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Benthem de Grave R, Bull CN, Monjardino de Souza Monteiro D, Margariti E, McMurchy G, Hutchinson JW, Smeddinck JD. Smartphone Apps for Food Purchase Choices: Scoping Review of Designs, Opportunities, and Challenges. J Med Internet Res 2024; 26:e45904. [PMID: 38446500 PMCID: PMC10955402 DOI: 10.2196/45904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 11/30/2023] [Accepted: 12/20/2023] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Smartphone apps can aid consumers in making healthier and more sustainable food purchases. However, there is still a limited understanding of the different app design approaches and their impact on food purchase choices. An overview of existing food purchase choice apps and an understanding of common challenges can help speed up effective future developments. OBJECTIVE We examined the academic literature on food purchase choice apps and provided an overview of the design characteristics, opportunities, and challenges for effective implementation. Thus, we contribute to an understanding of how technologies can effectively improve food purchase choice behavior and provide recommendations for future design efforts. METHODS Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines, we considered peer-reviewed literature on food purchase choice apps within IEEE Xplore, PubMed, Scopus, and ScienceDirect. We inductively coded and summarized design characteristics. Opportunities and challenges were addressed from both quantitative and qualitative perspectives. From the quantitative perspective, we coded and summarized outcomes of comparative evaluation trials. From the qualitative perspective, we performed a qualitative content analysis of commonly discussed opportunities and challenges. RESULTS We retrieved 55 articles, identified 46 unique apps, and grouped them into 5 distinct app types. Each app type supports a specific purchase choice stage and shares a common functional design. Most apps support the product selection stage (selection apps; 27/46, 59%), commonly by scanning the barcode and displaying a nutritional rating. In total, 73% (8/11) of the evaluation trials reported significant findings and indicated the potential of food purchase choice apps to support behavior change. However, relatively few evaluations covered the selection app type, and these studies showed mixed results. We found a common opportunity in apps contributing to learning (knowledge gain), whereas infrequent engagement presents a common challenge. The latter was associated with perceived burden of use, trust, and performance as well as with learning. In addition, there were technical challenges in establishing comprehensive product information databases or achieving performance accuracy with advanced identification methods such as image recognition. CONCLUSIONS Our findings suggest that designs of food purchase choice apps do not encourage repeated use or long-term adoption, compromising the effectiveness of behavior change through nudging. However, we found that smartphone apps can enhance learning, which plays an important role in behavior change. Compared with nudging as a mechanism for behavior change, this mechanism is less dependent on continued use. We argue that designs that optimize for learning within each interaction have a better chance of achieving behavior change. This review concludes with design recommendations, suggesting that food purchase choice app designers anticipate the possibility of early abandonment as part of their design process and design apps that optimize the learning experience.
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Affiliation(s)
- Remco Benthem de Grave
- Open Lab, School of Computing, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Christopher N Bull
- Open Lab, School of Computing, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Eleni Margariti
- Open Lab, School of Computing, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Gareth McMurchy
- Open Lab, School of Computing, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Jan David Smeddinck
- Open Lab, School of Computing, Newcastle University, Newcastle upon Tyne, United Kingdom
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
- Ludwig Maximilian University, Munich, Germany
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Hanras E, Chevrier B, Dorard G, Boujut E. Who uses food barcode scanner apps and why? Exploration of users' characteristics and development of the Food Barcode Scanner App Questionnaire. J Hum Nutr Diet 2024; 37:155-167. [PMID: 37749952 DOI: 10.1111/jhn.13240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/01/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Food barcode scanner apps (FBSAs) are increasingly being used to verify food quality. By scanning a product's barcode, they can provide a range of information, including nutritional quality or information on the toxicity of food components. Although they seem to be widely used, no study has yet examined their use in the general population. The objectives of this study were therefore twofold: (a) to identify who the users of FBSA are and (b) to evaluate behaviours and cognitions associated with use of these apps through the development and validation of the Food Barcode Scanner App Questionnaire (FBSAQ). METHOD A total of 1626 women (average age of 37.51 years; SD = 12.67) from the general population were included in this study, with 25.7% reporting themselves as using at least one FBSA. Participants completed questionnaires assessing socio-demographic and health characteristics, the use of health apps and the FBSAQ, when relevant. RESULTS The users of FBSAs did not differ from nonusers in regard to key socio-demographic characteristics, but they were more likely to use healthcare services and other health apps than nonusers of FBSAs. Psychometric analyses allowed validation of the FBSAQ through three factors: pathological use, dietary concerns and exclusion of unhealthy components. CONCLUSION Data showed that the use of FBSAs can be beneficial for many individuals, as they help with food choices. However, some user may develop more problematic behaviours and have difficulties in not using these apps.
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Affiliation(s)
- Eva Hanras
- Université Paris Cité, Laboratoire de Psychopathologie et Processus de Santé, Boulogne-Billancourt, France
| | | | - Géraldine Dorard
- Université Paris Cité, Laboratoire de Psychopathologie et Processus de Santé, Boulogne-Billancourt, France
| | - Emilie Boujut
- Université Paris Cité, Laboratoire de Psychopathologie et Processus de Santé, Boulogne-Billancourt, France
- INSPE, Cergy Paris Université, Saint-Germain en Laye, France
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Shrestha A, Cullerton K, White KM, Mays J, Sendall M. Impact of front-of-pack nutrition labelling in consumer understanding and use across socio-economic status: A systematic review. Appetite 2023; 187:106587. [PMID: 37169260 DOI: 10.1016/j.appet.2023.106587] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
An unhealthy diet is a leading contributor to the increasing burden of overweight and obesity. Front-of-pack labelling (FOPL) is being recognized as a policy strategy to promote healthier choices yet there is limited evaluation of FOPL to suggest if it is effective for all population subgroups. This systematic review aimed to assess the impact of FOPL on consumer understanding and usage across socio-economic gradients. Six electronic databases were searched through a systematic search process using key terms for FOPL and socioeconomic status (SES) from 2011 to March 2022 to include studies evaluating the effectiveness of FOPL. A narrative synthesis was conducted and the results were assessed according to the effects of FOPL on consumer awareness, understanding, and usage across SES. The review included 36 articles. In general, people of all SES groups were aware of and more likely to pay attention towards FOPL than the nutrition information panel provided on the back of the package. However, the understanding and usage were relatively poor, particularly in low SES groups. While studies conducted in low SES populations suggest FOPL increased the purchase intention of healthy products, the stratified analysis across SES showed less beneficial effects in low SES individuals. The findings highlight simplified and easy-to-understand FOPLs such as Nutri-score and traffic light labelling are likely to be effective for all populations including low SES groups. Overall, the review suggests FOPLs are more visible than the nutrition information panel and may guide healthier food choices for people of all SES backgrounds. It is unclear whether FOPL influences actual purchasing and food intake as there are insufficient studies comparing the effects among higher and lower SES populations.
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Affiliation(s)
- Anita Shrestha
- School of Public Health and Social Work, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia.
| | - Katherine Cullerton
- School of Public Health, The University of Queensland, 288 Herston Road, Herston, QLD, 4006, Australia
| | - Katherine M White
- School of Psychology and Counselling, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia
| | - Jenni Mays
- School of Public Health and Social Work, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia
| | - Margo Sendall
- Department of Public Health, College of Health Sciences, Qatar University, Doha, Qatar
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Liao F, Li H. Which Front-of-Package Nutrition Label Is Better? The Influence of Front-of-Package Nutrition Label Type on Consumers' Healthy Food Purchase Behavior. Nutrients 2023; 15:nu15102326. [PMID: 37242208 DOI: 10.3390/nu15102326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/04/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023] Open
Abstract
To help consumers understand the healthfulness of food and make healthy food choices, manufacturers are increasingly providing front-of-package nutrition labels. However, not all types of front-of-package nutrition labels can promote consumers' healthy food purchase behavior. We explored the impact of front-of-package nutrition label type on the consumer purchase behavior of healthy food through three experiments. The results show that evaluative (vs. objective) front-of-package nutrition labels can improve consumer purchase intention and willingness to pay for healthy food. The spokesperson type moderates the influence of front-of-package nutrition labels on consumers' healthy food purchase behavior. Specifically, when the spokesperson type is a typical consumer, consumers are more willing to buy healthy foods with evaluative nutrition labels than those with objective nutrition labels. When the spokesperson type is a star, consumers are more willing to buy healthy food with objective nutrition labels (vs. evaluative nutrition labels). Finally, this study provides feasible suggestions for marketers to select appropriate front-of-package nutrition labels.
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Affiliation(s)
- Fen Liao
- School of Insurance, Shandong University of Finance and Economics, Jinan 250014, China
| | - Han Li
- College of Economics and Management, Huazhong Agricultural University, Wuhan 430070, China
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The Potential Impact of Different Taxation Scenarios towards Sugar-Sweetened Beverages on Overweight and Obesity in Brazil: A Modeling Study. Nutrients 2022; 14:nu14235163. [PMID: 36501192 PMCID: PMC9737639 DOI: 10.3390/nu14235163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
The adoption of fiscal policies based on the specific taxation of sugar-sweetened beverages (SSBs) has been recommended by international health agencies, as they are measures that potentially reduce consumption. This study is an ex ante risk comparison that estimates the impact of three tax scenarios (20, 25, and 30%) with a 100% pass-on rate to SSBs on the prevalence of high weight and obesity in the Brazilian population. Data on the consumption habits, weight, and height of 46,164 adults aged 20 years or over from Brazilian recent national surveys were used. The shift in consumption after taxation was estimated based on the price elasticity of the demand. The percentage changes in overweight for 20, 25, and 30% taxation were 1.84% (95%CI: 1.82; 1.86), 1.89% (95%CI: 1.87; 1.90), and 2.25% (95%CI: 2.24; 2.27), respectively. The change in the prevalence of obesity was 1.93% (95%CI: 1.87; 2.00), 2.90% (95%CI: 2.80; 3.02), and 4.16% (95%CI: 4.01; 4.32), respectively. Taxes on SSBs may have a more favorable result among the heaviest consumers, who are young adults (20-29 years), especially men, thereby promoting a greater reduction in the prevalence of high weight and obesity.
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Maganja D, Trieu K, Reading M, Huang L, Hart AC, Taylor F, Stamatellis S, Arnott C, Feng X, Schutte AE, Di Tanna GL, Ni Mhurchu C, Cameron AJ, Huffman MD, Neal B, Wu JH. Protocol for a novel sodium and blood pressure reduction intervention targeting online grocery shoppers with hypertension - the SaltSwitch Online Grocery Shopping randomized trial. Am Heart J 2022; 252:70-83. [PMID: 35777455 DOI: 10.1016/j.ahj.2022.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/30/2022] [Accepted: 06/17/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND High dietary sodium intake is a leading cause of hypertension. A major source of dietary sodium is salt added to processed food products available in retail food environments. The fast-growing online grocery shopping setting provides new opportunities for salt reduction interventions that support consumers in choosing healthier options. METHODS The SaltSwitch Online Grocery Shopping randomized controlled trial is investigating the feasibility, acceptability, and effectiveness of a novel intervention for lowering salt consumption and blood pressure amongst people with hypertension who shop for groceries online. The intervention is based on a bespoke web browser extension that interfaces with a major retailer's online store to highlight and interpret product sodium content and suggest similar but lower-sodium alternatives. The primary outcome of interest is change in mean systolic blood pressure between individuals randomized (1:1) to the intervention and control (usual online shopping) arms at 12 weeks. Secondary outcomes are diastolic blood pressure, spot urinary sodium and sodium:potassium ratio, sodium purchases, and dietary intake. Intervention implementation and lessons for future uptake will be assessed using a mixed methods process evaluation. Participants with hypertension who shop online for groceries and exhibit high sodium purchasing behavior are being recruited across Australia. A target sample size of 1,966 provides 80% power (2-sided alpha = 0.05) to detect a 2 mm Hg difference in systolic blood pressure between groups, assuming a 15 mm Hg standard deviation, after allowing for a 10% dropout rate. DISCUSSION This trial will provide evidence on an innovative intervention to potentially reduce salt intake and blood pressure in people with hypertension. The intervention caters to individual preferences by encouraging sustainable switches to similar but lower-salt products. If effective, the intervention will be readily scalable at low cost by interfacing with existing online retail environments.
