health challenges and poor interagency and multisector co-ordination. Further examples building on this global portfolio will deepen understanding of success factors or failures over time in this critical area.

Qualitative analysis of front-of package labeling policy interactions between stakeholders and Health Canada

Background

Front-of-package labelling regulations proposed by Health Canada in their Healthy Eating Strategy (2016) were finally passed in 2022, but remain unimplemented. This study analyzed interactions that occurred between stakeholders and government related to this policy proposal to identify key themes and policy implications.

Methods

A qualitative framework analysis was conducted on publicly available documents for stakeholder correspondences related to front-of-package that occurred between 2016 and 2019 in Health Canada's Meetings and Correspondence on Healthy Eating database. Five sequential steps were applied: familiarization, identifying a thematic framework, indexing, charting, and mapping and interpretation. A complex systems (i.e., a dynamic system with multiple interconnecting components) lens was incorporated in the final step to deepen the analysis.

Results

Hundred and seventy-three documents were included, the majority from industry stakeholders (n = 108, 62.4%). Three overarching themes were identified: industry trying to control the agenda and resist regulation; questioning the evidence supporting the policy and its impact on the agri-food industry; and dismissing the need and effectiveness of the policy. Incorporating a complex system lens found industry and non-industry stakeholders held markedly different perspectives on how cohesive the system defined by the front-of-package labelling policy was, and the policy impact on its stability. Economic and opportunity costs were the main trade-offs, and symbol misinterpretation considered an unintended consequence by industry. Finally, some stakeholders argued for wider policy scope incorporating more products, while others requested a narrower approach through exemptions.

Conclusion

Interactions with industry stakeholders on health food policy proposals require careful consideration, given it may suit their interests to generate delays and policy discordance. Explicitly setting out the principles of engagement and actively encouraging non-industry stakeholder representation provides a more balanced approach to policy consultation and development.

Effects of front-of-package nutrition labelling systems on understanding and purchase intention in Jamaica: results from a multiarm randomised controlled trial

OBJECTIVE

To assess the effects of three different front-of-package labelling (FOPL) schemes on objective understanding and intention to purchase of products, in Jamaica.

SETTING

Supermarkets in Jamaica.

PARTICIPANTS

Adult supermarket shoppers in Jamaica (n=1206) aged 18 years old or older were included in the study, except for those visually impaired, or unable to give informed consent.

DESIGN

Multiarm parallel-group randomised trial.

INTERVENTIONS

Participants were randomly allocated to one of the three intervention groups or the control group. They were exposed to two-dimensional images of 12 mock-up products presented in random and balanced order. Participants assigned to the intervention groups were exposed to one FOPL scheme: black octagonal warning labels (OWL), magnifying glass high-in single icon (MGG) or traffic-light labelling (TFL). The control group was exposed to the nutrition facts up front.

OUTCOME MEASURES

OR for correctly understanding nutritional information (correctly selecting the least harmful option, correctly identifying sugars, sodium and/or saturated fats found to be in excess) and choosing to purchase the least harmful option (purchase intention), more often.

RESULTS

Compared with the control group, the odds for correctly selecting the least harmful option more often were 107% higher in the OWL group (OR 2.07, 95% CI 1.54 to 2.78; p<0.001), whereas the MGG (1.18, 95% CI 0.89 to 1.57; p=0.24) and the TFL (1.13, 95% CI 0.85 to 1.51; p=0.39) were inefficacious in improving such odds. OWL also resulted in the highest odds for correctly identifying a product with excessive amounts of sugars, sodium and/or saturated fats and for deciding to purchase the least harmful option or none of the options.

CONCLUSIONS

Octagonal warning labels performed best at improving the ability of adult shoppers in Jamaica to understand the nutrition information and at encouraging them to purchase the least harmful option more often.

Estimating the dietary and health impact of implementing front-of-pack nutrition labeling in Canada: A macrosimulation modeling study

Background

Front-of-pack labeling (FOPL) has been identified as a cost-effective policy to promote healthy diets. Health Canada has recently published FOPL regulations that will require food and beverages that meet or exceed set thresholds for sodium, sugars, or saturated fat to display a 'high in' symbol on the front of the package. Although a promising measure, its potential impact on dietary intakes and health have not yet been estimated in Canada.

