The Influence of Front-of-Package Nutrition Labeling on Consumer Behavior and Product Reformulation

SNaP-C: Validation of a novel, selective silver nanoparticle antioxidant capacity assay for Vitamin C content in beverages

A validated silver nanoparticle assay (SNaP-C) for quantitation of Vitamin C, as ascorbic acid (AA) and total AA (TAA), was applied to 31 beverages. SNaP-C assay results (LOD of 2.2 mg/L AA) were compared to AA and TAA determined by high-performance liquid chromatography with UV/Vis (LOD = 0.4 mg/L AA), and two well-known assays. All approaches were calibrated using meta-phosphoric acid stabilized AA, where the reducing agent tris(2-carboxyethyl) phosphine hydrochloride was added to convert dehydroascorbic acid to AA for determination of TAA. Statistical comparisons of these four resulting datasets were completed. SNaP-C and HPLC were not statistically significantly different (P > 0.05) for comparison of AA and TAA (mg/L) in these samples, whereas the CUPRAC and Folin-Ciocalteu assays statistically significantly overestimated values of AA and TAA content, respectively. The SNaP-C method is a novel assay that has high specificity for AA capable of quantifying TAA with addition of TCEP.

Reformulation of snacks offered to children and adolescents at school kiosks: is this strategy enough or just the tip of the iceberg?

Several studies have reported high overweight and obesity incidence among schoolchildren and adolescents, who mostly consume packaged snacks with critical nutrients exceeding the criteria of international profiling systems during school breaks. Then, the objectives of this work were to reformulate a snack consumed by Argentinian schoolchildren and adolescents (aged 6-13 years) to decrease its critical nutrient contents and to determine if this product would still be accepted. Chocolate chip vanilla cookies were selected for reformulation considering each recommended cut-off point for critical nutrients, since a prohibition of products with warning octagons being offered at schools would come into effect in Argentina. These cookies received good acceptability scores (above 3 of 5 points) and would be consumed by 8 of 10 schoolchildren in a sample of 200 participants. These findings underscore the importance of legislation promoting awareness of healthier eating habits and increasing the availability of healthier food options in schools.

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

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

The impact of an eco-score label on US consumers' perceptions of environmental sustainability and intentions to purchase food: A randomized experiment

Front-of-package labels indicating a product's environmental footprint (i.e., eco-score labels) offer promise to shift consumers towards more sustainable food choices. This study aimed to understand whether eco-score labels impacted consumers' perceptions of environmental sustainability and intentions to purchase sustainable and unsustainable foods. US parents (n = 1,013) completed an online experiment in which they were shown 8 food products (4 sustainable and 4 unsustainable). Participants were randomized to a control (n = 503, barcode on product packaging) or eco-score label group (n = 510, eco-score label on product packaging). The eco-score label was color-coded with a grade of A-F based on the product's environmental footprint, where "A" indicates relative sustainability and "F" indicates relative unsustainability. Participants rated each product's environmental sustainability and their future likelihood of purchase. We used multilevel mixed-effects linear regression models and examined moderation by product category and sociodemographic characteristics. The eco-score label lowered perceived sustainability of unsustainable products by 13% in relative terms or -0.4 in absolute terms (95% CI -0.5, -0.3; p<0.001). The eco-score label increased perceived sustainability of sustainable products by 16% in relative terms or 0.6 in absolute terms (95% CI 0.5, 0.7, p<0.001). Effects on purchase intentions were smaller, with a 6% decrease for unsustainable products (p = 0.001) and an 8% increase for sustainable products (p<0.001). For unsustainable products, the effect of eco-score labels on sustainability perceptions was greater for older adults, men, participants with higher educational attainment, and participants with higher incomes. For sustainable products, the effect of ecolabels on sustainability perceptions was greater for those with higher educational attainment. Eco-score labels have the potential to direct consumers towards more sustainable products. Future studies should investigate eco-score label effectiveness on behavioral outcomes.

What Is the Nutritional Quality of Pre-Packed Foods Marketed to Children in Food Stores? A Survey in Switzerland

Food marketing targeting children influences their choices and dietary habits, and mainly promotes food high in fat, sugar, and salt as well as ultra-processed food. The aim of this study was to assess the nutritional quality of food and beverages marketed to children over the age of 3 and available on the Swiss market. Products with at least one marketing technique targeting children on the packaging were selected from five food store chains. Three criteria to assess nutritional quality were used: (1) nutritional composition (using the Nutri-Score), (2) degree of processing (NOVA classification), and (3) compliance with the World Health Organization (WHO) Nutrient Profile Model (NPM). A total of 735 products were found and analyzed. The most common marketing techniques used were childish names/fonts (46.9%), special characters (39.6%), and children's drawings (31.3%). Most products had a Nutri-Score of D or E (58.0%) and were ultra-processed (91.8%). Only 10.2% of products displayed the Nutri-Score. The least processed products generally had a better Nutri-Score (p < 0.001). Most products (92.8%) did not meet the criteria of the WHO NPM. Products that met the WHO NPM criteria, organic products, and products with a nutritional claim generally had a better Nutri-Score and were less processed (ps < 0.05). Pre-packaged foods and beverages marketed to children in the Swiss market were mostly of poor nutritional quality. Public health measures should be adopted to improve the nutritional quality of foods marketed to children in Switzerland and restrict the marketing of unhealthy foods to children.

Evolution of household availability of added sugars and their sources in Brazil: analysis of Household Budget Surveys from 2002 to 2017

The objective of this study was to describe the evolution of household purchase of added sugars and their main food sources in Brazil. Nationally representative data from the Household Budget Surveys from 2002-2003, 2008-2009 and 2017-2018 were used. Energy and added sugar quantities were estimated by means of per capita food quantities. The items considered as food sources were: (1) table sugar: refined sugar and other energetic sweeteners and (2) processed and ultra-processed foods with added sugar: soft drinks; other drinks; sweets, candies and chocolates; cookies; cakes and pies and other foods. The parameters estimated were: mean share of added sugar in total energy and, for food sources, the share of added sugar in total sugar intake and the impact of variations in sources of added sugar between 2008 and 2017. There was a regular share of energy from added sugar to total energy intake between 2002 and 2008 but a reduced share in 2017. Between 2008 and 2017, there was a decrease in the share of refined sugar and other sweeteners and soft drinks to total sugar intake and an increased share of all other items. High-income households had a lower share of refined sugar and other energetic sweeteners, but a higher share of soft drinks, sweets, candies and chocolates. The decrease in added sugar in 2017 was mainly due to the lower share of soft drinks. In conclusion, Brazilians' total intake of added sugar was decreased, mostly owing to reduced consumption of sugar from soft drinks.

