A new study from South Africa comparing three different front-of-package (FOP) labeling schemes found that a nutrient warning label helped more participants correctly identify unhealthy products and more strongly reduced their intention to purchase those products, compared to a “multiple traffic light” label and a Guideline Daily Amounts label.

These findings, published in Appetite, come at an important time as South African policymakers consider draft regulation for the country’s first mandatory front-of-package label. While research from other countries has found that nutrient warning labels are the stronger FOP label option for identifying and discouraging consumption of unhealthy foods, some studies find that other labels, such as the traffic light, can also be effective. This suggests that context plays an important role and underscores the importance of testing a label designed specifically for South Africa.

“It was important to create a warning label for South Africa that can help people from different language backgrounds and literacy levels make informed decisions on what to buy and eat,” said Makoma Bopape (left), first author and Senior Lecturer in Human Nutrition and Dietetics at the University of Limpopo. “We achieved this using a triangle shape and exclamation mark that are associated with ‘warning’ in South Africa and by including icons for each nutrient, for example a saltshaker for sodium.”

In a randomized controlled trial, researchers from the University Limpopo, the University of the Western Cape, the University of Antwerp, and the University of North Carolina at Chapel Hill compared how well the different label types helped South African consumers:

• Identify products high in sugar, salt, or saturated fat;
• Identify unhealthy products; and
• Reduce intention to purchase unhealthy products.

Participants were randomly selected from the general South African population, which resulted in a representative sample of nearly 2,000 households. They first answered questions about a set of fictional products with no FOP labels, as a control condition. Next, they were randomly assigned to one of the three FOP label conditions and shown another set of products featuring that label. They then answered the same questions about the labeled products.

Researchers measured how many participants in each group correctly identified products high in nutrients of concern (sugar, salt, and saturated fat), how many correctly identified products as unhealthy, and whether participants’ intention to purchase the unhealthy products changed after seeing them with a specific FOP label.

“These findings are consistent with a rapidly growing body of evidence from around the world showing that warning labels are the most effective label type for helping consumers rapidly identify unhealthy foods — and perhaps more importantly, discouraging consumers from buying them,” said Lindsey Smith Taillie (right), co-author and Associate Professor of Nutrition at the University of North Carolina at Chapel Hill.

This research comes on the heels of another study by Bopape, Taillie, and Rina Swart, senior author and professor in Dietetics and Nutrition at the University of the Western Cape, in which they examined how the same warning labels impacted parents’ food purchasing decisions and perceptions of unhealthy foods. When shown images of products with warning labels, parents said they would buy less of the foods with warning labels and switch to non-labeled, healthier options. Parents in the study also expressed that their children’s health was their top priority. Warning labels made them think about future health impacts if their children continued eating ultra-processed foods high in sodium, sugar, and saturated fat.

Like many countries worldwide, South Africa faces high rates of obesity and other diet-related diseases including type 2 diabetes, hypertension, and heart disease — all exacerbated by consuming a diet high in sugar, sodium, or saturated fat. In addition to helping consumers easily and more accurately identify foods high in nutrients of concern and discourage purchases of those products, requiring FOP warning labels on the least-healthy foods and drinks could incentivize industry to offer healthier product choices.

Policies using similar FOP nutrient warning labels have already been implemented or passed in ten other countries — most in the last three years. Evidence of their impact in Chile, where FOP warning labels have been required on unhealthy packaged foods and drinks since 2016, suggests that findings from experiments like this one in South Africa can translate into real, population-level changes in shopping behavior once a policy is implemented. In its first year, Chile’s FOP warning label policy was associated with a 24% drop in sugary drink purchases and declines in sodium (–37%), total calories (–24%), calories from sugar (–27%), and calories from saturated fat (–16%) purchased from all foods and beverages.

“If South Africa adopts the labels used in this study into the current draft regulations, ours will be the first African country and second country in the world after Israel to use a mandatory warning label with icons for different nutrients,” said Swart (left). “In addition to helping guide South African consumers toward healthier choices on what to buy, eat, and feed their families, this could provide important evidence for other countries that have diverse languages and literacy levels.”

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This research was funded by Bloomberg Philanthropies.

For inquiries, contact Emily Busey.

Read the full paper in Appetite:

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AUTHORS

Makoma Bopape
University of Limpopo,
University of the Wester Cape

Jeroen De Man
University of Antwerp

Lindsey Smith Taillie
UNC-Chapel Hill

Shu Wen Ng
UNC-Chapel Hill

Nandita Murukutla
Vital Strategies, New York

Rina Swart
University of the Western Cape

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RESOURCES

Read more about the evidence for front-of-package labels.

View different front-of-package labeling policies around the world.

