Countries worldwide have implemented mandatory or voluntary front-of-package nutrition labeling systems. We provide a narrative review of ( a) real-world evaluations of front-of-package nutrition labels that analyze objective sales data and ( b) studies that objectively assess product reformulation in response to a front-of-package nutrition label implementation. We argue that there is sufficient scientific evidence to recommend that governments implement mandatory front-of-package nutrition labeling systems to improvepopulation health. We also present a conceptual framework to describe front-of-package label influence and provide recommendations for the optimal label design, emphasizing that labeling systems should be highly visible and salient, be simple and easy to understand, leverage automatic associations, and integrate informational and emotional messaging. The existing research suggests that Guideline Daily Amount labels should be avoided and that the Health Star Rating and Nutri-Score systems are promising but that systems with warning labels like the one in Chile are likely to produce the largest public health benefits.

Front-of-pack labeling is a cost-effective strategy to decrease population consumption of sodium, sugar, saturated fat, total fat, and trans-fatty acids, considered critical nutrients for chronic disease. Our main objective was to explore the subjective understanding of labels that are currently used internationally among low- and middle-income Mexican consumers. We performed two phases of 10 focus groups with adolescents (13–15 y), young adults (21–23 y), mothers of children 3–12 y, fathers of children 3–12 y and older adults (55–70 y). Seven FOPL were evaluated: Guideline Daily Amounts, Multiple Traffic Light, Chilean Warning labels, Warning labels in Red, 5-Color Nutrition Label, Health Star Rating, and Healthy Choice label. Data was analyzed with a triangulation of researchers using a content analysis, based on three codes: 1) awareness and use of the Guideline Daily Amounts, 2) acceptability, and 3) subjective understanding of labels. Most participants were aware of the Guideline Daily Amounts, however they rarely used it because interpreting the information displayed on the label was too complicated. Health Star Rating, Warning labels, Multiple Traffic Light and the Healthy Choice logo labels were the most understandable, however the acceptability of the The Healthy Choice logo decreased as it did not provide information on specific ingredients. The Warning labels was the only label able to warn about critical nutrients that could represent a health risk. The Warning labels in red was more accepted compared to Warning labels in black. Results show that directive and semi-directive labels, such as Warning labels, Health Star Rating or Multiple Traffic Light, may be better at helping population of low- and middle income make healthier food choices, than non-directive FOPL such as the Guideline Daily Amounts implemented in México. The study results highlight the potential of Warning labels to support decreases in the consumption of critical ingredients in low- and middle-income Mexican consumers.

Background: Front-of-pack (FOP) nutrition labeling is a cost-effective strategy to help consumers make informed and healthier food choices. We aimed to investigate the effect of the FOP labels used in the Latin American region on consumers’ shopping intentions when prompted to make their choices with specific nutrients-to-limit in mind among low- and middle-income Mexican adults (> 18 y).Methods: In this experimental study of an online simulated shopping situation participants (n = 2194) were randomly assigned to one of three labeling conditions: Guideline Daily Amounts (GDA), Multiple Traffic Lights (MTL), or red Warning Labels (WL). Participants were required to view a video explaining how to correctly interpret the assigned label. Primary outcomes were the overall nutritional quality (estimated using the Nutrient Profiling Scoring Criterion [NPSC] and NPSC baseline score) and mean energy and nutrient content of purchases. Secondary outcomes included shopping time variables. We also evaluated the impact of the labels across food categories (ready-made foods, dairy beverages, non-dairy beverages, salty snacks, and breakfast cereals) and sociodemographic subgroups.Results: The MTL and the WL led to a better overall nutritional quality of the shopping cart compared to the GDA (p < 0.05). According to the NPSC score, the WL led to a better nutritional quality across breakfast cereals and salty snacks compared to the GDA (p < 0.05); a similar effect was observed for the MTL among non-dairy beverages (p < 0.05). The MTL and the WL required shorter shopping times compared to GDA (p < 0.05). Across all labeling conditions, the nutritional quality of the shopping cart tended to be lower among those with low income, education and nutrition knowledge levels.Conclusion: WL and MTL may foster healthier food choices in a faster way among low- and middle-income groups in Mexico. To produce an equitable impact among consumers of all socioeconomic strata, efforts beyond simply the inclusion of a communication campaign on how to use and interpret FOP labels will be required.Trial registration: clinicaltrials.gov.NCT04308408Retrospectively registered March 16, 2020.

