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RESEARCHOVERVIEW2018 EDITION

Overview of Key Scientific Research Results on the Choices Programme and Positive Front-of-Pack Labelling

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Table of Contents1 Background on the Choices Programme 3

2 Introduction to this document 4

3 Impact of the Dutch Choices logo on product development and innovation 43.1 Impact on product composition 4

3.2 Impact on expected and actual taste perception 4

4 Impact of the Choices logo on consumer behavior 54.1 Impact of the Choices logo on purchasing behavior in the supermarket 5

4.2 Impact of the Choices logo in out-of-home settings 5

4.3 Impact of the Choices logo on consumption and product appreciation 5

4.4 Consumer surveys on the Choices logo 6

5 Potential impact of the Choices logo on diet, nutrient status and biomarkers: modelling studies 7

5.1 Potential impact of the Choices logo on nutrient

intakes 7

5.2 Potential impact of the Choices logo on cholesterol 8

6 Implementation evaluations of the Choices logo 96.1 Health claims categorized as symbols 9

7 Stakeholder perceptions on the Choices logo 97.1 Positions and perceptions of health policy leaders in Israel 9

8 Other applications of the Choices nutrition criteria 108.1 Applications for taxation 10

8.2 Label claims on fine bakery wares 10

9 Multiple models: research on other FOP programs 109.1 Evidence on consumer use is promising, but more research is needed 10

9.2 Is simpler better? 12

9.3 Understanding and credibility 12

9.4 Effect on product reformulation and consumer recognition 12

9.5 Potential effect on nutrient intake 12

9.6 Potentially greater impact when part of a comprehensive program 12

10 Summary of research findings 13

11 References 14

RESEARCH OVERVIEWFebruary 2018

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1 Background on the Choices

ProgrammeIn 2004, in an effort to stem the rising

tide of non-communicable diseases, the World Health Organization (WHO) called upon the food industry to help make healthy choices more available and easier for consumers to select. In

response, the Choices International Foundation was formed in 2006 with

three fundamental objectives:

To achieve these objectives, the Choices International Foundation relies upon a set of product-group-specifi c nutrition criteria, developed using independent science and international dietary guidelines as their basis.(1) The criteria can be used as benchmarks for product reformulation, healthy product offerings and front-of-pack labelling. Products that meet the Choices criteria are eligible to carry the Choices logo or, in some cases, another locally-relevant logo.

The criteria are periodically reviewed and revised by an International Scientifi c Committee, comprised of leading independent scientists with backgrounds in nutrition, food technology and consumer science. The methodology behind the product criteria was published in the European Journal of Clinical

Nutrition in 2011.(2) Food composition data were used to develop nutrient criteria and calculate the potential impact of the Choices Programme. Further details regarding the role of the Choices Programme, as well as the characteristics and availability of databases for its substantiation, have also been published.(3)

To encourage food companies to improve the composition of their products, thereby increasing the availability of healthier foods and beverages

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To help consumers quickly identify healthier options when making food purchases

To encourage healthy product promotion.

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3

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2 Introduction to this documentIn parallel to the Programme’s development and imple-

mentation, there has been ongoing independent scientifi c

research into the effects of the Choices logo. In the Neth-

erlands, the fi rst country to introduce the Choices logo,

Professor Jaap Seidell and his team at the VU University

Amsterdam studied the effects relating to the introduction

of the “Ik Kies Bewust-logo” (i.e. the Dutch version of the

Choices-logo, subsequently called ‘het Vinkje)’.

More recently, this research – in conjunction with other

studies – has yielded important information about positive

front-of-pack (FOP) logos and their effects on consumers

and producers. This document provides an overview of

the relevant studies on Choices as well as other positive,

interpretative FOP logo programs.

3 Impact of the Dutch Choices logo on product development and innovation3.1 Impact on product compositionOne of the aims of the Choices

Programme is to stimulate product

innovation towards healthier

products. As such, a study was

conducted in the Netherlands to

determine whether the Choices

logo encouraged the development

of healthier products.(4) Companies

participating in the Dutch Choices

Programme were asked to provide

data on the composition of old and

new products, which were then

assessed to determine the extent

to which new or reformulated

products have an improved com-

position in comparison to similar

products or replacement products.

