Checkmating the Nutri-Score: Will Food Patriotism Prevent the Harmonization of Front-of-Pack Labeling Schemes within the EU?

Front-of-pack labeling schemes are an effective but contested regulatory approach to nudge consumers towards healthy food choices. The Nutri-Score, being implemented by seven European countries, is one of the most elaborated and evidence-based examples. Therefore, the Nutri-Score has been deemed as the frontrunner within the EU Commission's attempt to harmonize front-of-pack labeling among EU member states under its Farm-to-Fork strategy (F2F) by the end of 2022. However, the endeavor is on the brink of failure due to massive resistance by Mediterranean member states and parts of the food industry capitalizing on patriotic narratives (e.g. Made in Italy). This comment investigates the Nutri-Score saga from a political and commercial determinants of health lens. It argues that an EU-wide roll-out of the label hinges on the specific interplay between political structures and stakeholder agency. As shown, the EU's weak decision-making power has been exploited by the No-Nutri-Score alliance.

Exploring the influence of food labels and advertisements on eating habits of children: a cross-sectional study from Punjab, India.

BACKGROUND: Maintaining healthy eating habits among children is challenging due to industrial tactics. There is little research on the effect of nutritional labels and tv ads on the eating habits of children. So the primary aim of the study was to explore the noticeability of the food packaging labels by the children, the information retrieved from the food nutrition labels, and their role in increased frequency of eating out in addition to the perceptions of their parents about the television ads. METHODS: A cross-sectional study was conducted at schools in Punjab, India. Using multi-stage stratified random sampling, we included 722 school-going children aged 14-18 and their parents. A structured predefined questionnaire collected data using a four-point Likert scale. Descriptive statistics and binary logistic regression were used to draw our inferences. RESULTS: About 46% of children were eating out > 3 times a week. Nearly 49% said they never looked at the expiry dates on the food packet, and 40% have yet to notice the quality certification. Nearly half do not understand the components of the food label, and 59% said they never changed their buying behavior because of the label. Only 37% of parents expressed their concerns about the timing of the ads when children watch television, while only 25.5% were concerned about the accuracy of the information. Concerns of the parents regarding the timing of the ads, and celebrity endorsements, were potential predictors for the increased frequency of eating out by the children. CONCLUSIONS: Low awareness regarding the utility of nutrition labels and minimal concerns of the parents increase the frequency of eating out. Unification of our existing policies regarding food labels and tv advertisements to develop family-centric interventions will bring us one step closer to improving the enabling environment to curb the growing menace of childhood obesity.

Evaluation of Combinations of Nudging, Pricing, and Labeling Strategies to Improve Diet Quality: A Virtual Grocery Store Experiment Employing a Multiphase Optimization Strategy.

BACKGROUND: Several intervention strategies have been shown to improve diet quality. However, there is limited evidence on the increase in effectiveness that may be achieved through select combinations of these strategies. PURPOSE: This study aimed to identify an effective multicomponent intervention to improve diet quality of a grocery basket by applying a Multiphase Optimization Strategy framework and testing various combinations of four promising strategies using a fully functional web-based grocery store: (i) front-of-pack food labels and real-time feedback of the healthiness of the shoppers' grocery basket, (ii) a tax, (iii) ordering products by a nutritional quality score, and (iv) healthier substitute offers. METHODS: We conducted a hypothetical shopping study (N = 756) with a randomized full factorial design (16 conditions) to estimate main and interaction effects of the four interventions. RESULTS: The "food labels & real-time feedback" and "ordering" strategies had significantly positive main effects on overall diet quality of the shopping basket (both at p < .001). We found no effects on diet quality for the "tax" and "healthier substitute offers." None of the two-way interaction effects for different strategies on overall diet quality and nutrients were significant. CONCLUSIONS: Having "food labels & real-time feedback" and "ordering" simultaneously seemed to be more effective at improving diet quality, compared to having only one of these interventions. These results suggest that a combination of food labels with real-time feedback and ordering interventions can be part of a promising multicomponent strategy to improve diet quality in online shopping platforms. TRIAL REGISTRATION: ClinicalTrials.gov NCT04632212.

