Food labels: A critical assessment

ObjectiveFoods sold in packages have both front-of-package (FOP) labels and back-of-package (BOP) labels. The aim of this review is to determine the role they play in informing consumers as to the composition of foods in order to help select a healthy diet.MethodsRecent literature was evaluated and findings combined with assessments made by the authors of food labels used in the United States and Canada.ResultsResearch shows that most consumers have difficulty understanding the information provided by both FOP and BOP food labels used in the United States and Canada. Research has evaluated the merits of alternative designs. FOP labels should be based on a clear and simple design. They should present information on key nutrients (total fat, saturated fat, sugar, and sodium or salt) and also energy value. They should have color and words that indicate “high,” “medium,” and “low” levels. Labels can also state quantity per serving. The traffic light system is the best example of this design. An extra traffic light indicating the overall health value of the food should be added. A clearer BOP label also is needed. Implementation of a new food labeling system will probably be opposed by the food industry. More research is needed into which food label designs are most effective, especially for persuading consumers to select healthier food.ConclusionsBoth FOP and BOP food labels used in the United States and Canada need to be redesigned using a traffic light system.     

Exploring the main and moderating effects of individual-level characteristics on consumer responses to sugar taxes and front-of-pack nutrition labels in an experimental marketplace

InterventionThis study examined whether the impacts of sugar taxes and front-of-pack (FOP) nutrition labels differ across socio-demographic subgroups.Research questionWhat are the main and moderating effects of individual-level characteristics on the nutrient content of participants’ purchases in response to varying taxation levels and FOP labels?MethodsData from an experimental marketplace were analyzed. A sample of 3584 Canadians aged 13 years and older received $5 to purchase an item from a selection of 20 beverages and 20 snack foods. Participants were shown products with one of five FOP labels and completed eight within-subject purchasing tasks with different tax conditions. Linear mixed models were used to estimate the main and moderating effects of 11 individual-level variables on the sugars, sodium, saturated fats, and calorie content of participants’ purchases.ResultsParticipants who were younger, male, and more frequent consumers of sugary drinks purchased products containing more sugars, sodium, saturated fats, and calories. Sex and age moderated the relationship between tax condition and sugars or calories purchased: female participants were more responsive than males to a tax that included fruit juice, and younger participants were more responsive to all sugar tax conditions than older participants. Reported thirst and education level also moderated the relationship between tax condition and calories purchased. No individual-level characteristics moderated the effects of FOP labels.ConclusionA small proportion (7 of 176) of the moderating effects tested in this study were significant. Sugar taxes and FOP labelling policies may therefore produce similar effects across key socio-demographic groups.Supplementary InformationThe online version contains supplementary material available at 10.17269/s41997-021-00475-x.     

Nutrition Claims on Fruit Drinks Are Inconsistent Indicators of Nutritional Profile: A Content Analysis of Fruit Drinks Purchased by Households With Young Children

BackgroundFruit drinks are the most commonly consumed sugar-sweetened beverage among young children. Fruit drinks carry many nutrition-related claims on the front of package (FOP). Nutrition-related claims affect individuals’ perceptions of the healthfulness of products and purchase intentions, often creating a “health halo” effect.ObjectiveThe aims of this study were to describe the prevalence of FOP nutrition-related claims on fruit drinks purchased by households with young children and to examine the association between claims and the nutritional profile of fruit drinks.DesignThe sample included 2059 fruit drinks purchased by households with children 0 to 5 years old participating in Nielsen Homescan in 2017. FOP labels were obtained from 2 databases that contain bar code–level information on all printed material on product labels. A codebook was used to code for presence of FOP nutrition-related claims. The coded claims data were linked by bar code with Nutrition Facts label data. Claim type prevalence was calculated, and the association between claim types and median calories and total grams of sugar per 100 mL was analyzed using Wilcoxon rank-sum tests. The percentages of products containing noncaloric sweeteners (NCSs) with and without each claim type were also calculated and compared.ResultsAlmost all (97%) fruit drinks sampled had at least 1 nutrition-related FOP claim. Implied natural claims such as “natural flavors” were the most common (55% of products), followed by claims about the presence of juice or nectar (49%). Claims about vitamin C (33%), sugar (29%), and calories (23%) were also common. Fruit drinks with vitamin C, juice or nectar, fruit or fruit flavor, and overt natural claims were higher in calories and sugar and less likely to contain NCSs compared with products without these claims. Fruit drinks with calorie, sugar, NCS, implied natural, and other claims were lower in calories and sugar and more likely to contain NCSs compared with products without these claims.ConclusionsClaims are prevalent on fruit drinks purchased by households with young children. This is concerning given prior research demonstrating that claims can mislead consumers. Regulatory actions such as requiring a warning or disclosure on drinks that contain added sugars or NCSs should be considered.     

