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1 CARDIFF METROPOLITAN UNIVERSITY CARDIFF SCHOOL OF HEALTH SCIENCES DEPARTMENT OF HEALTHCARE SCIENCES AND FOOD BSc (Hons) Human Nutrition and Dietetics BSc (Hons) Public Health Nutrition Dissertation Academic Paper Title: Impact of different front-of-pack nutrition labels on consumer s preference and ability to identify amount of total fat: a randomised controlled study of women aged Harriet Pyne Student Number: Supervisor: Hilary Wickett Student Declaration In Respect of Individual Work I declare that the whole of this work is the result of my individual effort and that all quotations from other authors have been acknowledged. Dissertation submitted in partial fulfilment of the requirements of the University of Wales for the Degree of Bachelor of Science with Honours. Signed: Date: 1

2 Impact of different front-of-pack nutrition labels on consumer s preference and ability to identify amount of total fat: a randomised controlled study of women aged Abstract Background Front-of-pack nutrition labels are potential tools to help consumers make healthier food choices; however, before determining its effect on purchasing behaviour, factors involved in its use must be explored. This study sought to explore which formats were the most preferred and which enabled the most accurate estimation of fat in a sample of adult women. Methods Among 17 adult women aged years recruited from an opportunistic sample, preference was measured for three front-of-pack labels: The Reference Intake, Coloured Reference Intake and Colour wheel formats. Using a randomised controlled design subjects were exposed to either: Reference Intake or Coloured Reference Intake label and asked to identify whether a food product was either high, medium or low in fat. Acceptability was also explored using qualitative design. Results Three label formats were ranked out of five for preference, consisting of liking and ease of use. The two coloured front-of-pack label formats was significantly more liked than the Reference Intake format. Out of the two coloured formats there was no statistically significant favourite. Participants randomised to the RI group had the least correct answers for determining the amount of fat per product (4.5 ± 0.51) compared to the RI Colour group (2.7 ± 1.23) (p=0.004). Participants in the study population described how they used food labels to make healthier food choices by avoiding red labels compared to being influenced by green labels. Portion size was an area described by the population 2

3 sample as being an issue with the user-friendliness of food labels, with a calling for more realistic portion sizes to be included on front-of-pack nutrition labelling. Conclusion Women aged prefer front-of-pack labels which contain colour coding for nutrients irrespective of the format and are better able to identify amounts of fats in foods using colour coding. This population group are more influenced by red labels than green labels when making food choices. Keywords: Front-of-pack, labelling, signposting, food labels. 3

4 Introduction There is increasing priority in the UK to more effectively prevent chronic diseases such as cardiovascular disease, obesity and diabetes (Van Kleef et al., 2008). Although there are numerous factors that contribute to these diseases, it has been well documented that diet is a major modifiable factor (Cowburn & Stockley, 2005; Van Kleef et al., 2008). However, it is not just the quantity of food consumed that is important in reducing disease risk; understanding the nutritional content of foods as a whole is key to making healthier food choices (Mejean et al., 2013). In addition to back-of-pack nutrition labelling, front-of-pack labels are potential tools to help consumers make healthier food choices (Mejean et al., 2013). In addition, front-of-pack labelling may potentially encourage the food industry to reformulate existing food products to have a healthier nutritional composition (Roodenburg et al., 2011). Nutrition labelling has been well established in the United Kingdom (UK) for many years. Towards the end of 2016, EU legislation will come into force and make it compulsory for food labels to include details of the nutritional content of foods (FSA 2014). In practise, this will bring the rest of Europe up to standard with the guidance, as the UK has been providing this information on a voluntary basis for some time. In recent years, the Food Standards Agency (FSA) has developed a Traffic-Light front-of-pack labelling system, and the Food and Drink Federation (FDF) has developed the Guideline Daily Amounts scheme (GDA). Both schemes aimed to increase clarity for consumers although having two competing schemes being introduced simultaneously was reported to have caused confusion (Lobstein et al., 2007). Due to European Regulation, GDAs changed to Reference Intakes (RI) in December 2014 for foods that already carry nutrition labelling (EU 2011). The main difference is that 4

