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

Self-reported decreases in the purchases of selected unhealthy foods resulting from the implementation of warning labels in Mexican youth and adult population

BACKGROUND

Front-of-package nutritional warning labels (WLs) are designed to facilitate identification and selection of healthier food choices. We assessed self-reported changes in purchasing different types of unhealthy foods due to WLs in Mexico and the association between the self-reported reductions in purchases of sugary beverages and intake of water and sugar-sweetened beverages.

METHODS

Data came from 14 to 17 year old youth (n = 1,696) and adults ≥ 18 (n = 7,775) who participated in the Mexican arm of the 2020-2021 International Food Policy Study, an annual repeat cross-sectional online survey. Participants self-reported whether the WLs had influenced them to purchase less of each of nine unhealthy food categories due to WLs. Among adults, a 23-item Beverage Frequency Questionnaire was used derive past 7-day intake of water and sugary beverages analyzed to determine the relationship between self-reported reductions in purchasing sugary drinks due to the WLs. Multilevel mixed-effects logistic regression models were fitted to estimate the percentage of participants who self-reported reducing purchases within each food group, and overall. Sociodemographic characteristics associated with this reduction were investigated as well.

RESULTS

Overall, 44.8% of adults and 38.7% of youth reported buying less of unhealthy food categories due to the implementation of WL, with the largest proportion reporting decreased purchases of cola, regular and diet soda. A greater impact of WLs on the reported purchase of unhealthy foods was observed among the following socio-demographic characteristics: females, individuals who self-identified as indigenous, those who were overweight, individuals with lower educational levels, those with higher nutrition knowledge, households with children, and those with a significant role in household food purchases. In addition, adults who reported higher water intake and lower consumption of sugary beverages were more likely to report reduced purchases of sugary drinks due to the WLs. Adults who reported greater water intake and lower sugary beverages intake were significantly more likely to report buying fewer sugary drinks due to the WLs.

CONCLUSION

Our findings suggest that implementation of WLs has reduced perceived purchases of unhealthy foods in Mexico. These results underscore the potential positive impact of the labeling policy particularly in subpopulations with lower levels of education and among indigenous adults.

Impact of nutrient warning labels on Colombian consumers' selection and identification of food and drinks high in sugar, sodium, and saturated fat: A randomized controlled trial

OBJECTIVE

This study assessed the impact of nutrient warnings on product selection and ability to identify food products high in nutrients of concern in Colombia.

METHODS

In an online experiment (May-June 2023), Colombian adults were randomized to a nutrient warning, guideline daily amounts (GDA), Nutri-Score, or no-label condition (n = 8,004). Participants completed selection tasks between two fruit drinks labeled according to their condition, one high in sugar and one not. Next, participants answered questions about products high in sugar, sodium, and/or saturated fat ("high-in" product). Finally, they selected which label would most discourage them from consuming a high-in product.

RESULTS

Fewer participants (17%) exposed to the nutrient warning indicated they would purchase the high-sugar fruit drink compared to Nutri-Score (27%, Holm-adjusted (adj) p<0.001) and no label conditions (31%, adj p<0.001); there were no differences between the nutrient warning and GDA label (14%, adj p = 0.087). Compared to the nutrient warning, the GDA label was slightly more effective at helping consumers identify which drink was high in sugar (89% versus 92%, adj p<0.001), while the Nutri-Score and no-label conditions were less effective. Compared to all other conditions, nutrient warnings were more effective at helping participants identify that products were high in nutrients of concern, were more effective at decreasing intentions to purchase these high-in products and were perceived as more effective. Nutrient warnings were most often selected as the label that most discouraged consumption.

CONCLUSIONS

Nutrient warnings are a promising policy to help consumers identify and discourage consumption of products high in nutrients of concern.

TRIAL REGISTRATION

Trial Registration: NCT05783726.

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.

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.

The Effects of an Educational Intervention About Front-of-Package Labeling on Food and Beverage Selection Among Children and Their Caregivers: Protocol for a Randomized Controlled Trial

BACKGROUND

Overweight and obesity pose a global public health challenge and have a multifactorial origin. One of these factors includes obesogenic environments, which promote ultraprocessed foods characterized by being high in calories, saturated fats, added sugars, and sodium. In Mexico, it has been estimated that 30% of the total energy consumed comes from processed foods. The Modification to the Official Mexican Standards introduces nutritional information through black octagonal seals that alert consumers about products with excessive amounts of some components for a better food selection in the population. However, the effects of warning labels on processed food selection and purchases among children remain unknown.

