Assessment of Knowledge and Self-Reported Use of Nutrition Facts Labels, Nutrient Content, and Health Claims among Saudi Adult Consumers

Abstract

Background
Few studies have investigated the knowledge and attitudes towards the nutrition facts label, the nutrient content and health claims (NHCs) among consumers from different countries/cultures.

Methods
This cross-sectional study assessed the knowledge and self-reported use of the nutrition facts label and NHCs among Saudi adults. A total of 722 participants were recruited using an online questionnaire.

Results
Total knowledge score was 5.8 ± 2.5/13 points (45%). Approximately, 18%, 77%, and 5% of the participants had low, medium, and high levels of knowledge, respectively. Participants were more knowledgeable on the nutrition facts label (2.6 ± 1.6/5 points) and health claims (2.7 ± 1.2/4 points) versus nutrient content claims (0.5 ± 0.7/4 points). The total use score was 20.1 ± 5.7/30 points (67%); approximately, 2%, 61%, and 37% of the participants were classified as low, medium, and high use level, respectively. Participants’ use of the nutrition facts label, nutrient content claims, and health claims was 10.0 ± 3.1/15, 6.5 ± 2.2/9, and 3.6 ± 1.8/6 points, respectively.

Conclusion
This study highlights the need for more education and public awareness programs to enhance consumer knowledge and use of the nutrition facts label and NHCs, and consequently lead to healthy dietary choices.

Full text

ORIGINAL RESEARCH
Assessment of Knowledge and Self-Reported Use
of Nutrition Facts Labels, Nutrient Content, and
Health Claims among Saudi Adult Consumers
Leila Arfaoui
1
Areej Alkhaldy
1
Ahad Alareeshi
1
Ghadeer AlSaadi
1
Shaima Alhendi
1
Afnan Alghanmi
1
Wejdan Alghafari
1
Mourad Assidi
2,3
1
Clinical Nutrition Department, Faculty
of Applied Medical Sciences, King
Abdulaziz University, Jeddah, 21589,
Saudi Arabia;
2
Center of Excellence in
Genomic Medicine Research, King
Abdulaziz University, Jeddah, 21589,
Saudi Arabia;
3
Medical Laboratory
Department, Faculty of Applied Medical
Sciences, King Abdulaziz University,
Jeddah, 21589, Saudi Arabia
Background: Few studies have investigated the knowledge and attitudes towards the
nutrition facts label, the nutrient content and health claims (NHCs) among consumers from
different countries/cultures.
Methods: This cross-sectional study assessed the knowledge and self-reported use of the
nutrition facts label and NHCs among Saudi adults. A total of 722 participants were recruited
using an online questionnaire.
Results: Total knowledge score was 5.8 ± 2.5/13 points (45%). Approximately, 18%, 77%,
and 5% of the participants had low, medium, and high levels of knowledge, respectively.
Participants were more knowledgeable on the nutrition facts label (2.6 ± 1.6/5 points) and
health claims (2.7 ± 1.2/4 points) versus nutrient content claims (0.5 ± 0.7/4 points). The
total use score was 20.1 ± 5.7/30 points (67%); approximately, 2%, 61%, and 37% of the
participants were classied as low, medium, and high use level, respectively. Participants’
use of the nutrition facts label, nutrient content claims, and health claims was 10.0 ± 3.1/15,
6.5 ± 2.2/9, and 3.6 ± 1.8/6 points, respectively.
Conclusion: This study highlights the need for more education and public awareness
programs to enhance consumer knowledge and use of the nutrition facts label and NHCs,
and consequently lead to healthy dietary choices.
Keywords: health claims, knowledge, nutrition facts label, nutrient claims, nutritional
information
Introduction
Optimal nutrition intake is one of the main lifestyle factors that contribute to
a reduced incidence of obesity and noncommunicable diseases.
1
Nutrition facts,
nutrient content, and health claims (NHCs) on food labels may be an effective tool
for communicating nutritional information to consumers.
2
Thus, the effort of public
health agencies to help consumers make healthy food choices and encourage them
to use the nutrition facts and declarations of NHC may be a cost-effective approach
to reducing the prevalence of obesity and noncommunicable diseases worldwide.
3,4
The nutrition facts label and NHCs are permitted in an increasing number of
countries given the continued growth of online food shopping.
5
The main nutri-
tional information on food labels (eg, nutritional content, list of ingredients, serving
size, and nutrient and health benet claims) help consumers to understand the
nutritional composition of a product and make informed decisions in selecting
foods to achieve a healthy diet.
2
Yet, the research in this area of knowledge and
Correspondence: Leila Arfaoui
Tel +966 126401000 (ext. 41612)
Email leila.arfaoui@gmail.com
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Received: 12 July 2021
Accepted: 29 September 2021
Published: 25 October 2021

food label use is limited. Previous research studies
reported an association between knowledge regarding the
nutrition facts label and healthier dietary decisions.
6
For
example, 6% less dietary fat was found among consumers
who used the nutrition facts label compared with those
who did not, accounting for a signicant decrease in the
risk of diet-related chronic diseases.
7,8
In addition,
a Korean study exploring the association between macro-
nutrients and micronutrients intake and nutrition label
reading among adults showed that males who used nutri-
tion labels had higher consumptions of calcium and vita-
min C than those who did not.
9
In the same study, those
who used nutrition labels among females consumed less
carbohydrates and calories than those who did not.
Moreover, individuals with higher incomes and higher
educational levels were more likely to use nutrition
labels.
9
Sufcient nutritional knowledge is powerful as it
improves attention, comprehension and memory, and
makes the decision-making process more orderly and
efcient.