Background: Front-of-package labelling is a cost-effective strategy to help consumers make healthier choices and informed food purchases. The effect of labels is mediated by consumer understanding and acceptability of the label. We compared the acceptability and understanding of labels used in Latin-America among low- and middle-income Mexican adults.Methods: Participants (n = 2105) were randomly assigned to one of three labels: Mexican Guideline Daily Allowances (GDA), Ecuador’s Multiple Traffic Lights (MTL), or Chile’s Warning Labels (WL) in red. Label acceptability was evaluated through items regarding likeability, attractiveness and perceived cognitive workload. Objective understanding was evaluated by asking participants to select the product with the lowest nutritional quality among three products. We measured the time participants took to choose the product. Differences in label acceptability, understanding and time required to choose a product across labels were tested.Results: Compared to the GDA, a higher proportion of participants liked the MTL and WL, considered them attractive, and with a lower perceived cognitive workload (p < 0.05). Participants had 4.00 (2.86–5.59) times the odds of correctly identifying the product with the lowest nutritional quality when using the MTL label and 4.52 (3.24–6.29) times the odds when using the WL, in comparison to the GDA. Time required to choose the product was lower for the MTL (Median: 11.25 s; IQR = 8.00–16.09) and the WL (Median = 11.94 s, IQR = 8.56–16.52) compared to the GDA (Median: 15.31 s; IQR = 10.81–20.21;p < 0.05). No differences were observed between the MTL and the WL.Conclusions: GDA had the lowest acceptability and understanding among the labels tested. The MTL and the WL were more accepted and understood, and allowed low- and middle-income consumers to make nutrition-quality related decisions more quickly. WL or MTL may foster healthier food choices in the most vulnerable groups in Mexico compared to the current labelling format.

Background: Obesity and chronic diseases could be prevented through improved diet. Most governments require at least one type of food labeling system on packaged foods to communicate nutrition information and promote healthy eating. This study evaluated adult consumer understanding and use of nutrition labeling systems in the US and Mexico, the most obese countries in the world. Methods: Adults from online consumer panels in the US (Whites n = 2959; Latinos n = 667) and in Mexico (n = 3533) were shown five food labeling systems: 1. Nutrition Facts Table (NFT) that shows nutrients of concern per serving; 2. Guideline Daily Amounts (GDA) that shows levels of nutrients of concern; 3. Multiple Traffic-Light (MTL) that color codes each GDA nutrient (green = healthy; yellow = moderately unhealthy; red = unhealthy); 4. Health Star Rating System (HSR) that rates foods on a single dimension of healthiness; 5. Warning Label (WL) with a stop sign for nutrients present in unhealthy levels. Participants rated each label on understanding (“easy”/“very easy to understand” vs “difficult”/“very difficult to understand”), and, for NFTs and GDAs, frequency of use (“sometimes”/“often” vs “never”). Mixed logistic models regressed understanding and frequency of use on indicators of labeling systems (NFT = ref), testing for interactions by ethnicity (US Latinos, US Whites, Mexicans), while controlling for sociodemographic and obesity-related factors. Results: Compared to the NFT, participants reported greater understanding of the WL (OR = 4.8; 95% CI = 4.4–5.3) and lower understanding of the HSR (OR = 0.34, 95% CI = 0.31–0.37) and the MTL (OR = 0.56, 95% CI = 0.52–0.61), with similar patterns across ethnic subgroups. Participants used GDAs less often than NFTs (OR = 0.48; 95%CI = 0.41–0.55), with the greatest difference among US Whites (OR = 0.10; 95%CI = 0.07–0.14). Conclusions: Understanding and use of the GDA was similar to that of the NFT. Whites, Latinos, and Mexicans consistently reported the best understanding for WLs, a FOPL that highlights unhealthfulness of a product. Therefore, a FOPL summary indicator, such as WLs, may be more effective in both the US and Mexico for guiding consumers towards informed food choices.

Background: Physical activity (PA) surveillance, policy, and research efforts need to be periodically appraised to gain insight into national and global capacities for PA promotion. The aim of this paper was to assess the status and trends in PA surveillance, policy, and research in 164 countries. Methods: We used data from the Global Observatory for Physical Activity (GoPA!) 2015 and 2020 surveys. Comprehensive searches were performed for each country to determine the level of development of their PA surveillance, policy, and research, and the findings were verified by the GoPA! Country Contacts. Trends were analyzed based on the data available for both survey years. Results: The global 5-year progress in all 3 indicators was modest, with most countries either improving or staying at the same level. PA surveillance, policy, and research improved or remained at a high level in 48.1%, 40.6%, and 42.1% of the countries, respectively. PA surveillance, policy, and research scores decreased or remained at a low level in 8.3%, 15.8%, and 28.6% of the countries, respectively. The highest capacity for PA promotion was found in Europe, the lowest in Africa and low- and lower-middle-income countries. Although a large percentage of the world’s population benefit from at least some PA policy, surveillance, and research efforts in their countries, 49.6 million people are without PA surveillance, 629.4 million people are without PA policy, and 108.7 million live in countries without any PA research output. A total of 6.3 billion people or 88.2% of the world’s population live in countries where PA promotion capacity should be significantly improved. Conclusion: Despite PA is essential for health, there are large inequalities between countries and world regions in their capacity to promote PA. Coordinated efforts are needed to reduce the inequalities and improve the global capacity for PA promotion.