Public Health Nutrition: page 1 of 10
The science on front-of-package food labels
Kristy L Hawley1,*, Christina A Roberto2, Marie A Bragg2, Peggy J Liu2,
Marlene B Schwartz2and Kelly D Brownell2
1The George Washington University School of Medicine and Health Sciences, 2300 I Street NW, Washington,
DC 20037, USA:2Department of Psychology, Yale University, Rudd Center for Food Policy and Obesity,
New Haven, CT, USA
Submitted 30 July 2011: Final revision received 23 December 2011: Accepted 7 February 2012
Objective: The US Food and Drug Administration and Institute of Medicine are cur-
rently investigating front-of-package (FOP) food labelling systems to provide science-
based guidance to the food industry. The present paper reviews the literature on FOP
labelling and supermarket shelf-labelling systems published or under review by
February 2011 to inform current investigations and identify areas of future research.
Design: A structured search was undertaken of research studies on consumer use,
understanding of, preference for, perception of and behaviours relating to FOP/
shelf labelling published between January 2004 and February 2011.
Results: Twenty-eight studies from a structured search met inclusion criteria.
Reviewed studies examined consumer preferences, understanding and use of
different labelling systems as well as label impact on purchasing patterns and
industry product reformulation.
Conclusions: The findings indicate that the Multiple Traffic Light system has most
consistently helped consumers identify healthier products; however, additional
research on different labelling systems’ abilities to influence consumer behaviour
Front-of-package food labelling
In May 2010 the White House Childhood Obesity Task
Force highlighted the need to ‘empower parents and
caregivers to make healthy choices’ with simple, practical
information, including improved front-of-package (FOP)
food labels(1). Currently the US Food and Drug Admin-
istration (FDA) has undertaken a Front-of-Package
Labeling Initiative(2)with the goal of reviewing available
evidence on FOP labelling systems to determine whether
one approach can be recommended over others. Con-
gress also requested that the Institute of Medicine (IOM)
examine this issue and in October 2010 the Committee on
Examination of Front-of-Package Nutrition Ratings Sys-
tems and Symbols released its first of two consensus
reports which reviewed the current FOP systems and
examined the strengths and limitations of the nutrition
criteria that underlie them(3).
A variety of FOP systems exist, including industry-
initiated systems in the USA(4), a Traffic Light (TL)
approach in the UK developed by the Food Standards
Agency (UK FSA)(5)and the ‘Choices’ programme check
mark system being used by food manufacturers around
the world(6). A number of major food manufacturers in
the USA and the UK have also voluntarily agreed to post
the number of calories per serving and the per cent daily
calorie value on the front of their food products(7). More
recently, prior to the FDA and IOM’s recommendations,
the Food Marketing Institute and the Grocery Manufacturers
Association, two of the industry’s largest trade groups,
announced the introduction of a new ‘Nutrition Keys’
labelling system(8). The four basic icons on the symbol will
provide information about calories, saturated fat, sodium
and sugars per serving as well as per cent daily value
(%DV)(9). The label will also highlight up to two nutrients
to encourage which include potassium, fibre, vitamin A,
vitamin C, vitamin D, calcium, iron and/or protein(9).
Much is at stake regarding an FOP labelling system.
An FDA survey found that 67% of respondents reported
using FOP symbols often or sometimes when making
purchasing decisions(10), but the array of non-standardized
labelling systems makes it difficult for consumers to evaluate
and compare the nutritional profiles of foods. In addition,
each labelling system is based on a different set of nutrition
criteria, which are susceptible to industry manipulation.
Furthermore, because people tend to use heuristic-based
decision making when pressed for time, consumers are
vulnerable to food manufacturers highlighting healthy
Public Health Nutrition
*Corresponding author: Email firstname.lastname@example.org
r The Authors 2012
aspects of an overall unhealthy product(11). Therefore, it is
critical that an informative, easily understood, science-based
FOP labelling system be implemented.
The current paper aims to: (i) evaluate existing
research to identify FOP/shelf labelling systems which
hold the most promise; and (ii) identify key FOP/shelf
labelling research needs.
A structured search of research studies published or under
review by February 2011 on consumer use, understanding
of, preference for, perception of and behaviours relating to
FOP labelling and supermarket shelf-labelling systems was
Inclusion and exclusion criteria
To be considered, a published, in press or under review
research paper had to meet the following criteria: (i) must
relate to FOP nutrition labelling and/or shelf-labelling sys-
tems and consumer use, understanding, preference, per-
ception or behaviour related to that label; (ii) the labels
examined must include symbols or nutrition information
flags located on the front of the package or on the super-
market shelf; and (iii) must relate to original research or a
review of research.