5 GDAs existed for men, women and children; there is only one set of RIs for an average adult (SACN 2013). Consumers, in general, have shown they prefer simplified front-of-pack nutritional information but have varying acceptance for the various front-of-pack formats created for example: The Traffic Light System (TLS), RI and a hybrid format; although there are various adaptations of each main format (Campos et al., 2011). The TLS concept was developed by the Food Standards Agency (FSA), who agreed that a consistent approach to labelling was needed (FSA 2013). It provides consumers with information on whether a food product contains low, medium or high amounts of fat, saturates, sugar and salt; represented by either a green, orange or red colour. It is reported that this gives consumers a quicker and easier way to make healthier food choices, and comparisons between food products (FSA 2013). The RI format shows the amount of energy and nutrients as a percentage of what a typical healthy adult should be eating on a 2000 kcal diet. The Hybrid format combines the two previous label formats. Studies carried out by the UK FSA have shown that the colour coded formats, such as the TLS and hybrid format as the most widely accepted and better understood by consumers (Borgmeier & Westenhoefer 2009; Malam et al., 2012). Systematic reviews, however, found that nutrition labels are not always used by consumers due to a lack of understanding of terms (Cowburn & Stockley, 2005; Campos et al., 2011). Differing consumer preferences for the various formats may be related to age, gender, time constraints when shopping and to conflicting appreciations of ease of use (Mejean et al., 2013). Most consumers are familiar with the most common front-of-pack formats however, little is known about how consumers interpret and apply this information to help make healthier food choices (Babio 2013). The extent to which labels are used varies across 5

6 subgroups, for example: use is lowest amongst adolescents and individuals with low income or education (Campos et al., 2011). Older adult women represent a particular demographic who are less likely to be constrained by factors such as cost and time when shopping. Research into this group show that they are mainly responsible for the household shopping and buy food for a number of family members, therefore having responsibility for a significant proportion of the household diet (Hess et al., 2012). A recent systematic review concluded that consumer s expressed a desire for nutrient information to be in large print with the use of colour; consumers often found front-of-pack labels with no colour more difficult to interpret and compare (Campos et al., 2011). Scarborough et al (2015) found that UK consumers use and like the additional presentations such as colour coding and %RIs, and that these can improve their ability to use nutrition information in certain situations. UK specific research has also demonstrated that consumers have expressed a preference for a hybrid label containing text, colour coding and %RIs (FSA 2013). Without further harmonisation of front-of-pack labelling, this variation could continue to make it harder for UK consumers to compare products and to use frontof-pack labelling as effectively as possible (Mejean et al., 2013). Interventions used at the point of sale, such as front-of-pack labelling, may help provide more accessible and coherent nutrition information for consumers, to encourage and make it easier for them to identify healthier food products (Cowburn & Stockley 2005 and Feunekes et al., 2008). However, there is a need for front-of-pack labelling to be consistent and easy to interpret in order to influence the consumer. 6

7 The present study aimed to assess, among various front-of-pack label formats, the types of formats most effective in terms of acceptability, and ability to identify foods high in fat, in a sample of women aged years. 7

8 Materials and Methods Study Population 17 adult women aged between 45 and 60 years living in South Devon, England were recruited from an opportunistic sample. All participants gave verbal consent to participate in the study and had the option to withdraw at any time. Ethical approval was obtained from the Cardiff School of Health Sciences ethic panel of Cardiff Metropolitan University prior to data collection, reference number:. (See Appendix 4). The participants were known to the researcher. Other than age and gender, no other exclusion criteria was applied. This demographic represent adults that are more likely to be of established career with a stable income and subsequently are less likely to be constrained by cost or time when shopping for food items. A number of studies have found that women report using front-ofpack labels more than men demonstrating that this group is more likely to be affected by changes in front-of-pack labelling than other demographics (Clegg & Lawless 2008; Malam et al, 2009). Study Design A two-arm parallel randomised control trial was designed to compare two front-of-pack nutrition label formats. Participants were randomly assigned to two groups: (i) Traffic Light System (TLS); and (ii) Reference Intake system. The self-administered questionnaire included both quantitative and qualitative design. The study design enabled investigation into awareness of front-of-pack labelling formats, food shopping habits and how these relate to preferences of front-of-pack labelling. Participants were randomly assigned to one of two groups. The questionnaire consisted of 3 sections. Both groups were exposed to 8