Comparison of Healthiness,Labelling, and Price between Private and Branded Label Packaged Foods in New Zealand (2015–2019)

We aimed to compare New Zealand private label (PL) and branded label (BL) packaged food products in relation to their current (2019) healthiness (sodium and sugar contents, and estimated Health Star Rating (HSR) score), display of the voluntary HSR nutrition label on the package, and price. Healthiness and HSR display of products were also explored over time (2015 to 2019). Data were obtained from Nutritrack, a brand-specific food composition database. Means and proportions were compared using Student t-tests and Pearson chi-square tests, respectively. Changes over time were assessed using linear regression and chi-square tests for trends (Mantel–Haenzel tests). Altogether, 4266 PL and 19,318 BL products across 21 food categories were included. Overall, PL products in 2019 had a significantly lower mean sodium content and price, a higher proportion of products with estimated HSR ≥ 3.5/5 (48.9% vs. 38.5%) and were more likely to display the HSR on the pack compared with BL products (92.4% vs. 17.2%, respectively). However, for most food categories, no significant difference was found in mean sodium or sugar content between PL and BL products. In the period 2015–2019, there were no consistent changes in estimated HSR score, sodium or sugar contents of PL or BL products, but there was an increase in the proportion of both PL and BL products displaying HSR labels. In most food categories, there were PL options available which were similar in nutritional composition, more likely to be labelled with the HSR, and lower in cost than their branded counterparts.     

Mandatory labels,taxes and market forces: An empirical evaluation of fat policies

The public-health community views mandatory Front-of-Pack (FOP) nutrition labels and nutritional taxes as promising tools to control the growth of food-related chronic diseases. This paper uses household scanner data to propose an ex-ante evaluation and comparison of these two policy options for the fromage blanc and dessert yogurt market. In most markets, labelling is voluntary and firms display fat labels only on the FOP of low-fat products to target consumers who do not want to eat fat. We here separately identify consumer preferences for fat and for FOP fat labels by exploiting an exogenous difference in legal labelling requirements between these two product categories. Estimates of demand curves are combined with a supply model of oligopolistic price competition to simulate policies. We find that a feasible ad valorem fat tax dominates a mandatory FOP-label policy from an economic perspective, but both are equally effective in reducing average fat purchases.     

Nutrition Facts Panels: Who Uses Them,What Do They Use,and How Does Use Relate to Dietary Intake?

Background

Nutrition labels are a low-cost tool with the potential to encourage healthy eating habits.

The Contribution of Major Food Categories and Companies to Household Purchases of Added Sugar in Australia

BackgroundThe Australian Government will soon be releasing a series of sugar reformulation targets for packaged foods.ObjectiveTo estimate the amount of added sugar purchased from packaged food and beverages and the relative contribution that food categories and food companies made to these purchases in 2018. The secondary objective was to examine differences in purchases of added sugar across income levels.DesignCross-sectional study.Participants/settingWe used 1 year of grocery purchase data from a nationally representative panel of Australian households (the NielsenIQ Homescan panel), combined with a packaged food and beverage database (FoodSwitch).Main outcome measuresAdded sugar purchases (grams per day per capita), purchase-weighted added sugar content (grams per 100 g) and total weight of products (with added sugar) purchased (grams per day per capita).Statistical analyses performedFood categories and food companies were ranked according to their contribution to added sugar purchases. Differences in added sugar purchases by income levels were assessed by 1-factor analysis of variance.ResultsAdded sugar information was available from 7188 households and across 26,291 unique foods and beverages. On average, the amount of added sugar acquired from packaged foods and beverages was (mean ± SE) 35.9 ± 0.01 g/d per capita. Low-income households purchased 11.0 g/d (95% CI: 10.9-11.0 g/d, P < .001) more added sugar from packaged products than high-income households per capita. The top 10 food categories accounted for 82.2% of added sugar purchased, largely due to purchases of chocolate and sweets, soft drinks, and ice cream and edible ices. Out of 994 food companies, the top 10 companies contributed to 62.1% of added sugar purchases.ConclusionsThe Australian Government can strengthen their proposed sugar reduction program by adding further category-specific targets, prioritizing engagement with key food companies and considering a broader range of policies to reduce added sugar intakes across the Australian population.     