Parents are more likely to choose a fruit drink with added sugar for their young child when the drink’s packaging includes nutrition-related claims, researchers with the Global Food Research Program found in a study published in the American Journal of Clinical Nutrition.

This study is among the first to look at how claims influence parents’ drink purchases for their young child (ages 1-5).

In their experiment, the research team invited parents to “shop” in a virtual convenience “store” (similar to a video game, right) on participants’ own computers. The study’s 2,219 participants were randomly assigned to view fruit drinks displaying one of three claims (“No artificial sweeteners,” “100% Vitamin C,” or “100% All Natural”) or no claim.

Findings

The research team found that healthful claims increased misperceptions about nutritional quality. Even though all drink labels also contained nutritional panel information, parents who viewed drinks with claims were more likely to incorrectly believe that the fruit drinks did not contain added sugar or were 100% juice.

“Parents who saw the claims were more likely to pick the sugary fruit drink instead of water, as well as choose the sugary fruit drink instead of 100% fruit juice,” said Marissa Hall, assistant professor at UNC-Chapel Hill’s Gillings School of Global Public Health and the study’s lead author. “The sugary fruit drinks had over 30 grams of added sugar, and that information was right there on the label. But still, the presence of a claim made parents more likely to think that the sugary fruit drinks did not have any added sugar. Also, the claims made parents think that the drinks were 100% fruit juice, which was not the case.”

These findings build on the authors’ research looking at how often nutrition-related claims appear on fruit drinks and how claims relate to drinks’ actual nutritional profile. They have also examined sociodemographic disparities between households that purchase fruit drinks with claims (under review). Key findings from these studies include:

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  Nutrition-related claims are ubiquitous: 97% of fruit drinks purchased had at least one and, on average, 3 to 4 nutrition-related claims on the front-of-package.
• Fruit drinks with claims related to vitamin C, juice or nectar, fruit or fruit flavor, and “natural” claims were higher in calories and sugar than fruit drinks without these claims.
• Less than a quarter of fruit drinks studied listed juice in their top two ingredients, but over half had juice, nectar, or fruit claims on the front of the package.
• U.S. households with infants and young children from socially disadvantaged groups were more likely to purchase fruit drinks.

Implications

Collectively, these studies’ findings suggest a need for stronger regulation of marketing claims on fruit drinks.

“Claims can make products seem healthier to parents than they really are,” said Lindsey Smith Taillie, PhD, senior author and assistant professor at Gillings School of Global Public Health. “This is problematic and important from a policy standpoint.”

“The FDA could consider requiring nutrient warning labels or disclaimers on the products to help inform consumers about the risk, or regulating use of certain claim types,” said Hall. “For example, the FDA could prohibit labeling a sugary fruit drink ‘all natural,’ if it contains above a certain amount of added sugar.”

Taillie notes that a precedent for such policies exists in other countries. “In Mexico, for example, beverages that are high in sugar are prohibited from carrying nutrition claims. This type of regulation could help make it easier for parents to be able to quickly and easily sort out the sugary drinks from the healthier options while grocery shopping.”

“The FDA has broad authority to combat deceptive labeling,” said Eva Greenthal, co-author and senior science policy associate at the public health advocacy group, Center for Science in the Public Interest. “The agency should consider requiring nutrient warnings on products that are high in added sugars, requiring more prominent ‘percent juice’ declarations on fruit drink labels, and prohibiting nutrient claims like ‘100% Vitamin C’ on beverages that are high in added sugars.”

Read more about these studies and their findings in our Fruit Drinks Study Series infographic fact sheet.

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This research was supported by grant #76337 from the Robert Wood Johnson Foundation’s Healthy Eating Research program.

AUTHORS:

Marissa G Hall
Allison J Lazard
Isabella CA Higgins
Jonathan L Blitstein
Emily W Duffy
Eva Greenthal
Sarah Sorscher
Lindsey Smith Taillie

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RESOURCES:

Learn more about the team’s findings on fruit drink claims in our fruit drinks fact sheet.

A study published today in PLOS ONE found that for Colombian adults, nutrient warning labels work better than two other common front-of-package (FOP) label types for discouraging consumption of ultra-processed foods.

The experiment

Researchers at Universidad Nacional de Colombia, Pontificia Universidad Javeriana, and UNC-Chapel Hill conducted a study involving over 8,000 Colombian adults. In this experiment, each participant was randomly assigned to one of four FOP label conditions:

1. An octagonal, stop sign nutrient warning label (below, left);
2. the industry-preferred voluntary Guideline Daily Amounts (GDA) label (below, center);
3. A color-coded Nutri-Score label used voluntarily in a handful of European countries (below, right); or
4. No FOP label (control condition).