OBJECTIVE

We aimed to evaluate the impact of a digital educational intervention focusing on front-of-package warning labels on the food selection and purchasing behavior of elementary schoolchildren and their caregivers.

METHODS

Children from 4 elementary schools in Mexico City, 2 public and 2 private schools, will participate in a randomized controlled trial. The schools will be chosen by simple random sampling. Schools will be randomized into 2 groups: intervention and control. In the control group, the dyads (caregiver-schoolchildren) will receive general nutritional education, and in the intervention group, they will receive guidance on reading labels and raising awareness about the impact of consuming ultraprocessed products on health. The educational intervention will be conducted via a website. Baseline measurements will be taken for both groups at 3 and 6 months. All participants will have access to an online store through the website, allowing them to engage in exercises for selecting and purchasing food and beverages. In addition, other measures will include a brief 5-question exam to evaluate theoretical understanding, a 24-hour reminder, a survey on food habits and consumption, application of a food preference scale, anthropometric measurements, and recording of school lunch choices.

RESULTS

Registration and funding were authorized in 2022, and we will begin data collection in September 2024. Recruitment has not yet taken place, but the status of data analysis and expected results will be published in April 2025.

CONCLUSIONS

The study is expected to contribute to evaluating whether reinforcing front-of-package warning labels with education enhances its effects and makes them more sustainable. Conducting this study will allow us to propose whether or not it is necessary to develop new intervention strategies related to front-of-package labeling for a better understanding of the population, improved food choices, and better health outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06102473; https://clinicaltrials.gov/study/NCT06102473.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54783.

Self-reported decreases in the purchases of selected unhealthy foods resulting from the implementation of warning labels in Mexican youth and adult population

Background

Front-of-package nutritional warning labels (WLs) are designed to facilitate identification and selection of healthier food choices. We assessed self-reported changes in purchasing different types of unhealthy foods due to WLs in Mexico and the association between the self-reported reductions in purchases of sugary beverages and intake of water and sugar-sweetened beverages.

Methods

Data came from 14-17 year old youth (n=1,696) and adults ≥18 (n=7,775) who participated in the Mexican arm of the 2020-2021 International Food Policy Study, an annual repeat cross-sectional online survey. Participants self-reported whether the WLs had influenced them to purchase less of each of ten unhealthy food categories due to WLs. Among adults, a 23-item Beverage Frequency Questionnaire was used derive past 7-day intake of water and sugary beverages analyzed to determine the relationship between self-reported reductions in purchasing sugary drinks due to the WLs. Multilevel mixed-effects logistic regression models were fitted to estimate the percentage of participants who self-reported reducing purchases within each food group, and overall. Sociodemographic characteristics associated with this reduction were investigated as well.

Results

Overall, 44.8% of adults and 38.7% of youth reported buying less of unhealthy food categories due to the implementation of WL, with the largest proportion reporting decreased purchases of cola, regular and diet soda. A greater impact of WLs on the reported purchase of unhealthy foods was observed among the following socio-demographic characteristics: females, individuals who self-identified as indigenous, those who were overweight, individuals with lower educational levels, those with higher nutrition knowledge, households with children, and those with a significant role in household food purchases. In addition, adults who reported higher water intake and lower consumption of sugary beverages were more likely to report reduced purchases of sugary drinks due to the WLs. Adults who reported greater water intake and lower sugary beverages intake were significantly more likely to report buying fewer sugary drinks due to the WLs.

Conclusion

Our findings suggest that implementation of WLs has reduced purchases of unhealthy foods in Mexico. These results underscore the positive impact of the labeling policy particularly in subpopulations with lower levels of education and among indigenous adults.

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.