Studies were excluded if they: (i) discussed policy and
legal strategies for obesity prevention and the FOP/shelf label
was only mentioned; (ii) included general information on
FOP/shelf labelling, but did not describe relevant research;
(iii) described nutrition criteria for FOP/shelf labelling, but
not consumer use; (iv) described research related to nutrition
labels, but not FOP/shelf labels specifically; (v) described
research on health claims; (vi) were not peer-reviewed
research, except for government reports; or (vii) related to
nutrition labelling on menus or trans fat labelling.
A search strategy using (‘FOP’ OR ‘front-of-pack’ OR ‘shelf
label’) AND nutrition was run in Medline and adapted
for other databases including Google Scholar, CINHAL,
PsychINFO, CDSR and AGRICOLA. Titles and abstracts
were screened for relevance; when in doubt, full papers
were reviewed and/or authors were contacted for clarifica-
tion. In addition, nutrition label researchers were contacted
for any in press or under review publications. Twenty-eight
studies were included in the current review (see Table 1).
Consumer preferences for label elements and
Front-of-package label simplicity
Consumer preferences for labelling systems were asses-
sed via focus groups in Germany, France, the UK and the
Netherlands. The study included young adults, families
and individuals over 55 years old(12). The participants
reported that an FOP label with information about cal-
ories, exercise, %DV and daily caloric amounts provided
too much information(12). Overall, participants in these
groups(12), as well as those participating in a large FOP
study undertaken by the UK FSA(13), expressed a desire
for a simple FOP label. The FDA also evaluated consumer
preference for various FOP labelling systems by con-
ducting eight focus groups across four US cities(14). Sixty-
eight adults from varying educational backgrounds
responded most positively to a simple keyhole summary
symbol that included the statement ‘meets FDA Healthy
Meal Guidelines’. In addition, a study conducted by
Unilever found that individuals with low perceived
nutritional knowledge reported difficulty understanding
complex FOP labels, although no difference between
education and comprehension level was observed(15).
How should front-of-package labels present calorie
Calorie information is one of the most frequently accessed
pieces of information on nutrition labels(12,13,16). In the UK
FSA study, calorie information was the most understood
element of FOP labels(13), and those trying to lose weight
reported using calorie information most frequently(13).
One study recommended that calorie information be
presented in a neutral, white box because when it was
displayed inside a starburst shape consumers interpreted
the attention-grabbing nature of the symbol as an indi-
cation that the calorie information was for the whole
Public Health Nutrition
Table 1 Studies included in the present review
1. Vyth EL, Steenhuis IH, Mallant SF et al. (2009)(6)
2. van Kleef E, van Trijp H, Paeps F et al. (2008)(12)
3. Malam S, Clegg S, Kirwin S et al. (2009)(13)
4. Lando AM & Labiner-Wolfe J (2007)(14)
5. Feunekes GI, Gortemaker IA, Willems AA et al. (2008)(15)
6. Kim WK & Kim J (2009)(18)
7. Kelly B, Hughes C, Chapman K et al. (2009)(19)
8. Gorton D, Ni Mhurchu C, Chen MH et al. (2009)(20)
9. Mo ¨ser A, Hoefkens C, Van Camp J et al. (2010)(21)
10. Levy AS, Mathews O, Stephenson M et al. (1985)(22)
11. Borgmeier I & Westenhoefer J (2009)(23)
12. Maubach H & Hoek J (2008)(24)
13. Andrews JC, Burton S & Kees J (2011)(25)
14. Jones G & Richardson M (2007)(26)
15. Vyth EL, Steenhuis IH, Vlot JA et al. (2010)(27)
16. Sacks G, Rayner M & Swinburn B (2009)(28)
17. Steenhuis IH, Kroeze W, Vyth EL et al. (2010)(30)
18. Drichoutis AC, Lazaridis P & Nayga RM (2009)(31)
19. Bialkova S & van Trijp H (2010)(32)
20. Lang JE, Mercer N, Tran D et al. (2000)(33)
21. Jeffery RW, Pirie PL, Rosenthal BS et al. (1982)(34)
22. Katz DL, Njike VY, Rhee LQ et al. (2010)(35)
23. Berning JP, Chouinard HH, Manning KC et al. (2010)(37)
24. Sutherland LA, Kaley LA & Fischer L (2010)(38)
25. Grunert KG, Wills JM & Fernandez-Celemin L (2010)(39)
26. Drewnowski A, Moskowitz H, Reisner M et al. (2010)(40)
27. Young L & Swinburn B (2002)(41)
28. Vyth EL, Steenhuis IH, Roodenburg AJ et al. (2010)(44)
2 KL Hawley et al.
package(14). Consumers also felt that calorie information
alone was not enough for them to make an informed
choice; however, that study did not identify what addi-
tional information consumers would want(14).