2,4
The cognitive processing model suggests that
consumers with prior knowledge tend to use label infor-
mation more effectively than those without knowledge.
2
Nutrition facts labels and NHCs are most commonly
used by consumers with specic health conditions, and
those following restricted diets, such as patients with
diabetes or hyperlipidemia.
10
Moreover, consumers who
frequently read food labels focus mainly on calories,
sugar, and fat information when purchasing unfamiliar
foods.
11–13
Existing evidence shows a noticeable lack of
understanding and use of NHCs among consumers, either
due to insufcient nutrition knowledge, confusion, or
underestimation of nutrient value.
5,14,15
Ares et al
reported that a lack of nutrition knowledge diminishes
consumers’ understanding of health claims, thereby redu-
cing the credibility of such claims.
5,16
Other factors that
have been reported to inuence knowledge and use of
NHC include familiarity, credibility, and availability in
supermarkets,
17,18
in addition to consumer awareness and
interest in healthy eating.
18,19
On an international basis, most studies performed thus
far focused on nutrition facts labels, while few studies
included NHC.
2
The internationalization of food systems
and integration of markets and industries is increasing.
Furthermore, studies from different cultures are increas-
ingly required to learn from and collaborate with other
international colleagues. This approach links food choice
data and determines the inuence of cultural factors on
these choices. Further studies regarding consumers’
knowledge of nutrition facts labels worldwide are also
required to identify the factors inuencing the knowledge,
attitudes, condence, and decision-making of the consu-
mer. This sharing will ultimately advance knowledge to
empower consumers to achieve informed dietary choices,
decrease the prevalence of diet-related diseases, and
improve public health.
In Saudi Arabia, the Saudi FDA has implemented
general labeling requirements on prepackaged food items,
imported, exported and locally produced, available in the
country’s market since 2013. These SFDA policies were
reinforced by its adherence to the Cooperation Council for
the Arab States of the Gulf regulation to disclose the
nutritional data on food product labels [Gulf Standard
Organization (GSO) 2233/2012]. Moreover, a recent
study about nutrition food labelling in Saudi Arabia
showed that among the 1153 food products randomly
sampled from fourteen stores, 88% displayed nutritional
facts.
20
Therefore, this study was conducted to assess the
level of consumers’ knowledge and self-reported use of
food labels and NHCs among Saudi adults. Moreover, the
relationships between consumer knowledge and self-
reported use and various participant characteristics (eg,
age, sex, education, and income) were assessed.
Materials and Methods
Study Design and Participants
This cross-sectional study was conducted between
January 20 and March 15, 2020. A total of 722 participants
aged ≥18 years were included in the study via convenience
sampling. An online survey, created using Google Forms,
was distributed through various social media applications,
such as WhatsApp and Twitter. Ethical approval was
obtained from the Research Ethics Committee at King
Abdulaziz University Hospital in Jeddah, Saudi Arabia
(Ref. number: 772–19). The study was performed accord-
ing to the ethical standards of the 1964 Declaration of
Helsinki. Informed consent was obtained from all
participants.
Sample Size Calculation
The sample size of the included participants was calcu-
lated using the online Epi Info sample size calculator
supported by the Division of Health Informatics &
Surveillance, and Center for Surveillance, Epidemiology
and Laboratory Services.
21
The data were obtained from
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the (blinded for peer review) General Authority for
Statistics (2019) and included an estimated total of
25,828,206 adults (aged ˃18 years). The effective sample
size for this study was 664 participants, with a 99% con-
dence interval and hypothesized 50% frequency of out-
come factor in the population.
Survey and Data Collection
The survey was developed using a questionnaire validated
by the United States Food and Drug Administration
22
with
some modications to cover the study aim. The survey
was shared with 30 individuals for piloting to assess the
timing, consistency, and clarity of the survey. Based on the
feedback from the pilot survey, some questions were
reworded and some of the groupings of questions/state-
ments were changed. In addition, some response options
for certain questions were changed. The nal survey
included three sections with a total of 39 questions. The
beginning of the survey informed participants regarding
the purpose of the study, desired outcomes of the survey,
estimated time for survey completion, condentiality,
information on ethical approval, and contact persons for
more details about the study.
The rst section of the survey (13 questions) covers the
participants’ information, including their sociodemo-
graphic prole (age, sex, group, marital status, educational
level, occupation, income level, and whether their grocery
shopping was done personally). This was followed by
questions concerning their health status (presence of any
chronic disease or food allergy) and use of any special
diet. In the same section, the participants were also asked
how they perceived their health in general.
The second section of the survey (13 questions) was
dedicated to determining the consumers’ knowledge of
nutrition facts labels and NHCs. They were asked about
the recommended daily calories for males and females.
Participants were subsequently exposed to a sample of
a juice box nutrition facts label and were requested to
respond to three questions regarding the serving size,
calorie content, and amount of total sugar. In addition,
participants were asked to explain the meaning of terms
included in the nutrition facts label, such as sugar-free,
calorie-free, light, and low sodium claims. The last four
questions in this section examined the participants’ knowl-
edge about the health claims. They were asked whether
vitamin D, fat, sodium, and ber intake affects the risk of
osteoporosis, heart disease, hypertension, and diabetes
mellitus, respectively (four possible response options
were provided: increase; decrease; no effect; or no
known effect). Only one of these four responses were
deemed to be correct and received a score of 1; wrong
responses received a score of 0. The total knowledge of
nutrition facts labels and NHC was evaluated by summing
the scores of the thirteen questions and categorizing the
results as “high” (˃75th percentile), “medium” (50th–75th
percentile), and “low” (<50th percentile).