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Affiliation(s)
- Damian Maganja
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia.
| | - Kathy Trieu
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Michelle Reading
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Liping Huang
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ashleigh Chanel Hart
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Fraser Taylor
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Steve Stamatellis
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Clare Arnott
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Xiaoqi Feng
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Aletta E Schutte
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Gian Luca Di Tanna
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Cliona Ni Mhurchu
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Adrian J Cameron
- Global Obesity Centre, Institute for Health Transformation, Deakin University, Melbourne, Victoria, Australia
| | - Mark D Huffman
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Cardiovascular Division and Global Health Center, Washington University, St. Louis, MO
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department of Epidemiology and Biostatistics, Imperial College London, South Kensington, London, United Kingdom
| | - Jason Hy Wu
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
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Riesenberg D, Peeters A, Backholer K, Martin J, Ni Mhurchu C, Blake MR. Exploring the effects of added sugar labels on food purchasing behaviour in Australian parents: An online randomised controlled trial. PLoS One 2022; 17:e0271435. [PMID: 36006973 PMCID: PMC9409597 DOI: 10.1371/journal.pone.0271435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/28/2022] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Devorah Riesenberg
- Global Obesity Centre, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Anna Peeters
- Global Obesity Centre, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Kathryn Backholer
- Global Obesity Centre, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Jane Martin
- Obesity Policy Coalition, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Cliona Ni Mhurchu
- National Institute for Health Innovation, School of Population Health, The University of Auckland, Auckland, New Zealand
- The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Miranda R. Blake
- Global Obesity Centre, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- * E-mail:
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Silva ARCS, Ni Mhurchu C, Anastácio LR. Comparison of two front-of-pack nutrition labels for Brazilian consumers using a smartphone app in a real-world grocery store: A pilot randomized controlled study. Front Nutr 2022; 9:898021. [PMID: 35990330 PMCID: PMC9389176 DOI: 10.3389/fnut.2022.898021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/08/2022] [Indexed: 11/21/2022] Open
Abstract
One of the suggestions for improving the understanding of food labels is implementing front-of-pack nutrition labeling (FoPNL), where nutritional information is objectively made available to consumers. Scientific data on the best FoPNL model to be adopted for the Brazilian population is still emerging, especially in real-world purchase situations. This study aims to evaluate/compare the proposed Brazilian and Mexican FoPNL systems, on different outcome measures, using an application, in dairy foods available in a supermarket aisle. This pilot randomized controlled trial in a real-world purchase situation was conducted in June/July 2021. A total of 230 participants were randomly allocated to one of the three study arms (Mexican and Brazilian FoPNL systems or control—nutritional information table and ingredients list). Using a smartphone, the participants scanned a product barcode and received the allocated FoPNL (with information about excessive added sugars, sodium, and/or saturated fat content) or the control. After, they answered questions related to our primary outcome (decision to buy or not to buy a product) and secondary outcomes (perceived healthiness, facilitation of a quick purchase decision, and identification of excess nutrients). The Mexican FoPNL system performed better in the primary outcome (3.74 ± 1.34) and “facilitation of a quick purchase decision” (3.59 ± 1.31), compared to the control (3.28 ± 1.45;p = 0.043 and 3.11 ± 1.42; p = 0.029). The Mexican FoPNL system performed better in supporting consumers to identify dairy foods, among the selected sample in this study, high in added sugars than the control (82.2% and 63.5% of correct answers, respectively; p = 0.009). For saturated fats, the Brazilian FoPNL resulted in 93.1% of correct answers against 48.2% for the control and 58.9% for the Mexican system (p ≤ 0.001). The Mexican FoPNL system facilitated consumer decision-making on when to buy or not to buy a selected dairy product and in helping to quickly decide which dairy products to buy, among the selected sample in this study, compared to the control. Considering the right answers of critical nutrients in excess or not, both models of FoPNL, delivered by a smartphone app, performed well.
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Affiliation(s)
| | - Cliona Ni Mhurchu
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Lucilene Rezende Anastácio
- Department of Food Science, Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Bablani L, Ni Mhurchu C, Neal B, Skeels CL, Staub KE, Blakely T. Effect of voluntary Health Star Rating labels on healthier food purchasing in New Zealand: longitudinal evidence using representative household purchase data. BMJ Nutr Prev Health 2022; 5:227-234. [PMID: 36619324 PMCID: PMC9813620 DOI: 10.1136/bmjnph-2022-000459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 07/20/2022] [Indexed: 01/11/2023] Open
Abstract
Front-of-pack labelling (FoPL) aims to promote healthier diets by altering consumer food purchasing behaviour. We quantify the impact of the voluntary Health Star Rating (HSR) FoPL adopted by New Zealand (NZ) in 2014, on (i) the quantity of foods purchased by HSR scores and food groups and (ii) the quantities of different nutrients purchased. We used Nielsen HomeScan household purchasing panel data over 2013-2019, linked to Nutritrack packaged food composition data. Fixed effects analyses were used to estimate the association of HSR with product and nutrient purchasing. We controlled for NZ-wide purchasing trends and potential confounding at the household and product level. In 2019, HSR-labelled products accounted for 24% (2890) of 12 040 products in the dataset and 32% of purchasing volume. Of HSR-labelled products, 1339 (46%) displayed a rating of 4.0-5.0 stars and 556 (19%) displayed a rating of 0.5-2.0 stars. We found little or no association between HSR labelling and the quantities of different foods purchased. Introduction of HSR was, however, associated with lower sodium (-9%, 95% CI -13% to -5%), lower protein (-3%, 95% CI -5% to 0%) and higher fibre (5%, 95% CI 2% to 7%) purchases when purchased products carrying an HSR were compared with the same products prior to introduction of the programme. Robust evidence of HSR labelling changing consumer purchasing behaviour was not observed. The positive effect on nutrient purchasing of HSR-labelled foods likely arises from reformulation of products to achieve a better HSR label.
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Affiliation(s)
- Laxman Bablani
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Cliona Ni Mhurchu
- National Institute for Health Innovation, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand,The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bruce Neal
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia,School of Public Health, Imperial College London, London, UK
| | - Christopher L Skeels
- Department of Economics, University of Melbourne, Melbourne, Victoria, Australia
| | - Kevin E Staub
- Department of Economics, University of Melbourne, Melbourne, Victoria, Australia
| | - Tony Blakely
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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Singh SK, Taillie LS, Gupta A, Bercholz M, Popkin B, Murukutla N. Front-of-Package Labels on Unhealthy Packaged Foods in India: Evidence from a Randomized Field Experiment. Nutrients 2022; 14:nu14153128. [PMID: 35956305 PMCID: PMC9370292 DOI: 10.3390/nu14153128] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/09/2022] [Accepted: 06/11/2022] [Indexed: 02/01/2023] Open
Abstract
Policies to require front-of-package labels (FOPLs) on packaged foods may help Indian consumers to better identify foods high in nutrients of concern, including sugar, saturated fat, and sodium, and discourage their consumption, which are outcomes that are critical for preventing rises in diet-related non-communicable disease. The objective was to test whether FOPLs helped Indian consumers identify “high-in” packaged foods and reduce intentions to purchase them. We conducted an in-person randomized experiment (n = 2869 adults between ages 18 and 60 years old) in six states of India in 2022. Participants were randomized to one of five FOPLs: a control label (barcode), warning label (octagon with “High in [nutrient]”), Health Star Rating (HSR), Guideline Daily Amount (GDA), or traffic light label. Participants then viewed a series of packaged foods high in sugar, saturated fat, or sodium with the assigned FOPL, and rated product perceptions and label reactions. Fewer than half of participants in the control group (39.1%) correctly identified all products high in nutrient(s) of concern. All FOPLs led to an increase in this outcome, with the biggest differences observed for the warning label (60.8%, p < 0.001), followed by the traffic light label (54.8%, p < 0.001), GDA (55.0%, p < 0.001), and HSR (45.0%, p < 0.01). While no FOPLs led to a reduction in intentions to purchase the packaged foods, the overall pattern of results suggested that warning labels are the most effective FOPL to help Indian consumers identify unhealthy foods.
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Affiliation(s)
- S. K. Singh
- Department of Survey Research and Data Analytics, International Institute for Population Sciences, Deemed University, Mumbai 400088, India
- Correspondence: (S.K.S.); (L.S.T.)
| | - Lindsey Smith Taillie
- Department of Nutrition, Gillings School of Global Public Health, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516, USA;
- Correspondence: (S.K.S.); (L.S.T.)
| | - Ashish Gupta
- Vital Strategies, New York, NY 27599, USA; (A.G.); (N.M.)
| | - Maxime Bercholz
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516, USA;
| | - Barry Popkin
- Department of Nutrition, Gillings School of Global Public Health, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516, USA;
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Impact of Obesogenic Environments on Sugar-Sweetened Beverage Consumption among Preschoolers: Findings from a Cross-Sectional Survey in Beijing. Nutrients 2022; 14:nu14142860. [PMID: 35889817 PMCID: PMC9321344 DOI: 10.3390/nu14142860] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 01/27/2023] Open
Abstract
The excessive consumption of sugar-sweetened beverages (SSBs) has been proven to be critical for obesity among preschoolers. This study aimed to describe the SSB consumption rates among preschoolers in the Dongcheng District of Beijing, China, and to explore the association between obesogenic environmental determinants and consumption. We applied a stratified cluster sampling method and recruited 3057 primary caregivers of preschoolers in June 2019 to participate in the survey. The caregivers reported their children’s consumption rates of six categories of SSBs and their exposure rates to SSB-related obesogenic environments. The associations between them were tested using multivariate logistic regression models. The mean (SD) age of the children was 5.6 (0.6) years and nearly half (48.3%) were girls. About 84.5% of the children had consumed SSBs over the past three months, and sugar-sweetened milk beverages had the highest consumption rate. Higher exposure to advertisements for the corresponding SSB categories in children, higher frequency rates of consuming SSBs and of taking children to fast-food restaurants in caregivers, and lower frequency rates of reading the Nutrition Facts Panels by caregivers were associated with higher SSB consumption rates among children (p < 0.05 in all of the SSB categories investigated, except for the Nutrition Facts Panel reading behaviors for the sports and energy beverages). SSB consumption among preschoolers is of concern, and comprehensive policy actions and education are urgently needed.
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12
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Jia J, Levy DE, McCurley JL, Anderson E, Gelsomin ED, Porneala B, Thorndike AN. Health Literacy, Numeracy, and Health Promotion: A Secondary Analysis of the Choosewell 365 Workplace Trial. Am J Prev Med 2022; 63:93-101. [PMID: 35282955 PMCID: PMC9232847 DOI: 10.1016/j.amepre.2021.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/17/2021] [Accepted: 12/22/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Health literacy and numeracy are linked to obesity and dietary behaviors. This study investigates whether the effect of a workplace behavioral intervention to prevent weight gain and improve diet differed by employee health literacy and numeracy. METHODS ChooseWell 365 was an RCT of hospital employees testing a 12-month intervention using nudges and feedback to promote healthier choices, building on existing cafeteria traffic light labels (e.g., green=healthy, red=unhealthy). Health literacy and numeracy were measured with the Newest Vital Sign (range=0-6) and General Numeracy Scale (range=0-3). Mixed-effects linear models examined if intervention effects on cafeteria purchases, diet quality (Healthy Eating Index 2015, range=0-100), and weight change over 24 months differed by higher versus lower health literacy or numeracy. Data were collected in 2016-2020 and analyzed in 2020-2021. RESULTS In 12 months, 510 participants completed the Newest Vital Sign and General Numerancy Scale; 36.7% had Newest Vital Sign<6 (lower health literacy) and 31.6% had General Numerancy Scale<2 (lower numeracy). Intervention participants increased healthy purchases over 24 months compared with controls in both higher and lower health literacy and numeracy groups. At 12 months, Healthy Eating Index 2015 scores increased in intervention versus control participants with lower health literacy (5.5 points, 95% CI=1.51, 9.54) but not in those with higher health literacy (p-interaction=0.040). BMI did not differ by health literacy or numeracy. CONCLUSIONS A behavioral intervention improved cafeteria food choices of hospital employees of varying health literacy and numeracy levels and improved diet quality among employees with lower health literacy, suggesting this group also improved food choices outside of work.
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Affiliation(s)
- Jenny Jia
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Douglas E Levy
- Mongan Institute Health Policy Research Center, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Jessica L McCurley
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Emma Anderson
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emily D Gelsomin
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts
| | - Bianca Porneala
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anne N Thorndike
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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13
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Aguenaou H, Babio N, Deschasaux-Tanguy M, Galan P, Hercberg S, Julia C, Jones A, Karpetas G, Kelly B, Kesse-Guyot E, Kontopoulou L, Labonté ME, Ni Mhurchu C, Pravst I, Pettigrew S, Riboli E, Salas-Salvadó J, Srour B, Touvier M, Vandevijvere S. Comment on Muzzioli et al. Are Front-of-Pack Labels a Health Policy Tool? Nutrients 2022, 14, 771. Nutrients 2022; 14:nu14102165. [PMID: 35631306 PMCID: PMC9145939 DOI: 10.3390/nu14102165] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/27/2022] [Indexed: 02/06/2023] Open
Abstract
As scientists working and publishing in the field of front-of-pack nutrition labelling (FOPNL) for many years, we have read with interest and concern the narrative review regarding their effectiveness by Muzzioli et al. [...].
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Affiliation(s)
- Hassan Aguenaou
- Joint Research Unit in Nutrition and Food, RDC-Nutrition AFRA/IAEA, Ibn Tofail University-CNESTEN, Rabat, Kenitra 14000, Morocco;
| | - Nancy Babio
- Departament de Bioquimica i Biotecnologia, Unitat de Nutrició Humana. (IISPV), Universitat Rovira i Virgili, 43201 Reus, Spain; (N.B.); (J.S.-S.)
- Consorcio CIBER, M.P. Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III (ISCIII), 28014 Madrid, Spain
| | - Mélanie Deschasaux-Tanguy
- Sorbonne Paris Nord University, Inserm U1153, Inrae U1125, Cnam, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Center—University of Paris (CRESS), 93017 Bobigny, France; (M.D.-T.); (P.G.); (S.H.); (E.K.-G.); (B.S.); (M.T.)
| | - Pilar Galan
- Sorbonne Paris Nord University, Inserm U1153, Inrae U1125, Cnam, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Center—University of Paris (CRESS), 93017 Bobigny, France; (M.D.-T.); (P.G.); (S.H.); (E.K.-G.); (B.S.); (M.T.)
| | - Serge Hercberg
- Sorbonne Paris Nord University, Inserm U1153, Inrae U1125, Cnam, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Center—University of Paris (CRESS), 93017 Bobigny, France; (M.D.-T.); (P.G.); (S.H.); (E.K.-G.); (B.S.); (M.T.)
- Public Health Department, Avicenne Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), 93000 Bobigny, France
| | - Chantal Julia
- Sorbonne Paris Nord University, Inserm U1153, Inrae U1125, Cnam, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Center—University of Paris (CRESS), 93017 Bobigny, France; (M.D.-T.); (P.G.); (S.H.); (E.K.-G.); (B.S.); (M.T.)
