Reds are more important than greens: how UK supermarket shoppers use the different information on a traffic light nutrition label in a choice experiment

Can Environmental Traffic Light Warning Labels Reduce Meat Meal Selection? A Randomised Experimental Study with UK Meat Consumers

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

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

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

The neural model of front-of-package label processing

Front-of-package (FOP) labels have been adopted in many countries to battle the obesity pandemic and its serious health consequences by providing clearer and easier-to-understand nutrition and health information. The effectiveness of FOP labels has been generally confirmed, with some contextual and individual factors modifying their effectiveness. Existing theories (eg, the dual-process theory) and shifting priorities for self-control, provide some explanations for the FOP label effect. However, the cognitive and neural mechanisms underlying the processing of FOP labels remain unknown. Here, a new model, namely, the neural model of FOP label processing, has been proposed to fill this gap by providing an integrated account of FOP label processing while simultaneously considering multiple important situational and individual factors in the same framework. This neural model is built on the core eating network (ie, the ventral reward pathway and the dorsal control pathway) for food cue processing and actual food consumption. The new model explains how FOP labels may facilitate attention, influence the core eating network, and thus alter food choices. It also demonstrates how motivation may modify FOP label processing in 2 ways: affecting attention (the indirect way) and changing the process of evaluating the food (the direct way). It further explains how some contextual and individual factors (eg, ego depletion, time pressure, and health knowledge) influence the process. Thus, the neural model integrates evidence from behavioral, eye-tracking, and neuroimaging studies into a single, integrated account, deepening understanding of the cognitive and neural mechanisms of FOP label processing. This model might facilitate consensus on the most successful FOP label. Moreover, it could provide insights for consumers, food industries, and policy makers and encourage healthy eating behaviors.

Product promotions in online supermarkets: prevalence of 'High Fat Sugar Salt' (HFSS) products and labelling characteristics

OBJECTIVE

To evaluate the prevalence of 'High Fat Sugar Salt' (HFSS) products and front-of-pack nutrition labelling (FOPNL) characteristics across promoted products in UK online supermarkets.

DESIGN

A cross-sectional survey conducted (December 2021-January 2022) on promoted products. Data on ingredients, nutritional composition and display of FOPNL were collected from product webpages. The UK's Nutrient Profiling Model and Multiple Traffic Light criteria were used to determine HFSS status and possession of inherent red traffic lights (iRTL), respectively. Data analysis determined the prevalence (i.e. percentage of products of the total number of products sampled) of HFSS; FOPNL and possession of iRTL. Chi-squared tests explored associations between these.

SETTING

Three major UK online supermarket retailer websites.

PARTICIPANTS

Product 'multibuy' and 'entrance' promotions, from selected product categories.

RESULTS

Among the sampled 625 promoted products, the prevalence of HFSS was greater in entrance (73 %) compared with multibuy (41 %) promotions (χ2 (1) = 34, P < 0·05), with variations in the former across retailers (49-92 %). The prevalence of HFSS products in multibuy promotions offered by two retailers varied by category (i.e. Confectionery 94-97 %, Yogurts 20-20 %, Soft Drinks 16-33 %, Ready Meals 1·4-18 %). Not all promoted products displayed FOPNL on webpages (70 %) or images (52 %). A number of iRTL were found to be possessed by both HFSS and non-HFSS-promoted products.

CONCLUSIONS

Prior to the 2022 implementation of Regulations restricting these, HFSS products were promoted in online supermarkets with varying display of FOPNL and possession of iRTL. Findings support future policy evaluation and mandatory digital FOPNL.

Promoting and disseminating consistent and effective nutrition messages: challenges and opportunities

Nutrition messages are a central part of policy making as well as communication via product information, advertising, healthcare advice and lifestyle campaigns. However, with amplified information (and misinformation) from a growing number of sources, inconsistent and conflicting food landscapes, and limited engagement from the public, nutrition messaging tensions have become more accentuated than previously. In this review, we focus on the challenges facing those wishing to effect dietary change through communication; and identify opportunities and future research questions. Beginning with a new working definition and taxonomy for the term ‘nutrition message’, we consider the evolution of public health nutrition messages from the past century and discuss which types of messages may be more effective. We then turn to the challenges of implementation and highlight specific barriers to recipients' understanding and change. While the evidence has many gaps and there is a need for systematic evaluation of nutrition messages, research indicates that recipients are more likely to act on fewer messages that provide clear benefits and which resonate with their perceived health needs, and which are relatively straightforward to implement. Effectiveness may be improved through consideration of how nutrition messages can be designed to complement key non-health drivers of food choice (taste, cost) and societal/cultural norms. Consistency can be achieved by aligning the wider food and messaging environment to desired public health actions; that is by ensuring that retail settings provide and signpost healthier choices, and that mass media nutrition messages work with, not against, public health advice.

A food bank program to help food pantries improve healthy food choices: mixed methods evaluation of The Greater Boston Food Bank's Healthy Pantry Program

BACKGROUND

The Greater Boston Food Bank's (GBFB) Healthy Pantry Program (HPP) is an online training that teaches food pantry staff to implement behavioral nudges (e.g., traffic-light nutrition labels, choice architecture) to promote healthier client choices. This study assessed if HPP was associated with healthier food bank orders by food pantries and identified implementation facilitators and barriers.

METHODS

This mixed methods study collected quantitative data from a matched cohort of 10 HPP food pantries and 99 matched control food pantries in eastern Massachusetts that allow clients to choose their own food, and qualitative data from structured individual interviews with 8 HPP pantry staff. A difference-in-differences analysis compared changes in percentage of pantries' food bank orders (by weight) of foods labeled green/yellow (healthier choices) and fresh produce from baseline to 6 and 10 months between HPP and control pantries. Interviews were coded for implementation facilitators and barriers.

RESULTS

Before starting HPP, green-yellow ordering was 92.0% (SD 4.9) in control and 87.4% (SD 5.4) in HPP pantries. Participation in HPP was not associated with changes in green-yellow or fresh produce ordering at 6 or 10 months. HPP implementation facilitators included HPP training being accessible (sub-themes: customizable, motivating) and compatible with client-choice values. Barriers included resource limitations (sub-themes: staff shortage, limited space) and concerns about stigmatizing client food choices with use of labels for unhealthy foods.

CONCLUSIONS

An online program to help pantries promote healthier client choices was not associated with changes in how much healthy food pantries ordered from the food bank, suggesting it did not substantially change client choices. Implementation challenges and high baseline healthy ordering may have influenced HPP's effectiveness.

Public understanding of sustainable diets and changes towards sustainability: A qualitative study in a UK population sample

Dietary consumption contributes significantly to the environmental impacts of daily life. Changes to consumption are required, but limited work investigates the reasoning underlying relevant dietary choices. This study aimed to explore public understanding of sustainable diets and any willingness or attempts to make changes towards sustainability in a sample of the UK population. A qualitative approach was used. Twenty-one participants (10 males; predominantly young adults; with a range of living circumstances and cooking responsibilities) were interviewed. Interviews were analysed using inductive thematic analysis. Four themes were identified that related to understanding sustainable diets: 'Consistent with the definition by the Food and Agriculture Organisation of the United Nations (FAO)', 'Multiple benefits', 'Unsure' and 'Competing Interests'. Four themes related to making changes: 'Willing, but unsure', 'Small easy changes', 'Enablers' and 'Barriers'. An additional theme 'COVID-19 pandemic' reflected the period when the work was done (February-May 2021). Within these themes, participants were able to define sustainable eating in a manner that was consistent with and incorporated aspects of the definition by the FAO, could identify sustainable actions that they were undertaking or could undertake, and considered these to be beneficial, but there was a lot of uncertainty, and alternative or competing definitions and actions were also given. Participants were also willing to make changes to make their diet more sustainable, and preferences were expressed for small easy changes of high impact, but there was again considerable uncertainty as to what changes to make. Caution due to the small and select sample is required, but suggestions from this work include increasing awareness and knowledge of the environmental impacts of dietary choices, focusing on small easy changes of likely impact and personal benefit, and increasing availability and accessibility to sustainable diets.