Objective

This study aims to estimate (1) the potential dietary impact of implementing a mandatory FOPL among Canadian adults; and (2) the number of diet-related non-communicable disease (NCD) deaths that could be averted or delayed due to these estimated dietary changes.

Methods

Baseline and counterfactual usual intakes of sodium, total sugars, saturated fats, and calories were estimated among Canadian adults (n = 11,992) using both available days of 24 h recalls from the 2015 Canadian Community Health Survey-Nutrition. The National Cancer Institute method was used to estimate usual intakes, and adjusted for age, sex, misreporting status, weekend/weekday, and sequence of recall. Estimated counterfactual dietary intakes were modeled from reductions observed in experimental and observational studies that examined changes in sodium, sugars, saturated fat, and calorie content of food purchases in the presence of a 'high in' FOPL (four counterfactual scenarios). The Preventable Risk Integrated ModEl was used to estimate potential health impacts.

Results

Estimated mean dietary reductions were between 31 and 212 mg/day of sodium, 2.3 and 8.7 g/day of total sugars, 0.8 and 3.7 g/day of saturated fats, and 16 and 59 kcal/day of calories. Between 2,183 (95% UI 2,008-2,361) and 8,907 (95% UI 8,095-9,667) deaths due to diet-related NCDs, mostly from cardiovascular diseases (~70%), could potentially be averted or delayed by implementing a 'high in' FOPL in Canada. This estimation represents between 2.4 and 9.6% of the total number of diet-related NCD deaths in Canada.

Conclusion

Results suggest that implementing a FOPL could significantly reduce sodium, total sugar, and saturated fat intakes among Canadian adults and subsequently prevent or postpone a substantial number of diet-related NCD deaths in Canada. These results provide critical evidence to inform policy decisions related to implementing FOPL in Canada.

Seeing the forest through the trees: the importance of the food matrix in diet quality and human health

Poor nutrition is linked to morbidity and mortality globally. The nutrition transition towards diets composed of high amounts of ultra-processed foods that are more refined, calorie-dense and nutrient poor, is considered a factor in the rise of diet-related metabolic diseases in low- and middle-income countries. Historically, nutrition strategies aimed at mitigating metabolic diseases linked to sub-optimal diets have targeted isolated nutrients, like fat; however, they overlook the complexity and importance of the whole food and food matrices, which can lead to unintended consequences, such as avoidance of nutrient-dense foods. Dairy foods, such as milk, cheese and yogurt are underconsumed, nutrient-dense foods that are often fall in the cross-hairs of reductionist nutrition strategies because of their contribution of calories, saturated fat, and sodium to the diet. This article highlights dairy foods as an example for exploring the complex matrices of food, nutrients, and other bioactive components that are associated with improved nutrient status and reduced risk of metabolic diseases, while considering a holistic approach to improving diet quality and human health. Statement of Significance Historically, nutrition strategies aimed at mitigating metabolic diseases linked to sub-optimal diets have targeted isolated nutrients, like fat; however, they overlook the complexity and importance of the whole food and food matrices, and can lead to unintended consequences. This article explores the complex matrices of nutrients and other bioactive components that are associated with improved nutrient status and reduced risk of metabolic diseases, and considers a holistic approach to improving diet quality and human health.

A randomized trial to evaluate the impact of Singapore's forthcoming Nutri-grade front-of-pack beverage label on food and beverage purchases

BACKGROUND

The epidemic of non-communicable diseases (NCDs) is a growing concern worldwide and Singapore is no exception to this global trend. As part of measures to address this concern, the Singapore government will implement a mandatory color-coded front-of-package (FOP) nutrition label for beverages, called Nutri-Grade (NG), which will complement the existing FOP label, Healthier Choice Symbol (HCS) logos, currently displayed on select food and beverage items. NG grades beverages on a four-point scale, A (healthiest) to D (least healthy), in terms of sugar and saturated fat levels. This study aimed to evaluate the effectiveness of the NG label on nutritional quality of pre-packaged beverages using a fully functional online grocery store.

METHODS

We conducted a 2-arm crossover trial involving actual purchases with 138 participants randomly exposed to: 1) Control with HCS logos displayed on qualifying items; 2) Similar to Control except that all beverages displayed the NG label. The effects of the NG label were estimated using a linear mixed-effects model that addresses correlations between repeated measures and accommodates missing data.

