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Effects of the Guiding Stars Program on purchases of ready-to-eat cereals with different nutritional attributes
... Eleven studies evaluated nutrition scoring (Table 2) [21][22][23][24][25][26][27][28][29][30][31]. The results of nutrition scoring interventions are largely positive. ...
... Yet, labels with multiple measures of healthfulness were found to have a null effect on healthy purchasing, likely overwhelming shoppers with high information costs [26]. Five quasi-experimental studies echoed the experimental study's increased effectiveness in simpler nutritional scoring systems, including studies of the NuVal and Guiding Stars program which both assign a single value to the healthfulness of a product [21][22][23]28,29]. For example, Rahkovsky et al. found that the Guiding Stars Program decreased sales of unstarred (least healthy) products at intervention stores by 2.58 percent, while also increasing sales of 1-star, 2-star, and 3-star cereals by 1.15 percent, 0.89 percent, and 0.54 percent. ...
... Five studies of nutrition scoring were pre-experimental [22,24,25,27,30]. Additionally, 10 studies collected objective data [21,22,[24][25][26][27][28][29][30][31]. Of the eleven interventions that utilized a nutrition scoring component, ten were conducted in a retail setting that explicitly or likely accepts SNAP benefits [21][22][23][24][26][27][28][29][30][31]. ...
This review identifies the most promising intervention strategies for promoting the purchase and consumption of healthier items within U.S. grocery retail settings, with a particular focus on those strategies that may be most effective when implemented within SNAP-authorized retail settings. Searches of nine electronic databases, as well as forward and backward searches, yielded 1942 studies. After being screened, 73 peer-reviewed academic articles were identified for inclusion. Of these, 33 analyzed single-component interventions, while 40 assessed multi-component interventions. The following unique intervention types were considered as evaluated in these studies for their ability to increase healthy item purchasing and consumption: (1) nutrition scoring, (2) nutritional messaging, (3) non-nutritional messaging, (4) endcaps and secondary placement, (5) point-of-sale interventions, (6) increased stocking, (7) food tasting and demonstrations, (8) nutrition education, and (9) placement on shelf interventions. Nutritional scoring and nutritional messaging emerged as the most rigorously tested and effective intervention strategies. Other strategies warrant more research attention. Simple intervention strategies, as opposed to complex ones, yield the most successful results and minimize shopper burden. Therefore, these strategies should be reviewed for policy implementation within SNAP-authorized grocery retailers.
... In almost half of the studies (16 studies), the goal was to increase sales of healthy products and the most targeted product category was fruits and vegetables, which was covered in 15 studies. Studies defined healthy products as fruit or vegetable [52][53][54][59][60][61][62][63][64][65][66][67][68][69][70], products with high nutritional "grade" (e.g., "3-star"or "green" rating) [57,[71][72][73][74][75][76][77][78], high fiber [61,62,70], low fat products [56,[79][80][81], low-calorie snacks [81] or healthy beverages (e.g., water or diet soda) [56,63]. ...
... Studies. Defined unhealthy products as high fat or saturated-fat products [56,61,62,66,70,[82][83][84], products with low-nutritional rating (e.g., unstarred or "red" rating) [73,74,77,78], sugar soda [56,63] and unhealthy snacks (e.g., chocolate, chips or cake) [58,85,86]. Reduction in total calories purchased [85,86] and reducing sales of the most unhealthy products within certain categories [77] was also defined as targeting unhealthy products. ...
... Information rich prompts, as nutrition labels and low-calorie labels were the most tested prompt. The guiding star labeling system (a program that indicated products with a multiple-level summary prompt rating product from 0 to 3 stars and that was developed for and introduced in one American supermarket chain) was evaluated in three of the studies [72][73][74]. Pricing was studied in nine studies, mostly in combination with promotion. In all of these studies, the price for healthy products was reduced. ...
Grocery stores are important settings to promote healthier food and beverage choices. The present paper aims at reviewing the effectiveness of different types of in-store interventions and how they impact sales of different product category in real grocery stores. Systematic search was conducted in six databases. In-store interventions were categorized according to the framework by Kraak et al. (2017) into one or more of eight interventions (e.g., place, profile, portion, pricing, promotion, healthy default picks, prompting and proximity). This systematic theme-based review follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) data screening and selection. Thirty-six studies were included in the qualitative synthesis and 30 studies were included in the meta-analysis, representing 72 combinations of in-store interventions. The analysis demonstrates that interventions overall had small significant effect size (ES) using Cohen's d on food purchase behavior (d = 0.17, 95% CI [0.04, 0.09]), with largest ES for pricing (d = 0.21) and targeting fruits and vegetables (d = 0.28). Analysis of ES of in-store interventions show that pricing, and pricing combined with promotion and prompting, effectively impacted purchase behavior. Interventions significantly impacted both sales of healthy and unhealthy products and significantly increased sales of fruits and vegetables, healthy beverage and total volume of healthy products. Results should however be interpreted with some caution, given the relatively low quality of overall evidence and low number of studies and observations for some types of intervention. Further research exploring impact on different in-store interventions and targeting especially unhealthy products are needed.
... Promotion was the most commonly utilized marketing P and was the focus of 23 studies. Overall, 1 study had mixed effects (positive + negative) [16], 5 had mixed effects (positive + null) [17][18][19][20][21], 8 had mixed effects (positive + null + negative) [22][23][24][25][26][27][28][29], 1 had negative effects [30], 2 had null effects [31,32], and 13 had positive effects [33][34][35][36][37][38][39][40][41][42][43][44][45], (see Table 2). ...
... Twenty-three studies used a promotion strategy [17,[19][20][21][22][24][25][26][27][28][30][31][32]34,[36][37][38][39][41][42][43][44][45] as the sole intervention approach. Ten promotion interventions had positive effects [34,[36][37][38][39][41][42][43][44][45], four reported mixed effects (positive + null) [17,[19][20][21], six reported mixed effects (positive + null + negative) [22,[24][25][26][27][28], two reported null effects [31,32], and one reported negative effects [30]. ...
... Twenty-three studies used a promotion strategy [17,[19][20][21][22][24][25][26][27][28][30][31][32]34,[36][37][38][39][41][42][43][44][45] as the sole intervention approach. Ten promotion interventions had positive effects [34,[36][37][38][39][41][42][43][44][45], four reported mixed effects (positive + null) [17,[19][20][21], six reported mixed effects (positive + null + negative) [22,[24][25][26][27][28], two reported null effects [31,32], and one reported negative effects [30]. ...
This review examines current research on manipulations of U.S. food retail environments to promote healthier food purchasing and consumption. Studies reviewed use marketing strategies defined as the 4Ps (product, price, placement, promotion) to examine results based on single-and multi-component interventions by study design, outcome, and which of the "Ps" was targeted. Nine electronic databases were searched for publications from 2010 to 2019, followed by forward and backward searches. Studies were included if the intervention was initiated by a researcher or retailer, conducted in-store, and manipulated the retail environment. Of the unique 596 studies initially identified, 64 studies met inclusion criteria. Findings show that 56 studies had at least one positive effect related to healthier food consumption or purchasing. Thirty studies used single-component interventions, while 34 were multi-component. Promotion was the most commonly utilized marketing strategy, while manipulating promotion, placement, and product was the most common for multi-component interventions. Only 14 of the 64 studies were experimental and included objective outcome data. Future research should emphasize rigorous designs and objective outcomes. Research is also needed to understand individual and additive effects of multi-component interventions on sales outcomes, substitution effects of healthy food purchases, and sustainability of impacts.
... There are a few exceptions of studies in real-life situations measuring the effect of nutrition labels on actual food purchases (these [2,[25][26][27][28][29][30][31][32][33][34][35][36][37][38]). Unfortunately, these studies normally lack a control group, and therefore, cannot support strong causal claims. ...
... Unfortunately, these studies normally lack a control group, and therefore, cannot support strong causal claims. Three exceptions that use controls are [16,28,32]. Nikolova & Inman (2015) [28] used a control group comparison as a robustness check in their study using scanner data from a large grocery chain before and after NuVal label implementation. ...
... However, having a cocktail of interventions at the same time made it hard to disentangle which of all the possible channels was driving the results in this study. Rahkovsky et al. (2013) [32] analyzed the change in customer purchases behavior regarding cereals in a chain of grocery stores that introduced the Guiding Star Program (GSP) three-star ranking system, which includes 0-star unlabeled products, versus similar US grocery stores that did not use the system. They observed that demand increased for more nutritious GSP-ranked cereals and decreased for less nutritious GSP-ranked cereals. ...
Recently, front-of-package (FOP) food labeling systems have captured the attention of researchers and policy makers. Several Latin American governments are currently considering employing different FOP labeling systems. However, there is much need for more research-based evidence in these countries. In this paper, we study whether food-purchasing decisions and the nutritional qualities of those purchases are influenced by randomly informing some customers and not others about an FOP label known as Nutri-Score. We also separate the information effect from the effect of being aware of the system. We combined a randomized field intervention in a university cafeteria in Bogotá, Colombia with data from an after-purchase survey and receipts. We found that randomly providing information on Nutri-Score increased total expenditure by 0.26 higher, with no change for less healthy items. Expenditure estimates were higher among customers who were aware of the system’s existence. Customers in the study were also 10% more likely to buy a healthier item than control customers were, and the concentration of protein in their purchases was greater. Information on the Nutri-Score system increased the store’s sales. This potential financial incentive may facilitate the implementation of Nutri-Score.
... Previous studies that examined the effect of applying nutrient profiling to shelf tags [16][17][18][19][20][21][22][23][24][25][26]37] mostly reported outcomes that favoured healthier purchasing. Of these studies, one was an online experiment [19]; two were uncontrolled, interrupted time-series trials [17,18]; one compared purchases between frequent shopper card holders and Nielsen panel members [16]; and four only examined sales of single product categories (e.g., yoghurt and cereals) [20,21,23,37]. ...
... Previous studies that examined the effect of applying nutrient profiling to shelf tags [16][17][18][19][20][21][22][23][24][25][26]37] mostly reported outcomes that favoured healthier purchasing. Of these studies, one was an online experiment [19]; two were uncontrolled, interrupted time-series trials [17,18]; one compared purchases between frequent shopper card holders and Nielsen panel members [16]; and four only examined sales of single product categories (e.g., yoghurt and cereals) [20,21,23,37]. A study by Hobin et al. reported the effect of the Guiding Stars ® shelf labelling system in a large Canadian supermarket chain [22], whereas a study by Vandevijvere et al. examined the application of the NutriScore nutrient profiling logo to electronic labels in a Belgian supermarket chain [26]. ...
Introduction:
Most people in Australia buy most of their food in supermarkets. Marketing techniques promoting healthy foods in supermarkets can be important to encourage healthy eating at a population level. Shelf tags that highlight the healthiness of products have been identified as one such promising initiative. The aim of this study was to assess changes in the healthiness of foods sold in an Australian supermarket chain following implementation of a shelf tag intervention based on the Australian Health Star Rating (HSR) system.
Methods:
A controlled, non-randomised trial was undertaken in seven supermarkets (intervention: n = 3; control: n = 4) of a single chain in Victoria, Australia, over 12 weeks (4 weeks baseline, 8 weeks intervention period) between August and November 2015. The intervention involved provision of a shelf tag indicating the HSR of all packaged products that scored 4.5 or 5 stars ('high-HSR products') using the Australian HSR system. Posters indicating the healthiness of fresh fruits and vegetables (not eligible for an HSR rating, as they are not packaged) were also installed. Weekly per store sales data were provided by the retailer. In an intention-to-treat analysis (with intervention status of individual products based on their eligibility to be tagged), the proportion (%) of all 'high-HSR' packaged food sold and the volume of key nutrients (saturated fat, total fat, sodium, total sugar, protein, carbohydrates and energy) per 100 g sold were assessed. Difference-in-difference analyses were conducted to determine the difference between intervention and control stores in terms of mean outcomes between baseline and intervention periods. Customer exit surveys (n = 304) were conducted to evaluate awareness and use of the shelf tags and posters.
Results:
The proportion of 'high-HSR products' sold increased in the intervention period compared to the baseline period in each of the three intervention stores (average increase of 0.49%, 95% CI: -0.02, 0.99), compared to a decrease of -0.15% (-0.46, 0.15) in control stores (p = 0.034). The overall increase in intervention compared to control stores (difference-in-difference) of 0.64% represents an 8.2% increase in the sales of 'high-HSR products'. Sales of total sugar, total fat, saturated fat, carbohydrates, sodium, protein and total energy in packaged food all decreased significantly more in intervention stores compared to control stores. Sales of fresh fruits and vegetables decreased in intervention stores compared to control stores. Customer surveys found that 34.4% noticed the shelf tags. Of those who noticed the tags, 58% believed the shelf tags influenced their purchases.
