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

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Background Switzerland, like other high-income countries, is facing a major public health challenge with the increasing burden of non-communicable diseases. Discussions are currently on-going in Switzerland regarding the implementation of a Front-of-Pack nutrition label (FoPL) as a public health measure to guide consumers towards healthier food choices, and the Nutri-Score represents an alternative supported by multiple actors. To date, no studies have investigated the performance of the Nutri-Score among Swiss consumers. This study aimed to compare the response of Swiss consumers to five FoPLs (Health Star Rating system, Multiple Traffic Lights, Nutri-Score, Reference Intakes and Warning symbol) in terms of perception and understanding of these labels and effects on food choices. Methods In 2019, 1,088 Swiss consumers were recruited and asked to select one product from among a set of three foods with different nutritional profiles and then classify the products within the sets according to their nutritional quality. Tasks were performed in situations without a label and then with one of the five FoPLs–depending on the group in which they were randomized–on the pack. Finally, participants were questioned on their perceptions regarding the label to which they were exposed. Results All FoPLs were favorably perceived, with marginal differences between FoPLs. The Nutri-Score demonstrated the highest percentage of improvement in food choices and the highest overall performance in helping consumers rank the products according to their nutritional quality. Conclusion Overall, the Nutri-Score was the most efficient FoPL in informing Swiss consumers of the nutritional quality of food products, and as such could be a useful tool to improve food choices and reduce the burden of chronic diseases in Switzerland.
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RESEARCH ARTICLE
Compared to other front-of-pack nutrition
labels, the Nutri-Score emerged as the most
efficient to inform Swiss consumers on the
nutritional quality of food products
Manon EgnellID
1
*, Pilar Galan
1
, Nathalie J. Farpour-Lambert
2
, Zenobia Talati
3
,
Simone Pettigrew
4
, Serge HercbergID
1,5
, Chantal Julia
1,5
1Nutritional Epidemiology Research Team (EREN), Sorbonne Paris Cite
´Epidemiology and Statistics
Research Center (CRESS), U1153 Inserm, U1125, Inra, Cnam, Paris 13 University, Bobigny,France,
2Department of Primary Care, University Hospitals of Geneva, Geneva, Switzerland, 3School of
Psychology, Curtin University, Bentley, WA, Australia, 4The Georges Institute, Sidney, Australia, 5Public
health department, Avicenne Hospital, AP-HP, Bobigny, France
*m.egnell@eren.smbh.univ-paris13.fr
Abstract
Background
Switzerland, like other high-income countries, is facing a major public health challenge with
the increasing burden of non-communicable diseases. Discussions are currently on-going
in Switzerland regarding the implementation of a Front-of-Pack nutrition label (FoPL) as a
public health measure to guide consumers towards healthier food choices, and the Nutri-
Score represents an alternative supported by multiple actors. To date, no studies have
investigated the performance of the Nutri-Score among Swiss consumers. This study aimed
to compare the response of Swiss consumers to five FoPLs (Health Star Rating system,
Multiple Traffic Lights, Nutri-Score, Reference Intakes and Warning symbol) in terms of per-
ception and understanding of these labels and effects on food choices.
Methods
In 2019, 1,088 Swiss consumers were recruited and asked to select one product from
among a set of three foods with different nutritional profiles and then classify the products
within the sets according to their nutritional quality. Tasks were performed in situations with-
out a label and then with one of the five FoPLs–depending on the group in which they were
randomized–on the pack. Finally, participants were questioned on their perceptions regard-
ing the label to which they were exposed.
Results
All FoPLs were favorably perceived, with marginal differences between FoPLs. The Nutri-
Score demonstrated the highest percentage of improvement in food choices and the highest
overall performance in helping consumers rank the products according to their nutritional
quality.
PLOS ONE | https://doi.org/10.1371/journal.pone.0228179 February 27, 2020 1 / 18
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OPEN ACCESS
Citation: Egnell M, Galan P, Farpour-Lambert NJ,
Talati Z, Pettigrew S, Hercberg S, et al. (2020)
Compared to other front-of-pack nutrition labels,
the Nutri-Score emerged as the most efficient to
inform Swiss consumers on the nutritional quality
of food products. PLoS ONE 15(2): e0228179.
https://doi.org/10.1371/journal.pone.0228179
Editor: Juergen Koenig, Universitat Wien, AUSTRIA
Received: September 24, 2019
Accepted: January 8, 2020
Published: February 27, 2020
Copyright: ©2020 Egnell et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting
Information files.
Funding: The present study received funding from
Sante
´Publique France (French Agency for Public
Health: https://www.santepubliquefrance.fr/). The
funders had no role in the study design, data
collection and analyses, decision to publish nor the
preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
Conclusion
Overall, the Nutri-Score was the most efficient FoPL in informing Swiss consumers of the
nutritional quality of food products, and as such could be a useful tool to improve food
choices and reduce the burden of chronic diseases in Switzerland.
Introduction
As is the case in other high-income countries, Switzerland is facing a major public health chal-
lenge in the form of the increasing burden of Non-Communicable Diseases (NCDs) [16].
According to a report of the Swiss Federal Office of Public Health published in 2017, 80% of
the direct and indirect human health costs in Switzerland were due to NCDs, notably includ-
ing cancers, diabetes and cardiovascular diseases [7]. Nutritional risk factors have been recog-
nized worldwide as some of the main drivers of these NCDs, and they therefore constitute key
levers to public health policies because they represent modifiable determinants of health that
could be addressed through primary prevention interventions [16]. According to the Nutri-
tion Survey MenuCH published in 2017, Swiss people consume too much sweet, salty and
meat products, and not enough legumes, fruits, vegetables and dairy products [8]. The preva-
lence rates of overweight and obesity are 41.6% and 13.9% in men and 19.7% and 11.3% in
women [8]. In this context, the Swiss nutritional strategy for the 2017–2024 period aims to
improve the nutritional status of the population and prevent NCDs by enhancing the food
environment and assisting consumers to make healthier food choices [7].
Internationally, among the variety of possible interventions, Front-of-Pack nutrition Labels
(FoPLs) have received growing attention from public health authorities [911]. They have
been demonstrated to be efficient tools to help consumers make healthier food choices at the
point-of-purchase as they deliver at-a-glance nutritional information [1214]. Moreover,
FoPLs act as an incentive for manufacturers to improve the nutritional quality of their prod-
ucts through innovation and reformulation [15,16]. In Switzerland, discussions are currently
ongoing regarding the implementation of FoPLs on pre-packed foods. Public health authori-
ties in the field of food (i.e. Swiss Federal Food Safety and Veterinary Office), consumer associ-
ations and some manufacturers support the introduction of the Nutri-Score, which is a
simplified labelling system designed to reflect the overall nutritional quality of food products.
The Nutri-Score is a summary and graded FoPL that can serve as a guide for consumers and
help them make informed choices [17]. It uses a 5-color scale (from dark green to dark orange)
with associated letters (from A to E) to indicate the overall nutritional quality of foods accord-
ing to a nutrient profiling system that takes into consideration both unfavourable food compo-
sition elements for which consumption should be limited (energy, total sugars, Saturated Fatty
Acids—SFA, and sodium) and favourable elements for which consumption should be encour-
aged (fruits, vegetables and nuts, fibre and protein). The Nutri-Score was originally developed
in France and has now also been adopted in Belgium and Spain.
While studies have shown the relative superiority of the Nutri-Score compared to other
label formats in various countries [18], in particular in France [17], no studies to date have
investigated the performance of the Nutri-Score (and other FoPLs) among Swiss consumers.
