The objective of the study was to compare the potential dietary impact of proposed and final front-of-pack labelling (FOPL) regulations (published in Canada Gazette I (CG1) and Canada Gazette II (CG2), respectively) by examining the difference in the prevalence of foods that would require a ‘High in’ front-of-pack nutrition symbol and nutrient intakes from those foods consumed by Canadian adults.

Foods in a generic food composition database (n 3676) were categorised according to the details of FOPL regulations in CGI and CGII, and the differences in the proportion of foods were compared. Using nationally representative dietary survey data, potential intakes of nutrients from foods that would display a ‘High in’ nutrition symbol according to CGI and CGII were compared.

Canada

Canadian adults (≥ 19 years; n 13 495)

Compared with CGI, less foods would display a ‘High in’ nutrition symbol (Δ = –6 %) according to CGII (saturated fat = –4 %, sugars = –1 %, sodium = –3 %). Similarly, potential intakes of nutrients-of-concern from foods that would display a ‘High in’ nutrition symbol were reduced according to CGII compared with CGI (saturated fat = –21 %, sugars = –2 %, sodium = –6 %). Potential intakes from foods that would display a ‘High in’ nutrition symbol were also reduced for energy and nutrients-to-encourage, including protein, fibre, calcium and vitamin D.

Changes to FOPL regulations may have blunted their potential to limit intakes of nutrients-of-concern; however, they likely averted potential unintended consequences on intakes of nutrients-to-encourage for Canadians (e.g. calcium and vitamin D). To ensure policy objectives are met, FOPL regulations must be monitored regularly and evaluated over time.

Nutrition labelling is mandatory on food products in retail stores, but compliance in the rapidly expanding online setting remains unclear. We assessed mandatory and voluntary labelling information across major U.S. online retailers.

Between January and August 2022, we evaluated a representative basket of sixty food and beverage items across eight product categories of ten major retailers. We evaluated online presence, accessibility and legibility of four mandatory elements – Nutrition Facts, ingredients, allergen statements and percent juice for fruit drinks – and presence of seven voluntary elements – nutrient content claims, health/qualified health claims, ingredient claims, structure–function claims, additive claims, front-of-package nutrient profiling symbols and other marketing claims.

Major online food retailers in the USA.

N/A.

On average, each mandatory element was present, accessible and legible for only 35·1 % of items, varying modestly by element (from 38·3 % for ingredients lists to 31·5 % for Nutrition Facts) but widely by retailer (6·6–86·3 %). Voluntary elements were present for 45·8 % of items, ranging from 83·7 % for marketing claims to 2·0 % for structure–function claims. Findings were generally consistent across the eight product categories. Voluntary elements were more frequently present than accessible and legible mandatory elements for six of ten retailers and seven of eight product categories.

Mandatory nutrition label elements are not commonly present, accessible and legible in online retail settings and are less consistently present than marketing elements. Coordinated industry and regulatory actions may be needed to ensure consumers can access mandatory nutrition information to make healthy and safe food choices online.

To assess the effect of different front-of-package labelling (FOPL) schemes on the objective understanding of the nutritional content and intention to purchase products, in Panama.

Single-blinded multi-arm parallel-group randomised controlled trial.

Supermarkets across Panama. Participants were exposed to two-dimensional images of fifteen mock-up products presented at random and balanced orders. Participants assigned to the intervention groups were exposed to mock-ups featuring one FOPL scheme: black octagonal warning labels (OWL), traffic-light labelling (TFL) or guideline daily amounts (GDA). The control group was not exposed to any FOPL scheme.

Adult supermarket shoppers (n 1200). Participants were blinded to group assignment.