The third section of the survey (13 questions), regard-
ing the use of nutrition facts labels and NHCs, began with
a question about how often the consumer read nutrition
facts labels (always, sometimes, rarely, or never).
Participants who indicated that they were always or some-
times reading the food labels continued to complete the
remaining questions (subsection a). These questions
assessed the frequency (often, sometimes, rarely, or
never) of reading the following ve parts in the nutrition
facts label: list of ingredients, nutrition information, ser-
ving size, calories, and claims. The participants were sub-
sequently asked about the use of the following ve claims
when buying products: low fat, no added sugar, light, diet
rich in ber helps to reduce the risk of diabetes mellitus,
and low sodium helps to lower the risk of hypertension.
The four responses were scored from 0 to 3, with higher
scores indicating frequent usage. The total use of nutrition
facts labels and NHCs was evaluated by summing the
scores of the thirteen questions and categorizing the results
as “high” (˃75th percentile), “medium” (50th–75th per-
centile), and “low” (<50th percentile).
In addition, participants were asked about how fre-
quently (often, sometimes, rarely, or never) they read the
following reasons to compare between brands and food
items, make sure that the advertisement on the package is
true, and check the nutrient content and level as well as the
recommended serving size. Participants who indicated that
they rarely or never read nutrition facts labels were asked
a follow-up question (subsection b) to determine the rea-
son for this answer, and the remaining of the survey was
not completed. Five reasons for not reading nutrition facts
labels (ie, not interested, not understandable, time consum-
ing, using other sources, or I know what to eat) were
provided, to which participants could respond “yes”,
“no”, or “I don”t know’.
Statistical Analysis
Data were analyzed using the SPSS software (Version
23.0; IBM Corp., Armonk, NY, USA.). Data were
described using frequency statistics and descriptive
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statistics are presented as mean and Standard deviation
(SD). A chi-squared test of independence and analysis of
variance were used to test the difference between two
variables. A p<0.05 denoted statistical signicance.
A Bonferroni correction was applied for multiple compar-
isons. To determine the predictors of participants’ knowl-
edge and use of nutrition labels and NHCs claims, forward
stepwise multiple regression analyses were performed
using participants’ characteristics as potential predictors
variables.
Results
Participant Characteristics
Table 1 presents the characteristics of the study partici-
pants. A total of 722 participants, with a response rate of
98%, agreed to ll out the survey. Of those, approximately
60% were females, 67.4% were aged <35 years, 80% had
Bachelor’s degree or above, 40.9% were employed, 36%
worked in the healthcare sector, and 41% had children.
Approximately, 57% of the participants shared grocery
shopping with the family. Around 16% of the participants
suffered from a chronic disease, mainly diabetes, hyper-
tension and heart diseases. About 13% of the participants
had food allergies, particularly relating to nuts/seeds
(n=35), sh/shellsh (n=17), milk/dairy products (n=15),
eggs (n=9), and others (eg, banana, strawberries, and
mango) (n=15). Almost 20% of the participants followed
a specic diet, such as the Keto diet (n=20), low-calorie
diet (n=39), low-carbohydrate diet (n=21), low-fat diet
(n=17), sugar-free diet (n=12), high-protein diet (n=6),
intermittent fasting (n=7), vegetarian/vegan diet (n=6),
and other diets (n=12). In terms of health perception,
19.1% of the participants reported poor-to-fair health,
whereas the remaining 80.9% thought they had a good-to-
excellent health.
Knowledge of the Nutrition Facts Label
and NHCs
Table 2 shows the knowledge of the participants towards
the nutrition facts label and NHCs. Only 37% and 38% of
the participants were aware of the recommended calories
for females and males, respectively. Using the nutritional
fact sample of a box of juice, approximately 48% of the
participants knew the serving size, 68% reported a correct
answer for the calories content, and 72% were able to
determine the calories and total sugar content. However,
only 12%, 16%, 15%, and 4% of the respondents could
explain the meanings of “sugar-free”, “calorie-free”, “light
or lite in fat”, and “low sodium”, respectively.
Approximately three-quarters (72%) of the participants
Table 1 Participant Characteristics (n=722)
Variable n %
Gender Male 285 39.5
Female 437 60.5
Age (years) 18–25 315 43.6
26–35 172 23.8
36–55 182 25.2
≥ 56 53 7.4
Educational level ≤ Elementary school 4 0.6
High school 140 19.4
≥ Bachelor 578 80.0
Work status Student 274 38.0
Employed 295 40.9
Unemployed 93 12.9
Retired 60 8.2
Monthly income (SR) < 5000 145 20.1
5000–10,000 169 23.4
10,001–15,000 119 16.5
> 15,000 289 40.0
Work related to
healthcare
No 461 63.9
Yes 261 36.1
Medical diagnosis No diseases 609 84.3
Diabetes (n=40) 113 15.7
Hypertension (n=33)
Heart diseases (n=14)
Gastrointestinal diseases
(n=6)
Thyroid diseases (n=9)
Asthma (n=11)
Food allergy No 631 87.4
Yes 91 12.6
Following diet No 582 80.6
Yes 140 19.4
Having children No 421 58.3
Yes 301 41.7
Grocery shopping All the time 158 21.9
Most of the time 151 20.9
Shared with family 413 57.2
Health perception Poor 22 3.0
Fair 116 16.1
Good 214 29.6
Very good 241 33.4
Excellent 129 17.9
Abbreviations: n, number of participants; SR, Saudi Riyal.