9 Section 1 and 3. Section 2 included questions exploring abilities to identify amount of fat from either the Traffic Light System (TLS) or RI (Reference intake) label format. The question style, using short questions with tick boxes, has been reported to yield high response rates from a previous study also assessing consumer use of food labels (Mackison et al, 2009). A pilot test was carried out prior to data collection including two participants who met the inclusion criteria and were given the questionnaire. After completion there was a discussion between the pilot test participants and the researcher regarding the understanding of the research tool. Following this, the tool was deemed fit for purpose without modification and these results were included in the full study. Food Labels The food label formats included to explore whether colour had an effect on ability to determine amount of fat in a product were either a Traffic Light System (TLS) format or a Reference Intake (RI) format (Fig. 1). The TLS system for the study used green, yellow and orange to represent low, moderate and high concentrations, respectively, of selected nutrients. The cut-off to establish the traffic-light colours was based on criteria from the UK Food Standards Agency, and it was specified that the labels represented 100g of the food product (FSA 2012). The RI used for labelling were based on the average requirements of an adult. 9

10 Figure 1 Front-of-pack nutrition labels used for exploring ability to determine amount of fat per food product To explore preference for different front-of-pack labels three labels were tested (Fig. 2). They differed in colour and level of detail. Figure 2 Front-of-pack nutrition labels studied to explore preference for different formats Colour RI Format RI Format Colour Wheel Format All the images used in the study were of labels typically found in UK supermarkets, based on logos introduced in the UK by the Food Standards Agency and similar to labels used in previous research (FSA 2012; Mejean et al., 2013). 10

11 Materials Objective acceptability and preference of the different food label formats was assessed by asking the participants in the questionnaire to rank different formats out of 5, adapted from previous research (Mejean et al., 2013). Qualitative aspects from the questionnaire were adapted from a UK based study completed from the Food Standards Agency exploring use of food labelling information in the UK (FSA 2010). This qualitative aspect was added to obtain data on participant s perceptions of food labels in their own words which has been shown to be advantageous in previous similar research (FSA 2010). Acceptability of front-of-pack labels. Label acceptability was evaluated via several indicators: ease of identifying health foods from the label, and whether the participant would take the label into account when shopping. These dimensions were inspired by the framework of system acceptability developed by Nielson, which has already been applied to front-of-pack labels by Mejean et al. (2013). For this test, participants were asked to rank each of the three labelling formats out of 5 that best corresponded to the proposed statement. Preference was assessed by asking participants to rank out of 5 how likely they were to take each of the three front-of-pack labelling formats into account when shopping. This was adapted from a large French study investigating consumer preference of front-of-pack labels (MeJean et al., 2013). Ability to identify foods high in fat from different front-of-pack labels. Ability to interpret different front-of-pack labelling formats and identify foods high in fat was examined using a two arm trial. 5 front-of-pack labels either in the TLS or RI format were used with participants identifying whether the food depicted by the label was either high, medium or 11

12 low in fat. The I don t know option was also included. This design was adapted from a randomised controlled trial investigating teenager s ability to select foods from differing front-of-pack labels (Babio et al., 2013). Statistical analyses were done using SPSS Statistics 22 for Windows. Qualitative data was examined by the principal researcher using the Framework method for thematic analysis using detection, categorisation and classification (Ritchie & Lewis, 2003). 12

13 Results Study Sample & Food shopping habits Seventeen adult women aged between 45 and 60 years were recruited and approached for the study. All of the participants were included; none were lost to drop out or excluded. The majority of the sample did their main food shop at either Tesco or Sainsbury s, which needs to be considered when interpreting the results. The vast majority of the sample (94%) found the importance of food labels either important or very important. Table 1 General characteristics of the sample (n=17 adults) Variables % Age Employment Working full time 18 Working part time 18 Non-working 59 (housewife) Retired 6 Unemployed 0 Table 2 Shopping habits of the sample (n=17 adults) Variables % Supermarket for main shop Sainsbury s 41 Tesco 41 Waitrose 6 Asda 6 Other 6 Frequency of food shopping Daily times a week 47 Once a week 35 Once a fortnight 12 Do you do the shopping Always 76 Often 24 13