A similar number of participants were randomised and analysed in each group: OWL (n 300), TFL (n 300), GDA (n 300) and control (n 300). The odds of choosing to purchase the least harmful or none of the options more often was the highest in the OWL group. Compared with the control group, these odds were two times higher in the OWL group (OR 2·13, 95 % CI 1·60, 2·84) and 57 % higher in the TFL (1·57, 1·40–2·56), with no changes in the GDA (0·97, 0·73–1·29). OWL also resulted in the highest odds for correctly identifying the least harmful option and for correctly identifying a product with excessive amounts of sugars, sodium and/or saturated fats.

OWL performed best in helping shoppers to correctly identify when a product contained excessive amounts of nutrients of concern, to correctly identify the least harmful option and to decide to purchase the least harmful or none of the options, more often.

This study aimed to identify correlates of nutrition label awareness and use, particularly subgroup differences among consumers. Two label types were assessed: (1) nutrition facts tables (NFt) in Australia, Canada, Mexico, UK, and USA and (2) front-of-package (FOP) labels, including mandatory Guideline Daily Amounts (Mexico), voluntary Health Star Ratings (Australia) and voluntary Traffic Lights (UK).

Respondents were recruited using Nielsen Consumer Insights Global Panel (n 21 586) and completed online surveys in November–December 2018. Linear regression and generalised linear mixed models examined differences in label use and awareness between countries and label type based on sociodemographic, knowledge-related and dietary characteristics.

Australia, Canada, Mexico, UK and USA.

Adults (≥18 years).

Respondents from the USA, Canada and Australia reported significantly higher NFt use and awareness than those in Mexico and the UK. Mexican respondents reported the highest level of FOP label awareness, whereas UK respondents reported the highest FOP label use. NFt use was higher among females, ‘minority’ ethnic groups, those with higher nutrition knowledge and respondents with ‘adequate literacy’ compared with those with ‘high likelihood of limited literacy’. FOP label use was higher among those with a ‘high likelihood of limited literacy’ compared with ‘adequate literacy’ across countries.

Lower use of mandatory Guideline Daily Amount labels compared with voluntary FOP labelling systems provides support for Mexico’s decision to switch to mandatory ‘high-in’ warning symbols. The patterns of consumer label use and awareness across sociodemographic and knowledge-related characteristics suggest that simple FOP labels may encourage broader use across countries.

To analyse the process for the development and implementation of mandatory nutritional warning labels in Uruguay, in order to inform future nutrition policy making and strategic engagement by public health actors.

The study design drew on policy analysis methodology and case study research methodology. Two main sources of information were selected and analysed for the current study: eighteen official documents from the Uruguayan government and 259 news reports, published between June 2017 and February 2021.

Uruguay, Latin America.

The Uruguayan Ministry of Public Health led a cross-sectoral working group composed of diverse governmental stakeholders, international organisations and the academia to develop the front-of-package nutrition labelling policy. A robust evidence-based approach, based on rigorous scientific knowledge generated in the country, was followed. However, changes in the systemic governing coalition as a consequence of a change in government led to a delay in the entry into force and changes in the regulation. The food industry was the main opponent to the warning label regulation and relied on widely reported corporate political activities to influence the policy process: information and messaging, legal action, policy substitution, opposition, fragmentation and destabilisation.

Key insights to inform future policy action in Uruguay and other jurisdictions were derived. Results stressed the importance of an evidence-based approach for policy design and the early engagement with actors from all the political system.

Considering the negative impact of the consumption of ultra-processed foods on health, the current study assessed the availability and nutritional profile of commercial ultra-processed foods for infants in Natal, Brazil.

A cross-sectional exploratory study.

Foods targeted at children under the age of 36 months sold in retail establishments located in high- and low-income areas of the one capital city of Brazil.

1645 food products consisting of ninety-five different types of food were available. The foods were assessed according to the NOVA classification: minimally processed, processed and ultra-processed. The nutritional content per 100 g was assessed according to processing classification.

Half of foods founded were breast milk substitutes and cereal foods (31·6 and 26·3 %, respectively). The foods were predominantly ultra-processed (79 %) and only 4·2 % were minimally processed, with similar proportions of ultra-processed foods being found in both high- and low-income areas. After excluding breast milk substitutes and follow-up formulas, all cereals, food supplements and some of the fruit or vegetable purees were ultra-processed, higher in energy density, fat, carbohydrate and protein and low in fibre (P < 0·05).