Front-of-pack health imagery on both 'healthy' and 'unhealthy' foods leads people to misremember seeing health claims: Two memory experiments.

Front-of-pack health imagery can shape people's inferences about food products' health benefits, even leading people to falsely remember reading health claims they never saw. However, research has typically examined these effects in situations where participants have little contextual information to guide their inferences about a product. The present research aimed to replicate the finding that front-of-pack health imagery leads participants to falsely remember reading health claims. It also extends that finding, by exploring whether this effect is moderated by the presence of contextual information signaling the product's actual 'healthiness'. In two pre-registered experiments, participants saw images of fictitious food products accompanied by written nutrition claims. Some of the products contained a health-related image whereas others did not. The supposed 'healthiness' of each product was manipulated by altering the color of the products' multiple traffic light (MTL) label (Experiment 1), or with an explicit healthiness statement (Experiment 2). Participants then attempted to remember the written claims that had appeared on each product's packaging. Health-related images increased participants' tendency to falsely remember reading health claims. But this was true regardless of whether or not participants saw contextual cues about the products' healthiness, either indirectly (Experiment 1) or directly (Experiment 2). These findings suggest that the presence of health imagery on a food product's package can lead consumers to infer health benefits, even when other, more direct cues indicate that the product is unhealthy. This research informs debates on safeguarding consumers from potentially misleading health claims, through the regulation of imagery in food marketing.

The impact of shelf tags with Nutri-Score on consumer purchases: a difference-in-difference analysis of a natural experiment in supermarkets of a major retailer in Belgium.

BACKGROUND: Delhaize, a major Belgian retailer, started implementing electronic shelf labels (ESL) with Nutri-Score since May 2019. Nutri-Score rates the healthfulness of packaged foods with five colours/letters from red/E (least healthy) to green/A (most healthy). This study evaluated the impact of ESL on consumer purchases, overall, and by food category. METHODS: For 43 intervention stores (implementing ESL in the period 27 May 2019-19 June 2019), a control store, from the same province and retailer-assigned cluster was matched. There were 14 unique control stores. By store, weekly non-food and food sales for 2018 and 2019 were received by Nutri-Score (A/B/C/D/E) and food category according to a retailer-assigned classification system. The primary outcomes were the proportion of food sales for Nutri-Score A,B,C,D,E. Difference-in-differences regression analysis was conducted to estimate the effect of the ESL intervention on proportion of overall food and food category sales for Nutri-Score A,B,C,D,E, using linear mixed models to account for clustering at store-level. We controlled for store characteristics (region, cluster, non-food sales) and week of the year. Analyses were weighted to re-balance discrepancy between the number of intervention and control stores. To account for multiple testing, a Bonferroni adjustment was applied. RESULTS: Comparing pre- and post-intervention periods, difference-in-differences for the proportion of Nutri-Score B and C product sales were more favourable in intervention than control stores (0.11 ± 0.04%, p = 0.007 and - 0.06 ± 0.03%, p = 0.026 respectively), while difference-in-differences for the proportion of Nutri-Score D product sales were less favourable in intervention than control stores (0.12 ± 0.04%, p = 0.002). For 17/58 food categories (representing 29% of total food sales) a positive impact [increase in healthier (Nutri-Score A, B) and/or decrease in less healthy (Nutri-Score D, E) food sales], and for 16/58 categories (representing 24% of total food sales) a negative impact was found. Positive impacts were found for vegetable, fruit and dairy products and confectionery. Negative impacts were found for bread and bakery products. CONCLUSION: The impact of ESL on consumer purchases was mixed. Favourable difference-in-differences were found for Nutri-Score B and C products and unfavourable difference-in-differences for Nutri-Score D products. Shelf labeling on its own is unlikely to significantly influence consumer behaviours.

Randomized trial evaluating the effectiveness of within versus across-category front-of-package lower-calorie labelling on food demand.

