Front of Pack Nutritional Labeling of Processed Foods Among Mexican Consumers
Phase: NA
Conditions: Food Labeling
Sponsor: Instituto Nacional de Salud Publica, Mexico

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Nutrition and Health Research Center 
Research Protocol 
Front of Pack Nutrition Labelling of processed foods 
for Mexican consumers 
 
 
Principal Investigator 
Alejandra Jáuregui de la Mota, DSc 
 
 
Co-investigators 
Mtra. Anabel Velasco Bernal, MSc 
Juan Rivera Domarco, PhD 
Jorge L. Vargas Meza, MPH 
Alejandra Contreras Manzano, Msc 
Simón Barquera Cercvera, PhD 
 
 
NCT: 7-68S4-17 
 
 
Cuernavaca, Morelos, January 24, 2017 
 
 
 

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Abstract 
  
Introduction.  
Chronic diseases related to diet are responsible for 80% of deaths in Mexico. Front of Pack 
Nutritional Labelling is a strategy that can contribute to improving healthy food choices 
among consumers. However, the FoPNL used in Mexico is not understood or used by most 
of the population.  
Objetivo.  
To design and evaluate FoPNL systems for processed foods that are easy to understand by 
Mexican consumers to promote healthy food choices. 
Methods  
Cross-sectional study with mixed methodology comprising three phases: 1) Design of FoPNL 
proposals, where the objective understanding and acceptability of current FOPNL systems 
in Latin America and other regions will be evaluated among Mexican consumers to design 
labeling proposals adequate for Mexican population, 2)Re-design of labelling proposals, 
where the objective and understanding of the labeling proposals will be evaluated to make 
the necessary adjustments, and 3) Efficacy of labeling proposals, where the efficacy of labels 
to improve healthy food choices will be evaluated using a randomized controlled trial of an 
on-line shopping simulation.  
Expected results 
Results will provide scientific evidence on the objective understanding and acceptability of 
a variety of FoPNL systems, which could be used by decision makers to promote new and 
better policies on FOPNL in Mexico, as well as researchers to design new research proposals.  
 
1 INTRODUCTION 
Non-Communicable Chronic Diseases related to diet, such as, obesity, Diabetes type 2 and 
cardiovascular diseases, are responsible for 60% of deaths around the world [1]. In response 
to the increasing trend of the burden of disease associated to diet, international 
organizations have suggested policies limiting the consumption of fats, sugars and salt as 
strategies to improve population intake. Front of Pack Nutrition Labelling (FoPNL) is an 
accepted strategy to provide nutritional information to consumers aiming to promote the 
informed selection of healthy foods (nutrients to promote or limit), ease comparisons 
between foods from the same food category as well as from different food groups or 
categories, summarize the nutritional value of a product, provide information about the 
nutritional contribution of different groups, and encourage the reformulation of food 
products. FoPNL can contribute in the improvement of population dietary intake and,  in 
the long run, reduce the risk of non-communicable chronic diseases in the population [2-4].  
Different FoPNL have been developed around the world. In general, FoPNL can be classified 
as 1) Specific nutrient systems or 2) Summary Labelling systems (Table 1). Specific nutrient 
labeling systems show the content of certain nutrients based on the percentage of the daily 

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recommended value, such as Guideline Daily Amounts (GDA). They can use traffic light 
colors or words to indicate that a product has high, medium or low nutrient content, declare 
calories per serving, may contain a symbol based on captions “high in fiber” and in some 
cases nutrients to limit and encourage appear together, as is the case of multiple traffic 
light. Another example of nutrient-specific labeling system would be the warning system 
(such as Chile’) that focuses on nutrients to limit. 
Summary Labelling Systems provide information about how healthy a food product isby  
displaying a symbol, icon or score on the food product. In order to assign these symbols, 
the nutrient content of foods is evaluated using nutrient profiling systems based on cut-off 
points or algorithms considering different nutrients (positive and negative). Summary 
labelling systems can be classified as simple or gradient formats. Simple formats, as the 
“Green Key Hole”, are only placed on products with fairly favorable nutritional composition. 
Gradient formats, as “NuVal”, show a gradation of the “healthiness” of foods based on their 
nutrimental composition.  
Current evidence of studies exploring the effectiveness of FoPNL on guidng consumers 
towards healthier food choices is inconsistent [2].  Most of the studies from European 
countries suggest that Multiple Traffic Lights are the most effective to increase healthy food 
selection [5, 6]. However, international research shows mixed results in relation to the ideal 
FoPNL to guide a healthy food selection [7]. Furthermore, few studies have explored the 
effectiveness of these strategies in Latin-American and Hispanic consumers [8-10]. 
Despite the above, different efforts have recently been made to implement a FoPNL in 
Latin-American countries, being the governments of Chile and Ecuador the leaders in the 
field [11]. In Mexico, in 2013 the Ministry of Health, launched the National Strategy for the 
Prevention and Control of Overweight, Obesity and Diabetes, wherein the implementation 
of a useful and easy to understand FoPNL was contemplated for Mexican population. [12]. 
Derived from that effort, GDA’s were adopted as the mandatory FoPNL system [13]. 
However, previous evidence shows that Mexican consumers do not understand or use the 
label to make healthy food choices [14], and understanding of this label may depend on the 
characteristics of consumers  [15, 16]. Additionally, the regulation includes a voluntary 
“Nutritional Distinctive”. This distinctive consists on a summary labelling system that can be 
placed on food products that meet the established criteria if requested by food 
manufacturers. In spite of this effort, most of the food industry companies have not 
requested the distinctive.  
The effectiveness of a FoPNL depends on different factors, among which the way consumers 
perceive the label is one of the most important [2]. Perception is influenced by 
undrestanding and acceptability of the label [2]. Even though experimental studies provide 
the best available evidence to assess the effectiveness of FoPNL, qualitative methodologies 
allow exploring in depth the perception of consumers of FoPNL [17]. The following project 
aims to extend available evidence related to the ideal FoPNL for Mexican consumers, using 
qualitative and quantitative methodologies.   
 