- Public Health Department, Avicenne Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), 93000 Bobigny, France
- Correspondence:
| | - Alexandra Jones
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2052, Australia; (A.J.); (S.P.)
| | - Georgios Karpetas
- Laboratory Teaching Staff, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece;
| | - Bridget Kelly
- Early Start, School of Health & Society, University of Wollongong, Wollongong, NSW 2522, Australia;
| | - Emmanuelle Kesse-Guyot
- Sorbonne Paris Nord University, Inserm U1153, Inrae U1125, Cnam, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Center—University of Paris (CRESS), 93017 Bobigny, France; (M.D.-T.); (P.G.); (S.H.); (E.K.-G.); (B.S.); (M.T.)
| | - Lamprini Kontopoulou
- Laboratory Teaching Staff, Nursing Department, University of Thessaly, 41500 Larissa, Greece;
| | - Marie-Eve Labonté
- Centre Nutrition, Santé et Société (NUTRISS), Institute of Nutrition and Functional Foods (INAF), Université Laval, Québec City, QC G1V 0A6, Canada;
- School of Nutrition, Université Laval, Québec City, QC G1V 0A6, Canada
| | - Cliona Ni Mhurchu
- National Institute for Health Innovation, The University of Auckland, Auckland 1142, New Zealand;
| | - Igor Pravst
- Nutrition and Public Health Research Group, Nutrition Institute, Trzaska Cesta 40, 1000 Ljubljana, Slovenia;
| | - Simone Pettigrew
- The George Institute for Global Health, University of New South Wales, Sydney, NSW 2052, Australia; (A.J.); (S.P.)
| | - Elio Riboli
- Department of Epidemiology and Biostatistics, Imperial College London, London W2 1PG, UK;
| | - Jordi Salas-Salvadó
- Departament de Bioquimica i Biotecnologia, Unitat de Nutrició Humana. (IISPV), Universitat Rovira i Virgili, 43201 Reus, Spain; (N.B.); (J.S.-S.)
- Consorcio CIBER, M.P. Fisiopatología de la Obesidad y Nutrición (CIBERObn), Instituto de Salud Carlos III (ISCIII), 28014 Madrid, Spain
| | - Bernard Srour
- Sorbonne Paris Nord University, Inserm U1153, Inrae U1125, Cnam, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Center—University of Paris (CRESS), 93017 Bobigny, France; (M.D.-T.); (P.G.); (S.H.); (E.K.-G.); (B.S.); (M.T.)
| | - Mathilde Touvier
- Sorbonne Paris Nord University, Inserm U1153, Inrae U1125, Cnam, Nutritional Epidemiology Research Team (EREN), Epidemiology and Statistics Research Center—University of Paris (CRESS), 93017 Bobigny, France; (M.D.-T.); (P.G.); (S.H.); (E.K.-G.); (B.S.); (M.T.)
| | - Stefanie Vandevijvere
- Department of Epidemiology and Public Health, Service of Lifestyle and Chronic Diseases, 1050 Brussels, Belgium;
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14
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Fuchs KL, Lian J, Michels L, Mayer S, Toniato E, Tiefenbeck V. Effects of Digital Food Labels on Healthy Food Choices in Online Grocery Shopping. Nutrients 2022; 14:nu14102044. [PMID: 35631185 PMCID: PMC9146588 DOI: 10.3390/nu14102044] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 02/01/2023] Open
Abstract
In order to induce the shift in consumer behavior necessary for the mitigation of diet-related diseases, front-of-package labels (FoPL) such as the Nutri-Score that support consumers in their efforts to identify nutritionally valuable products during grocery shopping have been found to be effective; however, they remain non-compulsory in most regions. Counter-intuitively, a similar stream of research on digital web-based FoPL does not yet exist, even though such digital labels hold several advantages over physical labels. Digital FoPL can provide scalable and personalized interventions, are easier to implement than physical labels, and are especially timely due to the recent increase in online grocery shopping. The goal of this study was to demonstrate the technical feasibility and intervention potential of novel, scalable, and passively triggered health behavior interventions distributed via easy-to-install web browser extensions designed to support healthy food choices via the inclusion of digital FoPL in online supermarkets. To that end, we developed a Chrome web browser extension for a real online supermarket and evaluated the effect of this digital food label intervention (i.e., display of the Nutri-Score next to visible products) on the nutritional quality of individuals’ weekly grocery shopping in a randomized controlled laboratory trial (N = 135). Compared to the control group, individuals exposed to the intervention chose products with a higher nutritional quality (e.g., 8% higher healthy trolley index (HETI), 3.3% less sugar, 7.5% less saturated fat). In particular, users with low food literacy seemed to benefit from the digital FoPL (e.g., 11% higher HETI, 10.5% less sugar, 5.5% less saturated fat). Furthermore, participants exposed to the food label advocated its introduction more strongly than the control group (p = 0.081). Consumers worldwide could easily install such applications to display digital food labels on their end devices, and would thus not have to wait for stakeholders in the food industry to eventually reach consensus on mandatory food label introduction.
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Affiliation(s)
- Klaus L. Fuchs
- ETH AI Center, ETH Zurich, 8092 Zurich, Switzerland;
- Correspondence: ; Tel.: +41-78-858-7037
| | - Jie Lian
- Institute of Computer Science (ICS-HSG), University of St. Gallen, 9000 St. Gallen, Switzerland; (J.L.); (S.M.)
| | - Leonard Michels
- Institute of Information Systems, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (L.M.); (V.T.)
| | - Simon Mayer
- Institute of Computer Science (ICS-HSG), University of St. Gallen, 9000 St. Gallen, Switzerland; (J.L.); (S.M.)
| | | | - Verena Tiefenbeck
- Institute of Information Systems, Friedrich-Alexander-Universität Erlangen-Nürnberg, 91054 Erlangen, Germany; (L.M.); (V.T.)
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15
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Health Star Ratings and Beverage Purchase Intentions: A Study of Australian and New Zealand Hospitality Consumers. Foods 2021; 10:foods10112764. [PMID: 34829045 PMCID: PMC8617703 DOI: 10.3390/foods10112764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 11/23/2022] Open
Abstract
This study examines the effects of a health star rating system on the attitudes of consumers and their purchase intentions towards beverage products sold in hospitality venues. Previous studies linking health ratings to the food and beverages of consumers mainly focus on fast-moving consumer goods and retail purchasing. However, purchasing patterns in hospitality and foodservice environments are distinct as consumers may be less concerned about health and more interested in the dining experience. Thus, this research focuses on: (1) whether the presence of health star ratings on beverage products influences the willingness of consumers to purchase in the context of the hospitality industry, and (2) identifying the demographic and psychographic factors influencing these behavioural intentions. Using Ordinary Least Squares regression to analyse data from an e-survey of 1021 consumers in Australia and New Zealand, the study found that health star ratings do have an impact on the willingness of consumers to purchase healthy beverages. Specifically, psychographic segmentation around ‘health goals’ is far more pertinent to understanding purchase behaviour in a hospitality setting than age, gender, income, or country. The findings present new insights into the importance of health star labelling on beverages and the purchase intentions of consumers.
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16
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Chan J, McMahon E, Brimblecombe J. Point-of-sale nutrition information interventions in food retail stores to promote healthier food purchase and intake: A systematic review. Obes Rev 2021; 22:e13311. [PMID: 34254422 DOI: 10.1111/obr.13311] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 12/01/2022]
Abstract
Providing simple information that identifies healthier/less healthy products at the point-of-sale has been increasingly recognized as a potential strategy for improving population diet. This review evaluated the effect on healthiness of food purchasing/intake of interventions that identify specific products as healthier/less healthy at the point-of-sale in food retail settings. Five databases were searched for peer-reviewed randomized controlled or quasi-experimental trials published 2000-2020. Effects on primary outcomes of the 26 eligible studies (322 stores and 19,002 participants) were positive (n = 14), promising (effective under certain conditions; n = 3), mixed (different effect across treatment arms/outcomes; n = 4), null (n = 3), negative (n = 1), or unclear (n = 1). Shelf-label studies (three studies of two rating systems across all products) were positive. Technology-delivered (mobile applications/podcast/kiosk) interventions were positive (n = 3/5) or promising/mixed (n = 2/5). In-store displays (n = 16) had mixed effectiveness. Interventions provided information on targeted healthier products only (n = 17), unhealthy products only (n = 1), both healthy and unhealthy (n = 2), and across all products (n = 5). No patterns were found between behavior change technique used and effectiveness. Study quality was mixed. These findings indicate that point-of-sale interventions identifying healthy/unhealthy options can lead to healthier customer purchasing behavior, particularly those delivered using shelf-labels or technology. Further research on discouraging unhealthy foods is needed.
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Affiliation(s)
- Jasmine Chan
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, Victoria, Australia.,Global Obesity Centre, Deakin University, Burwood, Victoria, Australia
| | - Emma McMahon
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Julie Brimblecombe
- Department of Nutrition, Dietetics and Food, Monash University, Notting Hill, Victoria, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
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17
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Hoenink JC, Stuber JM, Lakerveld J, Waterlander W, Beulens JWJ, Mackenbach JD. The effect of on-shelf sugar labeling on beverage sales in the supermarket: a comparative interrupted time series analysis of a natural experiment. Int J Behav Nutr Phys Act 2021; 18:49. [PMID: 33823851 PMCID: PMC8025575 DOI: 10.1186/s12966-021-01114-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 03/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nutrition labels show potential in increasing healthy food and beverage purchases, but their effectiveness seems to depend on the type of label, the targeted food category and the setting, and evidence on their impact in real-world settings is limited. The aim of this study was to evaluate the effectiveness of an industry-designed on-shelf sugar label on the sales of beverages with no, low, medium and high sugar content implemented within a real-world supermarket. METHODS In week 17 of 2019, on-shelf sugar labels were implemented by a Dutch supermarket chain. Non-alcoholic beverages were classified using a traffic-light labeling system and included the beverage categories "green" for sugar free (< 1.25 g/250 ml), "blue" for low sugar (1.25-6.24 g/250 ml), "yellow" for medium sugar (6.25-13.5 g/250 ml) and "amber" for high sugar (> 13.5 g/250 ml). Store-level data on beverage sales and revenue from 41 randomly selected supermarkets for 13 weeks pre-implementation and 21 weeks post-implementation were used for analysis. In total, 30 stores implemented the on-shelf sugar labels by week 17, and the 11 stores that had not were used as comparisons. Outcome measures were differences in the number of beverages sold in the four label categories and the total revenue from beverage sales in implementation stores relative to comparison stores. Analyses were conducted using a multiple-group Interrupted Time Series Approach. Results of individual store data were combined using random effect meta-analyses. RESULTS At the end of the intervention period, the changes in sales of beverages with green (B 3.4, 95%CI -0.3; 7.0), blue (B 0.0, 95%CI -0.6; 0.7), yellow (B 1.3, 95%CI -0.9; 3.5), and amber (B 0.9, 95%CI -5.5; 7.3) labels were not significantly different between intervention and comparison stores. The changes in total revenues for beverages at the end of the intervention period were also not significantly different between intervention and comparison stores. CONCLUSION The implementation of an on-shelf sugar labeling system did not significantly decrease unhealthy beverage sales or significantly increase healthier beverage sales. Nutrition labeling initiatives combined with complementary strategies, such as pricing strategies or other healthy food nudging approaches, should be considered to promote healthier beverage purchases.
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Affiliation(s)
- J C Hoenink
- Department of Epidemiology and Data Science, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands. .,Upstream Team, www.upstreamteam.nl, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands.
| | - J M Stuber
- Department of Epidemiology and Data Science, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands.,Upstream Team, www.upstreamteam.nl, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
| | - J Lakerveld
- Department of Epidemiology and Data Science, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands.,Upstream Team, www.upstreamteam.nl, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
| | - W Waterlander
- Department of Public and Occupational Health, Amsterdam Public Health research institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - J W J Beulens
- Department of Epidemiology and Data Science, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands.,Upstream Team, www.upstreamteam.nl, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Universiteitsweg 100, Utrecht, the Netherlands
| | - J D Mackenbach
- Department of Epidemiology and Data Science, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands.,Upstream Team, www.upstreamteam.nl, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
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18
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Silva ARCS, Braga LVM, Anastácio LR. A comparison of four different Nutritional Profile models in their scoring of critical nutrient levels in food products targeted at Brazilian children. NUTR BULL 2021. [DOI: 10.1111/nbu.12490] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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19
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Feteira-Santos R, Alarcão V, Santos O, Virgolino A, Fernandes J, Vieira CP, João Gregório M, Nogueira P, Costa A, Graça P. Looking Ahead: Health Impact Assessment of Front-Of-Pack Nutrition Labelling Schema as a Public Health Measure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041422. [PMID: 33546490 PMCID: PMC7913662 DOI: 10.3390/ijerph18041422] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 01/10/2023]
Abstract
This study aimed to describe the underlying process, used methods and major recommendations emerging from a comprehensive and prospective health impact assessment of the endorsement of a front-of-pack nutrition labelling (FOP-NL) system by the Portuguese health authorities. A mixed-methods approach was used to gather information on the impact of four FOP-NL schemes on consumers' selection of food products according to the perception of their nutritional quality, combining a systematic literature review, focus groups (FG), in-depth individual interviews, and an open-label crossover randomized controlled study. The relevance of FOP-NL as a public health promotion policy has emerged as a consensual idea among either FGs' participants (i.e., consumers and experts), or interviewed stakeholders. Although all of the evaluated FOP-NLs result better than no system on promoting the choice of the healthiest product, the effectiveness of easy-to-interpret FOP-NL among vulnerable groups raised concerns related to the need of integrating specific nutritional information to promote a better self-management of chronic diseases, and related to the level of literacy of consumers, which could impair the usage of FOP-NL. Educational campaigns addressing skills to use FOP-NL is recommended. Furthermore, a monitoring strategy should be considered to evaluate the long-term effectiveness of this policy in promoting healthier food choices, and in reducing diet-related non-communicable diseases burden.
