NCCHPP Nutrition Labelling Scientific Literature Extraction Table

NCCHPP – Nutrition Labelling – Scientific Literature Extraction Table

Extraction table used during the literature review conducted for the following document: Morestin, F., Hogue, M.-C., Jacques, M. & Benoit, F. (2011). Public policies on nutrition labelling: Effects and implementation issues — A knowledge synthesis. Montreal: National Collaborating Centre for Healthy Public Policy. The documents are presented in reverse chronological order and alphabetically by first author.

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects Borgmeier & Article in a - In Europe, labelling - Other studies: 25% of Even if there - Other - Other studies: Westenhoefer, scientific journal; is mandatory only if a consumers in supermarkets has been studies: use consumers like the 2009 source = claim has been made. are truly looking for nutrition little impact of labels idea of front-of- environmental - But there are no info on packages, most on consumer affected by package logos scan; primary labelling standards. read it accidentally rather choices, education, study - Existing systems: % than deliberately. The info introduction gender, age, (randomized daily intake, traffic is often misinterpreted, with of logos diet, nutrition trial, 420 lights, the “healthy consumers confused and could have knowledge. persons); choice” logo in the affected by the amount of resulted in - This authors = Netherlands. time available (Europeans reformu- study (logos): academics spend between 25 and 47 lations. Independent seconds on each product of format purchased in a used: more supermarket); is only one of good many sources of info decisions by (media, advertising, women and promotions may also affect people of choices); and does not normal prevent consumption of weight. No products appreciated for influence their taste. Use of found for benchmarks, numerical or education not, appears to help; (but this consumers say that they could be due understand front-of- to the package logos; daily intake convenience logos with colour codes and sample with traffic lights are logos well an over- understood. But there is representatio some exaggeration in the n of highly meaning of colours and educated traffic lights. Once they participants). have seen the logos, consumers say that they

NCCHPP – Nutrition Labelling – Scientific Literature Extraction Table

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects (cont’d) intend to make a different choice. Sales figures from supermarkets in the UK: following introduction of logos, sales of healthy products rose compared to a drop in the sales of comparable, less healthy products. - This study compared a health logo / multiple traffic lights / % daily intake / % with colours / absence of logo. Choice of healthiest product among equivalents, then participants assembled the day’s meals by choosing from among the products presented. - Logos help consumers identify the healthiest products (vs. absence of a logo), but the difference in correct answers is not that great. Logo giving the most correct answers: traffic lights, but the differences between logos were not large. - No influence on the choice of products consumed, independent of the logo format (and with the foods chosen, exceeded recommended values for all nutrients). Findings suggest that even if logos help consumers determine whether a product is healthy, this does not necessarily affect consumer

2 NCCHPP – Nutrition Labelling – Scientific Literature Extraction Table

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects choices. Gerend, 2009 Article in a - Other studies: - Other A law on scientific journal; contradictory evidence on studies: Men nutrition source = the effects of nutrition less likely to labels on (cont’d) environmental labelling in restaurants. use nutrition menus scan; primary labels in their would study (random- food involve ized trial, 288 decisions and some costs persons); author are less for = academic interested in restaurants choosing low- (e.g. calorie printing alternatives. new Data suggest menus), that young but such men may use costs nutrition info would be for weight relatively gain. low. - In this study (college students): when calories are shown, women made lower-cal choices (146 fewer calories per meal). If this happened once each week, it would make for 7,592 fewer calories per year, or 2.2 pounds less. Men: same

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects number of calories with or without info (in fact, slightly more calories with access to info, but this finding was not statistically significant).

Kelly et al., Article in a - The Australia New - Other studies: Labels may - Mandatory - Less - Most respondents 2009 scientific journal; Zealand Food lead to confusion and be labelling with objective supported info on source = Standards Code difficult to interpret; traffic lights understandin labels, particularly for environ-mental requires a nutrition objective measures show could lead g among saturated fats, sugar, scan; primary info label on all less use than self-reported companies respondents total fat and sodium. study packaged foods. use. Claims encourage to of lower - 90% found that a (randomized . Front-of-package consumers to limit their info reformulate. socio- uniform system would trial, 790 codes planned in the search to the front of the economic be easier to persons); UK and Europe: package, leading to quicker status understand. authors = public traffic lights and % judgments that are more (estimated by . % daily intake with health daily intake. positive but sometimes place of colour code was most professionals, - In 2006, the misleading. Traffic lights residence), preferred (41%), and academics Australian Food and allow consumers to more for the even more by those Grocery Council easily make better monochrome participants who had introduced voluntary selections among healthier % of daily already seen the % front-of-package products, at a glance. In the intake, but daily intake system labels with UK, purchase intentions not for the 3 (used by the industry percentage daily changed with exposure to other formats on a voluntary basis intake. In December traffic lights. (traffic lights; since 2006). 2007, this system - This study: test of 4 traffic lights + was adopted by over formats: traffic lights; lights overall traffic 15 large Australian + comprehensive traffic lights; % daily firms. lights; monochrome % daily intake with intake; % daily intake with colour code). colour code. - Objective understanding of labels was better among

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects respondents exposed to the two traffic lights formats (in contrast with preferred formats [see Acceptability]). - Most respondents found all formats easy to use (even if they made mistakes); slightly more found traffic lights “very” easy to use. - Perception of being able to make decisions at a glance. Higher among respondents exposed to the (cont’d) two traffic lights formats. - Items used most often in decision making (independent of format): fat and sodium. - 90% found that a standardized system would be easy to understand. Kuo, Jarosz, Article in a . USA: Nutrition - Assumption based on two - Generally, Simon, & scientific journal; Labeling and other empirical studies: chain Fielding, 2009 source = Education Act 10% of customers consume restaurants PubMed; (NLEA), 1990. lower-calorie meals provide modelling Applies to packaged (approximately 100 fewer nutrition (health impact foods but not to calories). info upon assessment); menus. - According to the assump- request, on authors = public - Generally, chain tions, introducing labelling the Internet health restaurants provide in the Los Angeles county’s or on-site, professionals / nutrition info upon chains with 15 or more but it is not academics request, on the restaurants will prevent very visible Internet or on-site, 40.6% of the annual weight (brochures, where it is not very gain among citizens 5 years liners). visible (brochures, of age and older (with liners). Senate Bill 1420, which - Recent approval of affects chains of 20 or more menu labelling restaurants, 37.3% regulations: NYC, prevented).

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects San Francisco, counties in Oregon and Washington state. In California, Senate Bill 1420 was approved in 2008, waiting for implementation: will require the state’s chain restaurants to list calories on menus and menu boards. Lobstein & Article in a - Nutrients combined - Problem of comparative - Sweden’s - Traffic lights [Technologi - European consumer Davies, 2009 scientific journal; in a single score for claims or logos: risk of lock logo: are easy to es:] organizations support source = comparison with other misunderstandings by one of the understand, - Easy to use of the traffic light PubMed; products in the same consumers, doe snit want goals is to even by define a system; took a position comments; category, such as to say that these products serve as an children and “high” or against the authors = NPO lock logo used in are recommended, only incentive to illiterate “low” level coexistence of different and academic Sweden (criteria set that they are healthier than food consumers. of nutrients systems. by government others in the same products - when - 73% of British (cont’d) agency, voluntary category. reformulatio Encouraging comparing consumers find that use, may be shown - [= impediment to better ns product products in having different on packaged foods, info?] Unique scores - The reformulation the same labelling systems is fruits and vegetables, developed by the industry: evidence is good, since category. confusing. fish, menus). mix absolute and relative shows that it is less likely - “High” or - Using only traffic - Single score for criteria, are tolerant of traffic lights to increase “low” level lights is considered too identifying healthy certain aspects. encourage health of nutrients: simplistic. products, several - With the percentage of product inequalities defined in - The Second WHO systems developed recommended daily intake, reformulatio than a regulations European Action Plan by the industry (e.g. manufacturers use different ns (remains measure on health for Food and Nutrition Kraft’s Sensible portion sizes, which may to be based on claims Policy (to which health Solutions). confuse consumers. confirmed consumer (Codex ministers committed) - Labelling based in - Multiple traffic lights (one whether the choice. Alimentariu includes appropriate percentage of for each major nutrient): change is s, the Euro- labelling (nutrient fact recommended daily proved that they allow maintained pean table with some intake for different consumers to evaluate over the long Union’s interpretation, such as nutrients, in the nutrient levels in a product term). regulation). traffic lights) as a key portion recommended by comparing several - Defining action area. by the manufacturer: products, and they can healthy and

