Acceptability and understanding of front-of-pack nutritional labels: an experimental study in Mexican consumers

The Relation between Consumer Perception and Objective Understanding of Front-of-Package Nutrition Labels (FOPNLs); Results from an Online Representative Survey

BACKGROUND

This study investigates the efficacy of Front-of-Pack Nutrition Labels (FOPNLs) as a cost-effective tool for improving dietary choices among Greek consumers. The purpose of the study was to investigate Greek customers' preferences and comprehension of commonly used European FOPNL schemes.

METHODS

The Hellenic Food Authority and the Agricultural University of Athens performed a representative online survey in March 2022, titled "The Role of Nutritional Labelling in Public Perception and Food Procurement." Consumers responded to a questionnaire separated into two parts. Part one included (i) personal, sociodemographic information, and (ii) subjective opinions on the FOPNL schemes, and part two comprised (iii) an objective understanding of NutriScore and NutrInform Battery, using 15 different foods. Participants were randomly allocated to these groups, and general mixed models were used for analysis.

RESULTS

A total of 1389 adults completed the first part of the survey, and 74.8% completed the second part. The Multiple Traffic Lights scheme was the preferred FOPNL, chosen by 48.4% of respondents, compared to 19.7% for NutrInform Battery and 12.3% for NutriScore. However, the mean objective assessment score was highest for NutriScore (5.8 ± 2.3) compared to NutrInform Battery (5.4 ± 1.9).

CONCLUSION

The results highlight the necessity for comprehensive nutrition education programs by showing a considerable gap between subjective preferences and an objective understanding of nutrition labels.

Determinants of obesity in Latin America

Obesity rates are increasing almost everywhere in the world, although the pace and timing for this increase differ when populations from developed and developing countries are compared. The sharp and more recent increase in obesity rates in many Latin American countries is an example of that and results from regional characteristics that emerge from interactions between multiple factors. Aware of the complexity of enumerating these factors, we highlight eight main determinants (the physical environment, food exposure, economic and political interest, social inequity, limited access to scientific knowledge, culture, contextual behaviour and genetics) and discuss how they impact obesity rates in Latin American countries. We propose that initiatives aimed at understanding obesity and hampering obesity growth in Latin America should involve multidisciplinary, global approaches that consider these determinants to build more effective public policy and strategies, accounting for regional differences and disease complexity at the individual and systemic levels.

Assessing transnational spillover effects of Mexico's front-of-package nutritional labeling system among Mexican Americans in the US

OBJECTIVE

In 2020, Mexico implemented innovative front-of-package nutrition warning labels (FoPWLs) for packaged foods to increase the salience and understanding of nutrition information. This study evaluated Mexican Americans' self-reported exposure to Mexican FoPWLs and self-reported effects of FoPWLs on purchasing behavior.

METHODS

The 2021 International Food Policy Study surveyed online panels of adult Mexican Americans in the US (n = 3361) to self-report on buying food at Mexican-oriented stores, noticing Mexican FoPWLs, and being influenced by FoPWLs to purchase less of eight different unhealthy foods (each assessed separately). After recoding the frequency of buying foods in Mexican stores and noticing FoPWLs (i.e., "often" or "very often" vs. less often), logistic models regressed these outcomes on sociodemographics, adjusting for post-stratification weights.

RESULTS

Most participants (88.0%) purchased foods in Mexican stores. Of these, 64.1% reported noticing FoPWLs, among whom many reported that FoPWLs influenced them to buy fewer unhealthy foods (range = 32% [snacks like chips] - 44% [colas]). Participants were more likely to buy foods in Mexican stores and notice FoPWLs if they were younger, had ≥two children at home vs no children (AOR = 1.40, 95%CI = 1.15-1.71; AOR = 1.37, 95%CI = 1.03-1.80, respectively), and more frequently used Spanish (AOR = 1.91, 95%CI = 1.77-2.07; AOR = 1.87, 95%CI = 1.69-2.07). Also, high vs. low education (AOR = 1.51, 95%CI = 1.17-1.94) and higher income adequacy (AOR = 1.37, 95%CI = 1.25-1.51) were positively associated with noticing FoPWLs. Being female and more frequent Spanish use were consistently associated with reporting purchase of fewer unhealthy foods because of FoPWLs.