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Affiliation(s)
- Rodrigo Feteira-Santos
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal; (R.F.-S.); (O.S.); (A.V.); (J.F.); (P.N.); (A.C.)
| | - Violeta Alarcão
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal; (R.F.-S.); (O.S.); (A.V.); (J.F.); (P.N.); (A.C.)
- Centro de Investigação e Estudos de Sociologia, ISCTE-Instituto Universitário de Lisboa (ISCTE-IUL), Avenida das Forças Armadas, 1649-026 Lisboa, Portugal
- Correspondence: ; Tel.: +351-217-999-489
| | - Osvaldo Santos
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal; (R.F.-S.); (O.S.); (A.V.); (J.F.); (P.N.); (A.C.)
- Unbreakable Idea Research, 2550-426 Painho, Portugal
| | - Ana Virgolino
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal; (R.F.-S.); (O.S.); (A.V.); (J.F.); (P.N.); (A.C.)
| | - João Fernandes
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal; (R.F.-S.); (O.S.); (A.V.); (J.F.); (P.N.); (A.C.)
| | - Carlota Pacheco Vieira
- Direção-Geral da Saúde, Alameda Dom Afonso Henriques, 1000-123 Lisboa, Portugal; (C.P.V.); (M.J.G.); (P.G.)
| | - Maria João Gregório
- Direção-Geral da Saúde, Alameda Dom Afonso Henriques, 1000-123 Lisboa, Portugal; (C.P.V.); (M.J.G.); (P.G.)
- Programa Nacional para a Promoção da Alimentação Saudável, Direção-Geral da Saúde, Alameda Dom Afonso Henriques, 1000-123 Lisboa, Portugal
- Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Rua do Campo Alegre 823, 4150-180 Porto, Portugal
| | - Paulo Nogueira
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal; (R.F.-S.); (O.S.); (A.V.); (J.F.); (P.N.); (A.C.)
- Direção-Geral da Saúde, Alameda Dom Afonso Henriques, 1000-123 Lisboa, Portugal; (C.P.V.); (M.J.G.); (P.G.)
- Laboratório de Biomatemática, Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - Andreia Costa
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal; (R.F.-S.); (O.S.); (A.V.); (J.F.); (P.N.); (A.C.)
- Direção-Geral da Saúde, Alameda Dom Afonso Henriques, 1000-123 Lisboa, Portugal; (C.P.V.); (M.J.G.); (P.G.)
- Escola Superior de Enfermagem de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - Pedro Graça
- Direção-Geral da Saúde, Alameda Dom Afonso Henriques, 1000-123 Lisboa, Portugal; (C.P.V.); (M.J.G.); (P.G.)
- Programa Nacional para a Promoção da Alimentação Saudável, Direção-Geral da Saúde, Alameda Dom Afonso Henriques, 1000-123 Lisboa, Portugal
- Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Rua do Campo Alegre 823, 4150-180 Porto, Portugal
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An R, Shi Y, Shen J, Bullard T, Liu G, Yang Q, Chen N, Cao L. Effect of front-of-package nutrition labeling on food purchases: a systematic review. Public Health 2021; 191:59-67. [PMID: 33517247 DOI: 10.1016/j.puhe.2020.06.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES This study systematically reviewed evidence from interventions on the effect of front-of-package (FOP) nutrition labeling on food purchases. STUDY DESIGN The study design used in this study is a systematic review. METHODS Keyword search was performed in PubMed, Web of Science, Scopus, and Cochrane Library. RESULTS Fifteen studies (10 randomized controlled trials, four pre-post studies, and one case-control study) met the eligibility criteria and were included in the review. Five studies were conducted in a controlled setting through the establishment of an online virtual supermarket or physical laboratory food store solely for the intervention. In contrast, the remaining ten studies were conducted in a naturalistic setting where people commonly purchase foods (e.g., supermarket, grocery store, school/hospital cafeteria, or vending machine). FOP labels assessed included traffic lights, health star rating, daily intake guides, health warnings, and high sugar symbol labels. Compared with the control, FOP labels were effective for helping participants make healthier food purchase decisions in five of the 12 studies that assessed traffic lights labels, in one of the two studies that assessed health warning labels, and in one study that assessed high sugar symbol labels. Three assessed health star ratings and one assessed daily intake guide labels, but none revealed an effect on food purchases compared with the control. CONCLUSIONS Findings on the effectiveness of FOP nutrition labels in 'nudging' consumers toward healthier food purchases remain mixed and inconclusive. Future studies should examine other types of FOP labels beside the traffic lights labels and explore the different effects by consumer affordability, population subgroup, and shopping environment.
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Affiliation(s)
- R An
- Brown School, Washington University, St. Louis, MO, 63130, USA
| | - Y Shi
- School of Medicine, University of California, La Jolla, San Diego, CA, 92093, USA
| | - J Shen
- Department of Physical Education, China University of Geosciences (Beijing), Beijing, 100083, China
| | - T Bullard
- Department of Kinesiology and Community Health, University of Illinois, Champaign, IL, 61801, USA
| | - G Liu
- Beijing Normal University, Beijing, 100875, China
| | - Q Yang
- Shanghai University of Science and Technology, Shanghai, 201400, China
| | - N Chen
- Tsinghua University, Beijing, 100084, China
| | - L Cao
- School of Management and Journalism, Shenyang Sport University, Shenyang, Liaoning, 110102, China.
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An R, Liu J, Liu R, Barker AR, Figueroa RB, McBride TD. Impact of Sugar-Sweetened Beverage Warning Labels on Consumer Behaviors: A Systematic Review and Meta-Analysis. Am J Prev Med 2021; 60:115-126. [PMID: 33059917 DOI: 10.1016/j.amepre.2020.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 06/11/2020] [Accepted: 07/13/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT As a primary source of added sugars, sugar-sweetened beverage consumption contributes to obesity. This study systematically synthesizes the scientific evidence regarding the impact of sugar-sweetened beverage warning labels on consumer behaviors and intentions. EVIDENCE ACQUISITION A keyword/reference search was performed in 2019 in Cochrane Library, PubMed, Web of Science, CINAHL, Scopus, and Google Scholar. Meta-analysis was conducted in 2020 to estimate the effect of sugar-sweetened beverage warning labels on consumers' purchase decisions. EVIDENCE SYNTHESIS A total of 23 studies (13 RCTs, 9 nonrandomized experiments, and 1 computer simulation study) met the eligibility criteria and were included. Labels were classified into 6 categories: (1) symbol with nutrient profile, (2) symbol with health effect, (3) text of nutrient profile, (4) text of health effect, (5) graphic with health effect, and (6) graphic with nutrient profile. Compared with the no-label control group, sugar-sweetened beverage warning label use was associated with reduced odds of choosing sugar-sweetened beverages (OR=0.49, 95% CI=0.41, 0.56) and a reduced sugar-sweetened beverage purchase intention (Cohen's d= -0.18, 95% CI= -0.31, -0.06). Across alternative label categories, the graphic with health effect (OR=0.34, 95% CI=0.08, 0.61), text of health effect (OR=0.47, 95% CI=0.39, 0.55), graphic with nutrient profile (OR=0.58, 95% CI=0.36, 0.81), and symbol with health effect (OR=0.67, 95% CI=0.39, 0.95) were associated with reduced odds of choosing sugar-sweetened beverages. CONCLUSIONS Sugar-sweetened beverage warning labels were effective in dissuading consumers from choosing them. Graphic with health effect labels showed the largest impact. Future studies should delineate the psychosocial pathways linking sugar-sweetened beverage warning labels to purchase decisions, recruit socioeconomically diverse participants, and design experiments in naturalistic settings.
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Affiliation(s)
- Ruopeng An
- Brown School, Washington University, St. Louis, Missouri
| | - Jianxiu Liu
- Department of Physical Education, Tsinghua University, Beijing, China.
| | - Ruidong Liu
- Department of Physical Education, Tsinghua University, Beijing, China
| | | | - Roger B Figueroa
- Division of Nutritional Sciences, College of Human Ecology, Cornell University, Ithaca, New York
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Drewnowski A, Monterrosa EC, de Pee S, Frongillo EA, Vandevijvere S. Shaping Physical, Economic, and Policy Components of the Food Environment to Create Sustainable Healthy Diets. Food Nutr Bull 2020; 41:74S-86S. [DOI: 10.1177/0379572120945904] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background: Sustainable healthy diets are those dietary patterns that promote all dimensions of individuals’ health and well-being; have low environmental pressure and impact; are accessible, affordable, safe, and equitable; and are culturally acceptable. The food environment, defined as the interface between the wider food system and consumer’s food acquisition and consumption, is critical for ensuring equitable access to foods that are healthy, safe, affordable, and appealing. Discussion: Current food environments are creating inequities, and sustainable healthy foods are generally more accessible for those of higher socioeconomic status. The physical, economic, and policy components of the food environment can all be acted on to promote sustainable healthy diets. Physical spaces can be modified to improve relative availability (ie, proximity) of food outlets that carry nutritious foods in low-income communities; to address economic access certain actions may improve affordability, such as fortification, preventing food loss through supply chain improvements; and commodity specific vouchers for fruits, vegetables, and legumes. Other policy actions that address accessibility to sustainable healthy foods are comprehensive marketing restrictions and easy-to-understand front-of-pack nutrition labels. While shaping food environments will require concerted action from all stakeholders, governments and private sector bear significant responsibility for ensuring equitable access to sustainable healthy diets.
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Affiliation(s)
- Adam Drewnowski
- University of Washington, Department of Epidemiology, Seattle, WA, USA
| | | | - Saskia de Pee
- UN World Food Programme, Rome, Italy
- Tufts University, Friedman School of Nutrition Science and Policy, Boston, MA, USA
| | - Edward A. Frongillo
- University of South Carolina, Arnold School of Public Health, Columbia, SC, USA
| | - Stefanie Vandevijvere
- Scientific Institute of Public Health (Sciensano), Department of Epidemiology and Public Health, Brussels, Belgium
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23
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Scapin T, Fernandes AC, Curioni CC, Pettigrew S, Neal B, Coyle DH, Rodrigues VM, Bernardo GL, Uggioni PL, Proença RPC. Influence of sugar label formats on consumer understanding and amount of sugar in food choices: a systematic review and meta-analyses. Nutr Rev 2020; 79:788-801. [PMID: 33313917 DOI: 10.1093/nutrit/nuaa108] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
CONTEXT Reducing population intakes of sugar has become a focus of many national and international public health policies. Packaged foods and beverages are key contributors to sugar intakes, and food labels can be an effective tool to reduce sugar consumption. OBJECTIVE The aim of this systematic review was to examine the influence of sugar label formats on 2 outcomes: consumers' understanding of sugar information, and the amount of sugar in consumers' food choices. DATA SOURCES Scopus, Web of Science, PubMed, CAB Abstracts, SciELO, and the Cochrane Library databases were searched up until February 4, 2020. STUDY SELECTION Randomized experiments or quasi-experiments were included if they investigated the influence of sugar label formats on consumers' understanding of sugar information or on the amount of sugar in consumers' food choices. DATA EXTRACTION Data were extracted independently by 2 authors. Mean differences (MDs), standardized mean differences (SMDs), and odds ratios (ORs) plus 95%CIs were used to describe between-group differences for intervention label formats using random-effects models. RESULTS Twenty-three studies, which examined 39 comparisons, were included. Label formats using "high in sugar" interpretative texts (traffic light labels [MD 41.6; 95%CI 37.9-45.4] and warning signs [OR 1.33; 95%CI 1.0-1.78]) were most effective in increasing consumers' understanding of the sugar content in packaged foods. Health warning messages (SMD -0.32; 95%CI -0.43 to -0.22), graphical depictions of sugar content in teaspoons (SMD -0.32; 95%CI -0.48 to -0.17), and warning signs (SMD -0.24; 95%CI -0.35 to -0.13) were most effective for influencing consumers to choose products with lower sugar content. CONCLUSIONS Formats that provide an interpretation of sugar information, particularly those indicating if a product is high in sugar, were more helpful than only numerical information for improving consumer understanding and promoting food choices with less sugar. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD42018081222.