A Randomized Controlled Study to Test Front-of-Pack (FOP) Nutrition Labels in the Kingdom of Saudi Arabia

One common strategy for governments to tackle the non-communicable disease (NCD) epidemic is front-of-package (FOP) nutrition labeling. The Kingdom of Saudi Arabia (KSA) is considering implementing a new FOP label that is based on either France's Nutri-Score (NS), which labels all foods (A = healthiest to E = least healthy) based on overall nutritional quality, or the Chilean warning label (WL) approach, which identifies foods to avoid based on select nutritional characteristics. Using a fully functional online grocery store, this study aimed to test these two promising FOP strategies by randomizing 656 KSA adults into one of the three versions of the store to complete a hypothetical grocery shop: no-label (control), NS, and WL. The NS was modified with a sugar percentage tag given that reducing sugar consumption is one of KSA's public health goals. We found that both modified NS labels and Chilean warning labels positively influenced food and beverage choices among KSA participants, but there were differential effects across the two labels. Relative to the control, NS improved the overall diet quality of the shopping baskets, measured by the weighted (by the number of servings) average NS point (ranging from 0, least healthy, to 55, healthiest), by 2.5 points [95% CI: 1.7, 3.4; p < 0.001], whereas results for WL were not statistically significant (0.6 points [95% CI: -0.2,1.5]). With respect to each nutritional attribute, we found that NS reduced sugar intake per serving, whereas WL was effective at decreasing energy and saturated fat intake per serving from food and beverages purchased. Our results suggest that the NS approach that identifies the healthiness of all foods using a holistic approach appears preferable if the purpose of the label is to improve overall diet quality as opposed to addressing select nutrients to avoid.

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.

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.

Exploring the influence of food labels and advertisements on eating habits of children: a cross-sectional study from Punjab, India

BACKGROUND

Maintaining healthy eating habits among children is challenging due to industrial tactics. There is little research on the effect of nutritional labels and tv ads on the eating habits of children. So the primary aim of the study was to explore the noticeability of the food packaging labels by the children, the information retrieved from the food nutrition labels, and their role in increased frequency of eating out in addition to the perceptions of their parents about the television ads.

METHODS

A cross-sectional study was conducted at schools in Punjab, India. Using multi-stage stratified random sampling, we included 722 school-going children aged 14-18 and their parents. A structured predefined questionnaire collected data using a four-point Likert scale. Descriptive statistics and binary logistic regression were used to draw our inferences.

RESULTS

About 46% of children were eating out > 3 times a week. Nearly 49% said they never looked at the expiry dates on the food packet, and 40% have yet to notice the quality certification. Nearly half do not understand the components of the food label, and 59% said they never changed their buying behavior because of the label. Only 37% of parents expressed their concerns about the timing of the ads when children watch television, while only 25.5% were concerned about the accuracy of the information. Concerns of the parents regarding the timing of the ads, and celebrity endorsements, were potential predictors for the increased frequency of eating out by the children.

CONCLUSIONS

Low awareness regarding the utility of nutrition labels and minimal concerns of the parents increase the frequency of eating out. Unification of our existing policies regarding food labels and tv advertisements to develop family-centric interventions will bring us one step closer to improving the enabling environment to curb the growing menace of childhood obesity.

Oh So Sweet: A Comparative Investigation of Retail Market Composition of Sweetened and Flavoured Beverages in Singapore and Australia

The consumption of sugar and non-nutritive sweeteners has been associated with poor health outcomes. The aim of this paper was to provide a comparison of the range of sweetened or flavoured beverages between two high-income countries in the Asia-Pacific region: Australia and Singapore. Following the FoodTrackTM methodology, nutrition, labelling, and price data were collected from major Australian and Singaporean supermarket chains and convenience stores. The nutrient profiles of products were tested for differences using Kruskal−Wallis and Mann−Whitney U tests. The greatest number of products collected in Australia were from the ‘carbonated beverages’ category (n = 215, 40%), and in Singapore the greatest number of products were from the ‘tea and coffee ready-to-drink’ category (n = 182, 35%). There were more calorically sweetened beverages in Singapore compared with Australia (n = 462/517 vs. n = 374/531, p < 0.001). For calorically sweetened products, the median energy of Singaporean products was significantly higher than Australian products (134 kJ vs. 120 kJ per 100 mL, p = 0.009). In Australia, 52% of sweetened or flavoured beverages displayed a front-of-pack nutrient signposting logo, compared with 34% of sweetened or flavoured beverages in Singapore. These findings also indicate that the consumption of just one serving of calorically sweetened carbonated beverages or energy drinks would exceed the WHO maximum daily free sugar recommendations.

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

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

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.

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.

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.