14 The population group had high scores from the health literacy questions with an average score of 88%. The majority of the participants scored 100% (n=15) (Table 3). Table 3 Participant s score (%) from questions determining health literacy Score (%) Amount of participants (%) 0 12 (n=2) (n=15) Ability to identify foods high in fat from two different label formats The TLS label format scored higher than the RI label when participants were asked to identify food products high in fat using the respective labels (Table 4). Table 4 Participants ability to identify amount of fat in foods; comparing RI and TLS format. Label TLS Group RI Group All Mean score (/5) S.D Range Mann-Whitney statistical analysis showed statistically significant differences between Label Group (RI and TLS format) and ability to identify the correct amount of fat (p=0.004). The RI Group had more incorrect answers compared to the TLS Group when identifying amount of fat from the food label. From the incorrect answers, the majority of the RI Group overestimated the amount of fat from the food label, with the majority of the TLS incorrect answers coming from an underestimation of the amount of fat from the food label (Table 5). 14

15 Table 5 Breakdown of incorrect answers by TLS and RI Group Label TLS n=4 RI n=21 Underestimated 4 8 Overestimated 0 13 Chi-squared statistical analysis showed a statistically significant difference between the Label Group (TLS and RI) and incorrect estimation level (p=0.023, t=5.159, df=1). Ease of identifying how healthy a product is from 3 front-of-pack label format The two colour label formats (Colour wheel and RI colour) scored higher than the noncolour label (RI) for ease of use (Table 6). Table 6 Participants mean score for ease of identifying healthiness of a product; comparing RI Colour, Colour Wheel and RI formats. Label RI Colour Colour Wheel RI Mean score (/5) S.D ANOVA showed statistically significant differences in label scores between RI and RI colour (p=0.000). ANOVA also showed statistically significant differences in label scores between RI and Colour wheel (p=0.000). There was no statistically significant differences in label score between RI colour and the Colour Wheel (p=0.947). 15

16 Preference for 3 different front-of-pack label formats When asked which of the three labels (RI colour, RI and Colour wheel) participants would consider when shopping, the two coloured label formats (Colour wheel and RI colour) scored higher than the non-colour label (RI) (Table 7). Table 7 Participant s rating for preference of front-of-pack labels; comparing RI colour, Colour Wheel and RI formats. Label RI Colour Colour Wheel RI Mean score (/5) S.D ANOVA showed statistically significant differences in label scores between RI and RI colour (p=0.00). ANOVA also showed statistically significant differences in label scores between RI and Colour wheel (p=0.00). There was no statistically significant differences in label score between RI colour and the Colour Wheel (p=0.366). Reported amount of information on three front-of-pack label formats The majority of participants found that the Colour RI and Colour Wheel had the right amount of information, whereas the majority of participants found the RI format to have not enough information (Table 8). 16

17 Table 8 Amount of information reported by consumers on three label formats; comparing Colour RI, RI and Colour Wheel formats. Colour RI (%) n=17 RI (%) n=17 Label Not enough information The right amount of information Too much information Colour wheel (%) n=17 Avoidance of red labels Food label colour was a strong theme in the qualitative part of the questionnaire. Nine participants mentioned label colours when describing how food labelling affected what foods they buy. In particular, six participants stated that they avoided or were put off by food labels which contained red colours: Try and avoid foods with a lot of reds in the label (ID 02) Using labels to compare foods Using labels to compare foods had a strong impact on what foods participants recalled buying. A number of participants (n= 6) described looking using food labels to buy food which they perceive to be healthier: I always look to see how many calories per portion and then try to buy the least calorie food (ID 09) 17

18 Two participants described how they used colours to compare food: Helps to compare food products I try and buy foods with green colours on labels (ID 11) However, one participant described how they don t use food labels to compare foods all the time: I don t use it all of the time. But sometimes compare two foods with the colours (ID 04) Using food labels to make healthier choices A large proportion of the participants referred to making healthier choices when explaining how food labelling information effected what foods they purchased. Thirteen participants described how food labels affect the healthiness of the foods they buy or think about purchasing: I look at the labels for new products. I try and buy low fat healthy products (ID 03) Preference of colours on food labels When asked about use friendliness of food labels, six participants showed a strong preference for colour coding on food labels: Colours help make it easier to find healthy foods (ID 11) Portion size clarity Interestingly, participants displayed concerns with regards to nutritional information and portion sizes. Three participants gave specific examples in regards to foods in which they explained that the portion sizes were too small and unrealistic: On chocolates, the calories are per 3 chocolates rather than the whole bag! (ID 09) 18

