Randomised controlled trial in an experimental online supermarket testing the effects of front-of-pack nutrition labelling on food purchasing intentions in a low-income population

Manon Egnell, Isabelle Boutron, Sandrine Péneau, Pauline Ducrot, Mathilde Touvier, Pilar Galan, Camille Buscail, Raphaël Porcher, Philippe Ravaud, Serge Hercberg, Emmanuelle Kesse-Guyot, Chantal Julia, Manon Egnell, Isabelle Boutron, Sandrine Péneau, Pauline Ducrot, Mathilde Touvier, Pilar Galan, Camille Buscail, Raphaël Porcher, Philippe Ravaud, Serge Hercberg, Emmanuelle Kesse-Guyot, Chantal Julia

Abstract

Background: The Nutri-Score, a front-of-pack nutrition label, has been adopted in 2017 in France but its impact on low-income populations is unknown, and they are more at risk of having unhealthy diets. The present study assessed the effects of the Nutri-Score on the nutritional quality of purchasing intentions among low-income individuals, compared with the current French labelling situation: references intakes (RIs) and no label, using a three-arm parallel-group randomised controlled trial.

Methods: Low-income active adults from the NutriNet-Santé cohort (household income below €1200/month) were asked to perform a shopping task in an experimental online supermarket after being randomised in one of the three conditions (Nutri-Score, RIs or no labelling). The main outcome was the overall nutritional quality of the virtual shopping cart, assessed with the French-modified Food Standards Agency Nutrient Profiling System (FSAm-NPS), and secondary outcomes were the nutrient content of the shopping carts. 524 subjects were randomised, and 336 included in the analyses.

Results: The Nutri-Score resulted in the highest overall nutritional quality of the shopping cart, as reflected by a FSAm-NPS score (1.86 (SD 3.59) points) significantly lower (reflecting higher nutritional quality) than the RIs (3.21 (SD 4.14) points, p≤0.05) but not significantly lower than no label (2.60 (SD 3.09) points, p=0.3). The Nutri-Score also resulted into significantly lower contents in calories and saturated fatty acids in the shopping cart, compared with the RIs only (p≤0.05).

Conclusion: The implementation of the front of pack nutrition label Nutri-Score, adopted in France and in different European countries, appears to have the potential to encourage purchasing intentions of foods from higher nutritional quality among low-income individuals, compared with the RIs label promoted by food manufacturers.Trial registration number: NCT02769455.

Trial registration: ClinicalTrials.gov NCT02769455 NCT03335644.

Keywords: food purchases; front-of-pack nutrition label; low-income individuals; nutritional quality.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Example of a product in the no label arm (A), Nutri-Score arm (B) and references intakes arm (C).
Figure 2
Figure 2
Flow diagram of the randomised controlled trial. *Subjects who validated their online shopping cart and did not encounter technical issues.