Conclusions:
With this study, we found that the use of shelf tags that highlight the healthiest packaged foods in a supermarket setting showed promise as a mechanism to improve the healthiness of purchases. Opportunities to scale up the intervention warrant exploration, with further research needed to assess the potential impact of the intervention on overall population diets over the longer term.
... Many studies have shown that shelf/front-of-package (FOP) nutrition labels can positively influence food purchasing patterns (Sutherland, Kaley, and Fischer 2010;Kiesel and Villas-Boas 2013;Rahkovsky et al. 2013;Cawley et al. 2015;Nikolova and Jeffrey Inman 2015;Machín et al. 2018). However, these studies assumed that suppliers are price takers and did not test whether they change prices in response to the shift in demand that may accompany a change in labeling. ...
... This is not to say that voluntary disclosure of informative nutrition information is never profitable. For example, the Guiding Stars program (a 0-to 3-star nutrient profiling algorithm), offered by Hannaford Inc. has been shown to be effective and has been available to consumers since 2006 (Sutherland, Kaley, and Fischer 2010;Rahkovsky et al. 2013). Johnson and Myatt's (2006) model of advertising suggests that firms have incentives to increase (decrease) dispersion of WTP for niche (massmarket) products. ...
Profit maximizing firms sometimes engage in voluntary informative advertising, usually to promote their reputation as honest brokers. One example of informative advertising is shelf nutrition labels that some supermarket chains voluntarily provide. Several studies have shown that voluntary shelf nutrition and similar front-of-pack nutrition labels positively influence food purchasing patterns. Yet these studies assumed that suppliers are price takers. Using one shelf nutrition label, NuVal, as an example, we revisit this assumption. We take advantage of the natural experiment that occurred when NuVal substantially changed its underlying scoring algorithm. As the NuVal label represents an independent expert assessment of the health quality of each food product, this natural experiment allows for testing the causal effect of the information on demand and price changes independent of the hype that comes with the rollout of a new information policy. After endogenizing prices, we find that price changes offset nearly 42% of the direct effects of the score changes. This result shows the potential benefits of this form of voluntary information disclosure but also that most previous analyses of nutrition labeling overstated the benefits because they failed to account for supply responses.
... Guiding Stars is a summary indicator that uses a simple zero to three stars metric to summarize the healthiness of food products, with more stars signifying healthier products. 2 Although the Guiding Stars system helps consumers by incorporating tradeoffs across attributes (determined by nutritionists), the effects of the program in the absence of a complementary campaign have been found to be small (Sutherland et al. 2010;Cawley et al. 2014;Rahkovsky et al. 2013;Hobin et al. 2017). Hobin et al. (2017) find that six months after implementation, fewer than 10% of consumers reported noticing and understanding the labels, implying that there may be scope for a national educational campaign to improve usage by first increasing awareness and understanding. ...
... They find that health communication campaigns that include use of mass media (and avoid coercion) have an average effect size of about 5 percentage points. (Sutherland et al. 2010;Cawley et al. 2014;Rahkovsky et al. 2013;Hobin et al. 2017). Moore et al. (2018) review 17 papers studying the impact of other types of educational interventions intended to increase understanding and use of such labels. ...
Front-of-package and on-shelf nutrition labelling systems in supermarkets have been shown to lead to only modest increases in the purchase of more nutritious foods. Educational campaigns may increase the use of these types of product labels if 1) there is a lack of consumer awareness and/or understanding of the labels, and 2) the information provided lead consumers to prefer different products. We study a large-scale, national campaign for the Guiding Stars® nutrition labels conducted by a grocery retailer in Canada who implemented the labels. Using detailed household transaction data, we find only a small increase in the purchase of higher star-rated foods during the campaign, driven by produce purchases, and 60% of the effect disappears after the campaign’s conclusion. To explain the limited response, exit surveys were conducted outside of stores before and after the campaign. Awareness and understanding of the nutrition labelling system increased marginally after the campaign, but there was no increase in self-reported use.
... Many considerations are relevant for the U.S. to formulate a mandatory FOP label policy (Andrews et al. 2011;Roberto et al. 2012;Rahkovsky et al. 2013;Phulkerd et al. 2017), including whether the FOP label is noticed and noticeable by consumers (Bialkova et al. 2013;Becker et al. 2015), presents information that is understood by consumers (IOM 2011;Neal et al. 2017) and effectively supports consumers' ability to identify unhealthy products (Balcombe et al. 2010) and select healthier products (Rahkovsky et al. 2013;Andrews et al. 2011;Neal et al. 2017). However, legal considerations for the feasibility of the U.S. government mandating specific FOP labels have not been reported. ...
... Many considerations are relevant for the U.S. to formulate a mandatory FOP label policy (Andrews et al. 2011;Roberto et al. 2012;Rahkovsky et al. 2013;Phulkerd et al. 2017), including whether the FOP label is noticed and noticeable by consumers (Bialkova et al. 2013;Becker et al. 2015), presents information that is understood by consumers (IOM 2011;Neal et al. 2017) and effectively supports consumers' ability to identify unhealthy products (Balcombe et al. 2010) and select healthier products (Rahkovsky et al. 2013;Andrews et al. 2011;Neal et al. 2017). However, legal considerations for the feasibility of the U.S. government mandating specific FOP labels have not been reported. ...
Front-of-package (FOP) food labels are symbols, schemes, or systems designed to communicate concise and useful nutrition-related information to consumers to facilitate healthier food choices. FOP label policies have been implemented internationally that could serve as policy models for the U.S. However, the First Amendment poses a potential obstacle to U.S. government-mandated FOP requirements. We systematically reviewed existing international and major U.S.-based nutrition-related FOP labels to consider potential U.S. policy options and conducted legal research to evaluate the feasibility of mandating a FOP label in the U.S. We identified 24 international and 6 U.S.-based FOP labeling schemes. FOP labels which only disclosed nutrient-specific data would likely meet First Amendment requirements. Certain interpretive FOP labels which provide factual information with colors or designs to assist consumers interpret the information could similarly withstand First Amendment scrutiny, but questions remain regarding whether certain colors or shapes would qualify as controversial and not constitutional. Labels that provide no nutrient information and only an image or icon to characterize the entire product would not likely withstand First Amendment scrutiny.
... Many products that would have been successfully marketed will not be marketed. Rahkovsky et al. (2013) pointed to survey data indicating that shoppers' use of the Nutrition Facts label is limited and that consumers struggle to understand it. The idea that a listing of nutrient quantities in a food might be too complex (credible and truthful, but not understandable) for many consumers to use led to the development of summary measures, and some pre-date NLEA. ...
... Foods at the low end of the ratings were not awarded a star, which consumers were left to infer indicated a low nutrition rating. Rahkovsky et al. (2013) studied effects on breakfast cereal demand and found that the stars shifted demand toward more nutritious cereals and away from less nutritious cereals. ...
Consumers are increasingly interested in farming methods and the nutritional quality of food. Manufacturers, in turn, are adding more information to food labels. In 1990, Congress passed two watershed laws on food labeling, one requiring nutrition labels to be included on most processed foods and the other requiring organic foods to meet a national uniform standard. This report examines the economic issues involved in five labels for which the Federal Government has played different roles in securing the information and making it transparent to consumers. In addition to the nutrition and organic labels, the report scrutinizes three other labels—one advertising foods made without genetically engineered ingredients, another advertising products made from animals raised without antibiotics, and the Federal country-of-origin label, which is now required for fresh and frozen fruits and vegetables, some nuts, fish and shellfish, ginseng, and certain meats. As interest grows in process-based and other types of food labeling, findings from these five case studies illustrate the economic effects and tradeoffs in setting product stan- dards, verifying claims, and enforcing truthfulness.
... Shelf labels that present a simplified rating on the healthfulness of food have been found to be more effective. Both and Rahkovsky et al. (2013) examined healthfulness of purchases before and after the introduction of the Guiding Stars program in Hannaford supermarkets. The Guiding Stars program assigns scores of zero, one, two, or three stars (with three stars being the most nutritious) to specific branded food items based on an independent published algorithm and places stars beneath the product on the shelf. ...
... found that the introduction of this nutrition rating system was associated with a significant decrease in sales of less nutritious foods and no significant change in sales of nutritious foods. Rahkovsky et al. (2013) focused only on the ready-to-eat cereal category and compared stores with and without the Guiding Stars program and found that consumers substituted nutritious for less nutritious cereals. Kiesel and Villas-Boas (2013) found in a field experiment that a shelf label of "no trans fat" significantly increased sales of treated products, even though this information is already provided in a less uniform format. ...
... The multiple traffic-light (MTL) label, which signposts levels of fats, sugars, and salt using icons coloured red (high), amber (medium), or green (low) is the best known example of an interpretive front-of-pack label [8]. In 2014, the Australian Government adopted the 'Health Star Rating (HSR)' front-of-pack labelling scheme [9], which has similarities to the retailer-developed 'Guiding Stars' programme in the United States (US) [10]. The HSR scheme uses a nutrient profiling algorithm to assign between 0.5 (least healthy) and 5.0 (most healthy) stars to a food in half star increments. ...
... Multiple experimental studies [12,[14][15][16][17][18][19][20] have described the comparative effects of different labelling systems on consumer preferences and the ability to correctly identify healthy and unhealthy food items. However, there are relatively few data to define effects of food labels on food purchasing behaviour in the real world and the findings are mixed [10,12,[21][22][23]. Consequently, the implementation of front-of-pack labelling in most countries has been limited. ...
Background:
Front-of-pack nutrition labelling may support healthier packaged food purchases. Australia has adopted a novel Health Star Rating (HSR) system, but the legitimacy of this choice is unknown.
Objective:
To define the effects of different formats of front-of-pack labelling on the healthiness of food purchases and consumer perceptions.
Design:
Individuals were assigned at random to access one of four different formats of nutrition labelling-HSR, multiple traffic light labels (MTL), daily intake guides (DIG), recommendations/warnings (WARN)-or control (the nutrition information panel, NIP). Participants accessed nutrition information by using a smartphone application to scan the bar-codes of packaged foods, while shopping. The primary outcome was healthiness defined by the mean transformed nutrient profile score of packaged foods that were purchased over four weeks.
Results:
The 1578 participants, mean age 38 years, 84% female recorded purchases of 148,727 evaluable food items. The mean healthiness of the purchases in the HSR group was non-inferior to MTL, DIG, or WARN (all p < 0.001 at 2% non-inferiority margin). When compared to the NIP control, there was no difference in the mean healthiness of purchases for HSR, MTL, or DIG (all p > 0.07), but WARN resulted in healthier packaged food purchases (mean difference 0.87; 95% confidence interval 0.03 to 1.72; p = 0.04). HSR was perceived by participants as more useful than DIG, and easier to understand than MTL or DIG (all p < 0.05). Participants also reported the HSR to be easier to understand, and the HSR and MTL to be more useful, than NIP (all p < 0.03).
Conclusions:
These real-world data align with experimental findings and provide support for the policy choice of HSR. Recommendation/warning labels warrant further exploration, as they may be a stronger driver of healthy food purchases.
... 33, 34 We found 4 US studies examining the effect of these 2 systems on food purchases. [35][36][37][38] An evaluation of the NuVal system, which rates the nutritional profile of a food on a scale of 1 to 100, examined supermarket transaction data from 535,000 shoppers at a major supermarket banner (or "chain") in the United States. Results indicate the system had a small but significant shift toward products purchased with a higher NuVal nutritional rating. ...
... Results of this natural experiment study show that the introduction of an on-shelf nutrition labelling system led to small but significant increases in the proportion of food purchased in the supermarket with higher star ratings over a 6-month period. The magnitude of the labelling system's effects on food-purchasing patterns are consistent with results of the previous evaluations of the Guiding Stars system in US supermarkets; [36][37][38] however, the current study extends earlier investigations by demonstrating the impact of this labelling system over millions of transactions across all food product categories in supermarkets. Although the size of the effect attributed to the introduction of this system is modest, small positive changes in the nutritional quality of food purchases across millions of shoppers in a national supermarket retailer could have sizable population effects on diet-related health conditions. ...
Context:
Providing a nutrition rating system on the front of food packages or on retail shelf tags has been proposed as a policy strategy for supporting healthier food choices. Guiding Stars is an on-shelf nutrition labelling system that scores foods in a supermarket based on nutritional quality; scores are then translated into ratings of 0 to 3 stars. It is consistent with evidence-informed recommendations for well-designed labels, except for not labelling 0-star products. The largest supermarket retailer in Canada rolled out the Guiding Stars system in supermarkets across Ontario, Canada. The aim of our study was to examine the extent to which consumers respond to an on-shelf nutrition labelling system in supermarkets to inform current and future nutrition labelling policies and practices.