RESULTS

We found that the NG label encouraged consumers to choose beverages with higher ratings. This led to a reduction in sugar from beverages purchased by 1.51 g [95% CI: - 2.68, - 0.34] per serving but was not effective at reducing saturated fat purchased (- 0.009 g [95% CI: - 0.22, 0.20]) per serving or improvements in overall diet quality, measured by the weighted (by the number of servings) average Nutri-Score value ranging from 1 to 5 (- 0.024 [95% CI: - 0.13, 0.08]).

CONCLUSIONS

Results suggest that the Nutri-Grade label is likely to reduce sugar purchased from beverages. However, to improve overall diet quality in Singapore, additional measures will be needed.

TRIAL REGISTRATION

This trial was registered on ClinicalTrials.gov under the identifier: NCT05018026 on 24th August 2021.

Awareness, use and understanding of nutrition labels among adults from five countries: Findings from the 2018-2020 International Food Policy Study

Few studies have compared the effects of different front-of-package label (FOPL) systems in the 'real world'. This study assessed adults' awareness, use and understanding of nutrition facts labels (NFLs) and nationally implemented FOPLs such as Health Star Ratings (HSR), Traffic lights, and Guideline Daily Amounts (GDAs) in five countries, including before and after implementation of Mexico's warning FOPLs in 2020. Data were from the International Food Policy Study, an annual repeat cross-sectional study conducted in 2018-2020 among adults (N=64,032) in Australia, Canada, Mexico, the UK and the US. Self-reported awareness, use, and understanding of NFLs (in all five countries) and FOPLs (in Australia, Mexico, and UK) were assessed over time, between countries, and between NFLs and FOPLs. Most respondents in all countries reported seeing their country's NFLs (awareness) 'often' or 'all the time' across all three years, with one third to half of respondents using NFLs 'often' or 'all the time' (Australia: 43-45%; Canada: 47-50%; Mexico: 36-39%; UK: 32-34%; US: 47-49%), and approximately one half to two thirds finding NFLs 'easy' or 'very easy to understand' (56-57%; 67-69%; 51-54%; 48-51%; 70-71%). In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were highest among all countries with a FOPL (p<0.001), whereas awareness and use were lowest for Australia's HSR (p<0.001). In countries with FOPLs, self-reported understanding was higher for FOPLs than NFLs, except for the GDA FOPL in Mexico. Only modest changes were observed over time. Warning FOPLs were associated with greater levels of self-reported awareness, use and understanding among adults compared to NFLs and GDA-based FOPLs. FOPLs implemented on a voluntary basis, such as Australia's HSR, may be less likely to be seen and used.

Are Front-of-Pack Nutrition Labels Influencing Food Choices and Purchases, Diet Quality, and Modeled Health Outcomes? A Narrative Review of Four Systems

Front-of-Pack Nutrition labels (FOPNLs) aim to improve consumers' food purchases and prompt product reformulation by the food and beverage industry. Despite their widespread use, the effectiveness of FOPNL in achieving these goals is still a matter of debate. This review has gathered 65 original studies exploring the performances of four widely used FOPNLs (Multiple Traffic Light, Warning signs, Nutri-Score and Health Star Rating). Although FOPNLs have been associated with healthier food purchases, the magnitude of improvements was small and dependent on study settings. Any associated health effects were modeled rather than observed. None of the four FOPNLs clearly outperformed the other ones on any outcome. Few studies dealt with the impact of FOPNL on product reformulation. Some of those studies, but not all, found small reductions in energy, sodium, sugar and saturated fat content of foods in some food categories. Although global trends point to a small favorable effect of FOPNL, this conclusion is subject to caution since the evidence is inconsistent and comes from a wide variety of contexts and study designs. There remain numerous research gaps, notably with regard to the optimal characteristics of FOPNLs, the durability of FOPNL effects on consumer behaviors, and any possible unexpected consequences.