 
 

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Table 1. Classification of Front of Pack Labelling Systems  
Labelling Systems 
Examples 
Specific Nutrients 
 
Guideline Dietary 
Allowances 
 
Front of Pack Labelling System 
in Mexico 
 
 
Multiple Traffic light 
 
 
Front of Pack Labelling System in Ecuador 
 
 
 
Front of Pack Labelling System in England 
 
 
Front of Pack Labelling System in Chile 
Summary 
 
Simple 
 
Green Key Hole, Switzerland 
 
Choices International 
Foundation 
 
Program Pick the Tick, Australia and New Zeland 
Gradient 
 
Health Star Rating, Australia and New 
Zeland 
 
         NuVal, 
United States 
 
Mixed 
 
 
 
GDAs+ Health Star Rating, 
Australia and New Zeland 
 
 
Colored GDA, England 
 
 

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2 BACKGROUND 
2.1 FRONT OF PACK NUTRITION LABELLING IN THE PURCHASE DECISION PROCESS  
The main purpose of Front of Pack labelling is to help consumers to easily and quickly 
evaluate the “healthiness” of a food product in the context of a full diet, and to compare 
nutriment levels in different products. 
In their theoretical framework, Grunert and Wills suggest that for a FoPNL to be used 
correctly during food choice process, consumers are required to conduct a process of 
searching, exposing and perceiving the information presented on the labels [2]. Consumers’ 
perception about the label will lead to information processing, which might be influenced 
by the acceptability and understanding of the label [2]. For that reason, both aspects 
(understanding and acceptability) could affect in an important way the use of the label.  
According to Nielsen’s conceptual model, (18) acceptability of a nutrition label is 
determined by different factors, including the liking, attractiveness and perceived cognitive 
load of the label. Label liking comprises different notions, including subjective preferences 
of consumers related to the label, or liking the label on the front of the food package. The 
attractiveness of the label is determined by the ease of identification (as an example, how 
easily consumers identify the label on the packaging) or perceived trust in the label, which 
could be improved by scientific or institutional endorsement [14, 19]. Perceived cognitive 
load refers to the perception of possible format defects that difficult understanding or cause 
discomfort [20].  
Front of Pack labelling understanding can be evaluated using subjective and objective 
measurements. Subjective understanding corresponds to the extent in which consumers 
believe they have understood the label. Objective understanding is measured by evaluating 
the consistency between consumer’s understanding and the information provided by the 
label [2], and provides a more accurate measurement that subjective comprehension, since 
subjective comprehension is susceptible to overestimation [2].  
Strong evidence shows that the use of an acceptable and understood FoPNL by consumers 
is associated with higher nutritional quality food selection [21]. In this regard, summary 
FoPNL are perceived as easier to understand in terms of perceived cognitive load, but since 
attractiveness and liking of the labels seem to be subjective perceptions, these latter 
aspects differ between individuals and populations [22]. On the other hand, scientific 
information on the understanding of different FoPNL formats has not been consistent [22]. 
Thus, most of the studies from European countries suggest that the Multiple Traffic light is 
the most effective format to increase healthy food selection [5, 6]. However, international 
research indicates mixed results related to an ideal FoPNL to guide consumers to choose 
healthy products[7]. 
In addition, it is not clear how to achieve FoPNL use among consumers with different 
characteristics [23]. Different factors have been related to the habitual use of FoPNL, such 
as previous diagnosis of a chronic disease (for example Diabetes), interest in health, 
attitudes towards a healthy diet, beliefs around the relevance of nutrition labels in guiding 
food selection, self-efficacy, education degree and nutrition knowledge [23], emphasizing 
that motivation is considered a key factor for the use of  FoPNL. Thus, FoPNL should be 

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implemented along with dissemination campaigns or education programs to promote the 
use of FoPNL in population [23].  
 
2.2 FRONT OF PACK NUTRITION LABELLING SYSTEMS FOR PROCESSED FOODS 
There are different proposals of front of pack nutrition labelling systems for processed 
foods. These can be classified in two large groups:  
2.2.1 Nutrient specific labelling systems  
2.2.1.1 Guideline Daily Amounts (GDA’s)  
GDA’s provide numeric details on the nutrients content of a product in comparison to the 
nutritional requirements to promote an adequate health for an average person. This system 
allows the consumer to make food choices based on calculations on the required foods to 
meet the required amount of nutrients.  
GDA’s were developed in 2005, based on the 1991 report from the Committee on Medical 
Aspects of Food and Nutrition Policy (COMA), Daily Reference Values (DRV´s), and a report 
on salt published by its predecessor, the Scientific Advisory Committee on Nutrition (SACN). 
Both Committees (COMA y SACN) indicated that reference values were intended as intake 
targets at the population level for the generation of public health policies and not for 
individual use. Despite this statement, the Institute of Grocery Distribution (IGD) mentions 
that GDA’s “help consumers to read nutrition information on the label in a context of their 
total diet” and add that consumers should be encouraged to “know the GDA´s” for each 
nutrient. Reference Values of GDA’s are calculated for an average female adult, with 
average weight and physical activity level. It does not distinguish between adult men and 
children, which could lead to wrong interpretations on daily needs for specific nutrients.  
In 2005, GDA’s were adopted by different food companies and retailers as Nestlé, Kellogg’s 
and Tesco. The most recent version of front of GDA’s consists on five cells in a single color 
showing the amount per portion (defined by Food Industry) and the percentage of GDA’s. 
In Mexico, GDA’s are the official FoPNL [13] (Figure 1). 
 
Figure 1. Example of Front of Pack Labelling of GDA’s used in Mexico [13] . 
 
2.2.1.2 Multiple Traffic light 
Multiple Traffic Light system is a method to identify risky contents for health of some 
nutrients such as sugar, total fat, saturated fat and sodium (Figure 1). One of the first 
countries to embrace this system was the United Kingdom, who in 2007 published the 
technical guide of front of pack consisting on a multiple nutrition traffic light. This guide 
precises the basis identified by The Food Standard Agency Board (FSA) to help consumers 
make healthy food choices, identifying health risks through traffic light colors: red, yellow 

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and green [24]. To date, this scheme is voluntary and food industry is not obligated to use 
it.   
 