CONCLUSIONS

Many Mexican Americans report both exposure to Mexican FOPWLs and reducing purchases of unhealthy foods because of them.

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

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

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.

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.

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.

Socioeconomic and Demographic Factors Associated with the Influence of the Food Traffic Light Labeling on the Decision of the Adult Population of Ecuador to Purchase Processed Foods, 2018

To determine the socioeconomic and demographic factors associated with the influence of the nutritional traffic light (NTL) on the decision to purchase processed foods using information from the National Health and Nutrition Survey (ENSANUT) 2018 of Ecuador, a cross-sectional and analytical study based on a secondary analysis of the information from the ENSANUT 2018 was performed. We collected data from 25,932 participants 18 years of age or older who knew or had seen the NTL, and for whom complete information on the variables of interest for the study was available. The "Influence of the NTL on the purchase decision of processed foods" was the outcome variable of the study. Generalized linear models of the Poisson family, with log link, were used to assess the association between socioeconomic factors and outcome, using crude (PR) and adjusted (aPR) prevalence ratios, with 95% confidence intervals (CI) and a p-value < 0.05. Participants who understood the NTL (aPR: 2.49; 95% CI: 2.19-2.83), with a higher educational level (aPR: 1.33; 95% CI: 1.09-1.61), women (aPR 1.06; 95% CI: 1.01-1.10), and who had a partner (aPR 1.09; 95% CI: 1.04-1.14) were more likely to be influenced by the NTL when deciding to purchase processed foods, compared to people who did not understand the NTL, who had no educational level or who only attended a literacy center, were men, and those without a partner. The inhabitants of the coastal region (aPR: 0.92; 95% CI: 0.88-0.97), the Amazon (aPR 0.93; 95% CI: 0.88-0.98), and the insular region (aPR 0.76; 95% CI: 0.68-0.84) had few probabilities of being influenced by the NTL in the decision to purchase processed foods, in comparison with the residents of the highlands. Similarly, compared to non-poor people, poor people had a lower probability of being influenced by the NTL (aPR 0.89; 95% CI: 0.82-0.97). Factors associated with the influence of NTL on the decision to purchase processed foods were identified. It is recommended to reformulate and focus awareness strategies for using the NTL to purchase processed foods by taking into account the associated factors.

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.

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.

Acceptability of policies targeting dietary behaviours and physical activity: a systematic review of tools and outcomes

BACKGROUND

Successful implementation of health policies require acceptance from the public and policy-makers. This review aimed to identify tools used to assess the acceptability of policies targeting physical activity and dietary behaviour, and examine if acceptability differs depending on characteristics of the policy and of the respondents.

METHODS

A systematic review (PROSPERO: CRD42021232326) was conducted using three databases (Science Direct, PubMed and Web of Science).

RESULTS

Of the initial 7780 hits, we included 48 eligible studies (n = 32 on dietary behaviour, n = 11 on physical activity and n = 5 on both), using qualitative and quantitative designs (n = 25 cross-sectional, quantitative; n = 15 qualitative; n = 5 randomized controlled trials; n = 3 mixed-methods design). Acceptability was analysed through online surveys (n = 24), interviews (n = 10), focus groups (n = 10), retrospective textual analysis (n = 3) and a taste-test experiment (n = 1). Notably, only 3 (out of 48) studies applied a theoretical foundation for their assessment. Less intrusive policies such as food labels and policies in a later stage of the implementation process received higher levels of acceptability. Women, older participants and respondents who rated policies as appropriate and effective showed the highest levels of acceptability.