Nutrition Marketing on Food Labels

ObjectiveThis research sought to determine how often nutrition marketing is used on labels of foods that are high in saturated fat, sodium, and/or sugar.Design and SettingAll items packaged with food labels (N = 56,900) in all 6 grocery stores in Grand Forks, ND were surveyed.Main Outcome Measure(s)Marketing strategy, nutrient label information, if the product was fruit/or milk based, and target age.AnalysisFrequency distributions were computed.ResultsForty-nine percent of all products contained nutrition marketing and of those, 48% had both nutrition marketing and were high in saturated fat, sodium and/or sugar (11%, 17%, and 31% respectively). Seventy-one percent of products marketed to children had nutrition marketing. Of those, 59% were high in saturated fat, sodium and/or sugar content, with more than half being high in sugar. The most commonly used nutrition marketing statements were “good source of calcium”, “reduced/low/fat free”, and “food company's health symbol”.Conclusions and ImplicationsNutrition marketing is commonly used on products high in saturated fat, sodium and/or sugar and is more often used on products marketed toward children than products marketed toward adults. Current food industry symbols may not be helping consumers select foods low in saturated fat, sodium or sugar.     

Associations Among Select State Policies and the Nutritional Quality of Household Packaged Food Purchases in the United States from 2008 Through 2017

BackgroundPolicy interventions are important public health tools because they can reach large numbers of people. State context has been associated with health outcomes, yet few studies have examined the extent to which state-level policies are associated with dietary quality.ObjectivesThe objective of this study was to evaluate whether state policies are associated with the nutritional quality of household packaged food purchases.DesignThis observational study used data from Nielsen Homescan, an open-cohort household panel where participants track purchases, and a combination of state-level food and social safety net policy variables from 2008 through 2017.Participants and settingThis study included 615,634 household-year observations in the United States from 2008 through 2017. Household-year observations were excluded in the case that a household did not make a minimum number of purchases and in the case that they had incorrect geographic information. The final analytic sample was 611,719 household-years.Main outcome measuresStudy outcomes included a set of nutrition-related measures of public health interest, including nutrients of concern (eg, sugar, saturated fat, and sodium) and calories from specific food groups (eg, fruits, nonstarchy vegetables, processed meats, mixed dishes, sugar-sweetened beverages, and desserts and snacks).Statistical analysisThis study used multilevel generalized linear models with state fixed effects on three samples: all households, only households with low income, and only households with low educational attainment.ResultsFew significant associations were found between healthy food retail policies and the nutritional quality of purchases, and mixed associations were found between social safety net policies and lower or higher quality packaged food purchases.ConclusionsLittle evidence was found that state policy context in 2008 through 2017 was associated with the quality of packaged food purchases. However, variation in state policies is increasing over time, warranting future research into the relationship between these policies, the quality of packaged food purchases, and the rest of the diet.     

The effect of food label cues on perceptions of quality and purchase intentions among high-involvement consumers with varying levels of nutrition knowledge

ObjectiveTo determine whether differences in nutrition knowledge affected how women (a high-involvement group) interpreted intrinsic cues (ingredient list) and extrinsic cues (“all natural” label) on food labels.MethodsA 2 (intrinsic cue) × 2 (extrinsic cue) × 2 (nutrition knowledge expert vs novice) within-subject factorial design was used. Participants were 106 female college students (61 experts, 45 novices). Dependent variables were perception of product quality and purchase intention.ResultsAs predicted by the elaboration likelihood model, experts used central route processing to scrutinize intrinsic cues and make judgments about food products. Novices used peripheral route processing to make simple inferences about the extrinsic cues in labels.Conclusions and ImplicationsConsumers' levels of nutrition knowledge influenced their ability to process food labels. The United States Food and Drug Administration should regulate the “all natural” food label, because this claim is likely to mislead most consumers.     

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

Background

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

Methods

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

Results

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

Conclusions

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

     

Influence of the San Francisco,CA, Sugar-Sweetened Beverage Health Warning on Consumer Reactions: Implications for Equity from a Randomized Experiment