Sociodemographic differences in nutrition labels effect on Chilean and Mexican youth

Objective

To examine sociodemographic differences in the awareness, understanding, use and effect of nutrition labels among Mexican and Chilean youth.

Methods

Online surveys among youth (10-17 years) were obtained in 2019 (n=2631). Participants reported their awareness, understanding, and use of their country-specific nutrition facts tables (NFT) and front-of-pack labels (FOPL) (Chile: warning labels [WLs]; Mexico: guideline daily amounts [GDA]). Additionally, participants reported their perceived healthfulness of a sweetened fruit drink after viewing one of six versions of it with different FOPL (no-label control, Health Star Rating, WLs, GDAs, Traffic Light, or Nutri-Score) during an experimental task.

Results

Higher self-reported nutrition knowledge was associated with higher NFT and FOPL awareness, understanding, and use, except for WL use. WLs were the most effective FOPL in decreasing the perceived healthfulness of the sweetened fruit drink compared to a no-label condition and other FOP labels. In Chile, the effect of GDA differed by income adequacy, while in Mexico Nutri-Score differed by age.

Conclusions

Results suggest that nutrition label awareness, use, understanding, and impact differ across demographics, favoring higher income and nutrition knowledge. Despite this, WLs are likely to have a positive impact on nutrition-related knowledge and behaviors among Mexican and Chilean youth, independently of their socio-demographic groups.

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.

Trends in Sugar From Packaged Foods and Beverages Purchased by US Households Between 2002 and 2020

BACKGROUND

Excess sugar consumption is a public health concern in the United States. How sugar purchases have changed over time, whether there are disparities across subpopulations, and the contribution of various food groups are unclear.

OBJECTIVE

To assess trends in sugar from packaged foods and beverages purchased by US households between 2002 and 2020.

DESIGN

This is an open cohort study.

PARTICIPANTS/SETTING

We obtained data from the NielsenIQ U.S. Homescan Consumer Panel, which collects data on household purchases of all consumer packaged goods in 52 metropolitan and 24 non-metropolitan markets across the United States. We assessed data on food and beverage purchases for 1,163,447 household-years.

MAIN OUTCOME MEASURES

The primary outcomes are the total sugar in grams purchased per capita per day and percentage of calories from sugar, by sociodemographic group.

STATISTICAL ANALYSES PERFORMED

We used linear regression to estimate trends in total grams of sugar per capita per day, percentage of calories from sugar, and percentage of total sugar purchases by food or beverage group. We estimated means for select years and tested for significance compared with 2002 and with the previous timepoint and calculated the overall P-value for the linear trend using time series regression.

RESULTS

Total sugar purchases decreased over the study period, both in absolute terms (-37.2 g/capita/day; 95% confidence interval [CI], -38.7, -35.6) and as a percentage of total calories purchased (-5.3 percentage points; 95% CI, -5.5, -5.2). Sugar purchases declined for all sociodemographic groups, but disparities have persisted or widened, particularly among individuals who are non-Hispanic Black, low-income, and with lower educational attainment. Beverages' contributions to sugar purchases decreased 8.1 percentage points (95% CI, -8.4, -7.8).

CONCLUSION

In the United States, purchases of sugar declined, but disparities by socioeconomic status and race or ethnicity persisted or widened. Policies to further reduce sugar consumption and the burden of diet-related disparities are needed.

Evaluation of the Nutritional Quality of Chinese Processed Meat Products: Comparison of Two Nutrient Profile Models

Processed meat products are one of the most consumed pre-packaged foods in China. They are also group-1 carcinogens, whose consumption has proved to be positively associated with the risk of noncommunicable diseases (NCDs). The purpose of this study is to analyze the nutrient content on the food label of processed meat products based on the China Standardized Database for the Composition of Pre-packaged Food and the National Open Database of the UK and France. The Chilean front-of-pack warning label (FOPWL) and the Chinese Healthier Choice Logo were used to compare the nutrient content of processed meat products from the three countries. It was found that cured meat products have the highest median energy (483 kcal/100 g), total fat content (38.7 g/100 g), and sodium content (2076 mg/100 g) and dried meat products have the highest median protein content (30.2 g/100 g) and carbohydrate content (38.2 g/100 g). In addition, there were significant differences in energy content and contents of total fat, protein, and carbohydrate across different products of the three countries (p < 0.001). A large number of processed meat products currently collected did not meet the criteria of the Chilean FOPWL and the Chinese Healthier Choice Logo. This study provided information on the healthiness of Chinese processed meat products and provided data for improving food formulations for different categories of processed meat products.

Policy Insights from High-Income Countries to Guide Safe, Nutritious, and Sustainable Alternative Proteins for Low- and Middle-Income Countries

The United Nations has encouraged governments to promote sustainable healthy diets to address undernutrition, obesity, and climate change. This perspective paper examines policy insights from selected high-income countries in Asia, Europe, and North America to understand how traditional and novel alternative proteins (AP) may support sustainable healthy diets in low- and middle-income countries (LMIC) where populations experience malnutrition in all forms. AP products must be affordable, locally sustainable, and culturally acceptable to improve diet quality and health. Food-based dietary guidelines are a policy tool to guide AP product formulation, manufacturing, processing, labeling, and marketing to ensure that these products complement traditional plant- and animal-source proteins in sustainable healthy diets. This paper suggests that a new food categorization taxonomy is needed to guide AP product recommendations. Decision-makers must harmonize multisectoral policies to ensure LMIC populations have access to sustainable healthy diets to achieve a protein transition and food systems transformation by 2050.

Nutritional knowledge, attitudes, and practices among residents in the Northeast areas of China during the COVID-19 epidemic

Background

The coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 infection continues to affect the daily life of communities worldwide. Nutrition is a vital determinant of overall health. Given the lack of specific drugs for COVID-19 and incomplete vaccination coverage, optimizing nutrition appears to be one of the most cost-effective means of enhancing immunity. Therefore, this study was designed to evaluate nutrition-related knowledge, attitudes, and practices (KAP) to offer insights into the personal determinants of dietary behavior during COVID-19 pandemic in four major cities within the Northeast region.

Methods

This cross-sectional study was conducted between January and December 2022 using a self-administered questionnaire. The data were entered in EpiData V-3.02 and analyzed using SPSS version 26. Binary logistic regression analysis was also employed to examine the association between dependent and independent variables.