CONCLUSION

Highly intrusive policies such as taxations or restrictions are the least accepted when first implemented, but respondents' confidence in the relevance and effectiveness of the policy may boost acceptability over the course of implementation. Studies using validated tools and a theoretical foundation are needed to further examine opportunities to increase acceptability.

Assessing Consumer Willingness to Pay for Nutritional Information Using a Dietary App

A healthy society is the foundation of development in every country, and one way to achieve a healthy society is to promote healthy nutrition. An unbalanced diet is one of the leading causes of noncommunicable diseases globally. If food was correctly selected and correctly consumed, both the problems of overeating and lack of nutrition could be largely solved while also decreasing public health costs. Interventions such as presenting necessary information and warning labels would help consumers make better food choices. Hence, providing nutritional information to consumers becomes essential. The present study investigates the importance of nutrition information labels on consumers' preferences by estimating their willingness to pay for features and information provided by a dietary software program (app). An application can easily display the information to the consumers and help them make informed food choices. A discrete choice experiment investigated consumers' preferences and willingness to pay to receive nutritional information. Mixed multinomial logit and latent class analysis were applied. The results showed the existence of heterogeneity in consumer preferences for different nutritional information provided by the application. Consumers are willing to pay more for salt and fat alerts. The results of this study allow for the analysis of consumers' interest in nutritional information. Such results are essential for the industry for future investments in similar applications that potentially could help consumers make better informed choices.

Analysis of stakeholders' responses to the food warning labels regulation in Mexico

Background

In Mexico, the inclusion of a front-of-pack label in the Official Mexican Standard 051 (NOM-051 for its Spanish acronym) has been widely discussed for years by different stakeholder groups. In 2019, the NOM-051 modification project was proposed, which included front-of-pack warning labels. To be modified, it underwent a public consultation period where stakeholders sent their comments to be reviewed and considered. The purpose of this study was to analyse the stakeholders’ perspectives during the public consultation of the NOM-051 modification project.

Methods

To assess perspectives, the 795 comments available on the National Commission for Regulatory Improvement website were analysed. Identity, expectations and demands were identified from each comment using content analysis in NVivo. In addition, frequencies and percentages were obtained.

Results

Fifty-six percent of the comments were opposed to the NOM-051 modification project. Industry and business interest nongovernmental organizations were against it; they considered that their revenues and profits would be affected. Public interest nongovernmental organizations, academia and health professionals were in favour, stating that the changes proposed are fundamental to informing consumers and improving food choices, and an essential factor in reducing the prevalence of overweight and obesity. Stakeholders in favour expected that eating habits would improve, and demanded that the front-of-pack warning label suggested in the modification proposal be maintained.

Conclusions

The comments opposed to the NOM-051 modification project were consistent with the literature, indicating that food industry stakeholders use all possible arguments to interfere in public health policies. The main issues used by the food industry to discredit the NOM-051 modification project coincide with those used in other countries to stop public health policies and with those used by the tobacco industry to avoid market regulations. On the other hand, those in favour looked after the interests of the Mexican population.

Effect of different front-of-package food labels on healthfulness perception of ultraprocessed food and intention to purchase the products- A randomised controlled trial

This study aimed to evaluate the effect of different labels on participants: identifying products high in nutrients of concern; identifying unhealthy products, and intention to purchase unhealthy products. This blinded randomised controlled trial included a representative sample of South African households (n = 1951). Per household we selected a member primarily responsible for food purchases. Participants were randomised into the Warning Label (WL), Guideline Dietary Amounts (GDA) or Multiple Traffic Light (MTL) arms. Each participant answered questions in a no label condition (control) followed by same questions in the label condition (experiment). Complete data were collected and analysed for 1948 participants (WL = 33.7%, GDA = 32.1% and MTL = 34.2%). The probability of correctly identifying products high in nutrients of concern and identifying products as being unhealthy was higher with the WL compared to the GDA or MTL for most items. There was no difference in performance between the GDA and the MTL when considering all items together. A higher percentage of participants reported a lower intention to purchase an unhealthy product after exposure to the WL compared to MTL for 5 out of 6 products; 2 out of 6 products for the WL compared to GDA and 2 out of 6 products for GDA compared to MTL. Compared to the control condition, exposure to each of the labels resulted in better identification of nutrients of concerns, unhealthy products and a lower intention to purchase when considering all specific outcome items together. The WL showed a higher potential to enable South African consumers to identify products high in nutrients of concern, identify unhealthy products and discourage purchasing of unhealthy products.