The influence of front-of-pack nutritional labels on eating and purchasing behaviors: a narrative review of the literature

BACKGROUND

Front-of-Pack Nutritional Labels are considered a useful tool to help consumers orient themselves in their food choices and direct their behavior toward a healthier diet. FOPNL development and use are part of a framework that includes cognitive, biological, hedonic and cultural aspects, able to affect consumers' eating and purchasing behavior.

AIM

Given the complexity of the matter, the aim of this narrative review is to analyze the combination of different factors that drive food choices and eating behaviors and to highlight some aspects that are not fully studied.

METHODS

The authors conducted the research using a top-down approach at first, followed by a bottom-up approach; starting with general considerations about the purchasing process, gradually narrowing the discussion to a specific sub-population, and finally extending the discussion back to more general reasonings about the direction to adopt in future, or at least to evaluate, for effective communication.

RESULTS

Biases and attitudes toward food products were found to regularly interfere with buying behavior patterns, making it impossible to standardize an average consumer. This reflects in current research, increasing the complexity of the topic. All determinants influencing food choices are often assessed individually rather than in a synergistic and multidimensional context, while the purchasing scenario is characterized by multiple stimuli to which the consumer is subjected. FOPNLs' impact on perceived healthiness has been studied in different conditions, but some population subgroups have not been sufficiently represented. In particular, the effect of FOPNLs on consumers suffering from eating disorders is understudied and needs further attention. Furthermore, some approaches can be compared to "negative nutrition" or "loss-framed communication", putting nutrients out of context, emphasizing losses more than gains and risking promoting negative feelings in consumers.

CONCLUSION

Due to the heterogeneity of studies, evidence on what works best in driving people to adopt lasting lifestyle changes is still mixed. Science communicators and policymakers should consider the possibility that a multi-component approach incorporating nutrition information and education may be a key strategy to promote consumers' self-consciousness and to support them in their cognitive efforts toward a healthy and sustainable diet.

LEVEL OF EVIDENCE

Level V, narrative review.

The Impact of Nutrition Labelling on Customer Buying Intention and Behaviours in Fast Food Operations: Some Implications for Public Health

This research examines customers’ intention to buy depending on their use of nutrition labelling (NL) in fast food operations (FFOs) and their intention to visit and recommend these FFOs with nutrition-labelled menus. The research model draws on the theory of planned behaviour (TPB) to examine customers’ intentions to buy from nutrition-labelled menus and their behaviour of visiting and recommending to others FFOs with nutrition-labelled menus. To achieve this purpose, a self-administrated questionnaire was distributed to and collected from a random sample of customers at FFOs in Greater Cairo, Egypt, i.e., McDonald’s and Subway. The results from the structural equation modelling (SEM) using AMOS software indicated positive and direct significant paths from the constructs of the TPB, except for customers’ attitude, to customer intention to buy nutrition-labelled menu items. The results also showed a positive significant impact of customers’ intention on their behaviour of visiting and recommending FFOs featuring nutrition-labelled menus. The findings showed that there is an awaking of nutritional awareness among fast-food customers and that providing nutritional information on fast-food menus will affect their purchasing intention in the future by encouraging them to make healthy food choices. Theoretical implications for scholars and managerial implications for FFOs, especially in relation to public health in general and healthy food choices in particular, are explained and discussed.

"Part of the Solution": Food Corporation Strategies for Regulatory Capture and Legitimacy

BACKGROUND

For decades, the food industry has sought to deflect criticisms of its products and block public health legislation through a range of offensive and defensive strategies. More recently, food corporations have moved on to present themselves as "part of the solution" to the health problems their products cause. This strategic approach is characterised by appeasement, co-option and partnership, and involves incremental concessions and attempts to partner with health actors. This paper details how corporate practices have evolved and changed over the past two decades and gives some definition to what this new political economy signifies for the wider behaviours of corporations producing and selling harmful commodities.

METHODS

This paper draws on public health and political science literature to classify the food industry's "part of the solution" strategy into three broad components: regulatory responses and capture; relationship building; and market strategies. We detail the key characteristics and consequences of each component.

RESULTS

The three components of the food industry's "part of the solution" strategy all involve elements of appeasement and co-option. They also improve the political environment and resources of the food industry. Regulatory responses offer incremental concessions that seek to maintain corporate influence over governance processes and minimise the threat of regulations; relationship building fosters access to health and government stakeholders, and opportunities to acquire and maintain channels of direct influence; and market strategies to make products and portfolios healthier bolster the market share and revenue of food corporations while improving their public image.

CONCLUSION

Rather being a signal of lost position and power, the food industry's repositioning as "part of the solution" has created a highly profitable political economy of 'healthy' food production, alongside continued production of unhealthy commodities, a strategy in which it is also less burdensome and conflictual for corporations to exercise political power and influence.

Nutri-Score and Nutrition Facts Panel through the Eyes of the Consumer: Correct Healthfulness Estimations Depend on Transparent Labels, Fixation Duration, and Product Equivocality

Research on front-of-pack labels (FOPLs) demonstrated that Nutri-Score is one of the most promising FOPLs regarding healthfulness estimation accuracy. Nevertheless, as consumers are exposed to both the Nutri-Score and the mandatory Nutrition Facts Panel (NFP) in the supermarket, it is key to understand if and how both labels interact. This study investigates the contribution of Nutri-Score and NFP regarding healthfulness estimation accuracy, whether this impact differs depending on the product, and what role visual attention plays. We set up an eye-tracking experiment in a controlled setting in which 398 participants rated the healthfulness of 20 products. The results confirmed the positive impact of the Nutri-Score on healthfulness estimation accuracy, though the impact was larger for equivocal (i.e., difficult to judge) products. Interestingly, NFP either had no effect (compared to a package without Nutri-Score or NFP) or a negative effect (compared to a package with Nutri-Score alone) on healthfulness estimation accuracy. Eye-tracking data corroborated that ‘cognitive overload’ issues could explain why consumers exposed to Nutri-Score alone outperformed those exposed to both Nutri-Score and NFP. This study offers food for thought for policymakers and the industry seeking to maximize the potential of the Nutri-Score.

Saudi Arabia's Healthy Food Strategy: Progress & Hurdles in the 2030 Road

The Kingdom of Saudi Arabia (KSA) is a leading country worldwide in the prevalence of non-communicable diseases (NCDs), which alone can explain 73% of mortality in the country. In response to the heavy burden of NCDs, the Saudi Food and Drug Authority (SFDA), in collaboration with other government entities, developed a healthy food strategy (HFS) aimed at enhancing healthy lifestyles and reducing the intake of salt, sugar, saturated fatty acids (SSF) and trans fatty acids (TFA). The objectives of the HFS, to facilitate consumers' identification of SSF and reduce the SSF and TFA content in food items, were addressed in collaboration with key stakeholders in the public and private sectors of the food industry. These reforms included voluntary and mandatory schemes to display nutrition information in food and beverage establishments, display allergens on food menus, encourage the adoption of front of pack nutrient labels (FoPNLs) on food products, ban the use of partially hydrogenated oils and establish limits for sodium composition in breads and selected food products. This manuscript contextualizes the HFS and presents the results of monitoring initiatives undertaken by the SFDA to assess compliance with these reforms.