For reformulated products, the

results indicated a signifi cant reduc-

tion in sodium, saturated fat and

added sugar in certain products. For

example, the sodium in reformu-

lated soups was reduced by 14%,

added sugar in dairy was reduced by

75% and saturated fat reduced by

30%. Fruit juice also had 53% more

fi ber. In newly-developed products,

sodium, saturated fat and added

sugar were often reduced compared

to similar products (e.g.sodium in

processed meats, by 38%, saturated

fat by 46%), while the sandwiches

had 24% less sodium and 33% more

fi ber (fi gure 1).

3.2 Impact on expected and actual taste perceptionOther research examined the

expected and perceived saltiness

and liking of soups with different

expressions on the label.(5) Next

to a control label, the following

three conditions were compared

to each other: 1) the Dutch Choices

logo; 2) a reduced-salt claim; and 3)

a Choices logo and a reduced-salt

claim together. The results suggest-

ed that consumers expected the

salt taste intensity (P < 0.001) to be

lower when the label stated ‘‘now

reduced in salt’’, compared to the

soup without such a label. Further-

more, consumers expected to like

the soup with the Choices logo

more than the same soup with both

the logo and the ‘‘now reduced

salt’’ label (P = 0.1). After consumers

tasted the soups, no differences in

liking or desire were found between

the soups with the different labels.

æ

ä

SOUPS

FRUIT JUICE

SANDWICHES

14% LESS SALT

53% MORE FIBER

24% LESS SODIUM

33% MORE FIBER

ææ

PROCESSED MEATS38% LESS SODIUM

46% LESS SATURATED FAT

FIGURE 1: POTENTIAL IMPACT OF CHOICES LOGO ON PRODUCT COMPOSITION IN THE NETHERLANDS

NEWLY-DEVELOPED PRODUCTS

æ

ææ

DAIRY75% LESS SUGAR

30% LESS SATURATED FAT

ä

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4 Impact of the Choices logo on consumer behavior4.1 Impact of the Choices logo on purchasing behavior in the supermarketThree studies specifi cally address the effect of the Choices

logo on consumer behavior in the supermarket:

Two recent studies, part of the

EU-funded CLYMBOL research

project, examined purchasing

behavior of consumers in the

Netherlands and Denmark. Prelim-

inary results, based on observed

purchase data, show that positive

FOP logos may drive purchasing

decisions. Researchers compared

data before and after the launch

of Choices and Keyhole logos

(fi gure 2) in the Netherlands and

Demark, respectively. They found

that average consumers in both

countries may be willing to pay

more for products displaying the

logo, suggesting the logos provide

valuable information. Preliminary

data show that consumers in the

Netherlands responded positively

to this guidance and increased

their purchases of Choices logo-bearing products. Data

may also suggest that the logo may have a greater

effect in product groups containing a mix of “healthy”

and “unhealthy” products, where additional consumer

guidance is needed.(6) These studies will be published in

peer-reviewed journals in the course of 2018.

A previous study examined actual use of the Choices logo.

(7) Approximately 400 supermarket shoppers were inter-

viewed after purchasing groceries regarding their attitudes

towards healthy eating. Researchers also recorded the

number of products the shoppers purchased bearing the

Dutch Choices logo. Results showed that respondents who

reported consciously buying products bearing the logo

bought more of these products than those who indicated

not consciously buying products with the logo. Respon-

dents with an awareness of health, weight and nutritional

information actively bought more products carrying the

logo, while respondents who considered food enjoyment

as important bought fewer items bearing the logo.