According to the theoretical framework from Grunert et al., defining the efficiency of FoPLs
requires taking into considerations the different aspects of their validation, including notably
consumer preferences/perception, understanding of the labels and their effects on declared
food choices or real food purchases in real-world or naturalistic experimental trials [19]. These
Nutri-Score emerged as the most efficient front-of-pack nutrition label among Swiss consumers
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different dimensions (perception, understanding, use) have been suggested to be influence by
FoPL format and sociodemographic and individual characteristics of consumers [19]. Studies
investigating preferences suggest that most commonly used FoPLs are generally positively per-
ceived [20,21], however favourable perceptions may not be adequate predictors of the extent
to which individual FoPLs can inform consumers of the nutritional quality of products and
guide their choices toward healthier foods [22]. By contrast, objective understanding, defined
as the capacity for consumers to correctly interpret the information that is provided by the
label as intended by its designers [19], is a superior indicator as it demonstrates the capacity of
the FoPL to help consumers rank food products according to their nutritional quality. Finally,
studies measuring the effects on food purchases in virtual or real supermarkets are more con-
vincing to define the efficiency of a specific FoPL [2333]; nevertheless experimental tasks on
food choices on a limited number of products are usually performed to avoid the technical and
financial constraints of studies in real-life conditions.
The objective of the present study was to inform current FoPL deliberations in Switzerland
by assessing the relative effectiveness of the Nutri-Score and four other FoPLs: Multiple Traffic
Lights (introduced in the United Kingdom), Health Star Rating system (implemented in New
Zealand and Australia), Warning symbol (introduced in Chile) and Reference Intakes (pro-
moted by agro-food-industries worldwide). We used the FOP-ICE study methodology that
was used to compare the effectiveness of FoPLs in 12 countries [18] by investigating three
dimensions: consumers’ perceptions and objective understanding of five FoPLs and their
resulting food choices.
Materials and methods
Population study
A total of 1,088 Swiss adults were recruited through a web panel provider (Pureprofile), apply-
ing quotas for sex (50% of women), age (one third in each of the following categories: 18–30
years, 31–50 years, over 51 years) and monthly household income (one third in each of the fol-
lowing categories: low, medium and high). Panel members were invited to complete an online
survey and could choose to do so in French, German or Italian. At the beginning of the survey,
participants were asked to provide information on sex, age, monthly household income, educa-
tion level, involvement in grocery shopping, self-estimated diet quality and self-estimated level
of nutrition knowledge. They were also asked to declare the frequency of purchase of the tested
food categories (pizzas, cakes, breakfast cereals) on a four-point scale (“Always”, “Often”,
“Sometimes” and “Never”). Those who responded “Never” to at least two of the three food cate-
gories were excluded to ensure responses reflected real-world food choice behaviors. The proto-
col of the study (similar to the FOP-ICE study) was approved by the Institutional Review Board
of the French Institute for Health and Medical Research (IRB Inserm n˚17–404 bis) and the
Curtin University Human Research Ethics Committee (approval reference: HRE2017-0760).
Participants were invited to provide their electronic consent during the online survey.
Front-of-pack nutrition labels
Five FoPLs with different type of graphical designs were tested in the present study (Fig 1
[34]).
Design and stimuli
Three food categories (pizzas, cakes, and breakfast cereals) were tested in the present study
and were selected due to being commonly available in Swiss supermarkets and incorporating
Nutri-Score emerged as the most efficient front-of-pack nutrition label among Swiss consumers
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products with wide variability in nutritional quality. In each food category, a set of three prod-
ucts with distinct nutrient profiles (higher, medium, and lower nutritional quality) was cre-
ated, allowing a ranking of products according to their nutritional quality. The ranking of the
relative nutritional quality between the three products was made depending on the informa-
tion provided by the FoPLs, and was similar whatever the FoPL. To avoid potential bias in
product evaluation (e.g., familiarity, habit), mocks packages featuring a fictional brand (“Sto-
fer”) were developed. When FoPLs were applied to the mock packages, they were affixed in the
same place on each food product and covered the same area on the package. To avoid unduly
influencing participants’ perceptions of the food products, no other nutritional information or
quality indicators was provided. All stimuli are displayed in S1,S2 and S3 Figs.
Procedure
Following the sociodemographic, lifestyle and nutrition-related questions at the beginning of
the survey, participants were asked to complete choice and understanding tasks, and then to
answer questions about their perceptions of the FoPL to which they had been assigned. To
avoid priming participants towards paying attention specifically to the FoPLs and modify their
choices accordingly by introducing first questions on perception and understanding [19], the
investigation of the dimensions was performed using the reversed order: food choice, objective
understanding and finally perception. First, participants were exposed to the three stimulus
sets (one for each food category) without any label on the front of mock packages. They were
asked to nominate which of the three displayed products they would buy, with an “I wouldn’t
buy any of these products” option also available. After each choice task, participants were
asked to rank the set of three products according to their nutritional quality (1- Highest nutri-
tional quality, 2- Medium nutritional quality, and 3- Lowest nutritional quality), with an “I
don’t know” option also available. The phrasing of the task used relative terms on nutritional
quality (highest/medium/lowest) in order to prevent participants from making assumption on
Fig 1. Front-of-pack nutrition labels tested in the present study. Three nutrient-specific FoPLs were included: (1) a
numeric-only monochromatic label, the Reference Intakes, that was implemented worldwide in 2006 following a
voluntary initiative of industrialists and displays the amounts in energy, fats, SFA, sugars and salt [35]; (2) a color-
coded label, the Multiple Traffic Lights, implemented in the United Kingdom in 2004, that indicates the amounts of
the same nutrients as the RIs, but with a colour associated with each nutrient depending on the amount (green—low,
orange—moderate, red—high) [36]; and (3) a warning system, the Warning symbol implemented in Chile in 2016 and
then in Peru in 2019, that advises when the level of a given unfavourable nutrient exceeds the limit established by the
Chilean Ministry of health [37]. Second, two summary FoPLs were tested: (1) a graded color-coded label, the Nutri-
Score, implemented in France in 2017 and later in 2018 in Belgium and Spain, that characterizes the overall nutritional
quality of the food or beverage using a graded scale of five colors from darkgreen (associated with the letter A) to dark
orange (associated with the letter E) [17] and (2) a hybrid FoPL, the Health Star Rating system, implemented in
Australia and New Zealand in 2014, that combines a graded scale of stars and information on nutrient amounts [38].
https://doi.org/10.1371/journal.pone.0228179.g001
Nutri-Score emerged as the most efficient front-of-pack nutrition label among Swiss consumers
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the absolute nutritional quality of the products. Choice and ranking tasks were completed by
food category, successively, with the order of presentation of the food categories randomized
between respondents. Second, participants were randomized to one of the five FoPL groups
and asked to complete the same choice and ranking tasks, but this time with a FoPL affixed to
the mock packages. An example of the procedure for the cakes category is presented in Fig 2
[34].
Statistical analyses
Food choice. A score between 1 and 3 points was attributed to the choice task of each
food category, with +1 for the lowest nutritional quality product, +2 for the intermediate nutri-
tional quality product and +3 points for the highest nutritional quality product, first for the no
labelling condition and second in the FoPL condition. No point was allocated when partici-
pants selected “I wouldn’t buy any of these products” option, and the response was considered
as missing. A score was then calculated for each food category using the difference of points
between the FoPL and no label conditions, resulting in a discrete continuous score ranging
from -2 to +2 points. Finally, a global score was computed by summing the score of each cate-
gory, resulting in a score between -6 and +6 points for each participant. The percentage of par-
ticipants whose food choices deteriorated or improved between the no label and FoPL
conditions was calculated for each FoPL group by food category. Associations between choice
score and FoPL type were assessed using a multivariable ordinal logistic regression model. The
model was performed on data from participants who selected a product in both the no label
and FoPL conditions.