BACKGROUND: Several front-of-pack (FOP) labels identify healthier options by comparing foods within product categories. Alternative approaches label healthier options by comparing across categories. Which approach is superior remains unknown. The objective of this study was to test the effect of a within-category versus across-category FOP lower calorie label on 1) the percentage of labeled products purchased, 2) several measures of calories purchased (total, per dollar and per serving), and 3) total spending. We also tested the moderating effects of hunger and mood on purchasing patterns. METHODS: Using an online grocery store, we conducted a 3 × 3 crossover trial involving actual purchases with 146 participants randomly exposed to: 1) no labeling control; 2) within-category lower calorie labels, and; 3) across-category lower calorie labels. We labeled the 20% of products with the lowest calories per serving within or across categories. Purchases were compared using a fixed effects regression on first-differenced outcomes. RESULTS: Relative to the control condition, there was a 3 percentage point increase (p = 0.01) in labelled products purchased in the within-category arm and a non-significant decrease of 1 percentage point (p = 0.711) in the across-category arm. There was no significant difference in the proportion of labeled products purchased between the two labelling conditions. Neither strategy resulted in reductions in any measure of calories purchased or in total spending. When limited to beverages, there was a 398 cal reduction (p = 0.01) in the within-category arm and a 438 cal reduction (p < 0.01) in the across-category arm versus the control. Mood and hunger did not modify the effects for either strategy. CONCLUSIONS: Results provide evidence that both labelling strategies have the potential to influence food purchasing patterns. However, we cannot definitely state that one labelling approach is superior or even that an increase in the proportion of labelled products purchased will lead to a reduction in calories purchased. TRIAL REGISTRATION: The American Economic Association's registry for randomized controlled trials, RCT ID: AEARCTR-0002325; Prospectively Registered October 06, 2017. In compliance with ICMJE policy, the trial was also registered on Clinicaltrials.gov, RCT ID: [NCT04165447]. Retrospectively Registered 11 November 2019.

Influence of front-of-pack labelling and regulated nutrition claims on consumers' perceptions of product healthfulness and purchase intentions: A randomized controlled trial.

Mandatory front-of-pack (FOP) labelling was proposed in Canada to highlight foods with high contents of sugars, sodium and/or saturated fats, which would be displayed on labels along with the mandatory Nutrition Facts table and voluntary nutrition claims. In an online survey, participants (n = 1997) were randomized to one of four FOP labelling conditions: 1) control, 2) warning label, 3) health star rating or 4) traffic light labelling. Participants were shown four drinks (a healthier drink with or without a disease risk reduction claim, a healthier drink with or without a nutrient content claim, a less healthy drink with or without a disease risk reduction claim and a less healthy drink with or without a nutrient content claim) in random order and one at a time. Participants rated perceived product healthfulness and purchase intentions using a 7-point Likert scale. Participants could access the Nutrition Facts table while viewing labels. Results showed less healthy drinks displaying any FOP labelling were perceived as less healthy compared to the control. In healthier drinks, health star rating and traffic light labelling created a 'halo' effect, which was not observed with warning labels. Similar results were observed with purchase intentions. Drinks displaying a disease risk reduction claim were perceived as healthier than those without (p < 0.001) regardless of product's healthfulness. The effect of a nutrient content claim was not significantly different. The effect of FOP labelling and claims was mitigated for those who used the Nutrition Facts table. FOP labelling was likely helpful for consumers with different levels of health literacy. Overall, FOP labelling had significantly stronger influence than nutrition claims on consumers' perceptions; however, the effect of each FOP label varied on healthier and less healthy drinks.

Pilot randomized controlled trial testing the influence of front-of-pack sugar warning labels on food demand.