In addition, FOP labels that include information about
daily caloric needs were viewed positively and could be
an important educational tool, as few people in the USA
can accurately identify such needs(14,16). European focus
group participants also favoured FOP labels that included
daily caloric reference values for men and women(12).
Furthermore, research on restaurant menu labelling has
shown that the statement ‘The recommended daily caloric
intake for an average adult is 2000 calories’ enhanced the
effect of menu labelling by staving off overeating at a
subsequent meal(17). One concern with a daily caloric
requirement and per cent dietary intake (%DI) labels is
that they are based on a recommended number of calories
that is not suitable for everyone.
It is also important to consider how calorie information
should be presented in relation to serving size. Individ-
uals in the USA, Korea and the UK were confused by
labels showing calories per serving for products often
consumed in one sitting (i.e. a muffin, 20 ounce soda
bottle)(13,14,18). This suggests that calorie information
should be listed per package for these types of foods.
In addition, participants in Europe felt that information
about calories per 100g should be avoided because it
makes it difficult to compare across products and does
not provide serving size information(12). More research on
how the presentation of calorie information per serving
or per package impacts purchasing behaviour and per-
ception of product healthfulness is greatly needed.
Should front-of-package labels include percentages?
The purpose of including percentages on labels is to put
the numbers in context of the overall diet. Research
strongly suggests, however, that percentages on FOP
labels are confusing and few people find them helpful. In
FDA focus groups, some consumers did not understand
%DV labels(14)and in European focus groups, symbols
including a graphic expression of %DV were viewed by
consumers as difficult to understand(12). In an Australian
study, individuals in socially disadvantaged areas were six
times less likely to identify the healthier of two foods
when using a monochrome %DI symbol in contrast to the
TL symbol which resulted in equitable performance
across socio-economic groups(19). In that study two ver-
sions of the TL label also yielded more correct answers for
the identification of nutrients in food products compared
with two variants of the %DI system(19).
In a study of 1525 supermarket shoppers in New
Zealand, the least preferred among four FOP labelling
systems was the %DI label(20). The UK FSA study also
found that many people had a poor understanding of
what information per cent guideline daily amount (%GDA)
conveys and those over 65 years old found labels with
%GDA information particularly difficult to comprehend(13).
These findings suggest avoiding percentages as a method of
providing dietary context on labels.
Should front-of-package labels include text to indicate
The UK FSA study found that the best predictor of suc-
cessful label comprehension was the appearance of text
indicating whether a product had ‘high’, ‘medium’ or ‘low’
levels of a specific nutrient(13). The study used a factorial
design for the presence and absence of %GDA, TL and
interpretive text to examine consumers’ evaluation of the
level of individual nutrients and the overall healthfulness
of a product. The inclusion of text increased the proportion
of correct answers for both product types (main meal sized
portion and snack) for both the evaluation of a single
nutrient and overall healthfulness of the product. In addi-
tion, interviews with customers revealed that shoppers who
did not understand that the TL colours were meaningful or
had trouble comprehending percentages were assisted by
the text. These findings suggest that such interpretive text
can greatly improve label comprehension.
The UK FSA recommends the use of a label combining
TL colours, text which specifies whether the product is high,
medium or low in a specific nutrient, and %GDA because it
was liked the best and had good comprehension(13). When
used alone %GDA was not found to be effective, but when
combined with both text and TL colours, the percentage
helped some shoppers to determine the level of individual
nutrients(13). These findings suggest that if percentages are
to be used on a label, they should be accompanied by text
to help with interpretation.
Should front-of-package labels include information
statements about exercise or energy balance?
There is very little research on how exercise labels or
statements about energy balance appearing on packaged
foods may influence consumer perception and behaviour.
In European focus groups(12), most participants disliked
exercise labels which gave the calories per serving of
the product plus the amount of exercise needed to burn
these calories. While younger consumers liked the label
because they found it easy to understand and motivating,
most others argued that the exercise labels would be
‘demotivating and patronizing’ and induce guilt. The
participants also indicated that FOP labels should avoid
phrases about energy balance on labels. For example,
a symbol including calories per serving and the phrase
‘balance your energy’ was least preferred and viewed
with scepticism as a marketing tool, which was ‘gimmicky
and coercive’. Some respondents saw the label as
meaningless because they did not understand what it was
trying to convey. Larger studies using quantitative meth-
ods, rather than focus groups, are needed to draw more
definitive conclusions about the impact of exercise and
energy balance phrases on FOP labels.
Public Health Nutrition
The science on front-of-package food labels3
What is the appropriate size for a front-of-package
Participants in the UK FSA study expressed concern that
the labels were too small and difficult to read, especially
for those requiring reading glasses(13). Given that consumer
ability to see the label is important, studies should report
information on the text size of the labels tested and further
research should seek to determine adequate label size.