Objective understanding. Objective understanding of the FoPLs by consumers was mea-
sured by the ability of participants to correctly rank the products within each set according to
nutritional quality. The ranking was considered correct when the three products within the set
were correctly ranked, leading to a +1 point score for the category, while -1 point was allocated
when the ranking was incorrect. No point was allocated when participant selected the “I don’t
Fig 2. Procedure of the choice and ranking tasks for the cakes category. After the choice and ranking tasks,
participants were invited to respond to questions about their perceptions on the FoPL to which they had been exposed.
Various dimensions were assessed including liking (e.g. “I like this label”), usefulness (e.g. “This FoP label is useful”),
awareness (e.g. “This FoP label stands out”), and perceived cognitive workload for the comparison of pre-packed foods
within the same food category (e.g. “This label is easy to understand”). For each question, respondents provided their
responses on a 9-point Likert scale ranging from “Strongly disagree” to “Strongly agree”.
https://doi.org/10.1371/journal.pone.0228179.g002
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know” answer. Thus, for each food category, a score for ranking accuracy was calculated using
the difference in points between the FoPL and no label conditions, ranging from -2 to +2
points, and leading to a global score of between -6 and +6 points for the three food categories
combined. The percentage of correct answers was computed by FoPL and food category and
displayed in a histogram. The association between FoPL type and the change in ability to cor-
rectly rank products according to nutritional quality was measured by an ordinal logistic
regression model.
For choice and understanding analyses, sex, age, level of household monthly income, edu-
cational level, involvement in grocery shopping, self-estimated diet quality and nutrition
knowledge and the response to “In the second half of this study, the food products contained a
nutrition label (example shown below). Do you remember seeing this label on products?” were
introduced as covariates.
The reference of the models (for choice and understanding analyses) was the Reference
Intakes label. Interactions between covariates and FoPLs were tested and stratified models
were computed when the p-value of the interaction term was below 0.10.
Perception. For each item on perception of the FoPLs, participants provided a rating
between 1 (corresponding to the statement “I strongly disagree”) and 9 (corresponding to the
statement “I strongly agree). The mean and standard deviation of scores were calculated for
each item and by FoPL type. A principal component analyses was performed to assess the con-
tribution of the different perception items to the overall perception of FoPLs. The items “This
label is confusing”, “I like this label”, “This label does not stand out”, “This label is easy to
understand”, “This label takes too long to understand”, “This label provides me the informa-
tion I need” and “I trust this label” were used as active variables in the analyses, and the label
type as an illustrative qualitative variable. Dimensions, corresponding to a linear combination
of active variables, have an eigenvalue reflecting the total variance explained by the dimension.
The number of retained dimensions was chosen to obtain a cumulative percentage of accept-
able variance. In the present analyses, only the two first dimensions were chosen, simplifying
the presentation of results. The contribution and coordinates of each active variable on the two
axes were obtained and the label variable was mapped on the axes as an illustrative variable.
Test values were provided for the label variable, allowing testing the significance of the devia-
tion from the origin of the qualitative variable. This difference can be considered significant at
95% level if the test value is greater than or equal to 2 in absolute value [39]. Due to the combi-
nation of positive and negative framing of the perception questions, participants who provided
the same answers to all perception questions were excluded from the analyses, except those
consistently giving a score of 5, which indicates a neutral perception.
All analyses in the present study were conducted on the SAS statistical software; statistical
tests were two-sided and a p-value 0.05 was considered statistically significant.
Results
Description of individual characteristics
Sociodemographic, lifestyle and nutrition-related characteristics of the study population are
presented in Table 1. The sample included 1,088 Swiss participants, of whom 49% were
women, 35% were individuals over 51 years, 36% had a primary or secondary education level,
and 32% reported a low household monthly income. In the sample, 66% declared being
responsible for grocery shopping, 20% reported a very or mostly unhealthy diet quality, and
28% had no or little knowledge about nutrition. A total of 29% of participants declared that
they did not recall having seen the label during the survey, with the highest percentage evident
among those assigned to the Health Star Rating System group.
Nutri-Score emerged as the most efficient front-of-pack nutrition label among Swiss consumers
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Food choices
Most of the participants did not change their food choices between the two labelling situations
(between 58.1% and 71.0% depending on the label and the food category) or did not select any
Table 1. Individual characteristics of the study sample (N = 1,088).
N %
Sex
Men 560 51.47
Women 528 48.53
Age, years
18–30 342 31.43
31–50 371 34.10
51 375 34.47
Education level
Primary education 68 6.25
Secondary education 326 29.96
Trade certificate 371 34.10
University, undergraduate degree 189 17.37
University postgraduate degree 134 12.32
Level of household monthly income
High 367 33.73
Medium 371 34.10
Low 350 32.17
Responsible for grocery shopping
Yes 718 65.99
No 86 7.90
Share job equally 284 26.10
Self-estimated diet quality
I eat a very unhealthy diet 20 1.84
I eat a mostly unhealthy diet 196 18.01
I eat a mostly healthy diet 769 70.68
I eat a very healthy diet 103 9.47
Nutrition knowledge
I do not know anything about nutrition 22 2.02
I am not very knowledgeable about nutrition 288 26.47
I am somewhat knowledgeable about nutrition 579 53.22
I am very knowledgeable about nutrition 199 18.29
Did you see the FOP label during the survey?
No 313 28.77
Unsure 105 9.65
Yes 670 61.58
Respondents recalling seeing the FoPL to which they were exposed
HSR 122 55.96
MTL 145 66.82
Nutri-Score 164 75.23
RIs 143 65.90
Warning symbol 196 89.91
HSR: Health Star Rating system; MTL: Multiple Traffic Lights; RIs: Reference Intakes
https://doi.org/10.1371/journal.pone.0228179.t001
Nutri-Score emerged as the most efficient front-of-pack nutrition label among Swiss consumers
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product in one or both of the labelling conditions (between 20.7% and 35.3%, depending on
the label type and the food category). The percentages of participants who improved or deteri-
orated in their choices between the FoPL and no label conditions are shown in Fig 3. For all
three food categories and all five FoPLs, the percentage of participants who improved their
food choices between the two labelling conditions was higher than those whose choices deteri-
orated, however results varied depending on the label. The Nutri-Score demonstrated the
greatest improvement (between 7.3% and 10.6% depending on the food category), while the
RIs (3.7% - 4.6%) and the Warning symbol (5.1% - 6.0%) showed the smallest improvement.
A significant interaction was observed with household monthly income (S1 Table). While
all labels tended to have a greater effect on food choices than the RIs among those on medium
incomes, the MTL and the Warning symbol were significantly less effective than the RIs
among individuals on low incomes.
Objective understanding
The percentages of correct answers in the no label and label conditions by FoPL type and food
category are shown in Fig 4. Compared to the no label condition, all FoPLs improved the per-
centage of correct answers, with some heterogeneous results between labels formats. For all
three food categories, the Nutri-Score produced the largest improvement in correct answers in
the ranking tasks, followed by the MTL. The relative performance of the other FoPLs varied by
food category.
Table 2. Associations between FoPL type and change in nutritional quality of food choices, by FoPL type and food category in participants who made a choice
a
(N = 1,000).
Food category N HSR MTL Nutri-Score Warning symbol
OR (95% CI) P OR (95% CI) P OR (95% CI) P OR (95% CI) P
All food categories 1000 1.44 [0.91–2.28] 0.1 1.18 [0.74–1.88] 0.5 1.83 [1.17–2.86] 0.008 0.89 [0.56–1.44] 0.6
Pizzas 834 1.56 [0.82–2.96] 0.2 1.14 [0.60–2.19] 0.7 1.90 [1.01–3.57] 0.05 1.09 [0.56–2.12] 0.8
Cakes 781 1.41 [0.74–2.69] 0.3 1.74 [0.92–3.27] 0.09 1.62 [0.86–3.03] 0.1 1.26 [0.64–2.50] 0.5
Breakfast cereals 779 1.49 [0.74–3.02] 0.3 0.94 [0.46–1.90] 0.9 1.57 [0.79–3.12] 0.2 0.75 [0.36–1.54] 0.4
a
The Reference Intakes were designated as the reference category for the ‘labels’ variable in the multivariate ordinal logistic regression.