Methods:
Capitalizing on a natural experiment, we conducted a quasi-experimental study across 3 supermarket banners (or "chains") in Ontario, one of which implemented the Guiding Stars system in 2012. We used aggregated supermarket transaction data to test the effect of Guiding Stars on the nutritional quality of food purchases in intervention supermarkets relative to control supermarkets. We also conducted exit surveys among 783 randomly selected shoppers from intervention and control supermarkets to assess consumer awareness, understanding, trust, and self-reported use of the labelling system.
Findings:
Relative to control supermarkets, shoppers in intervention supermarkets made small but significant shifts toward purchasing foods with higher nutritional ratings; however, shifts varied in direction and magnitude across food categories. These shifts translated into foods being purchased with slightly less trans fat and sugar and more fiber and omega-3 fatty acids. We also found increases in the number of products per transaction, price per product purchased, and total revenues. Results of the exit surveys indicate a modest proportion of consumers were aware of, understood, and trusted Guiding Stars in intervention supermarkets, and a small proportion of consumers reported using this system when making purchasing decisions. However, 47% of shoppers exposed to Guiding Stars were confused when asked to interpret the meaning of a 0-star product that does not display a rating on the shelf tag.
Conclusions:
This study demonstrates support for policies promoting on-shelf nutrition labels designed according to evidence-informed principles, but policymakers should move forward with caution when investing in such systems until research has confirmed optimal label design, clarified the mechanisms through which dietary intake is improved, and assessed associations with nutrition-related health outcomes.
... Shelf labels that present a simplified rating on the healthfulness of food have been found to be more effective. Both and Rahkovsky et al. (2013) examined healthfulness of purchases before and after the introduction of the Guiding Stars program in Hannaford supermarkets. The Guiding Stars program assigns scores of zero, one, two, or three stars (with three stars being the most nutritious) to specific branded food items based on an independent published algorithm and places stars beneath the product on the shelf. ...
... found that the introduction of this nutrition rating system was associated with a significant decrease in sales of less nutritious foods and no significant change in sales of nutritious foods. Rahkovsky et al. (2013) focused only on the ready-to-eat cereal category and compared stores with and without the Guiding Stars program and found that consumers substituted nutritious for less nutritious cereals. Kiesel and Villas-Boas (2013) found in a field experiment that a shelf label of "no trans fat" significantly increased sales of treated products, even though this information is already provided in a less uniform format. ...
Obesity was first identified as an issue of significant public policy concern in the late 1990s, after which US obesity rates continued to grow. Now, more than one-third of adult Americans are obese or extremely obese while a further one-third or more are overweight; in addition, one-third of American children are at least overweight, and about one-sixth are obese. In this chapter we document the obesity status of the nation and its genesis over the past 50 years. We review various concepts and measures of obesity, including the conventional BMI and alternatives. Then, using the BMI, we review the patterns of US obesity for adults and children over time, disaggregated spatially and among various sociodemographic groups.
... Shelf labels that present a simplified rating on the healthfulness of food have been found to be more effective. Both and Rahkovsky et al. (2013) examined healthfulness of purchases before and after the introduction of the Guiding Stars program in Hannaford supermarkets. The Guiding Stars program assigns scores of zero, one, two, or three stars (with three stars being the most nutritious) to specific branded food items based on an independent published algorithm and places stars beneath the product on the shelf. ...
... found that the introduction of this nutrition rating system was associated with a significant decrease in sales of less nutritious foods and no significant change in sales of nutritious foods. Rahkovsky et al. (2013) focused only on the ready-to-eat cereal category and compared stores with and without the Guiding Stars program and found that consumers substituted nutritious for less nutritious cereals. Kiesel and Villas-Boas (2013) found in a field experiment that a shelf label of "no trans fat" significantly increased sales of treated products, even though this information is already provided in a less uniform format. ...
Agricultural R&D has contributed to obesity by making food more abundant and cheaper, and some commentators have proposed that the agricultural research portfolio could be tilted more in favor of healthy foods, and away from less-healthy foods. We review these ideas in principle, and present a review of prior work and new evidence on the effects of past research investments and on the likely costs of changing the R&D portfolio as a way of fighting obesity in the United States. Our analysis suggests that redirecting agricultural research priorities would be a generally ineffective and highly expensive way of fighting obesity.
... Previous research shows that simplified shelf labels can be effective for this purpose (Levy et al., 1996;Feunekes et al., 2008). Other studies demonstrate that labels can have a positive impact on the purchasing decisions of health-related products (Kiesel & Villas-Boas, 2009;Sutherland et al., 2010;Rahkovsky et al., 2013;Nikolova & Inman, 2015;Cawley et al., 2015) and, more generally, on healthier eating (Kim et al., 2000;McLean-Meyinsse, 2001;Weaver & Finke, 2003). This study aims to analyze in-store communication interventions in the field of nutritional marketing, focusing particularly on the studied food categories, the strategies employed, and the outcomes achieved. ...
In recent times, the focus on clear and accessible nutritional labels in supermarkets has grown. Research has examined the effectiveness of these shelf labels in guiding consumer behavior, yielding mixed results. Nutrient-based summary labels like Guiding Stars, NuVal, and health claims are common. This study employs a Systematic Literature Review (SLR) to investigate in-store communication strategies for health-related product purchases. Forty experiments were identified, with results categorized as "Low Positive", "Highly Positive", "Positive", "Negative", or "Inconclusive". The research suggests that using multiple levers in in-store marketing is more effective in influencing the purchase of health-related products.
... • Rahkovsky et al (2013;US): The Guiding Stars Program (GSP) involving shelf labels affected the demand for ready-to-eat (RTE) cereals in one supermarket in the US. Significantly increased the demand for cereals that GSP considers more nutritious at the expense of cereals that GSP considers less nutritious. ...
This work was conducted at the request of the Centre for Population Health at the NSW Ministry of Health, to inform implementation of the relevant strategic direction of the NSW Healthy Eating Active Living (HEAL) Strategy 2013–2018. It is not intended to be an exhaustive review but rather to provide an indication of the rationale for intervening and the potential effectiveness of a broad range of policy options. It is also intended to inform ongoing stakeholder consultation regarding action with respect to the food environment. This consultation will necessarily take account of other evidence of effectiveness including likely reach and population impact, as well as implementation issues such as sustainability of effects, feasibility, acceptability, equity, and other factors affectingplanning and investment decisions. It is noted that no single action contained within this evidence synthesis will in itself be sufficient to affect weight status substantially at the population level. A portfolio of interventions within the food environment, alongside action to increase physical activity and reduce sedentary behaviours, is required to halt the progress of obesity and prevent chronic disease. This sentiment has been expressed many times previously but also recently in the McKinsey paper by Dobbs et al (November 2014) relating to an economic analysis for obesity prevention: “Existing evidence indicates that no single intervention is likely to have a significant overall impact. A systemic, sustained portfolio of initiatives, delivered at scale, is needed to reverse the health burden.” Similarly, no individual sector in society can address obesity acting on its own — neither governments, retailers, consumer-goods companies, restaurants, employers, media organisations, educators, healthcare providers, or individuals.Achieving the full potential impact requires engagement from as many sectors as possible. Ideally such actions would be contained within an overarching National Nutrition Policy in Australia. Finally, we would like to echo another sentiment of the McKinsey Global Institute discussion paper, that “… our analysis is by no means complete. Rather we see our work [on a potential program to address obesity] as the equivalent of the maps used by 16th-century navigators. Some islands were missing and some islands were misshapen in these maps, but they were helpful to the sailors of the era. We are sure that we have missed some interventions and over- or underestimated the impact of others. But we hope our work to be a useful guide….”
... The content and format of nutrition fact labels, as well as front-of-package nutrition and health claims such as "low sodium," are federally regulated (U.S. Food and Drug Administration, 2022). Some studies have provided evidence this nutritional label information may have improved diet quality in some ways (Campos et al., 2011;Kim et al., 2001;Kuchler et al., 2017;Rahkovsky et al., 2013;Variyam, 2008). To keep pace with emerging science and changes in DGA, the requirements for nutrition fact labels were revised with new label requirements implemented as of 2021. ...
Food prepared away from home (FAFH) has become a mainstay in U.S. consumers’ diets, accounting for more than 50 percent of total food expenditures since 2009 and more than 30 percent of total food energy intake since 2011. This report analyzes data from nationally representative food consumption surveys conducted between 1977 and 2018 to examine U.S. consumers’ dietary quality relative to the Federal dietary guidance and how this varies by food source. The food sources this report examines include food at home, food purchased at restaurant, food purchased at fast food, food obtained at school among K-12 school and daycare children, and other food away from home. Dietary quality is measured by nutrient and food-group density (i.e., intake amount per 1,000 calories) for 12 nutrients and 35 food groups. All analyses are conducted for individuals aged 2 and above, both as a group and subdivided by demographics. In general, U.S. consumers make more nutritious choices when grocery shopping for foods than when obtaining food from commercial eating establishments. Compared with FAFH, food at home (FAH) is denser in underconsumed nutrients and food groups—e.g., fiber, iron, whole grains, fruits, dairy, and dark green vegetables—and lower in the density of overconsumed nutrients and food groups including saturated fats, sodium, and refined grains. However, FAH has more added sugars in addition to lower intake of seafood and most types of vegetables. In recent years, school foods differ from other FAFH consumption due to a lower density of saturated fats and a higher density of whole grain, fiber, and fruit.
... First, we developed mock food packages resembling actual products belonging to three distinct categories: breakfast cereals, cakes and pizza. These food categories have been used as stimuli in other randomized experiments testing FoPL effectiveness in different populations [17,18]. As in other studies, for the present experiment we aimed to select food products that are consumed for various reasons and that represent a range of food types (breakfast meals, ready-to-eat lunch/dinner meals, desserts) and that have sufficient variability so that three nutritionally distinct products for each food category could be created. ...
Dietary practices are a key behavioral factor in chronic disease prevention; one strategy for improving such practices population-wise involves front-of-package labels (FoPL). This online randomized study, conducted in a quota-based sample of 1159 Polish adults (mean age = 40.9 ± 15.4 years), assessed the objective understanding of five FoPL: Health Star Rating, Multiple Traffic Lights, NutriScore, Reference Intakes (RI) and Warning Label. Objective understanding was evaluated by comparing results of two nutritional quality ranking tasks (without/with FoPL) using three food categories (breakfast cereals, cakes, pizza). Associations between FoPL exposure and objective understanding were assessed via multivariable ordinal logistic regression. Compared to RI and across food categories, significant improvement in objective understanding was seen for NutriScore (OR = 2.02; 95% CI: 1.41–2.91) and Warning Label (OR = 1.61; 95% CI: 1.12–2.32). In age-stratified analyses, significant improvement in objective understanding compared to RI emerged mainly among adults aged 18–30 years randomized to NutriScore (all food categories: OR = 3.88; 95% CI: 2.04–7.36; cakes: OR = 6.88; 95% CI: 3.05–15.51). Relative to RI, NutriScore was associated with some improvement in objective understanding of FoPL across and within food categories, especially among young adults. These findings contribute to the ongoing debate about an EU-wide FoPL model.
... The other study was conducted in the USA and focused on the sales of ready-to-eat cereals [18]. Over the course of 7 months, sales of cereals with no stars fell by 2.6% (comparing stores carrying the logo with control stores) while sales of cereals with one, two, and three stars increased by 1.15, 0.89, and 0.54%, respectively. ...
Background: Delhaize, a major Belgian retailer, started implementing electronic shelf labels (ESL) with Nutri-Score since May 2019. Nutri-Score rates the healthfulness of packaged foods with five colours/letters from red/E (least healthy) to green/A (most healthy). This study evaluated the impact of ESL on consumer purchases, overall, and by
food category.
Methods: For 43 intervention stores (implementing ESL in the period 27 May 2019–19 June 2019), a control store, from the same province and retailer-assigned cluster was matched. There were 14 unique control stores. By store, weekly non-food and food sales for 2018 and 2019 were received by Nutri-Score (A/B/C/D/E) and food category
according to a retailer-assigned classification system. The primary outcomes were the proportion of food sales for Nutri-Score A,B,C,D,E. Difference-in-differences regression analysis was conducted to estimate the effect of the ESL intervention on proportion of overall food and food category sales for Nutri-Score A,B,C,D,E, using linear mixed models
to account for clustering at store-level. We controlled for store characteristics (region, cluster, non-food sales) and week of the year. Analyses were weighted to re-balance discrepancy between the number of intervention and control stores. To account for multiple testing, a Bonferroni adjustment was applied.