Consumers' perception of nutritional facts table and nutritional traffic light in food products' labelling: A qualitative study

BACKGROUND AND OBJECTIVE

Traffic light labelling (TLL) policy has been adopted to improve consumers' food choices. This qualitative study examined the consumers' perception of TLL and nutritional facts table (NFT) in Iran.

DESIGN

We applied a qualitative method to explore public views and perceptions of NFT and TLL in Iran. Participants ageing 20-75 years old were selected by maximum diversity sampling and interviewed using a semi-structured in-depth interview. The interviews were continued until data saturation was achieved after interviewing 35 participants with five more interviews to ensure no new emerging perception. Data was analysed by directed content analysis in MAXQDA 10 software.

FINDINGS

Findings indicated that a large number of the participants were not aware of NFT and TLL. There are some reasons for not paying attention to NFT and TLL, which include lack of enough knowledge about NFT and TLL concepts and defects in appearance and details written in these labels, lack of appropriate education about labels, place of putting the labels and lack of enough time for using the labels during shopping.

CONCLUSIONS

It is concluded that educational interventions should be applied to ensure their effectiveness in improving healthy food choices.

Assessing Consumer Preferences for Suboptimal Food: Application of a Choice Experiment in Citrus Fruit Retail

Amid the trend of sustainable development, reducing food waste is a global concern and campaigns to reduce food waste have been launched. For example, the term “food sharing” has originated from Germany and promotes sharing food instead of wasting. “The Guerilla Kitchen”, which originated from Netherlands, is an organization that also promotes avoiding wasting food. Consequently, more and more people are paying attention on this issue and we think it is necessary to understand people’s acceptance of suboptimal food, as discarded suboptimal food represents a significant proportion of food waste. Additionally, at least one-third of the food globally produced each year is classified as suboptimal and cannot be sold in the market because of a poor appearance, damaged packaging, or near expiration date, thus presenting challenges for environmental, social, and economic sustainability. Previous studies on suboptimal food have focused more on appearances and packaging dates and less on investigating traceable agricultural and price discounts, which is where food classified as suboptimal entails a discount. Moreover, citrus product attributes such as appearance, size, freshness indicators, traceable agricultural products, and price discounts were determined in terms of consumer preference through pre-measurement here, then using a choice experiment method to clarify which attributes consumers care about most (N = 485 respondents). Conditional logistic regression and a random parameter logit model (RPL) are employed to examine the various properties of a marginal willingness to pay (WTP). RPL was also used to deduce the respondents’ choices based on differences in appearance and freshness indicator. The results showed that consumers place greater emphasis on the freshness indicators (harvesting/packaging date labels) and appearance of suboptimal citrus fruits but do not focus on the size. Consumers are willing to purchase citrus fruit with a flawed appearance, although the price needs to be reduced from the original price. Although suboptimal food does not reduce health, people may still not buy it and this result in food wastage. As a result, it is essential to increase awareness regarding suboptimal foods and reduce food waste to support sustainable development.

Analysing Credibility of UK Social Media Influencers' Weight-Management Blogs: A Pilot Study

Social media influencers (SMI) are individuals with large follower engagement, who can shape the thoughts and dietary behaviours of their audience. Concerns exist surrounding the spread of dietary misinformation by SMI, which may impact negatively on public health, yet no standards currently exist to assess the credibility of their information. This study aimed to evaluate the credibility of key SMI weight management (WM) blogs (n = 9), piloting a pre-prepared credibility checklist. SMI were included if they had a blue-tick verification on ≥2 social media (SM) and an active WM blog. A sample of blog posts were systematically evaluated against thirteen credibility indicators under four themes: ‘transparency’, ‘use of other resources’, ‘trustworthiness and adherence to nutritional criteria’ and ‘bias’. Indicators were yes/no questions to determine an overall credibility percentage for each SMI. The ten most recent meal recipes from each blog were evaluated against Public Health England’s (PHE) calorie targets and the UK ‘traffic light’ food labelling scheme to assess nutritional quality. Percentages ranged from 23–85%, the highest gained by a Registered Nutritionist. SMI blogs may not be credible as WM resources. Given the popularity and impact of SM in the context of overweight, obesity and WM, this study may inform the methodological approach for future research.

Breakfast on the go: Evaluating the nutritional content of supermarket products

OBJECTIVES

Breakfast consumption on the go is becoming an established food habit; this has been accompanied by a growing number of related products. Given the limited research on these products and the growing trend in breakfast consumption away from home and on the go, the aim of this cross-sectional study was to survey and scrutinize the nutritional composition of breakfast on-the-go products available in the UK.

METHODS

Field visits to supermarkets of the top seven grocery retailers (accounting for 88% of the UK market) were conducted in a large city in the UK. Breakfast on-the-go products (n = 128) were identified, and data (including price, energy, and nutrients) were collected. Products were categorized according to food format (i.e., breakfast biscuits, breakfast drinks, high-protein breakfast drinks, and porridge pots). Products were profiled according to front-of-pack nutrition labeling (i.e., low, medium, high) for fat, saturated fat, total sugars, and salt content. Nutrient content and profiles were examined across categories.

RESULTS

Significant associations were revealed between product type and nutrient profiles for total fat, saturated fat, and salt. Total sugar content varied from 11.8 g per portion observed in biscuits to high-protein breakfast drinks, which contained almost double this level (20.0 g). Notably, six of ten breakfast on-the-go items (60.2%) were profiled as high for total sugars (according to front-of-pack criteria). Most items were medium in total fat (87.5%), low in saturated fat (61.7%), and low in salt (56.3%).

CONCLUSIONS

Reformulation of breakfast on-the-go products, principally with respect to sugar content, is warranted. This is particularly relevant given the growing role of breakfast consumption on the go and ongoing developments in the sector as new product ranges and formats are introduced.

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.

Nutrition labels' strengths & weaknesses and strategies for improving their use in Iran: A qualitative study

BACKGROUND

This study aimed to explain the strengths and weaknesses of the Traffic light label (TLL) and nutrition facts label (NFL) and the strategies for improving their use in Iran, based on the perspectives of different stakeholders, including mothers, food quality control experts (FQC), nutritionists and food industry experts.

METHODS

We conducted 10 Focus Group Discussions (FGDs) with 63 mothers, 10 semi-structured interviews with FQCs, 1 FGD with 6 nutritionists and 1 FGD with 8 food industry experts. To clarify some of the questions that arose from the interviews, the researcher interviewed three policy makers who had sufficient information about the TLL. The discussions and interviews were transcribed verbatim and MAXQDA10 software was used for coding.

RESULTS

The most important findings of this study based on different stakeholders' perspectives were as follows: mothers believed that nutrition labels reduced the consumption of high-calorie products, although they found the TLL to be easier to understand than the NFL because of its red color. However, their weaknesses were their incompatibility with culture and the lack of trust in the information provided by manufacturers. FQCs pointed out the possibility of changing formulations and the appropriateness of the traffic light for patients, but like mothers, they believed that the labels did not suit the governing culture. Further weaknesses were, misleading the consumer, problems in the colorings reported by different laboratories, and different approaches adopted by regulatory experts. The simplicity of understanding TLL for the general public has been suggested by some nutritionists. Nevertheless, the multiplicity of colors of the TLL was the most important weakness presented by nutritionists and food industry experts and the failure to implement nutrition labels was another issue raised by experts. To improve the use of nutrition labels, notification via media especially television, community education and culture building were suggested by all stakeholders.

