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Effects of different front-of-pack labelling formats on the healthiness of food purchases – a randomized trial.

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Presentation on theme: "Effects of different front-of-pack labelling formats on the healthiness of food purchases – a randomized trial."— Presentation transcript:

1 Effects of different front-of-pack labelling formats on the healthiness of food purchases – a randomized trial

2 Disclosures None

3 Rationale for front-of-pack food labelling
Poor diet the leading cause of disease burden worldwide Nutrient declarations technically informative but difficult for most to use Front-of-pack labelling may facilitate healthier food choices by consumers In 2014 the Australian government commenced implementation of ‘Health Star Rating’ (HSR) system

4 Many possible label formats
Multiple Traffic Lights Health Star Rating Daily Intake Guide Warnings or recommendations

5 Registration and 1 week run-in
Design Randomization HSR MTL DIG WARN NIP Registration and 1 week run-in 1 month follow-up of all packaged food purchases

6 Registration and 1 week run-in
Design Randomization HSR MTL DIG WARN NIP Registration and 1 week run-in HEALTHY CHOICE 1 month collection of all packaged food purchases

7 Flow chart Registered (n=3,638) Randomised (n=1,578) HSR (n=315)
Analyzed (n=262) Items= 31,803 MTL (n=312) Analyzed (n=265) Items= 28,239 DIG (n=319) Analyzed (n=264) Items= 31,655 WARN (n=314) Analyzed (n=260) Items= 28,466 NIP (n=318) Analyzed (n=257) Items= 28,564 Failed one week run-in period (n=2060) Randomised (n=1,578)

8 Analysis Mixed models and analysis of variance
Primary - non-inferiority Secondary - superiority Primary outcome - mean healthiness of packaged foods (nutrient profile score) Secondary outcomes - sugar, sodium, saturated fat, energy density, spend, user perceptions of utility

9 Participant characteristics
All randomised (n=1578) Mean age, years (SD) 37.9 (11.2) Female (%) 83.8 Household income >A$100,000 (%) 39.6 Tertiary education or higher (%) 71.9 Employed (full or part-time) (%) 69.6 Mean number in household (SD) 3.2 (1.4) Mean number in household under 18yrs (SD) 1.0 (1.2)

10 Intervention and outcome metrics
All randomised (n=1578) Run-in (7 days) - Mean shopping episodes (SD) 3.0 (2.8) - Mean food items purchased (SD) 32 (55) Post-randomisation (28 days) 7.8 (7.1) 79 (82) - Mean barcodes scanned (SD) 31 (56)

11 Healthiness of food purchases HSR compared to alternatives
HSR vs. MTL HSR vs. DIG HSR vs. WARN Mean nutrient profile score -0.37 (-1.20, 0.46) 0.68 (-0.14, 1.50) -0.51 (-1.33, 0.32) p non-inferiority <0.001 p superiority 0.38 0.10 0.23

12 Healthiness of food purchases HSR compared to alternatives
HSR vs. MTL HSR vs. DIG HSR vs. WARN Mean nutrient profile score -0.37 (-1.20, 0.46) 0.68 (-0.14, 1.50) -0.51 (-1.33, 0.32) p non-inferiority <0.001 p superiority 0.38 0.10 0.23

13 Healthiness of food purchases HSR compared to alternatives
HSR vs. MTL HSR vs. DIG HSR vs. WARN Mean nutrient profile score -0.37 (-1.20, 0.46) 0.68 (-0.14, 1.50) -0.51 (-1.33, 0.32) p non-inferiority <0.001 p superiority 0.38 0.10 0.23

14 Healthiness of food purchases HSR compared to alternatives
HSR vs. MTL HSR vs. DIG HSR vs. WARN Mean nutrient profile score -0.37 (-1.20, 0.46) 0.68 (-0.14, 1.50) -0.51 (-1.33, 0.32) p non-inferiority <0.001 p superiority 0.38 0.10 0.23 Secondary outcomes – non-inferiority also demonstrated for sugar, saturated fat, energy density and spend (all p<0.05) but not for sodium (all p>0.08)