Another study, by the Dutch Agri-economic Institute

(LEI), evaluated the extent to which the addition of the

Dutch Choices logo to existing products, as well as the

introduction of new products carrying the logo in specifi c

product groups, affected purchases of these products. An

impact was perceived, but it is unclear to what extent it

can be attributed solely to the use of the logo on these

products. Furthermore, it was observed that within some

product groups, there was an increased market share of

logo-bearing products.(8)

4.2 Impact of the Choices logo in out-of-home settingsResearch conducted in 25 workplaces within the

Netherlands concluded that the Dutch Choices logo

did not have a notable effect on the sale of healthier

lunch foods, but may help employees opt for a healthier

selection.(9) Over a nine-week period, sales data from 13

cafeterias using the Choices logo were compared daily

with 12 control cafeterias offering the same non-logo

menu. In addition, 368 employees completed an online

questionnaire, both at the beginning of research and

following the period during which the logo was used. The

results did not demonstrate a nutritionally meaningful

effect on the sale of sandwiches, soups, snacks, fruit and

salads. Nevertheless, the questionnaire data showed that

health-conscious employees might fi nd the healthy choice

labelling useful.

In another experiment, conducted in a full-service restau-

rant setting, consumer response to nutrition information

on menu items was measured in order to subsequently

determine if consumers use this information to select their

menu items.(10) The experiment was conducted with 264

restaurant customers at a full-service, a-la-carte restaurant.

In the menu, the Dutch choices logo was explained to the

clients. Customers could choose from menu items carrying

the Dutch Choices logo, and comparable ones not carrying

the logo. Fifty-four percent of restaurant customers opted

for the Choices menu item. Logistic regression confi rmed

that people who desire nutritional information also

use this information in their choice of menu. The study

concluded with recommendations for the industry to direct

consumers toward healthier menu items.

4.3 Impact of the Choices logo on consumption and product appreciationSteenhuis, et al evaluated whether the “Ik Kies Bewust”

(Dutch Choices) logo had an effect on the amount of cake

consumed or taste appreciation by young women.(11) The

results indicated that a cake bearing the logo was not per-

ceived as healthy, but rather, as less unhealthy than a cake

which didn’t carry the logo. Furthermore, the presentation

FIGURE 2: CLYMBOL STUDY ON CHOICES AND KEYHOLE LOGOS

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of the cake with the Choices logo did not produce an

increased consumption of cake, or a different appreciation

of the taste.

4.4 Consumer surveys on the Choices logoBefore the launch of the “Ik Kies Bewust” logo, a baseline

measurement was taken. Annual surveys were then

conducted by global market research company GfK on

behalf of the Choices International Foundation in the form

of an internet survey among a representative sample (n>

1000) of the Dutch population. The most recent consumer

survey, reported here, took place in September 2013. To

interpret the results, it is important to note that the logo

in its most recent dual appearance (with a green or blue

circle around) and with the new name “Vinkje”, had not

been on the market long. The new logo gradually replaced

the old logo between 2011 and 2013. The survey took place

following the fi rst phase of a communication campaign to

introduce the new logo to the public.

Results revealed the following (fi gure 3):

• Over 90% recognized the logo (aided recognition)

• Over 50% found the logo (very) credible, 11% (very)

incredible

• In the Netherlands, the logo existed in two colors: green

for basic products (according to the Dutch Choices criteria)

and blue for non-basic food groups, like snacks, soups and

sugary drinks. One third of respondents said they knew

the difference between the logos, but when asked for an

explanation, only one third of them explained it correctly.

Many others, though, did link the logo with health or a

healthier variant within a product group.

• Around half of the interviewees claimed to pay attention

to the logo when shopping, and sometimes or often a

purchased a product because it had the logo.

• Over 50% of the interviewees were willing to pay some-

what more for a product with the logo.

An earlier Dutch GfK survey based on focus group interviews

(performed by employees of the VU University Amsterdam

provided a qualitative and quantitative process evaluation

of the introduction of the Choices logo.(12) Four months

after the logo introduction, consumers reported increased

exposure and those interested in health reported using it.

Elderly and obese consumers reported being more in need of

the logo than their counterparts who were younger or had

normal weights. Women found the logo to be more credible

and attractive than men did, prompting the researchers to

speculate that raising awareness of logo use by government

and scientifi c authorities could improve program credibility.