Which front-of-package label do consumers prefer?
Only a handful of studies have asked consumers about
their preferences regarding different FOP labels. In addition,
there is a dearth of research comparing preferences for
different industry and non-industry developed labels.
However, existing research comparing the Multiple Traffic
Light (MTL) label to other FOP labels suggests that con-
sumers prefer a TL system.
A New Zealand study of 1525 supermarket shoppers
found the MTL symbol was preferred most often(20). An
interview-based study of 1019 consumers in Korea(18)found
that 58% of respondents believed colour differences based
on nutrient content (as seen on the MTL label) convey
important information, but 33% of respondents had diffi-
culty understanding what the information was conveying.
Two surveys, one conducted in Germany and one in
Belgium, investigated perceptions of their widely used
GDA label compared with the MTL(21). The GDA label
provides average energy and macronutrient intake levels
per serving that people should consume daily. This label
has been criticized because the nutrient reference levels
are not grounded in science, the nutrition requirements
are based on those for an average adult and therefore not
applicable to groups with different needs, and the portion
sizes used are unrealistically small. Participants in Ger-
many preferred the MTL label because it was easier to
understand and seen as more appealing and trustworthy
than the widely used GDA label. However, a similar study
in Belgium found that Belgians preferred the GDA label
to the MTL, although this was partly explained by Bel-
gians’ familiarity with the GDA symbol. However, older
individuals and those with a higher BMI had less of a
preference for the GDA label.
More studies on perceptions and use of the MTL label
and other existing FOP symbols in US samples are needed.
However, several studies have found that consumer pre-
ference for a label format is not indicative of label com-
prehension(13,19,22)or ability to use a label to choose a
healthy product(22). This suggests that less emphasis
should be placed on studies examining preference alone.
Consumer understanding and use of labels
Which front-of-package label best helps consumers assess
Existing literature suggests that consumers are better able
to evaluate food products when using the MTL label
compared with other approaches. A study of 790
respondents conducted in Australia(19)tested consumer
perceptions and performance using four different FOP
labels: (i) a TL system ranking levels of total fat, saturated
fat, sugar and sodium; (ii) TL rankings plus an overall
rating (TL1) for the product; (iii) a monochrome %DI
label indicating the per cent dietary contribution of
energy, protein, total fat, saturated fat, total carbohydrate,
sugar, fibre and sodium; (iv) a colour-coded %DI system
with the same nutrients ranked plus a colour code for
total fat, saturated fat, sugar and sodium. Each respondent
was exposed to one labelling format on two sets (a healthy
product and less healthy product) of two different food
products. A product was defined as healthy if it was eligible
to carry a health claim based on the Australia and New
Zealand 2007 Food Standards Agency Nutrient Profiling
guidelines. The authors found that while people initially
thought they would have the easiest time using a colour-
coded %DI label, the TL label was most successful in
assisting customers select the healthier food product.
In a two-part experimental study, 420 participants were
randomized to one of five label formats: (i) a simple tick;
(ii) an MTL format; (iii) a monochrome GDA; (iv) a colour-
coded GDA; or (v) a no label control. Exposure to the MTL
symbol yielded the highest percentage of correct choices
when trying to decide which of two foods was healthier(23).
However, when participants completed a virtual super-
market task during which they were asked to select all the
foods they would eat the next day, no differences in the
energy content of the foods was found across the label
A study of 1525 ethnically diverse shoppers in New
Zealand found that the Simple Traffic Light (STL) format
led to increased ability to correctly determine if a food
was healthy, followed very closely by the MTL label(20).
‘Not healthy’ was defined as high in fat, saturated fat and
sodium, and low in fibre, as assessed by a registered die-
titian. The nutrition information panel and %DI label yielded
fewer correct distinctions regarding food healthfulness.
In contrast, an Internet survey of 1630 participants from
four European countries found that survey respondents
viewed the MTL as the easiest to comprehend and most
credible. However, when making selections between heal-
thy and less healthy products in the food spreads category,
the MTL label differentiated significantly less between pro-
ducts compared with a label with Smileys or with Stars(15).
This significant difference was not found between the other
products studied (dairy drink and ice cream), which high-
lights the need for future research to examine more product
categories when testing label formats.