Figure 2. Traffic Light system used in United Kingdom. 
 
2.2.2 Summary Front of Pack Labelling System 
These Front of Pack labelling systems use a grading system based on pre-established criteria 
to evaluate the healthiness of a product. They are classified in two: simple or gradient 
format.  
2.2.2.1 Simple Format 
Simple Summary Front of Pack Labelling Systems give a symbol to the food products that 
meet certain pre-established nutriment criteria. There are different labels of this type, 
including the program “Pick the Tick” in New Zealand (Figure 3-A) [25], the “Nutrient 
Distinctive” in Mexico (Figure 3-B), or the international program Choices (Figure 3-C). Each 
one of these labeling systems set their own nutriment criteria. As an example, the program 
Pick the Tick evaluates the energy content, saturated fat, total sugar, sodium and fiber 
products through established criteria.  
The Choices program has developed different general criteria for food categories for the 
content of trans fatty acids, saturated fats, sodium, added sugars, fiber and energy, which 
are adjusted according the country where are applied  [26].  
 
A
         B
         C
 
 
 
Figure 3. Different examples of Front of Pack Nutrition Labelling Logos A. Pick the Tick Logo in New Zealand. B. Nutrition 
Distinctive Logo in Mexico C. International Smart Choices Logo 
Generally, the symbol is given to the products of food companies that meet the defined 
nutritional criteria. A license is given to display the logo on the pack of the approved 
products. Products are analyzed chemically by an independent laboratory of the 
manufacturer. If the products do not meet the criteria, companies are advised to 
reformulate the product composition of the product to obtain the logo.   
 

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2.2.2.2 Gradient Format 
Gradient Labelling Systems evaluate the nutritional content of food products using aa 
nutritional profiling system and categorize the products from the healthiest to the less 
healthy. There are different examples of these Front of Pack labelling systems.  
In Australia, government recommends the use of a five star system, where more stars 
indicate a better nutritional composition of the product, called Health Star Rating (Figure 
4-A)[27]. In the United States, the Institute of Medicine recommends a similar Labelling 
System of three stars called Guiding Stars (Figure 4-B)[27]. In the same country, different 
supermarkets use the FoPNL called NuVal [28], which evaluates the nutritional content of 
more of 30 nutriments to promote and limit through the General Index of Nutritional 
Quality [29] assigning a value from 1 to 100, where a higher value indicates a healthier 
nutritional composition (Figure 4-C).  
 
A.
        B.
 
C. 
 
Figura 4. Different examples of Front of Pack Nutritional Labelling that use a gradient format. A. Health Star Rating: 
required FoPNL in Australia and New Zealand. B. Guiding Stars: FoPNL recommended by the Institute of Medicine in the 
United States.  
 
2.3 FRONT OF PACK EXPERIENCES IN LATIN AMERICA 
 
2.3.1 Chile 
Due to the increase in overweight and obesity in the last decade in children from Chile, their 
government has taken a series of actions to handle this issue, including regulations for 
advertising aimed to children and front of pack labelling.(30) Regarding to labelling, article 
120 bis, establish that if a meal or food product exceeds the amount of energy, sugars, 
saturated fats and sodium according to the guidelines shown in Chart 2, must carry a specific 
label emphasizing the nutritional characteristics exceeded in the product.   (31, 32). 
Chart 2. Content of energy, sodium, total sugars and saturated fats limits in food. 
Content Limits 
Energy 
(kcal) 
Sodium 
(mg) 
Total Sugars 
(g) 
Saturated Fats 
(g) 
Solid Food (in 100g) 
275 
400 
10 
4 
Liquid Food(in 100 ml) 
70 
100 
5 
3 
*Decree 13/2015, Ministry of Health of Chile. 
 
The development of the proposal of Front of Pack Labelling was recommended by the 
Ministry of Health to the University of Chile. To do this, researchers used qualitative 
methodologies (metaplan) and quantitative (point of sale questionnaires) to explore the 
design and image elements that helped to transmit the message of Front of Pack in a group 

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of Chilean consumers. Details of this investigation are presented in another document (33). 
In this way, the final proposal of Front of Pack Labelling consisted on a black octagon with 
the captions “High in…” for each nutrient that exceeds the established amounts according 
the guidelines shown in Table 2 (Figure 5). 
 
 
Figure 5. Captions proposed by decree 13/ 2015, Ministry of Health of Chile.  
This regulation came into force in June 2016, so the strategy falls short of results. However, 
information given in Ministry of Health networks, mentions that this strategy has had 
positive results since it has improved healthy food selection in Chilean consumers (34). 
2.3.2 Ecuador 
In August 2014, Ecuador government published an Agreement for the establishment of a 
mandatory Front of Pack Labelling for all processed food (food subject to technological 
operations for processing, modification and preservation)(35). The caption considers the 
content of transgenic statement when they go over 0.09% of the product, and require the 
placement of references on the components of fats, sugars and salt (sodium) through a red, 
yellow or Green horizontal bar, according their concentration level, along with the captions 
“High in…”, “Medium in…” or “Low in…” respectively (Figure 6).    
 
 
Figure 6. Equator Front of Pack Labelling. 
The effectiveness of this study has not been evaluated yet, however, a study done in Quito 
city indicated that the traffic light label has become a Little seen instrument and with Little 
use according to shoppers.(37) 

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2.3.3 Mexico 
In Mexico, in 2013 the Ministry of Health launched the National Strategy to Prevent and 
Control Overweight, Obesity and Diabetes, which considered the enforcement of a useful 
and easy to comprehend FoPNL to Mexican consumers [12]. Due to this effort, in 2014 the 
Agreement that establishes the GDA system as the required FoPNL in the country was 
published [13]. From June 30th from that year, all food products in the market –with a few 
exceptions- must have the Front of Pack Labeling according to the established guidelines.  
However, the establishment of this FoPNL format as an official system in Mexico is not 
backed up with scientific evidence or previous exercises in Mexican consumers. Previous 
evidence suggests Mexican consumers might not understand or use the label to make 
healthy food choices [14], and comprehension level of the label might depend on the aimed 
group of consumers [15, 16]. This way, different civil society organizations have advocated 
for the revision of the Front of Pack Labelling sustaining that this one does not meet all the 
recommended criteria by the Pan-American Health Organization for Front of Pack 
Labelling.(8) 
In parallel, the regulation includes a voluntary “Nutritional Distinctive”. This distinctive 
consists in a summary labelling system that can be located on the food that meets the 
established criteria in the agreement and at the request of manufacturers. Just like the 
establishment of the GDA’s as the official FoPNL, the design of the distinctive was not a 
result of an exercise based on scientific evidence. Despite this effort, most of the food 
industry companies have not welcomed the use of the distinctive.  
 