A policy study on front-of-pack nutrition labeling in the Americas: emerging developments and outcomes

Poor nutrition is one of the leading causes of non-communicable diseases (NCDs), especially in the WHO Region of the Americas (AMRO). In response, international organisations recommend front-of-pack nutrition labelling (FOPNL) systems that present nutrition information clearly to help consumers make healthier choices. In AMRO, all 35 countries have discussed FOPNL, 30 countries have formally introduced FOPNL, eleven have adopted FOPNL, and seven countries (Argentina, Chile, Ecuador, Mexico, Peru, Uruguay and Venezuela) have implemented FOPNL. FOPNL has gradually spread and evolved to better protect health by increasingly adopting larger warning labels, contrasting background devices for better salience, using "excess" instead of "high in" to improve efficacy, and adopting the Pan American Health Organization's (PAHO) Nutrient Profile Model to better define nutrient thresholds. Early evidence illustrates successful compliance, decreased purchases and product reformulation. Governments still discussing and waiting to implement FOPNL should follow these best practices to help reduce poor nutrition related NCDs. Translated versions of this manuscript are available in Spanish and Portuguese in the supplementary material.

Guideline Daily Amounts Versus Nutri-Score Labeling: Perceptions of Greek Consumers About Front-of-Pack Label

Nutrition information is becoming more urgent than ever so that consumers can make informed choices when buying food. This study aimed to investigate consumers' perceptions and behavior of the front-of-pack label (FOPL), between two specific labeling systems, the Nutri-Score and the Guideline Daily Amounts (GDA). This is a post hoc analysis of data from a previous, more extensive cross-sectional study conducted from April 2021 to June 2021. A total of 510 participants were included in the study, of whom 49.6% were women. Participants' perceptions were assessed in nine questions on a five-point Likert scale (1=strongly disagree, 5=strongly agree). Multivariate variance analysis (MANOVA) was performed to test the effects of the label GDA vs. Nutri-Score on the overall positive and negative perceptions. We found that the Nutri-Score label was significantly more understandable (p=0.003), clear, visible, and preferable (p<0.001) than the GDA label, which required more time to be understood. The findings indicate that the interpretive label, Nutri-Score, was superior to the non-interpretive label GDA, in terms of consumers' perception, more visibility, less time-consuming, and reliability. The FOPL can improve the ability of consumers in Greece to understand the healthfulness of food products.

Two countries, similar practices: the political practices of the food industry influencing the adoption of key public health nutrition policies in Guatemala and Panama

OBJECTIVE

To identify the corporate political activity (CPA) strategies used by food industry actors during the development of two public health nutrition policies in Central America: Law #570 (taxation of sugar-sweetened beverages) in Panama and Bill #5504 (labelling and food marketing regulations) in Guatemala.

DESIGN

We triangulated data from publicly available information from 2018 to 2020, (e.g. industry and government materials; social media material) with semi-structured interviews with key stakeholders.

SETTING

Guatemala and Panama.

PARTICIPANTS

Government, academia and international organisations workers in health and nutrition.

DESIGN

CPA strategies were categorised according to an existing internationally used taxonomy into action-based, instrumental strategies (coalition management, information management, direct involvement and influence in policy, legal action) and discursive strategies.

RESULTS

Instrumental strategies included the establishment of relationships with policymakers and direct lobbying against the proposed public policies. Discursive strategies were mainly criticising on the unfounded ground that they lacked evidence of effectiveness and will imply negative impacts on the economy. The industry pointed at individuals for making their own food choices, in order to shift the focus away from the role of its products in contributing to ill health.

CONCLUSION

We provide evidence of the political practices used by the food industry to interfere with the development and implementation of public health nutrition policies to improve diets in Central America. Policymakers, public health advocates and the public should be informed about those practices and develop counterstrategies and arguments to protect the public and policies from the vested interests of the food industry.

Protocol for a novel sodium and blood pressure reduction intervention targeting online grocery shoppers with hypertension - the SaltSwitch Online Grocery Shopping randomized trial

BACKGROUND

High dietary sodium intake is a leading cause of hypertension. A major source of dietary sodium is salt added to processed food products available in retail food environments. The fast-growing online grocery shopping setting provides new opportunities for salt reduction interventions that support consumers in choosing healthier options.

