Potential effect of different nutritional labels on food choices among mothers: a study protocol.

BACKGROUND: The prevalence of non-communicable diseases (NCDs) is increasing in the world. Healthy food choice and adequate physical activity are key factors in preventing NCDs. Food labeling is a strategy that can inform consumers to choose healthier foods at the point of purchase. In this study, we intend to examine the status of existing labels and to clarify their strengths and weaknesses. Then, for the first time in Iran, we will design a type of physical activity equivalent calorie label and will test it on some food groups of packaged products including dairy products, sweetened beverages, cakes, and biscuits. METHODS: This study will be conducted in two phases. In phase 1, nutrition fact labels and traffic light labels will be assessed through focus group discussions and interviews among different groups of mothers, industrialists and nutrition and food industry specialists as to determine strengths and weaknesses of the current labels on packaged products. Then, the initial layout of the physical activity calorie equivalent label will be drawn with respect to the viewpoints received from mothers. Thereafter, we will include the scientific opinions to it for creating the first draft of our new label. In phase 2, a total of 500 mothers of students 6-12 years old randomly assigned to five groups. The study groups will be as follows: (1) without nutrition label group, (2) current traffic light label group, (3) current traffic light label group in which, a brochure will be used to inform mothers, (4) physical activity calorie equivalent label group, and (5) physical activity calorie equivalent label group in which a brochure will be used to inform mothers. Some samples of dairy products, beverages, cakes, and biscuits will be presented. ANOVA and multiple linear regressions will be used to examine the association between the label type and the main consequence (energy of the selected products) and secondary outcome (time). DISCUSSION: The effect of the new food labels will be evaluated based on the differences between the calories of selected food groups. TRIAL REGISTERATION: Iranian Registery of Clinical Trials [IRCT]20,181,002,041,201 N1.

Physical activity equivalent labeling vs. calorie labeling: a systematic review and meta-analysis.

BACKGROUND: Many countries are trying to identify strategies to control obesity. Nutrition labeling is a policy that could lead to healthy food choices by providing information to consumers. Calorie labeling, for example, could lead to consumers choosing lower calorie foods. However, its effectiveness has been limited. Recently, physical activity equivalent labeling (i.e., displaying calories in terms of estimated amount of physical activity to burn calories) has been proposed as an alternative to the calorie-only label. The aim of this review was to identify and evaluate the published literature comparing effects on health behavior between physical activity equivalent labeling and calorie-only labeling. METHOD: We searched the following databases: Pubmed/medline, Scopus, Web of science, Agris, Cochrane library, Google Scholar. We also searched along with reference lists of included articles. Articles that were published between 1 January 2000 and 31 October 2016 were eligible for inclusion provided they reported on studies that examined the effects of both types of labeling and included at least one outcome of interest. Mean and standard deviations of the included results were combined using a fixed-effect model. The difference in calories purchased between people exposed to physical activity labeling and calorie-only labeling was calculated as weighted mean difference by using a fixed-effect model. RESULT: The difference of calories ordered between physical activity label and calorie label groups was not statistically significant (SMD: -0.03; 95% CI: -0.13, 0.07). The difference of calories ordered between physical activity label and calorie label according to real vs unreal (e.g. web-based) condition was 65 Kcal fewer in real-world settings. CONCLUSION: Physical activity calorie equivalent labeling in minutes does not significantly reduce calories ordered compared to calorie-only labeling.

Designing a new physical activity calorie equivalent food label and comparing its effect on caloric choices to that of the traffic light label among mothers: a mixed-method study.

Objective: We designed a new type of 'physical activity calorie equivalent' (PACE) food label in Iran to compare its effect with that of the traffic light food label (TLL) on caloric choices. Design: Mixed-method study. Participants: Mothers of school children between the ages of 6-12 years. Setting: In the qualitative phase, 10 focus group discussions (FGDs) were conducted with various groups of mothers, and two FGDs were conducted with food science and nutrition experts to design a new PACE label. In the quantitative phase, 496 mothers were randomly assigned to five groups: (1) no nutrition label, (2) current TLL, (3) current TLL + educational brochure, (4) PACE label, and (5) PACE label + brochure. Samples of dairy products, beverages, cakes, and biscuits were presented. ANOVA and multiple linear regressions were applied to examine the association between label types and calories of the selected products as our main outcome. Results: The mothers' perspectives were classified into two sub-themes, the PACE label's facilitators and barriers. The new PACE label's characteristics were divided into two subcategories: (a) appearance, and (b) nutritional information, including 14 codes. In the quantitative section, mean calories of the selected foods were lowest in the TLL + brochure group (831.77 kcal; 95% CI: 794.23-869.32), and highest in the PACE label group (971.61; 95% CI: 926.37-1016.84). Conclusion: The new PACE label was a combination of PACE, TLL, and warning labels. It did not significantly affect lower caloric choice, however, the TLL + brochure option was effective in choosing foods with fewer calories.Clinical trial registration: The study was registered in the Iranian Registry of Clinical Trials 23 (IRCT20181002041201N1).

Nutrition labels' strengths & weaknesses and strategies for improving their use in Iran: A qualitative study.

BACKGROUND: This study aimed to explain the strengths and weaknesses of the Traffic light label (TLL) and nutrition facts label (NFL) and the strategies for improving their use in Iran, based on the perspectives of different stakeholders, including mothers, food quality control experts (FQC), nutritionists and food industry experts. METHODS: We conducted 10 Focus Group Discussions (FGDs) with 63 mothers, 10 semi-structured interviews with FQCs, 1 FGD with 6 nutritionists and 1 FGD with 8 food industry experts. To clarify some of the questions that arose from the interviews, the researcher interviewed three policy makers who had sufficient information about the TLL. The discussions and interviews were transcribed verbatim and MAXQDA10 software was used for coding. RESULTS: The most important findings of this study based on different stakeholders' perspectives were as follows: mothers believed that nutrition labels reduced the consumption of high-calorie products, although they found the TLL to be easier to understand than the NFL because of its red color. However, their weaknesses were their incompatibility with culture and the lack of trust in the information provided by manufacturers. FQCs pointed out the possibility of changing formulations and the appropriateness of the traffic light for patients, but like mothers, they believed that the labels did not suit the governing culture. Further weaknesses were, misleading the consumer, problems in the colorings reported by different laboratories, and different approaches adopted by regulatory experts. The simplicity of understanding TLL for the general public has been suggested by some nutritionists. Nevertheless, the multiplicity of colors of the TLL was the most important weakness presented by nutritionists and food industry experts and the failure to implement nutrition labels was another issue raised by experts. To improve the use of nutrition labels, notification via media especially television, community education and culture building were suggested by all stakeholders. CONCLUSIONS: The findings of this study underscore the importance of implementing the policy of nutrition labeling in Iran. Mothers and nutritionists believed TLL to be more appropriate for the public to understand, however, FQCs and food industry experts believed that NFL was more suitable in guiding consumers toward healthy food choices. Education and information dissemination via media on interpretive TLL may affect consumer behavior toward food purchases.