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Affiliation(s)
- Tailane Scapin
- Nutrition Postgraduate Program, Nutrition in Foodservice Research Centre (NUPPRE), Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil.,The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Ana C Fernandes
- Nutrition Postgraduate Program, Nutrition in Foodservice Research Centre (NUPPRE), Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Cintia C Curioni
- Department of Social and Applied Nutrition, Institute of Nutrition, Rio de Janeiro State University (UERJ), Rio de Janeiro, Brazil
| | - Simone Pettigrew
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Daisy H Coyle
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Vanessa M Rodrigues
- Nutrition Postgraduate Program, Nutrition in Foodservice Research Centre (NUPPRE), Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Greyce L Bernardo
- Nutrition Postgraduate Program, Nutrition in Foodservice Research Centre (NUPPRE), Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Paula L Uggioni
- Nutrition Postgraduate Program, Nutrition in Foodservice Research Centre (NUPPRE), Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
| | - Rossana P C Proença
- Nutrition Postgraduate Program, Nutrition in Foodservice Research Centre (NUPPRE), Federal University of Santa Catarina (UFSC), Florianópolis, Santa Catarina, Brazil
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Yoder AD, Proaño GV, Handu D. Retail Nutrition Programs and Outcomes: An Evidence Analysis Center Scoping Review. J Acad Nutr Diet 2020; 121:1866-1880.e4. [PMID: 33229206 DOI: 10.1016/j.jand.2020.08.080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/05/2020] [Accepted: 08/18/2020] [Indexed: 02/06/2023]
Abstract
As nutrition-related diseases contribute to rising health care costs, food retail settings are providing a unique opportunity for registered dietitian nutritionists (RDNs) to address the nutritional needs of consumers. Food as Medicine interventions play a role in preventing and/or managing many chronic conditions that drive health care costs. The objective of this scoping review was to identify and characterize literature examining Food as Medicine interventions within food retail settings and across consumer demographics. An electronic literature search of 8 databases identified 11,404 relevant articles. Results from the searches were screened against inclusion criteria, and intervention effectiveness was assessed for the following outcomes: improvement in health outcomes and cost-effectiveness. One-hundred and eighty-six papers and 25 systematic reviews met inclusion criteria. Five categories surfaced as single interventions: prescription programs, incentive programs, medically tailored nutrition, path-to-purchase marketing, and personalized nutrition education. Multiple combinations of intervention categories, reporting of health outcomes (nutritional quality of shopping purchases, eating habits, biometric measures), and cost-effectiveness (store sales, health care dollar savings) also emerged. The intervention categories that produced both improved health outcomes and cost-effectiveness included a combination of incentive programs, personalized nutrition education, and path-to-purchase marketing. Food as Medicine interventions in the food retail setting can aid consumers in navigating health through diet and nutrition by encompassing the following strategic focus areas: promotion of health and well-being, managing chronic disease, and improving food security. Food retailers should consider the target population and desired focus areas and should engage registered dietitian nutritionists when developing Food as Medicine interventions.
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25
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Effectiveness of interpretive front-of-pack nutritional labelling schemes on the promotion of healthier food choices: a systematic review. INT J EVID-BASED HEA 2020; 18:24-37. [PMID: 31895716 DOI: 10.1097/xeb.0000000000000214] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS Interpretive front-of-package nutrition labelling can contribute to healthier food habits. This systematic review aimed to examine the effectiveness of interpretive front-of-package nutrition labelling schemes on consumers' food choices, namely at the moment of food purchase, and to analyse if this potential front-of-package nutrition labelling's effect varies according to different socioeconomic groups. METHODS Electronic databases (Cochrane Library, PubMed, Scopus, and Web of Science) search was performed to identify peer-reviewed articles describing longitudinal studies evaluating the effect of front-of-package nutrition labelling schemes on consumers' food choices, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-Equity 2012 Extension guidelines. No publication-period or language restrictions were applied. PROGRESS-Plus framework was used to report if and how socioeconomic factors were considered in analyses of front-of-package nutrition labelling-related interventions' effect. RESULTS Nine studies were selected for narrative synthesis (seven randomized controlled trials and two cross-over trials). When compared with no-interpretive-label conditions, front-of-package nutrition labelling showed a positive impact for nutritional content understanding, healthiness perception of products, selection of products with better nutritional quality, and purchase intention. However, there is no robust evidence of superiority of a specific front-of-package nutrition labelling scheme's effect, neither on consumers' understanding of nutritional content nor on food choices. An evaluation of the studies following the PROGRESS-Plus framework revealed that socioecononomic status and education were the most frequently used dimensions, when assessing the effect of interpretative front-of-pack nutrition labels. More evidence is necessary to determine the role of front-of-pack nutrition labels in decreasing inequalities between different population subgroups, namely among the most vulnerable subgroups, on the promotion of healthy food choices. CONCLUSION Well controlled longitudinal studies, following a real-world evidence approach, are needed to clarify front-of-package nutrition labelling's impact on consumers' food choices, namely at purchase points, taking into account the most vulnerable population subgroups, such as those with lower literacy and/or financial resources.
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Bablani L, Ni Mhurchu C, Neal B, Skeels CL, Staub KE, Blakely T. The impact of voluntary front-of-pack nutrition labelling on packaged food reformulation: A difference-in-differences analysis of the Australasian Health Star Rating scheme. PLoS Med 2020; 17:e1003427. [PMID: 33216747 PMCID: PMC7679009 DOI: 10.1371/journal.pmed.1003427] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 10/19/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Front-of-pack nutrition labelling (FoPL) of packaged foods can promote healthier diets. Australia and New Zealand (NZ) adopted the voluntary Health Star Rating (HSR) scheme in 2014. We studied the impact of voluntary adoption of HSR on food reformulation relative to unlabelled foods and examined differential impacts for more-versus-less healthy foods. METHODS AND FINDINGS Annual nutrition information panel data were collected for nonseasonal packaged foods sold in major supermarkets in Auckland from 2013 to 2019 and in Sydney from 2014 to 2018. The analysis sample covered 58,905 unique products over 14 major food groups. We used a difference-in-differences design to estimate reformulation associated with HSR adoption. Healthier products adopted HSR more than unhealthy products: >35% of products that achieved 4 or more stars displayed the label compared to <15% of products that achieved 2 stars or less. Products that adopted HSR were 6.5% and 10.7% more likely to increase their rating by ≥0.5 stars in Australia and NZ, respectively. Labelled products showed a -4.0% [95% confidence interval (CI): -6.4% to -1.7%, p = 0.001] relative decline in sodium content in NZ, and there was a -1.4% [95% CI: -2.7% to -0.0%, p = 0.045] sodium change in Australia. HSR adoption was associated with a -2.3% [-3.7% to -0.9%, p = 0.001] change in sugar content in NZ and a statistically insignificant -1.1% [-2.3% to 0.1%, p = 0.061] difference in Australia. Initially unhealthy products showed larger reformulation effects when adopting HSR than healthier products. No evidence of a change in protein or saturated fat content was observed. A limitation of our study is that results are not sales weighted. Thus, it is not able to assess changes in overall nutrient consumption that occur because of HSR-caused reformulation. Also, participation into labelling and reformulation is jointly determined by producers in this observational study, impacting its generalisability to settings with mandatory labelling. CONCLUSIONS In this study, we observed that reformulation changes following voluntary HSR labelling are small, but greater for initially unhealthy products. Initially unhealthy foods were, however, less likely to adopt HSR. Our results, therefore, suggest that mandatory labelling has the greatest potential for improving the healthiness of packaged foods.
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Affiliation(s)
- Laxman Bablani
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
- * E-mail:
| | - Cliona Ni Mhurchu
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- The George Institute for Global Health, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - Bruce Neal
- The George Institute for Global Health, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | | | - Kevin E. Staub
- Department of Economics, University of Melbourne, Melbourne, Australia
| | - Tony Blakely
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
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Muller L, Ruffieux B. What Makes a Front-of-Pack Nutritional Labelling System Effective: The Impact of Key Design Components on Food Purchases. Nutrients 2020; 12:nu12092870. [PMID: 32961760 PMCID: PMC7551239 DOI: 10.3390/nu12092870] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/07/2020] [Accepted: 09/16/2020] [Indexed: 01/12/2023] Open
Abstract
The relative impacts on food purchases of many alternative front-of-pack nutritional labelling systems were tested, with various methods—from opinion pool to nationwide experiments. Clearly, some systems induce better purchasing responses, having better nutritional impacts on food baskets. Nonetheless, we still ignore what the ingredients of an efficient label are. Here, we propose guidance for label designers. To do so, we first propose a typology that breaks down established labelling systems into four elementary components: Directiveness, Scope and Gradation, Set of Reference and Sign. On this basis, we then build seven alternative generic labelling systems that we test in a framed-field experiment enabling us to measure the effect of each component on food purchases in isolation. Our results show that an effective front-of-pack labelling system should be Food-Directive (instead of Diet-Directive) and be displayed on both healthy and unhealthy food. The reference set, which is across categories or within categories, produces the same average nutrition score but generates contrasting behavioural responses.
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28
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Young L, Rosin M, Jiang Y, Grey J, Vandevijvere S, Waterlander W, Ni Mhurchu C. The effect of a shelf placement intervention on sales of healthier and less healthy breakfast cereals in supermarkets: A co-designed pilot study. Soc Sci Med 2020; 266:113337. [PMID: 32950330 DOI: 10.1016/j.socscimed.2020.113337] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 10/23/2022]
Abstract
Supermarkets are the principal source of grocery food in many high-income countries. Choice architecture strategies show promise to improve the healthiness of food choices. A retailer-academic collaboration was formed to co-design and pilot selected commercially sustainable strategies to increase sales of healthier foods relative to less healthy foods in supermarkets. Two co-design workshops, involving supermarket corporate staff and public health nutrition academics, identified potential interventions. One intervention, more prominent shelf placement of healthier products within one category (breakfast cereals), was selected for testing. A pilot study (baseline, intervention and follow-up, 12-weeks each) was undertaken in six supermarkets (three intervention and three control) in Auckland, New Zealand. Products were ranked by nutrient levels and profile, and after accounting for the supermarkets' space management principles, healthier products were placed at adult eye level. The primary outcome was change in sales of healthier products relative to total category sales. Secondary outcomes were nutrient profile of category sales, in-store product promotions, customer perceptions, and retailer feedback. There was no difference in proportional sales of more prominently positioned healthier products between intervention (56%) and control (56%) stores during the intervention. There were no differences in the nutrient profile of category sales. A higher proportion of less healthy breakfast cereals were displayed in intervention versus control stores (57% vs 43%). Most customers surveyed supported shelf placement as a strategy (265, 88%) but noted brand preferences and price were more salient determinants of purchases. Retailers were similarly supportive but balancing profit, health/nutrition and customer satisfaction was challenging. Shelf placement alone was not an effective strategy to increase purchases of healthier breakfast cereals. This study showed co-design of a healthy eating intervention with a commercial retailer is feasible, but concurrent retail environment factors likely limited the public health impact of the intervention.
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Affiliation(s)
- Leanne Young
- National Institute for Health Innovation, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.
| | - Magda Rosin
- National Institute for Health Innovation, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Yannan Jiang
- National Institute for Health Innovation, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Jacqui Grey
- National Institute for Health Innovation, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
| | - Stefanie Vandevijvere
- Scientific Institute of Public Health (Sciensano), Rue Juliette Wytsmanstraat 14, 1050, Brussels, Belgium
| | - Wilma Waterlander
- Amsterdam UMC, University of Amsterdam, Department of Public Health, P.O. Box 19268, 1000, GG Amsterdam, the Netherlands
| | - Cliona Ni Mhurchu
- National Institute for Health Innovation, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
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Santos O, Alarcão V, Feteira-Santos R, Fernandes J, Virgolino A, Sena C, Vieira CP, Gregório MJ, Nogueira P, Graça P, Costa A. Impact of different front-of-pack nutrition labels on online food choices. Appetite 2020; 154:104795. [PMID: 32798050 DOI: 10.1016/j.appet.2020.104795] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 05/09/2020] [Accepted: 06/29/2020] [Indexed: 01/10/2023]
Abstract
Front-of-pack nutrition labels (FOP-NL) are efficient tools for increasing consumers' awareness of the nutritional quality of food products, prompting healthier food choices. The main goal of this study was to evaluate the impact of four FOP-NL schemes - Traffic Light label (TL), Guideline Daily Amounts (%GDA), Nutri-Score (NS) and Health Star Rating (HSR) - on consumers' selection of food products according to perceived nutritional quality. A cross-sectional open-label crossover randomized controlled study was carried out among Portuguese consumers. A web-based questionnaire was used to assess participants' a) preferences regarding FOP-NLs and b) capacity to select healthy products in a food selection task using the information from FOP-NL schemes. When performing the selection task, participants had the option to indicate that they could not decide simply based on the presented FOP-NL (requiring more information). Overall, 357 adults participated in the study. Regarding consumers' preferences, TL received the most favorable responses, while NS received the fewest. All FOP-NLs performed better than the no-nutritional label control condition in the food selection task. The highest proportion of correct choices was obtained for TL (72.3%), followed by HSR (70.9%), %GDA (70.0%) and NS (62.2%), though no significant differences were found among FOP-NLs. Percentages of respondents indicating not being able to answer due to lack of information affected the proportion of correct choices, with 10.3% for TL, 12.9% for %GDA, 14.6% for HSR, and 25.8% for NS, indicating they were unable to choose without additional information. Although no particular FOP-NL system stood out as the most significantly effective, TL was the most preferred by Portuguese adults. Long-term real-world evidence is necessary to assess the impact of FOP-NL systems on individuals' food choices.
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Affiliation(s)
- Osvaldo Santos
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal; Unbreakable Idea Research, Lda, Painho, Portugal.
| | - Violeta Alarcão
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal; Centro de Investigação e Estudos de Sociologia (CIES-IUL), Instituto Universitário de Lisboa (ISCTE-IUL), Lisboa, Portugal.
| | - Rodrigo Feteira-Santos
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal.
| | - João Fernandes
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal.
| | - Ana Virgolino
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal.
| | - Catarina Sena
- Direção-Geral da Saúde, Lisboa, Portugal. Alameda D, Afonso Henriques, 45, 1049-005, Lisboa, Portugal
| | - Carlota Pacheco Vieira
- Direção-Geral da Saúde, Lisboa, Portugal. Alameda D, Afonso Henriques, 45, 1049-005, Lisboa, Portugal
| | - Maria João Gregório
- Programa Nacional para a Promoção da Alimentação Saudável, Direção-Geral da Saúde, Lisboa, Portugal, Alameda D, Afonso Henriques, 45, 1049-005, Lisboa, Portugal; Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto. Rua do Campo Alegre, 823, 4150-180, Porto, Portugal.
| | - Paulo Nogueira
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal; Direção-Geral da Saúde, Lisboa, Portugal. Alameda D, Afonso Henriques, 45, 1049-005, Lisboa, Portugal; Laboratório de Biomatemática, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal.
| | - Pedro Graça
- Programa Nacional para a Promoção da Alimentação Saudável, Direção-Geral da Saúde, Lisboa, Portugal, Alameda D, Afonso Henriques, 45, 1049-005, Lisboa, Portugal; Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto. Rua do Campo Alegre, 823, 4150-180, Porto, Portugal.
| | - Andreia Costa
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa. Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal; Direção-Geral da Saúde, Lisboa, Portugal. Alameda D, Afonso Henriques, 45, 1049-005, Lisboa, Portugal; Escola Superior de Enfermagem de Lisboa, Lisboa, Portugal, Avenida Professor Egas Moniz, 1649-028, Lisboa, Portugal.