METHODS

The SaltSwitch Online Grocery Shopping randomized controlled trial is investigating the feasibility, acceptability, and effectiveness of a novel intervention for lowering salt consumption and blood pressure amongst people with hypertension who shop for groceries online. The intervention is based on a bespoke web browser extension that interfaces with a major retailer's online store to highlight and interpret product sodium content and suggest similar but lower-sodium alternatives. The primary outcome of interest is change in mean systolic blood pressure between individuals randomized (1:1) to the intervention and control (usual online shopping) arms at 12 weeks. Secondary outcomes are diastolic blood pressure, spot urinary sodium and sodium:potassium ratio, sodium purchases, and dietary intake. Intervention implementation and lessons for future uptake will be assessed using a mixed methods process evaluation. Participants with hypertension who shop online for groceries and exhibit high sodium purchasing behavior are being recruited across Australia. A target sample size of 1,966 provides 80% power (2-sided alpha = 0.05) to detect a 2 mm Hg difference in systolic blood pressure between groups, assuming a 15 mm Hg standard deviation, after allowing for a 10% dropout rate.

DISCUSSION

This trial will provide evidence on an innovative intervention to potentially reduce salt intake and blood pressure in people with hypertension. The intervention caters to individual preferences by encouraging sustainable switches to similar but lower-salt products. If effective, the intervention will be readily scalable at low cost by interfacing with existing online retail environments.

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.

Joint association of food nutritional profile by Nutri-Score front-of-pack label and ultra-processed food intake with mortality: Moli-sani prospective cohort study

OBJECTIVE

To jointly analyse two food dimensions, the Food Standards Agency Nutrient Profiling System (FSAm-NPS), used to derive the Nutri-Score front-of-pack label, and the NOVA classification in relation to mortality.

DESIGN

Prospective cohort study.

SETTING

Moli-sani Study, Italy 2005-10.

PARTICIPANTS

22 895 participants (mean age 55 (SD 12) years; 48% men).

MAIN OUTCOMES MEASURES

Associations between dietary exposures and mortality risk, assessed using multivariable cause specific Cox proportional hazard models controlled for known risk factors.

RESULTS

A total of 2205 deaths occurred during 272 960 person years of follow-up. In the highest quarter of the FSAm-NPS index compared with the lowest quarter, multivariable adjusted hazard ratios for all cause and cardiovascular mortality were 1.19 (95% confidence interval 1.04 to 1.35; absolute risk difference 4.3%, 95% confidence interval 1.4% to 7.2%) and 1.32 (1.06 to 1.64; 2.6%, 0.3% to 4.9%), respectively. The hazard ratios were 1.19 (1.05 to 1.36; absolute risk difference 9.7%, 5.0% to 14.3%) and 1.27 (1.02 to 1.58; 5.0%, 1.2% to 8.8%), respectively, for all cause and cardiovascular mortality when the two extreme categories of ultra-processed food intake were compared. When these two indices were analysed jointly, the magnitude of the association of the FSAm-NPS dietary index with all cause and cardiovascular mortality was attenuated by 22.3% and 15.4%, respectively, whereas mortality risks associated with high ultra-processed food intake were not altered.

CONCLUSIONS

Adults with the lowest quality diet, as measured using the FSAm-NPS dietary index (underpinning the Nutri-Score), and the highest ultra-processed food consumption (NOVA classification) were at the highest risk for all cause and cardiovascular mortality. A significant proportion of the higher mortality risk associated with an elevated intake of nutrient poor foods was explained by a high degree of food processing. In contrast, the relation between a high ultra-processed food intake and mortality was not explained by the poor quality of these foods.

Comparison of two front-of-pack nutrition labels for Brazilian consumers using a smartphone app in a real-world grocery store: A pilot randomized controlled study