19 Others explained difficulties with calculating the nutritional content of the foods dependant on the portion size they would have, being different to the portion size on the packet of the food: Sometime I have to calculate how much I m going to eat and the calories in it s the label only gives the calories for a small amount (i.e. large packet of crisps, chocolates, pizza) (ID 07) When asked what the participants either liked or would want to change in regards to food labelling three participants stated that portion sizes need to be more realistic of what is eaten: Per item ie. A whole pizza rather than per slice. Needs to be realistic (ID 14) 19

20 Discussion The present study aimed to assess, among various front-of-pack label formats, the types of formats most effective in terms of acceptability, and ability to identify foods high in fat, in a sample of women aged years. As the participants were recruited by opportunistic sampling and were known to the researcher, they have shown a greater interest in nutritional issues and are likely to have a healthier lifestyle than the general population; demonstrating limited external validity. The sample size of this research must also be taken into consideration when interpreting the results. Another limitation was that the self-reported data might not be an accurate reflection of actual label use in real-life settings. For example, measures of ability to identify products high in fat might not be an accurate reflection of actual label use in real-life settings that involve time pressure and distracting factors forming part of marketing strategies. Although this population group has been specifically targeted as they have been shown to be less likely to be influence by these factors (Hess et al., 2012). The main findings from the present study suggest that front-of-pack nutrition labels containing colours can improve the accuracy of judgements regarding the amount of fat that a food product contains. Results have shown that this population group regard front-ofpack food labelling with a high importance and have shown a strong preference for a colour coded label. The study also produced unexpected findings in that consumers have shown they want improved clarity over labelled portion sizes and for these to be more realistic to what is purchased and eaten in a real life situation. 20

21 Participants randomised to the TLS format group were more likely to correctly determine the amount of fat (high, medium or low) contained in a food compared with the RI model. Few studies of similar design have evaluated the effect that different types of front-of-pack nutritional labels have on consumer s ability to quantify amount of fat from a food product. The results however, have some similarities with previous research; the present study confirms the previous findings of Babio 2013 in which adolescents using a colour-based front-of-pack labels chose a significantly healthier diet compared with the same monochrome model. In the present study the colours used in the TLS format helped participants to identify the amount of fat in the product, thus theoretically making it possible for them to make healthier choices in a real life settings and choosing a diet closer to dietary recommendations. The most probable and robust explanation for the findings is that the TLS format is more immediately comprehensible to consumers and easier to interpret, which has been previously reported (Campos et al., 2011). Therefore it offers the potential choice to select foods with fewer calories, sugar, fats and salt. This was further supported by the qualitative data from the present study which showed consumer s preference for colour on food labels as a key theme, with indications that it increased ease of use and clarity. The qualitative results showed that consumers often avoid red colours on labels; the avoidance of red labels was greater emphasised compared to a liking and selection of green colours on labels. Consumer s avoidance of red coloured labels could be affected by reformulation of products, as swapping food products containing red labels to amber is likely to have a greater effect on the consumer than a move from amber to green. This may reflect the makeup of the sample, who may have different health concerns to the general population. However, research by Balcombe et al into colour- 21

22 coding baskets of food investigated which were chosen by consumers. Their results showed a similar pattern, in that consumers were more influenced by the red labels than the green labels. There could be many explanations for this, one being the historical significance of the colour red as danger and representing harm, which would explain how consumers attention are payed more to this than that of the green labels. Differences were also observed between reported ease of use between the RI, Colour RI and Colour Wheel systems. Label scores were statistically significant between the RI format and both the colour systems, with the two colour systems scoring highest for consumer ease of use. These findings were in line with previous research showing that the TLS label, which provides more detailed information on the composition of packaged foods, was best appreciated by consumers. This could be explained by the possibility that consumers find it easier to identify and compare food products, which could be harder to do with the noncolour formats. This was also a key theme from the qualitative data demonstrating that consumer s use colours on nutrition labels to help them compare food products. However, although the colour coded label formats performed better than the non-colour coded formats, differences in ease of use between the two differing coloured formats were not statistically significant. Previous research in the general public has shown that the perception of differing front-ofpack formats also depends on the chosen target population, and that poorly educated individuals showed better acceptability of simple formats. Thus, because there is no clear preference for a colour coded front-of-pack format, the choice of the format may vary and depend on the chosen target population. 22