BACKGROUND: Front-of-pack (FOP) nutrition warning labels to identify potentially harmful foods/beverages have recently been considered in Singapore. The objective of this study was to pilot test two promising FOP warning labels intended to reduce purchases of products high in sugar to determine whether a full scale trial testing one or both these labels using actual purchases is warranted. METHODS: Five hundred twelve participants ≥21 years old and residing in Singapore completed all study elements online via the NUSMart Online Grocery Store study website. The study was designed as a Randomized Controlled Trial (RCT) where consumers were randomized and asked to hypothetically shop in one of three versions of an online grocery store; 1) no FOP label (control), 2) a graphical high-in-sugar label shaped like a stop sign, or 3) a text-based warning label. The proportion of labelled products purchased (primary outcome) and all secondary measures of diet quality were calculated using participants' orders. Ordinary Least Squares (OLS) regression was used to compare purchasing behavior across the three study arms. RESULTS: The proportion of high-in-sugar products selected (i.e., those targeted for labelling) was largest in the no label control arm at 20%. The proportion was a non-statistically significant 2 percentage points lower (P = 0.146) for the high-in-sugar stop-sign label arm and 4 percentage points lower (P < 0.05) in the warning label with deterrent text arm. We could not reject the hypothesis of equal effectiveness of the two warning labels (P = 0.231). CONCLUSIONS: Results suggest that the two health warning labels have potential to reduce demand for high-in-sugar products in Singapore. Future studies should test the influence of these labels using actual purchases in efforts to identify whether either labelling strategy should be considered for adoption in the local setting. TRIAL REGISTRATION: The American Economic Association's registry for randomized controlled trials; AEARCTR-0003800 . Registered 18 January 2019.

Evaluation of the Nutritional Quality of Chinese Processed Meat Products: Comparison of Two Nutrient Profile Models.

Processed meat products are one of the most consumed pre-packaged foods in China. They are also group-1 carcinogens, whose consumption has proved to be positively associated with the risk of noncommunicable diseases (NCDs). The purpose of this study is to analyze the nutrient content on the food label of processed meat products based on the China Standardized Database for the Composition of Pre-packaged Food and the National Open Database of the UK and France. The Chilean front-of-pack warning label (FOPWL) and the Chinese Healthier Choice Logo were used to compare the nutrient content of processed meat products from the three countries. It was found that cured meat products have the highest median energy (483 kcal/100 g), total fat content (38.7 g/100 g), and sodium content (2076 mg/100 g) and dried meat products have the highest median protein content (30.2 g/100 g) and carbohydrate content (38.2 g/100 g). In addition, there were significant differences in energy content and contents of total fat, protein, and carbohydrate across different products of the three countries (p < 0.001). A large number of processed meat products currently collected did not meet the criteria of the Chilean FOPWL and the Chinese Healthier Choice Logo. This study provided information on the healthiness of Chinese processed meat products and provided data for improving food formulations for different categories of processed meat products.

Evaluation of a front-of-pack food labeling intervention on a college campus.

Objective: To evaluate the process of implementation and impact of a front-of-pack labeling intervention on purchases of labeled food products. Participants: A convenience sample of 111 college students were recruited to complete a survey as they exited markets where the intervention was being implemented. Participants had to have purchased at least one consumable item. Methods: Intercept surveys and audits were conducted at three markets, two times each over a period of three weeks. Results: The audits indicated high implementation fidelity (82% overall). However, customer surveys revealed that only 42% noticed the front-of-pack sticker, and the majority (89%) did not purchase an item with the sticker. However, customers who noticed the sticker were significantly more likely to purchase an item with the sticker (p = .002). Conclusions: These findings provide preliminary evidence for the feasibility and effectiveness of a front-of-pack labeling intervention in a university market setting.

A Randomized Controlled Study to Test Front-of-Pack (FOP) Nutrition Labels in the Kingdom of Saudi Arabia.