One of the suggestions for improving the understanding of food labels is implementing front-of-pack nutrition labeling (FoPNL), where nutritional information is objectively made available to consumers. Scientific data on the best FoPNL model to be adopted for the Brazilian population is still emerging, especially in real-world purchase situations. This study aims to evaluate/compare the proposed Brazilian and Mexican FoPNL systems, on different outcome measures, using an application, in dairy foods available in a supermarket aisle. This pilot randomized controlled trial in a real-world purchase situation was conducted in June/July 2021. A total of 230 participants were randomly allocated to one of the three study arms (Mexican and Brazilian FoPNL systems or control—nutritional information table and ingredients list). Using a smartphone, the participants scanned a product barcode and received the allocated FoPNL (with information about excessive added sugars, sodium, and/or saturated fat content) or the control. After, they answered questions related to our primary outcome (decision to buy or not to buy a product) and secondary outcomes (perceived healthiness, facilitation of a quick purchase decision, and identification of excess nutrients). The Mexican FoPNL system performed better in the primary outcome (3.74 ± 1.34) and “facilitation of a quick purchase decision” (3.59 ± 1.31), compared to the control (3.28 ± 1.45;p = 0.043 and 3.11 ± 1.42; p = 0.029). The Mexican FoPNL system performed better in supporting consumers to identify dairy foods, among the selected sample in this study, high in added sugars than the control (82.2% and 63.5% of correct answers, respectively; p = 0.009). For saturated fats, the Brazilian FoPNL resulted in 93.1% of correct answers against 48.2% for the control and 58.9% for the Mexican system (p ≤ 0.001). The Mexican FoPNL system facilitated consumer decision-making on when to buy or not to buy a selected dairy product and in helping to quickly decide which dairy products to buy, among the selected sample in this study, compared to the control. Considering the right answers of critical nutrients in excess or not, both models of FoPNL, delivered by a smartphone app, performed well.

Relationship between front-of-pack labeling and nutritional characteristics of food products: An attempt of an analytical approach

The adoption of supplementary nutrition information, i.e., front-of-pack labeling (FOPL), on pre-packed food products is advocated as a tool to improve the consumers' knowledge of the nutrient content or the nutritional quality of foods, but also to drive products reformulation by the food industry. Ultimately, FOPL should help people to select foods in order to compose an overall balanced diet, which is essential for health. However, the extent to which the different FOPL systems proposed in the European Union (EU) (interpretative or informative) are effectively able to convey the information useful to improve both food choices and dietary habits of the consumers is still under debate and needs to be analyzed in detail. The use of 3 FOPL schemes proposed within the EU (Nutri-Score, Keyhole and NutrInform Battery) to compare products available on the Italian market within different food categories, highlights some critical issues: (1) different FOPL provide to consumers different kinds of information; (2) systems based on similar theoretical approaches can provide conflicting information; (3) the algorithms on which interpretative FOPL are based can give the same summary information for products differing in nutrient composition, impact on the overall dietary balance and therefore on the health of people with different characteristics, physiological/pathological conditions, and nutritional requirements; (4) on the other hand, products with similar nutrient composition can obtain different interpretative FOPL; (5) informative systems are generally more complex and require greater both attention and knowledge from the consumer; (6) FOPL based on 100 g of product overlook the role of portion (and frequency of consumption) in determining the nutrient intake without informing on the contribution of a single food to the overall diet; (7) FOPL based on scoring systems could promote the reformulation of selected products, especially with a composition very close to the threshold limits; (8) for the portion-based informative FOPL systems, the incentive for reformulation could essentially involve the reduction of portion size. Finally, the importance of nutritional education interventions, which are required to encourage the use by consumers of informative FOPL systems, cannot be neglected to improve the quality of diets regardless of the FOPL used.

Uncovering the Effect of European Policy-Making Initiatives in Addressing Nutrition-Related Issues: A Systematic Literature Review and Bibliometric Analysis on Front-of-Pack Labels

The last decades have been marked by the introduction of front-of-pack labels (FoPL) as an institutional corrective action against obesity and nutrition-related illnesses. However, FoPL-related policy-making initiatives issued by the European Union evolved over time and led to a diversity of labels with different effects on consumers’ decisions. As a result, the extant literature adapted to the regulative scenario over the years and investigated the effects of the labels, creating consensus on some topics while being fragmented on others. Similarly, policy-makers adapted some regulations to the evidence supported by the research. With the aim to systematize the overall structure and evolution of the literature on FoPL, investigate the presence of a consensus on specific topics through a co-citation analysis, and examine the evolution of the consensus and co-citation networks over the years and potential research gaps, we report the results of bibliometric and co-citation analyses and a systematic literature review involving 170 papers and a selection of 49 articles published in the last months, for a total of 219 articles, analysed according to three timespans (Period 1 (1989–2011); Period 2 (2012–2016) and Period 3 (2017–2022)). Our findings highlight the interplay of policy development and FoPL research, the presence of few self-reinforcing and well-established co-citation networks based on validated evidence in the literature and the presence of alternative emerging theories that offer different and valid perspectives overlooked by mainstream co-citation research networks.