2.3.4 Nutrient profiling systems for Front of Pack Nutrition Labelling of Food 
The allocation of the Front of Pack nutrition Label for food is established through different 
criteria according nutriment composition of the same. These criteria are frequently a result 
of the use of a specific nutrient profile. The Nutrient Profile is a tool that allows to classify 
food depending on their nutrient composition and their contribution to the total diet 
balance, considering the benefit or risk potential to the population health [38].  
2.3.4.1 Uses of the Nutrient profile  
Assigning food in a category based on its nutritional content, has many applications besides 
the front of pack label. A nutritional profile can be used also as a tool to [38]: consumer 
education,  regulating health and nutritional statements of food products, promoting the 
development of new products and reformulation of the existing ones, formulation of 
nutrition policies, regulation of advertising aimed to children, among others.  
2.3.4.2 Ideal elements on a nutritional profile  
In spite of the multiple purposes for which a nutritional profile can be constructed, its 
development must follow consistent, rigorous rules based on scientific evidence [39].  In 
these rules, the selection of nutrients to evaluate and reference amounts, the creation of 
an appropriated algorithm to calculate nutritional density, and the validation of a selected 
model against an objective measurement of a healthy diet are found. Therefore, every 
nutritional profile must be [39]: 
• Objective – Based on scientific evidence 

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• Simple – Based on daily values and food portions that consumers can relate to their 
diet. 
• Balanced – Based on nutrients to limit and promote.  
• Validated – Against measurements of “healthy diet”. Improve sense of writing.  
• Transparent – Based on available algorithms and data to the public. 
• Aimed to consumers – Possibility to guide to better food elections and healthier 
diets.  
2.3.4.3 Characteristics of nutritional profiles  
The development of a nutritional profile might consider several methodologies, standards 
and algorithms. Therefore, it is important to understand the wide range of nutritional 
profiles available now a day through the following characteristics: 
2.3.4.3.1 Nutrients to evaluate 
A nutritional profile must take account of the context for which it will be developed. The 
inclusion of nutrients to evaluate must be based on its importance in public health. There 
is indicating evidence of nutriments imbalance, and food groups in diet, can increase the 
risk to develop obesity, associated diseases (cardiovascular disease, diabetes, 
dyslipidemias, cancer, etc.)  of importance to public health [40].  A nutritional profile can be 
developed based on [41]: 
a) Nutrients to promote. Generally those deficient in population diet or known for their 
benefits in health. 
b) Nutrients to limit. Nutrients consumed in excess represent a health risk. Generally fats, 
sugars and sodium.   
c) Mixed.  A combination of the above. These systems encourage consumers to consider 
food as a whole, or the total supply of nutrients, which is more consistent from a diet 
view point. 
 
2.3.4.3.2 Evaluation system  
The nutritional profile can apply specific criteria to evaluate the nutriment content in food 
by groups or use the same for all. Final score must balance nutrients to promote and limit. 
This can be achieved by a subtraction or quotient between the two types of nutrients. An 
example of a balanced algorithm is the Nutrient Rich Food Index [39],  where the final score 
of the food is the result between the score of the nine nutrients to promote and the three 
nutrients to limit (Chart 1). Later, each food is assigned to a category of a scale of five 
categories based on this rating. 
Another example is the nutritional profile, currently under development, from FSANZ, a 
derive from the UK FSA profile. This nutritional profile evaluates food to promote (% of 
fruits, vegetables, nuts, protein and fiber) and limit (energy, saturated fat, total sugars and 
sodium), giving a score to each one of them.   
 
3 RESEARCH QUESTION 
What FoPNL system has the best acceptability and understanding for healthy food selection 
in Mexican population? 

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4 JUSTIFICATION 
Front of pack nutritional labeling is a strategy that can contribute to increase healthy food 
choices among consumers and nutritional quality of foods through product reformulation 
[42,43]. Front of pack labelling is particularly relevant in countries like Mexico, where more 
than 80% of the burden of deaths is attributed to chronic diseases [44]. Despite the former, 
the front of pack labeling system used in Mexico is not the most adequate for our 
population.  
Per the latest National Health and Nutrition Survey, more than 75% of Mexicans ignore the 
number of calories required daily [44]. This information is required to interpret GDA’s 
correctly. This survey also reports that only 23% of the population reads the label, and that 
only 9.7% uses this information to make healthy choices [44]. In this line, some studies have 
reported that GDA understanding among Mexican population is poor, even among 
populations with higher education levels and nutrition knowledge [14-16]. 
Based on the former, the current front of pack labelling system needs to be revised to 
identify other labels that could be more effective than GDA’s, based on a better 
acceptability and understanding.  
This study aims to fill this gap of knowledge by providing scientific evidence on the 
acceptability and understanding of a variety of front of pack labelling systems. This evidence 
could be used by decision makers to design public policies related to front of pack labeling, 
as well as other researchers to design new research proposals.   
 