One common strategy for governments to tackle the non-communicable disease (NCD) epidemic is front-of-package (FOP) nutrition labeling. The Kingdom of Saudi Arabia (KSA) is considering implementing a new FOP label that is based on either France's Nutri-Score (NS), which labels all foods (A = healthiest to E = least healthy) based on overall nutritional quality, or the Chilean warning label (WL) approach, which identifies foods to avoid based on select nutritional characteristics. Using a fully functional online grocery store, this study aimed to test these two promising FOP strategies by randomizing 656 KSA adults into one of the three versions of the store to complete a hypothetical grocery shop: no-label (control), NS, and WL. The NS was modified with a sugar percentage tag given that reducing sugar consumption is one of KSA's public health goals. We found that both modified NS labels and Chilean warning labels positively influenced food and beverage choices among KSA participants, but there were differential effects across the two labels. Relative to the control, NS improved the overall diet quality of the shopping baskets, measured by the weighted (by the number of servings) average NS point (ranging from 0, least healthy, to 55, healthiest), by 2.5 points [95% CI: 1.7, 3.4; p < 0.001], whereas results for WL were not statistically significant (0.6 points [95% CI: -0.2,1.5]). With respect to each nutritional attribute, we found that NS reduced sugar intake per serving, whereas WL was effective at decreasing energy and saturated fat intake per serving from food and beverages purchased. Our results suggest that the NS approach that identifies the healthiness of all foods using a holistic approach appears preferable if the purpose of the label is to improve overall diet quality as opposed to addressing select nutrients to avoid.

Front-of-pack labels: "Directive" versus "informative" approaches.

Front-of-pack labels (FOPLs) aim at communicating to consumers the health value of food items in support of public health policies. Two main types can be discerned: directive and semidirective FOPLs using color schemes (e.g., Nutri-Score) and informative FOPLs (e.g., Nutrinform Battery). Directive approaches tend to show a "wear-out effect" and, additionally, they tend to have various underlying conceptual problems. Usually, their nutritional scores are calculated using changing, arbitrary algorithms and involve a reductionist set of parameters of debatable validity. Thus, they overstate the effects of selected nutritional factors, such as saturated fat and energy, while overlooking the food matrix and the more holistic aspects of nourishment. Moreover, they do not reflect the portion that is consumed, ignore the preparation steps at home, and fail to serve as a useful basis for composing a healthy diet. Also, so long as the nutritional formulations match the algorithmic standards, they tend to allow ultra-processed products. Thus, this might confuse and mislead consumers. Overconfidence in green-colored labels could even result in unbalanced dietary choices, whereas avoidance of red products may eliminate certain foods from the diet that are rich in essential nutrients (e.g., cheese), leading to opposite results than aimed for. The latter is particularly relevant to vulnerable populations, such as the young, pregnant women, and older adults, or for individuals with specific needs. Taken together, directive FOPLs such as Nutri-Score contradict the declared intent of the European Commission to empower consumers to undertake healthy and balanced diets based on easily accessible and robust information. Although informative systems usually also keep the focus on a few selected nutritional parameters, they have are less paternalizing and obviate the need to classify foods as healthy or unhealthy. They also focus attention on the individual portions that are consumed (even if the definition of portion size remains contentious). Given the importance of dietary patterns, rather than individual foods or nutrients, directiveFOPLs of the Nutri-Score type represent a regretful case of nutritionism. Finally, attempts to associate the adoption of a FOPL with an improvement in the health status are few and mainly applied in virtual settings; none of which are longitudinal, nor have they been able to identify a causal link.

Perception and Understanding of Guideline Daily Amount and Warning Labeling among Mexican Adults during the Law Modification Period.

Front-of-pack labeling (FOPL) is a tool that enables consumers to compare foods and select healthier options. Due to low understanding of the Guideline Daily Amount (GDA) labeling among Mexicans, a law was implemented in October 2020 that modified the FOPL to a warning labeling (WL) system. The purpose of this study was to compare the perception and understanding of GDA and WL during the law modification period. We conducted a panel design with two measurements: (1) using GDA label (September 2020) and (2) using WL (October-November). We estimated differences in GDA vs. WL through multinomial logistic regression models and changes were measured through predictive margin contrasts and Wald tests. When comparing the same products with different labels, the participants reported that it would be unlikely/very unlikely that they would consume products packaged with the WL (81.5%; 95%CI: 79.2, 83.8) compared to those with GDA (24.2%; 95%CI: 21.7, 26.7). Consumers' perception was that the quantities of packaged products they should consume was small or very small when they used the WL (93.8%; 95%CI: 92.4, 95.5) compared to GDA (41.6%; 95%CI: 39.7, 44.6). When comparing food groups, participants were more confident about choosing healthy products when using the WL compared to the GDA. During the implementation of WL in Mexico, the studied population had a better perception and understanding of less healthy packaged foods when using WL, compared to the GDA label.