Results

A total of 4,092 respondents were included in the study. Most of the respondents demonstrated had inadequate nutrition knowledge, 26% of them provided ≥60% of correct answers. About one-third of the respondents were knowledgeable about the daily levels of oil, salt, milk, water, vegetables and fruits for adults. Furthermore, our results showed that 60.6% of participants held positive attitudes toward healthy eating. Additionally, only 54.6% of the participants have heathy dietary practices during COVID-19 pandemic. Binary logistic regression analysis showed that the following characteristics were associated with displaying unhealthy dietary behaviors: being men, having a lower education level, having a family income of 10,000-19,999 and more than 20,000, being resided in Harbin, Shenyang, and Changchun. Importantly, the strongest associations were observed between poor dietary knowledge and unhealthy eating behaviors. Similarly, dietary attitudes were strongly associated with healthy dietary behaviors when the effects of other factors were excluded; responders with negative attitudes were more likely to exhibit unhealthy eating behaviors.

Conclusion

Our findings suggest that residents in the Northeast China possessed a relatively low level of nutritional knowledge, which directly influenced their dietary practices during the COVID-19 pandemic. This study provides valuable insights into the cross-sectional description and key factors related to nutrition-related KAP, serving as a basis for future policymaking to respond more effectively to health crises.

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.

Effects of front-of-package caffeine and sweetener disclaimers in Mexico: cross-sectional results from the 2020 International Food Policy Study

OBJECTIVE

Front-of-package warning labels introduced in Mexico in 2020 included disclaimers that caution against allowing children to consume products with non-sugary sweeteners and caffeine. We examined the awareness and use of the disclaimers among Mexican adults and youth 1 month after the regulation was implemented. We also investigated their impact on the perceived healthfulness of industrialised beverages designed for children.

DESIGN

Data on the awareness and use of the disclaimers were analysed. Two between-subjects experiments examined the effect of a sweetener disclaimer (Experiment 1, youth and adults) or a caffeine disclaimer (Experiment 2, only adults) on the perceived healthfulness of industrialised beverages. Interactions between experimental conditions and demographic characteristics were tested.

SETTING

Online survey in 2020.

PARTICIPANTS

Mexican adults (≥18 years, n 2108) and youth (10-17 years, n 1790).

RESULTS

Most participants (>80 %) had seen the disclaimers at least rarely, and over 60 % used them sometimes or frequently. The sweetener disclaimer led to a lower perceived healthfulness of a fruit drink (adults: 2·74 ± 1·44; youth: 2·04 ± 0·96) compared with the no-disclaimer condition (adults: 3·17 ± 1·54; youth: 2·32 ± 0·96) (t's: >4·0, P values: <0·001). This effect was larger among older adults and male youth. The caffeine disclaimer did not affect adult's perceived healthfulness of a caffeinated drink (t = 0·861, P value = 0·3894).

CONCLUSIONS

There were high awareness and use of the sweeteners and caffeine disclaimers shortly after the warning labels were implemented. The sweetener disclaimer appears to be helping consumers modify their perceptions regarding industrialised beverages for children. Findings may help decision-makers improve the regulation and better target communication strategies.

Parent Experiences With Warning Labels After Policy Implementation in Uruguay

OBJECTIVE

To explore the perception and experiences of parents of children and adolescents during the first year of the mandatory implementation of nutritional warning labels in Uruguay.

DESIGN

Qualitative research based on semistructured interviews.

SETTING

Montevideo, Uruguay.

PARTICIPANTS

Twenty-eight parents of children and adolescents.

PHENOMENON OF INTEREST

Perception of and experiences with warning labels, a front-of-pack nutrition labeling scheme that has become increasingly popular in Latin America.

ANALYSIS

Content analysis of the transcripts based on a deductive-inductive approach.

RESULTS

Interview transcripts evidenced high awareness, acceptance, and understanding of warning labels among parents of children and adolescents. Most participants reported considering warnings for decision making and changing their purchase decisions because of their implementation, particularly when choosing foods for their children. They reported their children were aware of and understood warnings but did not tend to take them into account when choosing foods.

CONCLUSIONS AND IMPLICATIONS

Results from the present work contribute to the growing body of literature showing the effectiveness of warning labels. Lack of interest or perceived benefits and structural barriers emerged as key motives for not using the warnings when making purchasing decisions, suggesting the need to develop additional strategies to increase policy effectiveness.

Minimal Effective Dose of Beans Required to Elicit a Significantly Lower Glycemic Response Than Commonly Consumed Starchy Foods: Predictions Based on In Vitro Digestion and Carbohydrate Analysis

Beans elicit lower glycemic responses (GRs) than other starchy foods, but the minimum effective dose (MED) to reduce GR is unknown. We sought to determine the MED of beans compared to common starchy foods. Overnight-fasted healthy volunteers consumed ¼c (phase 1, n = 24) or ½c (phase 2, n = 18) of black, cranberry, great northern, kidney, navy and pinto beans and corn, rice, pasta and potato (controls), with blood glucose measured before and for 2 h after eating. GRs (incremental areas under the curves, iAUCs) after beans were consumed were compared to those of controls by ANOVA followed by Dunnett's test. To qualify for MED, beans had to elicit an effective reduction in GR, defined as a statistically significant reduction in iAUC of ≥20% (i.e., a relative glycemic response, RGR, ≤80). Outcomes from in vitro digestion were compared with in vivo RGR. Both doses of all six beans effectively reduced GR versus all four starchy controls, except for ¼c and ½c cranberry and pinto vs. corn, ¼c great northern and navy vs. corn and ¼c navy and pinto vs. potato. MED criteria were met for 18 comparisons of the ¼c servings, with four of the remaining six met by the ½c servings. The overall mean ± SEM RGR vs. controls was similar for the ¼c and ½c servings: 53 ± 4% and 56 ± 3%, respectively. By multiple regression analysis, RGR = 23.3 × RDS + 8.3 × SDS - 20.1 × RS + 39.5 × AS - 108.2 (rapidly digested starch, p < 0.001; slowly digested starch, p = 0.054; resistant starch, p = 0.18; available sugars, p = 0.005; model r = 0.98, p = 0.001). RGR correlated with in vitro glucose release (r = 0.92, p < 0.001). The MED of beans is ¼ cup. For n = 30 comparisons (n = 24 beans vs. controls, n = 6 controls vs. each other), an effective reduction in GR was predicted from in vitro carbohydrate analysis with 86% sensitivity and 100% specificity.