In addition to helping consumers identify the healthier
of two products, the TL system impacts perceptions of
healthfulness. When 294 parents and caregivers in New
Zealand evaluated pictures of cereals, those who saw the
MTL label reported significantly lower health scores for
cereals of poor nutritional quality compared with a control
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4 KL Hawley et al.
condition, while those who viewed a %DI label gave
lower, but not significantly different ratings from a control
condition(24). In contrast, a web-based study examining
perceptions of healthfulness for a frozen chicken dinner
with a ‘Smart Choices’ logo, a TL plus %GDA or no logo
revealed that participants viewed an unhealthy product
as being healthier and having lower levels of negative
nutrients when it had a Smart Choices symbol on it rela-
tive to a no logo control. This was also true, although less
strong, for the TL plus %GDA symbol compared with the no
logo control. Furthermore, the Smart Choices icon, relative
to the control, led to more favourable product attitudes and
purchase intentions as well as reduced assumptions that
regularly eating the food would lead to heart disease and
weight gain. The TL plus %GDA also led to an increase in
favourable product attitudes and purchase intentions, but
did not impact perceptions of eating the food and devel-
oping heart disease or gaining weight(25).
An eye-movement study of ninety-two participants
comparing a label with eight nutrients to a label with the
same nutrients plus TL symbols for specific nutrients
found that nutrients on the TL were examined most(26).
Unlike the colourless label format where testing found
that the nutrients people examined had a limited impact
on the nutrients they used when making a judgement, the
TL guided people to important nutrients which they used
when making healthfulness judgement. More research
testing different FOP labels using eye-movement tech-
nology would be useful.
Which front-of-package labels impact food purchases?
Little research exists on the impact FOP labelling systems
have on purchasing patterns. One study examined sales
of products with the Choices logo(27). Four hundred and
four customers exiting nine different grocery stores in the
Netherlands completed questionnaires while research
staff counted the number of their purchased products that
contained the Choices logo. The study found that most
products purchased with the logo were in the dairy
category, followed by oils and fats, vegetables and fruits,
and finally soups. Out of the 246 participants who were
familiar with the Choices label, seventy-two participants
reported purchasing products with the logo and did
indeed buy more products with the logo relative to those
who did not report buying Choices products.
There are few studies examining the impact FOP labels
have on actual sales of food products. One study con-
ducted in the UK examined supermarket sales data for
two types of food products (chilled pre-packaged meals
and fresh pre-packaged sandwiches) sold by a major
retailer four weeks before and after the implementation of
the TL label(28). The study investigators found that the TL
labels did not substantially influence the sale of healthier
products. However, only two categories of food were
examined over a short period of time. Additionally,
such before-and-after studies should be accompanied by
informational campaigns to ensure consumers are edu-
cated about the change in label format and the meaning
of the label.
Which front-of-package labels impact food
In addition to a lack of research on purchasing patterns,
few studies have examined how FOP labels influence
food consumption. One concern with placing an FOP
label on food products is that people may eat even more
of the product because they perceive it to be healthy. For
example, this ‘health halo’ effect has been documented
for products labelled as ‘low fat’(29). To test this possibility
with the Choices logo, participants in a laboratory-based
study using a cross-over design(30)were given a piece of
chocolate mousse cake. In one condition, they were told
the cake qualified for a Choices logo, which was further
explained on an information card. In the other condition,
they were not told the cake qualified for the Choices
symbol. When the Choices logo appeared on the cake, it
was perceived as ‘less unhealthy’, but there was no dif-
ference in taste perception or cake consumption relative
to when the cake did not have the logo on it. This sug-
gests that the logo does not promote overconsumption of
unhealthy foods or cause people to think a food will taste
worse because it is viewed as healthier. It is possible,
however, that this would not be the case with other food
products that are not as obviously unhealthy. More
research on the impact FOP labelling systems have on
purchasing and consumption of foods is greatly needed.
For which front-of-package labels are people willing to
A study in Greece found that students participating in a
laboratory experiment were willing to pay more for
products with nutrition labels v. without. However among
the products with nutritional information, the students’
willingness to pay differed across label formats(31). The
study participants were presented with different labelling
schemes and were asked what they would pay for each
product with a nutritional label via a second price Vickrey
auction. Products with a European Union-endorsed label
or a TL label were valued more than a US government-
endorsed label and an unlabelled product. The authors
noted that the US label provided much more information
which might have overwhelmed participants and led to
What are the potential problems of the Multiple Traffic
While the MTL symbol has a growing body of research
support, several issues regarding this system arose during
the UK FSA study. One concern is that some people did
not realize that the red/amber/green colours had mean-
ing(13). Some assumed the colours were simply being
used to make the labels stand out. In addition, some
Public Health Nutrition
The science on front-of-package food labels5
individuals thought the colours were related to specific
nutrients (i.e. fats were always in red). However, this
problem was overcome when text was included on the
FOP label to indicate high/medium/low levels of nutri-
ents in food products. An additional problem uncovered
by the UK FSA study was that some consumers did not
know that different nutrients have different maximum
daily amounts, which explained why 0?5g of salt had an
orange label, but 1?4g of sugars had a green label.
What label characteristics increase attention to
a front-of-package label?
