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.

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.

To assess the attitudes and perceived knowledge of health professionals regarding the food product judgemental-labelling reform that began in January 2020 in Israel.

Cross-sectional survey.

An online survey among health professionals working in the Israeli health system.

456 participants (118 physicians, 207 nurses, 131 nutritionists).

Most respondents (89·9 %) were women, 36 % had over 20 years of professional experience. All nutritionists, 96·6 % of physicians and 94·7 % of nurses reported hearing about the reform, and most (88·9 % of nurses, 76·3 % of physicians and 75·6 % of nutritionists) claimed supporting the reform to a great or very great extent. Most respondents believe they should discuss issues related to healthy eating with their patients (91·8 % of nurses, 94·9 % of physicians and all nutritionists), but only about half (47·5 % of physicians and 57·0 % of nurses) reported that they have sufficient knowledge in this field, particularly about food labelling. Almost two-thirds of nutritionists (60·3 %) reported instructing patients to change their food intake according to labelling v. 40·1 % and 34·7 % of nurses and physicians, respectively. Only some respondents felt that they could influence their patients’ nutrition habits. Most participants believe that additional regulatory measures should also be used to promote healthy nutrition.

There is a gap between the desire of physicians and nurses to provide nutritional guidance to the public and their actual knowledge about the labels’ meaning as well as their competencies in providing nutrition counselling. When formulating a reform, policymakers should provide clear guidelines about the expectations of implementing it in therapeutic practice.

To examine the labelling status of trans-fat of pre-packaged foods sold in Hong Kong.

Data from 19 027 items in the 2019 FoodSwitch Hong Kong database were used. Ingredient lists were screened to identify specific (e.g. partially hydrogenated vegetable oil, PHVO) and non-specific trans-fat ingredient indicators (e.g. hydrogenated oil). Trans-fat content was obtained from the on-pack nutrition labels, which was converted into proportion of total fat (%total fat). Descriptive statistics were calculated for trans-fat content and the number of specific, non-specific and total trans-fat ingredients indicators found on the ingredients lists. Comparisons were made between regions using one-way ANOVA and χ2 for continuous and categorical variables, respectively.

Cross-sectional audit.

Not applicable.

A total of 729 items (3·8 % of all products) reported to contain industrially produced trans-fat, with a median of 0·4 g/100 g or 100 ml (interquartile range (IQR): 0·1–0·6) and 1·2 %totalfat (IQR: 0·6–2·9). ‘Bread and bakery products’ had the highest proportion of items with industrially produced trans-fat (18·9 %). ‘Non-alcoholic beverages’ had the highest proportion of products of ‘false negatives’ labelling (e.g. labelled as 0 trans-fat but contains PHVO; 59·3 %). The majority of products with trans-fat indicator originated from Asia (70 %).

According to the labelling ∼4 % of pre-packaged food and beverages sold in Hong Kong in 2019 contained industrially produced trans-fat, and a third of these had trans-fat >2 %total fat. The ambiguous trans-fat labelling in Hong Kong may not effectively assist consumers in identifying products free from industrially produced trans-fat.

The Keyhole is an internationally recognised front-of-pack nutrition label, guiding consumers to healthier food options. It indicates products in accordance with specific criteria for dietary fats, sugars, fibres, salt and wholegrains. The objective of this study was to simulate the potential impact of the Keyhole on adolescents’ energy and nutrient intakes by modelling a shift from reported food intakes to foods meeting the Keyhole criteria.

Self-reported dietary intake data were derived from a cross-sectional survey. Multiple replacement scenarios were calculated, where foods meeting the Keyhole criteria replaced reported non-compliant foods with varying proportions of replacement.

Dietary survey ‘Riksmaten Adolescents 2016–2017’ in schools across Sweden.

A nationally representative sample of 3099 adolescents in school years 5, 8 and 11 (55 % girls).

Overall, replacement with foods meeting the Keyhole criteria led to more adolescents meeting nutrition recommendations. Largest median intake improvements were seen for wholegrains (+196 %), SFA (-13 %), PUFA (+17 %) and fibres (+15 %). Smallest improvements were seen for free sugars (-3 %) and salt (-2 %), partly explained by the ineligibility of main food sources of free sugars for the Keyhole, and non-inclusion of ready meals that are often high in salt. Most micronutrient intakes were stable or improved. Unintentional effects included decreases in vitamin A, MUFA and energy intakes. Largest potential improvements in fat and fibre sources were observed in the youngest age group.