Consumers' Response to Sugar Label Formats in Packaged Foods: A Multi-Methods Study in Brazil

Providing information about the sugar content of packaged foods on product labels is an important strategy to lower consumers' sugar intake. This study assessed the effect of exposure to different sugar labels on consumers' understanding of the sugar content of foods and their food choices. In the first phase, five focus groups were conducted with a convenience sample of Brazilian adults to explore their perceptions about food labelling in general and sugar labelling in particular. Based on the qualitative results, four sugar label formats were developed and subsequently tested in a five-arm study on 1,277 adults via a randomised controlled online survey. The formats were: (i) no sugar information—control, (ii) total and added sugar content displayed in the Nutrition Information Panel (NIP), (iii) a front-of-package (FoP) octagonal warning for “high-in-sugar” products, (iv) a FoP magnifying glass warning for “high-in-sugar” products, and (v) a “high-in-sugar” warning text embedded on the NIP. Participants from the focus groups reported being confused about the meaning of “sugar” and “added sugar” on food labels and indicated that more interpretive labels, such as the FoP warnings, would help them choose products with low sugar content. In the experiment, all intervention sugar label formats improved participants' understanding of the sugar content of the tested food products, with the FoP warnings (iii and iv) showing the best results. While non-significant differences among label conditions were observed for food choices, the FoP octagonal warning prompted participants to choose high-in-sugar products less often. Given current public policy agendas aiming to reduce added sugar intake, there is a need to strengthen food labelling policies and nutrition disclosure policies that target the display of added sugar and build consumer awareness in using these tools to avoid high-in-sugar products.

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.

Effects of Digital Food Labels on Healthy Food Choices in Online Grocery Shopping

In order to induce the shift in consumer behavior necessary for the mitigation of diet-related diseases, front-of-package labels (FoPL) such as the Nutri-Score that support consumers in their efforts to identify nutritionally valuable products during grocery shopping have been found to be effective; however, they remain non-compulsory in most regions. Counter-intuitively, a similar stream of research on digital web-based FoPL does not yet exist, even though such digital labels hold several advantages over physical labels. Digital FoPL can provide scalable and personalized interventions, are easier to implement than physical labels, and are especially timely due to the recent increase in online grocery shopping. The goal of this study was to demonstrate the technical feasibility and intervention potential of novel, scalable, and passively triggered health behavior interventions distributed via easy-to-install web browser extensions designed to support healthy food choices via the inclusion of digital FoPL in online supermarkets. To that end, we developed a Chrome web browser extension for a real online supermarket and evaluated the effect of this digital food label intervention (i.e., display of the Nutri-Score next to visible products) on the nutritional quality of individuals’ weekly grocery shopping in a randomized controlled laboratory trial (N = 135). Compared to the control group, individuals exposed to the intervention chose products with a higher nutritional quality (e.g., 8% higher healthy trolley index (HETI), 3.3% less sugar, 7.5% less saturated fat). In particular, users with low food literacy seemed to benefit from the digital FoPL (e.g., 11% higher HETI, 10.5% less sugar, 5.5% less saturated fat). Furthermore, participants exposed to the food label advocated its introduction more strongly than the control group (p = 0.081). Consumers worldwide could easily install such applications to display digital food labels on their end devices, and would thus not have to wait for stakeholders in the food industry to eventually reach consensus on mandatory food label introduction.

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.

Effect of Warning Labels on Consumer Motivation and Intention to Avoid Consuming Processed Foods

Nutritional warnings (NWs) as a front-of-package label were implemented as a public policy aiding consumers with recognizing processed foods with high levels of critical nutrients (sodium, saturated fats, carbohydrates, and calories). However, in spite of this tool being well positioned in consumer decision making, there is little extant knowledge about the relationship between the message sent by NW, nutritional knowledge, consumer motivation, and the intention to avoid consuming processed foods. To understand these dimensions’ relations, a theoretical model was created and subsequently tested through structural equations. We applied a survey to 807 home food purchasing decision makers. The results show that the direct effect of NW messages raises the intention to avoid processed foods, while eating motivation is negative in its direct effect on the same avoidance intention. However, the message sent by NWs had a mediating effect between the intentions to avoid processed food and eating motivation but showed no such effect on nutritional knowledge. This suggests that the message sent by NWs was able to turn negative eating motivation into positive eating motivation to avoid processed foods. In conclusion, NWs help mitigate eating motivations, as well as boost the intention to avoid processed foods.