Labels Affect Food Choices, but in What Ways?

To reduce obesity and thus promote healthy food choices, front-of-pack (FOP) labels have been introduced. Though FOP labels help identify healthy foods, their impact on actual food choices is rather small. A newly developed so-called swipe task was used to investigate whether the type of label used (summary vs. nutrient-specific) had differential effects on different operationalizations of the "healthier choice" measure (e.g., calories and sugar). After learning about the product offerings of a small online store, observers (N = 354) could, by means of a swipe gesture, purchase the products they needed for a weekend with six people. Observers were randomly assigned to one of five conditions, two summary label conditions (Nutri-Score and HFL), two nutrient (sugar)-specific label conditions (manga and comic), or a control condition without a label. Unexpectedly, more products (+7.3 products)-albeit mostly healthy ones-and thus more calories (+1732 kcal) were purchased in the label conditions than in the control condition. Furthermore, the tested labels had different effects with respect to the different operationalizations (e.g., manga reduced sugar purchase). We argue that the additional green-labeled healthy products purchased (in label conditions) "compensate" for the purchase of red-labeled unhealthy products (see averaging bias and licensing effect).

Consensus-building around the conceptualisation and implementation of sustainable healthy diets: a foundation for policymakers

BACKGROUND

Healthy and sustainable diets need to be adopted to reduce the negative impact of food consumption on human and planetary health. Food systems account for a third of greenhouse gas emissions. "Dietary Patterns for Health and Sustainability" is a World Health Organization (WHO) project that aims to build consensus among international food, health, and sustainability experts and policymakers on how to conceptualise healthy and sustainable diets and on the actions and policies that could be implemented in the WHO European Region to promote these diets.

METHODS

A qualitative study among European food, health, and sustainability experts and policymakers to elicit their views on multiple dimensions of food sustainability and health was carried out using a three-phase process, including semi-structured interviews, a Nominal Group Technique, and focus groups during a participatory WHO workshop held in Copenhagen. Thematic analysis was used to analyse the three data sources.

RESULTS

The workshop resulted in a shared understanding of the interconnected components of sustainable healthy eating habits. As a result of this understanding, a variety of potential solutions were identified, including actions across different policy domains, tools, strategic guidelines, needs, and pathways for sustainable healthy diets. The pathways included the need for a multi-stakeholder approach, as well as the simultaneous execution of an aligned and coherent mix of policies at the local and national levels.

CONCLUSIONS

The prioritised actions should be aimed at helping government policymakers promote sustainable healthy diets and make decisions on improving dietary patterns for citizens' health and wellbeing in line with the United Nations Sustainable Development Goals in the European Region.

Front-of-Package Labels on Unhealthy Packaged Foods in India: Evidence from a Randomized Field Experiment

Policies to require front-of-package labels (FOPLs) on packaged foods may help Indian consumers to better identify foods high in nutrients of concern, including sugar, saturated fat, and sodium, and discourage their consumption, which are outcomes that are critical for preventing rises in diet-related non-communicable disease. The objective was to test whether FOPLs helped Indian consumers identify “high-in” packaged foods and reduce intentions to purchase them. We conducted an in-person randomized experiment (n = 2869 adults between ages 18 and 60 years old) in six states of India in 2022. Participants were randomized to one of five FOPLs: a control label (barcode), warning label (octagon with “High in [nutrient]”), Health Star Rating (HSR), Guideline Daily Amount (GDA), or traffic light label. Participants then viewed a series of packaged foods high in sugar, saturated fat, or sodium with the assigned FOPL, and rated product perceptions and label reactions. Fewer than half of participants in the control group (39.1%) correctly identified all products high in nutrient(s) of concern. All FOPLs led to an increase in this outcome, with the biggest differences observed for the warning label (60.8%, p < 0.001), followed by the traffic light label (54.8%, p < 0.001), GDA (55.0%, p < 0.001), and HSR (45.0%, p < 0.01). While no FOPLs led to a reduction in intentions to purchase the packaged foods, the overall pattern of results suggested that warning labels are the most effective FOPL to help Indian consumers identify unhealthy foods.