15 Healthiness of food purchases HSR compared to alternatives
HSR vs. MTL HSR vs. DIG HSR vs. WARN Mean nutrient profile score -0.37 (-1.20, 0.46) 0.68 (-0.14, 1.50) -0.51 (-1.33, 0.32) p non-inferiority <0.001 p superiority 0.38 0.10 0.23 No differences across subgroups (age, gender, education, etc.) except self-reported baseline nutrition knowledge (p=0.001)

16 HSR compared to alternatives
User perceptions HSR compared to alternatives HSR vs. MTL HSR vs. DIG HSR vs. WARN Nutrition knowledge 0.36 (-0.03, 0.75) p=0.07 0.44 (0.06, 0.82) p=0.02 0.25 (-0.13, 0.64) p=0.20 Usefulness of labels -0.01 (-0.52, 0.50) p=0.97 0.76 (0.26, 1.26) p=0.003 0.07 (-0.43, 0.58) p=0.78 How understandable 0.62 (0.19, 1.05) p=0.005 1.02 (0.60, 1.44) P<0.001 0.22 (-0.21, 0.64) p=0.32 Value of having on all food packs 0.44 (0.00, 0.88) p=0.05 0.70 (0.27, 1.13) p=0.002 0.43 (0.00, 0.87) p=0.05 All p non-inferiority <0.001

17 HSR compared to alternatives
User perceptions HSR compared to alternatives HSR vs. MTL HSR vs. DIG HSR vs. WARN Nutrition knowledge 0.36 (-0.03, 0.75) p=0.07 0.44 (0.06, 0.82) p=0.02 0.25 (-0.13, 0.64) p=0.20 Usefulness of labels -0.01 (-0.52, 0.50) p=0.97 0.76 (0.26, 1.26) p=0.003 0.07 (-0.43, 0.58) p=0.78 How understandable 0.62 (0.19, 1.05) p=0.005 1.02 (0.60, 1.44) P<0.001 0.22 (-0.21, 0.64) p=0.32 Value of having on all food packs 0.44 (0.00, 0.88) p=0.05 0.70 (0.27, 1.13) p=0.002 0.43 (0.00, 0.87) p=0.05 All p non-inferiority <0.001

18 HSR compared to alternatives
User perceptions HSR compared to alternatives HSR vs. MTL HSR vs. DIG HSR vs. WARN Nutrition knowledge 0.36 (-0.03, 0.75) p=0.07 0.44 (0.06, 0.82) p=0.02 0.25 (-0.13, 0.64) p=0.20 Usefulness of labels -0.01 (-0.52, 0.50) p=0.97 0.76 (0.26, 1.26) p=0.003 0.07 (-0.43, 0.58) p=0.78 How understandable 0.62 (0.19, 1.05) p=0.005 1.02 (0.60, 1.44) P<0.001 0.22 (-0.21, 0.64) p=0.32 Value of having on all food packs 0.44 (0.00, 0.88) p=0.05 0.70 (0.27, 1.13) p=0.002 0.43 (0.00, 0.87) p=0.05 All p non-inferiority <0.001

19 Healthiness of food purchases Active compared to NIP control
HSR vs NIP MTL vs NIP DIG vs NIP WARN vs NIP Mean nutrient profile score 0.37 (-0.47, 1.21) 0.74 (-0.11, 1.58) -0.31 (-1.15, 0.52) 0.87 (0.03, 1.72) P superiority 0.39 0.09 0.46 0.04 Secondary outcomes: 20 comparisons, one p=0.04 (MTL, sugar) and one p=0.05 (WARN, price), no clear pattern of differences

20 Healthiness of food purchases Active compared to NIP control
HSR vs NIP MTL vs NIP DIG vs NIP WARN vs NIP Mean nutrient profile score 0.37 (-0.47, 1.21) 0.74 (-0.11, 1.58) -0.31 (-1.15, 0.52) 0.87 (0.03, 1.72) P superiority 0.39 0.09 0.46 0.04 Secondary outcomes – 20 comparisons, one p=0.04 (MTL, sugar) and one p=0.05 (WARN, price), no clear pattern of differences