CONCLUSIONS

The findings of this study underscore the importance of implementing the policy of nutrition labeling in Iran. Mothers and nutritionists believed TLL to be more appropriate for the public to understand, however, FQCs and food industry experts believed that NFL was more suitable in guiding consumers toward healthy food choices. Education and information dissemination via media on interpretive TLL may affect consumer behavior toward food purchases.

The efficacy of 'high in' warning labels, health star and traffic light front-of-package labelling: an online randomised control trial

OBJECTIVE

To examine the impact of front-of-package (FOP) labels on perceived healthfulness, purchasing intentions and understanding of common FOP systems.

DESIGN

A parallel, open-label design randomised participants to different FOP labelling conditions: 'high in' warning labels (WL), multiple traffic light labelling (TLL), health star ratings (HSR) (all displayed per serving) or control with no interpretive FOP labelling. Participants completed a brief educational session via a smartphone application and two experimental tasks. In Task 1, participants viewed healthy or unhealthy versions of four products and rated healthiness and purchasing intention on a seven-point Likert-type scale. In Task 2, participants ranked three sets of five products from healthiest to least healthy.

SETTING

Online commercial panel.

PARTICIPANTS

Canadian residents ≥ 18 years who were involved in household grocery shopping, owned a smartphone and met minimum screen requirements.

RESULTS

Data from 1997 participants (n 500/condition) were analysed. Task 1: across most product categories, the TLL and HSR increased perceived healthiness of healthier products. All FOP systems decreased perceived healthiness of less healthy products. Similar, albeit dampened, effects were seen regarding purchasing intentions. Task 2: participants performed best in the HSR, followed by the TLL, WL and control conditions. Lower health literacy was associated with higher perceived healthiness and purchasing intentions and poorer ranking task performance across all conditions.

CONCLUSIONS

All FOP labelling systems, after a brief educational session, improved task performance across a wide spectrum of foods. This effect differed depending on the nutritional quality of the products and the information communicated on labels.Trial Registration: NCT03290118.

Consumers' food choices, understanding and perceptions in response to different front-of-pack nutrition labelling systems in Belgium: results from an online experimental study

Background

Front-of-pack nutrition labels (FoPLs) are increasingly implemented by governments internationally to support consumers to make healthier food choices. Although the Nutri-Score FOPL has officially been implemented in Belgium since April 2019, no study has been conducted before its implementation to compare the effectiveness of different FOPLs.

Methods

The aim of this study was to compare food choices, objective understanding and perceptions of Belgian consumers in response to five different FOPLs, currently implemented in different countries internationally, namely the Health Star Ratings (HSR), the Multiple Traffic Lights (MTL), Nutri-Score, Guideline Daily Amounts (GDA), and Warning symbols. During the summer 2019, 1007 Belgian consumers were recruited and randomized to one of the five different FOPLs. Through an online questionnaire they were asked to choose one of three different foods within each of three categories (pizzas, cakes, breakfast cereals), as well as rank those same three foods according to nutritional quality, in the condition without as well as with FOPL. In addition, various questions were asked on their perceptions in relation to the FOPL they were exposed to.

Results

Perceptions of consumers were favorable for all FOPLs with no significant differences between the different FOPLs. There were no significant differences in food choices among the different FOPLs, but Nutri-Score performed best for ranking food products according to nutritional quality.

Conclusions

While there were no significant differences among different FOPLs for food choices and perceptions, the Nutri-Score was the most effective FOPL in informing Belgian consumers of the nutritional quality of food products.

Compared to other front-of-pack nutrition labels, the Nutri-Score emerged as the most efficient to inform Swiss consumers on the nutritional quality of food products

Background

Switzerland, like other high-income countries, is facing a major public health challenge with the increasing burden of non-communicable diseases. Discussions are currently on-going in Switzerland regarding the implementation of a Front-of-Pack nutrition label (FoPL) as a public health measure to guide consumers towards healthier food choices, and the Nutri-Score represents an alternative supported by multiple actors. To date, no studies have investigated the performance of the Nutri-Score among Swiss consumers. This study aimed to compare the response of Swiss consumers to five FoPLs (Health Star Rating system, Multiple Traffic Lights, Nutri-Score, Reference Intakes and Warning symbol) in terms of perception and understanding of these labels and effects on food choices.

Methods

In 2019, 1,088 Swiss consumers were recruited and asked to select one product from among a set of three foods with different nutritional profiles and then classify the products within the sets according to their nutritional quality. Tasks were performed in situations without a label and then with one of the five FoPLs–depending on the group in which they were randomized–on the pack. Finally, participants were questioned on their perceptions regarding the label to which they were exposed.

Results

All FoPLs were favorably perceived, with marginal differences between FoPLs. The Nutri-Score demonstrated the highest percentage of improvement in food choices and the highest overall performance in helping consumers rank the products according to their nutritional quality.

Conclusion

Overall, the Nutri-Score was the most efficient FoPL in informing Swiss consumers of the nutritional quality of food products, and as such could be a useful tool to improve food choices and reduce the burden of chronic diseases in Switzerland.

Perceived healthiness of food items and the traffic light front of pack nutrition labelling: choice-based conjoint analysis and cross-sectional survey

BACKGROUND

Although traffic light labelling (TLL) is designed to aid the selection of healthier choices, consumers often have to make trade-offs between (un)desirable attributes. With the current emphasis of public health on sugar reduction, the present study aimed to investigate the relative influence of sugar on the perceived healthiness of products.

METHODS

A choice-based conjoint analysis (CBC) survey was designed to assess the relative importance of the macronutrients commonly used in TLL, as well as the rescaled utilities of three attribute levels (red, amber and green), which involved 858 participants aged ≥18 years, who were recruited from the general population of Nottingham. An additional cross-sectional online survey was completed by another 901 participants to assess public knowledge about the intake recommendations underpinning the TLL.

RESULTS

Usable data for CBC analysis showed that, when deciding upon the healthiness of items, sugar was significantly the most important macronutrient (mean 0.34, 95% confidence interval = 0.32-0.35) among the 641 participants. Red labelling was significantly more influential than green across macronutrients. In the substudy, 13.3% of participants correctly identify the maximum recommended intake of free sugars. Moreover, 42.8% of the total sample could not identify whether the sugar information on TLL refers to the total or free sugar content.

CONCLUSIONS

Despite a lack of knowledge about the recommendations underpinning the TLL criteria, decisions made by participants concerning the healthfulness of food products were significantly influenced by sugar content. TLL appears to guide consumer beliefs in the absence of deep knowledge. The dominance of sugar in decision making is unsurprising in the current public health climate.

A randomized controlled trial examining consumers' perceptions and opinions on using different versions of a FoodFlip© smartphone application for delivery of nutrition information

Background

Food labelling is a common intervention to improve diets, where the back-of-pack Nutrition Information Panel (or Nutrition Facts table (NFt)) provides comprehensive nutrition information on food packages. However, many consumers find it difficult and time-consuming to identify healthier foods using the NFt. As a result, different interpretative nutrition rating systems (INRS) may enable healthier food choices and it is essential that consumers have the tools to allow for easily accessible nutrition information. The objective of this study was to examine consumers’ perceptions of different (INRS) for delivery of nutrition information using different versions of a smartphone app, FoodFlip©.