Brazilian Consumers’ Perception towards Food Labeling Models Accompanying Self-Service Foods

The study aimed to evaluate consumers’ perception of self-service foods’ nutrition labels. This qualitative and quantitative assessment was performed with potential consumers at food services. Four food labeling formats, traditional, simplified, traffic-light, and warning, were proposed to evaluate three types of sandwiches: simple, chicken, and hamburger. Data were collected via an online survey from April to May 2020. The study included 413 subjects. The respondents preferred the traffic-light format, but there was a good understanding and acceptability of all four models. The traffic-light and warning nutrition labeling models, which showed health warnings, led to a reduction in the choice of the Simple Sandwich and the Hamburger. Most respondents (96.1%, n = 397) agreed that it is necessary to complement the information on food labels with ingredients and the number of calories per serving. Therefore, it is essential to have legislation regulating such issues. Consumers’ choices improved with the increase in the information placed on the products. This research demonstrated that nutrition labels explain what exists currently and that consumers require such information. Thus, food labeling may positively influence consumers’ choices.

Impact of nutrient warning labels on choice of ultra-processed food and drinks high in sugar, sodium, and saturated fat in Colombia: A randomized controlled trial

OBJECTIVE

This study assessed nutrient warnings' impact on product selection and identification of food products high in nutrients of concern in Colombia.

METHODS

In an online experiment (October 2020), 8,061 Colombians were randomized to a nutrient warning, guideline daily amounts (GDA), Nutri-Score, or no-label condition. They viewed two fruit drinks labeled according to their condition, one high in sugar and one not, and completed selection tasks. Next, they assessed four products high in sugar, sodium, and/or saturated fat ("high in" product). Finally, they selected which label would most discourage them from consuming a "high in" product.

RESULTS

The nutrient warning performed better on most outcomes. Twenty percent of participants exposed to the nutrient warning would purchase the high-sugar fruit drink compared to GDA (24%, p<0.01), Nutri-Score (33%, p<0.001), and no label (29%, p<0.001). GDA performed slightly better than the nutrient warning in identifying the high-sugar fruit drink (91% vs 88%, p<0.001). The nutrient warning best helped participants correctly identify other "high in" products (75% vs. 23% no-label, 26% Nutri-Score, and 43% GDA, all p<0.001) and had the highest perceived message effectiveness (3.86 on 5-point scale vs. 2.97 GDA and 2.70 Nutri-Score, both p<0.001) and lowest likelihood of purchasing "high in" products (2.58 on 5-point scale vs. 3.23 GDA, 3.49 Nutri-Score, and 3.51 no label, all p<0.001). The nutrient warning most discouraged participants from wanting to consume "high in" products.

CONCLUSIONS

Nutrient warnings are a promising policy to help consumers identify and discourage consumption of products high in nutrients of concern.

TRIAL REGISTRATION

Trial Registration: NCT04567004.

Consumers’ Knowledge and Use of Nutritional Labelling Information in Lagos, Nigeria

Nutrition labelling is a topical issue, being a vital aid that shapes consumers’ food choices and could be an efficient tool for the prevention of consumer vulnerability to diet-related diseases such as cancer, high blood pressure, hypertension, and obesity. However, data on the public use of nutritional labels as an information source on nutritional properties of foods and health claims, especially as it relates to Nigeria, are not popular in the literature. This study seeks to examine consumers’ use of labelling information: knowledge; attitude, and practice. A cross-sectional study with the aid of a survey elicited information from 374 randomly selected shoppers in five shopping malls in Lagos State. Data were analysed using the T-test method. Findings show that while the majority of the respondents (70.6%) read the nutritional information, only 64.9% understand the information presented on food labels. The study also reveals that the majority of the respondents (57.5%) do not know that information on food labels should be presented in the English language before any other language as recommended by the National Agency Food and Drug Administration and Control (NAFDAC). While 57.9% of consumers have a positive attitude towards using food labels, 58% of the respondents’ buying decisions are influenced by food labels. The study concludes that consequent upon the importance of nutritional knowledge and wellbeing, consumers of Fast Moving Goods in Nigeria are beginning to consciously pay attention to nutritional labels. The study recommends that producers of Fast Moving Consumer Goods (FMCG) products in Nigeria should adopt the total disclosure of ingredients and nutritional content of their products. Also, regulatory bodies in charge of pre-packaged food products in Nigeria (NAFDAC) should go the whole way and make nutritional labelling mandatory.