21 Active compared to NIP control
User perceptions Active compared to NIP control HSR vs NIP MTL vs NIP DIG vs NIP WARN vs NIP Nutrition knowledge 0.3 (-0.06, 0.7) p=0.10 -0.02 (-0.4, 0.4) p=0.91 -0.1 (-0.5, 0.3) p=0.60 0.1 (-0.3, 0.5) p=0.70 Usefulness of labels 0.6 (0.1, 1.1) p=0.03 0.6 (0.1, 1.1) p=0.03 -0.2 (-0.7, 0.3) p=0.49 0.5 (-0.01, 1.0) p=0.06 How understandable 0.6 (0.2, 1.1) p=0.004 0.01 (-0.4, 0.5) p=0.96 -0.4 (-0.8, 0.04) p=0.08 0.4 (-0.02, 0.9) p=0.06 Value of having on all food packs 0.3 (-0.2, 0.7) p=0.20 -0.2 (-0.6, 0.3) p=0.51 -0.4 (-0.9, 0.03) p=0.07 -0.1 (-0.6, 0.3) p=0.53

22 Active compared to NIP control
User perceptions Active compared to NIP control HSR vs NIP MTL vs NIP DIG vs NIP WARN vs NIP Nutrition knowledge 0.3 (-0.06, 0.7) p=0.10 -0.02 (-0.4, 0.4) p=0.91 -0.1 (-0.5, 0.3) p=0.60 0.1 (-0.3, 0.5) p=0.70 Usefulness of labels 0.6 (0.1, 1.1) p=0.03 0.6 (0.1, 1.1) p=0.03 -0.2 (-0.7, 0.3) p=0.49 0.5 (-0.01, 1.0) p=0.06 How understandable 0.6 (0.2, 1.1) p=0.004 0.01 (-0.4, 0.5) p=0.96 -0.4 (-0.8, 0.04) p=0.08 0.4 (-0.02, 0.9) p=0.06 Value of having on all food packs 0.3 (-0.2, 0.7) p=0.20 -0.2 (-0.6, 0.3) p=0.51 -0.4 (-0.9, 0.03) p=0.07 -0.1 (-0.6, 0.3) p=0.53

23 Active compared to NIP control
User perceptions Active compared to NIP control HSR vs NIP MTL vs NIP DIG vs NIP WARN vs NIP Nutrition knowledge 0.3 (-0.06, 0.7) p=0.10 -0.02 (-0.4, 0.4) p=0.91 -0.1 (-0.5, 0.3) p=0.60 0.1 (-0.3, 0.5) p=0.70 Usefulness of labels 0.6 (0.1, 1.1) p=0.03 0.6 (0.1, 1.1) p=0.03 -0.2 (-0.7, 0.3) p=0.49 0.5 (-0.01, 1.0) p=0.06 How understandable 0.6 (0.2, 1.1) p=0.004 0.01 (-0.4, 0.5) p=0.96 -0.4 (-0.8, 0.04) p=0.08 0.4 (-0.02, 0.9) p=0.06 Value of having on all food packs 0.3 (-0.2, 0.7) p=0.20 -0.2 (-0.6, 0.3) p=0.51 -0.4 (-0.9, 0.03) p=0.07 -0.1 (-0.6, 0.3) p=0.53

24 Strengths and weaknesses
Randomised, blinded, controlled, large, real-world setting Weaknesses Limited use of smartphone intervention, use of app as surrogate for on-pack labelling, incomplete reporting of purchases, only addresses packaged foods Likely impact Bias towards the null, underestimated or missed real effects

25 In context NZ Starlight trial – AJCN 2017; 105:695-704 n=1,357
HSR vs NIP MTL vs NIP HSR vs NIP Directly comparable methods and outcome evaluations MTL vs NIP

26 Conclusions Strong likelihood that HSR, MTL or WARN will result in healthier food choices than NIP. But not DIG HSR clearly superior to other formats in terms of user perceptions HSR is now the labelling format with the strongest evidence base Australian government choice of HSR was reasonable Modifications that strengthen HSR might improve effectiveness

27 Strengthening the HSR with colours and descriptors
1.5 UNHEALTHY CHOICE 4.5 HEALTHY CHOICE

28 Acknowledgements NHMRC Bupa National Heart Foundation of Australia
Michelle Crino, Elizabeth Dunford, Annie Gao, Rohan Greenland, Nicole, Cliona Ni Mhurchu, Audra Millis, Simone Pettigrew, Gary Sacks, Jacqui Webster, Jason HY Wu

29

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