Nutri-Score: Awareness, Perception and Self-Reported Impact on Food Choices among French Adolescents.

To date, no studies have evaluated the appropriation of the front-of-pack Nutri-Score labeling among adolescents, although they are both consumers and buyers of food products. Therefore, the objectives of the present study were (1) to assess Nutri-Score awareness, perception and self-reported impact on food choices in French adolescents and (2) to identify the determinants associated with higher Nutri-Score awareness and self-reported impact on food choices. A web-based survey was conducted in November 2021 among 1201 adolescents. Multivariate logistic models were used to evaluate the relationships between individual factors and Nutri-Score awareness and self-reported impact on food choices. Almost all the adolescents reported to know the Nutri-Score (97.0%) and more than 9 out of 10 considered this logo easy to understand and easy to identify on food packages. Finally, 54% self-reported that the label had already impacted their food choices. Girls (2.28 (1.09−4.77), p = 0.028) and the 15−17-year-olds (3.12 (1.32−7.35), p = 0.0094) were more likely to be aware of the label compared with their respective counterparts (i.e., boys and the 11−14-year-olds). Regarding the impact of food choices, the use of the Nutri-Score by the parents was the most determinant criterion (7.74 (5.74−10.42), p < 0.0001). Thus, promotion campaigns should target both adolescents and parents.

The Nutri-Score algorithm: Evaluation of its validation process.

The Nutri-Score front-of-pack label, which classifies the nutritional quality of products in one of 5 classes (A to E), is one of the main candidates for standardized front-of-pack labeling in the EU. The algorithm underpinning the Nutri-Score label is derived from the Food Standard Agency (FSA) nutrient profile model, originally a binary model developed to regulate the marketing of foods to children in the UK. This review describes the development and validation process of the Nutri-Score algorithm. While the Nutri-Score label is one of the most studied front-of-pack labels in the EU, its validity and applicability in the European context is still undetermined. For several European countries, content validity (i.e., ability to rank foods according to healthfulness) has been evaluated. Studies showed Nutri-Score's ability to classify foods across the board of the total food supply, but did not show the actual healthfulness of products within different classes. Convergent validity (i.e., ability to categorize products in a similar way as other systems such as dietary guidelines) was assessed with the French dietary guidelines; further adaptations of the Nutri-Score algorithm seem needed to ensure alignment with food-based dietary guidelines across the EU. Predictive validity (i.e., ability to predict disease risk when applied to population dietary data) could be re-assessed after adaptations are made to the algorithm. Currently, seven countries have implemented or aim to implement Nutri-Score. These countries appointed an international scientific committee to evaluate Nutri-Score, its underlying algorithm and its applicability in a European context. With this review, we hope to contribute to the scientific and political discussions with respect to nutrition labeling in the EU.

An Experimental Study Evaluating the Influence of Front-of-Package Warning Labels on Adolescent's Purchase Intention of Processed Food Products.

Front-of-package warning labels (WLs) are among the public health policies adopted by some countries, mainly in Latin-America, to tackle childhood obesity; however, their impact is still under review. The aim of this study was to assess, using an experimental design, whether WLs influence purchase intention of processed foods and identification of the healthiest products among adolescents in Peru, in May 2019, just before WLs mandatory implementation. Four hundred forty-nine adolescents from two public schools were randomly assigned to an experimental group (received three different processed products with either zero, one or two WLs, informing if they were high in sugar, sodium and/or saturated fats) or a control group (received the same products but unlabeled). Participants chose which product they would buy, and which they considered to be the healthiest. No differences between groups were found neither in purchase intention (p = 0.386) nor in the identification of the healthiest product (p = 0.322). In both groups, the most-selected product was always the healthiest of the triad (>40% in purchase intention and >80% in identification of the healthiest). Front-of-package WLs did not influence purchase intention, or identification of healthier products among adolescents from public schools in Peru. Mass media and educational campaigns should accompany the WLs implementation to help achieve the policy objective.