Online Consumer Survey Comparing Different Front-of-Pack Labels in Greece

According to the WHO, front-of-pack nutrition labeling provides simplified nutrition information in the form of symbols, colors or words that can help consumers understand the nutritional quality of food, thus leading them to healthier food choices. It is considered of the utmost importance to explore the knowledge and understanding of consumers about this form of nutrition labeling. The aim of this study was to investigate the understanding and perceptions of Greek consumers in response to five different front-of-pack nutrition labels (FoPLs): the Multiple Traffic Lights, Health Star Rating System, Guideline Daily Amounts, Warning Symbols and Nutri-Score. From April 2021 to June 2021, 1278 participants from Greece took part in an online survey where they were asked to rank three products according to their nutritional quality. The classification process was performed first without FoPLs and then with FoPLs. The ability to classify products according to their nutritional quality was evaluated with multinomial logistic regression models, and the Nutri-Score label presented greater improvements when compared to the GDA label for Greek consumers. The Nutri-Score seemed to better help the Greek consumers rank foods according to their nutritional value.

Using a Naturalistic Store Laboratory for Clinical Trials of Point-of-Sale Nutrition Policies and Interventions: A Feasibility and Validation Study

Point-of-sale policies such as warnings and taxes are promising tools for improving the nutritional quality of food purchases. Research studies conducted in naturalistic store laboratories could improve the quality of evidence about point-of-sale interventions by allowing for realistic exposure in a controlled setting. This study aimed to assess whether purchasing behavior in a naturalistic store laboratory setting was similar to real-life purchasing behavior and to evaluate participants’ perceptions of store realism and the acceptability of research study protocols in this setting. In a longitudinal observational study in 2019, Latinx parents in North Carolina (n = 61) attended five weekly visits at the UNC Mini Mart, a naturalistic store laboratory that resembled a small convenience store. At each visit, participants purchased a week’s supply of beverages. Purchases of beverages in the Mini Mart were compared to participants’ purchases from receipts submitted the week prior to the study. Analyses compared the percentage of participants buying sugary drinks and non-sugary drinks in the Mini Mart vs. in real stores using Chi-Square tests with Fisher’s p. The percentage of parents who purchased sugary drinks in the Mini Mart (93%) was not significantly different from the percentage who purchased sugary drinks during the week before the study (74%, p = 0.28). The percentage purchasing non-sugary drinks was similar in the two settings (85% in the Mini Mart vs. 85% from receipts, p = 0.33). Nearly all participants reported that their Mini Mart purchases were similar to real-life purchases (96%); the Mini Mart felt like a real store (94%); they could find all the beverages they were looking for (92%); and they could imagine doing their real-life beverage shopping in the Mini Mart (92%). Moreover, retention was high, with 97% of participants attending the final study visit. These results indicate that naturalistic store laboratories are a promising method for increasing the ecological validity of trials to evaluate point-of-sale interventions.

Changes in the calorie and nutrient content of purchased fast food meals after calorie menu labeling: A natural experiment

BACKGROUND

Calorie menu labeling is a policy that requires food establishments to post the calories on menu offerings to encourage healthy food choice. Calorie labeling has been implemented in the United States since May 2018 per the Affordable Care Act, but to the best of our knowledge, no studies have evaluated the relationship between calorie labeling and meal purchases since nationwide implementation of this policy. Our objective was to investigate the relationship between calorie labeling and the calorie and nutrient content of purchased meals after a fast food franchise began labeling in April 2017, prior to the required nationwide implementation, and after nationwide implementation of labeling in May 2018, when all large US chain restaurants were required to label their menus.