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects proposed by many change purchase selections unhealthy large agri-food (remains to be confirmed products is businesses with the whether the change is feasible Confederation of maintained over the long even if Food and Drink term). difficult: Industries of the EU. - 73% of British consumers experiment - Traffic lights: find that having different s like the launched by Britain’s labelling systems is traffic lights Food Standards confusing. have set Agency in 2006. Is the criteria. voluntary and [Cooperatio provides guidelines; n between industries have some stakeholder flexibility. s?] Traffic - In the UK, FDS and lights: % daily intake are launched competing systems in after years use. In 2008 the Food of Standards Agency preparatory evaluated different research systems and and committed to consultatio (cont’d) adopting the one that ns with the worked best for agri-food consumers. industry. The European - Labelling Commission, in a based on regulatory proposal, % of proposed labels with recom- percentages of mended recommended daily daily intake intake. for different nutrients, in the portion recommen d- ed by the manufactur er: proposed by many

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects large agri- food companies with the Confederati on of Food and Drink Industries of the EU. Adopted by several companies in the UK vs. the traffic light system. - In the UK, traffic lights and % daily intake are competing (cont’d) systems. In 2008 the Food Standards Agency evaluated the different systems and committed to adopting the one that worked best for consumers. Ludwig & Article in a - [= reach, so related to - - Direct - Intense - Argument of the U.S. Brownell, 2009 scientific journal; effectiveness] One third of Assumption: costs will opposition restaurant industry: the

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects source = the calories consumed in the industry be minimal, from the benefits to consumers PubMed; the U.S. come from food would be particularly restaurant are unproven. comments; from outside the home. encouraged when industry to - Another reason authors = - Assumption: A large to compared the assumed by the academic / portion of the American reformulate with the different authors: fear of health public wants to lose weight, menus. potential U.S. revenue loss (see side professional so info on calories would - [Not in public regula-tions effects). affect consumption costs, since health on posting behaviour. they are a benefits. calorie - Research data: Some direct result counts on observational studies (not of menus. very robust) on restaurants application] suggest that the availability Risk that and awareness of nutrition restaurants info may reduce calorie will lose consumption. Of the revenues if experimental studies (which consumers also have limitations), 6 buy fewer showed effectiveness and 2 high-calorie showed no effect. dishes. - Assumption: effectiveness could increase over time, since changes in human behaviour are gradual. - Assumption: people could compensate for lower calorie consumption in restaurants by consuming more elsewhere. But even here, the fact that a part of consumption is transferred outside fast food restaurants could be beneficial.

Mello, 2009 Article in a - In 2008, in NYC the - One third of the calories - February . NYSRA went to court scientific journal; Board of Health and consumed by Americans 2009, a to contest the source = the mayor adopted a each day come from federal methodological rigour PubMed; regulation that restaurant meals. appeal of studies supporting

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects “comments” on required chain - Good face validity of court labelling. legal issues; restaurants to list nutrition labels for confirmed - In response, the author = calorie counts on encouraging healthier food legality of Board presented data academic menus and menu choices. the NY supporting each step boards (following a - Effect of labels on food regula-tion. in the causal chain of 1st version of the choices: the empirical data [Cooperatio the intervention. The regulation in 2006- are limited and n] The Board found it 2007). contradictory. Some studies Board of unrealistic to require - Six local gov’ts and on food and restaurants Health did data from a random one state gov’t (self-reported and objective not consult controlled trial before adopted similar data) show a positive effect; the NY intervening. regulations; 7 and 19 other studies on restaurants State - In 2008 the FDA other gov’ts are (self-reported and objective Restaurant issued a brief in considering doing the data) show no effect. Association support of the Board of same; federal laws - Study in Sept. 2008: 84% (NYSRA) Health. have been introduced of New Yorkers were on the - The FDA and the in both houses of surprised by the calorie regula-tion, Institute of Medicine Congress. counts. 73% said that the but recommended posting - The NLEA (the info had affected their submitted calorie counts in Nutrition Labelling purchase. the bill for restaurants. and Education Act) public - 99% of the public’s exempts meat, dairy comment comments were in products and food and studied favour of the served in restaurants. 2,200 regulation. responses. The Board used a - Dangers national survey that of a found that 83% of decentral- adults want nutrition ized info in restaurants. approach - Survey conducted in to the state immediately regulation: before the regulation a was applied found that patchwork 80% of citizens wanted of local the regulation laws would extended to cover the make state as a whole. (cont’d) application difficult for chain restaurants

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects . [Interferenc e] NYSRA filed a lawsuit against the Board of Health for two regulations based on preemption arguments (i.e. prohibi-tion of regulations from lower jurisdictions on subjects regulated by Congress) and infringemen t of restaurant owners’ freedom of speech. According to the Court, regulations requiring presentatio n of non- (cont’d) controversi al, factual info do not violate the

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects First Amendmen t. - Preemption argument accepted by the Court for the 1st regulation but not for the 2nd because it applies to food (dishes served in restaurants ) not covered by the NLEA. Pomeranz, Article in a In Sept. 2008, [Legislative - In 2008, the Teret, scientific journal; California became the compliance Governor of Georgia Sugarman, source = Yale first state to adopt a ] signed a law supported Rutkow, & Rudd Center regulation. It would - The NLEA by the industry to Brownell, 2009 website; legal apply starting in 2011 is an prevent local commentaries; to chain restaurants example of regulation initiatives. authors = and quash existing compelled - The law adopted in academics local regulations, speech: the California is a such as those in San obligation compromise with the Francisco and Santa to present industry. It quashed Clara. factual, existing local uncontrove regulations such as r-sial those in San Francisco commercial and Santa Clara. info is considered constitution al

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects - Until now, preemption has been used mainly to prevent local regula-tions on labelling in restaurants . E.g.: in 2008, the Governor of Georgia signed a (cont’d) law supported by the industry that prevents local regulation initiatives. San Francisco, Santa Clara, and NYC were sued by industry on the pretext that the NLEA pre- empted their regulations, but the FDA has clarified

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects that the NLEA does not preempt regulations concerning restaurants , and a federal court found in favour of NYC and the FDA. The law adopted in California is a compromise with industry; it quashes existing local regulations such as those of San Francisco and Santa Clara.

Roberto, Article in a NYC had asked for - Only half of the large The restaurant industry Agnew, & scientific journal; calorie counts to be restaurant chains make is opposed to labelling Brownell, 2009 source = Yale posted in chain nutrition info available in regulations, arguing Rudd Center restaurants. Other one form or another. that the cost of website; primary cities and states were - This study: the restaurants changing and the study (cross- considering similar studied made the info avail- cluttering of their sectional policies. able either in a poster on menus are unjustified, survey, the wall (but not next to the since they already observations, cashiers) or in pamphlets, make the nutrition info

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects 4,311 customers or else on a computer on available online and on of 4 fast-food the premises. the premises. restaurants); - 6 customers out of 4,311 authors = (0.1%) consulted the info academics before making a purchase. Implication: the info should be posted in a very visible location, such as on the menu boards. Wills, Schmidt, Article in a - Other studies: There is - Other studies: Pillo-Blocka, & scientific journal; widespread interest among simplified info on the Cairns, 2009 source = consumers for nutrition info front of packages PubMed; data on labels. pleases European from several - Food labels are among consumers, but they primary studies the 3 primary sources of differ on format (cross-sectional info for people trying to preferences studies); authors change their diet (U.S.), (differences tied to = research and first source in Canada. diverging preferences communications - Half of those who often in terms of ease of organizations read labels try to find foods use, desire to be fully co-funded and that are supposed to be informed, feeling that co-managed by good for your health they are not being the agri-food (Canada). pushed toward industry and - Labels used by 58% of adopting certain other parties consumers (particularly on behaviours). (universities, the first purchase or to - U.S. consumers public compare two products at recommend changes organizations) the same price or with the to format, font, same front-of-package standardization of claims) (U.S.). Presence of portion sizes, claims on packages causes clarifications including (cont’d) greater use of the nutrition on the percentage of label. daily intake, moving - Understanding: key info to the front of consumers do not know the package. how to interpret the calorie - Credibility of food info in terms of their daily labels: for 40% of needs (U.S.). Poor consumers (Canada). understanding and little use of % of daily intake (U.S.).