Analyzing consumer behaviour towards food and nutrition labeling: A comprehensive review

Studying consumer behaviour towards food and nutrition labelling (F&NL) is increasingly becoming important across the world. Bibliometric analysis is a way to identify influential research, track trends, and understand methodologies in any field. In this paper, we used bibliometric analysis and a review of theories too to critically evaluate theories and concepts used in studying consumer behaviour towards F&NL. Using the Scopus database, we obtained 1017 articles, which were further filtered to perform various analyses like Co-occurrence and co-authorship network analysis. We found limited East and Southeast Asia-based research. Personal beliefs, attitudes, and past experiences were identified as influencers of consumer behaviour regarding food labelling. Trending topics were food waste, purchase intention, and sustainability labels.

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

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

Online RCT of Icon Added-Sugar Warning Labels for Restaurant Menus

INTRODUCTION

To reduce added-sugar consumption, jurisdictions are considering requiring restaurant menu labels to identify high-added-sugar items. This study examined the impacts of added-sugar warning labels on hypothetical choices, knowledge of items' added-sugar content, and perceptions of high-added-sugar items.

STUDY DESIGN

The design was an online RCT.

SETTING/PARTICIPANTS

National sample of adults (N=15,496) was recruited to approximate the U.S. distribution of sex, age, race, ethnicity, and education.

INTERVENTION

Participants viewed fast-food and full-service restaurant menus displaying no warning labels (control) or icon-only added-sugar warning labels next to high-added-sugar items (containing >50% of the daily recommended limit).

MAIN OUTCOME MEASURES

The main outcome measures were hypothetical ordering of ≥1 high-added-sugar item, grams of added sugar ordered, and knowledge of items' added-sugar content assessed in 2021 and analyzed in 2021-2022.

RESULTS

Warning labels reduced the relative probability of ordering ≥1 high-added-sugar item by 2.2% (probability ratio=0.978, 95% CI=0.964, 0.992; p=0.002); improved knowledge of added-sugar content (p<0.001); and led to a nonstatistically significant reduction of 1.5 grams of added sugar ordered, averaged across menus (p=0.07). The label modestly reduced the appeal of high-added-sugar items, increased perceptions that consuming such items often will increase Type 2 diabetes risk, increased perceived control over eating decisions, and increased injunctive norms about limiting consumption of high-added-sugar items (ps<0.001). However, in the warning condition, only 47% noticed nutrition labels, and 21% recalled seeing added-sugar labels. When restricting the warning condition to those who noticed the label, the result for grams of added sugar ordered was significant, with the warning condition ordering 4.9 fewer grams than the controls (95% CI= -7.3, -2.5; p<0.001).

CONCLUSIONS

Added-sugar warning labels reduced the probability of ordering a high-added-sugar menu item and increased participants' knowledge of whether items contained >50% of the daily value for added sugar. The modest magnitudes of effects may be due to low label noticeability. Menu warning labels should be designed for noticeability.

REGISTRATION

This study was registered at AsPredicted.org #65655.

Use of nutritional warning labels at the point of purchase: An exploratory study using self-reported measures and eye-tracking

Nutritional warning labels are gaining relevance in the region of the Americas as a policy tool to reduce information asymmetry and encourage healthier food choices. However, empirical evidence about consumer experiences with warning labels after implementation is still scarce. In this context, the aim of the present work was to explore the use of nutritional warning labels after policy implementation in Uruguay, using a combination of eye-tracking and self-reported data. The study was conducted in three supermarkets, in two regional capitals, 19 months after the entry into force of the policy. A total of 224 participants were intercepted while entering the facilities of the supermarket and asked to wear a mobile eye-tracker while making their food purchases. Then, they were asked a series of questions about their awareness and use of warning labels. Although participants reported high awareness and understanding of the labels, active search and use at the point of purchase was low. Only 6% of the consumers declared having actively searched for the warning labels and 7% fixated their gaze on the labels. The majority of the participants (72%) who declared having seen the warnings on a product, purchased it anyway. However, 56% declared having changed their food choice decisions as a consequence of the implementation of the policy. Participants' accounts about reasons for (not) taking into account the warning labels provide relevant insights for the development of strategies to encourage citizens to increase policy effectiveness and encourage healthier food choices.

Design and approval of the nutritional warnings' policy in Peru: Milestones, key stakeholders, and policy drivers for its approval

Nutritional warnings are used as a public health strategy to address obesity. Peru approved in 2013 and implemented in 2019 a law requiring nutritional warnings on the marketing and packaging of processed foods high in sugar, sodium, saturated fat, and containing trans-fat. The complexity behind the design and approval of these policies over six years provides unique learnings, that inform the obesity prevention context, especially when proposed policies face strong opposition from powerful stakeholders. Our study aims to describe the milestones and key stakeholders' roles and stances during the nutritional warnings policy design in Peru, and to identify and analyze the main drivers of policy change that explain its approval. In 2021, interviews were conducted with 25 key informants closely involved in its design. Interviews were analyzed using the Kaleidoscope Model as a theoretical framework. Relevant policy documents and news were also analyzed. Milestones for this policy included the approval of the Law, Regulation, and Manual. Policy supporters were mainly from Congress, civil society advocates, and Health Ministers. Opponents came from Congress, ministries linked to the economic sector, the food industry, and media. Across the years, warnings evolved from a single text, to traffic lights, to the approved black octagons. Main challenges included the strong opposition of powerful stakeholders, the lack of agreement for defining the appropriate evidence supporting nutritional warning parameters and design, and the political instability of the country. Based on the Kaleidoscope Model, the policy successfully targeted a relevant problem (unhealthy eating decisions) and had powerful advocates who effectively used focusing events to reposition the warnings in the policy agenda across the years. Negotiations weakened the policy but led to its approval. Importantly, government veto players were mostly in favor of the policy, which enabled its final approval despite the strong opposition.

Kilocalorie labelling in the out-of-home sector: an observational study of business practices and consumer behaviour prior to implementation of the mandatory calorie labelling policy in England, 2022

BACKGROUND

Regulations mandating kilocalorie (kcal) labelling for large businesses in the out-of-home food sector (OHFS) came into force on 6th April 2022 as a policy to reduce obesity in England. To provide indicators of potential reach and impact, kcal labelling practices were studied in the OHFS, and customer purchasing and consumption behaviours prior to implementation of the mandatory kcal labelling policy in England.

METHODS

From August-December 2021, large OHFS businesses subject to the kcal labelling regulations were visited prior to regulations coming into force on 6th April 2022. 3308 customers were recruited from 330 outlets and collected survey information on the number of kcal purchased and consumed by customers, customers' knowledge of the kcal content of their purchases, and customers noticing and use of kcal labelling. In a subset of 117 outlets, data was collected on nine recommended kcal labelling practices.