Perception and Understanding of Guideline Daily Amount and Warning Labeling among Mexican Adults during the Law Modification Period

Front-of-pack labeling (FOPL) is a tool that enables consumers to compare foods and select healthier options. Due to low understanding of the Guideline Daily Amount (GDA) labeling among Mexicans, a law was implemented in October 2020 that modified the FOPL to a warning labeling (WL) system. The purpose of this study was to compare the perception and understanding of GDA and WL during the law modification period. We conducted a panel design with two measurements: (1) using GDA label (September 2020) and (2) using WL (October–November). We estimated differences in GDA vs. WL through multinomial logistic regression models and changes were measured through predictive margin contrasts and Wald tests. When comparing the same products with different labels, the participants reported that it would be unlikely/very unlikely that they would consume products packaged with the WL (81.5%; 95%CI: 79.2, 83.8) compared to those with GDA (24.2%; 95%CI: 21.7, 26.7). Consumers’ perception was that the quantities of packaged products they should consume was small or very small when they used the WL (93.8%; 95%CI: 92.4, 95.5) compared to GDA (41.6%; 95%CI: 39.7, 44.6). When comparing food groups, participants were more confident about choosing healthy products when using the WL compared to the GDA. During the implementation of WL in Mexico, the studied population had a better perception and understanding of less healthy packaged foods when using WL, compared to the GDA label.

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.

Objective understanding of front of pack warning labels among Mexican children of public elementary schools. A randomized experiment

Background

Warning Labels (WL) highlight excessive amounts of critical nutrients in order to discourage consumption of unhealthful packaged food products. This study aimed to evaluate among Mexican school children, the objective understanding of traditional and numeric WL (aimed at small products) considered by the Mexican regulation, and whether cartoon characters influenced the understanding of WL. We also tested some communication strategies to facilitate the correct use of the WL.

Methods

We carried out a randomized experiment in July 2019 in public elementary schools from Morelos, Mexico. Participants aged 6–13 years, were randomly assigned to one of four groups: 1) Nutrient Facts Panel (NF) (n = 120), 2) Nutrient Facts Panel with cartoon characters (NF + C) (n = 83), considered the control groups, 3) Warning Labels (WL) (n = 109), and 4) Warning Labels with cartoon characters (WL + C) (n = 96). After allocation, children assigned to both WL groups (WL or WL + C), were randomly required to watch two posters simultaneously or a video explaining how to correctly interpret WLs. Logistic regression models adjusted by sex, age and cluster (school) were fitted.

Results

The percentage of children correctly choosing the healthiest or the unhealthiest option was higher for WL groups (56.8, 95%CI; 40.8–72.8) compared to NF groups (24.3, 95%CI; 20.4–28.3, p < 0.05). The understanding of traditional WL was higher (28.7, 95%CI: 22.8–35.4) than the numeric WL (19, 95%CI: 14.2–25.0, p < 0.05). But, correct answers for identifying healthy and unhealthy products were higher for numeric WL than for NF groups. Cartoon characters reduced the percentage of correct answers for choosing unhealthiest products (WL + C: 48.9, 95%CI: 25.6–72.4 vs WL: 58.7, 95%CI: 36.4–81.1, p < 0.05). The video was 2.23 times more helpful than the posters to the correct interpretation of the WL (p < 0.05).

Conclusions

In scholar Mexican children, traditional and numeric WL were useful to identify healthier and unhealthier packaged products in comparison to NF, suggesting that both WL formats may effectively communicate the excessive content of nutrients of concern among children. Cartoon characters may reduce the objective understanding of the WL, underscoring the need to regulate advertising directed to children along with the implementation of front-of-pack labeling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12937-022-00791-z.