A shift to Keyhole alternatives for everyday foods would improve adolescents’ nutrient intakes, even with smaller exchanges.

The rapid growth in web-based grocery food purchasing has outpaced federal regulatory attention to the online provision of nutrition and allergen information historically required on food product labels. We sought to characterise the extent and variability that online retailers disclose required and regulated information and identify the legal authorities for the federal government to require online food retailers to disclose such information.

We performed a limited scan of ten products across nine national online retailers and conducted legal research using LexisNexis to analyse federal regulatory agencies’ authorities.

USA.

N/A.

The scan of products revealed that required information (Nutrition Facts Panels, ingredient lists, common food allergens and per cent juice for fruit drinks) was present, conspicuous and legible for an average of only 36·5 % of the products surveyed, ranging from 11·4 % for potential allergens to 54·2 % for ingredients lists. More commonly, voluntary nutrition-related claims were prominently and conspicuously displayed (63·5 % across retailers and products). Our legal examination found that the Food and Drug Administration, Federal Trade Commission and United States Department of Agriculture have existing regulatory authority over labelling, online sales and advertising, and Supplemental Nutrition Assistance Programme retailers that can be utilised to address deficiencies in the provision of required information in the online food retail environment.

Information regularly provided to consumers in conventional settings is not being uniformly provided online. Congress or the federal agencies can require online food retailers disclose required nutrition and allergen information to support health, nutrition, equity and informed consumer decision-making.

Front-of-pack (FOP) nutrition labelling is a globally recommended strategy to encourage healthier food choices. We evaluated the effect of FOP labels on the perceived healthfulness of a sweetened fruit drink in an international sample of adult consumers.

Six-arm randomised controlled experiment to examine the impact of FOP labels (no label control, Guideline Daily Amounts (GDA), Multiple Traffic Lights, the Health Star Ratings (HSR), Health Warning Labels, and ‘High-in’ Warning Labels (HIWL)) on the perceived healthfulness of the drink. Linear regression models by country examined healthfulness perceptions on FOP nutrition labels, testing for interactions by demographic characteristics.

Online survey in 2018 among participants from Australia, Canada, Mexico, United Kingdom (UK) and United States.

Adults (≥18 years, n 22 140).

Compared with control, HIWL had the greatest impact in lowering perceived healthfulness (β from −0·62 to −1·71) across all countries. The HIWL and the HSR had a similar effect in Australia. Other labels were effective in decreasing the perceived healthfulness of the drink within some countries only, but to a lower extent. The GDA did not reduce perceived healthfulness in most countries. In the UK, the effect of HIWL differed by age group, with greater impact among older participants (> 40 years). There were no other variations across key demographic characteristics.

HIWL, which communicates clear, non-quantitative messages about high levels of nutrients of concern, demonstrated the greatest efficacy to decrease the perceived healthfulness of a sweetened fruit drink across countries. This effect was similar across demographic characteristics.

Evidence of the health and environmental harms of red meat is growing, yet little is known about which harms may be most impactful to include in meat reduction messages. This study examined which harms consumers are most aware of and which most discourage them from wanting to eat red meat.

Within-subjects randomised experiment. Participants responded to questions about their awareness of, and perceived discouragement in response to, eight health and eight environmental harms of red meat presented in random order. Discouragement was assessed on a 1-to-5 Likert-type scale.

Online survey.

544 US parents.

A minority of participants reported awareness that red meat contributes to health harms (ranging from 8 % awareness for prostate cancer to 28 % for heart disease) or environmental harms (ranging from 13 % for water shortages and deforestation to 22 % for climate change). Among specific harms, heart disease elicited the most discouragement (mean = 2·82 out of 5), followed by early death (mean = 2·79) and plants and animals going extinct (mean = 2·75), though most harms elicited similar discouragement (range of means, 2·60–2·82). In multivariable analyses, participants who were younger, identified as Black, identified as politically liberal, had higher general perceptions that red meat is bad for health and had higher usual red meat consumption reported being more discouraged from wanting to eat red meat in response to health and environmental harms (all P < 0·05).