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Browne J, Lock M, Walker T, Egan M, Backholer K. Effects of food policy actions on Indigenous Peoples' nutrition-related outcomes: a systematic review. BMJ Glob Health 2020; 5:e002442. [PMID: 32816952 PMCID: PMC7437701 DOI: 10.1136/bmjgh-2020-002442] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/12/2020] [Accepted: 06/18/2020] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Indigenous Peoples worldwide endure unacceptable health disparities with undernutrition and food insecurity often coexisting with obesity and chronic diseases. Policy-level actions are required to eliminate malnutrition in all its forms. However, there has been no systematic synthesis of the evidence of effectiveness of food and nutrition policies for Indigenous Peoples around the world. This review fills that gap. METHODS Eight databases were searched for peer-reviewed literature, published between 2000 and 2019. Relevant websites were searched for grey literature. Articles were included if they were original studies, published in English and included data from Indigenous Peoples from Western colonised countries, evaluated a food or nutrition policy (or intervention), and provided quantitative impact/outcome data. Study screening, data extraction and quality assessment were undertaken independently by two authors, at least one of whom was Indigenous. A narrative synthesis was undertaken with studies grouped according to the NOURISHING food policy framework. RESULTS We identified 78 studies from Canada, Australia, Aotearoa/New Zealand and the USA. Most studies evaluated targeted interventions, focused on rural or remote Indigenous communities. The most effective interventions combined educational strategies with policies targeting food price, composition and/or availability, particularly in retail and school environments. Interventions to reduce exposure to unhealthy food advertising was the only area of the NOURISHING framework not represented in the literature. Few studies examined the impact of universal food policies on Indigenous Peoples' diets, health or well-being. CONCLUSION Both targeted and universal policy action can be effective for Indigenous Peoples. Actions that modify the structures and systems governing food supply through improved availability, access and affordability of healthy foods should be prioritised. More high-quality evidence on the impact of universal food and nutrition policy actions for Indigenous Peoples is required, particularly in urban areas and in the area of food marketing.
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Affiliation(s)
- Jennifer Browne
- Deakin University, Global Obesity Centre, Institute for Health Transformation, Geelong, Victoria, Australia
| | - Mark Lock
- Deakin University, Global Obesity Centre, Institute for Health Transformation, Geelong, Victoria, Australia
| | - Troy Walker
- Deakin University, Global Obesity Centre, Institute for Health Transformation, Geelong, Victoria, Australia
| | - Mikaela Egan
- Victorian Aboriginal Community Controlled Health Organisation, Melbourne, Victoria, Australia
| | - Kathryn Backholer
- Deakin University, Global Obesity Centre, Institute for Health Transformation, Geelong, Victoria, Australia
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Kwon SJ, Kim Y. Sex-Based Differences in the Association between Nutrition Label Awareness and the Prevalence of Atopic Dermatitis: A Cross-Sectional Survey. Healthcare (Basel) 2020; 8:healthcare8030210. [PMID: 32668626 PMCID: PMC7551287 DOI: 10.3390/healthcare8030210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/08/2020] [Accepted: 07/10/2020] [Indexed: 11/16/2022] Open
Abstract
Atopic dermatitis is a chronic allergic disease with multifactorial causation. Although its association with diet has been demonstrated, it remains unclear whether the prevalence of atopic dermatitis among adults is associated with nutrition label awareness. Nutrition label awareness indicates knowledge of the existence of nutrition labels on processed food, and the use of them for food selection. In this cross-sectional study, we analyzed the relationship between nutrition label awareness and the prevalence of atopic dermatitis among men and women using data from the Korean National Health and Nutrition Examination Survey VI (2013–2015), including a nationally representative sample of 13,505 Korean adults (aged > 19 years). The relationship between the prevalence of atopic dermatitis and nutrition label awareness was evaluated using t-tests, χ2 tests and multivariate adjusted logistic regression analysis. Although univariate analysis showed that atopic dermatitis was associated with nutrition label awareness in both men and women, after adjustment for covariates, there was no significant association among men. The significant association between the prevalence of atopic dermatitis and nutrition label awareness among women reveals a sex-based difference in this relationship in adults, and atopic dermatitis may be managed and prevented among women by targeted education regarding nutrition labels and diet.
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Affiliation(s)
- Soo Jin Kwon
- Department of Nursing, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 06974, Korea;
| | - Yoonjung Kim
- Red Cross College of Nursing, Chung-Ang University, 84 Heukseok-ro, Dongjak-gu, Seoul 06974, Korea
- Correspondence: ; Tel.: +82-2-820-6855
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Abstract
PURPOSE OF REVIEW Guiding consumers toward more healthful food choices may help address the high prevalence of poor dietary quality and diet-related diseases. The use of front-of-package labels (FOPL) on food items is expanding to provide focused nutritional information or representations, often based upon nutrient profiling systems. RECENT FINDINGS FOPL provide a source of nutrition and health information that is readily understood by consumers, including those with limited literacy. There is evidence that FOPL can shift consumer behavior toward more nutritious and healthful choices. However, assessments of the effectiveness of FOPL have been restricted in scope and rely largely on simulation models rather than real-world environments. FOPL are a direct source of nutritional guidance at the point-of-purchase and provide an opportunity to convey critical information on ingredients that are associated with health promotion and/or increased risk of non-communicable diseases. However, limited evidence regarding the most effective forms of FOPL to achieve behavior change and challenges from the food industry impedes the establishment of standardized nutrient profiles and algorithms. Future opportunities for FOPL include the potential for integrating nutritional profiles with non-nutrient factors affecting health such as food processing and environmental sustainability.
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Role of different nutrient profiling models in identifying targeted foods for front-of-package food labelling in Brazil. Public Health Nutr 2020; 24:1514-1525. [PMID: 32515717 PMCID: PMC8025091 DOI: 10.1017/s1368980019005056] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective: To compare the degree of strictness and agreement of different nutrient profiling models (NPM) used to identify which foods would be required to show front-of-package (FOP) warning labels. Design: Using data of 11 434 packaged foods found in the five largest food retailers in Brazil, we used two published NPM: the Pan American Health Organization (PAHO) model and the NPM used in the Chilean nutritional FOP labelling policy, and compared them with a NPM proposed by the Brazilian National Health Surveillance Agency (Anvisa). The proportion of foods that would be required to show FOP warning labels was calculated overall and by food category. We also tested whether a modified version of the PAHO NPM would behave similarly to the original version. Setting: Brazil. Results: Two-thirds of the packaged products (62 %) would receive FOP warning labels under the PAHO NPM, as compared with 45 % of products using the proposed Anvisa NPM and 41 % if the Chilean NPM was applied. The PAHO NPM identified more foods high in critical nutrients such as sweetened dairy and non-dairy beverages, canned vegetables and convenience foods. Overall agreement between models was considered good with kappa coefficient ranging from 0·57 to 0·92 but was lower for some food categories. Conclusions: We found variations in the degree of strictness and agreement between assessed NPM. The PAHO NPM identified more foods and beverages high in sugar which are among the top contributors to sugar and energy intake in Brazil.
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The Effect of Front-of-Pack Nutritional Labels and Back-of-Pack Tables on Dietary Quality. Nutrients 2020; 12:nu12061704. [PMID: 32517284 PMCID: PMC7352904 DOI: 10.3390/nu12061704] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/26/2020] [Accepted: 06/02/2020] [Indexed: 11/16/2022] Open
Abstract
A healthy diet is important to prevent lifestyle diseases. Food labels have been proposed as a policy tool to improve the healthiness of food choices, as they provide information about nutritional content and health attributes which may otherwise have been unknown to the consumer. This study investigates the effect of food labels with different formats on dietary quality by using home-scan panel data and difference-in-difference methods to compare the change in dietary quality over time for households that start to use food labels with households that do not use labels. I find that the use of front-of-pack (FOP) nutritional labels increases overall dietary quality, which is driven by reduced intake of added sugar and increased intake of fiber. The use of back-of-pack (BOP) nutritional tables does not influence dietary quality. There is no additional benefit to overall dietary quality by using both labels. However, the results indicate that there could be a benefit of using both labels on certain nutrients. The results imply that additional policies are needed to supplement food labels in order to improve dietary quality.
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Franco-Arellano B, Vanderlee L, Ahmed M, Oh A, L'Abbé M. Influence of front-of-pack labelling and regulated nutrition claims on consumers’ perceptions of product healthfulness and purchase intentions: A randomized controlled trial. Appetite 2020; 149:104629. [DOI: 10.1016/j.appet.2020.104629] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 02/03/2020] [Accepted: 02/09/2020] [Indexed: 01/17/2023]
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Croker H, Packer J, Russell SJ, Stansfield C, Viner RM. Front of pack nutritional labelling schemes: a systematic review and meta-analysis of recent evidence relating to objectively measured consumption and purchasing. J Hum Nutr Diet 2020; 33:518-537. [PMID: 32364292 DOI: 10.1111/jhn.12758] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 03/24/2020] [Accepted: 03/24/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Front of pack labelling (FOPL) provides visible nutritional information and appears to influence knowledge and reformulation. However, a recent Cochrane review found limited and inconsistent evidence for behaviour change. The present review aimed to examine studies published subsequent the Cochrane review, focusing on prepackaged foods, examining the impact of FOPL on purchasing and consumption. METHODS Controlled experimental/intervention and interrupted time series (ITS) studies were included, with no age/geography restrictions. Exposures were FOPL with objectively measured consumption/purchasing outcomes. Thirteen databases were searched (January 2017 to April 2019) and forward citation searching was undertaken on the included studies. Purchasing data from experimental studies were meta-analysed. Two series of meta-analyses were undertaken; combined FOPL versus no-FOPL and specific FOPL scheme versus no-FOPL. Outcomes were sugar (g 100 g-1 ), calories (kcal 100 g-1 ), saturated fat (g 100 g-1 ) and sodium (mg 100 g-1 ). RESULTS We identified 14 studies, reporting consumption (experimental; n = 3) and purchasing (n = 8, experimental; n = 3, ITS). Meta-analysis of experimental studies showed sugar and sodium content of purchases was lower for combined FOPL versus no-FOPL (-0.40 g sugar 100 g-1 , P < 0.01; -24.482 mg sodium 100 g-1 , P = 0.012), with a trend for lower energy and saturated fat (-2.03 kcal 100 g-1 , P = 0.08; -0.154 g saturated fat 100 g-1 , P = 0.091). For specific FOPL, products purchased by 'high in' FOPL groups had lower sugar (-0.67 g sugar 100 g-1 , P ≤ 0.01), calories (-4.43 kcal 100 g-1 , P < 0.05), sodium (-33.78 mg 100 g-1 , P = 0.01) versus no-FOPL; Multiple Traffic Light had lower sodium (-34.94 mg 100 g-1 , P < 0.01) versus no-FOPL. Findings regarding consumption were limited and inconsistent. FOPL resulted in healthier purchasing in ITS studies. CONCLUSIONS This review provides evidence from experimental and 'real-life' studies indicating that FOPL encourages healthier food purchasing. PROSPERO CRD42019135743.
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Affiliation(s)
- H Croker
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - J Packer
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Simon J Russell
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - C Stansfield
- Evidence for Policy and Practice Information and Coordinating (EPPI-)Centre, Social Science Research Unit, UCL Institute of Education, University College London, London, UK
| | - R M Viner
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
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Vandevijvere S, Vermote M, Egnell M, Galan P, Talati Z, Pettigrew S, Hercberg S, Julia C. Consumers' food choices, understanding and perceptions in response to different front-of-pack nutrition labelling systems in Belgium: results from an online experimental study. ACTA ACUST UNITED AC 2020; 78:30. [PMID: 32266069 PMCID: PMC7119293 DOI: 10.1186/s13690-020-00404-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/02/2020] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Stefanie Vandevijvere
- 1Sciensano (Scientific Institute of Public Health), J. Wytsmanstraat 14, 1050 Brussel, Belgium
| | - Marie Vermote
- 1Sciensano (Scientific Institute of Public Health), J. Wytsmanstraat 14, 1050 Brussel, Belgium
| | - Manon Egnell
- 2INSERM (Institut National de la Santé et de la Recherche Médicale), Paris, France
| | - Pilar Galan
- 3INRA (Institut National de la Recherche Agronomique), Paris, France
| | - Zenobia Talati
- 4The George Institute for Global Health, Sydney, Australia
| | | | - Serge Hercberg
- 2INSERM (Institut National de la Santé et de la Recherche Médicale), Paris, France
| | - Chantal Julia
- 2INSERM (Institut National de la Santé et de la Recherche Médicale), Paris, France
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Egnell M, Galan P, Farpour-Lambert NJ, Talati Z, Pettigrew S, Hercberg S, Julia C. 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. PLoS One 2020; 15:e0228179. [PMID: 32107489 PMCID: PMC7046267 DOI: 10.1371/journal.pone.0228179] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/08/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Manon Egnell
- Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), U1153 Inserm, U1125, Inra, Cnam, Paris 13 University, Bobigny, France
- * E-mail:
| | - Pilar Galan
- Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), U1153 Inserm, U1125, Inra, Cnam, Paris 13 University, Bobigny, France
| | | | - Zenobia Talati
- School of Psychology, Curtin University, Bentley, WA, Australia
| | | | - Serge Hercberg
- Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), U1153 Inserm, U1125, Inra, Cnam, Paris 13 University, Bobigny, France
- Public health department, Avicenne Hospital, AP-HP, Bobigny, France
| | - Chantal Julia
- Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), U1153 Inserm, U1125, Inra, Cnam, Paris 13 University, Bobigny, France
- Public health department, Avicenne Hospital, AP-HP, Bobigny, France
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Ahmed M, Oh A, Vanderlee L, Franco-Arellano B, Schermel A, Lou W, L'Abbé MR. A randomized controlled trial examining consumers' perceptions and opinions on using different versions of a FoodFlip© smartphone application for delivery of nutrition information. Int J Behav Nutr Phys Act 2020; 17:22. [PMID: 32050996 PMCID: PMC7017573 DOI: 10.1186/s12966-020-0923-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 02/03/2020] [Indexed: 01/28/2023] Open
Abstract
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).