Correlates of Self-Reported and Functional Understanding of Nutrition Labels across 5 Countries in the 2018 International Food Policy Study

BACKGROUND

Nutrition labels on prepackaged foods are an important source of nutrition information; however, differences in comprehension of varying label formats can limit their use and effectiveness.

OBJECTIVES

This study examined levels and correlates of consumers' self-reported understanding of Nutrition Facts tables (NFts) and front-of-package (FOP) labels, as well as functional NFt understanding.

METHODS

Adults (≥18 y) in Australia (n = 3901), Canada (n = 4107), Mexico (n = 4012), the United Kingdom (n = 5121), and the United States (n = 4445) completed online surveys in November/December 2018. Descriptive statistics summarized sample profiles by country. Linear regression models examined the association between label understanding (self-reported NFt and FOP, functional NFt) and consumer dietary behaviors, functional nutrition knowledge, and sociodemographic characteristics. NFt understanding was measured in all countries, with FOP labeling assessed only in Mexico, Australia, and the United Kingdom.

RESULTS

Self-reported and functional NFt understanding was significantly higher in the United States and Canada (P < 0.0001). In adjusted analyses, functional NFt understanding was significantly higher among women compared to men (P < 0.0001); respondents from the "majority" ethnic group in their respective countries compared with minority ethnic groups (P < 0.0001); those with higher education levels (P < 0.0001) and functional nutrition knowledge compared with their lower education and nutrition knowledge counterparts (P < 0.0001), respectively; and those making efforts to consume less sodium, sugar, or fat compared with those not reporting dietary efforts (P < 0.0001). Self-reported FOP label understanding was significantly higher for interpretive labeling systems in Australia (health star ratings) and the United Kingdom (traffic lights) compared with Mexico's Guideline Daily Amounts (GDAs) (P < 0.0001).

CONCLUSIONS

Nutrition labels requiring greater numeracy skills (i.e., NFts, GDAs) were more difficult for consumers to understand than interpretive FOP labels (i.e., traffic lights). Differences in NFt and FOP label understanding by income adequacy and education suggest potential disparities in labeling policy effects among vulnerable subgroups.

Secondary Outcomes of a Front-of-Pack-Labelling Randomised Controlled Experiment in a Representative British Sample: Understanding, Ranking Speed and Perceptions

Front-of-pack labels (FOPLs) provide simplified nutritional information that aims to inform consumer choice and encourage reformulation. We conducted an online randomised controlled experiment on a representative British sample to test the effectiveness of FOPLs across a range of outcomes. The primary outcomes have been published; here, we present the secondary outcomes: the ability to rank the healthiest product and the time to complete the rankings by comparing the FOPL groups and a no-label control, as well as a descriptive analysis of the perceptions. Participants from the NatCen panel were randomised to one of five experimental groups (Multiple Traffic Lights; Nutri-Score; Warning Label; Positive Choice tick; no-label control). Six food/drink categories were selected (pizza, drinks, cakes, crisps, yoghurts, breakfast cereals), and three products were created with varying healthiness. The participants (analytic sample = 4530) were asked to rank the products in order of healthiness twice (baseline: no label; follow-up: experimental group label). Compared to the control, the probability of correctly ranking the healthiest product at follow-up was significantly greater for the N-S, MTL and WL across all products. The time to correctly complete the ranking was fastest for the N-S, PC and no-label control. The descriptive analysis showed that the FOPLs were perceived favourably, and especially N-S and MTL. The findings were supportive of the primary analyses, with those results suggesting that N-S performed the best, and then MTL.

News coverage of Mexico's front-of-package food label policy

Objectives

To examine news coverage of Mexico’s front-of-package food labelling policy.

Methods

We used Lexis Nexis to identify newspaper articles that mention the proposed law in four Mexican newspapers representing politically centre-left and centre-right perspectives. We coded for type and valence of arguments, sources and research evidence cited.