RESULTS

The average number of kcals purchased (1013 kcal, SD = 632 kcal) was high with 69% of purchases exceeding the recommendation of a maximum of 600 kcal per meal. Participants underestimated the energy content of their purchased meals by on average 253 kcal (SD = 644 kcals). In outlets providing kcal labelling in which customer survey data was collected, a minority of customers reported noticing (21%) or using (20%) kcal labelling. Out of the 117 outlets assessed for kcal labelling practices, 24 (21%) provided any in-store kcal labelling. None of the outlets met all nine aspects of recommended labelling practices.

CONCLUSIONS

Prior to implementation of 2022 kcal labelling policy, the majority of sampled OHFS large business outlets in England did not provide kcal labelling. Few customers noticed or used the labels and on average customers purchased and consumed substantially more energy than recommended in public health guidelines. The findings suggest that reliance on voluntary action for kcal labelling implementation failed to produce widespread, consistent, and adequate kcal labelling practices.

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.

Awareness, use and understanding of nutrition labels among children and youth from six countries: findings from the 2019 - 2020 International Food Policy Study

BACKGROUND

Nutrition facts tables (NFTs) on pre-packaged foods are widely used but poorly understood by consumers. Several countries have implemented front-of-package labels (FOPLs) that provide simpler, easier to use nutrition information. In October 2020, Mexico revised its FOPL regulations to replace industry-based Guideline Daily Amount (GDA) FOPLs with 'Warning' FOPLs, which display stop signs on foods high in nutrients of concern, such as sugar and sodium. This study examined self-reported awareness, use, and understanding of NFTs and FOPLs among young people in six countries with different FOPLs, with an additional focus on changes before and after implementation of Mexico's FOPL warning policy.

METHODS

A 'natural experiment' was conducted using 'pre-post' national surveys in Mexico and five separate comparison countries: countries with no FOPL policy (Canada and the US), countries with voluntary FOPL policies (Traffic Lights in the UK and Health Star Ratings in Australia), and one country (Chile) with mandatory FOPL 'warnings' (like Mexico). Population-based surveys were conducted with 10 to 17-year-olds in 2019 (n = 10,823) and in 2020 (n = 11,713). Logistic regressions examined within- and between-countries changes in self-reported awareness, use, and understanding of NFTs and FOPLs.

RESULTS

Across countries, half to three quarters of respondents reported seeing NFTs 'often' or 'all the time', approximately one quarter reported using NFTs when deciding what to eat or buy, and one third reported NFTs were 'easy to understand', with few changes between 2019 and 2020. In 2020, awareness, use and self-reported understanding of the Warning FOPLs in Mexico were higher than for NFTs in all countries, and compared with GDA FOPLs in Mexico (p < .001). Mandated Warning FOPLs in Mexico and Chile had substantially higher levels of awareness, use, and understanding than the voluntary Traffic Lights in the UK and Health Star Ratings in Australia (p < .001 for all).

CONCLUSIONS

Mandated easy-to-understand FOPLs are associated with substantially greater levels of self-reported awareness, use and understanding at the population-level compared to NFT and GDA-based labeling systems.

Effects of Sugary Beverage Text and Pictorial Warnings: A Randomized Trial

INTRODUCTION

Multiple U.S. localities have introduced legislation requiring sugar-sweetened beverage (SSB) warnings. This study effects of different warning designs on beverage selections and perceptions.

STUDY DESIGN

The study was an RCT.

SETTING/PARTICIPANTS

An online virtual convenience store and survey were used with a nationally representative sample of primary caregivers of 6-11-year-olds (n=961). Data were collected in January 2020 and analyzed in May-July 2020.

INTERVENTION

Participants were randomized to view SSBs with 1 of 4 front-of-package label designs: (1) no-warning control, (2) health-related text warning, (3) sugar pictorial warning (image of beverage sugar content in cubes/teaspoons/packets with health-related warning text), or (4) health pictorial warning (image of possible health consequences of overconsuming SSBs with health-related warning text).

MAIN OUTCOME MEASURES

Outcomes included participants' beverage choice for their child and perceptions of beverages, their assigned labels, and warning policies.

RESULTS

Proportionally fewer participants chose a SSB in the sugar pictorial warning condition (-13.4 percentage points; 95% CI= -21.6 to -0.1 percentage points; p=0.007) and in the health pictorial warning condition (-14.7 percentage points; 95% CI= -22.8 to -0.1 percentage points; p=0.004) compared to the control. Sugar pictorial warnings led to more accurate added-sugar content estimates than all conditions and greater label trust and support for sugar-sweetened beverage warning policies than health pictorial warnings.

CONCLUSIONS

SSB warning policies may be most effective if they mandate images of beverages' added sugar content accompanied by warning text.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT03648138.

Framing a New Nutrition Policy: Changes on Key Stakeholder's Discourses throughout the Implementation of the Chilean Food Labelling Law

The global implementation of structural policies to tackle obesity has been slow, likely because of the competing interests of governments and the food industry. We used the discussion of the Chilean Food Labeling Law to identify influential stakeholders in the media and their frames during different periods of the law's implementation. This involved a content analysis of the food regulation media coverage in five key periods from 2007, when the food bill was first introduced in Congress, to 2018, when the second phase of the law was implemented (N = 1295). We found that most of the law coverage was through elite press. Half of the sources were from the food industry (26.7%) and government (26.2%), while other stakeholders, were less prevalent. Frames were mostly competing, except for cooperation with the law. The main food industry frame used during the discussion of the law was the "economic threat" (41.9%), whose prevalence decreased at the post-implementation period (13%, p < 0.01). No other relevant stakeholders changed their framing. Our results highlight that there are several aspects of public health communication, such as the type of media used, the involvement of scholars and civil society, and the framing, that could be improved to advance food environment policies.

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.