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Affiliation(s)
- Mavra Ahmed
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Medical Science Building, 1 King's College Circle, Room 5368, Toronto, ON, M5S 1A8, Canada
| | - Angela Oh
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Medical Science Building, 1 King's College Circle, Room 5368, Toronto, ON, M5S 1A8, Canada
| | - Lana Vanderlee
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Medical Science Building, 1 King's College Circle, Room 5368, Toronto, ON, M5S 1A8, Canada.,School of Public Health and Health Systems, University of Waterloo, Waterloo, N2L 3G1, Canada
| | - Beatriz Franco-Arellano
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Medical Science Building, 1 King's College Circle, Room 5368, Toronto, ON, M5S 1A8, Canada
| | - Alyssa Schermel
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Medical Science Building, 1 King's College Circle, Room 5368, Toronto, ON, M5S 1A8, Canada
| | - Wendy Lou
- Dalla Lana School of Public Health, University of Toronto, Toronto, M5T 3M2, Canada
| | - Mary R L'Abbé
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Medical Science Building, 1 King's College Circle, Room 5368, Toronto, ON, M5S 1A8, Canada.
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Improving Nutrition Information in the Eastern Mediterranean Region: Implementation of Front-Of-Pack Nutrition Labelling. Nutrients 2020; 12:nu12020330. [PMID: 31991939 PMCID: PMC7071186 DOI: 10.3390/nu12020330] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/10/2020] [Accepted: 01/19/2020] [Indexed: 11/22/2022] Open
Abstract
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.
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Waterlander WE. Are Front-of-Pack Nutrition Labels the Silver Bullet for Achieving Healthier Population Diets? Am J Public Health 2019; 109:1067-1068. [PMID: 31268767 DOI: 10.2105/ajph.2019.305169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Wilma E Waterlander
- Wilma E. Waterlander is with the Department of Public Health, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, Netherlands
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Labonté ME, Emrich TE, Scarborough P, Rayner M, L’Abbé MR. Traffic light labelling could prevent mortality from noncommunicable diseases in Canada: A scenario modelling study. PLoS One 2019; 14:e0226975. [PMID: 31881069 PMCID: PMC6934336 DOI: 10.1371/journal.pone.0226975] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 12/09/2019] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Marie-Eve Labonté
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Teri E. Emrich
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Scarborough
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Mike Rayner
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Mary R. L’Abbé
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- * E-mail:
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Egnell M, Talati Z, Gombaud M, Galan P, Hercberg S, Pettigrew S, Julia C. Consumers' Responses to Front-of-Pack Nutrition Labelling: Results from a Sample from The Netherlands. Nutrients 2019; 11:nu11081817. [PMID: 31390835 PMCID: PMC6723811 DOI: 10.3390/nu11081817] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 07/31/2019] [Accepted: 08/02/2019] [Indexed: 11/17/2022] Open
Abstract
Front-of-pack labels (FoPLs) are efficient tools for helping consumers identify healthier food products. Although discussions on nutritional labelling are currently ongoing in Europe, few studies have compared the effectiveness of FoPLs in European countries, including the Netherlands. This study aimed to compare five FoPLs among Dutch participants (the Health Star Rating (HSR) system, Multiple Traffic Lights (MTL), Nutri-Score, Reference Intakes (RIs), and Warning symbols) in terms of perception and understanding of the labels and food choices. In 2019, 1032 Dutch consumers were recruited and asked to select one product from among a set of three foods with different nutritional profiles, and then rank the products within the sets according to their nutritional quality. These tasks were performed with no label and then with one of the five FoPLs on the package, depending on the randomization arm. Finally, participants were questioned on their perceptions regarding the label to which they were exposed. Regarding perceptions, all FoPLs were favorably perceived but with only marginal differences between FoPLs. While no significant difference across labels was observed for food choices, the Nutri-Score demonstrated the highest overall performance in helping consumers rank the products according to their nutritional quality.
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Affiliation(s)
- Manon Egnell
- Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), U1153 Inserm, U1125 Inra, Cnam, Paris 13 University, 93000 Bobigny, France.
| | - Zenobia Talati
- School of Psychology, Curtin University, Kent St, Bentley, WA 6102, Australia
| | - Marion Gombaud
- Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), U1153 Inserm, U1125 Inra, Cnam, Paris 13 University, 93000 Bobigny, France
| | - Pilar Galan
- Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), U1153 Inserm, U1125 Inra, Cnam, Paris 13 University, 93000 Bobigny, France
| | - Serge Hercberg
- Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), U1153 Inserm, U1125 Inra, Cnam, Paris 13 University, 93000 Bobigny, France
- Public Health Department, Avicenne Hospital, AP-HP, 93000 Bobigny, France
| | - Simone Pettigrew
- The George Institute for Global Health, Sydney, NSW 2042, Australia
| | - Chantal Julia
- Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cité Epidemiology and Statistics Research Center (CRESS), U1153 Inserm, U1125 Inra, Cnam, Paris 13 University, 93000 Bobigny, France
- Public Health Department, Avicenne Hospital, AP-HP, 93000 Bobigny, France
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Egnell M, Crosetto P, d'Almeida T, Kesse-Guyot E, Touvier M, Ruffieux B, Hercberg S, Muller L, Julia C. Modelling the impact of different front-of-package nutrition labels on mortality from non-communicable chronic disease. Int J Behav Nutr Phys Act 2019; 16:56. [PMID: 31307496 PMCID: PMC6631735 DOI: 10.1186/s12966-019-0817-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 07/09/2019] [Indexed: 01/09/2023] Open
Abstract
Background Front-of-Package nutrition labels (FoPLs) are intended to help reduce the incidence of nutrition-related non-communicable diseases through an improvement in diet quality. FoPLs have been shown to improve the nutritional quality of purchases and have been associated with improved diet quality, which is in turn associated with reduced risk of non-communicable diseases. However, the potential impact of FoPLs on reducing mortality from chronic diseases has never been estimated. Methods Data from a laboratory experimental economics test were used to investigate the effects of five different FoPLs (Nutri-Score, Health Star Rating system, Multiple Traffic lights, Reference intakes and SENS (Système d’Etiquetage Nutritionnel Simplifié)) on the nutritional quality of household purchases. The relative differences in nutrient content and composition of food purchases were then applied to dietary intakes using data from an observational study, thus yielding estimates for ‘reference’ and ‘labelled’ diets. A macro-simulation study using the PRIME model was then conducted to estimate the impact of the modification in dietary intake as a result of FoPL use on mortality from diet-related non-communicable diseases. Results The use of FoPLs led to a substantial reduction in mortality from chronic diseases. Approximately 3.4% of all deaths from diet-related non-communicable diseases was estimated to be avoidable when the Nutri-Score FoPL was used. The remaining FoPLs likewise resulted in mortality reduction, although to a lesser extent: Health Star Rating system (2.8%), Reference Intakes (1.9%), Multiple Traffic Lights (1.6%), and SENS (1.1%). Conclusions FoPLs have the potential to help decrease mortality from diet-related non-communicable diseases, and the Nutri-Score appears to be the most efficient among the five formats tested. Electronic supplementary material The online version of this article (10.1186/s12966-019-0817-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Manon Egnell
- Sorbonne Paris Cité Epidemiology and Statistics Research Centre (CRESS), U1153 Inserm, U1125, Inra, Cnam, University of Paris 13, Nutritional Epidemiology Research Team (EREN), 93017, Bobigny, France.
| | | | - Tania d'Almeida
- Sorbonne Paris Cité Epidemiology and Statistics Research Centre (CRESS), U1153 Inserm, U1125, Inra, Cnam, University of Paris 13, Nutritional Epidemiology Research Team (EREN), 93017, Bobigny, France
| | - Emmanuelle Kesse-Guyot
- Sorbonne Paris Cité Epidemiology and Statistics Research Centre (CRESS), U1153 Inserm, U1125, Inra, Cnam, University of Paris 13, Nutritional Epidemiology Research Team (EREN), 93017, Bobigny, France
| | - Mathilde Touvier
- Sorbonne Paris Cité Epidemiology and Statistics Research Centre (CRESS), U1153 Inserm, U1125, Inra, Cnam, University of Paris 13, Nutritional Epidemiology Research Team (EREN), 93017, Bobigny, France
| | - Bernard Ruffieux
- Inra, UMR 1215 GAEL, 38000, Grenoble, France.,Polytechnic Institute of Grenoble, 38031, Grenoble, France
| | - Serge Hercberg
- Sorbonne Paris Cité Epidemiology and Statistics Research Centre (CRESS), U1153 Inserm, U1125, Inra, Cnam, University of Paris 13, Nutritional Epidemiology Research Team (EREN), 93017, Bobigny, France.,Public Health Department, Avicenne Hospital, 93000, Bobigny, France
| | | | - Chantal Julia
- Sorbonne Paris Cité Epidemiology and Statistics Research Centre (CRESS), U1153 Inserm, U1125, Inra, Cnam, University of Paris 13, Nutritional Epidemiology Research Team (EREN), 93017, Bobigny, France.,Public Health Department, Avicenne Hospital, 93000, Bobigny, France
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Centurión M, Machín L, Ares G. Relative Impact of Nutritional Warnings and Other Label Features on Cereal Bar Healthfulness Evaluations. JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR 2019; 51:850-856. [PMID: 30819654 DOI: 10.1016/j.jneb.2019.01.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/19/2019] [Accepted: 01/28/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To investigate the relative influence of nutritional warnings and 2 marketing strategies commonly used in food labels, nutrient claims, and fruit images on consumers' healthfulness judgments. DESIGN Labels of cereal bars were designed according to a full factorial design with 3 2-level variables: images of fruit (with vs without), nutrient claims about the fiber content (with vs without), and nutritional warnings about excessive content of sugar and saturated fat (with vs without). SETTING Experiment conducted in Montevideo, Uruguay. PARTICIPANTS One hundred Uruguayan people, 75% female, aged 18-56 years. MAIN OUTCOME MEASURES Healthfulness perception and eye-tracking variables. ANALYSIS The researchers used ANOVA to evaluate the influence of the experimental design's variables on perceived healthfulness and eye-tracking measures. RESULTS Nutritional warnings caught participants' attention and reduced the amount of visual attention needed to evaluate healthfulness. Participants mainly relied on nutritional warnings to make healthfulness judgments. CONCLUSIONS AND IMPLICATIONS Findings of the current work confirm the potential of nutritional warnings to influence consumers' healthfulness perception, overriding the effect of other label cues used by the food industry to convey the concept of healthfulness.
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Affiliation(s)
- Marcia Centurión
- Centro de Investigación Básica en Psicología, Facultad de Psicología, Universidad de la República, Montevideo, Uruguay
| | - Leandro Machín
- Centro de Investigación Básica en Psicología, Facultad de Psicología, Universidad de la República, Montevideo, Uruguay
| | - Gastón Ares
- Centro de Investigación Básica en Psicología, Facultad de Psicología, Universidad de la República, Montevideo, Uruguay; Sensometrics and Consumer Science, Instituto Polo Tecnológico de Pando, Facultad de Química, Universidad de la República, Pando, Canelones, Uruguay.
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Egnell M, Boutron I, Péneau S, Ducrot P, Touvier M, Galan P, Buscail C, Porcher R, Ravaud P, Hercberg S, Kesse-Guyot E, Julia C. Front-of-Pack Labeling and the Nutritional Quality of Students' Food Purchases: A 3-Arm Randomized Controlled Trial. Am J Public Health 2019; 109:1122-1129. [PMID: 31219721 DOI: 10.2105/ajph.2019.305115] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To assess the effects of the Nutri-Score label (relative to the Reference Intakes label or no label) on the nutritional quality of students' food purchases. Methods. A 3-arm randomized controlled trial was conducted in France in 2017; 2907 participants were randomized into 1 of the 3 study arms (Nutri-Score, Reference Intakes, no label) and invited to purchase groceries from an experimental Web-based supermarket. The main outcome was the overall nutritional quality of purchases, measured according to a modified version of the Food Standards Agency Nutrient Profiling System (FSAm-NPS/HCSP) score. Results. The mean (±SD) FSAm-NPS/HCSP score was lower in the Nutri-Score group (2.02 ±3.56) than in the Reference Intakes group (2.69 ±3.44), reflecting higher nutritional quality; however, there was no significant difference between the Nutri-Score and no-label (2.45 ±3.28) groups or between the Reference Intakes and no-label groups. Shopping cart content was lower in calories and saturated fatty acids and higher in fruits and vegetables in the Nutri-Score arm than in the other arms. Conclusions. The Nutri-Score label appeared to improve the nutritional composition of students' food purchases relative to the Reference Intakes label or no label.
