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

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

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

The Potential Effectiveness of Nutrient Declarations and Nutrition and Health Claims for Improving Population Diets

Nutrition labeling supports healthier diets by aiding purchase decisions and stimulating reformulation. This systematic literature review applied Cochrane methods to synthesize and appraise evidence on the effectiveness of nutrient declarations and nutrition and health claims on diet-related outcomes. The search spanned 11 academic databases, from inception to July 2022. Evidence was synthesized using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) and vote counting. Data were available from 170 studies. Randomized controlled trials (RCTs) suggest that nutrient declarations likely improved consumer understanding of the nutritional quality/content of foods (moderate certainty) and may have improved the healthfulness of choices (low certainty) versus no label. RCT evidence also suggests that claims likely increased consumer perceptions of food healthfulness and increased choice and purchases of labeled foods (both moderate certainty), irrespective of nutritional quality. To improve label understanding and avoid misinterpretation, nutrient declarations may incorporate interpretive elements and claims can apply disqualifying conditions for their usage, on the basis of overall nutritional quality.

Establishing an EU-wide front-of-pack nutrition label: Review of options and model-based evaluation

This paper reviews the effectiveness of four types of front-of-pack nutrition labels (FoPLs) in influencing calorie purchases. The four FoPL types are poised for unified implementation across European countries. Further, this study extends its analysis to evaluate the impacts of the voluntary adoption of these FoPLs within 27 EU nations. Nutri-Score displays higher potential for yielding positive health and economic outcomes, compared with other FoPLs. Across EU countries, Nutri-Score is projected to avert nearly two million cases of non-communicable diseases, in total, between 2023 and 2050. Keyhole demonstrates effects of a similar magnitude but with no statistical significance. Nutri-Repere shows smaller impacts, while Nutri-Couleurs has non-significant effects. Nutri-Score is projected to significantly lower annual healthcare spending by 0.05%, whereas the other labels have negligible impacts. By reducing cases of disease, FoPLs have the potential to improve employment and work productivity. Nutri-Score surpasses the other labels with an estimated annual gain of 10.6 full-time equivalent workers per 100,000 individuals of working age across EU countries. In all, mandatory implementation of any of the four labels would lead to greater effects than those obtained with a voluntary implementation, providing evidence to inform legislation proposal for an EU-wide nutrition labelling system.

Dietary Knowledge and Eating Habits among Patients with Type 2 Diabetes in Lebanon

Little is known about the dietary knowledge (DK) and eating habits (EHs) of patients with type 2 diabetes (T2D) in Lebanon. Therefore, the aim of this study was to assess the DK and EH of the population with T2D and determine their associated factors. A cross-sectional survey enrolling 351 patients with T2D was carried out, using the snowball sampling technique. The survey used the UK Diabetes and Diet Questionnaire and the Dietary Knowledge questionnaire to assess participants' EH including the frequency of consumption of certain foods and their knowledge of food groups and food choices. While a higher DK index indicated better knowledge, a higher EH index indicated less healthy EH. Independent sample T-test and Mann-Whitney test were used for dichotomous variables, and ANOVA and Kruskal-Wallis tests were used for polytomous variables. Correlation analysis tested the association between two continuous variables. Two multiple linear regression models were used to identify factors associated with DK and EH. Overall, 67% of participants had good or adequate DK, and around 25% and 75% of them had healthy and less healthy EH, respectively. Better knowledge was significantly related to occupation, BMI, presence of comorbidities, and HbA1c testing during the last 3 months. Higher family income, physical activity, family history of diabetes, receiving help in medication administration from family or friends, and higher DK level were factors associated with healthier EH. Nutrition education and awareness campaigns aimed at patients and their families are needed to empower patients with adequate DK and skills to facilitate the adoption of healthy EH.

The estimated dietary and health impact of implementing the recently approved 'high in' front-of-package nutrition symbol in Canada: a food substitution scenario modeling study

Background

Front-of-pack labeling (FOPL) has been identified as a cost-effective policy to promote healthy food environments and to help consumers make healthier food choices. Consumer surveys report that after implementation of mandatory 'high in' FOPL symbols between 30 and 70% of consumers choose or were willing to choose products with fewer 'high in' symbols. Health Canada has recently published FOPL regulations that will require prepackaged food and beverages that meet or exceed thresholds for sodium, total sugars, or saturated fat to display a 'high in' FOPL nutrition symbol.

Objectives

The aims were to estimate the potential (1) dietary impact of substituting foods with similar foods that would display at least one less 'high in' symbol, and (2) the number of diet-related noncommunicable disease (NCD) deaths that could be averted or delayed due to estimated dietary changes.

Methods

Baseline and counterfactual intakes of sodium, total sugars, saturated fats, and energy were estimated among Canadian adults (n = 11,992) using both available days of 24 h-recall data from the 2015 Canadian Community Health Survey-Nutrition (CCHS). Similar foods to those reported in CCHS that would display at least one less 'high in' symbol (n = 239) were identified using a Canadian branded food composition database. Based on current FOPL consumer research, identified foods were substituted for 30, 50, and 70% of randomly selected CCHS-Nutrition adult participants and for all adult participants. Potential health impacts were estimated using the Preventable Risk Integrated ModEl.