23 Further work exploring variations in labelling perceptions is needed to efficiently target this age and gender group but with a low socio-economic status, and who are therefore at a higher risk of diet-related chronic diseases compared to other segments of the population (Mejean et al., 2013). The interpretation of results must take into account the characteristics of the study. Given the sample population (Women, years and high level of health literacy), the acceptability and preference of front-of-pack labels reported only represents the views of this specific sample; with the likelihood they are more health conscious than average. As noted above, perception of front-of-pack labels varies across different populations groups. However, despite the homogeneity of the population, wide differences in preference among the different labels were still observed, showing similarities to previous research (Mejean et al., 2013) The coloured front-of-pack label formats also performed strongest compared to the RI label format in terms of preference, which was measured by how likely the participants were to take the label into account when shopping. The findings were in line with previous research showing that coloured labels were best evaluated by consumers compared to more simplistic label designs not including colour coding (Mejean et al., 2013; Campos et al., 2011). The two coloured label formats were also shown to score well in regards to the amount of information that was contained on the label. Despite this, Colour coded nutritional labels have also been criticised for implying that some core foods are unhealthy, thereby potentially discouraging consumers from purchasing them. For example, most cheeses would be labelled red for nutrient content for total fat, saturated fat and salt, yet consumers are encouraged to choose dairy products because of 23

24 other nutritional benefits. This highlights the need for public education campaigns to accompany the possible introduction of a mandatory front-of-pack labelling system to help consumers interpret food labels in the context of nutritional guidelines Interestingly, when asked about issues regarding user-friendliness of food labels, a high proportion of the study sample reported portion sizes to be unrealistic compared to their normal eating habits and portion sizes. This was unexpected as the focus of the questionnaire investigating specifically the formats of varying label formats and which did not directly aim to explore consumer s perception on this specific area. Little research has been conducted in this field, particularly in adult samples; further research could be conducted quantifying what consumer s perceive to be normal portion sizes of particular foods and comparing these against manufacturer s portion sizes. More research is also required to explore the impact of front-of-pack labelling on food purchasing in real life environments. This could be tested using till receipts from study participants along with short interviews exploring purchasing behaviour in depth. The need for more research exploring other aspects of food packaging which can influence consumer s food choice i.e. nutrition claims for example, low fat or light was also highlighted. Without further investigation into how consumers use food labelling in real life situations, it would be difficult to determine which formats would be the most effective for promoting healthy food choice. This further research could help guide dietitians lobby for a consistent front-of-pack nutrition labelling system, which could potentially help consumer s make healthier food choices. Further still, introduction of a consistent front-of-pack label format being 24

25 accompanied by a health promotion campaign could improve understanding and food label use. To conclude, the results of this study are largely consistent with those of previous studies, showing consumer preference for coloured front-of-pack labels. The study also found that coloured front-of-pack labelling increased ability to correctly identify amount of fat in food products and that consumers are more influenced by red labels than green labels. However, portion sizes on nutrition labels were reported as being unrealistic, which could be effecting consumer engagement with food labels. 25

26 References: Babio, N., Paloma, V., Lopez, L., Benito, A., Basulto, J. and Salas-Salvado, J. (2013). Adolescents ability to select healthy food using two different front-of-pack food labels: a cross over study. Public Health Nutrition. 17(6), Balcombe, K., Fraser, I. and Falco, S. (2010). Traffic lights and food choice: A choice experiment examining the relationship between nutritional food labels and price. Food Policy. 35(3), Borgmeier, I. and Westenhoefer, J. (2009). Impact of different food label formats on healthiness evaluation and food hoice of consumers: a randomized-controlled study. BMC public health. 9(1), Campos, S., Doxey, J. and Hammond, D. (2011). Nutrition labels on pre-packaged foods: a systematic review. Public Health Nutrition. 14(8), Clegg, S. and Lawless, S. (2008). Comprehension and use of UK nutrition signpost labelling schemes: Scientific Rationale and Design. London: Food Standards Agency. Cowburn, G. and Stockley, L. (2005). Consumer understanding and use of nutrition labelling: a systematic review. Public Health Nutrition. 8(1), European Union (EU) 1169/2011 of October 2011 on the food provision of food information to consumers, amending Regulations (EC) No 1924/2006 and (EC) No 1925/2006 of the European Parliament and of the Council, and repealing Commission Directive 87/250/EEC, Commission Directive 1999/10/EC, Directive 2003/13/EC of the European Parliament and of the Council Commission Directives 2002/67/EC and 2008/5/EC and 2008/5/EC and Commission Regulation (EC) No 608/2004 [2011] OJ L204/18. Feunekes, G., Gortemaker,I., Willems, A., Lion, A. and can de Kommer, M. (2008). Front-ofpack nutrition labelling: testing effectiveness of different nutrition labelling fomrats frontof-pack in four European countries. Appetite. 50, Food Standards Agency (FSA) Qualitative Research to Explore Peoples Use of Food Labelling Information. Available at: [Accessed 15/1/16]. Food Standards Agency (FSA) Open board meeting 11 December 212, Front of Pack Labelling: Progress report and update. Available at: [Accessed 3/1/16]. Food Standards Agency (FSA) Guide to creating a front of pack (FoP) nutrition label for pre-packed products sold through retail outlets. Available at: _FoP_Nutrition_2014.pdf. [Accessed 2/1/15] Food Standards Agency (FSA) Food information Regulations 2014: Summary guidance for food business operators and enforcement officers in Scotland, Wales and Northern 26