BackgroundIn 2020, San Francisco, CA, amended an ordinance requiring warning labels on advertisements for sugary drinks to update the warning message. No studies have evaluated consumer responses to the revised message.ObjectivesTo evaluate responses to the 2020 San Francisco sugary drink warning label and to assess whether these responses differ by demographic characteristics.DesignRandomized experiment.Participants and settingDuring 2020, a convenience sample of US parents of children aged 6 months to 5 years (N = 2,160 included in primary analyses) was recruited via an online panel to complete a survey. Oversampling was used to achieve a diverse sample (49% Hispanic/Latino[a], 34% non-Hispanic Black, and 9% non-Hispanic White).MethodsParticipants were randomly assigned to view a control label (“Always read the Nutrition Facts Panel”) or the 2020 San Francisco sugary drink warning label (“SAN FRANCISCO GOVERNMENT WARNING: Drinking beverages with added sugar(s) can cause weight gain, which increases the risk of obesity and type 2 diabetes.”). Messages were shown in white text on black rectangular labels.Main outcome measuresParticipants rated the labels on thinking about health harms of sugary drink consumption (primary outcome) and perceived discouragement from wanting to consume sugary drinks. The survey was available in English and Spanish.Statistical analyses performedOrdinary least squares regression.ResultsThe San Francisco warning label elicited more thinking about health harms (Cohen’s d = 0.24; P < 0.001) than the control label. The San Francisco warning label also led to more discouragement from wanting to consume sugary drinks than the control label (d = 0.31; P < 0.001). The warning label’s influence on thinking about harms did not differ by any participant characteristics, including age, gender, race/ethnicity, education, income, or language of survey administration (all P values for interactions > 0.12).ConclusionsSan Francisco’s 2020 sugary drink warning label may be a promising policy for informing consumers and encouraging healthier beverage choices across groups with diverse demographic characteristics.     

The Impact of Toddler Milk Claims on Beliefs and Misperceptions: A Randomized Experiment with Parents of Young Children

BackgroundToddler milk (ie, a nutrient-fortified milk-based drink marketed for children aged 12 to 36 months) has been marketed increasingly in the United States with structure/function claims on product packaging that are potentially misleading.ObjectiveThis study examined how structure/function claims impact parents’ beliefs and perceptions about a toddler milk product.DesignThis was a 3-arm between-subjects randomized experiment.ParticipantsA diverse sample of 2,190 US parents of children aged 1 to 5 years were chosen to take an online survey.InterventionParticipants were randomly assigned to view a toddler milk package with either an unrelated claim (“new and improved,” ie, control condition), a “brain development” claim (ie, “brain” claim), or an “immunity-related” claim (ie, “immunity” claim).Main outcome measuresOutcomes included perceptions, intentions, and beliefs about the toddler milk product.Statistical analyses performedLinear regression for continuous outcomes and logistic regression for dichotomous outcomes.ResultsParents who were exposed to the “brain” claim or the “immunity” claim were more likely to incorrectly believe that the toddler milk was as healthy or healthier than cow’s milk compared with those who saw the control claim (89% for brain claim, 87% for immunity claim, and 79% for control; P < .001 for both comparisons). Parents exposed to either the brain or immunity claim had higher intentions to give the toddler milk to their child, higher perceived product healthfulness, and stronger beliefs that pediatricians would recommend the product compared with parents exposed to the control (all, P < .001).ConclusionsThese findings suggest that structure/function claims on toddler milk packaging may mislead parents and increase the appeal of toddler milk. Our findings support calls for public health policies to regulate marketing on toddler milk packaging.     

Food Marketing Practices of Major Online Grocery Retailers in the United States, 2019-2020

BackgroundFood marketing influences consumers’ preferences for and selection of marketed products. Although a substantial body of research has described food-marketing practices in brick-and-mortar stores, no research has examined food marketing in online grocery retail despite its growing importance as a source of food-at-home purchases.ObjectiveTo develop and apply a coding instrument to describe food marketing and the nutritional quality of marketed products in online grocery stores.DesignQuantitative content analysis and review of product Nutrition Facts labels and ingredients lists to calculate nutrient density and level of processing using the NOVA classification system.Participants/settingFoods and beverages (n = 3,473) marketed in the top revenue-generating online grocery retailers and those participating in the US Department of Agriculture Supplemental Nutrition Assistance Program Online Purchasing Pilot (n = 21) in 2019-2020.Main outcome measuresUse of marketing mix strategies (ie, product, placement, promotion, and pricing) across retailers and nutritional quality of marketed products. Products were considered of poor nutritional quality in the case that they were ultraprocessed (NOVA category 4) and excessive in sodium, saturated fat, free sugars, and/or other sweeteners. Products were also classified into 13 mutually exclusive food groups.Statistical tests performedThe proportion of retailers using each marketing strategy, proportion of products of poor nutritional quality, and proportion of products in each food group were calculated.ResultsRetailers commonly used product recommendations, search result ordering, branded website content, user-generated content, and social media engagement to market products online. Candy, sweets, and snacks made up the largest percentage of marketed products (17.3%), followed by fruit, vegetables, and legumes (16.7%). Most (62%) marketed products were of poor nutritional quality. Staple food categories such as fruits, vegetables, and grains were frequently marketed, particularly through price reductions and product recommendations.ConclusionsOnline grocery retailers use a variety of customizable food marketing strategies on their websites. Although most marketed products are of poor nutritional quality, there is potential for marketing of staple food categories online that is not feasible in a brick-and-mortar store.     

