# Abstract

 

## Introduction Governments throughout the world are using or considering various front-of-package (FOP) food labeling systems to provide nutrition information to consumers. Our web-based study tested consumer understanding of different FOP labeling systems. 

## Methods Adult participants (N = 480) were randomized to 1 of 5 groups to evaluate FOP labels: 1) no label; 2) multiple traffic light (MTL); 3) MTL plus daily caloric requirement icon (MTL+caloric intake); 4) traffic light with specific nutrients to limit based on food category (TL+SNL); or 5) the Choices logo. Total percentage correct quiz scores were created reflecting participants' ability to select the healthier of 2 foods and estimate amounts of saturated fat, sugar, and sodium in foods. Participants also rated products on taste, healthfulness, and how likely they were to purchase the product. Quiz scores and product perceptions were compared with 1-way analysis of variance followed by post-hoc Tukey tests. 

## Results The MTL+caloric intake group (mean [standard deviation], 73.3% [6.9%]) and Choices group (72.5% [13.2%]) significantly outperformed the no label group (67.8% [10.3%]) and the TL+SNL group (65.8% [7.3%]) in selecting the more healthful product on the healthier product quiz. The MTL and MTL+caloric intake groups achieved average scores of more than 90% on the saturated fat, sugar, and sodium quizzes, which were significantly better than the no label and Choices group average scores, which were between 34% and 47%. 

## Conclusion An MTL+caloric intake label and the Choices symbol hold promise as FOP labeling systems and require further testing in different environments and population subgroups. # Results 

## Study outcomes 

### Healthier product quiz Participant scores for the healthier product quiz varied significantly among groups ([Table 2](#)). The Choices group outperformed the no label group (Cohen's *d* = 0.40, *P* = .005) as did the MTL+caloric intake label group (*d* = 0.62, *P* < .001). The TL+SNL group had fewer correct answers than the Choices group (*d* = 0.63, *P* < .001), the MTL group (*d* = 0.69, *P* = .001), and the MTL+caloric intake group (*d* = 1.06, *P* < .001). ::::table-wrap

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## Consumer Understanding of Front-of-Package Nutrition Labels: Percentage Correct for Healthier Product Quiz Items (N = 480)^a^, 2010--2011

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Product Comparison (Nutrient Profile Model Score) No Label (n = 99) Choices (n = 98) MTL (n = 98) MTL+Caloric Intake (n = 90) TL+SNL (n = 95) χ^2^ *P*^b^

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**Beverages**\
Vintage Seltzer Water (0)^b^ 95 95 97 90 93 4.8 .31
Walgreens Refreshing Cola (2)\
**Breads and grains**\
Wonder Classic White Bread (5) 92 93 33 35 37 157.5 \<.001^c^
Arnold's Bread, Soft Honey Wheat (0)^b^\
Kingmills 50/50 Bread with Omega 3 (−4)^b^ 57 70 83 78 73 28.5 \<.001^c^
Auntie Hattie's Potato Bread (11)\
**Cereals**\
Kellogg's Mini-Wheats Unfrosted Bite Size (−6)^b^ 31 44 23 42 12 36.2 \<.001^c^
General Mills Cheerios (0)\
Meijer Frosted Bite Size Shredded Wheat (−2)^b^ 26 43 55 49 13 54.5 \<.001^c^
Uncle Sam Toasted Whole Wheat Flakes and Flaxseed (8)\
**Condiments and dressings**\
Kraft Tuscan House Italian Dressing (20)^b^ 91 87 93 89 91 9.9 .04
Kraft Buttermilk Ranch Dressing (26)\
Morehouse Mustard (10)^b^ 96 89 94 87 91 5.4 .25
Duke's Mayonnaise (23)\
**Desserts**\
Klondike Original Ice Cream Bar (17) 69 86 94 88 93 60.0 \<.001^c^
Breyer's Smooth and Dreamy Fat Free Ice Cream, Creamy Vanilla (-1)^b^\
Tesco Vanilla Ice Cream (7)^b^ 75 71 96 90 92 66.6 \<.001^c^
Mangum Classic Vanilla Ice Cream Bar (18)\
**Fats, oils, and spreads**\
I Can't Believe It's Not Butter! Spray (0)^b^ 20 36 85 72 67 133.8 \<.001^c^
Mazola Olive Oil (19)\
Imperial Margarine (24) 41 39 3 0 1 124.0 \<.001^c^
Utterly Butterly Spread (15)^b^\
**Snacks**\
Orville Redenbacher Original Kernel (−7)^b^ 91 96 96 89 92 9.3 .05
Kraft Macaroni and Cheese Baked Crackers (21)\
Fudges Cheddar Wafers (26) 60 56 90 86 85 78.0 \<.001^c^
Butterkist Salted Popcorn (20)^b^\
**Soups**\
Progresso Soup, Traditional Chicken Noodle (2)^b^ 84 76 93 90 90 35.4 \<.001^c^
Campbell's Condensed Soup, Chicken Noodle (3)\
Dinty Moore Scalloped Potatoes and Ham (5) 79 85 8 4 7 289.7 \<.001^c^
Stagg Classic Chili (0)^b^