A study using a visual search paradigm found that atten-
tional performance was faster when a logo was: (i) present
(instead of absent); (ii) doubled in size; and (iii) displayed
on the top-right of the package(32). Participants also
responded faster when viewing a monochromatic v. poly-
chromatic logo. Given the research described thus far
indicating the utility of a polychromatic TL, more research is
needed to understand the relationship between response
time and label comprehension. Finally, attentional perfor-
mance was improved when the logo location did not
change in consecutive tasks, suggesting that a single loca-
tion for the logo on each product may be most beneficial.
How often do consumers report using supermarket
In contrast to FOP food labels, another possible labelling
scheme is supermarket shelf-label systems. These systems
place nutrition information on the shelf underneath or
above the product, rather than on the actual product
packaging. A number of studies have evaluated con-
sumers’ preference for, awareness of and use of nutrition
labels placed on grocery store shelves. One study con-
ducted in eighteen Detroit supermarkets examined con-
sumer awareness and use of colour-coded shelf labels
that indicated varying levels of product healthfulness(33).
Exit surveys of 361 participants revealed that 28% of the
sample was aware of the shelf labels, and ethnic and
racial minority groups were significantly more likely to
report awareness than Caucasians. However, 37% of
participants reported they did not use the shelf-label
system, with only 17% of participants reporting use of the
system ‘often’ or ‘always’.
Another study of 400 participants involving eight
supermarkets in Minnesota examined the effect of shelf
labels using pre- and post-test surveys that assessed
consumer nutrition knowledge(34). Results indicated that
there were no differences in consumer knowledge between
the control and intervention supermarkets, although data
were only collected over the course of 9 months and
there were no intensive marketing efforts to promote the
programme. In one study, a quasi-experimental repeated-
measures design was used in twenty matched supermarkets
in Washington, DC and Baltimore, MD to evaluate con-
sumer use of shelf labels(22). Two years after the shelf labels
were implemented, 31% of customers in the shelf label
condition reported using the labels.
More recently, an interdisciplinary group of nutrition
and public health researchers developed the Overall
Nutritional Quality Index (ONQI), which served as the
basis for NuVal, a shelf-labelling system that considers
nutrient properties as well as associations between
nutrients and health outcomes(35). Katz et al. found that
approximately 80% of participants in one study (n 804)
reported the ONQI would influence their purchase
intentions. While there is a strong correlation between
various food products’ ONQI scores and the products’
nutritional rankings according to expert panellists(36), the
actual algorithm used as the basis for the labelling system
has not been released to the public for evaluation.
Overall, consumers view shelf-labelling systems posi-
tively and health-conscious consumers are strongly in
favour of them(35,37). However, none of these studies
directly compared whether consumers would prefer
shelf-labelling systems more than FOP labels.
Which shelf labels have impacted food sales?
A few studies have evaluated consumer use of shelf labels
through sales data, and have generally found a positive
impact of shelf labels on the purchase of healthy options.
A quasi-experimental repeated-measures design invol-
ving twenty grocery stores in the USA was used to
examine the effect of the ‘Special Diet Alert’ (SDA) pro-
gramme(22). This shelf-labelling programme was imple-
mented in ten of the twenty grocery stores, and sales data
were compared across various food categories for a
2-year period. In each store 1600 food items were grouped
into twenty-three food categories (e.g. butter/margarine) and
then assigned to a product sector that described the amount
of a given nutrient (e.g. low/reduced sodium sector). Valid
comparisons between the intervention and control stores
were made in sixteen instances (fourteen food categories):
seven sodium sector comparisons and nine calorie/fat/
Eight of these sixteen instances showed a significant
positive effect of the SDA programme. More specifically,
five low calorie/low fat/low cholesterol sectors (canned
fish, mayonnaise, butter, cottage cheese, fruit juice) and
three low sodium sectors (soft drinks, frozen vegetables,
tomato sauce) showed growth trends in market share
between the intervention and control stores consistent
with a positive programme effect. Significant market
share differences between the intervention and control
stores were not found in the following low fat/low cal-
orie/low cholesterol sectors: canned fruit, fresh milk, soft
drinks and cheese. A significant market share difference
between intervention and control stores was not found in
the following low sodium sectors: nuts and snacks, dry
cereals, crackers and butter/margarine. Results also
demonstrated that sales increased by 4 to 8% in the SDA
condition, indicating a positive effect of the programme.
Public Health Nutrition
6 KL Hawley et al.
A study comparing four supermarkets with shelf labels
and four control supermarkets failed to observe sales
differences based on the shelf-labelling system(34).