Methods

This study was part of a larger randomized controlled trial examining consumer perceptions of different INRS on food products. A nationally representative commercial sample of 2008 Canadians were randomized to one of four INRS intervention groups: 1) traffic light, 2) health star rating, 3) ‘high-in’ warning labels or 4) no INRS (NFt only; control) and asked to scan or enter 20 products into FoodFlip© from a list of food products provided to them with varying levels of healthfulness. After completing the app task, participants were asked a series of 7-point Likert-scale and open-ended questions to provide opinions on the usability and functionality of the app.

Results

Of the survey sample of 1997 participants, 95% (n = 1907) completed the app task, with similar number of participants in each treatment group. The mean age was 40 ± 12 years with no differences in sociodemographic characteristics between treatment groups. The health star rating ranked significantly lower in comparison to the other treatment groups in terms of usefulness (OR, 95% CI -0.67, 0.52–0.85), believability (0.59, 0.46–0.75), and understanding (0.55, 0.44–0.71) (p < 0.001). The health star rating (1.20, 0.94–1.53) and control (NFt) (1,1,1) ranked significantly lower than the traffic light or the ‘high-in’ warning labels for their ability to compare the healthfulness of products (p < 0.001).

Conclusion

This study demonstrated Canadian consumers’ preference for a nutrient-specific system (i.e. traffic light or ‘high-in’ warning labels). The app, which was liked by majority of the participants for its functionality and usability, has the potential to support healthy dietary decision making and may also encourage reformulation.

Trial registration

NCT03290118 (Clinicaltrials.gov).

Improving Nutrition Information in the Eastern Mediterranean Region: Implementation of Front-Of-Pack Nutrition Labelling

The provision of simplified nutrition information, in a prominent place on the front of food packages, is recommended as an important element of comprehensive strategies to tackle the burden of death and disease caused by unhealthy diets. There is growing evidence that front-of-pack nutrition labels are preferred by consumers, are more likely to be looked at or noticed than nutrition labelling on the back or side of packages and can help consumers to better identify healthier and less healthy products. This review summarizes current implementation of front-of-pack nutrition labelling policies in the countries of the WHO Eastern Mediterranean Region. Implementation of front-of-pack nutrition labelling in the Eastern Mediterranean Region remains limited, but three types of scheme were identified as having been implemented or at an advanced stage of development by governments in six countries. Through a review of reviews of existing research and evidence from country implementation, the authors suggest some pointers for implementation for other countries in the Region deciding to implement front-of-pack nutrition labelling policies.

Traffic light labelling could prevent mortality from noncommunicable diseases in Canada: A scenario modelling study

Background

Traffic-light labelling (TLL) is a promising front-of-pack system to help consumers make informed dietary choices. It has been shown that adopting TLL in Canada, through an optimistic scenario of avoiding, if possible, foods with red traffic lights, could effectively reduce Canadians’ intakes of energy, total fat, saturated fat, and sodium by 5%, 13%, 14% and 6%, respectively. However, the potential health impact of adopting TLL has not been determined in the North American context.

Objective

This study modelled the potential impact of adopting TLL on mortality from noncommunicable diseases (NCDs) in Canada, due to the previously predicted improved nutrient intakes.

Methods

Investigators used data from adults (n = 19,915) in the 2004 nationally representative Canadian Community Health Survey (CCHS)-Cycle 2.2. Nutrient amounts in foods consumed by CCHS respondents were profiled using the 2013 United Kingdom’s TLL criteria. Whenever possible, foods assigned at least one red light (non-compliant foods) were replaced with similar, but compliant, foods identified from a Canadian brand-specific food database. Respondents’ nutrient intakes were calculated under the original CCHS scenario and the counterfactual TLL scenario, and entered in the Preventable Risk Integrated ModEl (PRIME) to estimate the health impact of adopting TLL. The primary outcome was the number of deaths attributable to diet-related NCDs that could be averted or delayed based on the TLL scenario compared with the baseline scenario.

Results

PRIME estimated that 11,715 deaths (95% CI 10,500–12,865) per year due to diet-related NCDs, among which 72% are specifically related to cardiovascular diseases, could be prevented if Canadians avoided foods labelled with red traffic lights. The reduction in energy intakes would by itself save 10,490 deaths (9,312–11,592; 90%).

Conclusions

This study, although depicting an idealistic scenario, suggests that TLL (if used to avoid red lights when possible) could be an effective population-wide intervention to improve NCD outcomes in Canada.

Choosing or rejecting a food item, does framing matter? And what has sugar to do with it!

The color code of "Traffic Light Labels" (TLL) on food items indicates the amount (e.g., green = low) of fat, saturates, sugar and salt it contains. Consider two ways to select among food items (e.g., two cereal bars) based on their TLLs. You might choose between the two items or you might reject one of the two. Furthermore, differences between choose and reject might be driven more strongly by one factor (e.g., sugar) than by others. In Study 1 our participants made choose or reject decisions between food items with an all-orange TLL (all moderate) and a 2 red/2 green TLL (2 negative/2 positive). Both items had equal energy/caloric content. We found that, independent of the condition (Choose/Reject), participants went home more often with the 2 red/2 green item if sugar was green. This effect was stronger in the Choose than in the Reject condition. In Study 2, we additionally manipulated the energy content (low, high) of the items. In the case where both food items had a low energy content, similar results as in Study 1 were observed. If either or both items had high energy content, the choose/reject interaction with sugar disappeared. Only differences in energy content played a role in the reject condition. Overall, our results can be better explained by an "accentuation hypothesis" than by a "compatibility hypothesis". These findings could be used by choice architects to fight the current obesity crisis.

Consumer beliefs about healthy foods and diets

Background

The U.S. Food and Drug Administration has begun a public process to redefine how companies are allowed to use the term “healthy” on food packages. Although the definition is formulated based on the latest consensus in nutrition and epidemiological research, it is also important to understand how consumers define and understand the term if it is to be behaviorally relevant. This research is an exploratory study designed to provide a descriptive account of consumers’ perceptions of and beliefs about the meaning of “healthy” food.

Methods

A nationwide U.S. sample of 1,290 food consumers was surveyed in December 2018. Respondents answered 15 questions designed to gauge perceptions of healthy food and to elicit preference for policies surrounding healthy food definitions. Responses are weighted to demographically match the population. Categorical variables have a sampling error of ±2.7%. Exploratory factor analysis is used to determine latent dimensions of health perceptions related to food type.

Results

Consumers were about evenly split on whether a food can be deemed healthy based solely on the foods’ nutritional content (52.1% believing as such) or whether there were other factors that affect whether a food is healthy (47.9% believing as such). Consumers were also about evenly split on whether an individual food can be considered healthy (believed by 47.9%) or whether this healthiness is instead a characteristic of one’s overall diet (believed by 52.1%). Ratings of individual food products revealed that “healthy” perceptions are comprised of at least three underlying latent dimensions related to animal origin, preservation, and freshness/processing. Focusing on individual macronutrients, perceived healthiness was generally decreasing in a food’s fat, sodium, and carbohydrate content and increasing in protein content. About 40% of consumers thought a healthy label implied they should increase consumption of the type of food bearing the label and about 15% thought the label meant they could eat all they wanted.