Results: Comparing pre- and post-intervention periods, difference-in-differences for the proportion of Nutri-Score B and C product sales were more favourable in intervention than control stores (0.11 ± 0.04%, p = 0.007 and − 0.06 ± 0.03%, p = 0.026 respectively), while difference-in-differences for the proportion of Nutri-Score D product sales were less favourable in intervention than control stores (0.12 ± 0.04%, p = 0.002). For 17/58 food categories (representing 29% of total food sales) a positive impact [increase in healthier (Nutri-Score A, B) and/or decrease in less healthy (Nutri-Score D, E) food sales], and for 16/58 categories (representing 24% of total food sales) a negative impact was found. Positive impacts were found for vegetable, fruit and dairy products and confectionery. Negative impacts were found for bread and bakery products.
Conclusion: The impact of ESL on consumer purchases was mixed. Favourable difference-in-differences were found for Nutri-Score B and C products and unfavourable difference-in-differences for Nutri-Score D products. Shelf labeling on its own is unlikely to significantly influence consumer behaviours.
... Furthermore, although the independent effects of nudging and pricing strategies are relatively small, combining nudges with pricing strategies could result in an effect size relevant at the population level (Hoenink et al., 2020). Given the effectiveness of nudging and pricing strategies in real-world supermarkets in increasing favorable food purchasing behaviors (An, 2013;Kiesel & Villas-Boas, 2013;Ni Mhurchu et al., 2010;Rahkovsky et al., 2013;Sutherland et al., 2010) and the finding that these strategies seem equally effective across subgroups with different personal characteristics, the results are favorable as they suggest that nudging and pricing strategies can be implemented as generic health promoting interventions. Nevertheless, it is recommended to confirm our findings in a subsequent study with preplanned hypotheses and to explore the modifying role of other personal characteristics (e.g. ...
Nudging and pricing strategies are effective in promoting healthier purchases. However, whether the effects are equal across individuals with different personal characteristics is unknown. This exploratory study aimed to examine differential effects of nudging and pricing strategies on food purchases across individuals' levels of impulsivity, price sensitivity, decision-making styles, and food choice motives. Data from a virtual supermarket experiment where participants were exposed to five study conditions (control, nudging, pricing, salient pricing, and salient pricing with nudging) was used. Participants completed questionnaires assessing their impulsivity, price sensitivity, decision-making styles, and food choice motives. The outcome was the percentage of healthy food purchases. Effect modification was analyzed by adding interaction terms to the statistical models and post-hoc probing was conducted for statistically significant interaction terms. We used data from 400 Dutch adult participants (61.3% female, median age 30.0 years (IQR 24.0)). The effects of the nudging and pricing conditions on healthy food purchases were not modified by impulsivity, price sensitivity, decision-making styles, and the food choice motives ‘health’ and ‘price’. Only the interactions of the food choice motive ‘natural content of foods’ x pricing (B = −1.02, 90%CI = −2.04; −0.01), the food choice motive ‘weight control’ x nudging (B = −2.15, 90%CI = −3.34; −0.95), and ‘weight control’ x pricing (B = −1.87, 90%CI = −3.11; −0.62) were statistically significant. Post-hoc probing indicated that nudging and/or pricing strategies were more effective in individuals who gave lower priority to these food choice motives. The effects of nudging and pricing strategies on increasing healthy food purchasing behaviors, at least in a virtual environment, do not seem to be influenced by personal characteristics and may therefore be implemented as general health promoting strategies.
... These have been studied thoroughly and are considered not as helpful to consumers as the HSR scheme (Neal et al., 2017). Similar labelling systems are used in the USA, called the Guiding Stars scheme (Rahkovsky et al., 2013), and France, called the 5-Colour Nutrition Label (5-CNL) (Julia et al., 2016). ...
The focus on reducing rates of childhood obesity has become one of the main public health priorities in the United Kingdom. The government is addressing this through various strategies including Public Health England’s sugar reduction programme, which aims to decrease free sugar intake to 5% of individuals’ total energy intake (PHE, 2015a). There is precedent in the UK of using a single-nutrient approach in the management of non-communicable diseases (NCDs), with salt being used to address hypertension, and dietary fat for cardiovascular diseases and obesity. Using a four mixed- method studies, this PhD aims to investigate possible unintended consequences associated with the one-nutrient focus on sugar, including demonising the single nutrient targeted, promoting unhealthy dieting, detracting from a balanced healthy diet, creating stigma around obesity and exacerbating other health-related inequalities. Study one: Sugar looks brighter on Traffic Light Nutrition Labelling: Choice-Based Conjoint Analysis and Cross-sectional Survey With the current emphasis of public health on sugar reduction, this two-part study aimed to investigate the influence of Traffic Light Labelling (TLL) information about total sugar compared to other macronutrients when making decisions about the healthiness of products. The first part was a Choice-Based Conjoint analysis (CBC) assessing the relative importance of four macro-nutrient attributes commonly used in TLL (sugar, fat, saturated fat, salt) and the colour of each based on three food products (biscuits, cereal, and sandwich). The second part was a cross-sectional survey assessing public knowledge of the recommendations underpinning the TLL. The results suggest that, when participants decided upon the healthiness of biscuits, cereal or sandwich, sugar was the most important factor compared to fat, saturated fat, salt and price. While this may be considered a success in terms of sugar-reduction efforts, the lower level of attention paid to other macro-nutrients illustrates the potential negative impact of a single-nutrient focus to wider health campaigns. This is especially significant since participants had poor and overestimated nutritional knowledge. This research was published in the Journal of Human Nutrition and Dietetics: https://onlinelibrary.wiley.com/doi/abs/10.1111/jhn.12741 (Anabtawi et al., 2020) Study two: Are SSBs the devil? An exploratory analysis of children who consume sugar sweetened beverages in the UK The Soft Drinks Industry Levy (SDIL) came into effect on the 6th of April 2018 and was designed to reduce the intake of Sugar-Sweetened Beverages (SSBs), identified to be the largest contributor of sugar in children’s diets in the UK. This study used data collected as part of the National Diet and Nutrition Survey (NDNS) to explore the underlying characteristics of children who drink SSBs, through the application of a bias-free technique called hierarchical agglomerative clustering (HAC). The results demonstrated that there is no clear association between drinking SSBs and BMI among children aged 4-10. The logistic regression analysis illustrated that there is no specific trend across clusters in terms of significant association between children with different drinking habits and other variables. This analysis confirms the complexity of relationships across demographic and other health-related variables and emphasises the problematic nature of simplistic interventions that aim to tackle a particular behaviour or address a particular bodyweight category. Study three: The effect of three “Ps” on public perception of childhood obesity policy in the UK; Parenthood, Perceived weight and Political orientation A survey was conducted to investigate the perception of a representative sample of adults living in the UK (n=990) on the solutions to the childhood obesity issue and the effectiveness and appropriateness of interventions proposed by the UK Government in “Childhood Obesity: a Plan for Action”, parts 1 and 2. In the analysis there was a specific focus on how participants’ parenthood status, perception of their own bodyweight status and political orientation affects their views. The results showed a high level support from the public for most interventions proposed by the Government related to childhood obesity. Individuals’ political orientation played a role in shaping their attitudes and beliefs, with more conservative participants reporting higher support for individualistic solutions including biological, psychological and behavioural interventions. Being a parent had an influence on individuals’ attitudes toward the likelihood of childhood obesity solutions being effective and suitable. However, the effect of participants’ perceived weight status on their perceptions was less influential. These results demonstrate the importance of considering individuals’ different characteristics when developing policies and interventions to ensure that they are effective. Study four: Problems hiding in plain sight: A thematic analysis of the UK Government Policy “Childhood Obesity: a Plan for Action” parts 1 and 2 This study aimed to conduct a thematic analysis of the content of the documents representing the current Government position on childhood obesity and its policies relating to public health interventions: “Childhood Obesity: a Plan for Action” parts 1 and 2. This was undertaken through the application of Bacchi’s “What’s-the-Problem-Represented-to-be?” (WPR) approach. (Bacchi, 1999). The objectives were to (1) conduct a critical thematic analysis of “Childhood Obesity: a Plan for Action” parts 1 and 2 and (2) consider the potential negative consequences of promoting a specific obesity narrative. Three main themes identified using the interpretative inductive thematic analysis (Fade and Swift, 2011), were Where does responsibility for action lie?, Weight-centrism and Think inside the box. Using the WPR approach, three themes and two main issues were identified to be problematised in these documents: responsibility and weight. The analysis explored how and why these ‘problems’ were presented in a specific manner in the documents, through the process of examining the language and supporting evidence that were used to reflect the values and assumptions underlying the proposed interventions. The possible unintended consequences of these representations were considered. In particular, this research highlighted some negative effects that are correlated with the simplistic approach in tackling childhood obesity through focusing on individual behaviour and individuals’ control over their lifestyle for weight loss. These consequences include weight-bias, stigma, discrimination and cultural imperialism. For these reasons, health policies should be analysed comprehensively to increase their potential effectiveness and decrease associated concerns and negative unintended consequences. Discussion and Conclusion Each study individually, and the analysis of the studies and literature review combined, demonstrated that current strategies to reduce the rates of childhood obesity in the UK focus on reducing sugar intake. This linear and simplistic approach has not taken into account the complexity of the determinants and the interactions between them. The other significant issue is the pervasive theme of weight problematisation and sugar demonisation, both of which carry negative framing. This framing, as well as the complexities and interactions mentioned, may have potential negative consequences.
... The Guiding Stars applies a nutrient profiling algorithm to nutrient density measures to rate the nutritional quality of food items on a 0-3 star rating [28]. First, the nutrients of a food item are scored to reflect dietary recommendations from authoritative scientific bodies (e.g., the Dietary Guidelines for Americans (DGA)) [28,29]. Health-promoting nutrients such as vitamins receive positive scores, and health-risking nutrients such as sodium receive negative scores. ...
The Supplemental Nutrition Assistance Program (SNAP) provides millions of low-income Americans food benefits and other forms of nutrition assistance. Evidence indicates that SNAP reduces food insecurity. However, there is a concern that the food benefit may increase the demand for less healthy foods more than healthier foods, thereby reducing the overall nutritional quality of the participant’s food basket. This paper aims to examine the association of SNAP participation with the nutritional quality of food-at-home purchases of low-income households and to investigate the potential heterogeneity among consumers with different levels of nutrition attitude. This analysis used food purchase data from the USDA National Household Food Acquisition and Purchase Survey (FoodAPS). Our study sample included 2,218 low-income households, of which 1,184 are SNAP participants, and 1,034 are income-eligible nonparticipants. Multivariate regressions were performed to explore the SNAP-nutritional quality association. A household’s nutrition attitude was measured using its response to a question on whether the household searched for nutrition information online in the last 2 months. Households that affirmed they had an online nutrition search were treated as nutrition-oriented households (21.2% of the low-income sample), and households that did not were considered less nutrition-oriented households (78.8%). For robustness, we also created an alternative nutrition attitude measure based on reported use of the nutrition facts label. We found that among less nutrition-oriented households, SNAP participants had a statistically significant 0.097 points (p = 0.018) lower Guiding Stars rating than low-income nonparticipants. However, there was no significant SNAP-nutritional quality association among nutrition-oriented households. In conclusion, SNAP participation was associated with lower nutritional quality of food purchases among less nutrition-oriented households, but not among nutrition-oriented households. The results suggest that the intended nutritional benefits of restrictions on purchases of healthy foods may not reach the subgroup of nutrition-oriented SNAP participants.
... The mandatory introduction of the NS would offer them a viable solution to meet demands for simple FOP labels for food (Talati et al., 2019). Sales of healthy foods grow when FOP labels are applied to all products within a category, rather than just a selection of healthy options (Rahkovsky, Lin, Lin, & Lee, 2013;Sacks, Rayner, & Swinburn, 2009;Sutherland, Kaley, & Fischer, 2010). If manufacturers must display the NS on their product packaging, they also might seek to improve product compositions to achieve the best possible NS for their product, compared with direct competitors. ...
Making healthier food choices easier at the time of purchase is a challenge for public policy makers. The Nutri-Score can be an effective tool for guiding and steering consumers toward more informed, healthier purchasing decisions. This research investigates the impact of the presence of the Nutri-Score and its five categories on consumers’ perceived healthiness perceptions and purchase intentions. Consumers in the EU took part in two online experiments, in which they rated products from different categories, with or without Nutri-Scores, in terms of their perceived healthiness and purchase intentions. The presence of the Nutri-Score enabled respondents to assess the healthiness of products better; furthermore, it offers the potential to boost sales of healthy products, without affecting sales of unhealthy products. Perceived healthiness mediates the relationship between Nutri-Score categories and purchase intentions, and focusing on the healthiness of products can give producers a competitive advantage, regardless of whether it is a manufacturer brand or a private label. These findings offer actionable insights for public policy makers and manufacturers; they also suggest the need to embrace the Nutri-Score as the standard front-of-pack label to help fight the increasing obesity pandemic.