5 OBJECTIVES 
5.1 GENERAL OBJECTIVE 
To design and evaluate Nutritional Front of Pack Labelling Systems for processed foods that 
are easy to understand by Mexican consumers to promote healthy food choices. 
5.2 SPECIFIC OBJECTIVES 
1. To design alternatives of Front of Pack Labels that are easy to understand and useful 
in guiding healthy food choices among Mexican consumers.  
a. To explore how several nutrient profiling systems classify a sample of food 
products currently available in the Mexican market. 
b. To explore the acceptability and understanding of Front of Pack Labelling 
Systems used in the international food market in a sample of Mexican 
consumers living in urban areas. 
c. To identify the graphic and language elements of the labelling systems that 
facilitate the understanding of the message of the labels towards healthy 
food selection.  
d. To design Front of Pack labeling proposals considering the graphic and 
language elements identified in the previous step. 
2. To identify which of the proposed labels has the best performance, in terms of 
acceptability and objective understanding, in a sample of Mexican consumers.   

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a. To explore the acceptability and understanding of Front of Pack Labelling 
Systems used in the international food market in a sample of Mexican 
consumers living in urban areas. 
3. To evaluate the efficacy of the two best labelling proposals to promote healthy food 
choices using an on-line shopping simulation in a sample of Mexican consumers.   
 
6 HYPOTHESIS 
 
A front of pack labelling system that takes into account the graphic and language elements 
considered by Mexican consumers as relevant for communicating the “healthy” message, 
will be effective in improving the nutritional quality of food choices during an on-line 
shopping simulation in this population.  
 
7 METHODS 
The study will be a cross-sectional type with a mixed-methods approach, meaning with 
qualitative and quantitative data collection and it will comprise three phases. Along the 
three stages, we will work in parallel with a graphic design team and an expert company in 
consumers researches in order to strength the research team and the resulting Front of 
Pack Labelling proposals of this Project. 
7.1 PHASE 1. DESIGN OF FRONT OF PACK LABELLING PROPOSALS 
This first phase of the project comprises three stages. The first stage intends to identify 
Front of Pack Labelling Systems currently used around the world. During the second stage 
the acceptability and understanding of the identified Front of Pack Labelling Systems 
proposals will be explored. The last stage will consist on the design of Front of Pack labelling 
proposals using the findings of the previous stages.  
7.1.1 Stage 1. Identification of Front of Pack Labelling and Nutrient Profiling 
Systems 
7.1.1.1 Review of literature 
A scientific and gray literature research will be done to identify the Front of Pack Labelling 
Systems currently used around the world. From this first search, the research team will 
select by convenience the Front of Pack Labelling Systems to be explored in the next stage.  
All Front of Pack Labelling Systems currently used in Mexico and other Latin American 
countries will be included. In addition, Front of Pack Labelling Systems implemented in 
other countries that have shown effectiveness in improving healthy food choices will be 
selected.  The final sample of Front of Pack Labelling Systems will not exceed a total of six 
systems, and will be representative of the main system categories: specific nutrients (for 
example: multiple or simple traffic light) and summary (for example Smart Choices). The 
selection will consider labelling systems that evaluate only negative aspects (such as fats, 
sugars and salt) of the food product, and those evaluating positive (such as fruit, vegetables, 
nuts or fiber content) and negative aspects.  
In addition, a scientific literature research will be conducted to identify the nutrient profiling 
systems developed to date for the classification of food products based on their nutritional 

18 
 
content. The research team will select validated nutritional profiling systems and whose 
algorithm is public. The final sample of nutritional profiling systems will include those 
systems that consider only nutrients to limit as well as those that consider food to promote. 
7.1.1.2 Classification of products by nutrient profiling systems  
The performance of the identified nutrient profiling systems will be explored using a sample 
of food products currently available in the food market. The nutritional information of these 
products was collected as part of another research project included in the main research 
project. This data base has all collected information from 2014 to 2016 
Classification exercises will be performed using STATA version 14.0. The following food 
categories will be included:  1) milk and dairy products, 2) sugary beverages, 3) salty snacks, 
4) breakfast cereals, 5) ready to eat meals.  The results will be evaluated by the research 
team, with expertise in nutrition, and will select the nutritional profiling system that better 
classifies food based on their nutritional content. Researchers will select three products of 
each food category. The nutritional content of these products should be different enough 
as to show a grading, from the healthiest to the least healthy. These foods will be used for 
the quantitative evaluation of acceptability and understanding of the labelling proposals.  
7.1.2 Stage 2. Understanding and acceptability of Front of Pack Nutritional Labelling 
Systems among Mexican consumers 
This stage comprises the assessment of the acceptability and understanding of the Front of 
Pack Nutritional Labelling systems selected in the previous stage. For that purpose, 
qualitative methodologies will be used (focus groups) aiming to explore the labels and to 
identify the graphic and language elements of the labelling systems that facilitate the 
communication of the central message of the labels. Qualitative methodologies are an ideal 
option to explore the consumers’ perception regarding Front of pack labelling in depth [17]. 
Also, quantitative tools will be used to complement these areas.  
Given that the research team lacks of a marketing background, which is needed to guide 
the focus groups in order to identify the desired graphic and language elements of the 
labels, as well as to comply with the timing of the project, focus groups will be led by the 
company Cuartel General de Comunicación y Estrategia SC (Headquarters of 
Communication and Strategy PP). The Company, hereinafter so-called Cuartel, has wide 
experience in marketing research through qualitative and quantitative methodologies. 
Cuartel has done more than 3000 studies in Communication, Image, Positioning, Use and 
Habits, Segmentation, Product testing, Proof of concept, Advertising evaluation, Price, 
satisfaction and loyalty. The Research team of the National Institute of Public Health will 
supervise the focus groups to ensure the fidelity of the methodology as well as the ethical 
principles of the research. 
7.1.2.1 Participants and  y recruitment 
Initial contact and recruitment of participants will be done at different sale points, such as 
convenience stores, mini supers (Oxxo, Extra, 7 Seven), and retail stores located in different 
points of Mexico City. The selection of the sale points will be done by convenience, and will 
include those located in AGEBS (the Mexican equivalent for census tracts) classified as of 
intermediate socioeconomic level (3, 4 or 5) according to INEGI (National Institute of 
Statistic and Geography) [42]. 