Conclusions

Results suggest consumer’s perceptions of “healthy,” which is primarily based on fat content, partially aligns with the FDA definition but also suggest consumers perceive the word as a broader and more nuanced concept that defies easy, uniform definition. Results highlight areas where nutrition education may be needed and suggest disclosures may need to accompany health claims so that consumers know what, precisely, is being communicated.

UK consumer perceptions of a novel till-receipt 'traffic-light' nutrition system

Front-of-pack (FoP) traffic light nutrition labelling has been widely proposed as a tool to improve public health nutrition. Current evidence suggests that whilst consumers generally find them to be useful and an important source of information about a particular food or ingredient, this may have limited value in isolation when considering a person's overall nutritional intake. This study sought to examine UK consumers' use of existing FoP traffic light food labelling and ascertain public perception of a novel 'till-receipt' summary providing nutritional information about consumers entire shopping purchases. In total, 237 respondents completed an online questionnaire between May and June 2016. Almost two-thirds were female (n = 152, 64.1%) and the largest proportion of responses were received from those aged 25-32 years (n = 53, 22.4%) and 41-50 years (n = 53, 22.4%). About 83.5% of respondents suggested that they currently use traffic light information to inform their food purchases and 'health' was reported as the most important factor influencing food choice (42.2%; n = 100). Notably, 54.4% of respondents indicated that the novel till-receipt system could provide a solution to the potential limitations of existing FoP labelling and could help inform healthier food purchases. Our findings strengthen the existing evidence base to suggest that traffic light information is a useful tool to aid consumer food purchases. Moreover, our outcomes propose that consumers may benefit from a new receipt-based traffic light system which provides a more holistic summary of their entire food purchases.

Nudging to get our food choices on a sustainable track

Food production is one of the major contributors to environmental damage. Adaptations in our food choices are needed to preserve resources for the needs of future generations. More sustainable consumption patterns have been encouraged by economic incentives, laws, education and communication campaigns. Nonetheless, consumers still find difficulties in trying to change their current food habits. This review takes a behavioural approach in encouraging sustainable food choices among consumers. From a nudging perspective, many behavioural changes can be encouraged in a non-obtrusive way by adapting the complex food environment in which consumers are operating. These interventions do not restrict consumers' choices but rather adapt the choice architecture wherein food decisions are made. Drawing on the literature from diverse theoretical perspectives, we provide an overview of the application of nudging for more sustainable food choices and highlight where more research is needed. More specifically, we discuss research that used nudging to engender cognitive impact (i.e. the use of labels or visibility enhancements), affective responses (i.e. sensorial and social influence cues) and behavioural effects (i.e. adjustments in convenience and product size). We conclude that this review only shows the tip of the iceberg of the research on nudging and sustainable consumption that is likely forthcoming in the next few years, following the successes of nudging applications in other domains. Nonetheless, each individual nudging intervention requires careful examination. Personal predispositions towards the environment should be considered when designing interventions, demonstrating the complementarity of nudging with education on sustainable consumption.

Nutrient composition databases in the age of big data: foodDB, a comprehensive, real-time database infrastructure

OBJECTIVES

Traditional methods for creating food composition tables struggle to cope with the large number of products and the rapid pace of change in the food and drink marketplace. This paper introduces foodDB, a big data approach to the analysis of this marketplace, and presents analyses illustrating its research potential.

DESIGN

foodDB has been used to collect data weekly on all foods and drinks available on six major UK supermarket websites since November 2017. As of June 2018, foodDB has 3 193 171 observations of 128 283 distinct food and drink products measured at multiple timepoints.

METHODS

Weekly extraction of nutrition and availability data of products was extracted from the webpages of the supermarket websites. This process was automated with a codebase written in Python.

RESULTS

Analyses using a single weekly timepoint of 97 368 total products in March 2018 identified 2699 ready meals and pizzas, and showed that lower price ready meals had significantly lower levels of fat, saturates, sugar and salt (p<0.001). Longitudinal analyses of 903 pizzas revealed that 10.8% changed their nutritional formulation over 6 months, and 29.9% were either discontinued or new market entries.

CONCLUSIONS

foodDB is a powerful new tool for monitoring the food and drink marketplace, the comprehensive sampling and granularity of collection provides power for revealing analyses of the relationship between nutritional quality and marketing of branded foods, timely observation of product reformulation and other changes to the food marketplace.

A Pilot Randomized Controlled Trial of a Digital Intervention Aimed at Improving Food Purchasing Behavior: The Front-of-Pack Food Labels Impact on Consumer Choice Study

BACKGROUND

Most food in the United Kingdom is purchased in supermarkets, and many of these purchases are routinely tracked through supermarket loyalty card data. Using such data may be an effective way to develop remote public health interventions and to measure objectively their effectiveness at changing food purchasing behavior.

OBJECTIVE

The Front-of-pack food Labels: Impact on Consumer Choice (FLICC) study is a pilot randomized controlled trial of a digital behavior change intervention. This pilot trial aimed to collect data on recruitment and retention rates and to provide estimates of effect sizes for the primary outcome (healthiness of ready meals and pizzas purchased) to inform a larger trial.

METHODS

The intervention consisted of a website where participants could access tailored feedback on previous purchases of ready meals and pizzas, set goals for behavior change, and model and practice the recommended healthy shopping behavior using traffic light labels. The control consisted of Web-based information on traffic light labeling. Participants were recruited via email from a list of loyalty card holders held by the participating supermarket. All food and drink purchases for the participants for the 6 months before recruitment, during the 6-week intervention period, and during a 12-week washout period were transferred to the research team by the participating supermarket. Healthiness of ready meals and pizzas was measured using a predeveloped scale based solely on the traffic light colors on the foods. Questionnaires were completed at recruitment, end of the intervention, and end of washout to estimate the effect of the intervention on variables that mediate behavior change (eg, belief and intention formation).

RESULTS

We recruited 496 participants from an initial email to 50,000 people. Only 3 people withdrew from the study, and purchase data were received for all other participants. A total of 208 participants completed all 3 questionnaires. There was no difference in the healthiness of purchased ready meals and pizzas between the intervention and control arms either during the intervention period (P=.32) or at washout (P=.59).

CONCLUSIONS

Although the FLICC study did not find evidence of an impact of the intervention on food purchasing behavior, the unique methods used in this pilot trial are informative for future studies that plan to use supermarket loyalty card data in collaboration with supermarket partners. The experience of the trial showcases the possibilities and challenges associated with the use of loyalty card data in public health research.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN19316955; http://www.isrctn.com/ISRCTN19316955 (Archived by WebCite at http://www.webcitation.org/76IVZ9WjK).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s40814-015-0015-1.

Use, knowledge, and effectiveness of nutritional traffic light label in an urban population from Ecuador: a pilot study

Background

The nutritional traffic light label (NTLL) has become one of the most used Front of Package labels (FOP’s) around the world, for its simple and easy to understand graphical system. In Ecuador, this labelling system has recently been implemented; then, this research aims to evaluate the use and knowledge of NTLL and its effectiveness as a public health promotion strategy.

Method

In a cross-sectional study at two different urban supermarkets in Quito-Ecuador, a survey was conducted in 73 participants to inquire about knowledge, perspectives and purchasing habits regarding the NTLL. Objective data obtained from pictures of the participants’purchase was compared with subjective data obtained from the survey. For categorical variables, Chi square or Fisher’s Exact test were used and variables with a statistical significance at α = 0.1 were included in multivariate logistic regression models.