... The Guiding Stars were successful at deterring consumers away from food that was deemed "very poor" in nutrition quality. 81 Rahkovsky et al. 82 tested for the effectiveness of the Guiding Stars Program on ready-to-eat cereals and concluded that healthier cereals were purchased if price was held constant. Furthermore, Sutherland et al. also showed that the Guiding Star Program was effective at changing consumer choice over the course of multiple years. ...
A proliferation of processed foods and labeling claims motivated the Nutrition Labeling and Education Act of 1990, which mandated the Nutrition Facts Label. Providing nutrition information is often put forth as a way to change food choice; however, despite efforts to provide dietary information using nutrition labeling, more than a third of the U.S. has obesity and portions of the population continue to under consume vital nutrients. There has been progress beyond the Nutrition Facts Label in recent years with front‐of‐package labeling and menu labeling, which is crucial given changes in consumption trends for food‐away‐from‐home. Additionally, changes were recently made to the Nutrition Facts Label due to lack of awareness, understanding, and ability to effectively improve diet quality. This paper explores the literature to track the evolution of knowledge about attention to nutrition information and how nutrition information affects dietary choices.
... Over the course of six months there was an increase in mean star rating of 1.4% (comparing supermarkets that used the labeling system versus those that did not). The other study was in the USA and focused on the sale of readyto-eat cereals (Rahkovsky, Lin, Lin, & Lee, 2013). Over the course of seven months sales of cereals with no stars fell by 2.6% (comparing stores carrying the logo with control stores) while sales of cereals with one, two, and three stars increased by 1.15%, 0.89%, and 0.54%, respectively. ...
Front-of-package (FOP) labels may help shoppers make healthier food choices. The objectives of this review are, first, to establish the effectiveness of different FOP labels at enabling shoppers to identify which foods are healthy and which are not healthy, and, second, to assess whether different FOP labels induce shoppers to buy healthier foods. Some labels are nutrient-specific, such as Multiple Traffic Lights (MTL) and Guideline Daily Amounts (GDA). These labels state the content per serving of energy and of several substances, most commonly saturated fat, sugar, and sodium (or salt). Warning labels are another type of nutrient-specific FOP label (e.g., for food high in added sugar). Summary labels, such as Nutri-Score and labels with stars, translate the components of the food into a single value that indicates how healthy it is. Studies on FOP labels lack consistency. The majority of such studies indicate that they help shoppers to distinguish between healthy and less healthy foods. The designs that appear to be most successful in this regard are MTL, warning labels, and Nutri-Score. Labels based on GDA or that included stars were much less successful. Many studies using a simulated shopping situation reported that shoppers exposed to FOP labels had an increased intent to purchase healthier foods. Warning labels were the most consistently successful FOP design followed by MTL, Nutri-Score, and labels that included stars, while GDA failed in almost every study. Very few studies have been carried out in real-world supermarkets; the findings indicate that FOP labels or shelf labels may achieve a small degree of success (<2.0%) at persuading shoppers to buy healthier foods. Those advocating for effective FOP labels must resist opposition from food corporations.
... This was demonstrated in the very high mean score (7 out of 9) and a third of the sample selecting 9 ('strongly agree') for the item assessing whether the FoPL to which they were exposed should be compulsory on packs. Previous research supports the need for mandatory FoPLs, with supermarket studies reporting increased sales of healthier foods when FoPLs are applied to all products within a category rather than just a selection of products [34][35][36][37]. Although FoPLs should aid consumers in assessing the healthiness of individual products in isolation, they are most useful when they also allow consumers to compare healthiness across multiple products [38]. ...
Consumers’ perceptions of five front-of-pack nutrition label formats (health star rating (HSR), multiple traffic lights (MTL), Nutri-Score, reference intakes (RI) and warning label) were assessed across 12 countries (Argentina, Australia, Bulgaria, Canada, Denmark, France, Germany, Mexico, Singapore, Spain, the UK and the USA). Perceptions assessed included liking, trust, comprehensibility, salience and desire for the label to be mandatory. A sample of 12,015 respondents completed an online survey in which they rated one of the five (randomly allocated) front-of-pack labels (FoPLs) along the perception dimensions described above. Respondents viewing the MTL provided the most favourable ratings. Perceptions of the other FoPLs were mixed or neutral. No meaningful or consistent patterns were observed in the interactions between country and FoPL type, indicating that culture was not a strong predictor of general perceptions. The overall ranking of the FoPLs differed somewhat from previous research assessing their objective performance in terms of enhancing understanding of product healthiness, in which the Nutri-Score was the clear front-runner. Respondents showed a strong preference for mandatory labelling, regardless of label condition, which is consistent with past research showing that the application of labels across all products leads to healthier choices.
... Guiding Stars uses a four-point rating system to rate the healthfulness of food products (between zero and three stars) (Fischer et al., 2011). Studies based on store-level data found Guiding Stars increased the sales shares of healthy products relative to less healthy ready-to-eat cereal (RTEC) products after its first implementation in 2006 (Rahkovsky et al., 2013;Sutherland et al., 2010). However, this increase in the sales shares of healthy RTEC products was only attributed to the decline in the purchases of less-healthy products (Cawley et al., 2015). ...
Point-of-sale nutrition information has been adopted by numerous grocery stores to respond to the demand for easy-to-understand nutrition labeling by consumers. Although there is conflicting evidence regarding the effectiveness of providing nutrition information, previous research indicates simplified shelf nutrition labels may lead to healthier choices. However, these studies have not examined how different consumer segments respond to these labels, nor the differential impacts across foods. Using household purchase data from a store that voluntarily adopted the (now defunct) NuVal shelf nutrition labels (a 1-100 numeric score derived from a nutrition-profiling algorithm), we assess NuVal impacts across different consumers and foods. NuVal scores potentially influence not only purchase quantity but also likelihood of buying. Thus, the effect of NuVal was measured by estimating a two-part model and predicting consumers' unconditional purchase responses. We found evidence of heterogeneous impacts of NuVal across consumers and foods. High-income households and households with children shifted their yogurt and frozen dinner purchases to more healthful items. In contrast, households with children and households headed by heads with college education slightly shifted their canned soup purchases to less healthful options. Our findings suggest that specific foods and consumer segments are influenced by simplified shelf nutrition information and further research is necessary to better understand its effect on consumer dietary quality.
... Jus u'à p se t inq études ont évalué l'i pa t su les a hats els, e supe a h (Freedman and Connors, 2011;Rahkovsky, 2013;Sacks, 2009;Sacks, 2011;Schucker, 1992;Sutherland, 2010;Vyth, 2010b) et sept ont testé l'effet su les i te tio s d'a hat (Balcombe, 2010;Borgmeier and Westenhoefer, 2009;Feunekes, 2008;Ruffieux and Muller, 2011;Waterlander, 2013 (Borgmeier & Westenhoefer, 2009;Feunekes, 2008;Ruffieux & Muller, 2011). Cela peut s'e pli ue pa des diff e es thodologi ues i po ta tes. ...
L’obésité est aujourd’hui un problème sociétal mondial. Dans les pays développés, l’abondance alimentaire a contribué au développement d’un environnement « obésogène » en favorisant la surconsommation. Ainsi, la promotion de choix alimentaires favorables à la santé représente un enjeu de santé publique majeur. L’objectif de cette thèse était de fournir une approche épidémiologique des choix alimentaires lors de l’approvisionnement et de la préparation des repas. Ce travail a été réalisé sur la population NutriNet-Santé, large cohorte prospective d’observation d’adultes français basée sur Internet.Au moment de l’approvisionnement, les logos d’information nutritionnelle ont été évalués comme des outils potentiels pour guider les consommateurs lors de leurs choix. Quatre logos ont été comparés : les Repères Nutritionnels Journaliers, les Traffic Light Multiples, le logo simple Pick the Tick et le logo 5-Couleurs. Des quatre logos testés, le logo 5-Couleurs était perçu comme le plus facile à identifier et celui demandant le moins d’effort à comprendre. Il était le plus efficace pour augmenter la capacité des individus à classer trois produits en fonction de leur qualité nutritionnelle. Enfin, en situation d’achats simulée en ligne, ce logo était celui qui permettait d’accroitre de façon la plus importante la qualité nutritionnelle du panier d’achat par rapport à une situation sans logo.Lors de la préparation des repas, un premier objectif était de comprendre l’ensemble des déterminants mis en jeu, cette thématique restant peu étudiée dans la littérature. Cinq grandes motivations ont été identifiées : alimentation saine, contraintes, plaisir, régimes spécifiques et organisation. Le fait d’attacher de l’importance à avoir une alimentation saine était associé à une alimentation de meilleure qualité nutritionnelle, ainsi qu’à une moindre susceptibilité d’être en surpoids. Attacher de l’importance à un régime spécifique était également associé à une meilleure qualité d’alimentation mais à un surpoids plus important. Malgré des associations significatives pour les autres motivations, les effets observés étaient de faible ampleur. Ces résultats soulignent l’importance de promouvoir des choix alimentaires favorables au moment de la préparation du repas.Le fait de planifier ses repas, c’est-à-dire prévoir à l’avance ce qui va être consommé sur plusieurs jours, a également été évalué. Globalement, les individus qui planifiaient leurs repas avaient une alimentation plus en adéquation avec les recommandations nutritionnelles et plus variée, bien que les résultats en termes d’apports en énergie et groupes d’aliments indiquaient de faibles différences. Ils étaient également moins susceptibles d’être obèses (et en surpoids chez les femmes).L’ensemble de ces résultats suggèrent l’intérêt de fournir des outils (logo, outils d’aide à la décision au moment de la préparation des repas et d’aide à la planification) afin de guider les individus lors de leurs choix alimentaires et ainsi améliorer la qualité de leur alimentation.
... Guiding Stars is a voluntary program used by participating grocery retailers in the United States to help consumers identify nutritious foods using shelf labels in stores. Guiding Stars ratings are assigned using an algorithm that considers vitamins, minerals, dietary fiber, whole grains, omega-3 fatty acids, saturated fat, trans fat, added sugar, added sodium, and artificial colors [34,35]. Products that meet the criteria are indicated on shelf labels in several grocery store chains across the country. ...
Improvements in the healthfulness of packaged foods and beverages through reformulation could help reduce the prevalence of obesity among children and adolescents through improved diet quality. This study assessed changes in calories and four nutrients (saturated fat, total sugars, sodium, and dietary fiber) from 2012 through 2014 for packaged products frequently consumed by children and adolescents, simulated effects of potential improvements in 12 frequently consumed product categories based on actual purchasing patterns, and compared differences in prices of healthier versus less healthy products. Analysis of trends showed limited evidence that healthfulness of foods improved over the years examined. Simulation results showed minimal changes for calories and sodium, but daily intake of saturated fat could decrease by 4%, sugar consumption could decrease by 5%, and dietary fiber consumption could increase by 11% if products were reformulated to meet an existing healthfulness standard. Using a higher standard, caloric intake could decline by 4%, saturated fat by 6%, sugar by 9%, and sodium by 4%, and dietary fiber could increase by 14%. Healthier versions of most products ranged from an average of 3 to 12 cents more per serving, but not all healthier versions were more costly. Overall, reformulation is a potential avenue for improving diet quality in households with children and adolescents, but price could be a barrier to purchasing healthier products for some households.
... The number of nutrition elements and the type of nutrition information on product packages or in the store might be increased, including point-of-purchase signage and textual elements that convey prominent and easy-to-understand information. In addition to the mandatory Nutrition Facts label, research has suggested that front-of-package nutrition icons could help consumers identify food products with more nutritious profiles (IOM, 2011;Rahkovsky, Lin, Lin, & Lee, 2013). Future research may explore whether more numerous and more prominent icons on the front of packages improve attention and whether any improvement leads to healthier dietary choices. ...