19 
 
An initial questionnaire will be used to explore elegibility criteria, including general 
demographic information (age, sex, information contact), consumption and purchase 
habits, as well as a series of questions to determine the individual socioeconomic level 
(Appendix 1). This rule is an algorithm developed by the Committee of Socioeconomic Levels 
and measures the extent in which the most important needs of households are satisfied by 
considering eight characteristics or possessions of the household and schooling of the 
person who most contributes to household expenses. The eight variables are: 1) schooling 
of the person who most contributes to expenses, 2) number of rooms, 3) number of 
bathrooms, 4) number of lamps/bulbs, 5)number of automobiles, 6) possession of a shower, 
7) possession of a stove, and 8) Type of flooring. As a result, this rule produces and index 
that ranks households into seven levels, from A (highest socioeconomic level) to E (lowest 
socioeconomic level). 
The questionnaire will be applied randomly with a systematic skip (every 5 consumers) at 
the exit of the sale point, after a brief explanation of the study objectives and informed 
consent. Participants classified as typical C or lower C and meeting inclusion criteria will be 
invited to participate in focus groups (see below). 
 There will be a total of five focus groups with an average of 5 to 10 participants each, which 
often buy and consume (twice a week), at least two of the categories of prepackaged meals 
and bottled beverages of interest for the study (mentioned in section 8.1.1.2) and meet the 
following inclusion criteria:  
• Group 1: Men and women 13 to 15 years old that visit the sales point by themselves, 
with a specific budget to purchase products.  
• Group 2: Men and women 21 to 23 years old, who visit the sales point at least twice 
a week, purchase these types of foods and/or beverages, for their own consumption 
and/or their family.  
• Group 3: Women, mothers of 3 to 12 year old children who visit the sales point at 
least twice a week, purchase these types of foods and/or beverages, for their own 
consumption and/or their family.  
• Group 4: Men, fathers of 3 to 12 year old children who visit the sales point at least 
twice a week, purchase these types of foods and/or beverages, for their own 
consumption and/or their family.  
• Group 5: Men and women 55 to 70 years old who visit the sales point at least twice 
a week, purchase these types of foods and/or beverages, for their own consumption 
and/or their family.  
    
Group 1 participants (Men and women from 13 to 15 years) will be contacted only if they 
attend the recruitment points accompanied by a parent or guardian. Participants who meet 
the inclusion criteria will be invited to participate voluntarily in the focus groups, indicating 
the day, time, place and duration of the event, as well as the incentive they will receive in 
return for their participation. Candidates who agree to participate in the study will receive 
at least three reminders via text message or phone call about the date and location of the 
focus groups. Group 1 participants will be asked to attend with a parent or guardian.  

20 
 
7.1.2.2  Materials to evaluate label understanding and acceptability  
The graphic design team will be asked to develop each of the Front of Pack labelling 
proposals in the following versions:   
a) Amplified option: Labels will be printed out in double letter size to explore the 
communication elements of each label (information, figures or hard data, texts, 
typography, colors, iconography, etc.).  
b) Real size: Real size food product dummies will be prepared to evaluate label 
understanding and acceptability. Dummies will reproduce real food products 
currently available on the Mexican market. These products will represent a range 
of foods with a gradient of nutritional quality (for example from the healthiest 
to the least healthy). Food selection will be done considering the categories 
previously mentioned and based on the food classification exercise done during 
the first stage of this phase of the study (section 8.1.1.2).  
Dummies will present all the elements of the frontal part of the package of real 
products, including other nutritional quality labels (such as nutritional or health 
declarations). However, other front-of-pack labeling system will be eliminated 
(for example GDA’s or the Mexican “Distintivo Nutricional”).   
c) Competitive environment: An image of store shelves or racks will be printed to 
evaluate the understanding and acceptability in a competitive environment. The 
image will present real food packages displaying one of the various labeling 
systems.  
The first focus group to be implemented will also work as a pilot group. Based on 
this experience  the required methodological and time adjustments will be made. 
Treatment and dedication to this first group will be similar to the rest of the focus 
groups, including moderation of the focus group, audio and video recording of the 
session, audio transcription, information analysis and final results. 
7.1.2.3 Procedures for data collection 
7.1.2.3.1 Qualitative Information 
Information will be collected according consumers’ perspective using focus groups. Data on 
the different categories of the processes of interpretation of the label and the decision 
making on food selection will be collected. These categories were carefully selected 
considering previous experiences on the design of Front of Pack Labelling Systems [21], as 
well as the conceptual framework of acceptability of systems proposed by Nielsen (18). The 
Guide of Topics for the Focus Group is structured according these categories:  
a) Perceptions towards Front of Pack Labelling, food selection and health. Knowledge, 
attitudes, intentions and behaviors related to Front of Pack Labelling, food selection 
and health. 
b) Acceptability of the different alternatives of Front of Pack Labelling, both in their 
amplified size and real size, considering the following items:  
a. Liking of labels 
b. Attractiveness of labels 
c. Cognitive load of label processing 