Messages about a variety of health and environmental harms of red meat could inform consumers and motivate reductions in red meat consumption.

To estimate the proportion of products meeting Fiji government labelling regulations, assess compliance with national Na reformulation targets and examine the Na and total sugar levels in packaged foods sold in selected major supermarkets.

We selected five major supermarkets in 2018 and collected the product information and nutritional content from the labels of all packaged foods sold. We organised 4278 foods into fourteen major food categories and thirty-six sub-categories and recorded the proportion of products labelled in accordance with the Fiji labelling regulations. We looked at the levels of Na and total sugar in each food category and assessed how many products complied with the Fiji reformulation targets set for Na. We also listed the companies responsible for each product.

Suva, Fiji.

Fourteen percentage of packaged foods in fourteen major categories met Fiji national labelling regulations. Na was labelled on 95·4 % products, and total sugar labelled on 92·4 %. The convenience foods category had the highest Na levels (1699 mg/100 g), while confectionery had the highest content of total sugar (52·6 g/100 g). Forty percentage of eligible products did not meet the proposed voluntary Na reformulation targets.

Our findings indicate significant room for improvement in nutrient labelling, as well as a need for further enforcement of reformulation targets and monitoring of changes in food composition. Through enacting these measures and establishing additional regulations such as mandatory front-of-pack labelling, government and food industry can drive consumers towards healthier food choices and improve the nutritional quality of packaged foods in Fiji.

Toddler milk (i.e. a nutrient-fortified milk-based drink marketed for children 12–36 months old) is increasingly being marketed in the USA despite not being recommended for young children. There is evidence of targeted toddler milk marketing to Latinos in the USA. This study aimed to explore toddler milk perceptions and behaviours among Latino and non-Latino parents.

An online survey assessed toddler milk perceptions, behaviours and interpretations of nutrition-related claims. Multivariable logistic and linear regression explored socio-demographic correlates of parent reported past purchases and perceived healthfulness.

Online.

National convenience sample of 1078 US parents of children aged 2–12 years (48 % Latino).

About half of parents (51 %) had previously purchased toddler milk and few (11 %) perceived toddler milk as unhealthy. Latino parents were more likely to have purchased toddler milk than non-Latino parents (P < 0·001), but there were no differences in perceived product healthfulness (P = 0·47). Compared to parents born in the USA, parents living in the USA 10 years or less were more likely to have purchased toddler milk (P < 0·001) and perceive toddler milk as healthier (P = 0·002). Open-ended interpretations of claims were primarily positive, suggesting ‘health halo’ effects.

Common misperceptions about toddler milk healthfulness suggest stronger labelling regulations are needed. Greater reported purchases by Latino parents and recent immigrants warrant further investigation.

To understand how healthy menu labelling information is used by parents/caregivers and where it fits within predictors of healthy meal choices when eating out.

Parents were recruited to complete a 15-min observational, online survey regarding their experiences and hypothetical choices when eating out with their child/ren.

Australia.

Eligible participants had one or more child/ren aged between 2 and 12 years and attended cafes, restaurants, hotels and clubs (CRHC) for lunch or dinner at least four times a year. Of initial respondents (n 1802), 92·5 % provided complete and valid data. Participants were 84·7 % female, ranging from 18 to 68 years old.

98·3 % believed that healthier alternatives should be available for children in CRHC. For general food choices, health was a strong motivator (45·7 %); however, parents reported eating at CRHC mainly for pleasure or a treat (61·2 %) and being driven by children’s taste preferences (85·9 %) when selecting menu items. 59·0 % of orders included a combination of healthy and traditional items. 42·0 % of the sample were influenced by the healthy choice (HC) labelling. Multiple regression revealed that, in addition to some demographic variables, the percent of HC ordered was positively associated with self-reported parent vegetable consumption, making food choices for the children for health reasons, familiarity with HC items and making order choices due to dietary needs and good nutrition.

Despite a preference for availability of healthier children’s menu choices in CRHC, menu labelling highlighting healthy options may have limited impact relative to child preferences.