Providing nutrition information at the point of purchase is one approach that can be used to help consumers adopt and maintain a healthy diet. Previous research has examined consumer self‐reported notice and use of the information as well as how the design of the information affects its attention and use in a laboratory environment using eye‐tracking methodology. This study advances the literature by applying eye‐tracking methodology to explore consumer visual and choice behavior in a real shopping environment, and by recognizing that nutrition information competes with other visual stimuli in the store and consumers are vulnerable to a “limited attention span” for nutrition information in a shopping setting. Data came from a cross‐sectional survey conducted in two grocery stores in the United States in July 2014 with a convenience sample of 60 grocery shoppers while they were selecting and buying items from one of three product categories (ready‐to‐eat cereal, snacks, and soup). The study finds that point‐of‐purchase nutrition information faced strong competition for participants’ attention from other visual elements in a real shopping environment and the attention is dominated by non‐nutrition elements, particularly brand/product name, product imagery, and product pricing. Nutrition‐related information, on the other hand, received much less attention, with claims and front‐of‐package nutrition symbols seen by more participants than the Nutrition Facts label. The study suggests that to more effectively enable nutrition information to “catch the eyes” of shoppers at the point of purchase, increasing consumer exposure to the information and enhancing shopper education may merit further investigation.
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... There is limited research examining the effectiveness of alternative nutrition signalling programs such as Guiding Stars and the Traffic Light label. Rahkovsky, Lin, Jordan Lin, and Lee (2013) examine the effects of the Guiding Stars program on demand for ready-to-eat breakfast cereals in the USA using a Rotterdam demand model and store scanner data, finding that sales of low-ranked cereals decreased, while sales of high-ranked cereals increased. Sutherland, Kaley, and Fisher (2010) use purchase data from 168 stores located in northern New England and New York to assess the effects of the Guiding Stars nutrition navigational system on food purchases. ...
Mandatory labelling of nutrition information with a numerical nutrition facts panel is commonly required for prepackaged food products. Recently, food manufacturers and retailers have developed simplified nutrition signals such as front-of-package labelling (e.g. the Traffic Light label) or retail shelf labels (e.g. Guiding Stars), which provide a more intuitive signal of nutritional content. Using survey data from a sample of consumers from western Canada, this paper examines consumer responses to two private nutrition labelling programs: Guiding Stars and the Traffic Light label. Consumers are more receptive to the Traffic Light label than the Guiding Stars. Ordered probit models explore the factors influencing the likelihood of using these nutrition signals. Trust in the food label, perceived difficulty of using nutrition information, nutrition knowledge, and the importance placed on nutrition influence receptively to these labels. Simplified nutrition labels are likely to complement, rather than substitute for, the existing Nutrition Facts Table.
... Our search of policy cases was not comprehensive due to the lack of a central database that tracks of programs, agency regulations, and local bills; yet, our search of multiple online resources and expert consultations made it less likely that we missed major relevant efforts. We focused on government-led efforts thus excluding non-governmental and private sector efforts, such as healthy food subsidy programs from insurers [173,174] and non-governmental organizations [175,176], industry-led FOP labels [177][178][179], reformulation efforts [180,181], and marketing standards [182]. Future work should evaluate the design and implementation of such efforts. ...
Purpose of review:
Suboptimal diet is a leading cause of cardiometabolic disease and economic burdens. Evidence-based dietary policies within 5 domains-food prices, reformulation, marketing, labeling, and government food assistance programs-appear promising at improving cardiometabolic health. Yet, the extent of new dietary policy adoption in the US and key elements crucial to define in designing such policies are not well established. We created an inventory of recent US dietary policy cases aiming to improve cardiometabolic health and assessed the extent of their proposal and adoption at federal, state, local, and tribal levels; and categorized and characterized the key elements in their policy design.
Recent findings:
Recent federal dietary policies adopted to improve cardiometabolic health include reformulation (trans-fat elimination), marketing (mass-media campaigns to increase fruits and vegetables), labeling (Nutrition Facts Panel updates, menu calorie labeling), and food assistance programs (financial incentives for fruits and vegetables in the Supplemental Nutrition Assistance Program (SNAP) and Women, Infant and Children (WIC) program). Federal voluntary guidelines have been proposed for sodium reformulation and food marketing to children. Recent state proposals included sugar-sweetened beverage (SSB) taxes, marketing restrictions, and SNAP restrictions, but few were enacted. Local efforts varied significantly, with certain localities consistently leading in the proposal or adoption of relevant policies. Across all jurisdictions, most commonly selected dietary targets included fruits and vegetables, SSBs, trans-fat, added sugar, sodium, and calories; other healthy (e.g., nuts) or unhealthy (e.g., processed meats) factors were largely not addressed. Key policy elements to define in designing these policies included those common across domains (e.g., level of government, target population, dietary target, dietary definition, implementation mechanism), and domain-specific (e.g., media channels for food marketing domain) or policy-specific (e.g., earmarking for taxes) elements. Characteristics of certain elements were similarly defined (e.g., fruit and vegetable definition, warning language used in SSB warning labels), while others varied across cases within a policy (e.g., tax base for SSB taxes). Several key elements were not always sufficiently characterized in government documents, and dietary target selections and definitions did not consistently align with the evidence-base. These findings highlight recent action on dietary policies to improve cardiometabolic health in the US; and key elements necessary to design such policies.
... The feeling of only partially understanding the meaning of the information on the label was expressed by consumers, even in the case of no other topics such as carbon labelling, or the value of emission footprints (Upham et al., 2011). Although classification methods are not new (Rahkovsky et al., 2013) and are perceived by consumers as very comprehensible (Feunekes, Gortemaker, Willems, Lion, & van den Kommer, 2008), respondents from sample B preferred the providing of truthful images of the production system to animal welfare products recognition (outdoor and cage-free images, for example). This marketing tool can encourage consumers to buy animal welfare beef meat because it demonstrates that, on average, consumers not only had a positive attitude towards more animal welfare husbandry systems with outdoor access and space allowance, but were also willing to pay a premium price for products from such systems . ...
A survey was carried out on preferences by Italian consumers about marketing strategies applicable to animal welfare beef meat recognition in the market. An ad hoc questionnaire was developed and submitted to 514 individuals, which were divided into two types of consumers: millennial and conventional consumers. The characteristics and preferences of the two considered sample groups were defined to better understand their attitudes during beef purchase. Additionally, the criteria used during meat choice and animal-friendly values associated with products deriving from high animal welfare standards were analysed. Finally, the most important methods for animal welfare beef meat recognition have been studied and compared between the two considered samples. Our study revealed varying perceptions about animal welfare by different generations of consumers during beef meat purchase. Both millennial and conventional consumers acknowledged that having detailed labels helps to easily recognise animal welfare meat on the market.
... Numerous health interventions have been studied or implemented in supermarket environments, including strategies ranging from education and promotions, to 'nudge' approaches informed by behavioral economics (Ball et al., 2011;Cawley et al., 2015;Milliron et al., 2012). Some examples include point-of-purchase strategies that help consumers to identify healthful foods, such as the "Guiding Stars Program," as well as the use of subliminal cues, such as product placement within supermarket aisles or on shelves (Foster et al., 2014;Milliron et al., 2012;Rahkovsky et al., 2013). Other approaches have sought to build consumers' nutritional and culinary knowledge with in-and out-of-store programming such as food tastings or cooking demonstrations (Dannefer et al., 2012;Reicks et al., 2014). ...
Public health interventions to increase supermarket access assume that shopping in supermarkets is associated with healthier food purchases compared to other store types. To test this assumption, we compared purchasing patterns by store-type for certain higher-calorie, less healthy foods (HCF) and lower-calorie, healthier foods (LCF) in a sample of 35 black women household shoppers in Philadelphia, PA. Data analyzed were from 450 food shopping receipts collected by these shoppers over four-week periods in 2012. We compared the likelihood of purchasing the HCF (sugar-sweetened beverages, sweet/salty snacks, and grain-based snacks) and LCF (low-fat dairy, fruits, and vegetables) at full-service supermarkets and six other types of food retailers, using generalized estimating equations. Thirty-seven percent of participants had household incomes at or below the poverty line, and 54% had a BMI >30. Participants shopped primarily at full-service supermarkets (55%) or discount/limited assortment supermarkets (22%), making an average of 11 shopping trips over a 4-week period and spending mean (SD) of 222). Of full-service supermarket receipts, 64% included at least one HCF item and 58% at least one LCF. Most trips including HCF (58%) and LCF (60%) expenditures were to full-service or discount/limited assortment supermarkets rather than smaller stores. Spending a greater percent of total dollars in full-service supermarkets was associated with spending more on HCF (p = 0.03) but not LCF items (p = 0.26). These findings in black women suggest a need for more attention to supermarket interventions that change retailing practices and/or consumer shopping behaviors related to foods in the HCF categories examined.
... However, widespread use of a single, effective FoPL is likely to have the greatest impact on product selection. For example, supermarket studies using a starbased rating system applied to shelf tags across all products found a shift toward increased purchases of healthier foods [28][29][30]. Other supermarket studies using the MTL did not observe any shift in purchases, however this may have been due to the label not being applied across all products [31,32]. ...
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. ResultsOf 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.
... This is in line with the findings of studies conducted in real-world shopping environments (using sales data) that show consumers' shift to purchasing more healthy foods when the same FOP label is consistently applied to all products in a store. 88,[92][93][94] It would also be beneficial to occasionally apply new elements to or alter the format of the fact-based, nondirective FOP labels (eg, GDA) to motivate consumers to read the nutrition information more deliberately. ...
Nutrition labeling literature yields fragmented results about the effect of front-of-package (FOP) nutrition label formats on healthy food choice. Specifically, it is unclear which type of nutrition label format is effective across different shopping situations. To address this gap, the present review investigates the available nutrition labeling literature through the prism of dual-process theory, which posits that decisions are made either quickly and automatically (system 1) or slowly and deliberately (system 2). A systematically performed review of nutrition labeling literature returned 59 papers that provide findings that can be explained according to dual-process theory. The findings of these studies suggest that the effectiveness of nutrition label formats is influenced by the consumer's dominant processing system, which is a function of specific contexts and personal variables (eg, motivation, nutrition knowledge, time pressure, and depletion). Examination of reported findings through a situational processing perspective reveals that consumers might prefer different FOP nutrition label formats in different situations and can exhibit varying responses to the same label format across situations. This review offers several suggestions for policy makers and researchers to help improve current FOP nutrition label formats.
... Interpretive FOP nutrition labels may guide healthier food choices [8,9], especially amongst more nutrition-conscious shoppers [10]. Importantly however, there is evidence suggesting that interpretive FOP labels also improve population diets through healthier product reformulation. ...
Interpretive, front-of-pack (FOP) nutrition labels may encourage reformulation of packaged foods. We aimed to evaluate the effects of the Health Star Rating (HSR), a new voluntary interpretive FOP labelling system, on food reformulation in New Zealand. Annual surveys of packaged food and beverage labelling and composition were undertaken in supermarkets before and after adoption of HSR i.e., 2014 to 2016. Outcomes assessed were HSR uptake by food group star ratings of products displaying a HSR label; nutritional composition of products displaying HSR compared with non-HSR products; and the composition of products displaying HSR labels in 2016 compared with their composition prior to introduction of HSR. In 2016, two years after adoption of the voluntary system, 5.3% of packaged food and beverage products surveyed (n = 807/15,357) displayed HSR labels. The highest rates of uptake were for cereals, convenience foods, packaged fruit and vegetables, sauces and spreads, and ‘Other’ products (predominantly breakfast beverages). Products displaying HSR labels had higher energy density but had significantly lower mean saturated fat, total sugar and sodium, and higher fibre, contents than non-HSR products (all p-values < 0.001). Small but statistically significant changes were observed in mean energy density (−29 KJ/100 g, p = 0.002), sodium (−49 mg/100 g, p = 0.03) and fibre (+0.5 g/100 g, p = 0.001) contents of HSR-labelled products compared with their composition prior to adoption of HSR. Reformulation of HSR-labelled products was greater than that of non-HSR-labelled products over the same period, e.g., energy reduction in HSR products was greater than in non-HSR products (−1.5% versus −0.4%), and sodium content of HSR products decreased by 4.6% while that of non-HSR products increased by 3.1%. We conclude that roll-out of the voluntary HSR labelling system is driving healthier reformulation of some products. Greater uptake across the full food supply should improve population diets.
... Front-of-the-package labels-such as traffic light labels that indicate the healthfulness of the packaged foods and may also include information on calories and other nutrients per serving-have been criticized, because these labels are self-regulated by the food industry and do not meet standard nutritional criteria for healthy food (Roberto et al. 2011). Evidence from the Netherlands and United Kingdom is mixed regarding how effectively traffic light labels influence healthfulness of purchases and calorie intake , Vyth et al. 2010), but US evidence from different retail chains (Cawley et al. 2015, Rahkovsky et al. 2013 and experiments (Kiesel & Villas-Boas 2013, Roberto et al. 2012) is more encouraging. ...