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Table 2 Participants’ Corrected Answers to Nutrition Facts Label and NHCs’s Knowledge Questions (n=722)
Knowledge
questions
Recommended calories and nutrition facts label questions Nutrient content claims meaning questions Health claims relationship questions Total knowledge
(mean ± SD)
p-value
Calories
recommended
for females
Calories
recommended
for males
Serving
size: 2
boxes of
juice
Calories
intake: 2
boxes of
juice
Total
sugar
content
in 1
box of
juice
“Sugar-
free”
“Calorie-
free”
“Light”
or
“Lite”
“Low
sodium”
Vitamin
D deciency
and
osteoporosis
High fat
intake
and
heart
diseases
High sodium
intake and
hypertension
High
ber
intake
and DM
Knowledge score
(mean ± SD)
2.6 ± 1.6 0.5 ± 0.7 2.7 ± 1.2 5.8 ± 2.5
Corrected
answers (n, %)
274 38 264 37 349 48 493 68 521 72 89 12 116 16 107 15 29 4 522 72 615 85 514 71 299 33
Age (years)
18–25 136 50 126 48 177 51 250 51 255 49 49 55 61 53 49 46 17 59 228 44 267 43 223 43 107 36 6.2 ± 2.4
26–35 63 23 66 25 88 25 114 23 123 24 24 27 29 25 33 31 9 31 115 22 143 23 116 23 73 24 5.8 ± 2.5 < 0.001*
36–55 64 23 61 23 73 21 109 22 114 22 14 16 22 19 20 19 3 10 137 26 161 26 138 27 91 30 5.5 ± 2.5
≥56 11 4 11 4 11 3 20 4 29 6 2 2 4 3 5 5 0 0 42 8 44 7 37 7 28 9 4.6 ± 2.4
Gender
Male 94 34 86 33 124 36 175 35 185 36 31 35 38 33 36 34 8 28 186 36 224 36 178 35 112 37 5.2 ± 2.5 < 0.001*
Female 180 66 178 67 225 64 318 65 336 64 58 65 78 67 71 66 21 72 336 64 391 64 336 65 187 63 6.2 ± 2.4
Educational
level
≤Elementary
school
1 0 2 1 1 0 3 1 3 1 0 0 0 0 2 2 0 0 2 0 2 0 1 0 1 0 4.5 ± 3.3 0.057
High school 52 19 52 20 57 16 92 19 100 19 12 13 21 18 23 21 5 17 90 17 113 18 95 18 45 15 5.4 ± 2.4
≥Bachelor 221 81 210 80 291 83 398 81 418 80 77 87 95 82 82 77 24 83 430 82 500 81 418 81 253 85 5.9 ± 2.5
Work status
Student 121 44 113 43 158 45 216 44 223 43 47 53 57 49 41 38 16 55 205 39 236 38 203 39 90 30 6.3 ± 2.4
Employed 112 41 108 41 138 40 193 39 202 39 30 34 40 34 46 43 10 34 202 39 249 40 196 38 138 46 5.6 ± 2.5 < 0.001*
Unemployed 29 11 30 11 42 12 65 13 68 13 7 8 14 12 13 12 2 7 72 14 80 13 70 14 39 13 5.7 ± 2.5
Retired 12 4 13 5 11 3 19 4 28 5 5 6 5 4 7 7 1 3 43 8 50 8 45 9 32 11 4.5 ± 2.3
Monthly
income (SR)
<5000 54 20 58 22 67 19 92 19 99 19 23 26 28 24 24 22 8 28 95 18 113 18 91 18 48 16 5.5 ± 2.7
5000–10,000 64 23 55 21 69 20 106 22 126 24 23 26 33 28 31 29 6 21 131 25 150 24 124 24 69 23 5.8 ± 2.4 0.304
10,001–15,000 35 13 37 14 53 15 80 16 83 16 12 13 21 18 17 16 5 17 85 16 105 17 86 17 58 19 5.7 ± 2.5
>15,000 121 44 114 43 160 46 215 44 213 41 31 35 34 29 35 33 10 34 211 40 247 40 213 41 124 41 5.9 ± 2.4
(Continued)
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Table 2 (Continued).
Knowledge
questions
Recommended calories and nutrition facts label questions Nutrient content claims meaning questions Health claims relationship questions Total knowledge
(mean ± SD)
p-value
Calories
recommended
for females
Calories
recommended
for males
Serving
size: 2
boxes of
juice
Calories
intake: 2
boxes of
juice
Total
sugar
content
in 1
box of
juice
“Sugar-
free”
“Calorie-
free”
“Light”
or
“Lite”
“Low
sodium”
Vitamin
D deciency
and
osteoporosis
High fat
intake
and
heart
diseases
High sodium
intake and
hypertension
High
ber
intake
and DM
Work related
to healthcare
No 153 56 150 57 181 52 283 57 317 61 46 52 51 44 62 58 8 28 309 59 379 62 293 57 171 57 5.2 ± 2.4 < 0.001*
Yes 121 44 114 43 168 48 210 43 204 39 43 48 65 56 45 42 21 72 213 41 236 38 221 43 128 43 6.8 ± 2.3
Having
children
No 173 63 164 62 232 66 317 64 322 62 62 70 81 70 67 63 21 72 303 58 354 58 299 58 157 53 6.1 ± 2.4 0.001 *
Yes 101 37 100 38 117 34 176 36 199 38 27 30 35 30 40 37 8 28 219 42 261 42 215 42 142 47 5.4 ± 2.5
Following diet
No 231 84 220 83 284 81 408 83 427 82 73 82 92 79 91 85 24 83 431 83 510 83 419 82 241 81 5.7 ± 2.5 < 0.001*
Yes 43 16 44 17 65 19 85 17 94 18 16 18 24 21 16 15 5 17 91 17 105 17 95 18 58 19 6.4 ± 2.2
Grocery
shopping
All 50 18 52 20 65 19 90 18 97 19 14 16 18 16 31 29 8 28 99 19 126 20 100 19 71 24 5.2 ± 2.5
Most 60 22 60 23 68 19 95 19 103 20 21 24 29 25 17 16 7 24 113 22 124 20 108 21 63 21 5.75 ± 2.33 0.001*
Some 164 60 152 58 216 62 308 62 321 62 54 61 69 59 59 55 14 48 310 59 365 59 306 60 165 55 6.1 ± 2.5
Health
perception
Poor 4 1 11 4 5 1 8 2 10 2 2 2 1 1 11 10 0 0 0 0 10 2 11 2 14 5 4.4 ± 2.2
Fair 44 16 48 18 57 16 80 16 85 16 15 17 13 11 20 19 4 14 11 2 106 17 91 18 42 14 5.4 ± 2.6 0.002*
Good 70 26 65 25 87 25 129 26 144 28 19 21 40 34 27 25 13 45 85 16 181 29 148 29 93 31 5.9 ± 2.2
Very good 89 32 87 33 121 35 179 36 186 36 29 33 36 31 32 30 7 24 147 28 210 34 172 33 101 34 5.9 ± 2.5
Excellent 67 24 53 20 79 23 97 20 96 18 24 27 26 22 17 16 5 17 100 19 108 18 92 18 49 16 6.3 ± 2.4
Notes: *Data are presented as number (n) and percentage (%). The p-values for χ2 tests were calculated for age, gender, educational level, work status, monthly income,
having children, following diet, grocery shopping, and health perception.