RECOGNITION

FIGURE 3: CONSUMER ATTITUDES ABOUT THE DUTCH CHOICES LOGO

ATTENTION

CREDIBILITY

VALUE

90% RECOGNIZED THE LOGO (AIDED RECOGNITION)

50% OF THE INTERVIEWEES CLAIMED TO PAY ATTENTION TO THE LOGO WHEN SHOPPING, AND SOMETIMES OR OFTEN A PURCHASED A PRODUCT BECAUSE IT HAD THE LOGO.

50% FOUND THE LOGO (VERY) CREDIBLE, 11% (VERY) INCREDIBLE

50% OF THE INTERVIEWEES WERE WILLING TO PAY SOMEWHAT MORE FOR A PRODUCT WITH THE LOGO.

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5 Potential impact of the Choices logo on diet, nutrient status and biomarkers: modelling studies5.1 Potential impact of the Choices logo on nutrient intakesCurrently, fi ve different studies have addressed the poten-

tial impact of Choices on nutrient intakes. Three of these

studies relied on data from the Netherlands, one included

data from seven different countries worldwide and one

studied the impact of a Choices-compliant diet in Brazil.

The fi rst study calculated the expected effect on the

daily diet of the Dutch population if regularly consumed,

non-compliant products were to be replaced with products

bearing the “Ik Kies Bewust” logo.(13) The replacement of

regular products with products bearing the Dutch Choices

logo resulted in a 15% decrease in energy intake, a 63%

decrease in trans fatty acids, a 40% decrease in saturated

fatty acids, a 36% decrease in sugar and a 23% decrease

in sodium. Furthermore, increases in the intake of fi ber

(28%), calcium (17%), iron (13%) and folic acid (5%) were

predicted. The authors therefore concluded that the

Choices Programme has the potential to have a substan-

tially positive impact on the diet of the Dutch population.

Another study derived the average intakes of energy,

trans fatty acids, saturated fatty acids, sodium, added

sugar and fi ber from dietary intake studies and food

consumption surveys in seven countries: The Netherlands,

Greece, Spain, the USA, Israel, China and South Africa

(fi gure 4).(14) For each of these key nutrients, the average

intakes were translated into three Typical Daily Menus per

country. Average intakes based on these three menus were

compared with average intakes from three Daily Choices

Menus. To compose the Choices Menus, foods from the

Typical Menus that did not comply with the Choices

criteria were replaced with compliant foods available

on the market. Comparison of intakes from the Choices

Menus with the survey data demonstrated that calculated

intakes of each of the key nutrients decreased, except for

fi ber intake, which increased. This shows that the Daily

Menu Method allows a quantitative look at the calculated

changes that sets of nutrient criteria - such as those of

the Choices Programme - can have on a country’s nutrient

intake. Furthermore, it confi rms that the criteria that have

been set for Choices are strict enough to potentially move

intakes into a direction that is more favorable for health.

A study based on the Dutch food consumption survey of

2003 calculated the impact of substituting regular products

with those bearing the Dutch Choices logo.(15) According

FIGURE 4: CALCULATED IMPACT ON MACRONUTRIENT INTAKE

100%

80%

60%

40%

20%

0%

-20%

-40%

-60%

-80%

-100%

THE NETHERLANDS ISRAEL BRAZIL

ENERGY DIETARY FIBERSAFA SODIUMTRANS-FATTY ACIDS

!"#$%%&'()*+,# -.%/ 0(' 1233

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to the market share of Choices products in 2007, a small

reduction in saturated fatty acids and sugar intake can be

achieved, while a maximal 100% substitution produces a

greater reduction (23% - 40%) of saturated fatty acids,

sodium or sugar intakes.

A Brazilian modelling study showed that replacing typical

Brazilian foods by Choices criteria-compliant products

may improve Brazilian diets by substantially decreasing

unfavorable nutrients while increasing dietary fiber.(16)

Replacing typical products from the Brazilian menu by

products complying with the Choices criteria, resulted in

a decrease of 52% in saturated fatty acids, 92% of trans

fatty acids, 14% of energy and 47% of sodium. Dietary

fiber increased by 87%. As data on key nutrients were

incomplete in the Brazilian food composition database,

the scientists created a new database by collecting infor-

mation from food labels, resulting in a catalog of 1720

industrialized products. Data on sugar or added sugar

were not sufficiently available to evaluate.