The Smart Choices front-of-package nutrition label. Influence on perceptions and intake of cereal

Numerous front-of-package (FOP) nutrition labeling systems exist, but it is unclear if such labels influence behavior. A single-summary label called Smart Choices (SC) appeared briefly on products in the United States in 2009. The current study aimed to evaluate (1) the influence the SC symbol has on the serving and consumption of cereal; and (2) the impact of providing calorie and serving size information on a FOP label. Two hundred and sixteen adults were randomized to a high-sugar breakfast cereal that had either (1) no label; (2) the SC symbol; or (3) a modified SC symbol with serving size information. Participants rated perceptions of healthfulness, taste, and purchase intent, estimated calories per serving and poured and ate the cereal for breakfast. Participants in the SC label conditions were better able to estimate calories per serving, but there were no differences across groups on perceptions of healthfulness, taste, purchase intent, and levels of vitamins, and sugar or amount of cereal poured or consumed. These results suggest that calories per serving information on FOP labels can increase knowledge, but the SC symbol had little impact on behavior. Studies examining FOP label influence on purchasing, consumption, and product reformulation are greatly needed to determine label utility.     

Favorable Commercial and Health Behavior Impacts of a Healthy Vending Policy at an Australian University

BackgroundThe World Health Organization recognizes universities as an important health-promotion setting, including in healthy food provision. Previous research shows that healthy food retail interventions also need to consider commercial sustainability, including financial outcomes, and should take a holistic approach to consumer experience.ObjectiveOur aim was to determine the health behavior and commercial outcomes of a multicomponent traffic light–based healthy vending policy implemented as one part of a holistic university food policy. The hypothesis was that purchases of less healthy “red” beverages would decrease compared with predicted sales, that purchases of healthier “green” and “amber” alternatives would increase, and that there would be no change in revenue.DesignA quasi-experimental design evaluated a real-world food policy using monthly aggregated sales data to compare pre-intervention (January 2016 to March 2018) and post-intervention period sales (December 2018 to December 2019).Participants/settingElectronic sales data were collected from 51 beverage vending machines across 4 university campuses in Victoria, Australia.InterventionA multicomponent policy was implemented between April and November 2018. Beverages were classified using a voluntary state government traffic light framework. Policy included display ≤20% red beverages and ≥50% green beverages; machine traffic light labeling; health-promoting machine branding; review of machine placement; and recycled bottle packaging.Main outcome measuresChanges in red, amber, and green volume sales, and revenue compared with predicated sales.Statistical analyses performedInterrupted time series analysis of sales data compared post-policy sales with predicted sales.ResultsIn the 13^th month post-policy implementation, there was a 93.2% (95% CI +35.9% to +150.5%) increase in total beverage volume sold and an 88.6% (95% CI +39.2% to +138.1%) increase in revenue. There was no change in red beverage volume sold, but increases in green (+120.8%; 95% CI +59.0% to +182.6%) and amber (+223.2%; 95% CI +122.4% to +323.9%) volume sold.ConclusionsSustained behavior change and commercial outcomes suggest that holistic vending interventions can effectively promote healthier beverage sales.     

Validating the food behavior questions from the elementary school SPAN questionnaire

BackgroundThe School Physical Activity and Nutrition (SPAN) questionnaire was developed as a surveillance instrument to measure physical activity, nutrition attitudes, and dietary and physical activity behaviors in children and adolescents. The SPAN questionnaire has 2 versions.ObjectiveThis study was conducted to evaluate the validity of food consumption items from the elementary school version of the SPAN questionnaire.DesignValidity was assessed by comparing food items selected on the questionnaire with food items reported from a single 24-hour recall covering the same reference period.Setting5 elementary schools in Indiana.ParticipantsFourth-grade student volunteers (N = 121) from 5 elementary schools.Main Outcome MeasureAgreement between responses to SPAN questionnaire items and reference values obtained through 24-hour dietary recall.AnalysisThe agreement between the questionnaire and the 24-hour recall was measured using Spearman correlation, percentage agreement, and kappa statistic.ResultsCorrelation between SPAN item responses and recall data ranged from .25 (bread and related products) to .67 (gravy). The percentage agreement ranged from 26% (bread and related products) to 90% (gravy). The kappa statistic varied from .06 (chocolate candy) to .60 (beans).Conclusions and implicationsResults from this study indicate that the SPAN questionnaire can be administered in the classroom quickly and easily to measure many previous day dietary behaviors of fourth graders. However, questions addressing consumption of “vegetables,” “candy,” and “snacks” need further investigation.