Healthy or Not Healthy? A Mixed-Methods Approach to Evaluate Front-of-Pack Nutrition Labels as a Tool to Guide Consumers

This study explored how South African food labels could be improved, to enhance customer evaluation of the overall healthiness of packaged food. Focus was given to the comparison of front-of-pack (FOP) nutrition labels as a quick assessment tool. The exploratory sequential mixed-methods design used qualitative interviews (n = 49) to gain insight into labeling challenges and select FOP nutrition labels for consumer testing. Consumers (n = 1261) randomly assessed two out of six possible FOP nutrition labels relative to a ‘no-label’ control in one of 12 online surveys, applied to a fictitious cereal product. A mixed-model analysis of variance was used to compare the differences in health ratings for the different FOP nutrition labels. The interviews revealed three themes for label improvement, that are presented over three time horizons. In terms of helping consumers identify less healthy products, the effect sizes were most prominent for health warnings (p < 0.01) and low health star ratings (p < 0.01). The findings of this research not only clarify whether FOP nutrition labeling formats used in other regions such as Europe, South America and Australia could be useful in the South African context, but they can assist policymakers and decision-makers in selecting an effective FOP label.

Nutrient profiles of commercially produced complementary foods available in Cambodia, Indonesia and the Philippines

OBJECTIVE

To assess the nutritional suitability of commercially produced complementary foods (CPCF) marketed in three South-East Asian contexts.

DESIGN

Based on label information declared on the products, nutrient composition and content of CPCF were assessed against the WHO Europe nutrient profile model (NPM). The proportion of CPCF that would require a 'high sugar' warning was also determined.

SETTING

Khsach Kandal district, Cambodia; Bandung City, Indonesia; and National Capital Region, Philippines.

PARTICIPANTS

CPCF products purchased in Cambodia (n 68) and Philippines (n 211) in 2020, and Indonesia (n 211) in 2017.

RESULTS

Only 4·4 % of products in Cambodia, 10·0 % of products in Indonesia and 37·0 % of products in the Philippines fully complied with relevant WHO Europe NPM nutrient composition requirements. Sixteen per cent of CPCF in Cambodia, 27·0 % in Indonesia and 58·8 % in the Philippines contained total sugar content levels that would require a 'high sugar' warning.

CONCLUSIONS

Most of the analysed CPCF were not nutritionally suitable to be promoted for older infants and young children based on their nutrient profiles, with many containing high levels of sugar and sodium. Therefore, it is crucial to introduce new policies, regulations and standards to limit the promotion of inappropriate CPCF in the South-East Asia region.

Perceived effectiveness of added-sugar warning label designs for U.S. restaurant menus: An online randomized controlled trial

Added-sugar consumption in the U.S. exceeds recommended limits. Policymakers are considering requiring restaurants to use menu warning labels to indicate items high in added sugar. We sought to determine whether icon-only and icon-plus-text added-sugar menu labels were (1) perceived as more effective at potentially reducing consumption of items high in added sugar and (2) increased knowledge of menu items' added-sugar content relative to control labels, and if effects differed by label design. A national sample of U.S. adults (n = 1327) participated in an online randomized experiment. Participants viewed menu items with either a control label, 1 of 6 icon-only labels, or 1 of 18 icon-plus-text labels with 3 text variations. For their assigned label, participants provided ratings of perceived message effectiveness (a validated scale of a message's potential to change behavior). Participants were also asked to classify menu items by their added-sugar content. The icon-only and icon-plus-text labels were perceived as more effective than the control label (means: 3.7 and 3.7 vs. 3.1, respectively, on a 5-point scale; p < 0.001). The icon-only and icon-plus-text groups each correctly classified 71% of menu items by added-sugar content vs. 56% in the control group (p < 0.001). All icons and text variations were perceived as similarly effective. In conclusion, relative to a control label, icon-only and icon-plus-text added-sugar menu labels were perceived as effective and helped consumers identify items high in added sugar. Menu warning labels may be a promising strategy for reducing added-sugar consumption from restaurants, but research on behavioral effects in real-world settings is needed. Clinical Trials Identifier:NCT04637412.