27 Ireland. Available at: [Accessed 15/1/16]. Hess, R., Visschers, V. and Siegrist, M. (2012). The role of health-related, motivational and sociodemographic aspects in predicting food label use: a comprehensive study. Public Health Nutrition. 15(3), Lobstein, T., Landon, J., Lincoln, P., Ash, R. and Press, V. (2007). The problems with Guideline Daily Amounts (GDAs) A review of the GDAs and their use for signalling nutritional information on food and drink labels. Available at: assets/reports/nhfgdareport.pdf [Accessed on 1/1/15]. Mackinson, D., Wriden, W. and Anderson, A. (2009). Validity and reliability testing of a short questionnaire developed to assess consumers use, understanding and perception of food labels. European Journal of Clinical Nutrition. 64, Malam, S., Clegg, S., Kirwa, S. and McGinigal, S. (2009). Comprehension and use of UK nutrition signpost labelling schemes [pdf] Available at: Mejean, C., Macoillard, P., Peneau, S., Hercberg, S. and Castebon, K. (2013). Consumer acceptabiligy and understanding of front-of-pack nutrition labels. J Hum Nutr Diet. 26, Ritchie, J. & Lewis, J. (2003). Qualitative Research practice: A guide for social science students and researchers. London: Sage. Roodenburg, A., Seidell, J. and Popkin, B. (2011). Development of international criteria for a front of package food labelling system: the International Choices Programme, European Journal of Clinical Nutrition. 65(11). Scarborough, P., Matthews, A., Eyles, H., Kaur, A., Hodgkins, C., Raats, M. and Rayner, M. (2015). Reds are more important than greens: how UK supermarket shoppers use the different information on a traffic light nutrition label in a choice experiment. International Journal of Behavioural Nutrition and Physical Activity. 12(1), 151. Scientific Advisory Committee on Nutrition (SACN) (2013). Paper for discussion: Adoption of Children s reference intakes for food labelling purposes. Available at: /sacn1305_childrens_ris.pdf [Accessed 15/1/15]. Van Kleef, E., can Trijp, H., Paepa, F. and Fernandez Celemin, L. (2008). Consumer preferences for front-of-pack calories labelling. Public Health Nutrition, 11(2),

28 Appendices 1. Research Tool Questionnaire 2. Raw data - Excel 3. SPSS Outputs 4. Ethical Approval letter 5. Qualitative data 28

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39 Appendix 3 - SPSS Output - Participants ability to identify amount of fat in foods; comparing RI and TLS format (Table 4 in main text). 39

40 SPSS Output - Breakdown of incorrect answers by TLS and RI Group (Table 5 in main text) 40

41 SPSS Output - Participants mean score for ease of identifying healthiness of a product; comparing RI Colour, Colour Wheel and RI formats (Table 6 in main text). 41

42 SPSS Output - Participant s rating for preference of front-of-pack labels; comparing RI and Colour Wheel formats (Table 7 in main text). 42

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44 Appendix 4 Ethics Approval Form 44