More recently, researchers investigating the impact of
the ‘Guiding Stars’ shelf-labelling system found changes
in sales of ready-to-eat cereals that translated into
2?9 million more items with stars being purchased monthly
and an equivalent decrease in the products that did
not receive stars(38). Strengths of the study include the
participation of 168 supermarkets and analyses of sales
data eight months before the start of the programme as
well as at 1- and 2-year follow-up periods. More sales data
of this nature are clearly needed and future research
should include comparisons across multiple food cate-
gories. In addition, the few studies which have examined
the influence of demographic factors on shelf-label system
use(22,38)have reported mixed results on the effect of
income and education on preference for shelf-labelling
systems(37)and/or used samples of primarily middle-aged
What nutrients should appear on front-of-package or
The decision regarding which nutrients to highlight on an
FOP labelling system is complex and consumer preference
is only a small piece. Respondents in the UK reported that
they most frequently look for fat, then sugar, calories, salt,
saturates and additives(39). In the UK FSA study participants
usually started with calorie information when determining
product healthfulness because it was the most easily
understood(13). Participants felt the next most understood
element was salt, and saturated fats were the least well
understood and used. Individuals with medical conditions
reported most frequently checking sugar content if diabetic
and salt and fat content for those with heart disease. Those
shopping for children most frequently checked salt and
sugar. In a Korean survey, most people felt four or five
nutrients should be displayed on the FOP label, including
calories, trans fat, total fat, cholesterol and sodium(18). In its
first report, the IOM noted that ‘Americans consume too
many calories, saturated fats, trans fats, and added sugars;
too much sodium; and too little vitamin D, calcium, potas-
sium, and fiber’(3), suggesting that these nutrients should be
the focus of FOP labels. However, in an online consumer
study of 320 mostly female participants located in the USA,
consumer perception of food healthfulness was most pri-
marily driven by the presence of protein, fibre, calcium and
vitamin C, and the absence of saturated fat and sodium(40).
The finding that the presence of positive nutrients can
greatly influence health perceptions cautions against the
inclusion of such nutrients on FOP labels appearing
on nutritionally poor foods. One option is to highlight
problem nutrients associated with the most prevalent health
problems in the USA. In addition, it should be considered
that those nutrients that appear on an FOP label will likely
be the greatest focus of potential industry reformulation.
Industry product reformulation
Which labels will promote food product reformulation?
Few studies have examined industry reformulation of
food products following the implementation of FOP
labelling systems. It is possible to argue that even a system
that produces little impact on consumer behaviour could
have considerable public health benefit if companies feel
compelled to reformulate their foods.
When a new logo system was introduced in New
Zealand, food companies excluded 33 tonnes of salt over
the course of a year by reformulating products(41). In
addition, following the FDA mandate to list trans fat
content on packaged food labels(42), the amount of trans
fats was reduced in many products(43), suggesting that
similar effects would be seen based on the nutrients
highlighted on FOP labels. In a larger study examining
the impact of the Choices programme on product refor-
mulation in the Netherlands, Vyth et al.(44)retrieved
nutritional information for 821 products from food man-
ufacturers participating in the programme. The authors
found that 168 products were reformulated after the
Choices logo was introduced and 236 newly developed
products meeting the Choices criteria were introduced
into the market. After reformulation, there was a sig-
nificant increase in fibre for fruit juices and sandwiches.
Sodium and SFA levels were reduced in processed meats
as was sodium in sandwiches, sandwich fillings and
soups. Dairy products saw a decrease in SFA, added sugar
and energy, and added sugars were reduced in sauces.
Finally, sandwich fillings also decreased in SFA, trans fat
and energy. Products that were newly developed had
increased fibre levels for fruit juice; less sodium and
increased fibre for processed meats; lower SFA and added
sugar and more fibre for dairy products; more fibre for
sandwiches, although added sugar levels increased; and
lower sodium and more fibre for soups. However, for
newly developed products, energy was unchanged across
all product groups. The Choices stamp used in the
Netherlands at this time did not include calorie informa-
tion on the logo. Displaying the calorie information with
the logo may have encouraged manufacturers to decrease
the energy in products.
Improving label awareness and trust
How do demographics impact label awareness and use?
In a study commissioned by the Choices Foundation(6),
the elderly, obese and those with diet-related health
problems expressed the need for an FOP logo, although
respondents over 50 years old were less familiar with the
Choices logo after it was launched. Interestingly, respon-
dents with a lower education reported paying more atten-
tion to the logo. In the Netherlands, women liked the
Choices logo more than men overall.
A study conducted in New Zealand(20), which recruited
ethnically diverse shoppers in supermarkets, found that
Public Health Nutrition
The science on front-of-package food labels7
those 18–24 years old were less likely to use labels. Indivi-
duals with special dietary requirements and from house-
holds with medium income compared to low income were
more likely to use labels.
Should a uniform labelling system be used on all products?