The multivariate model was adjusted for sex, age, education level, level of income, responsibility for grocery shopping, self-estimated diet quality, self-estimated
nutrition knowledge and awareness of the label during survey completion
HSR: Health Star Rating system; MTL: Multiple Traffic Lights; OR: Odds Ratio; CI: Confidence Interval.
https://doi.org/10.1371/journal.pone.0228179.t002
Table 3. Associations between FoPLs and the ability to correctly rank products according to nutritional quality, by FoPL and food category
a
(N = 1,088).
Food category N HSR MTL Nutri-Score Warning symbol
OR (95% CI) P OR (95% CI) P OR (95% CI) P OR (95% CI) P
All categories 1088 1.43 [1.00–2.05] 0.05 2.09 [1.46–2.99] <0.0001 4.02 [2.81–5.75] <0.0001 1.52 [1.05–2.18] 0.03
Pizzas 1034 1.43 [0.89–2.30] 0.1 1.50 [0.94–2.40] 0.09 2.36 [1.49–3.72] 0.0002 1.39 [0.86–2.26] 0.2
Cakes 1039 1.64 [1.06–2.54] 0.03 3.11 [2.03–4.78] <0.0001 5.97 [3.90–9.15] <0.0001 2.09 [1.35–3.25] 0.001
Breakfast cereals 1006 1.05 [0.68–1.64] 0.8 1.29 [0.83–1.98] 0.3 2.25 [1.47–3.43] 0.0002 1.03 [0.65–1.61] 0.9
a
The Reference Intakes were designated as the reference category for the ‘labels’ variable in the multivariate ordinal logistic regression.
The multivariate model was adjusted for sex, age, educational level, level of income, responsibility for grocery shopping, self-estimated diet quality, self-estimated
nutrition knowledge level and awareness of the label during survey completion.
HSR: Health Star Rating system; MTL: Multiple Traffic Lights; OR: Odds Ratio; CI: Confidence Interval.
https://doi.org/10.1371/journal.pone.0228179.t003
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No interaction with individual characteristics was found, except for age and self-estimated
diet quality. However, the interactions were quantitative, meaning that FoPLs improved the
participants’ ability to correctly rank products among all variable categories (S2 and S3
Tables).
Fig 3. Percentages of deterioration and improvement of the nutritional quality of food choices, by FoPL type and
food category. Associations between FoPL type and food choices are displayed in Table 2. The Nutri-Score was the
only FoPL to demonstrate a significant effect on the improvement of the nutritional quality of food choices compared
to the RIs label. This occurred overall (OR = 1.83[1.17–2.86], p-value = 0.008) and among pizzas (OR = 1.90[1.01–
3.57], p-value = 0.05).
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Nutri-Score emerged as the most efficient front-of-pack nutrition label among Swiss consumers
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Fig 4. Percentage of correct answers for ranking tasks, by FoPL and food category. Associations between FoPL type
and ability to correctly rank products are presented in Table 3. Overall, the Nutri-Score was the label leading to the
greatest improvement in ability to correctly rank products according to their nutritional quality compared to the RIs
(OR = 4.02[2.81–5.75] (p-value<0.0001), followed by the MTL (OR = 2.09[1.46–2.99], p-value<0.0001) and the
Warning symbol (OR = 1.52[1.05–2.18], p-value = 0.03). When analyses were performed by food category, the Nutri-
Score showed higher performances among the three categories, and was notably the only FoPL to show significant
improvements compared to the RIs label among pizzas and breakfast cereals. Among cakes, the performance of the
Nutri-Score was followed by the MTL, the Warning symbol and then the HSR.
https://doi.org/10.1371/journal.pone.0228179.g004
Nutri-Score emerged as the most efficient front-of-pack nutrition label among Swiss consumers
PLOS ONE | https://doi.org/10.1371/journal.pone.0228179 February 27, 2020 10 / 18
Perception
All results on FoPLs perception are presented in supporting information. The average scores
for all perception questions are displayed in S4 Fig. Overall, similar trends were found for the
five FoPLs on the different perception items.
The principal component analysis identified two main dimensions explaining 45.9% and
17.8% of the total variance respectively. The contribution values and coordinates of active vari-
ables on these two dimensions are displayed in S4 Table. The first dimension (horizontal axis)
opposed the items “I like this label”, “This label is easy to understand” and “This label provides
me the information I need” with the items “This label is confusing” and “This label takes too
long to understand”. The second dimension (vertical axis) was driven by the item “This label
does not stand out”.
When each label was mapped on the two axes as an illustrative variable, the graphic in S5
Fig was obtained. Although differences between FoPLs on the two dimensions appeared of
very low magnitude, the MTL appeared to be perceived as providing the “information
needed”, “being easy to understand” and “likeable”. Regarding the second dimension, the
Nutri-Score was perceived as “standing out” to a greater extent than the RIs and the Warning
symbol, both monochromatic formats (test values greater than 2 in absolute value).
Discussion
Overall, among the various FoPLs tested in the study, our results showed that the Nutri-Score
was the most effective scheme in encouraging healthier food choices among study participants
and allowing them to more accurately identify differences in the nutritional quality of foods
within product categories.
Many studies have explored the effects of different types of FoPLs on the nutritional quality
of consumers’ food choices or purchases, with mixed results according to the types of FoPLs
tested and/or the methodology used [21,23,28,29,3133,4069]. These studies suggest that
FoPLs can induce a small but significant beneficial effect on the nutritional quality of food
choices/purchases. Interpretive systems in particular, such as Nutri-Score [29,31,32], Multiple
Traffic Lights [29,33,45,48,55,65], Health Star Rating [31,46] and warning labels [28,41,42,54]
appear to be associated with healthier food choices. Moreover, comparative studies investigat-
ing the relative effects of various types of labels indicate limited differences between types of
FoPLs regarding their effects on food choices [26,27,29]. Our results regarding the Nutri-
Score’s effect on food choices are consistent with those of other studies investigating the
impact of the Nutri-Score in purchasing situations in France: experimental studies asking par-
ticipants to perform a shopping task in the presence or absence of a FoPL showed that, among
several schemes, the Nutri-Score was the most effective in improving the nutritional quality of
purchases [2931]. This alignment of results in neighboring countries may be related to similar
socio-cultural contexts and similar food culture. By comparison, results from the Americas
(Canada, Uruguay) suggest warning labels would be more effective among consumers from
these countries [26,28]. However, given the varied methodological approaches used in the dif-
ferent published studies to investigate the effects of FoPLs on food choices, caution is required
before concluding on this unique basis on the effectiveness of a given type of label. Robustness
of proof is higher when testing the impact of different FoPL on real food purchases in real-
world or naturalistic experimental trials. However, given the somewhat low magnitude of
effects observed, conducting adequately powered studies would require high resources. In this
case, our results suggest that if studies testing FoPL on food purchases in virtual or real super-
markets are not available, performance would be best approached by investigating the relative
ability of different FoPLs to help consumers understand the nutritional quality of foods (i.e.
Nutri-Score emerged as the most efficient front-of-pack nutrition label among Swiss consumers
PLOS ONE | https://doi.org/10.1371/journal.pone.0228179 February 27, 2020 11 / 18
through measures of objective understanding). Indeed, the effects of FoPLs on consumers’
ability to correctly rank products according to their nutritional quality were of higher magni-
tude than their effects on food choices (ORs ranging from 1.52 for the warning symbol to 4.02
for the Nutri-Score for objective understanding vs. 0.89 for the warning symbol to 1.82 for the
Nutri-Score for choice).