Results

88.7% of participants knew about the NTTL. 27.4% reported using the NTLL, while 28.4% of participants were observed to really use it. Significant associations between self-knowledge of the NTLL and education level (p = 0.007) or knowledge level (p = 0.001) were found. A significant association was also found between the refered use of the NTLL and the shopping influencing factor (p = 0.02). In the multivariate analysis an association between knowledge of the NTLL and observed use was found only when adjusted for the supermarket (p = 0.038).

Conclusion

This study found that the level of knowledge of the NTLL in the studied population was relatively high; however, both the referred and the observed use of the NTLL were low. Use and knowledge of the NTLL were associated with the socioeconomic and educational status of the participants. Thus, the change in nutritional patterns needs additional strategies to put the NTLL before the brand once customers make their purchases.

Assessment of Packaged Foods and Beverages Carrying Nutrition Marketing against Canada's Food Guide Recommendations

Canadians' food purchases consist largely of packaged processed and ultra-processed products, which typically fall outside the "core" foods recommended by Canada's Food Guide (CFG). Almost half of packaged products in Canada carry nutrition marketing (i.e., nutrient content and health claims). This study assessed whether packaged foods carrying nutrition marketing align with recommendations outlined in the 2007 CFG. Label data (n = 9376) were extracted from the 2013 Food Label Information Program (FLIP). Label components (including nutrition marketing) were classified using the International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) labelling taxonomy. The Health Canada Surveillance Tool (HCST) was used to assess the alignment of products to CFG. Each food or beverage was classified into one of five groups (i.e., Tier 1, Tier 2, Tier 3, Tier 4, "Others"). Products in Tier 1, 2 or water were considered "in line with CFG". Most products in the analyzed sample were classified as Tier 2 (35%) and Tier 3 (27%). Although foods with nutrition marketing were significantly more likely to align to CFG recommendations (p < 0.001), many products not "in line with CFG" still carried nutrition marketing. This study provides important baseline data that could be used upon the implementation of the new CFG.

Role of Front-of-Package Gluten-Free Product Labeling in a Pair-Matched Study in Women with and without Celiac Disease on a Gluten-Free Diet

Gluten-free (GF) product labeling is one of the most important determinants of food product choices by patients with celiac disease, due to the need for following a GF diet. The aim of this study was to assess the role of front-of-package GF product labeling in pair-matched celiac and non-celiac women on a GF diet in a choice experiment (CE). In subgroups of celiac (n = 77) and non-celiac pair-matched respondents on a GF diet, but with no gluten-related diseases diagnosed (n = 77), the influence of front-of package labeling of GF bread on the choice of products was assessed. The labeling assessed in a CE included for all the products crossed grain logotype and additional logotypes of European Union (EU) organic production, “dairy-free” product, wheat starch-free product, quality and vegan product, as well as additional “gluten-free” written information. It was stated that the frequency of selection of products with “gluten-free” written information did not differ between subgroups of celiac and non-celiac respondents, as well as in subgroups stratified by age, body mass index (BMI), place of residence, and economic status. The frequency of selection of products with “vegan” logotype was higher for non-celiac respondents than for celiac ones (p = 0.0011). The frequency of selection of a product with additional logotypes was influenced by BMI and place of residence, but not by age and economic status of assessed women.

Front-of-pack nutrition labelling in the European region: identifying what works for governments and consumers

OBJECTIVE

The present commentary introduces a Health Evidence Network (HEN) report that synthesises evidence of front-of-pack food labelling (FOPL) policy development and implementation across the European Region.

DESIGN

Countries were identified as having policies on interpretive FOPL from the WHO databases of Member State policies and online repositories of global food policies. For each identified country, evidence published from 1 January 1980 to 31 March 2018 was retrieved from peer-reviewed and grey literature. Extracted data were cross-checked with in-country representatives to ensure completeness and accuracy.

SETTING

WHO European Region, spanning fifty-three countries.

RESULTS

Fifteen countries had a government-endorsed policy on interpretive FOPL. Thirteen of these countries had introduced endorsement logos, while only three labelling systems provided an indicator for unhealthfulness. Common steps were identified in FOPL policy development, including: establishing FOPL as a nutrition policy priority; engaging stakeholders and the public; and collecting formative evidence on which to base the labelling system. Few countries had outlined formal provisions for evaluation of FOPL systems. The HEN report describes seven considerations for the adoption/review of FOPL policies to ensure these achieve the population nutrition aims of FOPL. These considerations relate to supporting consumer use and understanding of the labelling, policy feasibility and credibility, and ensuring policy implementation and accountability.

CONCLUSIONS

The HEN report encourages countries to consider FOPL policy that is applied widely across all products and provides negative evaluative judgements, possibly combined with positive indicators. Implementation provisions should drive widespread uptake of the system and allow for formal evaluation of impact.

Consumer Readiness to Reduce Meat Consumption for the Purpose of Environmental Sustainability: Insights from Norway

Food production is associated with various environmental impacts and the production of meat is highlighted as a significant source of greenhouse gas emissions. A transition toward plant-based and low-meat diets has thus been emphasised as an important contribution to reducing climate change. By combining results from a consumer survey, focus group interviews and an in-store field experiment, this article investigates whether Norwegian consumers are ready to make food choices based on what is environmentally sustainable. We ask how consumers perceive the environmental impacts of food consumption, whether they are willing and able to change their food consumption in a more climate-friendly direction, and what influences their perceptions and positions. The results show that there is uncertainty among consumers regarding what constitutes climate- or environmentally friendly food choices and that few consumers are motivated to change their food consumption patterns for climate- or environmental reasons. Consumers’ support to initiatives, such as eating less meat and increasing the prices of meat, are partly determined by the consumers’ existing value orientation and their existing consumption practices. Finally, we find that although providing information about the climate benefits of eating less meat has an effect on vegetable purchases, this does not seem to mobilise consumer action any more than the provision of information about the health benefits of eating less meat does. The article concludes that environmental policies aiming to transfer part of the responsibility for reducing greenhouse gas emissions to food consumers is being challenged by the fact that most consumers are still not ready to make food choices based on what is best for the climate or environment.

Traffic Light System Can Increase Healthfulness Perception: Implications for Policy Making

OBJECTIVE

To evaluate how information about low nutrient content included in the traffic light labeling system influences consumers' perception of the healthfulness of products with high content of 1 key nutrient, and to compare the traffic light system with warnings in terms of the perception of healthfulness.

DESIGN

Images of front-of-pack (FOP) nutrition labels (the traffic light labeling system with different numbers of nutrients with low content, and warnings) were evaluated in study 1, whereas product labels featuring the different FOP nutrition labels were evaluated in study 2.

SETTING

Online studies conducted in Montevideo, Uruguay.

PARTICIPANTS

A total of 1,228 Uruguayan Facebook users.

MAIN OUTCOME MEASURES

Perception of healthfulness.

ANALYSIS

The researchers used ANOVA to evaluate the influence of FOP nutrition labels on perceived healthfulness.

RESULTS

The inclusion of information about low nutrient content in the traffic light system statistically significantly increased the perception of the healthfulness of products with high nutrient content. Nutritional warnings showed healthfulness ratings similar to those of the simplified version of the traffic light system.

CONCLUSIONS AND IMPLICATIONS

Information about low nutrient content in the traffic light system might be used to infer health, and thus could raise the perception of healthfulness and decrease the traffic light system's efficacy in discouraging the consumption of unhealthful products. A simplified version of the traffic light highlighting only high-nutrient content or nutritional warnings seems to overcome this problem.