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects - Ease of use: 25% of consumers find the nutrition facts table easy to use (U.S.). - In purchase choice: nutrition is almost as important as taste, and much more important than cost and convenience (Canada). Bassett et al., Article in a - During the study: posting - Legal 2008 scientific journal; of calorie counts not yet attack, 1st source = CSPI mandatory in NY, only measure website; primary Subway does it, on a taken by study (cross- voluntary basis. the NYC sectional study, - Outside of Subway, 4% of Board of 7,318 customers customers have seen Health at 11 chain calorie info (according to quashed in restaurants in the restaurants, on liners, September NY); authors = posters, websites, etc.). 2007. health Among Subway customers - A new professionals (the info is on their displays, legal attack so it is visible but not against the unavoidable), 32% have new seen it. measure - Among Subway adopted in customers who have seen 2008 the info, 37% say that it (taking into influenced their purchase; account the they bought 99 fewer issues calories than those who raised in had seen but not used the the legal info. decision) is - Subway customers who on appeal had seen the info [at the time purchased 52 fewer of this calories than those who writing]. had not seen the info. Berman & Article in a - In the U.S, 34% of - The risk for - Often the - Arguments made by Lavizzo- scientific journal; calories are consumed restaurants costs of the restaurant

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects Mourey, 2008 source = outside the home. (even if nutrition associations against PubMed; - In one study, the there is no analyses labelling: the comments; probability of purchasing a available are already information is already authors = RW dish whose caloric content proof): loss assumed available on the Johnson tends to be underestimated of income, by the Internet or in Foundation went from 37% before the particularly large brochures, labelling is caloric info to 24% after in those with restaurant costly, consumers’ (analogy: the NLEA had menus chains. limited nutrition literacy coincided with a better diet featuring - The renders labelling at home, particu-larly mainly high- menus of useless, and some among label users). calorie fast-food restaurants already - Potential effect of in- foods. restaurants offer healthy choices restaurant labelling is - Reformula- are already identified as such. significant, even if it affects tions are updated on a minority of the meals possible if a regular served. For example, if the consumers basis. labels reduced change their - And these consumption by 100 purchasing two costs calories per meal for 10% habits are of the meals served in (analogy: the minimal. chain restaurants, NLEA coinci- Californians would ded with consume 9 billion fewer major calories each year. reform- - But change also depends ulations). on other factors: willingness - Possible to reduce total calories that changes consumed and availability in one sector of other tasty alternatives at (e.g.: a city a competitive price but with with a fewer calories. regulation) - Maximum effectiveness of will generate labelling: at time of others (e.g., purchase, not before (go on restaurants the Internet and memorize in the same the info) and not after (on chain, liners). elsewhere in - Selections identified as the country). healthy in the menus may be avoided because they are perceived as being not

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects as good, or as biasing percep-tions of their caloric content. Driskell, Article in a - Approx. half of consumers - Many Schake, & scientific journal; and students use labels to studies (and Detter, 2008 source = find nutrition info (study in the study in PubMed; this article: 58%). this article): primary study - Other studies: approx. women use (cross-sectional 75% of students find it the labels study, 205 useful to know the more than subjects); nutritional content of foods. men. authors = - Adults’ self-reported use - Labels have academics and of labels on foods is more health associated with a lower-fat influence in professionals diet. the - Study of students: after fat purchases of contents were posted in the persons on cafeteria, fat consumption low-fat diets. fell 16% (based on - Other purchase data from cash studies: registers). Results - Other study: 23% to 41% differed on of students select foods whether or because they are low in not nutrition calories, fat or sugar or are knowledge high in protein. can be - Study in this article: associated reasons given by subjects with label not using labels: it will not use. change my food choices (65%) or lack of time (27%). - Other studies: taste, price, time constraints and convenience influence food choices. Feunekes, Article in a - Other studies show that - Other - Other - Consumers perceive Gortemaker, scientific journal; consumers find nutrition studies have studies have logos as credible, Willems, Lion, source = labels difficult to understand shown that shown that particularly if they are & van den PubMed; two (particularly the numerical receiving a the elderly, officially approved by a Kommer, 2008 primary studies info and the terminology); health logo people with well-known

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects (cross-sectional consumers tend to use a encourages little organization (WHO or studies, 1,630 single nutrient (e.g. fat), but manufacture education a national association and 776 this may lead to a bad rs to and low- of nutritionists); on the subjects); choice; purchasers in reformulate. income other hand, an authors = supermarkets do not consumers approval from the EU (cont’d) Unilever analyze the info, making have more or the agri-food decisions in a few seconds. trouble industry is given less - Two types: detailed logos understandin credibility. have a more user-friendly g detailed - Consumers like the approach to giving info than nutrition idea of simplified front- traditional labels; simple labels. of-package labels, but logos interpret info by - This study: there are differences designating healthy More detailed between individuals products. labels are with respect to the - This study: all the logos more difficult desired level of detail. presented were understood for - Each type of logo (according to the consumers to studied was consumers’ reports AND understand if appreciated. Only one how they use it to they feel they received a poorer differentiate healthier and have little evaluation, probably less healthy products). Only knowledge because its logic is one logo is less well on nutrition, less intuitive. Traffic understood, probably and for those lights and % of daily because its logic is less who make intake: slightly lower intuitive. Traffic lights and little or no assessments. % of daily intake: somewhat use of - Consumers want logo less well used to nutrition formats that apply to differentiate products (and labels. all food categories (as percentages require more - Perceived compared to logos time to think, which is a and actual used for comparisons problem in real-life understandin within a single purchasing situations). g: no category). - After exposure to logos substantial (vs. without logos), intention differences to slightly increase by consumption of healthier background products and reduce variable. consumption of less healthy - In particular: products (no differ-ences No significant between the logos). differences - Authors’ recommendation: found in

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects present simple logos on the perceived front of packages, with understandin more detailed info (such as g of logos by % of daily intake) on the level of back. education. (cont’d) - On consumption intentions, no significant differences by background variable (age [all respondents under the age of 55], gender, education, income, profession, marital status, household composition, nutrition knowledge, perceived quality of diet). Hyde, 2008 Article in a - In current EU law, - Some - The European scientific journal; labelling is not industry Council – Agriculture source = mandatory unless a stakeholder and Fisheries PubMed; claim is made. s support (consisting of the comments; - In January 2008 the the traffic corresponding author = Commission light ministers of the freelancer recommended labels system, member states and that would indicate others are European Commission calories, fats, strongly representatives for saturated fats, sugar against it. agriculture, fisheries, and salt. health and consumer

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects - In May 2008, the protection) is European concerned that Parliament’s imposing legislation Environment, Public will be counter- Health and Food productive if it triggers Safety Committee conflicts between requested mandatory stakeholders. The front-of-package Council calls for the labelling with a colour sovereignty of member code. states to be respected. - In May 2008, the European Parliament’s Environment, Public Health and Food Safety Committee requested mandatory front-of-package labelling with a colour code. Kolodinsky, Article in a - 47% of Americans’ food - Other Green, scientific journal; budgets are spent on meals studies Michahelles, & source = eaten outside the home. suggest that Harvey-Berino, PubMed; - Other studies suggest that female 2008 primary study students are mostly students read (16 subjects in a interested in info on labels more focus group); calories, fat and vitamins, than male authors = but the food choices of students. academics young people do not Their interest appear to be influenced by is focused on reading labels. calories and - This study: students fats; male noticed nutrition labels in students are the restaurant area and more their disappearance during interested in the study periods. proteins. Important: a very visible - Men saw location near the food (if the labels, they are not very visible or but they did too small, some people will not influence not see them). their choices.