^a^ Study groups were no label (control), Choices (Choices symbol), MTL
(multiple traffic light), MTL+caloric intake (multiple traffic light
plus daily calorie recommendation icon), TL+SNL (traffic light plus
specific nutrients to limit.

^b^ Represents the "correct" answer (based on the product with the lower
Nutrient Profile Model [NPM Score] on a healthier product quiz that
asked participants to choose the healthier of 2 products in the same
food category ([11](#)). The NPM adds points for negative nutrients (eg,
saturated fat, sugar, sodium) and calories and subtracts points for
positive nutrients (fiber, protein). Foods with a score of less than 4
and beverages with a score of less than 1 are considered healthy.

^c^ Significant based on a χ^2^ test comparing front-of-package label
groups and a Bonferroni corrected α level of .003.:::: 

### Saturated fat, sodium, and sugars quizzes The label groups differed significantly on the saturated fat quiz. All 3 TL groups significantly outperformed the no label and Choices groups (*P* < .001 for all TL comparisons). Cohen's *d* effect sizes for the control group versus the TL groups were as follows: MTL, *d* = 3.09; MTL+caloric intake, *d* = 3.70; and TL+SNL, *d* = 1.90. The 2 MTL groups had significantly higher scores than all other groups. There were also significant differences among study groups on the sugars and sodium quizzes, which were similar to the pattern of findings for the saturated fat quiz. 

### Accuracy of calories-per-serving estimate The 4 label groups significantly differed on ability to estimate calories per serving ([Table 3](#)). All 3 TL groups led to more accurate calories-per-serving estimates compared with the Choices and no-label groups: MTL, *d* = 0.73; MTL+caloric intake, *d* = 0.77; TL+SNL, *d* = 0.75; (*P* < .001 for all comparisons). Only 17% of participants provided an incorrect estimate of recommended daily caloric intake, which did not differ across group (χ^2^~4~) = 7.0, *P* = .14). ::::table-wrap
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## Consumer Understanding of Front-of-Package Nutrition Labels: Food and Beverage Ratings^a^ (N = 480)^b^, 2010--2011

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Outcome No Label, Control Group(n = 99) Choices (n = 98) MTL (n = 98) MTL+ Caloric Intake (n = 90) TL+SNL (n = 95) *P^c^* η^2 d^