Second, the results for objective understanding allow to discriminate across FoPLs, with the
Nutri-Score having a higher performance than other labels. These findings are in line with the
results of the FOP-ICE study and subsequent studies using the same methodology that showed
that the Nutri-Score had a significantly greater ability to help consumers rank the overall nutri-
tional quality of food products in numerous European countries: France, Germany, Spain, the
United Kingdom, Denmark, and Bulgaria [18,34,70]. Results in the Netherlands using the
same methodology of the FOP-ICE study showed also similar trends [34]. The literature shows
that labels including some form of color-coding are easier to identify and interpret [71,72],
and red, green and yellow/amber on food packages are directly associated with evaluation of
products’ healthfulness by consumers [73], and interpreted as ‘stop’ and ‘go’ signals [74]. This
element is somewhat strengthened by the fact that the HSR, which uses a similar algorithm to
classify foods, and provides a monochrome translation of the information had a lower perfor-
mance than Nutri-Score. Conversely, nutrient-specific systems, and in particular those relying
heavily on numerical information, require a cognitive workload that can hinder their under-
standing and use in purchasing situations. These elements suggest that the key features of the
Nutri-Score that may in part explain its performance are the use of color-coding and of a sum-
mary indicator of the nutritional quality of the product [18,71,75]. However, the use of such
simplified messaging may be associated to halo effects in products favourably labeled, which
should be further investigated in the specific case of FoPLs. Effects of a FoPL on consumers’
objective understanding of the nutritional quality of foods and on their food choices provide
an evaluation of the performance of the system, linked to its potential impact on the nutritional
and health status of the population [76]. The fact that the effects of the Nutri-Score aligned on
these two dimensions in this study suggest it would indeed be an effective intervention for the
Swiss population.
Finally, consumers’ perceptions of FoPLs suggest that all five types of labels tested in the
present study are considered acceptable by consumers, with limited discrimination across
schemes. As respondents only viewed one FoPL, our results may be interpreted as indicating
an overall favorable perception of FoPLs in the sample rather than an absence of preference
towards a specific scheme [77]. Indeed, consumers tend to agree on the fact that the back-of-
pack nutritional declaration is difficult to understand [78,79], and the demand for simplified
front-of-pack labels [13] is increasing as evidenced by the current upward trend in implemen-
tation of FoPLs around the world [80]. Results from studies presenting various FoPL models
to consumers suggest that color-coded labels would be preferred by consumers [50,72,81], and
summary systems more specifically by more disadvantaged groups [82].
Strengths of our study include the use of a randomized design to compare the effects of var-
ious types of FoPL designs across their three main dimensions (effect on choice, ability to
improve assessment of nutritional quality, and consumer perceptions). As randomization was
applied to the order of presentation of the food categories and the order of presentation of the
foods within the sets, a potential learning effect was avoided. Our study is nevertheless subject
to limitations. First, Swiss consumers were recruited online using quota sampling, and as such
caution is required when extrapolating the results to the broader population. However, the
quota sampling ensured that various socio-economic groups were equally represented in our
sample, particularly lower income groups who may be a specific target for nutrition interven-
tions. Second, to reduce priming effects, participants were blinded to the objective of the study
Nutri-Score emerged as the most efficient front-of-pack nutrition label among Swiss consumers
PLOS ONE | https://doi.org/10.1371/journal.pone.0228179 February 27, 2020 12 / 18
and were provided no information on the objective or the meaning of the FoPL to which they
were exposed. Participants may therefore have overlooked the information provided by FoPLs,
leading to an underestimation of the labels’ effects, although it could be closer to real life con-
ditions. Nevertheless, all FoPLs were equally impacted by this effect. Moreover, the limited
information provided to participants reinforce the ecological validity of our results, given that
the implementation of FoPLs in real-life settings would not necessarily be associated with
extensive information provision.
In conclusion, among the different options tested in the study, the Nutri-Score appears to
be the most effective FoPL to inform Swiss consumers of the nutritional quality of food prod-
ucts and could therefore be a helpful tool to guide consumers to integrate a nutritional dimen-
sion in purchasing situations. This point is particularly important considering that the Nutri-
Score has also been shown recently in a simulation study to have the potential to decrease mor-
tality from diet-related NCDs [76].
Supporting information
S1 Table. Associations between FoPL type and change in nutritional quality of food
choices, by monthly income level, across the three food categories.
(DOCX)
S2 Table. Associations between FoPLs and the ability to correctly rank products according
to nutritional quality, by FoPL and food category.
(DOCX)
S3 Table. Associations between FoPLs and the ability to correctly rank products according
to nutritional quality, by FoPL and food category.
(DOCX)
S4 Table. Contributions and coordinates of active variables on the two dimensions from
the principal component analyses.
(DOCX)
S1 Fig. Stimuli for the category of cakes with the corresponding front-of-pack nutrition
labels.
(PDF)
S2 Fig. Stimuli for the category of breakfast cereals with the corresponding front-of-pack
nutrition labels.
(PDF)
S3 Fig. Stimuli for the category of pizzas with the corresponding front-of-pack nutrition
labels.
(PDF)
S4 Fig. Average scores for perception questions.
(PDF)
S5 Fig. Principal component analysis map showing projection of the FoPLs across two
dimensions.
(PDF)
Nutri-Score emerged as the most efficient front-of-pack nutrition label among Swiss consumers
PLOS ONE | https://doi.org/10.1371/journal.pone.0228179 February 27, 2020 13 / 18
Acknowledgments
The authors would like to thank Mr Mark Orange for creating the mock packages, and all
researchers and doctoral students who tested the online survey. We also would like to thank
Karen Assman, for the German translation of the online survey. The present study received
funding from Sante
´Publique France (French Agency for Public Health).
Author Contributions
Conceptualization: Zenobia Talati, Simone Pettigrew, Serge Hercberg, Chantal Julia.
Formal analysis: Manon Egnell, Chantal Julia.
Funding acquisition: Simone Pettigrew, Chantal Julia.
Investigation: Manon Egnell, Pilar Galan, Nathalie J. Farpour-Lambert, Zenobia Talati,
Simone Pettigrew, Serge Hercberg, Chantal Julia.
Methodology: Zenobia Talati, Simone Pettigrew, Chantal Julia.
Project administration: Simone Pettigrew, Chantal Julia.
Supervision: Zenobia Talati, Simone Pettigrew, Chantal Julia.
Validation: Zenobia Talati, Simone Pettigrew, Serge Hercberg, Chantal Julia.
Writing – original draft: Manon Egnell, Pilar Galan, Chantal Julia.
Writing – review & editing: Pilar Galan, Nathalie J. Farpour-Lambert, Zenobia Talati, Simone
Pettigrew, Serge Hercberg, Chantal Julia.
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Nutri-Score emerged as the most efficient front-of-pack nutrition label among Swiss consumers
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... Research on the effectiveness of FOPL has been carried out on various products. A significant Swiss study (Egnell et al., 2020) examined the impact of FOPL on three product categoriespizzas, cakes, and breakfast cereals. Improvement was recorded in the nutritional quality of food choices in all types of products. ...
... The survey was conducted during the summer of 2021 and studied the consumer behaviour of 1000 respondents divided into two samples, as the study was devoted to two different nutritional FOPL designs. Part of the methodology can be understood as replicating research realised with partially similar objectives in other European countries (Egnell et al., 2020). The basis for the analysis is created by survey research. ...
... The analysis described above provides a view that does not consider the fact that the positive effect of the label can be viewed as a change in consumer choice towards the most nutritious product and its shift from the worst to a slightly better option. Therefore, we analysed changes in consumer choice using methodology introduced by Egnell et al. (2020), where variants of products were classified on a 3-point scale, where number 1 represents the worst variant from the nutritional point of view and three the best one, while the product category score was calculated as a difference between choice with FOPL and without FOPL. As can be seen in Figure no. ...
