Author s response to reviews Title: Use of food labels by adolescents to make healthier choices on snacks: a cross sectional study from Sri Lanka Authors: Ishanka Talagala (drmaheshkeerthi@gmail.com;drishanka@gmail.com) Carukshi Arambepola (carukshi@yahoo.com) Version: 1 Date: 21 Jan 2016 Author s response to reviews: Editor-In-Chief BMC Public Health 21 January 2016. Dear Sir, I am extremely thankful to you and the reviewers for reviewing our manuscript entitled, Use of food labels by adolescents to make healthier choices on snacks: a cross sectional study from Sri Lanka We greatly appreciate the comments made by the reviewers, which were valuable in improving the quality of our paper. According to the comments, we have revised the manuscript where appropriate as shown below. These revisions refer to the manuscript sent with track changes. We hope we have answered all the queries adequately. Yours truly, Dr.IshankaTalagala (Corresponding author) MBBS, MSc(Community Medicine)
Reviewer 1 1. Overall Comments: This is an interesting paper and has the potential to show the understanding of snacks label amongst younger generation affecting their dietary choices; though, additional details in introduction and methods section are needed along with an improvement in the writing style of the entire manuscript. We thank the reviewer. We have done a substantial revision to improve the content and the writing of the manuscript. Specific comments: Abstract: 2. Background: Remove hyphen between non communicable and diseases. During the revision, this sentence has been removed. Line 4 3. Methods: Additional information on the duration of the study, statistical software and tests used for analysis. Please break the first sentence in two. Define proper and improper for better understanding. The suggested additional informationhas been added within the restriction of word limit. First sentence has been broken into two. Proper and improper label users have been defined. Details are given under methods in the main text. 4. Results: Give of participants after majority in first sentence. We have combined the two sentences and madethe correction, as suggested. The majority of all participants a. Clarify in second sentence whether this percentage (61%) is from all participants/ adolescents or males. We have combined the two sentences, so that the percentages now refer to all the participants. b. Second sentence should have on and not of before biscuits Correction made, as suggested. c. Make the last part of second sentence i.e. following their own choice into a new sentence.
We have combined the two sentences, so that the percentages now refer to all the participants. We feel the information given in one sentence has made the content clearer. d. Define most often and good knowledge in next paragraph of results. Good knowledge definition is provided in the abstract as those who scored above the 75th percentile mark (please also refer to lines 92-97). Definition of most often ; we were interested in a grading system to obtain data on the frequency of label reading. Therefore, to make it more comprehend to the participants, we had given the option in lay terms. Please refer to line 121-123 of the text. Due to the limited word count in the abstract, this was not mentioned. e. Conclusions: School based programmes should be more focused. May be giving an example of ongoing school programme in which it can be made a part will make it more clear. We thank the reviewer for pointing this out. We have made the changes as suggested f. Please mention a line on marketing strategies in results section. We have mentioned under results in the abstract that brand names and imported products which are used as marketing strategies by the marketers showed a significant association with the improper label use. However we have modified to make it more clearly to the reader. g. Be consistent in using non- communicable diseases We have made changes accordingly Background 1. Line no. 7-8: Please provide reference. Reference given, as suggested.line 10. 2. I would suggest to rephrase the next lines in this paragraph: starting with the snacks and labels definitions followed by how snacking is common amongst all age groups. This could then lead to the prevalence of snacking amongst adolescents and reasons for same.
We have revised this section, as suggested to ensure the flow and clarity. Lines 11-18 3. Line 11: Give data on how much energy contribution through snacks has increased. We have added this information to the sentence, as suggested. Lines 15-16 4. Line 21-23: May be rewrite it as This involves the practices on frequency of reading labels, attention paid instead of Using the information given on labels involves. We have revised this sentence, as suggested. Lines 25-27 5. Line 24: Rewrite as understanding the use of food/ drink labels to choose snack. We have revised this sentence, as suggested. Lines 37 6. Line 26-32: Kindly rephrase this paragraph, it may be clearer especially in stating the marketing strategies used. Also, I would suggest to use marketing strategies used by manufacturing companies instead of media. We have already mentioned the marketing strategies used. However, were-phrased this paragraph, as suggested for clarity. Lines 31-34. We have also changed to marketing strategies used by the manufacturer instead of media as suggested. Line 30 7. In next lines, please give details on the studies mentioned to make a strong argument in support of the present study. We have rearranged this paragraph, with evidence for a stronger justification. Lines 37-39 8. Objectives: These should be more specifically stated. The objectives in abstract and here are giving different meaning; no mention of how it will influence the dietary practices. We have revised the text to be more specific, as suggested by the reviewer. It is also in line with the one given in the introduction. Lines 42-44 Methods
1. Line 41: Mention Sri Lanka. We have changed accordingly. Line 47 2. Reference missing for school census data. This information was obtained following personal communication with the Education Department of the Colombo district, Sri Lanka. These data are only locally published and circulated within the Ministry of Education of Sri Lanka. Line 49 3. Be consistent in using participants/ adolescents/ students throughout the paper as at some places the authors are using students while at others adolescents has been used. We have used students consistently in the text. 4. Give more details of the study in terms of duration of study; food labels as defined in study; questionnaire used; narking scheme; statistical software used; version and tests applied with level of significance considered. We have revised the text, as suggested. Lines 46,65and 86-103 5. Sample size is 542 or 524? Any drop- outs from study? The calculated required sample size for the study was 524 students. Since, data were collected from all students in each cluster there was a total 542 students included in the study. There were no drop-outs. We have made this clear to the reader in lines 55-57 6. What do you mean by proxy consent? Parent guardian of whom? Were the permission/ consent taken from the schools as well? Please mention Consent was taken from a parent or the guardian of the student and additionally, consent from the students was taken through assent forms prior to data collection. Administrative clearances were obtained from the Director of Education- Western province, Sri Lanka and from the principals of each selected school (please refer to lines 59-63).