Comparison of Nutri-Score and Health Star Rating Nutrient Profiling Models Using Large Branded Foods Composition Database and Sales Data

Front-of-package nutrition labelling (FOPNL) is known as an effective tool that can encourage healthier food choices and food reformulation. A very interesting type of FOPNL is grading schemes. Our objective was to compare two market-implemented grading schemes-European Nutri-Score (NS) and Australian Health Star Rating (HSR), using large Slovenian branded foods database. NS and HSR were used for profiling 17,226 pre-packed foods and drinks, available in Slovenian food supply dataset (2020). Alignment between models was evaluated with agreement (% of agreement and Cohen's Kappa) and correlation (Spearman rho). The 12-month nationwide sales-data were used for sale-weighing, to address market-share differences. Study results indicated that both models have good discriminatory ability between products based on their nutritional composition. NS and HSR ranked 22% and 33% of Slovenian food supply as healthy, respectively. Agreement between NS and HSR was strong (70%, κ = 0.62) with a very strong correlation (rho = 0.87). Observed profiling models were most aligned within food categories Beverages and Bread and bakery products, while less aligned for Dairy and imitates and Edible oils and emulsions. Notable disagreements were particularly observed in subcategories of Cheese and processed cheeses (8%, κ = 0.01, rho = 0.38) and Cooking oils (27%, κ = 0.11, rho = 0.40). Further analysis showed that the main differences in Cooking oils were due to olive oil and walnut oil, which are favoured by NS and grapeseed, flaxseed and sunflower oil that are favoured by HSR. For Cheeses and cheese products, we observed that HSR graded products across the whole scale, with majority (63%) being classified as healthy (≥3.5 *), while NS mostly graded lower scores. Sale-weighting analyses showed that offer in the food supply does not always reflect the sales. Sale-weighting increased overall agreement between profiles from 70% to 81%, with notable differences between food categories. In conclusion, NS and HSR were shown as highly compliant FOPNLs with few divergences in some subcategories. Even these models do not always grade products equally high, very similar ranking trends were observed. However, the observed differences highlight the challenges of FOPNL ranking schemes, which are tailored to address somewhat different public health priorities in different countries. International harmonization can support further development of grading type nutrient profiling models for the use in FOPNL, and make those acceptable for more stake-holders, which will be crucial for their successful regulatory implementation.

Designing Effective Alcohol Warnings: Consumer Reactions to Icons and Health Topics

Introduction

New warning labels for alcohol could reduce alcohol-related health harms. This study examined consumer responses to alcohol warnings with different designs.

Methods

A national sample of 3,051 U.S. adults completed an online survey in August 2021. Participants were randomized to 1 of 4 warning topics (addiction, liver damage, early death, or colon cancer). Participants viewed 3 labels, presented in random order: 2 types of warning labels (text-only and icon) showing a newly developed warning message about their assigned topic and a text-only control label showing a neutral message. Participants rated each label on effectiveness at discouraging alcohol consumption (primary outcome) and attention (secondary outcome) using 1 to 5 Likert-type scales. Participants also rated warnings with different causal language variants (e.g., "increases risk of," "contributes to") and marker words (e.g., "WARNING," "SURGEON GENERAL WARNING").

Results

Both the text-only and icon warnings were perceived as more effective (Average Differential Effects [ADEs]=0.79 and 0.86, respectively) and more attention-grabbing (ADEs=0.43 and 0.69, respectively) than control labels (all ps<0.001). The icon warnings were rated as more effective and attention-grabbing than the text-only warnings (ADEs=0.07 and 0.27, respectively, both ps<0.001). Although all warning topics outperformed the control messages, warnings about addiction were rated as less effective and attention-grabbing than the other topics. A majority (60%) of participants selected "increases risk of" as the most discouraging causal variant and a plurality (47%) selected "SURGEON GENERAL WARNING" as the most discouraging marker word.

Conclusions

New alcohol warnings could discourage alcohol consumption, especially if warnings include icons.

Influence of Healthy Brand and Diagnosticity of Brand Name on Subjective Ratings of High- and Low-Calorie Food

Brand names on food packaging and the diagnosticity of brand names have notable effects on consumer preferences. However, their effects on healthy food consumption are not clear. The objective of this study was to investigate the effect of healthy brands and the diagnosticity of brand names on consumers' subjective ratings of different calorie foods. In two studies, participants viewed 32 pictures of high- and low-calorie food product packaging from healthy and unhealthy brands and rated their feelings and willingness to pay online. Study 1 used real brand names, and Study 2 used fictional brand names and added press releases to manipulate diagnosticity. The present study demonstrated that participants perceived foods from healthy brands as healthier but less delicious and were more willing to buy low-calorie foods from healthy brands. Moreover, only when the brand name was of high diagnosticity were high-calorie foods rated as more likable, and did the willingness to pay for low-calorie foods increase. Collectively, these findings highlight the influence of the healthy brand on consumers' subjective ratings of food. It is also inspiring for healthy food marketing.

Eating contexts determine the efficacy of nutrient warning labels to promote healthy food choices

Introduction

Unhealthy food choices increase the risk of obesity and its co-morbidities. Nutrition labels are a public health policy that aims to drive individuals toward healthier food choices. Chile has been an example of this policy, where mandatory nutrient warning labels (NWL) identify processed foods high in calories and critical nutrients. Eating contexts influence individual food choices, but whether eating contexts also influence how NWL alter the decision process and selection during food choice is unknown.

Methods

In an online mouse-tracking study, participants prompted to health, typical, or unrestricted eating contexts were instructed to choose between pairs of foods in the presence or absence of NWL. Conflict during choices was analyzed using mouse paths and reaction times.

Results

NWL increased conflict during unhealthy food choices and reduced conflict during healthy choices in all contexts. However, the probability that NWL reversed an unhealthy choice was 80% in a healthy, 37% in a typical, and 19% in an unrestricted context. A drift-diffusion model analysis showed the effects of NWL on choice were associated with an increased bias toward healthier foods in the healthy and typical but not in the unrestricted context.

Discussion

These data suggest that the efficacy of NWL to drive healthy food choices increases in a healthy eating context, whereas NWL are less effective in typical or unrestricted eating contexts.

Consumer Reactions to Positive and Negative Front-of-Package Food Labels

INTRODUCTION

The National Academy of Medicine recommends that the U.S. adopt an interpretative front-of-package food labeling system, but uncertainty remains about how this system should be designed. This study examined reactions to front-of-package food labeling systems that use positive labels to identify healthier foods, negative labels to identify unhealthier foods, or both.

METHODS

In August 2021, U.S. adults (N=3,051) completed an online randomized experiment. Participants were randomly assigned to 1 of 4 labeling conditions: control (calorie), positive, negative, or both positive and negative labels. Labels were adapted from designs for a 'healthy' label drafted by the Food and Drug Administration and displayed on the front of product packaging. Participants selected products to purchase, identified healthier products, and reported reactions to the labels. Analyses, conducted in 2022, examined the healthfulness of participants' selections using the Ofcom Nutrient Profiling Model score (0-100, higher scores indicate being healthier).