The idea that farm subsidies contribute significantly to obesity and that reducing these subsidies would go a long way toward solving the problem has been popular among the mainstream media and in policy circles. However, economists who have evaluated the issue have consistently found that farm subsidies have had negligible impacts on US obesity patterns. If anything, farm income support policies, including various subsidies and price supports, have made fattening food more expensive and reduced US obesity. New evidence from our updated economic simulation model reinforces that view and the conclusion that reformulation of farm subsidies would be ineffective and even counterproductive as a way of fighting US obesity.
El consumo elevado de componentes críticos en los alimentos ultraprocesados se ha asociado con la prevalencia de obesidad y otras enfermedades no transmisibles. En las últimas décadas el consumo de estos productos se ha incrementado en la población joven. En México, el Sistema de Etiquetado Frontal de advertencia (EFA) debe advertir al consumidor sobre el contenido de componentes críticos en la dieta para fomentar consumos más saludables. La evaluación de la aceptación y uso del EFA respecto a la selección de alimentos para su consumo, ha sido insuficiente. Se analizó la asociación entre la aceptación, el uso y la comprensión-objetiva del EFA con el consumo de alimentos en adultos jóvenes. Análisis transversal y descriptivo del uso del EFA para la selección de alimentos en 450 participantes. Se aplicaron dos cuestionarios: uno midió la aceptación, uso y comprensión-objetiva del EFA, y un cuestionario de frecuencia de consumo de alimentos que evaluó la selección y consumo de productos en la dieta. El 76.4% aceptó el EFA, 66.7% lo usó y 50.4% demostró comprensión-objetiva. El consumo de alimentos con grandes aportes de componentes críticos fue el predominante. Solamente en 3 de los 20 componentes dietéticos analizados se cumplieron las recomendaciones de ingestión diaria. Quienes no utilizaron el EFA presentaron 1.6 veces más riesgo de elegir alimentos no recomendables para su consumo. Aunque un elevado porcentaje de la población aceptó y usó el EFA, la no comprensión del EFA implicó mayor riesgo de consumir alimentos no recomendables.
Nutritional warning labels are gaining relevance in the region of the Americas as a policy tool to reduce information asymmetry and encourage healthier food choices. However, empirical evidence about consumer experiences with warning labels after implementation is still scarce. In this context, the aim of the present work was to explore the use of nutritional warning labels after policy implementation in Uruguay, using a combination of eye-tracking and self-reported data. The study was conducted in three supermarkets, in two regional capitals, 19 months after the entry into force of the policy. A total of 224 participants were intercepted while entering the facilities of the supermarket and asked to wear a mobile eye-tracker while making their food purchases. Then, they were asked a series of questions about their awareness and use of warning labels. Although participants reported high awareness and understanding of the labels, active search and use at the point of purchase was low. Only 6% of the consumers declared having actively searched for the warning labels and 7% fixated their gaze on the labels. The majority of the participants (72%) who declared having seen the warnings on a product, purchased it anyway. However, 56% declared having changed their food choice decisions as a consequence of the implementation of the policy. Participants' accounts about reasons for (not) taking into account the warning labels provide relevant insights for the development of strategies to encourage citizens to increase policy effectiveness and encourage healthier food choices.
Food purchase choices, one of the main determinants of food consumption, is highly influenced by food environments. Given the surge in online grocery shopping because of the COVID-19 pandemic, interventions in digital environments present more than ever an opportunity to improve the nutritional quality of food purchase choices. One such opportunity can be found in gamification. Participants (n = 1228) shopped for 12 items from a shopping list on a simulated online grocery platform. We randomized them into four groups in a 2 × 2 factorial design: presence vs. absence of gamification, and high vs. low budget. Participants in the gamification groups saw foods with 1 (least nutritious) to 5 (most nutritious) crown icons and a scoreboard with a tally of the number of crowns the participant collected. We estimated ordinary least squares and Poisson regression models to test the impact of the gamification and budget on the nutritional quality of the shopping basket. In the absence of gamification and low budget, participants collected 30.78 (95% CI [30.27; 31.29]) crowns. In the gamification and low budget condition, participants increased the nutritional quality of their shopping basket by collecting more crowns (B = 4.15, 95% CI [3.55; 4.75], p < 0.001). The budget amount (30) did not alter the final shopping basket (B = 0.45, 95% CI [-0.02; 1.18], p = 0.057), nor moderated the gamification effect. Gamification increased the nutritional quality of the final shopping baskets and nine of 12 shopping list items in this hypothetical experiment. Gamifying nutrition labels may be an effective strategy to improve the nutritional quality of food choices in online grocery stores, but further research is needed.
Food labels provided the information needed to guide the selection of foods that will help individuals meet nutrition and health goals. Recent changes in the format for back-of-package labels necessitate the reinterpretation of food label information. Different designs for front-of-package food labels are discussed. Health claims on food labels are regulated by the FDA. This chapter explains how to best utilize the information provided by food labels.KeywordsNutrition labelingNutrition Facts LabelDaily ValuesFront-of-package food labelshealth claims
In 2010, the White House announced the goal of eradicating food deserts—low-income neighborhoods without nearby supermarkets—in seven years. The efficacy of this initiative is premised on the presumption, mostly untested in 2010, that food deserts significantly contribute to health disparities in low-resourced communities. We synthesize the post-2010 line of research that seeks to establish causality in the relationship between food access and nutrition/health. All things considered, there is so far little evidence that food deserts have a causal effect of meaningful magnitude on health and nutrition disparities. The causes of diet quality disparity lie more on the side of food demand than on supply. Therefore, from the public health perspective, policies that lower the relative price of healthy food or change the “deep parameters” of preferences in favor of healthy food would be more appealing than eliminating food deserts.
Expected final online publication date for the Annual Review of Resource Economics, Volume 13 is October 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
shelf nutrition labels are one of a handful of practical strategies that hold the promise of improving nutrition and public health. We use a difference‐in‐differences approach to estimate the effect of the NuVal shelf label—an interpretive numeric score, now defunct, that rated the overall nutrition of foods from one (least healthful) to 100 (most healthful)—on consumer demand for yogurt. The results indicate that NuVal labels affected product sales through an information provision effect that increases with the value of the nutrition score on the product and a publicity (i.e., salience) effect that is unrelated to the level of the score. A one‐point increase in NuVal score on a yogurt product is estimated to increase demand by 0.23%.
This JRC Science for Policy report was produced in support of a Commission report on front-of-pack (FOP) nutrition labelling. It provides a review of the scientific literature concerning FOP nutrition labelling and its effects on consumers, food business operators, and the single market. A major emphasis is placed on consumer attention, preferences, and understanding of different FOP schemes, as well as effects on food purchasing and implications for diet and health. The report also considers in how far producer efforts on food reformulation and innovation may be affected by the introduction of FOP nutrition labelling schemes, describes potential unintended consequences of introducing FOP nutrition labelling, and highlights knowledge gaps and directions for future research. An extensive, yet non-exhaustive overview of FOP schemes around the globe complements the literature review.
Large changes to food retail settings are required to improve population diet. However, limited research has comprehensively considered the business implications of healthy food retail strategies for food retailers. We performed a systematic scoping review to identify types of business outcomes that have been reported in healthy food retail strategy evaluations. Peer‐reviewed and grey literature were searched. We identified qualitative or quantitative real‐world food or beverage retail strategies designed to improve the healthiness of the consumer nutrition environment (eg, changes to the “marketing mix” of product, price, promotion, and/or placement). Eligible studies reported store‐ or chain‐level outcomes for measures of commercial viability, retailer perspectives, customer perspectives, and/or community outcomes. 11 682 titles and abstracts were screened with 107 studies included for review from 15 countries. Overall item sales, revenue, store patronage, and customer level of satisfaction with strategy were the most frequently examined outcomes. There was a large heterogeneity in outcome measures reported and in favourability for retailers of outcomes across studies. We recommend more consistent reporting of business outcomes and increased development and use of validated and reliable measurement tools. This may help generate more robust research evidence to aid retailers and policymakers to select feasible and sustainable healthy food retail strategies to benefit population health within and across countries.
Other food policies have also been implicated in the obesity epidemic. Our findings are generally negative regarding both the contributions of USDA’s food and nutrition programs (FANPs) to obesity and the potential for modifying them effectively and economically to reduce obesity. Some say strengthening the role of the US government in regulation of food labeling (the nutrition facts panel, other requirements for specific types of labels on the front or back of packages, and calorie postings at restaurants) and marketing to children will help fight obesity. Changes to current food labeling practices that are underway in the United States have potential to help some consumers to make more healthful food choices, but it is left to the food industry to self-regulate food marketing to children, and changes here have been largely ineffective. “Nudges” have been shown to complement the effectiveness of some existing policies.
To describe ready-to-eat (RTE) cereal purchases in 2008 in the USA according to cereal nutritional quality and marketing strategy and household sociodemographic characteristics.
Cross-sectional study of purchases in one year. Each type of cereal was assigned to one of four nutrition quality categories (based on Nutrient Profile Index, NPI) and one of four advertising categories based on television exposure and analysis of packaging (child-targeted, family-targeted, adult-targeted and no television advertising). Medians and distributions of purchase indicators were calculated for the cereal categories and the distributions were compared across sociodemographic groups.
RTE cereals (n 249) with complete label and nutritional content.
RTE cereal purchases according to household sociodemographic characteristics obtained from Nielsen Homescan, a nationally representative panel of households.
Purchases of RTE cereals were highest in households with one or more child and lowest in African-American and Asian households, as well as those earning <$US 30 000 per annum. The lowest-quality products were purchased by four times as many households as the highest-quality cereals, but loyalty to these products was lower. Purchases of cereals by households with children and in African-American and Hispanic households increased as cereal nutritional quality declined. Compared with non-advertised products, advertised child-targeted cereals were purchased thirteen times more frequently; family-targeted brand purchases were ten times higher; and adult-targeted cereals were purchased four times more frequently.
Our findings suggest that improving the nutritional quality of RTE cereals with advertising targeted to children could also lead to increased consumption of healthier products by young people.
Purpose
To describe the collaborative process between a grocery retailer and a panel of nutrition experts used to develop a nutrition guidance system (Guiding Stars) that evaluates the nutrient profile of all edible products in the supermarket, and to report the results of the food and beverage ratings.
Design
A collaboration between a private retailer and members of the scientific community that led to the development of a scoring algorithm used to evaluate the nutritional quality of foods and beverages.
Setting/Subjects
Northeast supermarkets (n = 160).
Measures
Food and beverage nutrition ratings and distribution of stars across different grocery categories.
Analysis
Descriptive statistics for rating distributions were computed. T-tests were conducted to assess differences in mean nutrient values between foods with zero versus three stars or a dichotomized variable representing all foods with one to three stars.
Results
All edible grocery items (n = 27,466) were evaluated, with 23.6% earning at least one star. Items receiving at least one star had lower mean levels of sodium, saturated fat, and sugars and higher amounts of fiber than products not earning stars.
Conclusion
The Guiding Stars system rates edible products without regard to brand or manufacturer, and provides consumers with a simple tool to quickly identify more nutritious choices while shopping. The low percentage of products qualifying for stars reflects poorly on the food choices available to Americans.
Matched sampling is a method for selecting units from a large reservoir of potential controls to produce a control group of modest size that is similar to a treated group with respect to the distribution of observed covariates. We illustrate the use of multivariate matching methods in an observational study of the effects of prenatal exposure to barbiturates on subsequent psychological development. A key idea is the use of the propensity score as a distinct matching variable. Statistics Version of Record
In 1998 the medical costs of obesity were estimated to be as high as 40 billion of increased medical spending through 2006, including 147 billion per year by 2008.
The Day Reconstruction Method (DRM) assesses how people spend their time and how they experience the various activities and settings of their lives, combining features of time-budget measurement and experience sampling. Participants systematically reconstruct their activities and experiences of the preceding day with procedures designed to reduce recall biases. The DRM's utility is shown by documenting close correspondences between the DRM reports of 909 employed women and established results from experience sampling. An analysis of the hedonic treadmill shows the DRM's potential for well-being research.
Download link at: http://sitemaker.umich.edu/norbert.schwarz/day_reconstruction_method__time_use____well-being
In differentiated product markets where consumer preferences are characterized by brand loyalty, an important role for advertising may be to overcome brand loyalty by encouraging consumers to switch to less familiar brands. Using a scanner panel dataset of breakfast-cereal purchases, I find evidence consistent with the hypothesis that advertising counteracts the tendencies of brand loyalty toward repeat purchasing. Equivalently, advertising reduces switching costs in this market. Furthermore, counterfactual experiments demonstrate that in markets with brand loyalty, advertising is an attractive and effective option-relative to alternative promotional activities, such as price discounts-of stimulating demand for a brand. Copyright 2004 Blackwell Publishing, 350 Main Street, Malden, MA 02148, USA, and 9600 Garsington Road, Oxford OX4 2DQ, UK..