References

    1. Laraia BA, Leak TM, Tester JM, et al. . Biobehavioral factors that shape nutrition in low-income populations: a narrative review. Am J Prev Med 2017;52:S118–26. 10.1016/j.amepre.2016.08.003
    1. World Health Organization Preventing chronic diseases a vital investment - Part 2. Chapter 2. Chronic disease and poverty, 2005. Available:
    1. Drewnowski A The cost of US foods as related to their nutritive value. Am J Clin Nutr 2010;92:1181–8. 10.3945/ajcn.2010.29300
    1. Darmon N, Ferguson E, Briend A. Do economic constraints encourage the selection of energy dense diets? Appetite 2003;41:315–22. 10.1016/S0195-6663(03)00113-2
    1. Darmon N, Briend A, Drewnowski A. Energy-Dense diets are associated with lower diet costs: a community study of French adults. Public Health Nutr 2004;7:21–7. 10.1079/PHN2003512
    1. Darmon N, Lacroix A, Muller L, et al. . Food price policies improve diet quality while increasing socioeconomic inequalities in nutrition. Int J Behav Nutr Phys Act 2014;11:66. 10.1186/1479-5868-11-66
    1. Campos S, Doxey J, Hammond D. Nutrition labels on pre-packaged foods: a systematic review. Public Health Nutr 2011;14:1496–506. 10.1017/S1368980010003290
    1. Storcksdieck Genannt Bonsmann S, Wills JM. Nutrition labeling to prevent obesity: reviewing the evidence from Europe. Curr Obes Rep 2012;1:134–40. 10.1007/s13679-012-0020-0
    1. Hawley KL, Roberto CA, Bragg MA, et al. . The science on front-of-package food labels. Public Health Nutr 2013;16:430–9. 10.1017/S1368980012000754
    1. Hersey JC, Wohlgenant KC, Arsenault JE, et al. . Effects of front-of-package and shelf nutrition labeling systems on consumers. Nutr Rev 2013;71:1–14. 10.1111/nure.12000
    1. Kleef EV, Dagevos H. The growing role of front-of-pack nutrition profile labeling: a consumer perspective on key issues and controversies. Crit Rev Food Sci Nutr 2015;55:291–303. 10.1080/10408398.2011.653018
    1. Julia C, Hercberg S, World Health Organization . Regional office for Europe. development of a new front-of-pack nutrition label in France: the five-colour Nutri-Score. Public Health Panor 2017;03:712–25.
    1. Castro IA, Majmundar A, Williams CB, et al. . Customer purchase intentions and choice in food retail environments: a scoping review. Int J Environ Res Public Health 2018;15. 10.3390/ijerph15112493. [Epub ahead of print: 08 11 2018].
    1. Wiig K, Smith C. The art of grocery shopping on a food stamp budget: factors influencing the food choices of low-income women as they try to make ends meet. Public Health Nutr 2009;12:1726–34. 10.1017/S1368980008004102
    1. Drichoutis A, Lazaridis P, Nagya RM. Nutrition knowledge and consumer use of nutritional food labels. Eur Rev Agric Econ 2005.
    1. Darmon N, Drewnowski A. Contribution of food prices and diet cost to socioeconomic disparities in diet quality and health: a systematic review and analysis. Nutr Rev 2015;73:643–60. 10.1093/nutrit/nuv027
    1. Arrêté du 31 octobre 2017 fixant la forme de présentation complémentaire la déclaration nutritionnelle recommandée par l’Etat en application des articles L. 3232-8 et R. 3232-7 du code de la santé publique | Legifrance. Available: [Accessed 6 Jun 2019].
    1. Egnell M, Boutron I, Péneau S, et al. . Front-of-Pack labeling and the nutritional quality of students' food Purchases: a 3-Arm randomized controlled trial. Am J Public Health 2019;109:1122–9. 10.2105/AJPH.2019.305115
    1. Haut Conseil de la santé publique Avis relatif l’information sur la qualité nutritionnelle des produits alimentaires, 2015. Available:
    1. Food and Drink Federation Reference intakes (previously guideline daily amounts), 2017. Available: [Accessed 4 Oct 2019].
    1. Hercberg S, Castetbon K, Czernichow S, et al. . The Nutrinet-Santé study: a web-based prospective study on the relationship between nutrition and health and determinants of dietary patterns and nutritional status. BMC Public Health 2010;10:242. 10.1186/1471-2458-10-242
    1. Argouarc’h J, Cazenave-Lacrouts M-C. Les niveaux de vie en 2015. Insee, 2017.
    1. Dmitrienko A, Tamhane AC. Gatekeeping procedures with clinical trial applications. Pharm Stat 2007;6:171–80. 10.1002/pst.291
    1. Crosetto P, Muller L, Ruffieux B. Réponses des consommateurs trois systèmes d’étiquetage nutritionnels en face avant. Cahier de Nutrition et de Diététique, 2016.