Abbreviations: DM, diabetes mellitus; NHCs, nutrient content and health claims; SR, Saudi Riyal; SD, standard deviation.
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knew that vitamin D deciency and high sodium levels
increase the risk of osteoporosis and hypertension, respec-
tively. Approximately 85% of the participants were con-
scious of the association between high fat intake and the
risk of heart diseases. However, only one-third (33%)
knew that high ber intake lowers the risk of diabetes
mellitus.
Overall, the mean knowledge score was 5.8 ± 2.5 of
a maximum of 13 points (45%). Participants’ knowledge
of nutrition facts label (2.6 ± 1.6) and health claims (2.7 ±
1.2) was similar, but higher than that for the nutrient
content claims (0.5 ± 0.7). Using the percentile thresholds
indicated in the Methods section, the number of partici-
pants classied as having lower, medium, and high knowl-
edge was 128 (18%), 555 (77%), and 39 (5%),
respectively.
Results of the associations between participant charac-
teristics and the total knowledge of nutrition facts label
and NHCs showed that females had signicantly higher
knowledge than males (p < 0.001) (Table 2). Moreover,
younger participants (aged 18–25 years) had higher overall
knowledge than older participants (p < 0.001). Students
were shown to have higher signicant knowledge (p <
0.001) than employed, unemployed, and retired partici-
pants. Additionally, participants employed in occupations
related to the healthcare sector had higher knowledge
scores (p < 0.001) than those working in other domains.
It was also noted that participants who did not have chil-
dren had a higher knowledge score regarding nutrition
facts label and NHCs (p = 0.001). Participants who shared
grocery shopping with the family tended to have a higher
knowledge score versus those who personally did all or
most of the grocery shopping (p = 0.001). Participants who
followed a special diet had more knowledge of nutrition
labels than those who did not. Moreover, participants who
rated their health status as excellent tended to have higher
knowledge (p = 0.002).
Self-Reported Use of the Nutrition Facts
Label and NHCs
Table 3 shows the participants’ answers to questions
regarding the use of the nutrition facts label and NHC.
Approximately 19% and 44% of the participants reported
that they always or sometimes read the nutrition facts
label, respectively, representing nearly two-thirds of the
study population. However, 27.9% of the participants
reported that they rarely or never (9.5%) read the nutrition
facts label and NHC.
Among participants who reported that they always or
sometimes read nutrition facts label when purchasing food
items, approximately 36%, 38%, and 31% stated that they
often read the list of ingredients, the nutrition facts, and
the serving size, respectively. About 46% of the partici-
pants indicated that they read the calories content, and
only 21% appeared to pay attention to claims.
Additionally, participants often based food purchases on
the inclusion of the following claims in the nutrition facts
label: “low fat” (48%), “no added sugar” (44%), and “light
or lite” (38%). In contrast, only 20% and 25% declared
reading the health claims “diet rich in ber helps to reduce
the risk of diabetes mellitus” and “low sodium helps to
lower the risk of hypertension”, respectively.
Overall, the mean usage score was 20.1 ± 5.7 of
a maximum of 30 points (67%). Participants’ usage was
as follows: nutrition facts label (10.0 ± 3.15 of 15 points),
nutrient content claims (6.5 ± 2.2 of 9 points), and health
claims (3.6 ± 1.8 of 6 points). Using the percentile thresh-
olds indicated in the Methods section, the number of
participants classied with lower, medium, and high use
was 9 (2%), 275 (61%), and 168 (37%); respectively.
Results of the associations between participants’ char-
acteristics and the nutrition facts label and NHC use
showed that only gender had signicant effects (p =
0.010). Notably, females had higher usage scores than
males (p = 0.010), and “consumers following diet” were
more likely to use nutrient content and health claims on
the nutrition facts label (p = 0.040).
Figure 1 illustrates the most common reason for using
the nutrition facts label among participants who answered
that they always or sometimes read the nutrition facts
label. Around 46% of the participants reported often
using the nutrition facts label and NHC to compare differ-
ent food items as well as to check the content of nutrients
in food. Approximately 40% of the participants often used
the nutrition facts label and NHC to determine the pre-
sence of an ingredient to avoid, obtain information on the
nutritional content, or decide which brand of a food item
to buy. Lastly, about one-third of the participants declared
that they often used food labels to plan meals, check
whether the advertising is true, and determine the quantity
of the food product they or their family should consume.