Results

We identified N=361 relevant articles. Coverage of the front-of-package food label policy was primarily news (vs editorial/opinion). While most were neutral in tone, left-leaning newspapers had slightly more positive overall coverage compared with right-leaning newspapers, indicated by publishing more stories in favour of the policy, fewer in opposition, more propolicy arguments and more frequent inclusion of perspectives by government officials and public health advocates. Despite some evidence of bias, there was a general lack of credible opposition to the policy and mention of opponents across newspapers.

Conclusions and policy implications

The relative absence of food and beverage industry stakeholders in news coverage of the food label policy is unexpected given their documented involvement in prior food policy debates. We discuss possible reasons for their conspicuous absence and lessons for public health advocates around the globe.

Types and Aspects of Front-of-Package Labeling Preferred by Parents: Insights for Policy Making in China

The WHO recommends front-of-package labeling (FOPL) to help parents make healthier food choices for their children. But which type of FOPL resonates with parents in China? We performed a cross-sectional study to investigate parental preferences for five widely used formats of FOPL. A multi-stage cluster sampling method was applied to selected parents of students in primary and secondary schools in six provinces and municipalities from July 2020 to March 2021. A close-ended questionnaire was used to collect demographic information, parents’ preferences for five FOPL in three dimensions, perceptions of the importance of nutrients labeled on FOPL, and prepackaged foods that need FOPL most. Chi-square tests were used to examine the characteristics among five groups. The results showed that multiple traffic lights (MTL) was preferred by parents, followed by warning labels. Parents thought the most needed nutrients to label were sugar, salt, and total fat. The top three prepackaged foods to label were “baked food”, “milk and dairy products” and “sugar-sweetened beverages”. Our findings indicate that nutrient-specific FOPL formats with interpretive aids were preferred by Chinese parents. These new findings can help inform the planning and implementation of FOPL in China and help Chinese parents make healthier food choices.

Polish Consumers' Understanding of Different Front-of-Package Food Labels: A Randomized Experiment

Dietary practices are a key behavioral factor in chronic disease prevention; one strategy for improving such practices population-wise involves front-of-package labels (FoPL). This online randomized study, conducted in a quota-based sample of 1159 Polish adults (mean age = 40.9 ± 15.4 years), assessed the objective understanding of five FoPL: Health Star Rating, Multiple Traffic Lights, NutriScore, Reference Intakes (RI) and Warning Label. Objective understanding was evaluated by comparing results of two nutritional quality ranking tasks (without/with FoPL) using three food categories (breakfast cereals, cakes, pizza). Associations between FoPL exposure and objective understanding were assessed via multivariable ordinal logistic regression. Compared to RI and across food categories, significant improvement in objective understanding was seen for NutriScore (OR = 2.02; 95% CI: 1.41–2.91) and Warning Label (OR = 1.61; 95% CI: 1.12–2.32). In age-stratified analyses, significant improvement in objective understanding compared to RI emerged mainly among adults aged 18–30 years randomized to NutriScore (all food categories: OR = 3.88; 95% CI: 2.04–7.36; cakes: OR = 6.88; 95% CI: 3.05–15.51). Relative to RI, NutriScore was associated with some improvement in objective understanding of FoPL across and within food categories, especially among young adults. These findings contribute to the ongoing debate about an EU-wide FoPL model.

Implementation of childhood obesity prevention and control policies in the United States and Latin America: Lessons for cross-border research and practice