Results

Mean dietary reductions of between 73 and 259 mg/day of sodium, 2.0 and 6.9 g/day of total sugars, 0.2 and 0.5 g/day of saturated fats, and 14 and 46 kcal/day of energy were estimated. Between 2,148 (95% UI 1,913-2,386) and 7,047 (95% UI 6,249-7,886) of deaths due to diet-related NCDs, primarily from cardiovascular diseases (70%), could potentially be averted or delayed if Canadians choose products with fewer 'high in' symbols.

Conclusion

Results suggest that FOPL could significantly reduce sodium and total sugar intakes among Canadian adults, the consequences of which could avert or delay an important number of diet-related NCD deaths. These findings provide relevant data to support the importance of the impending FOPL regulations.

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.

Exploring the effects of added sugar labels on food purchasing behaviour in Australian parents: An online randomised controlled trial

Background

Evidence of the effects of front-of-pack added sugar labelling remains limited, especially for foods other than sugary drinks. More information is needed about which labels are likely to be most effective in reducing intended purchases of products with higher added sugar content in realistic contexts to inform policymakers’ decisions.

Objective

To determine the impact of added sugar labels on intended purchases of high sugar breakfast cereals, yoghurt, and non-alcoholic beverages.

Methods

Australian parents who were regular purchasers of relevant product categories completed an online parallel randomised controlled trial from 31 August 2020 to 13 February 2021. Participants selected their intended purchase from 10 products in each of packaged beverages, breakfast cereal, and yoghurt categories after randomisation to one of seven added sugar labelling conditions in current use or under consideration by the Australian Government. Logistic regressions assessed differences between intervention and control conditions in the odds of intended purchases of a high sugar product.

Results

2825 eligible participants were randomised with 2582 valid surveys analysed (Control n = 367; ‘Nutrition Information Panel (NIP) with Added Sugar’ n = 364; ‘Teaspoons of Sugar’ n = 369; ‘Warning’ n = 371; ‘Health Star Rating (HSR) using Total Sugar’ n = 368; ‘HSR with Added Sugar’ n = 371; ‘Sugar in the Ingredients List’ n = 372). No consistent effects were found on intended purchases of high sugar products overall or within product categories for any of the tested labels compared to controls (overall, ‘NIP with Added Sugar’: OR 1.00 [95%CI 0.83,1.20]; ‘Teaspoons of Sugar’: 0.94[0.80,1.11]; ‘Warning’: 1.10[0.93,1.30]; ‘HSR with Total Sugar’: 1.01[0.85,1.21]; ‘HSR with Added Sugar’: 1.09[0.92,1.30]; ‘Sugar in the Ingredients List’: 1.01[0.85,1.21]).

Conclusions

Findings reinforce the importance of ensuring nutrition labelling policies are introduced as part of a suite of interventions to influence both consumer and manufacturer behaviour.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12620000858998. Registered 28 August 2020, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000858998.

Evaluation of the Ability of Nutri-Score to Discriminate the Nutritional Quality of Prepacked Foods Using a Sale-Weighting Approach

The implementation of mandatory front-of-pack nutrition labelling is currently being discussed in the European Union (EU). The Nutri-Score (NS) was developed in France to empower consumers to make informed and healthier food choices. Based on strong evidence of its efficacy in supporting healthy choices, it has already been implemented for voluntary use in some EU member states, making it relevant to developing a harmonised EU scheme. This study aimed to evaluate the NS’s discriminating ability on products available in the food supply and compare it with Slovenian national nutritional recommendations based on an adapted WHO Europe (WHOE) profile. The innovative approach of the study is that we used sale-weighting to address the public health importance of available foods, with consideration of market share. We profiled 15,822 products available in the Slovenian food supply in 2017. The NS had a high ability to discriminate food products based on nutritional composition. Products that are generally encouraged in dietary recommendations (fruits, vegetables, cereals) had, in most cases, better NS grades than less favourable products (confectionery, snack foods, added fats), which is also in line with the national nutrition policy programme. The discriminating ability of the model was also shown within food (sub)categories (e.g., plain and flavoured yoghurt). Sale-weighting showed that offerings do not always reflect sales. Major differences between offerings and sales were observed for beverages, dairy, fruits/vegetables, and edible oils/emulsions. Additionally, sale-weighted distribution tended towards less favourable nutritional composition, particularly in categories with overall smaller offerings of products with favourable composition. The NS showed moderate agreement with the WHOE profile (κ = 0.57); differences were particularly observed in flavoured yoghurts, juices, cooking oils, and cheeses. Modelling the operation of the NS with representative real-life food samples provided insight valuable for developing and implementing harmonised mandatory front-of-pack nutrition labelling in Europe.