The findings reveal that ultra-processed foods for infants are widely available in Brazil, reaffirming the need to strengthen the regulation of foods for infants and young children by introducing complementary measures designed to promote the production and marketing of foods manufactured using lower levels of processing.

To evaluate if the inclusion of nutritional warnings in food ordering websites can discourage consumers from purchasing foods with excessive content of nutrients associated with non-communicable diseases (NCD).

Participants were randomly assigned to one of the two experimental conditions: control (n 225) or nutritional warnings (n 222). Nutritional warnings corresponded to separate black octagonal signs containing the word ‘Excess’ followed by the corresponding nutrient: total fat, saturated fat, sugars and sodium. Participants were asked to purchase a lunch for themselves using a simulated food ordering website.

Online study in Uruguay.

Convenience sample of 447 Uruguayan participants, recruited using social media.

In the control condition, 76 % of the participants selected a dish or a beverage with excessive content of at least one nutrient in the simulated food ordering website. When nutritional warnings were included, this percentage significantly decreased to 62 % (P = 0·002). In addition, nutritional warnings caused a significant reduction in the percentage of participants who selected dishes with excessive content of total fat: 50 % v. 62 % (P = 0·012).

Results from the present work provide preliminary evidence that the inclusion of nutritional warnings in food ordering websites could discourage consumers from selecting dishes and beverages with excessive content of nutrients associated with NCD.

To examine the impact of front-of-package (FOP) labels on perceived healthfulness, purchasing intentions and understanding of common FOP systems.

A parallel, open-label design randomised participants to different FOP labelling conditions: ‘high in’ warning labels (WL), multiple traffic light labelling (TLL), health star ratings (HSR) (all displayed per serving) or control with no interpretive FOP labelling. Participants completed a brief educational session via a smartphone application and two experimental tasks. In Task 1, participants viewed healthy or unhealthy versions of four products and rated healthiness and purchasing intention on a seven-point Likert-type scale. In Task 2, participants ranked three sets of five products from healthiest to least healthy.

Online commercial panel.

Canadian residents ≥ 18 years who were involved in household grocery shopping, owned a smartphone and met minimum screen requirements.

Data from 1997 participants (n 500/condition) were analysed. Task 1: across most product categories, the TLL and HSR increased perceived healthiness of healthier products. All FOP systems decreased perceived healthiness of less healthy products. Similar, albeit dampened, effects were seen regarding purchasing intentions. Task 2: participants performed best in the HSR, followed by the TLL, WL and control conditions. Lower health literacy was associated with higher perceived healthiness and purchasing intentions and poorer ranking task performance across all conditions.

All FOP labelling systems, after a brief educational session, improved task performance across a wide spectrum of foods. This effect differed depending on the nutritional quality of the products and the information communicated on labels.

Trial Registration: NCT03290118.

To assess the effects of nutritional warnings during the first month after the date of full compliance by the food industry in Uruguay in terms of citizen awareness, self-reported use and ability to understand nutritional information.

The present work encompassed two online studies, conducted before (Study 1) and during the first month after the date of full compliance by the food industry (Study 2). An after-only design was used to assess awareness of the policy, exposure to nutritional warnings on food packages and self-reported use of warnings for making purchase decisions in Study 2. An after-only with control group experimental design was used to assess the effect of nutritional warnings on understanding of nutrition information in Studies 1 and 2.

Uruguay, one of the Latin American countries, that has recently implemented nutritional warnings.

A non-probabilistic sample of 1772 participants was recruited using Facebook advertisements targeted at Uruguayan adult users.