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects - Subjects in the control group were interested in labels. - Item that received the most attention: calories. - Many subjects based their decisions more on ingredients than calories. - Some said that the labels changed their purchase decisions. - But other factors limited purchases: price (healthy foods are often more expensive; students have limited budgets) and convenience (length of wait at different counters). - Characteristics of this environment: students (cont’d) know the menu and have often made their decision before they arrive, so they may be less inclined to read nutrition info; conversely, they do not perceive these meals as a special occasion, so they would be more inclined to choose healthy alternatives. Louie, Flood, Article in a - In Australia, the - Consumers find the NIP Some - A logo that is made Rangan, scientific journal; Nutrition Information difficult to understand. observers official by a law or Hector, & Gill, source = Panel (NIP) is - Research has shown that fear that the government standards 2008 PubMed; mandatory; use of very simple logos (such as traffic light is much more credible. comments; logos is already the Heart Foundation tick or thresholds - Australian industry is authors = voluntary. the glycaemic index) help discourage interested in posting % academics - In 2006, Australian consumers identify reformulatio of daily intake for Food and Grocery healthier foods in the same n (difficult to international harmon- Council category. move from ization, since many recommended listing - Criteria for “private” logos one level to countries use this

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects % daily intakes; many may not be very another), but system. Industry fears companies have transparent. other that red lights will already complied. - The proliferation of logos threshold affect sales creates confusion. systems (particularly since - Traffic lights: it has been have reformulation is costly, shown that they improve nevertheless takes time and interpretation of nutrition encouraged presents a business info, in particular because the risk). they encourage consumers reformulatio to consider several n of some nutrients instead of only products. one. In the UK, this had the expected effect on sales. BUT: does not present info on calories and positive nutrients. Traffic lights may discourage the consumption of “red” yet healthy foods (like cheese). - Authors’ recommendation: add “global” traffic lights that also take into account positive nutrients. (cont’d) - % of daily intake: poorly understood and interpreted by most consumers (in particular, in one study, by 71% of adults). MacMaolain, Article in a - Nutrition labelling - Other studies: consumers - In 2006 - The European 2008 scientific journal; was not harmonized find nutrition labels difficult the Commission source = CSA; in the European to interpret. Directorate recognizes that legal Union before a new General for consumers are not commentary; directive was Health and satisfied with the author = introduced in 1990; Consumer current labelling academic under the directive Protection provisions. (still in force), of the - In 2008, the labelling is optional European European Commission unless a claim has Commissio proposed changing the been made. n published 1990 directive to make - In 2008, the a nutrition labelling

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects European consultatio mandatory, but it was Commission n document flexible about the proposed changing with the format that could be the 1990 directive to goal of used. The make nutrition developing development of labelling mandatory, a coherent parallel national but it was flexible labelling systems was about the format that approach. authorized, on the could be used. The condition that they do development of not contradict EU rules parallel national and do not make a systems was given format authorized, on the mandatory. condition that they do not contradict EU rules and do not make any given format mandatory.

Pomeranz & Article in a - The NLEA imposed - Americans spend 48% of - The cost - The - According to surveys, Brownell, 2008 scientific journal; nutrition labelling on their food budget in of creating jurispruden consumers want source = packaged foods and restaurants. new menus ce allows nutrition info in PubMed; legal regulated voluntary - Consumers regularly and menu gov’ts at all restaurants. commentary; claims about foods consult food labels, and this boards is levels to - The FDA has been authors = and in restaurants. influences purchases (less minimal require explicit: all levels of academics - The Menu purchases of less healthy (they are nutrition gov’t can require Education and foods). often labelling in nutrition labelling in Labeling Act was already restaurants restaurants. tabled in the House of changed in . Representatives in fast food - Care (cont’d) 2003 and 2007. restaurants needs to be - Of the 20 proposed ). taken when or adopted restaurant drafting labelling laws, 17 laws to required posting ensure that calorie counts on they cannot menu boards and 16 be on menus (where contested most of the laws also by industry. required indicating

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects certain nutrients). Rutkow, Article in a - The NLEA was - Half of the large chain - Some - The Surgeon Vernick, scientific journal; passed in 1994. It restaurants do not provide states have General, the FDA and Hodge, & Teret, source = requires labelling on nutrition info. introduced the Institute of 2008 PubMed; legal packaged foods but - Non-menu labelling laws Medicine asked that commentary; not in restaurants options (Internet, liners, (supported nutrition info be made authors = unless they make a brochures) do not provide by more available on academics claim. appropriate access to the industry), foods consumed and - Half of the large info when meals are being that limit prepared outside the restaurant chains do ordered. the ability home. not provide nutrition of - Some states info. communitie introduced laws - In 2007-2008, many s to adopt (supported by industry) bills were presented laws on limiting communities’ in the Senate and the nutrition ability to adopt nutrition House, but with little labelling in labelling laws in success. On the other restaurants restaurants (Ohio, hand, two dozen (State of Georgia and states and Washingto Washington state). communities n, Ohio, - As a result, King introduced laws Georgia). County in the State of (NYC, San Francisco - As a Washington negotiated and King County, result, King its regulation with the which includes County in Washington Seattle). the State of Restaurant Washingto Association. n negotiated with the Washingto n (cont’d) Restaurant Association and made its regulation less restrictive. In exchange,

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects the WRA withdrew its support for the State- level bill. - As the NYC case shows, the NLEA does not imply preemption of other attempts to regulate labelling in restaurants . Signal et al., Article in a - In 2002, use of the - 73% of New Zealand - Pick the - Studies of - In the 4 groups 2008 scientific journal; Nutrition Information consumers say that they Tick has African studied: preference for source = Panel (NIP) became regularly or sometimes use reduced the Americans: a simple systems based PubMed; mandatory in New the Pick the Tick logo. amount of minority use on images rather than primary study Zealand on packaged salt in nutrition words, particularly ( focus groups); foods. approved labels. multiple traffic lights. authors = - The National Heart products - Studies of - Maoris and Tongans academics Foundation has a (through low-income prefer single traffic voluntary labelling reformulatio consumers: signals (use is faster program (Pick the n) 35%-45% do than multiple lights). Tick) used on the not use - Samoans and products of over 60 labels; Tongans would like to manufacturers. problems see a picture of understandin someone from their g the info and community on labels limited food identifying healthy budgets. But products. another study - Asked for multilingual shows that info, except Maoris, even in this who think that healthy group, labels don’t apply to reading them (they cannot buy (cont’d) labels is these products).

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects associated a - Maoris and better diet Tongans suggest [Note: This placing healthy foods was a study in one part of the of supermarket and beneficiaries putting info on books of food of discount coupons. stamps, i.e. - For Maoris, not being subsidized able to buy foods food marked healthy (by a purchases]. logo) is another NZ STUDY OF judgment of their LOW-INCOME behaviour. CONSUMERS, - Maoris believe that MAORIS, industry does not want SAMOANS AND a single traffic light TONGANS: system, so this system - Most use needs to be mandatory neither NIP if it is to work. nor Pick the Tick (slightly more use among Tongans). Reasons: problems understandin g the NIP, cost of healthy food, lack of time for reading labels and finding Pick the Tick foods in stores. - Purchases governed by habit and cost.

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects - Even when the logos were in a preferred format, cost remained a problem.

Taylor & Article in a - Nutrition labelling - [Intervention theory] Adoption of - - In the 1980s: with Wilkening, scientific journal; supervised by the Labelling allows but does the NLEA Challenge: consumers’ growing 2008 source = FDA began in the not lead to healthier food also sought limited interest in healthy diets PubMed; 1970s. Was voluntary choices (motivation is also to stimulate space on and the industry’s comments; except when nutrition required). And it still needs reformulatio labels interest in marketing, authors = FDA claims were made to be properly adapted and ns - The claims proliferated. retirees (making it used (depends on users’ NLEA’s Consumers and mandatory). skills). application industry expressed - In the 1980s: with - The FDA is willing to rules were fears about their consumers’ growing organize the label so that subject to a credibility. interest in healthy the public will be able to publication - In response, diets and the observe and understand procedure Congress adopted the industry’s interest in the info and its importance in order to NLEA. marketing, claims in one’s daily eating. Order collect - Beyond the NLEA, in proliferated. of presentation on the label comments. 2004 the FDA Consumers and (calories, fat and other) is Thousands encouraged industry expressed based on the fact that fat is were restaurants to present fears about their the first concern in the received nutrition info. credibility. American diet. % of daily from - The NLEA was intake selected because it industry, adopted by Congress was the best understood researcher in 1990. Applies to among the formats tested s, packaged foods but with consumers. consumers not to menus. - Graphically, the label is and the designed for readability and public understanding health (standardized label, font community. size, bold fonts, lines between nutrients, box setting it apart from the rest).