Marketing strategies used for alternative protein products sold in Australian supermarkets in 2014, 2017, and 2021.

Introduction: Marketing plays an important role in consumers' perceptions and acceptance of new foods. The purpose of this study was to investigate the marketing strategies used for alternative protein products available in Australia in 2014, 2017, and 2021. Methods: Product data were extracted from FoodTrack™, an established database of packaged supermarket products. Marketing strategies investigated included product format descriptors, front of pack (FOP) labeling claims, price, and in-store placement (2021 only). Results: Data from 292 alternative protein products (n = 12 tofu-based products; n = 100 legume-based products; and n = 180 plant-based meats) were analyzed. Across the product range, "burgers" (n = 86), "strips and similar" (n = 51) and "sausages" (n = 42) were the most common product formats, accounting for ∼61% of the product range. Nutrient content claims featured on 273 (93%) products. "Positive" nutrient claims (those highlighting the presence of a nutrient) occurred on FOP labels four times more than "negative" nutrient claims (those highlighting the absence or low levels of a nutrient; 432 versus 101, respectively). Protein-related claims were the most common "positive" nutrient claim (n = 180, 62%). Health claims on FOP labels appeared on 10% of products. Most products (n = 265, 91%) mentioned a dietary pattern (such as "vegetarian" and "plant-based"), or a combination of dietary patterns on their FOP label. The price of alternative products increased over time; between 2014 and 2021, on average, the unit price increased (9% increase, p = 0.035) and the pack size decreased (14% decrease, p < 0.001). There was inconsistency in product placement across the eight stores visited. Occasionally (n = 3 of 13 locations), chilled alternative protein products were positioned near conventional meat products. More commonly, alternative protein products shared space with other vegetarian products (such as non-dairy cheeses and tofu blocks) or alongside convenience products, suggesting these products are promoted as convenience foods, or options for individuals with special dietary needs. Discussion: This study provides a useful evidence base to understand the marketing strategies used for alternative protein products. It appears from this analysis that considerable effort has gone into providing consumers with a level of familiarity and comfort prior to purchasing these alternative protein products.

Methodology for the Review and Update of Nutrient Criteria Underpinning Front-of-Pack Labeling: Application to the Glycemic Index Symbol.

Background: Nutrient criteria underlying front-of-pack food labeling programs can play an important role in improving dietary intakes. Currently, no methodology for the development or update of nutrient criteria has been published, nor the methods used by food regulatory bodies. The scientific publication of methodology outlining the development and update of nutrient criteria underpinning front-of-pack food labeling programs highlighting healthier food choices is needed. Objective: To develop and provide a globally applicable and transparent methodology for researchers to follow when reviewing existing or developing new nutrient criteria for front-of-pack labeling. Methods: The Nutrient Criteria Methodology involved five phases: Phase I, the development of guiding principles; Phase II, collection of information for subsequent phases, including a pre-scope of the literature and selection of food composition database(s) for modeling; Phase III, literature review of all possible nutrients relevant to the nutrient criteria; Phase IV, database modeling to set quantitative limits for each selected nutrient; Phase V, assessment of the criteria against an established nutritional quality assessment tool. As an example, the methodology was applied to the update of the GI Symbol Product Eligibility and Nutrient Criteria (PENC). Results: A comprehensive and replicable methodology, based on best practice protocols and ensuring both scientific credibility and practicality of use by industry, was developed. Application of the five phases of the methodology to the GI Symbol PENC highlighted the ability of the methodology to uncover nutritional measures currently missing in many nutrient criteria for front-of-pack food labeling programs and other national food labeling systems, such as glycemic load and the unsaturated to saturated fat ratio. Foods achieving the PENC had a higher Health Star Rating than foods not achieving the PENC. Conclusion: Our Nutrient Criteria Methodology can be applied to the development and update of global nutrient criteria underpinning front-of-pack food labeling programs. Further research into the implementation of additional nutritional measures found to be important for human health is recommended, with the goal of the prevention of diet-related disease.