Nutrient-specific system versus full fact panel: Testing the benefits of nutrient-specific front-of-package labels in a student sample

Current food labels include comprehensive nutritional information, but evaluations of their effects on judgments of nutritional quality and food choice are scarce. Building on previous empirical research that demonstrated that amount and complexity of information is negatively related to judgment accuracy, this study used an experimental design to evaluate nutritional information labels of varying complexity. Lens model analysis (Brunswik, 1952; Cooksey, 1996; Hammond, 1955; Stewart, 1976) was used to study the judgment process. Nutrition judgment accuracy was assessed by comparing nutrition judgments to a nutrition expert criterion (NuVal^®) in three package labeling conditions. The conditions were: no nutritional information highlighted; nutrients highly related to nutritional quality highlighted using a front-of-package (FOP) label; and nutrients unrelated to nutritional quality highlighted using a FOP label. Findings indicate a limited role of FOP labeling in increasing judgment accuracy, consistency of nutritional information usage, and food choice. Implications for understanding labeling efforts to improve food choices are discussed.

The role of nutritional labelling and signposting from a European perspective

The past half-century has been characterised by major technological developments and massive societal change, which have profoundly changed how food is produced, processed, sold and consumed. These days we are faced with a huge choice of pre-packaged foods when we shop in modern supermarkets and we can buy seasonal food all year round, in and out of season. For decades now, the need to guide choice has been recognised, and retailers and many manufacturers have provided increasing amounts of on-pack information and signposting, and more recently UK retailers have led the way in championing front-of-pack information provision, to supplement the standard back-of-pack nutrient composition table. From a European perspective, the present paper summarises developments in nutrition labelling information and signposting, the legislation that controls on-pack declarations, and research conducted to assess whether or not the information is used, understood and supports healthier choices. It also considers whether more could be done to influence behaviour change positively, giving examples of approaches identified in the research.

Evaluating the ≤10:1 wholegrain criterion in identifying nutrient quality and health implications of UK breads and breakfast cereals

OBJECTIVE

To evaluate the nutrient quality of breads and breakfast cereals identified using the wholegrain definition of ≤10:1 carbohydrate:fibre ratio.

DESIGN

Following a cross-sectional study design, nutritional information was systematically gathered from food labels of breads and breakfast cereals that met the ≤10:1 carbohydrate:fibre criterion. The median nutrient content was compared with the UK Food Standards Agency's nutrient profiling standards and the associations between carbohydrate:fibre ratio and other nutrients were analysed. Subgroup analyses were undertaken for products with and without fruit, nuts and/or seeds.

SETTING

Products from four major supermarket stores in the UK.

SUBJECTS

Breads (n 162) and breakfast cereals (n 266).

RESULTS

Breads which met the ≤10:1 criterion typically contained medium fat, low saturated fat, low sugar and medium Na. Breakfast cereals typically contained medium fat, low saturated fat, high sugar and low Na. In both groups, as the carbohydrate:fibre ratio decreased, fat content increased (bread: P=0·029, r=-0·171; breakfast cereal: P=0·033, r=-0·131) and, in breakfast cereals, as the ratio increased, sugar content increased (P<0·0005, r=0·381). Breakfast cereals with fruit, nuts and/or seeds contained, per 100 g, more energy (P=0·002), fat, saturated fat and sugar (all P<0·0005), while seeded breads had more energy, fat and saturated fat (all P<0·0005).

CONCLUSIONS

Overall, breads and breakfast cereals meeting the ≤10:1 criterion have good nutritional quality, suggesting that the criterion could be useful in public health and/or food labelling. The utility of applying the ≤10:1 criterion to products containing fruit, nuts and/or seeds is less clear and requires further research.

The impact of interpretive and reductive front-of-pack labels on food choice and willingness to pay

BACKGROUND

This study examined how front-of-pack labels and product healthfulness affect choice and willingness to pay across a range of foods. It was hypothesized that: (i) product choice and (ii) willingness to pay would be more aligned with product healthfulness when healthfulness was expressed through the Health Star Rating, followed by the Multiple Traffic Light, then the Daily Intake Guide, and (iii) the Nutrition Facts Panel would be viewed infrequently.

METHODS

Adults and children aged 10+ years (n = 2069) completed an online discrete choice task involving mock food packages. A 4 food type (cookies, corn flakes, pizza, yoghurt) × 2 front-of-pack label presence (present, absent) × 3 front-of-pack label type (Daily Intake Guide, Multiple Traffic Light, Health Star Rating) × 3 price (cheap, moderate, expensive) × 3 healthfulness (less healthy, moderately healthy, healthier) design was used. A 30 s time limit was imposed for each choice.

RESULTS

Of the three front-of-pack labels tested, the Health Star Rating produced the largest differences in choices, with 40% (95% CIs: 38%-42%) of respondents selecting the healthier variant, 33% selecting the moderately healthy variant (95% CIs: 31%-35%), and 23% (95% CIs: 21%-24%) selecting the less healthy variant of the four products included in the study. The Multiple Traffic Light led to significant differences in choices between healthier (35%, 95% CIs: 33%-37%) and less healthy products (29%, 95% CIs: 27%-31%), but not moderately healthy products (32%, 95% CIs: 30%-34%). No significant differences in choices were observed by product healthfulness when the Daily Intake Guide was present. Only the Health Star Rating resulted in a significantly greater willingness to pay for healthier versus less healthy products. The Nutrition Facts Panel was viewed for only 7% of all mock packages.

CONCLUSIONS

Front-of-pack labels that are more interpretive, such as the Health Star Rating, can be more effective at directing consumers towards healthier choices than reductive front-of-pack labels such as the Daily Intake Guide. The study results provide policy makers with clear guidance on the types of front-of-pack labels that are most likely to achieve positive health outcomes at a population level.

Applying behavioral insights to delay school start times

Healthy People 2020 established a national objective to increase the proportion of 9th-to-12th-grade students reporting sufficient sleep. A salient approach for achieving this objective is to delay middle and high school start times. Despite decades of research supporting the benefits of delayed school start times on adolescent sleep, health, and well-being, progress has been slow. Accelerating progress will require new approaches incorporating strategies that influence how school policy decisions are made. In this commentary, we introduce four strategies that influence decision-making processes and demonstrate how they can be applied to efforts aimed at changing school start time policies.

Towards environmentally sustainable human behaviour: targeting non-conscious and conscious processes for effective and acceptable policies

Meeting climate change targets to limit global warming to 2°C requires rapid and large reductions in demand for products that most contribute to greenhouse gas (GHG) emissions. These include production of bulk materials (e.g. steel and cement), energy supply (e.g. fossil fuels) and animal source foods (particularly ruminants and their products). Effective strategies to meet these targets require transformative changes in supply as well as demand, involving changes in economic, political and legal systems at local, national and international levels, building on evidence from many disciplines. This paper outlines contributions from behavioural science in reducing demand. Grounded in dual-process models of human behaviour (involving non-conscious and conscious processes) this paper considers first why interventions aimed at changing population values towards the environment are usually insufficient or unnecessary for reducing demand although they may be important in increasing public acceptability of policies that could reduce demand. It then outlines two sets of evidence from behavioural science towards effective systems-based strategies, to identify interventions likely to be effective at: (i) reducing demand for products that contribute most to GHG emissions, mainly targeting non-conscious processes and (ii) increasing public acceptability for policy changes to enable these interventions, targeting conscious processes.This article is part of the themed issue 'Material demand reduction'.