A comparison and evaluation is made of recent proposals for multivariate matched sampling in observational studies, where the following three questions are answered: (1) Algorithms: In current statistical practice, matched samples are formed using "nearest available" matching, a greedy algorithm. Greedy matching does not minimize the total distance within matched pairs, though good algorithms exist for optimal matching that do minimize the total distance. How much better is optimal matching than greedy matching? We find that optimal matching is sometimes noticeably better than greedy matching in the sense of producing closely matched pairs, sometimes only marginally better, but it is no better than greedy matching in the sense of producing balanced matched samples. (2) Structures: In common practice, treated units are matched to one control, called pair matching or 1-1 matching, or treated units are matched to two controls, called 1-2 matching, and so on. It is known, however, that the optimal structure is a full matching in which a treated unit may have one or more controls or a control may have one or more treated units. Optimal 1 - k matching is compared to optimal full matching, finding that optimal full matching is often much better. (3) Distances: Matching involves defining a distance between covariate vectors, and several such distances exist. Three recent proposals are compared. Practical advice is summarized in a final section.
This research examines how low-literate consumers use nutritional labels on packages and the ways such usage can be facilitated. Using research on nutritional labeling and on low-literate consumers as bases, the authors design an experiment to test specific hypotheses about the effects of graphic versus nongraphic formats on usage of nutrition information by consumers with different levels of literacy. The authors discuss implications of the findings for further research and for public policy.
A theory of consumer demand with variable preferences. The assumption that the individual consumer has a unique ordinal utility index function is replaced by the assumption that he has a family of ordinal utility functions; advertising expenditures by the sellers of commodities are assumed to determine which one of these ordinal utility functions is to be maximized. From these assumptions are derived a number of theoretical relations which measurements defining advertising elasticities of demand must satisfy. The relations involving shifts in demand and advertising elasticities of demand are shown to be analogues of the theorems of consumer demand under fixed preferences.
A comparison and evaluation is made of recent proposals for multivariate matched sampling in observational studies, where the following three questions are answered: (1) Algorithms: In current statistical practice, matched samples are formed using “nearest available” matching, a greedy algorithm. Greedy matching does not minimize the total distance within matched pairs, though good algorithms exist for optimal matching that do minimize the total distance. How much better is optimal matching than greedy matching? We find that optimal matching is sometimes noticeably better than greedy matching in the sense of producing closely matched pairs, sometimes only marginally better, but it is no better than greedy matching in the sense of producing balanced matched samples. (2) Structures: In common practice, treated units are matched to one control, called pair matching or 1–1 matching, or treated units are matched to two controls, called 1–2 matching, and so on. It is known, however, that the optimal structure is a full matching in which a treated unit may have one or more controls or a control may have one or more treated units. Optimal 1 — k matching is compared to optimal full matching, finding that optimal full matching is often much better. (3) Distances: Matching involves defining a distance between covariate vectors, and several such distances exist. Three recent proposals are compared. Practical advice is summarized in a final section.
Academic research presents an important information source that consumers, firms, and public policy makers use for decision
making. This paper reviews and synthesizes the literature in marketing journals to examine whether empirical studies thoroughly
addresses the Nutrition Labeling and Education Act (NLEA) objectives. Findings indicate that a large number of published studies
fail to directly address the NLEA objectives. The remaining studies are discussed and organized in juxtaposition with the
three objectives framing the legislation. Finally, the paper pinpoints the paucity of generalizable research with regard to
the objectives of the NLEA while identifying fertile directions for future research.
Shelf management is a difficult task in which rules of thumb rather than good theory and hard evidence tend to guide practice. Through a series of field experiments, we measured the effectiveness of two shelf management techniques: “space-to-movement,” where we customized shelf sets based on store-specific movement patterns; and “product reorganization” where we manipulated product placement to facilitate cross-category merchandising or ease of shopping. We found modest gains (4%) in sales and profits from increased customization of shelf sets and 5–6% changes due to shelf reorganization. Using the field experiment data, we modeled the impact of shelf positioning and facing allocations on sales of individual items. We found that location had a large impact on sales, whereas changes in the number of facings allocated to a brand had much less impact as long as a minimum threshold (to avoid out-of-stocks) was maintained.
A retail chain manager must draw on experience based on data available from his points of sale to diagnose space misallocations in stores and to make recommendations. This paper presents an empirical estimate of shelf space elasticities from a variety store chain database at product category level with a share of space vs. share of sales econometric model. It suggests that external influences could explain space elasticity differences. Results show that space elasticities increase with the impulse buying rate of the product category and do not depend on the type of store.
The U.S. Government is promoting whole-grain foods, responding to mounting evidence of their association with maintaining a healthy weight and reducing the risk of heart problems and other diseases. This study compared Americans’ consumption of grains with the recommendations in the Government’s 2005 Dietary Guidelines, using data from USDA’s Continuing Survey of Food Intakes by Individuals, 1994-96 and 1998. The analysis confirmed a national preference for refined grains—only 7 percent of survey respondents met the 2005 whole-grain recommendation. The authors compared grain consumption by economic and demographic characteristics of consumers, and also examined the effects of consumers’ social, economic, and demographic characteristics and dietary perceptions and practices. The results suggest that consumers who perceive grain consumption as important and read food labels during shopping tend to eat more whole grains than other people. When data from more recent surveys are analyzed, results of the present study can serve as a baseline from which to gauge changes in the American diet and the consumption of whole grains.
To improve diet quality and overall population health, the need to develop nutritional rating systems that are comprehensive in scope and easy for the consumer to understand and use at the point-of-purchase has emerged.
Our aim was to examine the effect of a comprehensive storewide supermarket point-of-purchase nutrition navigation intervention by using a shelf-label 3-tiered star icon on consumer food and beverage choices and their associated nutritional quality.
By using a natural experiment design, purchasing data from 2006 to 2008 were obtained from a Northeast supermarket chain with 168 stores located in northern New England and New York and examined at preimplementation and at 1- and 2-y follow-up periods.
The nutrition navigation system studied showed significant changes in food purchasing immediately after implementation, and these changes continued to be significant 1 and 2 y later. When the same 8-mo period (January-August) each year was compared, in 2006, 24.50% of items purchased earned a star rating; this proportion increased to 24.98% (P < 0.001) and 25.89% (P < 0.0001) at the 1- and 2-y follow-up periods, respectively. For a 4-wk period, 1 y after program implementation, consumers purchased significantly more ready-to-eat cereals with stars (eg, less added sugars and more dietary fiber) and fewer no-star, high-sugar, low-fiber cereals.
Increasing rates of obesity and declining diet quality for Americans strongly support the need for effective supermarket point-of-purchase programs, such as the Guiding Stars nutrition navigation program, that provide clear, concise, and simplified nutrition information to guide consumer food and beverage choices.
To estimate per-person and aggregate direct medical costs of overweight and obesity and to examine the effect of study design factors. PubMed (1968-2009), EconLit (1969-2009) and Business Source Premier (1995-2009) were searched for original studies. Results were standardized to compute the incremental cost per overweight person and per obese person, and to compute the national aggregate cost. A total of 33 US studies met review criteria. Among the four highest-quality studies, the 2008 per-person direct medical cost of overweight was 1723. The aggregate national cost of overweight and obesity combined was $113.9 billion. Study design factors that affected cost estimates included use of national samples vs. more selected populations, age groups examined, inclusion of all medical costs vs. obesity-related costs only, and body mass index cut-offs for defining overweight and obesity. Depending on the source of total national healthcare expenditures used, the direct medical cost of overweight and obesity combined is approximately 5.0% to 10% of US healthcare spending. Future studies should include nationally representative samples, evaluate adults of all ages, report all medical costs and use standard body mass index cut-offs.
The 2005 Dietary Guidelines were unique because they offered quantitative recommendations for consumption of whole-grains. This case study examines the hypothesis that the changed recommendations were responsible for the recent increase in retail sales and consumption of whole-grain food products. We find that release of the Dietary Guidelines and related media attention did increase availability and sales of whole-grain foods. A large impact on consumption occurred through reformulation of existing products, induced by competition among food suppliers. This study reveals the key role product reformulation plays in inter-firm competition and in realization of dietary changes recommended by public policy.
Nutrition labels on food packages are designed to promote and protect public health by providing nutrition information so that consumers can make informed dietary choices. High levels of total fat, saturated fat and cholesterol in diets are linked to increased blood cholesterol levels and a greater risk of heart disease. Therefore, an understanding of consumer use of total fat, saturated fat, and cholesterol information on food labels has important implications for public health and nutrition education. This study explores the association between dietary intakes of these three nutrients and psychological or demographic factors and the search for total fat, saturated fat, and cholesterol information on food labels. Psychology literature suggests a negative association between intakes of these nutrients and probability of search for their information on food labels. Health behavior theories also suggest perceived benefits and costs of using labels and perceived capability of using labels are associated with the search behavior. We estimate the relationship between label information search and its predictors using logistic regressions. Our samples came from the 1994-1996 Continuing Survey of Food Intakes by Individuals and Diet and Health Knowledge Survey conducted by the United States Department of Agriculture. Results suggest that search for total fat, saturated fat, and cholesterol information on food labels is less likely among individuals who consume more of the three nutrients, respectively. The search is also related to perceived benefits and costs of using the label, perceived capability of using the label, knowledge of nutrition and fats, perceived efficacy of diets in reducing the risk of illnesses, perceived importance of nutrition in food shopping, perceived importance of a healthy diet, and awareness of linkage between excessive consumption of the nutrients and health problems. These findings suggest encouraging search of food label information among consumers with unhealthy dietary habits would need innovative approaches. Yet, nutrition education can be instrumental in encouraging this search by stimulating motivation and providing technical help.
Comprehension of food labels can be important for patients, including those with chronic illness, to help follow dietary recommendations. Patient comprehension of food labels was examined, along with the relationship of comprehension to their underlying literacy and numeracy skills.
From June 2004 to April 2005, a cross-sectional study of 200 primary care patients was performed. A 24-item measure of food label comprehension was administered. Literacy was measured with the Rapid Estimate of Adult Literacy in Medicine (REALM), and numeracy with the Wide Range Achievement Test, third edition (WRAT-3).
Most patients (89%) reported using food labels. While 75% of patients reported at least a high school education and 77% had 9th-grade literacy skills, only 37% had 9th-grade math skills. On average, patients answered 69% (standard deviation, 21%) of the food-label questions correctly. Common reasons for incorrect responses included misapplication of the serving size, confusion due to extraneous material on the food label, and incorrect calculations. For example, only 37% of patients could calculate the number of carbohydrates consumed from a 20-ounce bottle of soda that contained 2.5 servings. Higher comprehension of food labels was significantly correlated (all p values were less than 0.001) with higher income (rho=0.39), education (rho=0.49), literacy (rho=0.52), and numeracy (rho=0.67).
Patients demonstrated deficits in understanding nutrition labels. Poor label comprehension was highly correlated with low-level literacy and numeracy skills, but even patients with higher literacy could have difficulties interpreting labels. Providers need to consider patients' literacy and numeracy when providing dietary recommendations. Opportunities may exist for the U.S. Food and Drug Administration to promote changes to make food labels more comprehensible.
There are both public health and food industry initiatives aimed at increasing breakfast consumption among children, particularly the consumption of ready-to-eat cereals. The purpose of this study was to determine whether there were identifiable differences in nutritional quality between cereals that are primarily marketed to children and cereals that are not marketed to children. Of the 161 cereals identified between January and February 2006, 46% were classified as being marketed to children (eg, packaging contained a licensed character or contained an activity directed at children). Multivariate analyses of variance were used to compare children's cereals and nonchildren's cereals with respect to their nutritional content, focusing on nutrients required to be reported on the Nutrition Facts panel (including energy). Compared to nonchildren's cereals, children's cereals were denser in energy, sugar, and sodium, but were less dense in fiber and protein. The proportion of children's and nonchildren's cereals that did and did not meet national nutritional guidelines for foods served in schools were compared using chi2analysis. The majority of children's cereals (66%) failed to meet national nutrition standards, particularly with respect to sugar content. t tests were used to compare the nutritional quality of children's cereals with nutrient-content claims and health claims to those without such claims. Although the specific claims were generally justified by the nutritional content of the product, there were few differences with respect to the overall nutrition profile. Overall, there were important differences in nutritional quality between children's cereals and nonchildren's cereals. Dietary advice for children to increase consumption of ready-to-eat breakfast cereals should identify and recommend those cereals with the best nutrient profiles.
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Assessing the Economics of Obesity and Obesity Interventions
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A theory of demand with preference variables
- Basmann
Direct medical cost of overweight and obesity in the USA: a quantative systematic review
- Tsai