High awareness and self-reported use of nutritional warnings during the first month after the date of full compliance in Uruguay were observed. In addition, the before and after comparison showed that the implementation of warnings increased citizens’ ability to use nutritional information to compare products and to identify products with excessive content of sugar, fat, saturated fat and sodium.

The current study confirms results from experimental studies and provides additional evidence to support the implementation of nutritional warnings as one of the public policies that can contribute to tackle obesity and non-communicable diseases.

Studies have shown that the consumption of added sugars may be associated with harmful health effects. The present study investigated the presence and types of added sugars in packaged foods.

Cross-sectional analysis of the presence and types of added sugars in the ingredients lists of packaged foods sold in a major Brazilian supermarket. The nomenclature of ingredients classified as added sugars and their frequency were identified. Data were organised and analysed through descriptive statistics: absolute and relative frequencies of the presence of added sugars categorised by food groups were calculated, and ingredients were analysed by text mining using R statistical environment.

A supermarket in Florianópolis, a metropolis in southern Brazil.

Packaged food products (n 4539) classified into eight groups.

Of the 4539 products, 71 % had some type of added sugar. The group with the highest frequency of added sugars was ‘products in which carbohydrates and fats are the main energy source’ (93 %). Food groups containing predominantly salty foods had a high frequency of added sugars, such as ‘meats and eggs’ (61 %). In total, 179 different terms for added sugars were identified, of which sugar, maltodextrin and glucose syrup were the most frequent.

Most of the packaged foods sold in Brazil contain added sugars, which may hamper adherence to the recommendation of limiting added sugars intake. The data may be useful for monitoring tendencies in the use of added sugars in packaged foods and as supplementary information to support the improvement of food label regulations.

To understand parents’ knowledge and use of nutrition labelling and to explore its associated factors.

Cross-sectional survey.

Two schools providing a nine-year educational programme in Putuo District, Shanghai, China, were selected for the study. Information was included on demographic data and knowledge of the Chinese Food Pagoda.

Students and their parents (n 1770) participated in a questionnaire survey.

Of questionnaires, 1766 were completed (response rate 99·8 %). Utilization rate of nutrition labelling was 19·3 %. Among 624 parents knowing nutrition labelling, 22·1 % understood all the information included, 70·7 % understood it partially and 7·2 % could not understand it at all. Use of nutrition labelling by parents was related to the following factors (OR; 95 % CI): high educational level of parent (1·465; 1·165, 1·841), parent’s knowledge of the Chinese Food Pagoda (1·333; 1·053, 1·688), parent’s consumption of top three snacks which are unhealthy (1·065; 1·023, 1·109), parent’s assumption that nutrition labelling would affect their choice of food (1·522; 1·131, 2·048), student’s willingness to learn about labels (1·449; 1·093, 1·920) and student’s knowledge and use of labels (2·214; 1·951, 2·513).

Parents’ knowledge and use of nutrition labelling are still at a lower level, and some information included in the nutrition labels is not understood by parents. The forms of the existing nutrition labelling need to be continuously improved to facilitate their understanding and usefulness. It is necessary to establish nutrition projects focusing on education and use of nutrition labels which help parents and their children make the right choices in selecting foods.

To objectively evaluate voluntary nutrition and health claims and marketing techniques present on packaging of high-market-share ultra-processed foods (UPF) in Australia for their potential impact on public health.

Cross-sectional.

Packaging information from five high-market-share food manufacturers and one retailer were obtained from supermarket and manufacturers’ websites.

Ingredients lists for 215 UPF were examined for presence of added sugar. Packaging information was categorised using a taxonomy of nutrition and health information which included nutrition and health claims and five common food marketing techniques. Compliance of statements and claims with the Australia New Zealand Food Standards Code and with Health Star Ratings (HSR) were assessed for all products.

Almost all UPF (95 %) contained added sugars described in thirty-four different ways; 55 % of UPF displayed a HSR; 56 % had nutrition claims (18 % were compliant with regulations); 25 % had health claims (79 % were compliant); and 97 % employed common food marketing techniques. Packaging of 47 % of UPF was designed to appeal to children. UPF carried a mean of 1·5 health and nutrition claims (range 0–10) and 2·6 marketing techniques (range 0–5), and 45 % had HSR≤3·0/5·0.