Progress has been made in the development and widespread implementation of effective interventions to address childhood obesity, yet important challenges remain. To understand how the United States and Latin American countries achieved success in implementing obesity policies and programs (PAPs) and identify improvement opportunities using implementation science principles. We identified three comparative case studies: (1) front-of-food package labeling (Mexico and Chile); (2) Open Streets/play streets (Colombia and the United States); and (3) the Baby-Friendly Hospital Initiative (Brazil and the United States). Information from multiple sources (e.g., scientific and gray literature and key informant interviews) was synthesized to describe barriers, facilitators, and progress of PAPs across RE-AIM framework dimensions. Evidence-based advocacy along with political will and evidence of scalability and impact were key for successful launch and implementation of all PAPs. Diverse adaptations of PAP design and implementation had to be done across contexts. Stronger process and impact monitoring and evaluation systems that track equity indicators are needed to maximize the population benefits of these PAPs. Implementation science offers an important contribution toward addressing knowledge gaps, enhancing obesity policy dialogue, and producing transferable lessons across the Americas and, therefore, should be used for research and evaluation during PAP development and throughout the implementation and maintenance phases.

Factors predicting nutritional knowledge, illness perceptions, and dietary adherence among hypertensive middle-aged women: Application of transtheoretical model

BACKGROUND

Healthy dietary adherence might be one of the effective and modifiable factors for hypertension (HTN) control; therefor, empowering patients for self-care management including healthy food patterns play a key role in guiding their care, in partnership with health care providers. This study aimed to identify the factors predicting nutritional knowledge, illness perceptions, and adherence to a diet based on transtheoretical model (TTM) among hypertensive middle-aged women.

MATERIALS AND METHODS

A cross-sectional survey was conducted on 164 patients with HTN attending west health centers of Tehran, Iran, in 2020. Simple random sampling was used. Sociodemographic characteristics of the respondents were collected, a valid and reliable measure on nutritional knowledge, illness perceptions, and adherence to diet, and a researcher-made measure based on TTM constructs through in-person interview was applied. Descriptive statistics and general linear model were utilized for data analysis using SPSS version 25. The significance level was considered less than 0.05.

RESULTS

Mean and standard deviation of participants was 50.82 ± 8.77 years. Multivariate regression analysis indicated that family income (P < 0.001) and body mass index (P < 0.001) predicted nutritional knowledge and adherence to diet, respectively. Decisional balance and self-efficacy constructs predicted nutrition knowledge and illness perceptions (P < 0.001). In adherence to diet, overcoming the temptation construct was indicated as the only predictor (P < 0.001).

CONCLUSION

Study findings highlighted the necessity of tailoring and implementing interventions based on TTM using appropriate strategies to promote quality of HTN management approach in nutritional knowledge, illness perceptions, and dietary adherence.

A health consumer ontology of fast food information

A variety of severe health issues can be attributed to poor nutrition and poor eating behaviors. Research has explored the impact of nutritional knowledge on an individual's inclination to purchase and consume certain foods. This paper introduces the Ontology of Fast Food Facts, a knowledge base that models consumer nutritional data from major fast food establishments. This artifact serves as an aggregate knowledge base to centralize nutritional information for consumers. As a semantically-linked data source, the Ontology of Fast Food Facts could engender methods and tools to further the research and impact the health consumers' diet and behavior, which is a factor in many severe health outcomes. We describe the initial development of this ontology and future directions we plan with this knowledge base.

How Is Functional Food Advertising Understood? An Approximation in University Students

In functional food advertising, messages are not always easily understandable for the target audience. Current European legislation, enforced through Regulation 1924/2006, specifies that such messages should be clear and precise so as not to mislead the consumer. The objective of this study was to observe consumers' understanding of messages in functional food advertisements. The methodology used was a self-administered survey filled out by 191 students enrolled in a Degree in Advertising and Public Relations at the University of Alicante (Spain). The results suggest that a large number of students do not know what functional food is and obtain information about these products mainly from labelling/packaging. The major means of communication through which they learn about health benefits via advertising is the internet, followed by television. Most respondents indicated that they understood related advertisements and found it helpful to be given additional information on health benefits. Worthy of note, the greater their level of understanding of the messages, the higher their level of distrust of advertising messages, which they considered to be deceptive or misleading.