Among the participants who answered that they rarely
or never read the nutrition facts label, 63% reported that it
is time-consuming, or they were not interested. Other
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participants declared that they already knew the foods they
purchased (56%), have difculty in understanding the
provided information (50%), or have other preferred
sources of nutrition information (41%) (Figure 2).
Interestingly, we compared the nutrition facts label infor-
mation and health claims knowledge between the partici-
pants who never/rarely read food labels and those who
sometimes/always read them. The former group of parti-
cipants had signicantly higher knowledge scores (p <
0.001) than the latter group (Figure 3).
We subsequently compared the knowledge
score between the participants who always/sometimes
(6.3 ± 2.4 points) and rarely/never (5.0 ± 2.4 points)
read the nutrition facts label information and NHCs.
The results showed that the former group had
signicantly (p < 0.0001) higher knowledge scores
than the latter group.
Predictors of Nutrition Facts Labels and
NHCs Knowledge and Use
The overall scores of nutrition facts labels and NHCs
knowledge as well as use were subjected to multiple
regression analyses with participants’ characteristics as
potential predictors variables. The regression model of
both knowledge and use were statistically signicant [F
(7, 718) = 13.517, p <0.001)] and [F (2, 447) = 6.626,
p <0.01)], respectively. Among participants’ character-
istics gender, educational level, following a special
diet, health status, jobs related to health sector, occu-
pation, and participation in grocery shopping were
Table 3 Participants’ Answers to Nutrition Facts Label and NHC Self-Reported Use Questions (n=722)
Questions
1. How often do you read food labels? (n=722) n %
Always 136 9.5
Sometimes 315 27.9
Rarely 202 43.6
Never 69 18.8
a. When you buy a food product, how often do you read the following
information on food labels? (n=451)
Often (%) Sometimes (%) Rarely
(%)
Never (%)
Nutrition facts label regarding reading
List of ingredients 36.2 44.3 14.4 5.1
Nutrition facts 38.9 44.1 14.4 2.7
Serving size 31.0 36.4 21.9 10.7
Calories 46.3 35.0 14.6 3.9
Claims 20.9 35.5 28.6 15.1
Mean nutrition facts label score ± SD 10.04 ± 3.15
b. How often do you use the information below when you buy a food product? (n=451)
1. Nutrient content claims regarding using
“Low fat” when purchasing a food product 48.4 35.5 11.7 4.4
“No added sugar” when purchasing a food product 44.3 37.7 13.1 4.9
“Light” or “Lite in calories” when purchasing a food product 38.4 36.8 14.2 10.6
Mean nutrient content claims score ± SD 6.5 ± 2.2
2. Health claims regarding using … … … … when purchasing a food product
“diet rich in ber helps to reduce the risk of diabetes mellitus” 20.6 32.1 34.6 12.6
“low sodium helps to reduce the risk of hypertension” 25.3 36.4 22.8 15.5
Mean health content claims score ± SD 3.6 ± 1.8
Total use score (mean ± SD) 20.1 ± 5.7
Abbreviations: NHCs, nutrient content and health claims; n, number of participants; SD, standard deviation.
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found to be signicant predictors of nutrition facts
labels and NHCs knowledge (Table 4). In fact, males,
retired participants, those who have jobs not related to
health sector, persons who did all grocery shopping
exclusively by themselves, who does not follow a diet
as well as those who declared having poor or fair
health, have less knowledge scores comparing to their
counterparts (β <0; negative correlation). In addition,
educational level has a signicant positive correlation
with knowledge which means that participants having
bachelor’s degree or above have higher nutrients and
health knowledge score than others.
Only gender and following diet were identied as sig-
nicant predictors of nutrition facts labels and NHCs use
(β <0; negative correlation) (Table 4). Males and persons
who are not following diet had lower usage score of
nutrition facts labels and NHCs than females, and those
following a diet, respectively.
Figure 2 Participants’ reasons for rarely or never using nutrition facts label
(n=271).
Figure 3 Distribution of the total nutrition facts label and NHCs knowledge scores among participants who always/sometimes read food labels versus those who rarely/
never read them (n=722, p<0.001).
Figure 1 Reasons for using nutrition facts label among participants who answered always or sometimes reading the label (n=451).
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Discussion
Currently, there is conicting ndings about the impor-
tance of prior knowledge and attitude towards nutrition
facts label. Studies conducted in Western countries pro-
posed that education and nutrition knowledge are impor-
tant factors prior to food selection, and may improve the
use of nutrition facts label and NHCs;
23,24
yet, a few
studies suggest that nutritional knowledge has no direct
association with food. This discrepancy could be due to
differences in sample size, ethnicity of the examined popu-
lation, research methods used, study time, and other parti-
cipant characteristics. Therefore, no rm conclusions can
be drawn, and additional research studies from different
countries including different sample characteristics are
warranted. The present study was performed to assess
consumers’ knowledge and self-reported use of the nutri-
ent facts label and NHCs among Saudi consumers. The
ndings of this study could contribute to the existing
global evidence related to estimating the knowledge status
and use among consumers. Moreover, the results may help
to promote informed healthy dietary choices and purchas-
ing knowledge, as well as enlighten consumers about
recommended food choices. This information could be
used to develop tailored educational and public awareness
programs for consumers in Saudi Arabia and countries
with similar cultural characteristics.