7. Give reference for all definitions. Mention the label contents the authors considered in this study. We have revised as suggested. Lines 68-70 and 91-100. The label contents considered were according to the food labelling and advertising regulations of Sri Lanka (please refer to lines 82-84) and detailed contents are shown in table 4. 8. Please explain hypothetical labels. Due to ethical reasons, the actual labels of food items already available in the market could not be used in the study. Therefore, authors created labels hypothetically, of similar snack products that are available in the market.76-78 and 82-83 9. Data analysis section is unclear. Thank you for pointing this out. We have made revisions to make it more clear to the reader. Lines 86-103 Results 1. It would be interesting to look at the list of snacks consumed by adolescents. May be the authors can give a table showing this. The food/drink items consumed by over 60% of the adolescents are already given in the text. All other food items have been consumed in smaller proportions (less than 5% each). Refer to Table 1. 2. Split line no. 72-73 into two sentences. Shift line 74 (all participants.) after the majority consisted of males. We have revised the text as suggested. Lines 108 3. Line 82: Define most of the time As explained above, we were interested in a grading system to obtain data on the frequency of label reading. Therefore, to make it less difficult for the participants, we had given the option in
lay terms in graded responses such as most of the time, rarely. Please refer to lines 77-79 under methods in the text. 4. Please give a table showing the comparison analysis done between males and females. Since this is a sub analysis under practice of food labels, and we felt that the maximum number of tables in the manuscript should be 6, we have given the details in the text. Lines 117-119 5. Line 89: use more than instead of over We have changed accordingly. Line 122 6. Section on interpreting the information on labels for making a healthy choice could be presented as a table only. Please remove so many details from this part which is repetition of table only. We have revised the text accordingly. Lines 127-129 7. Line 123: define good nutrition related knowledge and poor knowledge We have revised accordingly and defined the terms under methods. Lines 91-94 8. A table for the Section on Factors associated with improper use of labels on packaged snacks should be given. We felt that the maximum number of tables in the manuscript should be 6. Therefore, we have shown only the significant factors in tables. We could not show the non-significant factors in tables as suggested by the reviewer but are mentioned in the text. Lines 151-155 and 157-162. Also refer to Table 6 9. Make sure to give p-values at all relevant places (showing associations/ correlations) For the factors which were significantly associated, p values were mentioned along with the factor. Line 167. For factors which were not significantly associated, p values were given collectively as p >0.05. Lines 155 and 162
10. Table 1: Give N in title of table Revised as suggested 11. Table 2: Mention % represented. Define all the frequencies used in table in the footnote. Revised as suggested. 12. Table 3: Mention % represented. Superscript 1 has not been described. We have mentioned the number and the percentage of students based on their selection under each pair of hypothetical food/drink label in Table 3. We have revised it to be clearer to the reader. Superscript 1: Thank you for pointing this out. We have made the revisions 13. Table 4: Give both n and % for each knowledge domain considered Revisions were made as suggested 14. Table 5: Kindly specify whether presented n or % of data. Thank you for pointing this out. We have revised accordingly Discussion 15. May be the authors can give sub- headings in discussion. We thank and appreciate this suggestion. Since giving subheadings might affect the flow of the discussion, it was not changed as suggested by the reviewer 16. Line 163-174: Please give details of the study quoted. Revisions were made as suggested. Lines 180-189
17. Line 169: C should be small in Cola drinks Revised accordingly. Line 188 18. Please rephrase line 171-175. We have revised to make it clearer to the reader. Lines 191-196 19. Line 181: Should have colon instead of semi- colon after self- administered questionnaires Revised accordingly. Line 205 20. Line 190-197: Please give details of study the authors are referring to: may be where these were done and on whom? The text was revised as suggested. Wherever applicable, we have described and discussed the references in detail, in line with the flow of the discussion.lines214-222 21. Line 193: remove p- value Revised accordingly. Line 221 22. The authors can delete line 197. We have removed this statement as suggested by the reviewer 23. Line 203: Is contradictory to what authors stated in introduction (line 2-5) We apologize. We do not understand this comment 24. I would suggest the authors to give example of strategies adopted in developed countries and from other developing countries to increase the use of food labels and their understanding. For example, study done in Europe (FLABEL) did public health campaigns to alert consumers to