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Healthier product quiz 67.8 (10.3) 72.5 (13.2)^e,i^ 71.0 (7.7)^i^ 73.3 (6.9)^e,i^ 65.8 (7.3)^f,g,h^ \<.001 .002
Saturated fat quiz 33.6 (16.3) 35.7 (15.9)^g,h,i^ 90.7 (20.4)^e,f,i^ 92.3 (15.1)^e,f,i^ 64.9 (16.5)^e,f,g,h^ \<.001 .131
Sugars quiz 47.2 (19.6) 41.9 (19.4) ^g,h,i^ 90.0 (20.7) ^e,f,i^ 92.6 (15.5)^e,f,i^ 77.2 (19.5)^e,f,g,h^ \<.001 .080
Sodium quiz 42.6 (20.7) 47.1 (21.1) ^g,h,i^ 93.5 (16.4) ^e,f,i^ 94.1 (15.6)^e,f,i^ 72.4 (15.7) ^e,f,g,h^ \<.001 .085
Absolute difference in estimated and actual calories per serving 115.1 (171.8) 88.9 (105.4) ^g,h,i^ 15.2 (88.1) ^e,f^ 16.9 (57.6)^e,f^ 14.8 (78.5)^e,f^ \<.001 .118
Healthfulness^j^ 4.4 (1.3) 4.6 (1.4) ^g,h,i^ 3.8 (1.2)^e,f^ 3.6 (1.1)^e,f^ 3.8 (1.2)^e,f^ \<.001 .009
Taste^j^ 5.8 (1.4) 5.3 (1.5) 5.6 (1.4) 5.4 (1.4) 5.5 (1.3) .16 .001
**Intent to purchase^j^**\
For self 4.1 (1.5) 4.1 (1.7) 3.8 (1.4) 3.6 (1.5) 3.7 (1.4) .12 .002
For children 4.3 (1.7) 4.1 (1.9) 4.0 (1.6) 4.0 (1.7) 4.0 (1.5) .66 .001

^a^ The 7 products used in this analysis were Nesquik Chocolate Milk,
McVitie's Toasting Waffles, Health Valley Apple Cereal Bars, I Can't
Believe It's Not Butter! Mediterranean Blend, Pfeiffer Dressing
California French, Orville Redenbacher Smart Pop Kettle Corn Microwave,
and Campbell's Chunky Grilled Sirloin Steak with Hearty Vegetable.

^b^ Study groups were no label (control), Choices (Choices symbol), MTL
(multiple traffic light), MTL+calorie (multiple traffic light plus daily
calorie recommendation icon), TL+SNL (traffic light plus specific
nutrients to limit. Table values are mean (SD). The total N varied with
the number of participants that completed each question.

^c^ Significant based on univariate ANOVAs comparing front-of-package
label groups and a Bonferroni corrected α level of .003.

^d^ Represents the effect size for the overall ANOVA analysis.

^e^ Significantly different from control group (no label), *P* < .05,
based on univariate analysis of variance (ANOVA) and post-hoc Tukey
tests.

^f^ Significantly different from Choices label, *P* < .05, based on
univariate ANOVA and post-hoc Tukey tests.

^g^ Significantly different from MTL label, *P* < .05, based on
univariate ANOVA and post-hoc Tukey tests.

^h^ Significantly different from MTL+caloric intake, *P* < .05, based
on univariate ANOVA and post-hoc Tukey tests.

^i^ Significantly different from TL+SNL label, *P* < .05, based on
univariate ANOVA and post-hoc Tukey tests.

^j^ Measured on a 9-point Likert scale.:::: 

### Perceptions of health, taste, and intent to purchase The label groups differed significantly on perceptions of product healthfulness ([Table 3](#)). Products were viewed as significantly less healthy in the TL groups relative to the Choices (*P* < .001) and no-label groups (*P* < .001). Cohen's *d* effect sizes for the control group versus the TL groups were as follows: MTL, *d* = .50; MTL+caloric intake, *d* = .75; and TL+SNL, *d* = .53. Perceptions of taste and purchase intent did not significantly differ across label groups. 

### Outcomes for soup product For the soup product, which was the only individual product that qualified for a Choices symbol, the Choices group performed significantly worse on the sugar quiz (*P* < .001) than the MTL and MTL+caloric intake groups. The Choices group performed better than the control group on estimating saturated fat (*P* < .001), sodium (*P* < .01), and calories (*P* < .004), but performed significantly worse on these outcomes than all 3 TL groups (*P* < .001) ([Table 3](#)).


Extracted trial result:
Outcome: Scores on sugar quiz (continuous)
Intervention: MTL+caloric intake group
Comparator: choices group
Intervention group size: 90
Intervention mean: 92.6
Intervention standard deviation: 15.5
Comparator group size: 98
Comparator mean: 41.9
Comparator standard deviation: 19.4