Effects on consumers' subjective understanding of a new front-of-pack nutritional label: a study on Italian consumers

Front-of-pack nutritional label (FOPL) systems have been developed worldwide to amplify and simplify nutritional information and induce healthier choices. This study explores consumers' internal reactions - in terms of subjective understanding and liking - to a new FOPL: the NutrInform Battery. The investigation aims to assess the clear comprehension by consumers of the information provided by the NutrInform Battery FOPL scheme, based on a sample of 200 Italian respondents, in a real-life setting, with products representative of the most widely consumed food categories, using a between-subject design. Participants were randomly assigned to one of the two conditions: products marked with NutrInform Battery or Nutri-Score labels. The results provided evidence of the effectiveness of NutrInform Battery in being perceived by consumers as an informative FOPL scheme. Specifically, consumers found NutrInform Battery more informative and helpful than Nutri-Score in terms of their understanding of the product composition.

Effectiveness of Different Front-of-Pack Nutrition Labels among Italian Consumers: Results from an Online Randomized Controlled Trial

In Italy, discussions are currently ongoing to implement a front-of-pack nutrition label (FoPL) while a growing number of European countries are adopting the Nutri-Score. The effectiveness of the Nutri-Score among Italian consumers requires further investigation. This study compared five FoPLs among Italian participants (Health Star Rating system, multiple traffic lights, Nutri-Score, reference intakes, warning symbol) in terms of food choices and understanding of the labels by consumers. In 2019, 1032 Italian consumers completed an online survey in which they were asked to select one product they would likely purchase from a set of three foods with different nutrient profiles and then classify the products within the set according to their nutritional quality, first with no label and then with one of the five FoPLs on the pack. While no significant difference across labels was observed for food choices, the Nutri-Score demonstrated the highest overall performance in helping consumers to correctly rank the products according to their nutritional quality compared to the reference intakes (OR = 2.18 (1.50–3.17), p-value < 0.0001). Our results provide new insights on the effectiveness of the Nutri-Score, which would be a relevant tool to inform Italian consumers on the nutritional quality of food products.

Impact of front-of-pack nutrition labels on consumer purchasing intentions: a randomized experiment in low- and middle-income Mexican adults

BACKGROUND

Front-of-pack (FOP) nutrition labeling is a cost-effective strategy to help consumers make informed and healthier food choices. We aimed to investigate the effect of the FOP labels used in the Latin American region on consumers' shopping intentions when prompted to make their choices with specific nutrients-to-limit in mind among low- and middle-income Mexican adults (> 18 y).

METHODS

In this experimental study of an online simulated shopping situation participants (n = 2194) were randomly assigned to one of three labeling conditions: Guideline Daily Amounts (GDA), Multiple Traffic Lights (MTL), or red Warning Labels (WL). Participants were required to view a video explaining how to correctly interpret the assigned label. Primary outcomes were the overall nutritional quality (estimated using the Nutrient Profiling Scoring Criterion [NPSC] and NPSC baseline score) and mean energy and nutrient content of purchases. Secondary outcomes included shopping time variables. We also evaluated the impact of the labels across food categories (ready-made foods, dairy beverages, non-dairy beverages, salty snacks, and breakfast cereals) and sociodemographic subgroups.

RESULTS

The MTL and the WL led to a better overall nutritional quality of the shopping cart compared to the GDA (p < 0.05). According to the NPSC score, the WL led to a better nutritional quality across breakfast cereals and salty snacks compared to the GDA (p < 0.05); a similar effect was observed for the MTL among non-dairy beverages (p < 0.05). The MTL and the WL required shorter shopping times compared to GDA (p < 0.05). Across all labeling conditions, the nutritional quality of the shopping cart tended to be lower among those with low income, education and nutrition knowledge levels.

CONCLUSION

WL and MTL may foster healthier food choices in a faster way among low- and middle-income groups in Mexico. To produce an equitable impact among consumers of all socioeconomic strata, efforts beyond simply the inclusion of a communication campaign on how to use and interpret FOP labels will be required.

TRIAL REGISTRATION

clinicaltrials.gov. NCT04308408 Retrospectively registered March 16, 2020.