RESULTS

Participants exposed to only positive labels, only negative labels, or both positive and negative labels had healthier selections than participants in the control arm (differences vs control=1.13 [2%], 2.34 [4%] vs 3.19 [5%], respectively; all p<0.01). The both-positive-and-negative-labels arm outperformed the only-negative-labels (p=0.03) and only-positive-labels (p<0.001) arms. The only-negative-labels arm outperformed the only-positive-labels arm (p=0.005). All the 3 interpretative labeling systems also led to improvements in the identification of healthier products and beneficial psychological reactions (e.g., attention, thinking about health effects; all p<0.05).

CONCLUSIONS

Front-of-package food labeling systems that use both positive and negative labels could encourage healthier purchases and improve understanding more than systems using only positive or only negative labels.

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.

Trend of minimally processed and ultra-processed beverages purchased in Brazilian households: Less milk and much soft drink (2002-2003 to 2017-2018)

The consumption of ultra-processed beverages, including sugar-sweetened and artificially sweetened ones, is associated with several health problems, which is different considering minimally processed beverages. The objective of this study was to assess the trends in the volume of minimally and ultra-processed beverages purchased for consumption in Brazilian households and their relationship with the proportion of dietary energy derived from ultra-processed foods and beverages. Drawing on data from the nationwide 2002-03, 2008-09, and 2017-18 Household Budget Surveys, the daily volume of beverages purchased per capita (milligrams) was investigated. The minimally processed beverages purchased declined over the period [2002-2003: x ¯ 156.5 ml (95%CI: 148.3-164.8); 2017-2018: x ¯ 101.6 ml (95%CI: 98.1-105.1)] and ultra-processed beverages were stable [2002-03: x ¯ 117.9 ml (95%CI: 108.1-127.7); 2017-18: x ¯ 122.8 (95%CI: 111.2-134.4)]. The most purchased beverage in 2002-2003 was milk [ x ¯ : 154.7 ml (95%CI: 146.4-162.9)], while in 2017-2018 regular soft drinks were the most purchased [ x ¯ : 110.7 ml (95%CI: 99.2-122.2)]. There was a decrease in the purchase of whole and skimmed milk and an increase in the purchase of other ultra-processed beverages between the periods. With the increase in the proportion of ultra-processed foods and beverages in the diet, the volume of ultra-processed beverage purchases rose and minimally processed beverages declined. The monitoring of beverage consumption and the implementation of public policies, such as taxation on ultra-processed beverages, are essential to promote improvements in health and curbing non-communicable diseases.

Is nutrition labeling associated with decreased obesity? A quantitative approach to nutritional health policy in Ecuador

Few studies assess consumer response to nutrition labeling, especially in less-developed countries. We analyzed the link between nutrition labeling and obesity in Ecuador using a representative cross-sectional sample of 29,770 individuals from the National Health and Nutrition Survey (ENSANUT) in 2018. Nutrition labeling reduced the probability of obesity in adolescent (12-18 years old) and adult (18-59 years old) people by 4% (CI: - 5.7, - 2.2) and 8.4% (CI: - 12.7, - 4.0), respectively. The magnitude of average treatment effect of using nutrition label on obesity ranged from 0.90 (CI: - 1.299, - 0.500) to 1 (CI: - 1.355, - 0.645) BMI points for adolescent, and from 1.16 (CI: - 1.554, - 0.766) to 1.80 (CI: - 2.791, - 0.811) BMI points for adult. The effect of nutrition labeling is greater among the less obese. We recommend that health policy makers and clinicians continue to promote nutrition labeling especially where obesity is not chronic, where nutrition labeling is most successful.

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.

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.

Perceived effect of warning label on parental food purchasing and drivers of food selection among South African parents–An exploratory study

Household food purchasing decision is a complex process influenced by factors such as marketing, cost, children food preference and parental choices. Most food products targeted toward children are unhealthy and are aggressively marketed to increase desirability among parents and children making healthier food selection even harder. The warning label (WL) is identified as a simple front-of-package labeling format that assist consumers to easily identify unhealthy foods and reduce their purchasing. This was a qualitative study that aimed to investigate the perceived effect of the warning label (WL) on parental food purchasing and drivers of food selection among parents. The study was conducted in a mainly rural part of South Africa, in Limpopo Province. Data were collected from 44 adult participants, all parents with children aged below 16 years selected using the snowball sampling method. Seven focus groups diversified according to age, literacy, income and urbanicity were utilized for data collection. Using a focus group discussion guide, parents were shown images of six products (crisps, soda, juice, biscuits, cereals, and yogurt) superimposed with the WL and questions asked were based on those images. Thematic analysis revealed that although some parents felt undeterred by the WL, some felt they would alter their food purchasing in the presence of the WL. Other parents felt they would reduce the frequency or the amount purchased or completely stop purchasing labeled products for their children. Motives behind perceived behavior modification included children's health being perceived as a priority and labeled products being viewed as unhealthy. Factors such as pressure from children, taste, poor nutrition knowledge and affordability seemed to influence parental food selection. These findings have important policy implications by providing evidence to policymakers that the WL may alter parental food purchasing and also provide insight into drivers of food selection among South African parents.

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.

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.

A comparative assessment of two different front-of-package nutrition label designs: A randomized experiment in Brazil

This study compares the effectiveness of different front-of-package label designs in a Brazilian sample (n = 1384). Eligible adults were randomized to one of two study arms and viewed images of snacks with either a triangular warning label (TL) or a rectangular ‘high in’ label with a magnifying glass (ML). They responded to a series of questions that captured label usefulness, understanding, and purchase intentions. Compared to participants in the ML arm, those in the TL arm agreed that the TL communicated important information [Mean (SD) - 5.47 (0.07) vs 4.49 (0.08), p-value <0.001], was a useful tool [Mean (SD) - 6.12 (0.06) vs 5.75 (0.07), p-value <0.001], and was easier to understand as measured subjectively [Mean (SD) - 4.96 (0.07) vs 4.44 (0.08), p-value <0.001]. However, both the TL and the ML performed similarly in communicating nutrient information as measured by the objective understanding of nutrient content [57.09% vs 54.65%, p-value 0.259]. The ML performed marginally better at improving purchase intentions [Mean (SD) - 2.57 (0.07) vs 2.79 (0.08), p-value <0.049]. The current study adds to the growing evidence base on the pathways through which FoP labels, particularly ‘high in’ labels, might influence consumer perceptions and behavior. It is also one of the first studies to provide evidence on the utility of the ML design for Brazil.

Impact of front-of-pack labels on the perceived healthfulness of a sweetened fruit drink: a randomised experiment in five countries

OBJECTIVE

Front-of-pack (FOP) nutrition labelling is a globally recommended strategy to encourage healthier food choices. We evaluated the effect of FOP labels on the perceived healthfulness of a sweetened fruit drink in an international sample of adult consumers.