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects - In the former voluntary labelling system, companies determined the portion sizes: this created confusion due to different portion sizes and, sometimes, manipulations (smaller portions used for high-calorie foods). van Kleef, van Article in a - Examples of simple - [Intervention theory]: If - The food - Advantages of logos Trijp, Paeps, & scientific journal; front-of-package nutrition labelling is industry in as seen by consumers: Fernandez- source = labelling: Pick the correctly applied and the they are visible, make Celemin, 2008 PubMed; Tick (Australia and appropriately used and Netherland it easier to make primary study New Zealand, since consumers understand and s presents comparisons with other (cont’d) (12 focus 1989), Green Keyhole trust it, it can help them logos that products, save time. groups of (Sweden, since take the nutrition content of show - According to approx. 10 1989), Heart Check foods into account in their calorie consumers, logos persons each); (U.S., since 1995), purchase decisions and counts on should grab attention authors = Health Check make informed decisions the front of compared to other info academics, (Canada, since on healthy options for a the on the package (use of marketing 1998). healthier diet. package. colour) and be research - The food industry in - No convincing data readable (font size). agency, the Netherlands proving that dietary - Preference for simple research and presents logos behaviour improves logos that are communications showing calorie (particularly self-reported understood at a organization co- counts on the front of measures, collected under glance. Considered funded and co- packages. controlled conditions). less informative than managed by the - Obstacles: lack of time, more complete logos, agri-food understanding (consumers but if the logo is industry and the say that they have trouble changed too much, public translating the info into food some will not use it. choices; in particular, - Interesting that the problems with overly preferred amount of technical terms), and they info varies by country: doubt the accuracy of the the British like more info. complete logos, - In this study: many perhaps because they consumers use labels when are used to using making new purchases but them. not often for regular - Some participants

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects purchases. (particularly the - Many consumers limit elderly) asked for info their info searches to the on other nutrients, in logo on the front of the addition to calories. package. - Providing context (% - Better understanding of daily intake of calories) info when short health is widely appreciated, claims on the front of particularly when packages is combined with differences are noted complete info on the back. between women and - Calories are the most- men. Questions raised used indicator and the most over whether an widely-understood idea “average” value can be among European applied to different consumers. The info is individuals (may be (cont’d) seen as a summary of the solved by an info product’s nutritional value, campaign on the but few consumers know needs of different how to interpret it. groups). - Problems interpreting - Calories per portion what a portion is and how considered more to make the calculations. practical; calories per 100g considered more appropriate when comparing products. - Some participants thought that the logos would be used mostly by women. - [Judgment concerning side effects] Some respondents said that the logos should not instil guilt vs. their pleasure in eating. - Appreciated that logos are an info measure rather than coercive. - Respondents

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects generally trusted logos, but considered it important that they are supported by the authorities and info campaigns. - Short health claims on the front of the package combined with complete info on the back: generates confidence in the info. Variyam, 2008 Article in a - Before the NLEA, - Before the NLEA: lack of Before the scientific journal; the FDA established standardization and the implement source = voluntary labelling rareness of nutrition labels ation, the PsycINFO; rules in 1975 (only made it difficult to compare FDA had secondary mandatory when products and interpret info. done a analyses claims were made). - 60% of products had cost- (modelling); - NLEA passed in labels in 1990, 96% in benefit (cont’d) author = the 1990, application 1996. Significant decline in analysis of USDA rules in 1993, applied misleading claims after the labelling in May 1994. NLEA was introduced. (based on - Similar rules for - In 1994-1996, 66% of predicted voluntary labelling of adults reported using changes in fruits and vegetables labels. the and seafood (under - Another study (comparing consumptio the FDA) and meat 8 months before and after n of fat, and poultry (under the the NLEA): new labels saturated USDA). permitted better fat and understanding of nutrition cholesterol info. ). - Other studies: beneficial effects of label use on food consumption. - Modelling [warning: old data (1994-1996 surveys) and the models do not control for all explanatory factors]: use of labels has modest but beneficial

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects impact (greater consumption of fibre and iron), but there is no evidence of a drop in the consumption of fat, saturated fats and cholesterol. Golan, Kuchler, Article in a Rapid expansion of [Almost the entire article is - The main - Voluntary - Labelling by a third & Krissof, 2007 government voluntary labelling on intervention theory; also impact of labelling is party enhances the journal; source = some parallel evidence, mandatory an credibility of voluntary CSA; since it deals with all forms labelling advertis- labelling. This comments; of labelling: organic food, could be ing option organization must be authors = the fair trade, etc.]. product for the credible: in some USDA - Consumers do not use reformulatio industry. cases (in the U.S.), it is labels to change their n or the Industry national government purchasing patterns if they introduction will use it organizations that are doubt the importance or of new as long as seen as more credible accuracy of the info. products, the (the FDA, the USDA); - Assumption made by opening new expected in others (in Europe), consumers: if many areas of benefits international or products are labelled competition. are greater consumer (voluntarily), those without The example than the organizations are the a label are of lower quality. of trans fat costs. preferred third parties. (cont’d) - According to economic shows how theory, voluntarily labelling the industry is not enough: in product began to categories without desirable reformulate characteristics, no even before industries have begun the labelling; industries can mandatory decide to provide only labelling was relative rather than absolute introduced info (comparisons with and other products). consumer - According to economic demand theory, many tools could be appeared. more useful to influence This may consumption and affect production than mandatory consumption labels: externalities more than

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects affecting producers such as consumers’ prohibitions, quotas, actual production rules and taxes. responses to labels.

Grunert & Wills, Article in a - Intervention theory based - Interest in - [Authors’ - Some consumers 2007 scientific journal; on a series of assumptions: nutrition info comments] resist nutrition info, source = consumers want labels; strongest : labelling which is perceived as PsycINFO; exposure; perception; among reduces an attempt to impose a literature review understanding (subjective women, the cost for scientific approach on (scientific and or objective) and liking; use parents of consumers something (food) grey literature (direct and indirect – i.e. young of looking closely tied to pleasure since 2002 on effects on purchases of children and for info. and pushing European other products -, occasional the elderly consumers to make consumers); and self-sustaining). (more certain choices (in authors = Determinants: an interest in concerned particular, through academics & nutrition, knowledge, about their overly simplistic logos research and consumer characteristics health). considered communication (which are in fact more - Label paternalistic). organizations correlated with the real reading: - The majority of co-funded and determinants, i.e. an same groups. respondents say that co-managed by interest in and knowledge - Understand- the labels need to be the agri-food of nutrition, price, health ing: even improved. industry and status) label format. Many low-income - Liking: in general, public of the documents consulted and low- consumers are (cont’d) organizations make no mention of a education favourable to theoretical framework. consumers, improving labels and to - Consumers’ are interested the elderly, front-of-package logos. in having nutrition info and ethnic They like simplification, (particularly on calories and groups say but nevertheless want fat), but this is not their that they find to know what the primary concern (vs. food front-of- simplified info on logos safety, taste, price, etc.). package means. Very simple More interest in having info labelling easy logos (single traffic on transformed foods, less to lights, health logo) are on fresh foods and comfort understand. less appreciated. foods (like chocolate). More But low- Multiple lights appear interest in having info at income and to be better liked for first purchase. Less interest low- their simplicity, and when in a hurry. education logos presenting % of

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects - Good general understand- consumers daily intake are better ing of calories, but and the liked for their more confusion about nutrients. elderly do not detailed info and - Looking for labels: most do as well as because they are less consumers do not actively other groups paternalistic. Finally, it look for them. in objective is not clear which of - Reading the labels: comprehensi the two systems approx. 50%-60% say they on- Use: consumers prefer. always or sometimes read Women, the Systems with colour labels (probably an elderly, codes are appreciated. overestimate: some wealthier For recommended consumers confuse groups and daily intake: no clear nutrition info with the list of more results on whether ingredients and claims). educated consumers prefer info More read labels during first groups say presented in grams or purchase, less when in a that they use as a %. The same is hurry. Sometimes reading the info more. true for preferences on is selective (particularly for info by portion or per fat, then calories). 100g (but there was a - Subjective understanding: consensus on one ambiguous. Majority said issue: portions must be that they understand the clearly defined). info, but also said the labels - Liking in terms of were difficult to find and use: in some studies, confusing. On the other consumers say that hand, there was a “unfavourable” logos (cont’d) consensus on front-of- would not keep them package logos: easy to from consuming understand (particularly products appreciated traffic lights and % daily for their taste, but that intake with a colour code). they could make - Objective (measured) changes to their understanding: rate of consumption. Others correct responses depends believe that info given on the task and info format through colour codes (some formats facilitate would be difficult to certain tasks) and ignore and could diminishes as the need to therefore have a interpret increases. greater impact on their - Use of labels (warning, purchases. Some many studies confuse consumers believe that