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.

The present study aimed at surveying the nutritional quality of prepacked biscuits and sweet snacks sold on the Italian market, and at identifying whether the product type and other information reported on the pack could discriminate the overall quality of products analysed.

Data on energy, nutrient and salt content of the products from two different categories of prepacked sweet cereal products (i.e. biscuits and sweet snacks) were collected from thirteen retailers present on the Italian market. Based on the product type, nutrition and health claim (NHC) and gluten-free (GF) declaration, a comparison of nutrient profile within each category was performed.

This work is part of the Food Labelling of Italian Products (FLIP) study that aims at systematically investigating the overall quality of the prepacked foods sold on the Italian market.

A total of 1290 products were analysed (63 % biscuits and 37 % sweet snacks). After comparing different product types within each category, a high intra-type product variability was evidenced, which was more pronounced for biscuits. Overall, NHC-carrying products seemed to have a better nutrition profile than those without claims, except for salt content. Conversely, a comparison between GF and gluten-containing products did not show consistent results within the two categories analysed.

Due to the high intra-type variability within each category, the different characteristics and regulated information reported on the pack do not seem to be a clear marker of the overall nutritional quality of biscuits and snacks.

To analyse the Na content of bread by comparing the amount of salt and Na among the label, laboratory analysis and international guidelines.

Ten selected bakeries provided 3239 randomly selected samples of bread, which were weighed on-site. Triplicate samples were retrieved from each bakery (thirty samples) for analysis. Bread production was observed, and ingredient labels were queried to determine salt weights, which were used for comparison with the laboratory analysis. Flame photometry and the method for chlorides were utilised for analysing Na. Laboratory findings were compared to nine different international nutritional guidelines for Na consumption.

Florianopolis, south of Brazil.

Ninety independent bakeries locally producing Portuguese rolls were queried; rolls from ten conveniently selected bakeries were retrieved for further analysis.

The average weight of the rolls was 50·2 ± 5·3 g. The average amount of salt (g) per roll, by laboratory and label analyses, was 0·69 ± 0·0 and 0·62 ± 0·1 g, respectively. The mean level of Na (mg) reported on nutrient labels (478·2 ± 93·4/100 g) was significantly lower than by laboratory analysis (618·2 ± 73·8/100 g), P < 0·001. There was a difference for Na in rolls produced in the bakeries considering the unit weight of rolls (P ≤ 0·001) per 100 g (P = 0·026) and the mode of production. The consumption of two averaged units of rolls was equivalent to 51·7 % of the Brazilian guideline daily amount for Na for children and 31 % for adults.

The nutrient labels underreported Na values. This study strengthens the importance of monitoring Na of breads in Brazil.

To assess the prevalence of partially hydrogenated oils (PHO), hydrogenated oils (HO) and/or both in Canadian packaged foods in 2013 and 2017 and to determine the mean trans-fatty acid (TFA) content of products declaring such oils.

Repeated cross-sectional study of the Food Label Information Program.

Food labels (n 32 875) were collected from top Canadian grocery retailers in 2013 and 2017. Proportions of products declaring PHO, HO and/or both in the Ingredients List were calculated by year and food category. The percentage contribution of TFA (g) to total fat (g) was calculated and compared against the voluntary TFA limits, defined as <2 % of total fat content for fats and oils, and <5 % for all other foods. Foods exceeding limits were identified. The mean TFA content (in g/serving and per 100 g) was calculated for products with these oils.

The use of PHO, HO and/or both significantly decreased in Canadian foods from 2013 to 2017 (0·8 to 0·2 %, 5 to 2·4 % and 5·7 to 2·6 %, respectively, for PHO, HO and/or both). The mean TFA content of products containing PHO increased (0·34 to 0·57 g TFA/serving); although it was not statistically significant, it is still concerning that TFA content increased. The TFA content significantly decreased in foods with HO (0·24 to 0·16 g TFA/serving, P < 0·05) during 2013–2017.

Products with PHO continue to be present in the Canadian marketplace, despite voluntary efforts to eliminate them. Products with HO should also be monitored, as they can also contribute to TFA content in foods.