Table 4 Predictors of Nutrition Facts and NHCs Knowledge and Use
Nutrition Facts and NHCs Knowledge
Variables βpCI 95%
Gender Male −0.798 <0.001** −1.154 −0.443
Female Reference category
Educational level Bachelor and above 0.448 0.045*0.011 0.886
Elementary/ Middle/High School Reference category
Occupation Student 0.382 0.104 −0.079 0.842
Retired −0.696 0.034*−1.339 −0.052
Employed /unemployed Reference category
Jobs related to health sector No −1.453 <0.001** −1.823 −1.084
Yes Reference category
Grocery shopping All −0.423 0.047*−0.841 −0.006
Some/most Reference category
Following diet No −0.761 0.001** −1.179 −0.342
Yes Reference category
Health Status Poor −1.813 <0.001** −2.801 −0.825
Fair −0.560 0.003** −0.929 −0.191
Good/ very good/excellent Reference category
Nutrition facts and NHCs use
Variables βpCI 95%
Gender Male −1.475 0.007** −2.553 −0.397
Female Reference category
Following diet No −1.450 0.018*−2.646 −0.255
Yes Reference category
Notes: **p < 0.01; *p < 0.05.
Abbreviations: NHCs, nutrient and health claims, β is the standardized coefcient; CI, condence interval.
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Overall, the mean knowledge score was 45%. The
knowledge regarding the nutrition facts label (52%) and
health claims (67%) was higher compared with that for the
nutrient content claims (12%). Similar low knowledge
scores for nutrient content claims were reported in pre-
vious studies carried out in the UK and Italy, where con-
sumers had greater knowledge of health claims than
nutrient content claims.
14,25
This could be attributed to
the observation that consumers tend to view food as
being healthier if it carries a health claim.
5
Other studies
have suggested that even if consumers are familiar with
nutrient content claims, they may not be able to understand
their proper meaning or impact on health.
17
In addition, it
is thought that consumers pay more attention to health
claims as a result of the effects of marketing and adver-
tisements. Moreover, consumers rely more on noticeable
information presented on the front of food packages when
their purchase decisions are made quickly in
supermarkets.
26,27
About 62% of the study population declared that they
always or sometimes used the nutrition facts label and
NHCs when purchasing food items. This percentage was
higher than those found in other countries culturally close
to Saudi Arabia, such as Bahrain (42%), Turkey (16%),
and Malaysia (45%).
27–29
This high usage of nutrition
facts label and NHCs in Saudi Arabia may be due mainly
to the higher educational level of our cohort. In fact, 80%
of our cohort have a bachelor’s degree or above, however,
only 15%, 35% and 60% of the participants were univer-
sity graduated in Turkey, Malaysia and Bahrain,
respectively.
27–29
Similar positive statistical correlations
between the level of education and consumer’s reading
and using food labels were also reported
elsewhere.
27,28,30
Therefore, further studies with larger
and more representative samples are warranted to be able
to generalize the ndings. The high frequency of food
label use in Saudi Arabia may also be the result of the
recent signicant efforts of the Ministry of Health in
delivering public health promotion programs and raising
health awareness about healthy dietary choices, obesity
prevention, physical activity promotion, diabetes control,
and cardiovascular disease.
31,32
In addition, in 2018, the
Saudi Food and Drug Authority launched a strategy of
healthy food regulation which aimed “to reduce the levels
of sugar, salt and saturated and transformed fat in the food
products”.
33
Food manufacturers and importers were
required to provide products with lower sugar, salt, satu-
rated, and trans-fat contents. These efforts could help to
raise consumers’ awareness about the importance of read-
ing nutritional information and claims on food labels to
plan an individualized and healthy diet.
In the present study, overall, the participants exhibited
better usage than knowledge regarding the nutrition facts
label and NHCs. Higher knowledge scores were noted
among participants who always/sometimes read the nutri-
tion facts label information and NHC. It has been reported
that prior nutritional knowledge could support the use of
nutrition facts labels.
2
This is achieved by enabling the
consumers to focus on important information in the nutri-
tion facts label and ignore the marketing advertainments,
facilitate their memory and comprehension of nutrition
facts labels, and support the application of the remembered
and comprehended information to making healthy food
choices.
2
In addition, prior knowledge, education, and
greater experience have also been shown to impact con-
sumer attitude toward NHCs and support the understand-
ing of NHCs.
2
Although participants have higher usage than knowl-
edge scores in both nutrition facts and nutrient claims, it is
important to highlight that this trend was reversed in the
health claims section. In fact, although 71% of participants
knew that high sodium levels increase the risk of hyper-
tension and 33% were aware that high ber intake lowers
the risk of diabetes mellitus, only 25% and 20% of parti-
cipants, respectively, used these two health claims when
purchasing food products. In line with these ndings, an
Italian study showed that 36% of consumers often pur-
chased food products with nutrient content claims; how-
ever, this percentage decreased to 26% for health claims.
14
Thus, it appears that participants lack trust in the health
claims on food labels. This is consistent with a public
mindset in Saudi Arabia and globally that only drugs—
not nutrients—can treat health problems or improve the
health status.
In this study, about one-third of the respondents
declared they rarely or never read food labels because it
is time-consuming or they were not interested. Other par-
ticipants also declared that they already knew the foods
they purchased. Half of the participants indicated that they
have difculty in understanding the food labels. Similar
results were found in South Africa, where “not interested”
and “buying the same type of product all time” were the
main reasons for not reading food labels.
34
Additional
reasons for not reading the nutritional information on
food labels, such as “small print on food labels”, “difcult
terminology”, and “inability to understand nutritional
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labels”, were also recorded in other studies.
35,36
Therefore,
further studies are warranted to investigate the factors that
could be used to enhance the use of labels.