Most UPF packaging featured nutrition and health statements or claims despite the high prevalence of added sugars and moderate HSR. The degree of inappropriate or inaccurate statements and claims present is concerning, particularly on packaging designed to appeal to children. Public policies to assist parents to select healthy family foods should address the quality and accuracy of information provided on UPF packaging.

Warnings have recently been proposed as a new type of directive front-of-pack (FOP) nutrition labelling scheme to flag products with high content of key nutrients. In the present work, this system was compared with the two most common FOP nutrition labelling schemes (Guideline Daily Amounts (GDA) and traffic-light system) in terms of goal-directed attention, influence on perceived healthfulness and ability to differentiate between products.

Goal-directed attention to FOP labels was evaluated using a visual search task in which participants were presented with labels on a computer screen and were asked to indicate whether labels with high sodium content were present or absent. A survey with 387 participants was also carried out, in which the influence of FOP labels on perceived healthfulness and ability to identify the healthful alternative were evaluated.

Warnings improved consumers’ ability to correctly identify a product with high content of a key nutrient within a set of labels compared with GDA and received the highest goal-directed attention. In addition, products with high energy, saturated fat, sugar and/or sodium content that featured warnings on the label were perceived as less healthful than those featuring the GDA or traffic-light system. Warnings and the traffic-light system performed equally well in the identification of the most healthful product.

Results from the present work suggest that warnings have potential as directive FOP nutrition labels to improve consumer ability to identify unhealthful products and highlight advantages compared with the traffic-light system.

The present study investigated whether parent/child pairs would select more healthful foods when: (i) products were labelled with front-of-package (FOP) nutrition labels relative to packages without labels; (ii) products were labelled with colour-coded Multiple Traffic Light (MTL) FOP labels relative to monochromatic Facts up Front (FuF) FOP labels; and (iii) FOP labels were explained via in-aisle signage v. unexplained.

Participants were randomly assigned to one of five conditions: (i) FuF labels with in-aisle signs explaining the labels; (ii) FuF labels, no signage; (iii) MTL labels with in-aisle signage; (iv) MTL labels, no signage; (v) control group, no labels/signage. Saturated fat, sodium, sugar and energy (calorie) content were compared across conditions.

The study took place in a laboratory grocery aisle.

Parent/child pairs (n 153) completed the study.

Results did not support the hypothesis that MTL labels would lead to more healthful choices than FuF labels. The presence of FOP labels did little to improve the healthfulness of selected foods, with few exceptions (participants with v. without access to FOP labels selected lower-calorie cereals, participants with access to both FOP labels and in-aisle explanatory signage selected products with less saturated fat v. participants without explanatory signage).

Neither MTL nor FuF FOP labels led to food choices with significantly lower saturated fat, sodium or sugar. In-aisle signs explaining the FOP labels were somewhat helpful to consumers in making more healthful dietary decisions. New FOP labelling programmes could benefit from campaigns to increase consumer awareness and understanding of the labels.

To analyse patterns of knowledge, comprehension, attitudes and practices regarding the traffic light label placed on processed food packages to inform Ecuadorian consumers about levels of added fat, sugar and salt.

Twenty-one focus group discussions organized by age group, sex and place of residence. Interviews with representatives of companies that manufacture or market processed foods. Analysis of regulations and structured observations of processed food labels.

Cities and towns in Ecuador’s coastal, highland and eastern lowland regions.

One hundred and seventy-eight participants in twenty-one focus group discussions and nine key informants.

Focus group participants knew about the traffic light label and understood the information it conveys, but not all changed their attitudes and practices related to the purchase and consumption of processed foods. Children, adolescents and adult males reported using the information infrequently; adolescents interested in health and adult women used the label the most to select products. Representatives of companies that manufacture or market processed foods generally opposed the policy, stating that the information is misleading. Nevertheless, some companies have reduced levels of added fat, sugar or salt in their products.