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects reading with use): many they will use logos consumers say that they more when they have “use” the info. Positively doubts about whether correlated with the first products are healthy. purchase of a product and transformed foods, negatively correlated with concerns over price and lack of time. Studies have found lower purchase intentions for marginally healthy products carrying a logo. Measure of actual purchases: anecdotal evidence (supermarket sales figures) indicates a rise in healthy products sold and a drop in sales of less healthy products after the labels were introduced; implementation of labels identifying high-fat products in supermarkets had no significant effect on customers’ consumption of fat; another study showed (cont’d) that changes depended on the product: when the product is considered healthy (yoghurt), the info is ignored; choices of prepared dishes depends on appearance, taste and practical issues (nutrition info plays almost no role); info is used for cereals, but only during 1st purchase. Hignett, 2007 Article in a In March 2006 the - % of daily intake was - Before - The FSA tested 4 scientific journal; FSA recommended a tested but poorly adopting systems with source = voluntary approach understood by many the traffic consumers. The most

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects PubMed; based on 4 principles: consumers. lights, the appreciated: multiple comments / presenting info on 4 - Use: consumers say that FSA traffic lights. news; author = nutrients (fat, they do not boycott red consulted - Received support Food Standards saturated fats, salt, products, rather they “stakeholde from health and Agency (the UK) sugar), presenting balance their consumption rs.” consumer content by portion, of green/amber/red - One third associations. using a three-colour products. of code, and applying - Sales data: sales of supermark the approach in healthier products rose ets and accordance with FSA quickly. many criteria. It did not manufactur promote using % of ers daily intake, but let adopted companies use it if the FDS they wanted. system. Targeted products: those that consumers had difficulty evaluating (cereals, prepared foods). Some companies neverthe-less decided to include other products. - One third of supermarkets and many manufacturers adopted the system. Lando & Article in a - In 2003, the FDA - Participants expressed an - Large RESTAURANTS Labiner-Wolfe, scientific journal; formed an internal interest in nutrition. companies - Most participants 2007 source = work group on obesity - Many thought about such as would like to have info PubMed; that recommended whether products were Coca-cola in fast-food primary study (8 exploring changes to healthy before buying them, and Kraft restaurants. focus groups of the labels on but this was balanced Foods have - Despite being (cont’d) approx. 8 packaged foods. It against taste, convenience, changed interested in many persons each); asked restaurants to price, temptation and family labels on nutrients, many authors = the voluntarily provide preferences. products participants felt that FDA nutrition info. - Some participants have consumed providing only calorie rules of thumb on in one counts in restaurants acceptable quantities of sitting, would be sufficient

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects calories and nutrients, and presenting (particularly since too use labels to find this info. nutrition much info on menu Participants are more info for the boards would be aware of some nutrients whole confusing). than others, depending on package. - Participants their diet, eating strategy suggested placing info and health problems. on packages, liners, - Some participants made brochures, take-out mistakes in their portion bags, posters near size calculations. cash registers and - Some respondents said menu boards. that they did not understand - Most liked the idea of the meaning of % daily showing all the healthy intake. choices in a separate - Respondents were section of the menu. concerned that healthier - Having a health logo products (identified by a on the menu next to logo) are more expensive healthy foods would be or not as good. appreciated, if the logo has a standard and understandable definition. PACKAGING - Most participants thought that food that is usually all consumed in one sitting should be labelled accordingly (not as if it contained several portions). Many would like to be spared the need to make calcula-tions. When a 2-column label was tested (1 portion (cont’d) or entire package), some felt that showing info on 1 portion served no purpose. - Some participants suggested removing

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects the % of daily intake and keeping only quantities. Some felt that the % of daily intake did not apply to them because they were on a 2,000- calorie-a-day diet. - Front-of-package logo indicating # of calories: some participants felt that it is useful, others said that it isn’t enough for informed decision making. Many said that it serves no purpose to duplicate info that is already on the label. - Health logo test: favourable reactions, helps make quick selections. But the logo is worthwhile only if one understands what it means and is certain that it is only used on products that meet certain criteria. Lindhorst, Article in a When the law was In November Corby, Roberts, scientific journal; passed in Canada in and & Zeiler, 2007 source = 2003: Dieticians of December PubMed; before Canada and the 2004: and after with no Canadian Diabetes reported control group; Association attitudes and authors = health developed an behaviours professionals education program on on labelling (cont’d) nutrition labels (importance (Healthy Eating is in given to Store for You: HESY) nutrition info;

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects targeting several use during groups such as low- purchase income and low decisions; literacy to ease of use complement Health for comparing Canada’s public two products) campaign. differs only slightly by income level. Switt, 2007 Article in a - In 2005, the UK’s - Use: consumers do not - The FSA In an FSA - One third - In 2005, the FSA scientific journal; FSA developed the boycott red products, rather hopes that in test, another of surveyed over 2,600 source = traffic light system, a they balance consumption addition to system supermark consumers on 4 PubMed; voluntary approach of green, amber and red providing showing ets and systems to find the one comments; based on 4 principles: products. info, the recommende many they preferred. Result: author = JADA presenting info on 4 - Sales data: sales of system will d daily manufactur traffic lights. Another publisher nutrients (fat, healthier products rose encourage intakes with a ers system also proved saturated fats, salt, quickly. consumers colour code adopted very popular: sugar), presenting - Reminder: logos like traffic to ask for was popular, the traffic Recommended daily their content by lights [note: calorie counts healthier but poorly light quantities with colour portion, using a three- not shown] can help products and understood system. codes. colour code, and consumers make more encourage by - In July - The FSA believes applying it in informed decisions but do producers to consumers of 2006, some that the voluntary accordance with FSA not prevent consumption of reformulate low socio- large agri- approach is the best, criteria. excessive portions. products. economic businesses avoiding the Targeted products: Sainsbury’s status and committed bureaucratic aspect of those that consumers CEO minorities. to listing regulations. have difficulty confirmed the # of evaluating (cereals, that it calories per prepared foods), influenced portion and although some the % of daily companies decided to development intake on include other of new the front of products. products. packages. - One third of supermarkets and many manufacturers adopted the traffic light system. - In July 2006, some (cont’d) of the large agri-food

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects companies committed to providing the # of calories per portion and % of daily intake on the front of packages for products sold in Europe. - Examples of U.S. programs: PepsiCo (Smart Spot, based on FDA and National Academy of Sciences directives), Unilever (Choices Program, based on U.S. Dietary Guidelines [DHHS]) and General Mills (Goodness Corner, based on FDA directives). Antonuk & Article in a - The FDA plans to - [Experiment: give some - - Some - Consumer groups Block, 2006 scientific journal; amend regulations on students a package of [Experiment: companies believe that current source = per-portion, per- candies with a standard give some agreed to American labelling PubMed; package labelling. label (per-portion info) and students a voluntarily practices are primary study give the others a package package of present a misleading when (before-after with a two-column label candies with second nutrition info is shown experiment, 112 (info per portion and for the a standard column for a single portion on persons); entire package), then label (per- with packages that contain authors = compare candy portion info) nutrition several portions but academics consumption.] and give the intake are nevertheless - Among the students not others a figures for consumed in one on a diet: less consumption package with the entire sitting. if they had the two-column a two-column package. - In response, the FDA label. label (info per plans to amend the - Among students on a diet: portion and regulations. no difference. for the entire => A benefit appears to package), exist, but it is limited to then compare those who do not pay candy

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects attention to typical portions. consumption. Limitation: in this ] (cont’d) experimental situation, - Typically students were required to the students read the label. not on a diet read the label less than the other students. - Students on diets paid more attention to labels (in general) and found the info more important and easier to understand than the others. - No gender effects were found. Blitstein & Article in a - Other studies: the nutrition - Other - The Institute of Evans, 2006 scientific journal; facts table is often studies: Medicine believes that source = misinterpreted. nutrition we expect consumers PubMed; - This study: approx. 50% knowledge is to have increasing primary study of consumers “always or associated health literacy. (cross-sectional, almost always” use labels with label 1,139 persons, in purchase decisions. use. but analyses - This study: performed on labels are data for only used more in 390 persons); purchase authors = decisions by research women, older institute and and more academic educated