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Undoubtedly, the proportion of the obese population has increased significantly in recent decades. Using FOPL (front-of-pack labelling) with clear nutritional information could also be helpful in eliminating this problem. The main aim of this contribution is to analyse the effects of using nutritional FOPL on consumers’ choices. The analysis was based on the research, while 1000 respondents were asked to choose the desired product variant in three categories – cereals, yoghurts and protein bars without FOPL and with FOPL on their package. Two of the most discussed FOPL systems in the EU (Nutri-Score and Nutrinform) were analysed. Changes in consumer choice were analysed using non-parametric statistics, multiple correspondences, and correlation analysis. The results showed that both FOPLs affect the consumer in all products. The effects of FOPL resulted in choosing the best product (for cereals from 47% to 49%; for yoghurts from 28% to 31%; for bars from 28% to 42%) and improved consumers´ choice. There are differences in effects between Nutri-Score (NS) and Nutrinform (NI). NS seems to be a more effective system because it has a stronger positive impact on consumers´ choices. For cereals, the selection improved by 18% (NS) vs. 15% (NI), for yoghurts by 17% (NS) vs. 13% (NI), and for bars 28% (NS) vs. 20% (NI). The results among different product categories were not consistent. Consumers' attitudes toward a healthier diet can be improved using nutritional FOPL.
... Overall, and in line with the previous literature review, the studies listed in Table 15 suggest that simpler labels may be more easily understood than complex labels Dubois et al., 2021;Egnell et al., 2019cEgnell et al., , 2020aHagmann & Siegrist, 2020;Vargas-Meza et al., 2019a), even though some participants report needing further information to select the healthiest product (Santos et al., 2020). In their study, Santos and colleagues observed that this lack of additional information when BOP information is not available can affect the proportion of correctly identified healthy choices (Santos et al., 2020). ...
... Especially those with poor education and low health literacy were less able to interpret the information provided by the FOPNL schemes, as shown in ranking tasks (Goodman et al., 2018;Graça et al., 2019). However, other studies found that the ability to rank products according to their healthiness in the presence of various FOP nutrition labels did not vary across socio-economic groups Egnell et al., 2018bEgnell et al., , 2020a. Actually, the understanding of FOPNL by consumers of different socio-economic groups varied according to the type of scheme displayed. ...
Research
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This addendum of the JRC Science for Policy report “Front-of-pack nutrition labelling schemes: a comprehensive review” provides an update of the former publication regarding the effects of front-of-pack nutrition labelling (FOPNL) schemes on consumers' understanding, food purchases, diet and health, as well as food reformulation. This addendum was produced to further inform the Commission’s proposal for harmonised mandatory FOPNL announced in the Farm to Fork Strategy. The previous report provided a review of the scientific literature regarding the effects of FOPNL on consumers, and food business operators. Emphasis was placed on consumer attention, preferences, and understanding of diverse FOPNL schemes, as well as FOPNL schemes’ effects on food purchases and their implications for diet and health. The report also discussed whether and to what extent the introduction of FOPNL schemes may affect producer efforts on food reformulation and innovation, highlighted potential unintended consequences of introducing FOPNL, and described knowledge gaps and directions for future research. The literature review was complemented by an overview of FOPNL schemes. In addition to an update and extension of the previous report with recent literature (published between May 2018 and 1 February 2021), the current report additionally addresses the effects of different labelling aspects (e.g. use of reference quantities, voluntary vs. mandatory implementation, combination of front-of-pack nutrition labels and claims on consumer understanding and consumer behaviour).
... Front-of-Pack Nutrition Labels (FoPLs) have received growing attention from public health authorities. They have been demonstrated to be efficient tools to help consumers make healthier food choices at the point-of-purchase as they deliver at-a-glance nutritional information (Egnell et al., 2020). Numerous studies in the French context, and one study in other countries including some European countries, have been carried out to validate the graphical format of the Nutri-Score, regarding several dimensions of its effectiveness (Dréano-Trécant et al., 2020). ...
... In terms of reason for shopping, 80% of respondents (24) most often buy groceries for the family, 6 respondents said, "for themselves", while in terms of frequency of purchase, most respondents said they make purchases several times a week (19) and once a week (6). ...
... A close-ended online questionnaire adapted from previous studies [1,22,[27][28][29][30][31] was administered to collect demographic information of parents and students, parents' preferences for five formats of FOPL in three dimensions [27][28][29][30], parents' perception of the importance of nutrients to be on FOPL [1,31], and prepackaged food that most needs to be on FOPL [22]. To test the rationality (i.e., usage of text, option settings, and clear expression) and feasibility (i.e., time spent and personnel allocation) of the questionnaire, a pilot survey was conducted among a convenience sample of ten adult residents and four students in grade five in elementary school. ...
... A close-ended online questionnaire adapted from previous studies [1,22,[27][28][29][30][31] was administered to collect demographic information of parents and students, parents' preferences for five formats of FOPL in three dimensions [27][28][29][30], parents' perception of the importance of nutrients to be on FOPL [1,31], and prepackaged food that most needs to be on FOPL [22]. To test the rationality (i.e., usage of text, option settings, and clear expression) and feasibility (i.e., time spent and personnel allocation) of the questionnaire, a pilot survey was conducted among a convenience sample of ten adult residents and four students in grade five in elementary school. ...
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Citation: Cui, J.; Yan, R.; Astell-Burt, T.; Gong, E.; Zheng, L.; Li, X.; Zhang, J.; Xiang, L.; Ye, L.; Hu, Y.; et al. Types and Aspects of Front-of-Package
... This is a letter-based, colour-coded indicator that is increasingly used in many countries to convey information on the nutrient value of a given food. Despite some concerns around its capacity to reduce calorie intake 54 , the Nutri-Score is one of the clearest and simplest food labelling approaches to signal the nutritional quality and healthiness of food products [55][56][57] and one of the most effective labelling tools to encourage healthy purchases 58 . Food and beverage products marked with a dark-or light-green letter A or B are generally recommended for a healthy diet, while products with an orange D or red E should be consumed in small quantities and less often, as they are unhealthy (see Extended Data Fig. 2 for an overview of the different Nutri-Score letters). ...
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The food system is a major source of both environmental and health challenges. Yet, the extent to which policy-induced changes in the patterns of food demand address these challenges remains poorly understood. Using a survey-based, randomized controlled experiment with 5,912 respondents from the United Kingdom, we evaluate the potential effect of carbon and/or health taxes, information and combined tax and information strategies on food purchase patterns and the resulting impact on greenhouse gas emissions and dietary health. Our results show that while information on the carbon and/or health characteristics of food is relevant, the imposition of taxes exerts the most substantial effects on food purchasing decisions. Furthermore, while carbon or health taxes are best at separately targeting emissions or dietary health challenges, respectively, a combined carbon and health tax policy maximizes benefits in terms of both environmental and health outcomes. We show that such a combined policy could contribute to around one third of the reductions in residual emissions required to achieve the United Kingdom’s 2050 net-zero commitments, while discouraging the purchase of especially unhealthy snacks, sugary drinks and alcohol and increasing the purchase of fruit and vegetables.
... First, the immediate effect of the Nutri-Score (NS) food label on the dietary quality of food choices was assessed (RQ1). Because individuals with low food literacy are less receptive to contemporary nutrition-related awareness campaigns, RQ2 aimed to address the potential of digital food labels as an effective instrument among this group, as suggested by recent studies that proved this effect for printed food labels [32][33][34]. In addition, selective attention towards product attributes and information provided is considered as pivotal in determining the impact of a piece of information on subsequent decisions (e.g., [35]). ...