45 Appendix 5 - Qualitative Data Arranged by theme Quote ID Theme Question: Tell me more about how, if at all, food labelling effects what foods you purchase? Conscious raising, n=1 Sometimes it catches my eye and makes me ID 05 Conscious raising think about what I am buying Avoidance of reds, n=5 Try and avoid foods with a lot of reds in the ID 02 Avoidance of reds label I try and avoid foods high in sugar especially if ID 07 Avoidance of reds they are red. But I don t look at the labels of the foods I buy all the time like milk, eggs, bread, beans, cheese On days when I m trying to be healthy I look at ID 10 Avoidance of reds the food labels more and choose foods with less reds I m put off when I see something red ID 12 Avoidance of reds It sometimes catches my eye if something is all ID 13 Avoidance of reds red on the label and ill swap it for something else healthier Using food labels to compare foods, n=2 I don t use it all of the time. But sometimes ID 04 Using food labels to compare two foods with the colours Helps to compare food products I try and buy foods with green colours on labels Using food labels to make healthier choices, n=6 I look at the labels for new products. I try to buy low fat health products I try and avoid high fat foods if the packet has lots of red labels. I only look at the label if it is easy to see I always look to see how many calories per portion and try and buy the least calorie food I look out for sugars and fats to see if there are better products. I do not know much about others Sometimes I look when I m being careful about what I eat, but not that often I look at the labels of packets when buying unhealthy foods i.e pizza to try and limit how unhealthy are ID 11 ID 03 ID 08 ID 09 ID 16 ID 06 ID 14 compare foods Using food labels to compare foods Making healthier choices Making healthier choices Making healthier choices Making healthier choices Making healthier choices Making healthier choices Non-influenced, n=1 Doesn t affect what I buy ID 15 Non-influenced 45

46 Misc, n=2 Needs to be clear, factual, and colour coding helps a lot ID 17 Misc I always look at the label ID 01 Misc Question: Tell me more about any issues you may have regarding the user friendliness of food labels? Differing formats, n=1 Different supermarkets have different labels ID 01 Differing formats Interpreting portion sizes, n=4 I don t like it when it says for a portion of 50g when the portion you have is bigger Sometimes I have to calculate how much I m going to eat and the calories in it as the label only gives the calories for a small amount (i.e. large packet of crisps, chocolates, pizza) Per portion isn t always the same amount that id eat so I have to try and work it out On chocolates, the calories are per 3 chocolates rather than being the whole bag! ID 06 ID 07 ID 14 ID 09 Interpreting portion sizes Interpreting portion sizes Interpreting portion sizes Interpreting portion sizes Preference for colour, n=6 Needs to be easy to read, colour helps make it ID 03 Preference for colour quicker I like the colour labels much easier than using ID 04 Preference for colour the table on the pack of the packet On biscuits there is no colour coding just the ID 10 Preference for colour numbers Colours help make it easier to find healthy ID 11 Preference for colour foods I like the colours. It is easy to quickly see if ID 12 Preference for colour something is healthy Colour coding helps a lot ID 17 Preference for colour Size of label, n=3 Sometimes they are too small and I can t see them ID 02 Size of label Sometimes they are too small to read ID 05 Size of label Quite small labels I need my glasses ID 13 Size of label Quantity measurements, n=1 I think all labels should have amount of tsps. Of sugar rather than grams ID 08 Quantity measurements Non label user, n=1 No issues don t really look at them ID 15 Non label user Understanding difficulties, n=1 Can be difficult to understand ID 16 Understanding difficulties Question: What is one thing that you either like or would want to change about food labelling? Mandatory, n=4 46

47 For all products to have it on ID 01 Mandatory Every packet should have it ID 05 Mandatory Have one type of label for all foods ID 11 Mandatory All colour coded ID 17 Mandatory Colour coding, n=3 I find the colour labels very easy ID 04 Colour coding Colour coding on unhealthy food ID 10 Colour coding Keep the colour on the front of the packets ID 12 Colour coding Size, n=2 Make it easier to see bigger ID 02 Size Bigger and bolder ID 13 Size Portion size clarity, n=3 The portion size thing (mentioned above) ID 06 Portion size clarity More realistic portion sizes ID 09 Portion size clarity Per item i.e. A whole pizza rather than per slice. ID 14 Portion size clarity Needs to be realistic Health claims, n=1 If something is low fat but high in sugar it ID 07 Health claims should say low fat and high sugar I like total calories on the food to be shown on ID 16 Health claims the front Quantity measurement, n=1 Make sugar clearer in tpsp of amount of added ID 08 Quantity measurement sugar Nothing, n=1 Nothing ID 15 Nothing Misc, n=1 n/a ID 03 Misc 47

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