The traffic light label is an effective tool for conveying complex information. Its potential contribution to reduce consumption of products with high levels of fat, sugar and salt could be enhanced by promoting healthy diets among consumers who have not changed purchasing and consumption behaviour, by placing the label on front panels and by monitoring the production and marketing of processed foods.

To test modifications to nutrition label serving size information on understanding of energy (calorie) content among youth and young adults.

Participants completed two online experiments. First, participants were randomly assigned to view a beverage nutrition label with a reference amount of per serving (250 ml), per container (473 ml) or a dual-column format with both reference amounts. Participants were then randomized to view a cracker nutrition label which specified a single serving in small font, a single serving in large font, or the number of servings per bag with single serving information below. In both experiments, participants estimated energy content. Logistic regression analysis modelled correct energy estimation. Finally, participants reported their preference for serving size display format.

Canada.

Canadian youth and young adults (n 2008; aged 16–24 years).

In experiment 1, participants randomized to view the nutrition label with per container or dual column were more likely to correctly identify energy content than those using per serving information (P<0·01). For experiment 2, the serving size display format had no association with correct energy estimation. The majority of participants (61·9 %) preferred the serving size format that included servings per package.

Labelling foods with nutrition information using a serving size reference amount for the entire container increased understanding of energy content. Consumers prefer nutrition labels that include more prominently featured serving size information. Additional modifications that further improve consumers’ accuracy should be examined. These results have direct implications for nutrition labelling policy.

To evaluate consistency levels of nutrition labelling on supermarket websites.

This is a comparative, quantitative study examining page position, content and design of nutrition labels on own-brand and branded products. Online and in-store nutrition labels were examined, categorised and analysed to discern variety of label designs used and consistency between online and in-store labelling.

Five large online food retailers in the UK.

Nutrition labels displayed on 100 webpages were examined for twenty branded and own-brand products. Equivalent labels on in-store packaged products were also examined.

Eight different combinations of nutrition label designs were found. The online supermarket sites were found to use from three to six of these label combinations across the sample. The consistency level between online and in-store package labels ranged from 25 % to 90 %. In many cases the nutrition label required scrolling to view and in all cases items could be purchased without the label being visible from the search result listings.

The main recommendation of the paper is that online nutrition labelling needs to be much more consistently presented than is currently practised, both within each website and between online and in-store experiences. Particular attention should be made to polychrome colour and the inclusion of summary graphics. Designers should also ensure visibility of the label and raise its vertical page position. The paper also proposes additional expansion of the use of nutrition information online, using nutrition values as database fields in search criteria and checkout aggregation reporting.

To assess the Na content reported on the labels of processed foods sold in Brazil that are usually consumed as snacks by children and adolescents.

Cross-sectional study that assessed Na content and serving size reporting on processed food labels.

A supermarket that is part of a large chain in Brazil.

All foods available for sale at the study’s location and reported in the literature as snacks present in the diets of Brazilian children and adolescents.

Of the 2945 processed foods, 87 % complied with the reference serving sizes, although variability in reporting was observed in most of the food subgroups. In addition, 21 % of the processed foods had high Na levels (>600 mg/100 g) and 35 % had medium Na levels (>120 and ≤600 mg/100 g). The meats, oils, fats and seeds groups as well as the prepared dishes had higher percentages of foods classified as high Na (81 %, 58 % and 53 %, respectively).

Most of the processed foods had high or medium Na content. We emphasize the importance of revising Brazilian nutrition labelling legislation to standardize reference serving sizes to avoid variation. Besides, we point out the potential for reducing Na levels in most processed foods, as evidenced by the variability in Na content within subgroups. Finally, we have identified the need to develop a method to classify Na levels in processed foods with specific parameters for children and adolescents.