Article
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In order to induce the shift in consumer behavior necessary for the mitigation of diet-related diseases, front-of-package labels (FoPL) such as the Nutri-Score that support consumers in their efforts to identify nutritionally valuable products during grocery shopping have been found to be effective; however, they remain non-compulsory in most regions. Counter-intuitively, a similar stream of research on digital web-based FoPL does not yet exist, even though such digital labels hold several advantages over physical labels. Digital FoPL can provide scalable and personalized interventions, are easier to implement than physical labels, and are especially timely due to the recent increase in online grocery shopping. The goal of this study was to demonstrate the technical feasibility and intervention potential of novel, scalable, and passively triggered health behavior interventions distributed via easy-to-install web browser extensions designed to support healthy food choices via the inclusion of digital FoPL in online supermarkets. To that end, we developed a Chrome web browser extension for a real online supermarket and evaluated the effect of this digital food label intervention (i.e., display of the Nutri-Score next to visible products) on the nutritional quality of individuals’ weekly grocery shopping in a randomized controlled laboratory trial (N = 135). Compared to the control group, individuals exposed to the intervention chose products with a higher nutritional quality (e.g., 8% higher healthy trolley index (HETI), 3.3% less sugar, 7.5% less saturated fat). In particular, users with low food literacy seemed to benefit from the digital FoPL (e.g., 11% higher HETI, 10.5% less sugar, 5.5% less saturated fat). Furthermore, participants exposed to the food label advocated its introduction more strongly than the control group (p = 0.081). Consumers worldwide could easily install such applications to display digital food labels on their end devices, and would thus not have to wait for stakeholders in the food industry to eventually reach consensus on mandatory food label introduction.
... Even though mass-media and significant stakeholders have extensively criticized the Nutri-Score as an instrument able to assist the consumers in their choices, increasing evidences suggest that Nutri-Score is, by far, the best FPNL available to help consumers in the identification of nutritional quality of foods (13)(14)(15)(16)(17). Its potential efficacy has been proven also in Italian consumers (6,18), but inception of Nutri-Score labeling by Italian Food Industry for domestic market remains problematic, and some alternatives have been proposed with mixed acceptance either by the general population and stakeholders (18). ...
Article
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Background and aim: A growing number of European Countries have adopted front-of-pack nutrition labels (FPNL) in order to assist costumers' alimentary choices, and particularly Nutri-Score. While its acceptance in Italy has been slowed by ongoing debates, we assessed corresponding knowledge, attitudes and practices of a sample of Italian Medical Professionals (MP). Methods: A total of 153 MP participated into an internet-based survey by completing a structured questionnaire. While 43.1% reported any knowledge of Nutri-Score, the overall understanding of its conceptual issues was quite low (50.8% after percentual normalization of the knowledge score). Only half of participants acknowledge some usefulness of FPNL, and their acceptance as a guide for nutritional choices was seemingly low (36.6%), being more likely in MP participants from Northern regions (Odds Ratio 9.610, 95% confidence intervals 2.667-34.637), living with children < 14 year or age (3.658, 1.463-9.145), and perceiving some usefulness in FPNL (3.595, 1.381-9.356). In turn, having any knowledge of Nutri-Score and being of male gender were negative effects. Conclusions: Nutri-Score is a useful instrument in guiding consumers' alimentary choices, but the actual understanding of its rationale by participants MP was insufficient. Specifically aimed interventions should be tailored in order to cope with a significant share of MP reporting false beliefs and misunderstanding.
Article
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Objective To jointly analyse two food dimensions, the Food Standards Agency Nutrient Profiling System (FSAm-NPS), used to derive the Nutri-Score front-of-pack label, and the NOVA classification in relation to mortality. Design Prospective cohort study. Setting Moli-sani Study, Italy 2005-10. Participants 22 895 participants (mean age 55 (SD 12) years; 48% men). Main outcomes measures Associations between dietary exposures and mortality risk, assessed using multivariable cause specific Cox proportional hazard models controlled for known risk factors. Results A total of 2205 deaths occurred during 272 960 person years of follow-up. In the highest quarter of the FSAm-NPS index compared with the lowest quarter, multivariable adjusted hazard ratios for all cause and cardiovascular mortality were 1.19 (95% confidence interval 1.04 to 1.35; absolute risk difference 4.3%, 95% confidence interval 1.4% to 7.2%) and 1.32 (1.06 to 1.64; 2.6%, 0.3% to 4.9%), respectively. The hazard ratios were 1.19 (1.05 to 1.36; absolute risk difference 9.7%, 5.0% to 14.3%) and 1.27 (1.02 to 1.58; 5.0%, 1.2% to 8.8%), respectively, for all cause and cardiovascular mortality when the two extreme categories of ultra-processed food intake were compared. When these two indices were analysed jointly, the magnitude of the association of the FSAm-NPS dietary index with all cause and cardiovascular mortality was attenuated by 22.3% and 15.4%, respectively, whereas mortality risks associated with high ultra-processed food intake were not altered. Conclusions Adults with the lowest quality diet, as measured using the FSAm-NPS dietary index (underpinning the Nutri-Score), and the highest ultra-processed food consumption (NOVA classification) were at the highest risk for all cause and cardiovascular mortality. A significant proportion of the higher mortality risk associated with an elevated intake of nutrient poor foods was explained by a high degree of food processing. In contrast, the relation between a high ultra-processed food intake and mortality was not explained by the poor quality of these foods.
Article
Various front-of-pack food labels (FoPLs) are being introduced across the world, and discussion continues about the most effective label formats to improve consumers’ (i) understanding of the relative healthiness of alternative products and (ii) product choices. Of increasing interest is the relative ability of different types of labels to steer consumers away from unhealthy options (aversion) versus steer them towards healthier options (attraction). The aim of this study was to assess aversion and attraction outcomes for five FoPLs (Health Star Rating, Multiple Traffic Lights, Nutri-Score, Reference Intakes, and Warning Label) across 18 countries (n=18393). Descriptive analyses assessed improvements in consumer understanding and choice outcomes for each label across three different types of food products. Binary logistic regressions were used to compare the relative ability of the labels to improve respondents’ understanding of product healthiness and their product choices, using the industry-developed Reference Intakes as the comparator. Aversion and attraction effects were assessed for each label/food type combination. Across the total sample, the Nutri-Score performed best in terms of both attraction and aversion results for understanding and simulated choice outcomes, followed by the Multiple Traffic Lights. The Reference Intakes exhibited the weakest performance overall, with the Warning Label and Health Star Rating falling in between. The most effective FoPLs featured a colour-coded spectrum design. The results indicate that front-of-pack labels that are effective in guiding consumers towards healthier food products can also be effective in steering them away from unhealthy options.