    1. Acton RB, Jones AC, Kirkpatrick SI, et al. . Taxes and front-of-package labels improve the healthiness of beverage and snack purchases: a randomized experimental marketplace. Int J Behav Nutr Phys Act 2019;16:46. 10.1186/s12966-019-0799-0
    1. Ares G, Varela F, Machin L, et al. . Comparative performance of three interpretative front-of-pack nutrition labelling schemes: insights for policy making. Food Qual Prefer 2018;68:215–25. 10.1016/j.foodqual.2018.03.007
    1. Carrad AM, Louie JC-Y, Milosavljevic M, et al. . Consumer support for healthy food and drink vending machines in public places. Aust N Z J Public Health 2015;39:355–7. 10.1111/1753-6405.12386
    1. Crosetto P, Lacroix A, Muller L. Nutritional and economic impact of five alternative front-of-pack nutritional labels: experimental evidence. Eur Rev Agric Econ 2019:jbz037.
    1. Thorndike AN, Riis J, Sonnenberg LM, et al. . Traffic-light labels and choice architecture: promoting healthy food choices. Am J Prev Med 2014;46:143–9. 10.1016/j.amepre.2013.10.002
    1. Ministère des Solidarités et de la Santé Evaluation ex ante de systèmes d’étiquetage nutritionnel graphique simplifié - Rapport final du Comité scientifique, 2017. Available: [Accessed 26 Jul 2019].
    1. Vyth EL, Steenhuis IHM, Vlot JA, et al. . Actual use of a front-of-pack nutrition logo in the supermarket: consumers' motives in food choice. Public Health Nutr 2010;13:1882–9. 10.1017/S1368980010000637
    1. Ruffieux B, Muller L. Etude sur l’influence de divers systèmes d’étiquetage nutritionnel sur la composition du panier d’achat alimentaire, 2011.
    1. Feunekes GIJ, Gortemaker IA, Willems AA, et al. . Front-of-pack nutrition labelling: testing effectiveness of different nutrition labelling formats front-of-pack in four European countries. Appetite 2008;50:57–70. 10.1016/j.appet.2007.05.009
    1. Aschemann-Witzel J, Grunert KG, van Trijp HCM, et al. . Effects of nutrition label format and product assortment on the healthfulness of food choice. Appetite 2013;71:63–74. 10.1016/j.appet.2013.07.004
    1. Malam S, Clegg S, Kirwan S. Comprehension and use of UK nutrition Signpost labelling schemes. Guildford, UK: University of Surrey, 2009.
    1. Mejean C, Macouillard P, Péneau S, et al. . Consumer acceptability and understanding of front-of-pack nutrition labels. J Hum Nutr Diet 2013;26:494–503. 10.1111/jhn.12039
    1. Egnell M, Ducrot P, Touvier M, et al. . Objective understanding of Nutri-Score Front-Of-Package nutrition label according to individual characteristics of subjects: comparisons with other format labels. PLoS One 2018;13:e0202095. 10.1371/journal.pone.0202095
    1. Grunert KG, Fernández-Celemín L, Wills JM, et al. . Use and understanding of nutrition information on food labels in six European countries. Z Gesundh Wiss 2010;18:261–77. 10.1007/s10389-009-0307-0
    1. Grunert KG, Wills JM, Fernández-Celemín L. Nutrition knowledge, and use and understanding of nutrition information on food labels among consumers in the UK. Appetite 2010;55:177–89. 10.1016/j.appet.2010.05.045
    1. Vasiljevic M, Pechey R, Marteau TM. Making food labels social: the impact of colour of nutritional labels and injunctive norms on perceptions and choice of snack foods. Appetite 2015;91:56–63. 10.1016/j.appet.2015.03.034
    1. Antúnez L, Giménez A, Maiche A, et al. . Influence of interpretation AIDS on attentional capture, visual processing, and understanding of Front-of-Package nutrition labels. J Nutr Educ Behav 2015;47:292–9. 10.1016/j.jneb.2015.02.010
    1. Kelly B, Hughes C, Chapman K, et al. . Consumer testing of the acceptability and effectiveness of front-of-pack food labelling systems for the Australian grocery market. Health Promot Int 2009;24:120–9. 10.1093/heapro/dap012
    1. Paskett ED, Reeves KW, McLaughlin JM, et al. . Recruitment of minority and underserved populations in the United States: the centers for population health and health disparities experience. Contemp Clin Trials 2008;29:847–61. 10.1016/j.cct.2008.07.006
    1. Sharpe KM, Staelin R, Huber J. Using extremeness aversion to fight obesity: policy implications of contaxt dependent demand. J Consum Res 2008.
    1. Egnell M, Crosetto P, d'Almeida T, et al. . Modelling the impact of different front-of-package nutrition labels on mortality from non-communicable chronic disease. Int J Behav Nutr Phys Act 2019;16:56. 10.1186/s12966-019-0817-2

Source: PubMed

スポンサーと協力者

医学的状態

薬物療法

3
購読する