DESIGN

Six-arm randomised controlled experiment to examine the impact of FOP labels (no label control, Guideline Daily Amounts (GDA), Multiple Traffic Lights, the Health Star Ratings (HSR), Health Warning Labels, and 'High-in' Warning Labels (HIWL)) on the perceived healthfulness of the drink. Linear regression models by country examined healthfulness perceptions on FOP nutrition labels, testing for interactions by demographic characteristics.

SETTING

Online survey in 2018 among participants from Australia, Canada, Mexico, United Kingdom (UK) and United States.

PARTICIPANTS

Adults (≥18 years, n 22 140).

RESULTS

Compared with control, HIWL had the greatest impact in lowering perceived healthfulness (β from -0·62 to -1·71) across all countries. The HIWL and the HSR had a similar effect in Australia. Other labels were effective in decreasing the perceived healthfulness of the drink within some countries only, but to a lower extent. The GDA did not reduce perceived healthfulness in most countries. In the UK, the effect of HIWL differed by age group, with greater impact among older participants (> 40 years). There were no other variations across key demographic characteristics.

CONCLUSIONS

HIWL, which communicates clear, non-quantitative messages about high levels of nutrients of concern, demonstrated the greatest efficacy to decrease the perceived healthfulness of a sweetened fruit drink across countries. This effect was similar across demographic characteristics.

Pandemic-related financial hardship and disparities in sugar-sweetened beverage consumption and purchasing among San Francisco Bay Area residents during COVID-19

Some reports suggest that the COVID-19 pandemic resulted in shifts to unhealthier diets. These unhealthier diets may include sugar-sweetened beverages (SSBs), which strongly contribute to diabetes and other chronic diseases. Using cross-sectional surveys in the San Francisco Bay Area, California, USA we sought to assess self-reported SSB consumption during the pandemic's shelter-in-place and self-reported changes in SSB purchasing from before to during the pandemic's shelter-in-place, stratifying by indices of pandemic-related financial hardship. Nearly 60% of our diverse sample (N = 943) reported that it was harder to pay for basics (like food and utilities) during shelter-in-place. Among those who found it harder to pay for basics and received financial assistance during shelter-in-place, we found a ten-fold higher frequency of daily SSB consumption compared to those not facing new financial hardship (2.76 [95% CI: 1.78, 3.74] versus 0.30 [95% CI: 0.23, 0.37] times/day). There were no statistically significant increases in reported purchasing of any SSB, but those with new financial hardship during shelter-in-place reported greater purchasing of regular soda relative to those with no new hardship (0.20 on a 3-point scale [95% CI: 0.03, 0.37]). Our findings suggest that new hardship may increase unhealthy behaviors and worsen existing disparities in SSB consumption. Such disparities are a reminder of the urgent need to reduce economic inequity and improve the quality of our emergency food system in order to mitigate the impact of public health crises like the COVID-19 pandemic.

The impact of pictorial health warnings on purchases of sugary drinks for children: A randomized controlled trial

BACKGROUND

Pictorial warnings on tobacco products are promising for motivating behavior change, but few studies have examined pictorial warnings for sugary drinks, especially in naturalistic environments. This study aimed to examine the impact of pictorial warnings on parents' purchases of sugary drinks for their children in a naturalistic store laboratory.

METHODS AND FINDINGS

Parents of children ages 2 to 12 (n = 325, 25% identifying as Black, 20% Hispanic) completed a shopping task in a naturalistic store laboratory in North Carolina. Participants were randomly assigned to a pictorial warnings arm (sugary drinks displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (sugary drinks displayed a barcode label). Parents selected 1 beverage and 1 snack for their child, as well as 1 household good; one of these items was selected for them to purchase and take home. The primary outcome was whether parents purchased a sugary drink for their child. Secondary outcomes included reactions to the trial labels, attitudes toward sugary drinks, and intentions to serve their child sugary drinks. Pictorial warnings led to a 17-percentage point reduction in purchases of sugary drinks (95% CI for reduction: 7% to 27%), with 45% of parents in the control arm buying a sugary drink for their child compared to 28% in the pictorial warning arm (p = 0.002). The impact of pictorial warnings on purchases did not differ by any of the 13 participant characteristics examined (e.g., race/ethnicity, income, education, and age of child). Pictorial warnings also led to lower calories (kcal), purchased from sugary drinks (82 kcal in the control arm versus 52 kcal in the pictorial warnings arm, p = 0.003). Moreover, pictorial warnings led to lower intentions to serve sugary drinks to their child, feeling more in control of healthy eating decisions, greater thinking about the harms of sugary drinks, stronger negative emotional reactions, greater anticipated social interactions, lower perceived healthfulness of sugary drinks for their child, and greater injunctive norms to limit sugary drinks for their child (all p < 0.05). There was no evidence of difference between trial arms on noticing of the labels, appeal of sugary drinks, perceived amount of added sugar in sugary drinks, risk perceptions, or perceived tastiness of sugary drinks (all p > 0.05).

CONCLUSIONS

Pictorial warnings reduced parents' purchases of sugary drinks for their children in this naturalistic trial. Warnings on sugary drinks are a promising policy approach to reduce sugary drink purchasing in the US.

TRIAL REGISTRATION

The trial design, measures, power calculation, and analytic plan were registered before data collection at www.clinicaltrials.gov NCT04223687.

The Nutritional Profile and On-Pack Marketing of Toddler-Specific Food Products Launched in Australia between 1996 and 2020

With the food system evolving, it is not clear how the nutrition and on-pack claims of toddler foods have been impacted. Data on the trends in Australia are lacking, so we sought to determine the changes in the nutrition and on-pack claims of toddler-specific packaged foods over time. A retrospective cross-sectional analysis was conducted using the Mintel Global New Products Database. The number of toddler-specific foods increased from 1996 to 2020. Over time, a lower proportion of meals and snacks were classified as “ultra-processed”, but a higher proportion of snacks were classified as “discretionary”. Meals launched after 2014 had higher median values for energy, saturated fat, and sugar than those in earlier years. Toddler snacks launched after 2014 had lower median values for sodium, and higher median values for fat, saturated fat, and sugar than those in earlier years. The mean number of total claims per package increased over time for snacks, with an increase in unregulated claims for both meals and snacks. Public health action is needed to ensure that the retail food environment for young children is health-promoting, including stringent and clear regulations for on-pack claims, and compositional guidelines and guidance on how to reduce the number of ultra-processed foods for toddlers.