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects consumers, and married persons (hypothesis: over time, eating habits in a couple tend to converge). (cont’d) No significant association between use and BMI or ethnicity. Borra, 2006 Article in a - 11% of participants - Confusion over the scientific journal; always looked at nutrition meaning of % of daily source = info or ingredients, 32% intake, but consumers PubMed; almost always, 40% believe that it would be primary studies sometimes. a useful tool for (cross-sectional - At purchase, 58% first calories if it was study and focus considered calories and explained to them. groups); author 56% first looked at fat = organization levels. funded by the - 83% always or sometimes agri-food read labels when industry purchasing a product for the first time. - Consumers said they were confused about what % of daily intake means. Krukowski, Article in a A law on nutrition - [Logic model]: the - 52% of - Public health Harvey-Berino, scientific journal; labelling in usefulness of labels in college organizations and Kolodinsky, source = restaurants was restaurants depends on students do consumer protection Narsana, & PubMed; tabled in the House of them being read and not usually groups have asked for Desisto, 2006 primary study Representatives in understood. look at labels a law that would (cross-sectional, November 2003 and - 33% of the general public (compared to require chain two samples: is being reviewed by does not generally look at 33% of the restaurants to indicate 649 and 316 the Subcommittee on labels. general calorie counts on their participants); Health. - 67% of respondents know public). menus. authors = the recommended daily - Women and

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects academics intake of calories. people who - Recommendations: Start eat more at by educating consumers on home and eat the recommended quantity less fast of calories and on how to foods read read labels; develop labels more definitions of foods that often. No have low, medium or high clear caloric content (rather than relationship giving precise values); and between BMI change food portions and and label prices rather than reading. continuing to emphasize - Women are personal responsibility. better at estimating (cont’d) their recommende d daily intake of calories. - Posting caloric content in restaurants: women, the general public (as compared to college students) and people who eat more at home and eat less fast foods use labels more often to find lower-calorie foods. No clear relationship found

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects between BMI and label use. Levi, Chan, & Article in a - Logic model: strategies Authors’ Pence, 2006 scientific journal; such as regulating nutrition hypothesis source = labels in restaurants (U.S.): PsycINFO; postulate that individuals intense primary study are very involved in the involvement, (cross-sectional, problem (consciously particularly in 358 persons); reviewing and retaining info decisions authors = on the subject), and this around food, academics leads to changes in beliefs, is considered attitudes and behaviours. a feminine activity. - In the sample (students), there are significantly more women in the group of people intensely (cont’d) involved in food decisions. - Women consider the info on labels more important than men. - For men, it is important to use approaches other than nutrition info.

O'Dougherty et Article in a - Judgments about the - 62% of respondents

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects al., 2006 scientific journal; importance of price, taste, would support a law source = nutrition and convenience: requiring restaurants to PsycINFO; 83% of respondents list nutrition info on primary study considered nutrition info menu boards (same (cross-sectional, important when making results as a national 79 persons); purchases in stores, but survey conducted in authors = only 58% when choosing 2003). Reasons given academics meals in fast-food by respondents: would restaurants (while the 3 allow informed other factors are decision making and considered important by would make merchants 87% to 96% of and individuals respondents, respectively). accountable. - During purchases made in - Reasons given by stores, 75% often or opponents: it is an sometimes look at nutrition issue of personal labels. choice and - 32% of respondents could responsibility, not a not estimate the legal issue; a policy recommended daily intake would be unnecessary, of calories and maximum serve no purpose or be amount of fat. This ineffective in altering suggests that posting consumers’ decision nutrition info in restaurants making; a policy would would be of limited place too great a usefulness unless it is burden on merchants. accompanied by information on daily requirements.

Rothman et al., Article in a - In 1993, the nutrition - 90 million Americans do - Fewer - 70% of participants 2006 scientific journal; info format in the U.S. not have sufficient literacy correct want easy-to- (cont’d) source = CSA; was revised so that it or numeracy to function in answers understand nutrition primary study would be more widely the current health given by the labels. (cross-sectional, used. environment. Among the elderly, 200 persons); subjects of this study women, authors = (considered relatively well African academics educated), 77% had Americans, sufficient literacy (high obese school diploma or higher), people, and

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects but 63% had insufficient people numeracy (lacked a high without school diploma). private - Increased use of labels insurance, after they were revised by less the FDA in 1994 [update of education or the mandatory standardized chronic label]. diseases. - Other study: 78% of Even subjects were able to controlling for compare two products, but other factors, only 20% could correctly low literacy calculate a product’s and low contribution to their daily numeracy are intake. strongly - Most of the respondents associated said that they use the labels with fewer and find them easy to correct understand. answers. - Questions on nutrition - Even the labels: 69% gave correct more answers (but on certain educated questions, only 20%-30% consumer gave correct answers). may have Frequent errors: info on problems portion size poorly or understandin improperly used; confusion g labels. about info other than what was asked (e.g. absolute values vs. percentages) and complex info. Mistakes (cont’d) made in calculations. - Authors’ recommendations for improved understanding of labels: clarify the info on portions; for smaller products, present nutrition info for the entire product; present simplified info for different portion sizes;

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects remove info that few consumers appear to understand and that tends to confuse them (e.g.: % of daily intake). Wansink & Article in a - Perceptions of low fat - Persons of Chandon, 2006 scientific journal; labels: consumers infer normal source = (wrongly) that these weight PsycINFO; products have fewer consume primary studies calories. more of (3 cross- - They overestimate the products sectional studies appropriate portion size. considered of 296, 74 and - Labelling snacks as low- rather healthy 179 persons); fat increases consumption (there is less authors = (in a single sitting) by up to guilt when academics 50%. the products - The authors draw a are labelled parallel between “low fat” low-fat, but labelling and health logos not when developed by many products that companies. are considered more hedonistic are labelled low-fat). Objective info on portion size helps prevent over- consumption. - Among (cont’d) overweight persons, consumption of all products increases, and even more than

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects among persons of normal weight (less guilt over any product labelled low- fat). Objective info on portion size has no effect. - No significant differences observed between different levels of nutrition knowledge. - No gender effects found. Wootan & Article in a - The NLEA exempts - Americans spend half of - Cost of - The fact - The Surgeon General Osborn, 2006 scientific journal; restaurants from their food budgets in nutrition that half of and the Institute of source = labelling regulations. restaurants. analyses is restaurants Medicine have PubMed; The American - 54% of restaurants approx. provide the recommended that primary study Congress and a provide info on at least US$220 info shows nutrition info be (cross-sectional dozen states are some menu items (vs. 35% per menu that it is available in study, 287 of the considering laws that in 1994). item, giving feasible. restaurants. 300 largest will require nutrition - But 56% of restaurants do a one-time - 2/3 of Americans chain info labelling in chain not provide info on the cost of support nutrition info in restaurants in restaurants. majority of the dishes on US$18,000 restaurants. the U.S.); their menus. for an 80- authors = CSPI - Among those that provide item menu. (lobbying info: 86% do it on their - Costs of organization) website (for some it is the revising only source of info, yet this and requires Internet access reprinting and making a selection menus

Reference Characteristics Status Effectiveness Unintended Equity Cost Feasibility Acceptability of Document Effects before going to the should be restaurant). modest, (cont’d) - 85% of adult Americans since it is sometimes or always read done food labels. several - Reading labels on times a packaged foods is year associated with a healthier anyway, for diet. marketing reasons. Wootan, Article in a - In 1994, the NLEA - Americans consume a - In 2005, - According to the Osborn, & scientific journal; covered packaged third of their calories in McDonald’s representatives of Malloy, 2006 source = site foods and exempted restaurants. announced restaurants, many of CSPI; primary restaurants. - Even in the largest fast that it the large chains study - The American food chain (McDonald’s), would already provide (observation Congress and a nutrition info on most menu provide nutrition info on cross-sectional, dozen states were items is only available on- nutrition posters and brochures. 29 restaurants); considering laws that site in 59% of restaurants. info on authors = would require chain - The info is mostly packages lobbyists restaurants to provide presented in pamphlets and (but this calorie counts and on the back of tray liners implies that other nutrition info on (which are given after the consumers their menus. purchase is made); in a only see minority of outlets, it is the info provided on posters or in after they information leaflets. have - In 62% of restaurants, placed their investigators had to speak orders). to at least 2 employees to receive the info. - Another study: only 44% of the large restaurant chains in the U.S. provide info on most of their standard items, of which 86% present it on their websites (this requires access to the Internet and making a selection before going to the restaurant).