Technical Report
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Background: So far, Switzerland could not rely on nationally representative data on measured anthropometric data and eating behaviors when establishing health related strategies and guidelines. The data from the first National Nutrition Survey for adults (menuCH) now complement information from other surveys, to inform public health policies and health professionals. Setting: One-year cross-sectional nutrition survey conducted from January 2014 till February 2015. Data were collected on 2085 participants aged 18-75 years representing 4’622’018 inhabitants (49.9% men and 50.1% women) residing in the three main linguistic regions of Switzerland (German, French and Italian). Methods: Interviews were carried out in German, French or Italian by trained dieticians in 10 study centers. Participants provided written informed consent. Respondent completed a self-administered paper-pencil dietary and physical activity behavior questionnaire including reported anthropometric and sociodemographic characteristics. Body weight, height and waist circumference were measured using standardized procedures. Body mass index (BMI) and waist circumference were categorized using WHO criteria. After sample weighting and calibration, descriptive stratified statistical analysis was performed, considering linguistic regions, sex, age groups and educational levels. Results: The net response rate was 38%. Average BMI was 25.9 kg/m2 for men and 24.1 kg/m2 for women, with little differences across linguistic regions. Mean BMI was 23.5, 25.0, 25.9 and 26.1 kg/m2 in the 18-34, 35-49, 50-64 and 65-75 year categories, respectively. The prevalence of overweight and obesity was 41.6% and 13.9% in men, 19.7% and 11.3% in women, 31.0% and 12.5% in the Germanspeaking region, 29.9% and 12.3% in the French-speaking region, and 30.1% and 15.6% in the Italianspeaking region, respectively. The prevalence of waist circumference at increased and highly increased metabolic risk was 16.7% and 16.5% overall, 18.6% and 16.4% in men as well as 14.8% and 16.6% in women, respectively. About 53% of the population wishes to reduce body weight. Three out of four people in the population have heard about the food pyramid and two-third about five fruits and vegetables a day. Among special diets, 4.9% of the population report to follow a vegetarian diet, 4.1% an energy restriction diet, 3.3% a fat restriction diet and 2.6% a lactose-free diet. A substantial proportion of the population (56.4% of women and 38.1% of men) reports to take vitamin or mineral supplements. The majority of the population (>80%) takes a snack at least once per day, with similar pattern during weekdays and weekends. Women are more likely to spend a long time cooking (>40 minutes) than men (50.3% vs 30.7%). The most frequently consistently skipped meal is breakfast for 5.2% of the population, followed by lunch (2.2%) and dinner (0.6%). Nearly 50% of the population report to walk at least 30 minutes per day, five days per week. The majority of the population (87.0%) reports to be trained, regularly physically active or irregularly active, thereby meeting current recommendations. One third of the population reports a sitting time higher than 8h30 minutes per day, which reflects a high level of sedentarity. Conclusion: menuCH, the first National Nutrition Survey for adults in Switzerland, provides important novel information on overweight, obesity and waist circumference based on measured data, in the population aged 18-75 years. The survey also shows that knowledge about dietary recommendations is very good, vitamin and mineral supplements are frequently consumed and self-reported cooking habits differ by sex. Reported physical activity levels are quite high, despite a high level of sedentarity.
Article
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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.
Article
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Front-of-pack labels (FoPLs) are efficient tools for helping consumers identify healthier food products. Although discussions on nutritional labelling are currently ongoing in Europe, few studies have compared the effectiveness of FoPLs in European countries, including the Netherlands. This study aimed to compare five FoPLs among Dutch participants (the Health Star Rating (HSR) system, Multiple Traffic Lights (MTL), Nutri-Score, Reference Intakes (RIs), and Warning symbols) in terms of perception and understanding of the labels and food choices. In 2019, 1032 Dutch consumers were recruited and asked to select one product from among a set of three foods with different nutritional profiles, and then rank the products within the sets according to their nutritional quality. These tasks were performed with no label and then with one of the five FoPLs on the package, depending on the randomization arm. Finally, participants were questioned on their perceptions regarding the label to which they were exposed. Regarding perceptions, all FoPLs were favorably perceived but with only marginal differences between FoPLs. While no significant difference across labels was observed for food choices, the Nutri-Score demonstrated the highest overall performance in helping consumers rank the products according to their nutritional quality.
Article
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Background: Front-of-Package nutrition labels (FoPLs) are intended to help reduce the incidence of nutrition-related non-communicable diseases through an improvement in diet quality. FoPLs have been shown to improve the nutritional quality of purchases and have been associated with improved diet quality, which is in turn associated with reduced risk of non-communicable diseases. However, the potential impact of FoPLs on reducing mortality from chronic diseases has never been estimated. Methods: Data from a laboratory experimental economics test were used to investigate the effects of five different FoPLs (Nutri-Score, Health Star Rating system, Multiple Traffic lights, Reference intakes and SENS (Système d'Etiquetage Nutritionnel Simplifié)) on the nutritional quality of household purchases. The relative differences in nutrient content and composition of food purchases were then applied to dietary intakes using data from an observational study, thus yielding estimates for 'reference' and 'labelled' diets. A macro-simulation study using the PRIME model was then conducted to estimate the impact of the modification in dietary intake as a result of FoPL use on mortality from diet-related non-communicable diseases. Results: The use of FoPLs led to a substantial reduction in mortality from chronic diseases. Approximately 3.4% of all deaths from diet-related non-communicable diseases was estimated to be avoidable when the Nutri-Score FoPL was used. The remaining FoPLs likewise resulted in mortality reduction, although to a lesser extent: Health Star Rating system (2.8%), Reference Intakes (1.9%), Multiple Traffic Lights (1.6%), and SENS (1.1%). Conclusions: FoPLs have the potential to help decrease mortality from diet-related non-communicable diseases, and the Nutri-Score appears to be the most efficient among the five formats tested.
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Background Sugar taxes and front-of-package (FOP) nutrition labelling systems are strategies to address diet-related non-communicable diseases. However, there is relatively little experimental data on how these strategies influence consumer behavior and how they may interact. This study examined the relative impact of different sugar taxes and FOP labelling systems on beverage and snack food purchases. Methods A total of 3584 Canadians 13 years and older participated in an experimental marketplace study using a 5 (FOP label condition) × 8 (tax condition) between-within group experiment. Participants received $5 and were presented with images of 20 beverages and 20 snack foods available for purchase. Participants were randomized to one of five FOP label conditions (no label; ‘high in’ warning; multiple traffic light; health star rating; nutrition grade) and completed eight within-subject purchasing tasks with different taxation conditions (beverages: no tax, 20% tax on sugar-sweetened beverages (SSBs), 20% tax on sugary drinks, tiered tax on SSBs, tiered tax on sugary drinks; snack foods: no tax, 20% tax on high-sugar foods, tiered tax on high-sugar foods). Upon conclusion, one of eight selections was randomly chosen for purchase, and participants received the product and any change. Results Compared to those who saw no FOP label, participants who viewed the ‘high in’ symbol purchased less sugar (− 2.5 g), saturated fat (− 0.09 g), and calories (− 12.6 kcal) in the beverage purchasing tasks, and less sodium (− 13.5 mg) and calories (− 8.9 kcal) in the food tasks. All taxes resulted in substantial reductions in mean sugars (− 1.4 to − 4.7 g) and calories (− 5.3 to − 19.8 kcal) purchased, and in some cases, reductions in sodium (− 2.5 to − 6.6 mg) and saturated fat (− 0.03 to − 0.08 g). Taxes that included 100% fruit juice (‘sugary drink’ taxes) produced greater reductions in sugars and calories than those that did not. Conclusions This study expands the evidence indicating the effectiveness of sugar taxation and FOP labelling strategies in promoting healthy food and beverage choices. The results emphasize the importance of applying taxes to 100% fruit juice to maximize policy impact, and suggest that nutrient-specific FOP ‘high in’ labels may be more effective than other common labelling systems at reducing consumption of targeted nutrients. Electronic supplementary material The online version of this article (10.1186/s12966-019-0799-0) contains supplementary material, which is available to authorized users.
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Front-of-Package labels (FoPLs) are efficient tools for increasing consumers’ awareness of foods’ nutritional quality and encouraging healthier choices. A label’s design is likely to influence its effectiveness; however, few studies have compared the ability of different FoPLs to facilitate a consumer understanding of foods’ nutritional quality, especially across sociocultural contexts. This study aimed to assess consumers’ ability to understand five FoPLs [Health Star Rating system (HSR), Multiple Traffic Lights (MTL), Nutri-Score, Reference Intakes (RIs), and Warning symbol] in 12 different countries. In 2018, approximately 1000 participants per country were recruited and asked to rank three sets of label-free products (one set of three pizzas, one set of three cakes, and one set of three breakfast cereals) according to their nutritional quality, via an online survey. Participants were subsequently randomised to one of five FoPL conditions and were again asked to rank the same sets of products, this time with a FoPL displayed on pack. Changes in a participants’ ability to correctly rank products across the two tasks were assessed by FoPL using ordinal logistic regression. In all 12 countries and for all three food categories, the Nutri-Score performed best, followed by the MTL, HSR, Warning symbol, and RIs.
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