Participants were asked to compare two fruit drinks with labels from their assigned group. One of the fruit drinks was healthier (contained naturally occurring and no added sugar), and one of the fruit drinks was less healthy (contained 39.4 grams of sugar and included added sugar). They were asked to pick the healthier product, choose which drink they thought was higher in sugar, and indicate which one they would rather buy. 

Next, participants answered questions about other products (yogurt, cookies, sliced bread, and breakfast cereal) to see if they could correctly pick which ones were high in a nutrient of concern (e.g., sugar, saturated fat) and whether FOP labels discouraged them from wanting to consume the product. Finally, participants viewed all three label types and picked which one would discourage them most from wanting to consume the product. 

Findings

Of the FOP label types tested, nutrient warning labels were most effective in each of these outcomes:

• Participants who correctly identified products with excess sugar, saturated fat, or sodium:
  • Nutrient warning labels: 75%
  • GDA label: 43%
  • Nutri-Score label: 26%
  • No label: 23%.  

• Participants who felt discouraged from consuming a product high in sugar, saturated fat, or sodium:
  • Nutrient warning labels: 72%
  • GDA label: 20%
  • Nutri-Score label: 9%. 

• Participants who chose the less healthy of two fruit drinks as the one they wanted to consume:
  • Nutri-Score: 33%
  • No label: 29%
  • GDA label: 24%
  • Nutrient warning label: 20%

The impact of the warning label on product selection was similar across education levels. This provides evidence that nutrient warning labels would not lead to increased disparities in product selection by education level.

This study builds on the team’s previous study published October, 2020 in Nutrients, which found that a “stop sign,” octagonal nutrient warning label (like those implemented in Chile, Peru, and Mexico) was more effective than a circular or triangular nutrient warning label at discouraging Colombian adults from wanting to buy ultra-processed products.

Importance

In July 2021, the Colombian government passed a new law — Ley Comida Chatarra (The Junk Food Law) — which has legislated mandatory front of package labeling for Colombia. Implementation of the junk food law must take place within one year of passage, and the regulatory norms, including final label design, are forthcoming. This study supports implementation of octagonal nutrient warning labels as the new mandatory FOP label in Colombia.

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Funding support for this study was provided by Bloomberg Philanthropies. Additional support for some authors was provided by the National Institutes of Health.

AUTHORS:

Mercedes Mora-Plazas
Isabella C. A. Higgins
Luis Fernando Gomez
Marissa G. Hall
Maria Fernanda Parra
Maxime Bercholz
Nandita Murukutla
Lindsey Smith Taillie

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RESOURCES:

Learn more about the evidence for front-of-package nutrient labels in our fact sheet.

View FOP label policies around the world in our front-of-package labeling policy maps.

A study published this week in PLOS Medicine is the first to examine in a realistic store setting whether pictorial health warnings on sugary drinks have an impact on which beverages parents choose to buy for their children.

For this randomized trial, parents of children ages 2–12 years were given a shopping task in the UNC Mini Mart — a mock convenience store “laboratory” designed and built by senior author Lindsey Smith Taillie, PhD and lead author Marissa Hall, PhD.

In the experiment, one group of parents shopped from a beverage selection that included pictorial warnings on the sugary drink options (right); the other group shopped the same beverage selection, but with no warnings on the sugary drinks. 

Key findings

The pictorial warning labels led to a 17-percentage-point difference in sugary drink purchases: In the group who saw the experimental labels while they shopped, 28% of parents bought their child a sugary drink, compared to 45% of parents in the group that did not see warnings. 

The pictorial warnings also led to

• Fewer calories purchased from sugary drinks, 
• Lower intentions to serve sugary drinks to their child, 
• Feeling more in control of healthy eating decisions, and 
• Greater thinking about the harms of sugary drinks.

These findings indicate that pictorial warnings could be a promising policy option for reducing parents’ purchases of sugary drinks for their children and ultimately reducing kids’ sugary drink consumption.

This is the team’s first experiment to be completed using the team’s UNC Mini Mart space following the validation pilot study. In additions to Drs. Taillie and Hall, the research team for this study included GFRP team members Isabella Higgins, MPP; Carmen Prestemon, BSPH; and GFRP alum Anna H. Grummon, PhD.

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Read more about this study’s findings and their implications in the Gillings School News.

What goes into building a mock store? Check out Dr. Taillie’s behind the scenes tour:

Who wants some behind-the-scenes photos from our recent RCT in @PLOSMedicine? We made a store! pic.twitter.com/38SvJlleAf

— Lindsey Smith Taillie (@lindseypsmith) February 2, 2022