The most frequent reasons provided for reading food
labels among respondents who declared that they always/
sometimes read them were to check the contents of nutri-
ents in food (eg, calories, salt, vitamins, or fat) and com-
pare food items. This awareness of Saudi consumers
regarding the importance of healthy food choices is attrib-
uted to the government awareness and education initiatives
discussed earlier in this article. These ndings are also in
line with those reported by Shine et al
37
who found that
consumers paid most attention to the nutrient content in
foods. Another study also emphasized the existence of
relationships between the use of food labels, and both
health awareness and lifestyle behavior.
38
The presence
of these relationships demonstrates that consumers who
often read food labels tend to care more for their health
and maintain a healthy lifestyle.
38
Notably, respondents who always/sometimes read food
labels exhibited higher knowledge scores than participants
who rarely or never read food labels. Similar results were
shown in the review article published by Miller and
Cassady, in which they demonstrated that nutrition knowl-
edge strongly inuences food label use by facilitating the
comprehension of nutrition information and supporting the
application of that information to make food choices.
39
Lack of nutrition knowledge reduces the ability of con-
sumers to understand a health claim, thereby limiting the
credibility of these claims.
16
We investigated the associations between the demo-
graphic characteristics of the respondents and knowledge
and use of food labels and NHCs. The results showed that
female respondents exhibited higher knowledge and usage
scores than males regarding nutrition and health claims.
Similar results were previously reported in different
countries.
27,28,40
This may be due to the level of responsi-
bility and key role of females in household grocery shop-
ping in the Saudi society, as reported elsewhere.
41
A signicant association was also found between knowl-
edge scores and younger participants (aged 18–25 years),
which is consistent with the ndings reported
elsewhere.
9,42
This age group, which most likely includes
students or recent graduates, is more connected than ever
before via technology, smartphone applications, and social
media; therefore, they can easily access the web to obtain
specic knowledge about NHC. Moreover, knowledge
regarding the nutrition facts label and NHCs was found
to be higher among participants who did not have children
(consistent with ndings reported elsewhere
34
) and those
sharing grocery shopping with their family. This higher
level of knowledge may be explained by the fact that
respondents have more time available to read food labels
compared with parents and child-caring parents in charge
of household shopping. As expected, participants working
in the healthcare sector had more knowledge about nutri-
ent and health claims. This greater knowledge may be due
to their expertise in health-related topics, including nutri-
tion and dietetics. Additionally, results demonstrated that
respondents who followed a specic diet had a high level
of knowledge and use regarding nutrient and health
claims. Their specic diet requirements (fat, sugar,
sodium), medical conditions, or personal preferences may
encourage them to focus more and benet from both
nutrition fact information and NHCs, as shown by several
previous studies.
28,34,43
For instance, it has been found that
diabetic patients search for foods with a low glycemic
index.
28
Moreover, health motivation and an interest in
healthy eating are among the reported motivators of con-
sumer interest in nutrition information on food products
and NHCs use.
18,19
Moorman and Matulich also reported
that consumers who require information about food, diet,
and health spend more time searching for this
information.
44
To further validate these associations, stepwise regres-
sion analyses were performed to identify predictors of
knowledge and use of nutrition fact labels and NHCs in
our cohort. For knowledge section, educational level,
health status, health-related jobs, and participation in gro-
cery shopping were shown to be signicant predictors of
nutrition facts labels and NHCs knowledge. Interestingly,
only gender and following diet were identied as signi-
cant predictors of both knowledge and use as reported
elsewhere.
9,24,42
This study had some limitations. Firstly, the cross-
sectional design does not address causality and we were
only able to demonstrate associations. Secondly, the use of
convenience sampling and the social media to distribute
the online survey may have affected the generalizability of
the data and introduced some slight bias. However, con-
venience sampling and utilization of social media are
considered time- and cost-effective methods for the collec-
tion of responses from a large population. A study invol-
ving a larger cohort with different socio-demographic
characteristics is needed to evaluate more accurately the
knowledge and use of food labels and NHCs among Saudi
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individuals. Thirdly, since our data involved a large cohort
from different parts of Saudi Arabia, that are not reachable
during the COVID-19 pandemic, it was difcult to mea-
sure the weight and height of participants, and so have
their BMI. This parameter would be helpful to further
explain its possible effects on knowledge and use of food
labels and NHCs.
Conclusions
Despite the high level of education in our sample, there is
a clear need for more efforts to enhance the knowledge
and use of the nutrition facts label and NHCs. The aims of
these efforts would be to help the public make informed
and individualized healthy dietary choices. The outcomes
of this study highlight the need to initiate educational
programs that further enhance consumers’ ability to under-
stand information included in the nutrition facts label and
NHCs. Awareness campaigns could be conducted at
schools, universities, shopping malls, and workplaces,
focusing mainly on the meaning of common nutrient
claims and their appropriate use. Increased consumer
awareness would also encourage food industries to pro-
duce more palatable and healthier products, with clear and
simple NHCs and nutrition information that can be easily
assimilated and applied by consumers, in addition to tan-
gible nutrition and health benets. Additional intervention
studies are warranted to monitor consumers’ nutritional
knowledge and ensure that such knowledge is applied to
the use of the nutritional information presented on food
labels.
Acknowledgments
We would like to thank all our participants for their time
and contribution in this study.
Author Contributions
All authors made substantial contributions to conception
and design, acquisition of data, or analysis and interpreta-
tion of data; took part in drafting the article or revising it
critically for important intellectual content; agreed to sub-
mit to the current journal; gave nal approval of the
version to be published; and agree to be accountable for
all aspects of the work.
Funding
This research received no external funding.
Disclosure
The authors declare no conicts of interest for this work.
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