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

Felicia Jia Ler Ang, Sagun Agrawal, Eric A Finkelstein, Felicia Jia Ler Ang, Sagun Agrawal, Eric A Finkelstein

Abstract

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.

Keywords: Front-of-pack labeling; Nutrition labeling; Online grocery store; Sugar; Warning labels.

Conflict of interest statement

Ethics approval and consent to participate

This study protocols and procedures are in accordance with the Declaration of Helsinki and were approved by the National University of Singapore Institutional Review Board Reference Code: S-17-172. Written informed consent was obtained from all subjects.

Consent for publication

Not Applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Warning labels
Fig. 2
Fig. 2
Example of the Pilot-DIET NUSMart storefront with a sample of the warning labels on the same fictional product as it appears in each study arm
Fig. 3
Fig. 3
Participant flow diagram

References

    1. Reedy J, Krebs-Smith SM, Miller PE, Liese AD, Kahle LL, Park Y, et al. Higher diet quality is associated with decreased risk of all-cause, cardiovascular disease, and cancer mortality among older adults. J Nutr. 2014;144(6):881–889. doi: 10.3945/jn.113.189407.
    1. Basu S, Yoffe P, Hills N, Lustig RH. The relationship of sugar to population-level diabetes prevalence: an econometric analysis of repeated cross-sectional data. PLoS One. 2013;8(2):e57873. doi: 10.1371/journal.pone.0057873.
    1. Malik VS, Popkin BM, Bray GA, Despres JP, Willett WC, Hu FB. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010;33(11):2477–2483. doi: 10.2337/dc10-1079.
    1. Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ. 2013;346.
    1. Corvalan C, Reyes M, Garmendia ML, Uauy R. Structural responses to the obesity and non-communicable diseases epidemic: the Chilean law of food labeling and advertising. Obes Rev. 2013;14(Suppl 2):79–87. doi: 10.1111/obr.12099.
    1. Mozaffarian D. Dietary and policy priorities for cardiovascular disease, diabetes, and obesity: a comprehensive review. Circulation. 2016;133(2):187–225. doi: 10.1161/CIRCULATIONAHA.115.018585.
    1. Popkin BM, Hawkes C. Sweetening of the global diet, particularly beverages: patterns, trends, and policy responses. Lancet Diab Endocrinol. 2016;4(2):174–186. doi: 10.1016/S2213-8587(15)00419-2.
    1. Cowburn G, Stockley L. Consumer understanding and use of nutrition labelling: a systematic review. Public Health Nutr. 2005;8(1):21–28. doi: 10.1079/PHN2005666.
    1. Grunert KG, Wills JM. A review of European research on consumer response to nutrition information on food labels. J Public Health. 2007;15(5):385–399. doi: 10.1007/s10389-007-0101-9.
    1. Golan E, Kuchler F, Mitchell L, Greene C, Jessup A. Economics of food labeling. J Consum Policy. 2001;24(2):117–184. doi: 10.1023/A:1012272504846.
    1. Hawley KL, Roberto CA, Bragg MA, Liu PJ, Schwartz MB, Brownell KD. The science on front-of-package food labels. Public Health Nutr. 2013;16(3):430–439. doi: 10.1017/S1368980012000754.
    1. Becker MW, Bello NM, Sundar RP, Peltier C, Bix L. Front of pack labels enhance attention to nutrition information in Novel & Commercial Brands. Food Policy. 2015;56:76–86. doi: 10.1016/j.foodpol.2015.08.001.
    1. Machin L, Aschemann-Witzel J, Curutchet MR, Gimenez A, Ares G. Does front-of-pack nutrition information improve consumer ability to make healthful choices? Performance of warnings and the traffic light system in a simulated shopping experiment. Appetite. 2018;121:55–62. doi: 10.1016/j.appet.2017.10.037.
    1. Feunekes GI, Gortemaker IA, Willems AA, Lion R, van den Kommer M. Front-of-pack nutrition labelling: testing effectiveness of different nutrition labelling formats front-of-pack in four European countries. Appetite. 2008;50(1):57–70. doi: 10.1016/j.appet.2007.05.009.