nutrition labelling systems; educational programs to promote label understanding. Also, please improve on the discussion section. We have revised as suggested by the reviewer. Line 258-262 25. Please give limitations of the study: bias of self- administered questionnaire, small sample size. The sample size of 542 was adequate (524 was the minimum required size). We have made revisions additing limitations to the text as suggested by the reviewer. Lines 321-329 Conclusions: 26. This should provide what the meaning of the study findings is in terms of improving the use of food labels and healthy dietary choices to decrease the prevalence of NCDs. We have revised the text as suggested by the reviewer 27. I would suggest the author to copy- edit the entire paper. We have done a substantial revision to the entire text as suggested by the reviewer Reviewer 2 1. I found the manuscript difficult to read because of the flow and word choices. I think authors could greatly benefit from having an external English editor review the manuscript and improve wording and flow throughout prior to re-submission. We have done a substantial revision to improve the wordings and the flow of the entire manuscript. 2. The abstract has an acronym (IAB) that should be spelled out because it is not familiar to all readers. Results are including too many % and should be summarized highlighting some key results only.
Acronym Type I AB is explained in under the methods in the main text (Please refer to lines 49-50). This explanation was not included in the abstract due to the limited word count. Under results, we have mentioned only the most relevant findings due to the limited word count. 3. The first paragraph of background information links diet and diet only to NCDs. This needs to be better contextualized as poor diet is one component of individual s increased risk for NCD not the sole factor. I also think that it is important to highlight that snacks are part of a healthy diet among adolescents, especially when linking to the rationale for importance of label reading. We have made the revisions as suggested. Please refer to the lines 4-5 and lines 20-21. 4. Lines 26 32: Authors should provide a short description of label regulations in their country as to help readers understand what students have in hands when reading labels and choosing a product. We have revised accordingly (please refer to lines 40-42). 5. I think the rationale for the sampling method needs to be explained. Two girls and two boys were randomly selected from schools yet gender differences were rarely explored in the results (with a few exceptions, one of them in the discussion rather than results). Data analysis needs to be clearer (word choices) and also include p value. In Sri Lanka male: female student representation in schools is 1:1. Therefore, to make sure of the mutual representation of male students and female students in the study sample, two girls only schools and two boys only schools were selected. Lines 50-52 We apologize; we do not understand this comment made by the reviewer on gender difference. The intention of the investigators was not to assess the gender difference, but it was only checked as a factor that could be associated with the label use. Data analysis: Thank you for pointing this out. We have made revisions to make it more clear to the reader. Lines 86-103
6. What is the relevance of students study stream? Were any other differences explored in the analysis? Were students in sciences more likely to make proper choices? We assumed that students of science stream would be more knowledgeable on reading labels and selecting healthy snack options compared to the non- science stream students, owing to the nutrition related knowledge gained during their subject stream. 7. I would suggest keeping an explanation of table 3 in the text but without duplicating proportions. We have made revisions as suggested. Lines 127-129 8. Clarify sentence between lines 131-133 This explains the attitudes of the students towards the marketing strategies used by the manufacturers in marketing their product. Lines 144-148. Please kindly refer to Table 5 for details. 9. Lines 195 197: this statement would need to be embedded within the context of Sri Lanka culture and with great discretion about the possible impact on the health of females offspring. My suggestion would be to delete this. We have revised the text as suggested and deleted the statement. 10. Overall, this manuscript has potential and strengths in terms sample size and the approach to product selection (with to hypothetical products presented). However, in addition to great improvements to flow and wording, the discussion and conclusion need to explore policy level factors related to marketing, labeling, and food environments. Their results showed what many other studies have shown that knowledge does not translate in healthier choices so would the traffic light system or school programs aimed at students be effective in improving students snacking behaviours? Kocken PL et al., 2015; Olstad & Raine, 2013; and other recent studies in the area of marketing to children could enrich the discussion and take the results to another level that would enhance the significance of this manuscript to the available body literature. We have made substantial revisions to the whole manuscript including the discussion as suggested.