Several studies have found that consumers desire uniform
FOP systems across products(12,19). However, participants
in focus groups in the Netherlands expressed concern
that a diversity of product categories such as vegetables
and snacks carrying the same logo would be confusing(6).
Should front-of-package labels be government mandated
or done voluntarily by industry?
A common theme throughout several studies was that FOP
labels will be maximally effective if the label is perceived as
credible. Focus group studies have found that individuals
consistently desire a label where the definition of healthful-
ness is understood and comes from a trusted source(6,12,26).
European focus groups also found that an official endorse-
ment from a national or international organization strongly
increased the consumer perception of credibility, while
endorsements by the European Union and European food
manufacturers were perceived as less credible compared
with the WHO or a national nutrition organization(12). People
were more sceptical if they thought the symbol was
developed by the food industry(6). The UK FSA study also
found that some consumers were sceptical about FOP labels
because they thought the food companies were using
them to push certain products and therefore could not be
trusted(13). In contrast, others disliked the labels because they
felt the government was trying to tell them what to eat.
The need for an information campaign
After the implementation of the Choices programme in the
Netherlands, focus group participants generated a variety of
explanations for the logo such as ‘product health, safety or
natural or organic product’ and some people in the UK were
confused about the meaning of the TL colours. Given
concerns about the credibility of a system, misinterpretation
of FOP label elements and overall label messages(6), it will
be important to undertake a public health information
campaign to inform consumers about what an FOP label
means and how it should be interpreted. When the Nutri-
tion Facts panel was first released, the Nutritional Labeling
and Education Act funded a nationwide multi-lingual edu-
cation campaign that attempted to reach every American
household(45). However, little research exists evaluating the
marketing campaign’s influence. This will likely be an
important component of any FOP initiative.
Research on FOP labelling systems in a variety of coun-
tries has produced mixed results. Existing studies have
varied widely in the type of labelling systems tested, the
methods used, the outcomes examined and the partici-
pants studied (see Table 2). A concerted research effort is
necessary to discover which FOP or shelf labelling system
is most beneficial to consumers. An ineffective labelling
system could be misleading, deceptive, or at the very least
represent a lost opportunity to improve public health.
Based on current knowledge, the MTL label has the
most consistent support. Research suggests that an
effective MTL label should contain calorie information per
serving, daily caloric requirement information and convey
nutrient levels using high, medium or low text. The most
prevalent health problems in the USA would indicate the
need to highlight saturated fat, sodium and sugar. In
addition, products consumed in one sitting should con-
tain calorie information per package. A uniform labelling
system that is prominent and consistently located in the
top-right corner of the package should be implemented.
It is also important that the labelling system be viewed as
credible, which will most likely be achieved through
endorsements from national and international agencies,
rather than an industry-created system.
Such a label and its variants must be tested in diverse
populations. In addition, different versions of the TL
labels should be tested against possible alternatives that
have not yet been compared with the TL symbol,
including the Choices logo. Given that the Guiding Stars
and the SDA shelf-label systems have had some impact on
product sales, these should also be tested against the TL
and Choices symbol as both a shelf-tag labelling system
and a possible FOP graphic type. Furthermore, con-
sumers’ preference for and use of FOP labels should be
compared more generally with preference for and use of
supermarket shelf-labelling systems. Real-world studies
that evaluate sales data as well as consumer behaviour in
response to FOP and shelf labelling systems are greatly
needed. Finally, more research is needed to understand
Public Health Nutrition
Table 2 Summary of science on front-of-package (FOP)/shelf
> The Multiple Traffic Light label is the FOP system with the
greatest empirical support.
> FOP labels should convey calories per serving, daily caloric
requirements and specific nutrient levels with high/medium/low
> Highlighted nutrients should be associated with the most
prevalent health problems in the USA.
> Nutrients appearing on an FOP or shelf label will likely be the
greatest focus of industry reformulation.
> Products consumed in one sitting should contain calorie
information per package.
> Labels should be prominent in size and consistently displayed
on the top-right of the package.
> Shelf-labelling systems such as ‘Guiding Stars’ and ‘Special Diet
Alert’ hold promise.
> The labelling system should be viewed as a credible and trusted
source of information.
> More research is needed to test potential FOP and shelf
labelling systems among diverse US populations.
8 KL Hawley et al.
how best to inform and teach consumers to interpret a
new labelling system (see Table 3).
This work was supported in part by funding from the
Rudd Foundation and the Robert Wood Johnson Founda-
tion. None of the authors reported any financial disclosures
or conflicts of interest. K.L.H. and C.A.R. originated the idea
for the review paper and led the writing. M.A.B. contributed
significantly to the drafting of the original manuscript.
K.D.B., P.J.L. and M.B.S. provided critical feedback on drafts
of the manuscript.
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socio-economic backgrounds and literacy levels.
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