METHODS AND FINDINGS

We obtained weekly aggregated sales data from 104 restaurants that are part of a fast food franchise for 3 national chains in 3 US states: Louisiana, Mississippi, and Texas. The franchise provided all sales data from April 2015 until April 2019. The franchise labeled menus in April 2017, 1 year prior to the required nationwide implementation date of May 2018 set by the US Food and Drug Administration. We obtained nutrition information for items sold (calories, fat, carbohydrates, protein, saturated fat, sugar, dietary fiber, and sodium) from Menustat, a publicly available database with nutrition information for items offered at the top revenue-generating US restaurant chains. We used an interrupted time series to find level and trend changes in mean weekly calorie and nutrient content per transaction after franchise and nationwide labeling. The analytic sample represented 331,776,445 items purchased across 67,112,342 transactions. Franchise labeling was associated with a level change of -54 calories/transaction (95% confidence interval [CI]: -67, -42, p < 0.0001) and a subsequent 3.3 calories/transaction increase per 4-week period (95% CI: 2.5, 4.1, p < 0.0001). Nationwide implementation was associated with a level decrease of -82 calories/transaction (95% CI: -88, -76, p < 0.0001) and a subsequent -2.1 calories/transaction decrease per 4-week period (95% CI: -2.9, -1.3, p < 0.0001). At the end of the study, the model-based predicted mean calories/transaction was 4.7% lower (change = -73 calories/transaction, 95% CI: -81, -65), and nutrients/transaction ranged from 1.8% lower (saturated fat) to 7.0% lower (sugar) than what we would expect had labeling not been implemented. The main limitations were potential residual time-varying confounding and lack of individual-level transaction data.

CONCLUSIONS

In this study, we observed that calorie labeling was associated with small decreases in mean calorie and nutrient content of fast food meals 2 years after franchise labeling and nearly 1 year after implementation of labeling nationwide. These changes imply that calorie labeling was associated with small improvements in purchased meal quality in US chain restaurants.

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.

Evaluation of the Accurateness of the Nutritional Labels of Processed and Ultra-Processed Products Available in Supermarkets of Ecuador

Nutrition labeling is a public health tool that allows consumers to choose healthier foods and beverages. For this reason, there are protocols in place to monitor the food environment. The purpose of this study was to evaluate the consistency of nutrition labeling on packages for processed and ultra-processed products (UPPs) found at the main supermarkets in Cuenca, Ecuador. We conducted a descriptive cross-sectional study in which we identified label components on the packages of 1725 foods and beverages—including the nutrition table, statement on sweeteners, ingredient list, and the traffic light (TL) label—and determined the degree of consistency between the indicators reported on the traffic light label and those obtained from the information in the nutrition table. We found that 24% of products had inconsistencies in the traffic light label, and 10.9% of products had inconsistencies in the indicator for sugar specifically. The majority of inconsistencies were in the medium indicators for sugar (K = 0.68) and fat (0.75). The products with a medium indicator for sugar had a 1.98 (p < 0.05, 95% CI 1.15, 3.39) times higher chance of having inconsistencies in comparison with the low indicator. Health authorities must create new guidelines to allow for continued monitoring of the nutrition and traffic light labels on products accessible to consumers.

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

BACKGROUND

Front-of-package labelling is a cost-effective strategy to help consumers make healthier choices and informed food purchases. The effect of labels is mediated by consumer understanding and acceptability of the label. We compared the acceptability and understanding of labels used in Latin-America among low- and middle-income Mexican adults.

METHODS

Participants (n = 2105) were randomly assigned to one of three labels: Mexican Guideline Daily Allowances (GDA), Ecuador's Multiple Traffic Lights (MTL), or Chile's Warning Labels (WL) in red. Label acceptability was evaluated through items regarding likeability, attractiveness and perceived cognitive workload. Objective understanding was evaluated by asking participants to select the product with the lowest nutritional quality among three products. We measured the time participants took to choose the product. Differences in label acceptability, understanding and time required to choose a product across labels were tested.

RESULTS

Compared to the GDA, a higher proportion of participants liked the MTL and WL, considered them attractive, and with a lower perceived cognitive workload (p < 0.05). Participants had 4.00 (2.86-5.59) times the odds of correctly identifying the product with the lowest nutritional quality when using the MTL label and 4.52 (3.24-6.29) times the odds when using the WL, in comparison to the GDA. Time required to choose the product was lower for the MTL (Median: 11.25 s; IQR = 8.00-16.09) and the WL (Median = 11.94 s, IQR = 8.56-16.52) compared to the GDA (Median: 15.31 s; IQR = 10.81-20.21; p < 0.05). No differences were observed between the MTL and the WL.

CONCLUSIONS

GDA had the lowest acceptability and understanding among the labels tested. The MTL and the WL were more accepted and understood, and allowed low- and middle-income consumers to make nutrition-quality related decisions more quickly. WL or MTL may foster healthier food choices in the most vulnerable groups in Mexico compared to the current labelling format.