21 
 
c) Objective understanding of the different alternatives of Front of Pack Labelling, both in 
their amplified size and real size, considering the following items: 
a. Ability to understand the design elements  
b. Ability to understand the main message 
d) Usefulness of the different alternatives of Front of Pack Labelling, both in their 
amplified size and real size, considering the following items: 
a. Useful utility 
b. Motivational relevance 
c. Message for action 
e) Graphic and language elements that facilitate the understanding of the message 
towards the selection of healthy foods, considering the following items:  
a. Size of the texts 
b. Information 
c. Typography 
d. Colors 
e. Iconography 
f. Ideal Front of Pack Labelling 
Focus groups will have a duration of approximately two hours, and will be video and audio 
recorded in a digital file for its posterior transcription, codification and analysis. Before the 
focus groups starts, participants’ informed consent to participate on the Project and to 
record the session will be obtained. The informed consent meets the AMAI ethics, 
information management politics and Cuartel’s privacy terms, as well as the guidelines 
established by the Ethics Committee of the National Institute of Public Health (Appendix 
2). Subsequently, the Guide of Topics will be applied for the Focus Group (Appendix 3). 
7.1.2.3.2 Quantitative Information 
Once the focus group Guide has been completed, a questionnaire evaluating the 
acceptability and understanding of the different FoPNL Systems will be applied (See 
Appendixes). The questionnaire has been designed considering the different aspects that 
determine the acceptability of a system (18), as well as previous experiences recently 
published exploring acceptability and understanding of a new proposal of Front of Pack 
Labelling in European consumers [21]. The questionnaire consists of 26 items divided in 
three sections: 1) Demographic Information. 2) Acceptability of the FoPNL Systems 
proposals, and 3) Objective understanding of the Front of Pack Labelling.  
Acceptability: Participants will be asked to select the label that best corresponds to a series 
of affirmations. A total of four items will evaluate liking of the label, three items will evaluate 
the attractiveness of the label, and four items will explore perceived cognitive load. 
Objective Understanding. Participants will classify three products according to their 
nutritional quality, using the different FoPNL systems evaluated. For this purpose, images 
of three products of the same food category (previously selected during the exercises with 
the nutritional profiling system) displaying one of the FoPNL  will be shown. Participants will 
classify the products according to their nutritional quality. No other nutritional information 
will be provided. The classification will be considered correct if all three products are ranked 

22 
 
in the expected order, based on their nutritional quality. The same five food categories used 
in the exercises of nutritional profiling explained in section 8.1.1.2 will be tested. 
Demographic Information. Basic Information of age, sex, occupation, civil status, having 
children, schooling, interest in health, chronic diseases, as well as the geographical region 
of the participant using the zip code will be collected. In addition, questions used in the 
National Survey of Health and Nutrition 2016 will be included to collect information on 
socioeconomic level. For this questionnaire, the following 8 items will be considered to 
estimate the level of welfare condition of the participants: flooring, walls and ceiling 
material, number of rooms for sleeping, water supply, automobile possession, number of 
household goods (refrigerator, washing machine, microwave, stove, water heater), and the 
number of electronic appliances (television, radio, telephone, computer). 
7.1.2.4 Incentive 
At the end of the focus group, an electronic purse of the Walmart group of a value of 
$400.00 Mexican pesos will be awarded as remuneration for their participation on the 
Project. 
7.1.2.5 Fieldwork  
Focus groups will be led by previously trained personnel in leadership of focus groups. Two 
researchers with wide experience in qualitative methodologies will be involved in the 
moderation and analysis of the information obtained: one of the researchers will be in front 
of the group conducting the research dynamics, while the other one will remain behind 
Gesell dome observing the conduction of the groups, reactions of the interviewees and the 
whole verbal and not verbal language that us generated. The researcher behind Gesell 
dome will send notes to the moderator when considered necessary or when an investigator 
from the INSP considers necessary to investigate into a subject.  
7.1.2.6 Data analysis 
7.1.2.6.1 Analysis of quantitative data 
The analysis will be carried out using the statistical package Stata version 14. Descriptive 
tabulation of demographic data will be made through an estimation of means and standard 
deviations (or medians and interquartile ranges in case of variables with non-parametric 
distribution) for quantitative variables, as well as proportions for categorical variables.  
To evaluate label acceptability, the percentage of participants who selected each one of the 
proposed labels in relation to liking, attractiveness and perceived cognitive load of the label 
will be calculated.  To compare the performance of the label in respect to objective 
understanding, the percentage of correct responses by labelling system, will be calculated. 
These ratios will be calculated also by food category and by sub-groups (for example, 
schooling, sex). The differences by category will be explored using Chi square tests. 
7.1.2.6.2 Analysis of qualitative data 
Cuartel will use audio recordings to transcribe the complete text of each performed group. 
Transcriptions will be organized in categories of information, generation units of 
descriptive, interpretative or inferential meaning that facilitate the analysis and 
interpretation of the results, first through the analysis and comparison within categories of 
meaning and later inter categories. Appendix 4 shows the arrays of results to use according 
to the interest categories 

23 
 
7.1.3 Stage 3. Design of alternative of Front of Pack Labels 
Based on the results of previous stages, an image designer will be asked to design three 
front of pack labeling alternatives considering the language and design elements identified 
as relevant for front-of-pack labeling. The specific guidelines for the design of these 
proposals will be prepared by the research team in collaboration with Cuartel. 
7.2 PHASE 2. RE-DESIGN OF THE LABELLING PROPOSALS 
7.2.1 Stage 1. Exploration of acceptability and understanding 
During this stage, acceptability and objective understanding of the labels designed by the 
reseach team will be evaluated using the same methodology as the previous phase. In other 
words, qualitative (focus groups) and quantitative (questionnaire) methodologies will be 
used to evaluate acceptability and understanding of the new proposals of Front of pack 
labelling.   
7.2.2 Stage 2. Re-design of the labelling proposals 
The research team will select the two labelling proposals best evaluated in terms of 
acceptability and understanding. For this purpose, the results of the focus groups and the 
questionnaire will be considered. If needed, the design team will be asked to work on those 
aspects of the labels that consumers found unacceptable or not understandable during the 
focus group, with the aim to develop two revised proposals.   
7.3 
PHASE 3. EFFICACY OF THE FRONT OF PACK LABELLING PROPOSALS 
During the last Phase of the Project the efficacy of the re-designed front of pack labelling 
proposals will be tested in an on-line shopping simulation.  
7.3.1 Design of the study 
Three-arm randomized controlled trial without blinding 
7.3.2 Participants  
Participants will be 18 years old or older, who visit a sales point or retail store on regular 
basis (at least once a week) to make their food purchases.  
7.3.3 Recruitment 
Recruitment will be done through the Internet. In order to accomplish the required 
sample size, a company specialized in internet market segmentation in Mexico will be 
hired. This company will be responsible for disseminating and promoting the on-line 
shopping website. The recruitment strategy will be designed by this company based on 
eligibility criteria and sample size requirements to detect statistical differences between 
intervention groups (See section 8.3.7) 
7.3.4 
Intervention  
The intervention will consist on an on-line purchase simulation with different labelling 
systems on food products. Participants will be randomly assigned to one of the three 
conditions using a randomization program: Control group, (no front-of-pack labeling), Label 
Proposal 1, and Label Proposal 2. Due to the nature of the intervention there will be no 
blinding of the intervention.  
7.3.4.1 
Virtual environment for an online shopping simulation 
A supplier will be hired to develop a virtual environment for the on-line shopping 
simulation. The virtual environment will consist of five components or moments presented 