    1. Antúnez LE, Giménez ABS, Maiche AP, Ares GP. Influence of interpretation aids on attentional capture, visual processing, and understanding of front-of-package nutrition labels. J Nutr Educ Behav. 2015;47(4):292–299. doi: 10.1016/j.jneb.2015.02.010.
    1. Ares G, Giménez A, Bruzzone F, Antúnez L, Sapolinski A, Vidal L, et al. Attentional capture and understanding of nutrition labelling: a study based on response times. Int J Food Sci Nutr. 2012;63(6):679–688. doi: 10.3109/09637486.2011.652598.
    1. Roberto CA, Shivaram M, Martinez O, Boles C, Harris JL, Brownell KD. The smart choices front-of-package nutrition label. Influence on perceptions and intake of cereal. Appetite. 2012;58(2):651–657. doi: 10.1016/j.appet.2012.01.003.
    1. Hodgkins C, Barnett J, Wasowicz-Kirylo G, Stysko-Kunkowska M, Gulcan Y, Kustepeli Y, et al. Understanding how consumers categorise nutritional labels: a consumer derived typology for front-of-pack nutrition labelling. Appetite. 2012;59(3):806–817. doi: 10.1016/j.appet.2012.08.014.
    1. Hartley J, Black A, Rayner M. Just read the label: understanding nutrition information in numeric, verbal and graphic formats. (London: HMSO, 1992) Inf Design J. 1996;8(1):86–90. doi: 10.1075/idj.8.1.10har.
    1. Hammond D. Health warning messages on tobacco products: a review. Tob Control. 2011;20(5):327–337. doi: 10.1136/tc.2010.037630.
    1. Borland R, Hill D. Initial impact of the new Australian tobacco health warnings on knowledge and beliefs. Tob Control. 1997;6(4):317–325. doi: 10.1136/tc.6.4.317.
    1. Roberto CA, Wong D, Musicus A, Hammond D. The influence of sugar-sweetened beverage health warning labels on Parents’ choices. Pediatrics. 2016;137(2):e20153185. doi: 10.1542/peds.2015-3185.
    1. Bansal-Travers M, Hammond D, Smith P, Cummings KM. The impact of cigarette pack design, descriptors, and warning labels on risk perception in the US. Am J Prev Med. 2011;40(6):674–682. doi: 10.1016/j.amepre.2011.01.021.
    1. Moran AJ, Roberto CA. Health warning labels correct Parents’ misperceptions about sugary drink options. Am J Prev Med. 2018.
    1. Strahan EJ, White K, Fong GT, Fabrigar LR, Zanna MP, Cameron R. Enhancing the effectiveness of tobacco package warning labels: a social psychological perspective. Tob Control. 2002;11(3):183–190. doi: 10.1136/tc.11.3.183.
    1. Wilkinson C, Room R. Warnings on alcohol containers and advertisements: international experience and evidence on effects. Drug Alcohol Rev. 2009;28(4):426–435. doi: 10.1111/j.1465-3362.2009.00055.x.
    1. VanEpps EM, Roberto CA. The influence of sugar-sweetened beverage warnings. Am J Prev Med. 2016;51(5):664–672. doi: 10.1016/j.amepre.2016.07.010.
    1. Arrua A, Machin L, Curutchet MR, Martinez J, Antunez L, Alcaire F, et al. Warnings as a directive front-of-pack nutrition labelling scheme: comparison with the guideline daily amount and traffic-light systems. Public Health Nutr. 2017;20(13):2308–2317. doi: 10.1017/S1368980017000866.
    1. Ruff RR. Sugar-sweetened beverage consumption is linked to global adult morbidity and mortality through diabetes mellitus, cardiovascular disease and adiposity-related cancers. Evid Based Med. 2015;20(6):223–224. doi: 10.1136/ebmed-2015-110267.
    1. Singh GM, Micha R, Khatibzadeh S, Shi P, Lim S, Andrews KG, et al. Global, regional, and National Consumption of sugar-sweetened beverages, fruit juices, and Milk: a systematic assessment of beverage intake in 187 countries. PLoS One. 2015;10(8):e0124845. doi: 10.1371/journal.pone.0124845.
    1. Malik VS, Popkin BM, Bray GA, Despres JP. Hu FB. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation. 2010;121(11):1356–1364. doi: 10.1161/CIRCULATIONAHA.109.876185.
    1. Bollard T, Maubach N, Walker N, Ni Mhurchu C. Effects of plain packaging, warning labels, and taxes on young people’s predicted sugar-sweetened beverage preferences: an experimental study. Int J Behav Nutr Phys Act. 2016;13(1):95. doi: 10.1186/s12966-016-0421-7.

Source: PubMed

Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

3
Abonner