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Affiliation(s)
- Manon Egnell
- Manon Egnell, Sandrine Péneau, Mathilde Touvier, Pilar Galan, Camille Buscail, Serge Hercberg, Emmanuelle Kesse-Guyot, and Chantal Julia are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Nutritional Epidemiology Research Team, Paris 13 University, Bobigny, France. Isabelle Boutron, Raphaël Porcher, and Philippe Ravaud are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Centre d'épidémiologie clinique, Hôtel-Dieu Hospital, Paris, France. Pauline Ducrot is with Santé Publique France, National Public Health Agency, Saint-Maurice, France
| | - Isabelle Boutron
- Manon Egnell, Sandrine Péneau, Mathilde Touvier, Pilar Galan, Camille Buscail, Serge Hercberg, Emmanuelle Kesse-Guyot, and Chantal Julia are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Nutritional Epidemiology Research Team, Paris 13 University, Bobigny, France. Isabelle Boutron, Raphaël Porcher, and Philippe Ravaud are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Centre d'épidémiologie clinique, Hôtel-Dieu Hospital, Paris, France. Pauline Ducrot is with Santé Publique France, National Public Health Agency, Saint-Maurice, France
| | - Sandrine Péneau
- Manon Egnell, Sandrine Péneau, Mathilde Touvier, Pilar Galan, Camille Buscail, Serge Hercberg, Emmanuelle Kesse-Guyot, and Chantal Julia are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Nutritional Epidemiology Research Team, Paris 13 University, Bobigny, France. Isabelle Boutron, Raphaël Porcher, and Philippe Ravaud are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Centre d'épidémiologie clinique, Hôtel-Dieu Hospital, Paris, France. Pauline Ducrot is with Santé Publique France, National Public Health Agency, Saint-Maurice, France
| | - Pauline Ducrot
- Manon Egnell, Sandrine Péneau, Mathilde Touvier, Pilar Galan, Camille Buscail, Serge Hercberg, Emmanuelle Kesse-Guyot, and Chantal Julia are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Nutritional Epidemiology Research Team, Paris 13 University, Bobigny, France. Isabelle Boutron, Raphaël Porcher, and Philippe Ravaud are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Centre d'épidémiologie clinique, Hôtel-Dieu Hospital, Paris, France. Pauline Ducrot is with Santé Publique France, National Public Health Agency, Saint-Maurice, France
| | - Mathilde Touvier
- Manon Egnell, Sandrine Péneau, Mathilde Touvier, Pilar Galan, Camille Buscail, Serge Hercberg, Emmanuelle Kesse-Guyot, and Chantal Julia are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Nutritional Epidemiology Research Team, Paris 13 University, Bobigny, France. Isabelle Boutron, Raphaël Porcher, and Philippe Ravaud are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Centre d'épidémiologie clinique, Hôtel-Dieu Hospital, Paris, France. Pauline Ducrot is with Santé Publique France, National Public Health Agency, Saint-Maurice, France
| | - Pilar Galan
- Manon Egnell, Sandrine Péneau, Mathilde Touvier, Pilar Galan, Camille Buscail, Serge Hercberg, Emmanuelle Kesse-Guyot, and Chantal Julia are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Nutritional Epidemiology Research Team, Paris 13 University, Bobigny, France. Isabelle Boutron, Raphaël Porcher, and Philippe Ravaud are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Centre d'épidémiologie clinique, Hôtel-Dieu Hospital, Paris, France. Pauline Ducrot is with Santé Publique France, National Public Health Agency, Saint-Maurice, France
| | - Camille Buscail
- Manon Egnell, Sandrine Péneau, Mathilde Touvier, Pilar Galan, Camille Buscail, Serge Hercberg, Emmanuelle Kesse-Guyot, and Chantal Julia are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Nutritional Epidemiology Research Team, Paris 13 University, Bobigny, France. Isabelle Boutron, Raphaël Porcher, and Philippe Ravaud are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Centre d'épidémiologie clinique, Hôtel-Dieu Hospital, Paris, France. Pauline Ducrot is with Santé Publique France, National Public Health Agency, Saint-Maurice, France
| | - Raphaël Porcher
- Manon Egnell, Sandrine Péneau, Mathilde Touvier, Pilar Galan, Camille Buscail, Serge Hercberg, Emmanuelle Kesse-Guyot, and Chantal Julia are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Nutritional Epidemiology Research Team, Paris 13 University, Bobigny, France. Isabelle Boutron, Raphaël Porcher, and Philippe Ravaud are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Centre d'épidémiologie clinique, Hôtel-Dieu Hospital, Paris, France. Pauline Ducrot is with Santé Publique France, National Public Health Agency, Saint-Maurice, France
| | - Philippe Ravaud
- Manon Egnell, Sandrine Péneau, Mathilde Touvier, Pilar Galan, Camille Buscail, Serge Hercberg, Emmanuelle Kesse-Guyot, and Chantal Julia are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Nutritional Epidemiology Research Team, Paris 13 University, Bobigny, France. Isabelle Boutron, Raphaël Porcher, and Philippe Ravaud are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Centre d'épidémiologie clinique, Hôtel-Dieu Hospital, Paris, France. Pauline Ducrot is with Santé Publique France, National Public Health Agency, Saint-Maurice, France
| | - Serge Hercberg
- Manon Egnell, Sandrine Péneau, Mathilde Touvier, Pilar Galan, Camille Buscail, Serge Hercberg, Emmanuelle Kesse-Guyot, and Chantal Julia are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Nutritional Epidemiology Research Team, Paris 13 University, Bobigny, France. Isabelle Boutron, Raphaël Porcher, and Philippe Ravaud are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Centre d'épidémiologie clinique, Hôtel-Dieu Hospital, Paris, France. Pauline Ducrot is with Santé Publique France, National Public Health Agency, Saint-Maurice, France
| | - Emmanuelle Kesse-Guyot
- Manon Egnell, Sandrine Péneau, Mathilde Touvier, Pilar Galan, Camille Buscail, Serge Hercberg, Emmanuelle Kesse-Guyot, and Chantal Julia are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Nutritional Epidemiology Research Team, Paris 13 University, Bobigny, France. Isabelle Boutron, Raphaël Porcher, and Philippe Ravaud are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Centre d'épidémiologie clinique, Hôtel-Dieu Hospital, Paris, France. Pauline Ducrot is with Santé Publique France, National Public Health Agency, Saint-Maurice, France
| | - Chantal Julia
- Manon Egnell, Sandrine Péneau, Mathilde Touvier, Pilar Galan, Camille Buscail, Serge Hercberg, Emmanuelle Kesse-Guyot, and Chantal Julia are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Nutritional Epidemiology Research Team, Paris 13 University, Bobigny, France. Isabelle Boutron, Raphaël Porcher, and Philippe Ravaud are with the Sorbonne Paris Cité Epidemiology and Statistics Research Center and the Centre d'épidémiologie clinique, Hôtel-Dieu Hospital, Paris, France. Pauline Ducrot is with Santé Publique France, National Public Health Agency, Saint-Maurice, France
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Jones A, Thow AM, Ni Mhurchu C, Sacks G, Neal B. The performance and potential of the Australasian Health Star Rating system: a four‐year review using the RE‐AIM framework. Aust N Z J Public Health 2019; 43:355-365. [DOI: 10.1111/1753-6405.12908] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 04/01/2019] [Accepted: 04/01/2019] [Indexed: 12/14/2022] Open
Affiliation(s)
- Alexandra Jones
- George Institute for Global HealthUNSW Sydney New South Wales
- Charles Perkins CentreThe University of Sydney New South Wales
| | - Anne Marie Thow
- Menzies Centre for Health PolicyThe University of Sydney New South Wales
| | - Cliona Ni Mhurchu
- George Institute for Global HealthUNSW Sydney New South Wales
- National Institute for Health InnovationUniversity of Auckland New Zealand
| | - Gary Sacks
- School of Health and Social DevelopmentDeakin University Melbourne Victoria
| | - Bruce Neal
- George Institute for Global HealthUNSW Sydney New South Wales
- Department of Epidemiology and Biostatistics, School of Public HealthFaculty of Medicine, Imperial College London London United Kingdom
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van Buul VJ, Bolman CAW, Brouns FJPH, Lechner L. Use of nutritional information: analysing clusters of consumers who intend to eat healthily. J Nutr Sci 2019; 8:e17. [PMID: 31080590 PMCID: PMC6498756 DOI: 10.1017/jns.2019.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 11/13/2022] Open
Abstract
Consumers intending to eat healthily should consult available information on the energy, salt, sugar and saturated fat content of foods. Some consumers, however, do this more than others do. The objective of this research was to identify distinct subgroups within the group of consumers who intend to eat healthily, segmented according to the timing and frequency of their use of information about energy, salt, sugar and saturated fat. Furthermore, we analysed whether consulting this information actually led to healthier food choices. Data on use of specific nutritional information in a computerised task in which participants made multiple dichotomous food choices (e.g. high-fat v. low-fat cheese) were recorded from 240 participants using process tracing software. Participants could view nutritional information by hovering the mouse over specific areas of the screen. We found three clusters of participants based on use of information about energy, salt, sugar and saturated fat: low, medium and high information users. There was a between-clusters difference in how often the healthy option was chosen (88·95 % with high information v. 67·17 % with low information usage). Presence in the medium and high information clusters was partially predicted by perceived self-efficacy in making healthy choices. It appears that some consumers are very confident of their ability to make healthy choices, which is a reason for making less use of nutritional information prior to making food choices and may result in unhealthy choices. Our findings improve understanding of the conditions needed to develop effective interventions targeted at health-conscious consumers.
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Affiliation(s)
- Vincent J. van Buul
- Faculty of Psychology and Educational Sciences, Open University of the Netherlands, PO Box 2960, 6401 DL Heerlen, the Netherlands
| | - Catherine A. W. Bolman
- Faculty of Psychology and Educational Sciences, Open University of the Netherlands, PO Box 2960, 6401 DL Heerlen, the Netherlands
| | - Fred J. P. H. Brouns
- Faculty of Health, Medicine and Life Sciences, Department of Human Biology, NUTRIM-School of Translational Research in Nutrition and Metabolism, Maastricht University, 6200 MD Maastricht, the Netherlands
| | - Lilian Lechner
- Faculty of Psychology and Educational Sciences, Open University of the Netherlands, PO Box 2960, 6401 DL Heerlen, the Netherlands
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Shangguan S, Afshin A, Shulkin M, Ma W, Marsden D, Smith J, Saheb-Kashaf M, Shi P, Micha R, Imamura F, Mozaffarian D. A Meta-Analysis of Food Labeling Effects on Consumer Diet Behaviors and Industry Practices. Am J Prev Med 2019; 56:300-314. [PMID: 30573335 PMCID: PMC6340779 DOI: 10.1016/j.amepre.2018.09.024] [Citation(s) in RCA: 163] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 09/19/2018] [Accepted: 09/20/2018] [Indexed: 01/03/2023]
Abstract
CONTEXT The influence of food and beverage labeling (food labeling) on consumer behaviors, industry responses, and health outcomes is not well established. EVIDENCE ACQUISITION PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Ten databases were searched in 2014 for studies published after 1990 evaluating food labeling and consumer purchases/orders, intakes, metabolic risk factors, and industry responses. Data extractions were performed independently and in duplicate. Studies were pooled using inverse-variance random effects meta-analysis. Heterogeneity was explored with I2, stratified analyses, and meta-regression; and publication bias was assessed with funnel plots, Begg's tests, and Egger's tests. Analyses were completed in 2017. EVIDENCE SYNTHESIS From 6,232 articles, a total of 60 studies were identified, including 2 million observations across 111 intervention arms in 11 countries. Food labeling decreased consumer intakes of energy by 6.6% (95% CI= -8.8%, -4.4%, n=31), total fat by 10.6% (95% CI= -17.7%, -3.5%, n=13), and other unhealthy dietary options by 13.0% (95% CI= -25.7%, -0.2%, n=16), while increasing vegetable consumption by 13.5% (95% CI=2.4%, 24.6%, n=5). Evaluating industry responses, labeling decreased product contents of sodium by 8.9% (95% CI= -17.3%, -0.6%, n=4) and artificial trans fat by 64.3% (95% CI= -91.1%, -37.5%, n=3). No significant heterogeneity was identified by label placement or type, duration, labeled product, region, population, voluntary or legislative approaches, combined intervention components, study design, or quality. Evidence for publication bias was not identified. CONCLUSIONS From reviewing 60 intervention studies, food labeling reduces consumer dietary intake of selected nutrients and influences industry practices to reduce product contents of sodium and artificial trans fat.
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Affiliation(s)
- Siyi Shangguan
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts; Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ashkan Afshin
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts; Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington
| | - Masha Shulkin
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts; University of Michigan Medical School, Ann Arbor, Michigan
| | - Wenjie Ma
- Clinical and Translational Epidemiology Unit and Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Daniel Marsden
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts; School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
| | - Jessica Smith
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts; Bell Institute of Health and Nutrition, General Mills Inc., Minneapolis, Minnesota
| | - Michael Saheb-Kashaf
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts; School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Peilin Shi
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Renata Micha
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts
| | - Fumiaki Imamura
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts.
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