24 
 
in the following order: 1) Informed Consent, 2) Eligibility, 3) Collection of demographic data 
and shopping habits), 4) Virtual Store, y 5) Purchase feedback.  
1) Informed Consent. Before data collection, participants will be asked to give their 
consent to be part of the study through an Informed Consent Letter (See Appendix). 
Participants will not be able to give their consent until they read all the consent form 
(scroll all the way down). 
2) Eligibility. Participants will be asked to confirm they meet the established eligibility 
criteria. (See section 8.3.2) 
3) Demographic data collection. The same  initial questionnaire used in Phase 1 will 
be used to collect general demographic information (age, sex, information contact), 
consumption and purchase habits, as well as a series of questions to determine the 
individual socioeconomic level (Appendix 1). Additionally, information on habitual 
expenses per week at the supermarket will be requested.  
4) Virtual Shop. Participants will be randomly assigned to one of the three conditions 
of the interventions (no labelling, proposal 1 and proposal 2). Participants assigned 
to proposals 1 and 2 will receive a brief introduction to the corresponding label 
before entering the virtual shop. Once in the shop, participants will receive virtual 
money (equivalent to that reported on their usual spending per week). The virtual 
shop will emulate a real supermarket with the following sections: 1) milk and dairy, 
2) beverages, 3) salty snacks, 4) bakery and cereals, 5) ready to eat meals and 6) 
checkout. There will be no restrictions on the order of access to the sections or the 
number of visited sections. Within each section, participants will be presented a 
variety of real products with a gradient in nutritional quality. The products will 
display the label corresponding to the intervention condition as well as the 
nutritional quality of the product. These products will be selected by the INSP 
research team (from the healthiest to the least healthy). Foods will be presented on 
shelves (emulating a real supermarket environment) and will have similar costs to 
real life. The price of the products will be derived from the food data base used in 
the first phase of the project. Participants will have the possibility to explore the 
frontal side of each product’s package. As in previous stages, the frontal side will 
have all elements, including other quality labels (for example, nutritional or health 
claims), except for any other FoPNL system (for example GDA’s or the Nutritional 
Distinctive). Participants will be able to buy as much food as they wish, based on 
their assigned budget. Once the purchases have been made, participants will 
proceed to the checkout area to make their payment.  
5) Feedback purchase. Each participant will receive feedback on the nutritional quality 
of their purchases. Using a nutrient profiling system, the mean nutrtitional quality 
of the food products purchase will be calculated (see section 8.3.4). Based on this 
information, the participant will receive shopping tips for the selection of healthy 
foods based on the nutritional content reported on the back of the package.  
7.3.5 Outcome 
The outcome will be the nutritional quality of the products “bought” by the participants. 
Using a nutrient profiling system, the mean nutrtitional quality of the food products 

25 
 
purchase will be calculated (see section 8.3.4). Secondary outcomes will be energy and 
nutritional content in the shopping kart.    
7.3.6 Analysis of the Data 
The impact of the two label proposals will be evaluated using a linear regression model, 
where the outcome will be the mean nutritional quality of the products bought, whereas 
the independent variable will be the intervention group. The model will be adjusted for the 
main demographic confounders such as age, sex, civil status, having children and 
educational attainment and chronic disease. Differences will be considered statistically 
significant when p<0.05. Analysis will be carried out using STATA version 14.0. 
7.3.7 Sample size 
Based on previous experiences [46], and considering a significance level of 0.05 and a 
statistical power of 80%, at least 273 participants per intervention group will be required 
to detect a difference of 0.3 points in the mean nutritional quality between intervention 
groups (Figure 7).  
 
 
8 ETHICAL CONSIDERATIONS 
This research proposal will be carried out considering the guidelines established by the 
Institutional Research, Ethics and Biosecurity Boards.  
A written consent will be requested from all participants for the participation in focus 
groups, questionnaires and purchase simulations. Participants will receive a copy of the 
consent form with contact information of the head of the Ethics Committee, in case they 
have any questions or concerns regarding the project.  
Each participant will be assigned an identification number that is not related to any personal 
information. Information collected as part of the research will remain confidential and it 
will only be known by the researchers. All field and digital records of focus groups will be 
kept in the office of the principal investigator, and access will be restricted to researchers 
of this study only. Audio files will be destroyed once transcriptions and data analysis are 
completed.   
This study will not collect human biochemical samples in any of its three components, it 
does not imply any biosecurity risks for participants. Regarding ethical aspects, we consider 

26 
 
the proposal implies minimum risks for the participants, since the participants will provide 
their consent. At all times ethical principles of fieldwork will be respected: informed 
consent, autonomy and freedom to refuse to participate in the project. 
 
9  LIMITATIONS 
The sample for the three stages will not be representative of the Mexican population. 
Therefore, external validity of the results could be limited to people with similar 
characteristics of the sample. Nevertheless, previous experiences in Mexico show that 
understanding and acceptability of the different FoPNL alternatives does not differ by 
socioeconomic levels. We consider that the information collected will provide relevant 
information for the design and conduction of future studies in the topic of Front of Pack 
Labelling.  
The use of online tools could have a low response rate, limiting the sample size and 
consequently statistical power to find differences. However, we have considered hiring an 
expert company in online market segmentation for the dissemination of the online 
shopping simulation, as well as through websites with a high traffic of users. By reaching a 
higher number of individuals we will have a better chance of meeting the required sample 
size.  
The current study will not evaluate the effectiveness of the labelling proposal in a real 
environment. Therefore, results can only be interpreted as purchase intentions. The 
evaluation of effectiveness of a FoPNL in a real environment has political, logistic and 
economic implications that go beyond the scope of this Project. 

27 
 
 
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