Relationship between front-of-pack labeling and nutritional characteristics of food products: An attempt of an analytical approach.

The adoption of supplementary nutrition information, i.e., front-of-pack labeling (FOPL), on pre-packed food products is advocated as a tool to improve the consumers' knowledge of the nutrient content or the nutritional quality of foods, but also to drive products reformulation by the food industry. Ultimately, FOPL should help people to select foods in order to compose an overall balanced diet, which is essential for health. However, the extent to which the different FOPL systems proposed in the European Union (EU) (interpretative or informative) are effectively able to convey the information useful to improve both food choices and dietary habits of the consumers is still under debate and needs to be analyzed in detail. The use of 3 FOPL schemes proposed within the EU (Nutri-Score, Keyhole and NutrInform Battery) to compare products available on the Italian market within different food categories, highlights some critical issues: (1) different FOPL provide to consumers different kinds of information; (2) systems based on similar theoretical approaches can provide conflicting information; (3) the algorithms on which interpretative FOPL are based can give the same summary information for products differing in nutrient composition, impact on the overall dietary balance and therefore on the health of people with different characteristics, physiological/pathological conditions, and nutritional requirements; (4) on the other hand, products with similar nutrient composition can obtain different interpretative FOPL; (5) informative systems are generally more complex and require greater both attention and knowledge from the consumer; (6) FOPL based on 100 g of product overlook the role of portion (and frequency of consumption) in determining the nutrient intake without informing on the contribution of a single food to the overall diet; (7) FOPL based on scoring systems could promote the reformulation of selected products, especially with a composition very close to the threshold limits; (8) for the portion-based informative FOPL systems, the incentive for reformulation could essentially involve the reduction of portion size. Finally, the importance of nutritional education interventions, which are required to encourage the use by consumers of informative FOPL systems, cannot be neglected to improve the quality of diets regardless of the FOPL used.

Nutrition Classification Schemes for Informing Nutrition Policy in Australia: Nutrient-Based, Food-Based, or Dietary-Based?

Background: Policy makers are increasingly using nutrition classification schemes (NCSs) to assess a food's health potential for informing nutrition policy actions. However, there is wide variability among the NCSs implemented and no standard benchmark against which their contrasting assessments can be validated. Objectives: This study aimed to compare the agreement of nutrient-, food-, and dietary-based NCSs in their assessment of a food's health potential within the Australian food supply, and examine the conceptual underpinnings and technical characteristics that explain differences in performance. Methods: A dataset combining food compositional data from the Mintel Global New Products Database and the Australian Food Composition Database (AUSNUT 2011-2012) (n = 7322) was assembled. Products were classified by 7 prominent NCSs that were selected as representative of one or other of 1) nutrient-based NCSs [the Chilean nutrient profile model (NPM), Health Star Rating (HSR), Nutri-Score, the WHO European Region's NPM (WHO-Euro NPM), and the Pan American Health Organization's (PAHO) NPM]; 2) food-based NCS (NOVA), and 3) dietary-based NCS [Australian Dietary Guidelines (ADGs)]. Results: The PAHO NPM classified the lowest proportion (22%) of products as "healthy", and the HSR the highest (63%). The PAHO NPM, NOVA, WHO-Euro NPM, and the Chilean NPM classified >50% of products as "unhealthy," and the ADGs, HSR, and Nutri-Score classified <50% of products as "unhealthy." The HSR and Nutri-Score had the highest pairwise agreement (κ = 0.7809, 89.70%), and the PAHO NPM and HSR the lowest (κ = 0.1793, 53.22%). Characteristics of NCSs that more effectively identified ultraprocessed and discretionary foods were: category-specific assessment, the classification of categories as always "healthy" or "unhealthy," consideration of level of food processing, thresholds for "risk" nutrients that do not penalize whole foods; and no allowance for the substitution of ingredients. Conclusions: Wide variation was observed in agreement of the assessment of a food's health potential among the NCSs analyzed due to differing conceptual underpinnings and technical characteristics.