List of documents referenced in this table Antonuk, B. & Block, L. G. (2006). The effect of single serving versus entire package nutritional information on consumption norms and actual consumption of a snack food. Journal of Nutrition Education and Behavior, 38(6), 365-370. Bassett, M. T., Dumanovsky, T., Huang, C., Silver, L. D., Young, C., Nonas, C., … Frieden, T. R. (2008). Purchasing behavior and calorie information at fast- food chains in New York City, 2007. American Journal of Public Health, 98(8), 1-3. Berman, M. & Lavizzo-Mourey, R. (2008). Obesity prevention in the information age: Caloric information at the point of purchase. Journal of the American Medical Association, 300(4), 433-435. Blitstein, J. L. & Evans, W. D. (2006). Use of nutrition facts panels among adults who make household food purchasing decisions. Journal of Nutrition Education and Behavior, 38(6), 360-364. Borgmeier, I. & Westenhoefer, J. (2009). Impact of different food label formats on healthiness evaluation and food choice of consumers: A randomized- controlled study. BMC Public Health, 9(184). Borra, S. (2006). Consumer perspectives on food labels. American Journal of Clinical Nutrition, 83(5), 1235S. Driskell, J. A., Schake, M. C., & Detter, H. A. (2008). Using nutrition labeling as a potential tool for changing eating habits of university dining hall patrons. Journal of the American Dietetic Association, 108(12), 2071-2076. Feunekes, G. I., Gortemaker, I. A., Willems, A. A., Lion, R., & van den Kommer, M. (2008). Front-of-pack nutrition labelling: Testing effectiveness of different nutrition labelling formats front-of-pack in four European countries. Appetite, 50(1), 57-70. Gerend, M. (2009). Does calorie information promote lower calorie fast food choices among college students? Journal of Adolescent Health, 44(1), 84-86. Golan, E., Kuchler, F., & Krissof, B. (2007). Do food labels make a difference? ...Sometimes. Amber Waves, 5(5), 10-17. Grunert, K. G. & Wills, J. M. (2007). A review of European research on consumer response to nutrition information on food labels. Journal of Public Health, 15(5), 385-399. Hignett, R. (2007). Labelling to get noticed. Community Practitioner, 80(2), 12-13. Hyde, R. (2008). Europe battles with obesity. Lancet, 371(9631), 2160-2161. Kelly, B., Hughes, C., Chapman, K., Louie, J. C. Y., Dixon, H., Crawford, J., … Slevin, T. (2009). Consumer testing of the acceptability and effectiveness of front-of-pack food labelling systems for the Australian grocery market. Health Promotion International, 24(2), 120-129. Kolodinsky, J., Green, J., Michahelles, M., & Harvey-Berino, J. R. (2008). The use of nutritional labels by college students in a food-court setting. Journal of American College Health, 57(3), 297-302. Krukowski, R. A., Harvey-Berino, J., Kolodinsky, J., Narsana, R. T., & Desisto, T. P. (2006). Consumers may not use or understand calorie labeling in restaurants. Journal of the American Dietetic Association, 106(6), 917-920. Kuo, T., Jarosz, C. J., Simon, P., & Fielding, J. E. (2009). Menu labeling as a potential strategy for combating the obesity epidemic: A health impact assessment. American Journal of Public Health, 99(9), 1680-1686.

Lando, A. M. & Labiner-Wolfe, J. (2007). Helping consumers make more healthful food choices: Consumer views on modifying food labels and providing point-of-purchase nutrition information at quick-service restaurants. Journal of Nutrition Education and Behavior, 39(3), 157-163. Levi, A., Chan, K. K., & Pence, D. (2006). Real men do not read labels: The effects of masculinity and involvement on college students' food decisions. Journal of American College Health, 55(2), 91-98. Lindhorst, K., Corby, L., Roberts, S., & Zeiler, S. (2007). Rural consumers' attitudes towards nutrition labelling. Canadian Journal of Dietetic Practice and Research, 68(3), 146-149. Lobstein, T. & Davies, S. (2009). Defining and labelling 'healthy' and 'unhealthy' food. Public Health Nutrition, 12(3), 331-340. Louie, J. C., Flood, V., Rangan, A., Hector, D. J., & Gill, T. (2008). A comparison of two nutrition signposting systems for use in Australia. New South Wales Public Health Bulletin, 19(7-8), 121-126. Ludwig, D. S. & Brownell, K. D. (2009). Public health action amid scientific uncertainty: The case of restaurant calorie labeling regulations. Journal of the American Medical Association, 302(4), 434-435. MacMaolain, C. (2008). Waiter! There's a beetle in my soup. Yes Sir, that's E120: Disparities between actual individual behaviour and regulating food labelling for the average consumer in EU law. Common Market Law Review, 45, 1147-1165. Mello, M. M. (2009). New York City's war on fat. New England Journal of Medicine, 360(19), 2015-2020. O'Dougherty, M., Harnack, L. J., French, S. A., Story, M., Oakes, J. M., & Jeffery, R. W. (2006). Nutrition labeling and value size pricing at fast-food restaurants: A consumer perspective. American Journal of Health Promotion, 20(4), 247-250. Pomeranz, J. L. & Brownell, K. D. (2008). Legal and public health considerations affecting the success, reach, and impact of menu-labeling laws. American Journal of Public Health, 98(9), 1578-1583. Pomeranz, J. L., Teret, S. P., Sugarman, S. D., Rutkow, L., & Brownell, K. D. (2009). Innovative legal approaches to address obesity. The Milbank Quarterly, 87(1), 185-213. Roberto, C. A., Agnew, H., & Brownell, K. D. (2009). An observational study of consumers' accessing of nutrition information in chain restaurants. American Journal of Public Health, 99(5), 820-821. Rothman, R., Housam, R., Weiss, H., Davis, D., Gregory, R., Gebretsadik, T., ... Elasy, T. A. (2006). Patient understanding of food labels: The role of literacy and numeracy. American Journal of Preventive Medicine, 31(5), 391-398. Rutkow, L., Vernick, J. S., Hodge, J. G. Jr., & Teret, S. P. (2008). Preemption and the obesity epidemic: State and local menu labeling laws and the nutrition labeling and education act. Journal of Law, Medicine & Ethics, 36(4), 772-89, 611. Signal, L., Lanumata, T., Robinson, J. A., Tavila, A., Wilton, J., & Ni, M. C. (2008). Perceptions of New Zealand nutrition labels by Maori, Pacific and low- income shoppers. Public Health Nutrition, 11(7), 706-713. Switt, J. (2007). Labeling around the globe: Helping to direct food flow. Journal of the American Dietetic Association, 107(2), 199-200. Taylor, C. L. & Wilkening, V. L. (2008). How the nutrition food label was developed, part 1: The Nutrition Facts panel. Journal of the American Dietetic Association, 108(3), 437-442.

52 NCCHPP – Nutrition Labelling – Scientific Literature Extraction Table van Kleef, E., van Trijp, H., Paeps, F., & Fernandez-Celemin, L. (2008). Consumer preferences for front-of-pack calories labelling. Public Health Nutrition, 11(2), 203-213. Variyam, J. N. (2008). Do nutrition labels improve dietary outcomes? Health Economics, 17(6), 695-708. Wansink, B. & Chandon, P. (2006). Can 'low-fat' nutrition labels lead to obesity? Journal of Marketing Research, 43(4), 605-617. Wills, J. M., Schmidt, D. B., Pillo-Blocka, F., & Cairns, G. (2009). Exploring global consumer attitudes toward nutrition information on food labels. Nutrition Reviews, 67 Suppl 1, S102-S106. Wootan, M. G. & Osborn, M. (2006). Availability of nutrition information from chain restaurants in the United States. American Journal of Preventive Medicine, 30(3), 266-268. Wootan, M. G., Osborn, M., & Malloy, C. J. (2006). Availability of point-of-purchase nutrition information at a fast-food restaurant. Preventive Medicine, 43, 458-459.