Data from another modelling study in a Dutch young adult

population also show potential beneficial effects of Choic-

es on energy and nutrient intakes, plus unintended effects

on fat soluble vitamins as well (figure 5).(17) Calculated in-

take distributions showed that median energy intake was

reduced by 16% by replacing normally consumed foods

with Choices compliant foods. Intakes of nutrients with

a maximal intake limit were also reduced (ranging from

-23% for sodium and -62% for TFA). Effects on intakes of

beneficial nutrients varied from an increase of 28% for

fiber and 17% calcium to an unintentional reduction in

fat soluble vitamin intakes (-15 to -28%). The estimated

reduction of fat-based beneficial nutrient intakes can be

attributed to replacement of high-fat foods by alternatives

with a better fat quality or lower energy content. The

authors recommend studying this effect in more detail.

Nonetheless, it is concluded that for the nutrients used in

the Choices benchmarks, intakes shift substantially in a

beneficial direction when people consume Choices-compli-

ant foods. By choosing healthier options in each product

category, consumers could have substantially healthier

diets that are more in line with the WHO recommenda-

tions. The effect on fat-soluble vitamins should be taken

into account when this kind of criteria are considered to

implement mandatory.

These five studies show that nutrient intakes would move

substantially into a favorable direction when typical menus

are replaced by Choices compliant menus, although the

size of the effect depends on the local situation. Also,

they show that the Choices criteria are equally applicable

in non-European countries, like Brazil, even without

the adaptations and adjustments allowed for local food

FIGURE 5: CALCULATED IMPACT ON MICRO-NUTRIENT INTAKE IN YOUNG ADULTS (NL)

50

40

30

20

10

0

-10

-20

-30

-40

CALCIUM

CHANGE OF MEDIAN MICRONUTRIENT INTAKES (%)

IRON

FOLATE

POTASSIUM

VITAMIN A

VITAMIN B1

VITAMIN B2

VITAMIN B6

VITAMIN B12

VITAMIN C

VITAMIN D

VITAMIN E

RELATIVE CHANGE CHOICES (%) RELATIVE CHANGE CHOICES ENERGY ADJUSTED (%)

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6 Implementation evaluations of the Choices logoA study was conducted to investigate which factors influence the implementation of the Dutch

Choices logo in company canteens in the Netherlands.(19) Surveys were sent to 634 managers

of Dutch company canteens that are members of Sodexo or Albron, with a total of 316

completed replies. To encourage the implementation of the logo, it is important for catering

managers to consistently strive for healthy eating. The time it takes to produce freshly pre-

pared products complying with the Choices criteria should also be limited. Finally, it could be

recommended to include the Dutch Choices logo in the (health) policy of caterers, to further

encourage the implementation of the logo in company canteens within the Netherlands.

6.1 Health claims categorized as symbolsThe EU-funded CLYMBOL project, which ran from 2012 to 2016, researched consumer

understanding of symbols and claims, as well as how they affect purchasing behavior. Symbolic

general health claims, such as the Dutch Choices logo, were included in the research. The

authors found significant variation by country, with respect to the graphical appearance of

the logo as well as the goals and underlying principles (20).

7 Stakeholder perceptions on the Choices logo7.1 Positions and perceptions of health policy leaders in IsraelThis study aimed to examine positions and perceptions of 15 leading Israeli dietitians and health

officials regarding nutrition labelling and the Choices logo, before the planned launch in Israel in

February 2011, as well as how they would communicate it to the public as agents of influence.(21)

The study involved in-depth face-to-face and telephone interviews using semi-structured proto-

cols. The respondents considered that the nutrition facts panels usually found on the backs of

packages are too complicated for the average consumer. Similarly, fronts of packages are cluttered

with advertisements and health claims, causing confusion. The study participants would like to see

an integrative label on the front of the package to facilitate consumers’ decisions.

The results of the present study highlight the importance of a need for an integrated

programme of nutrition promotion, including the use of social marketing based on a

cooperative effort between the food industry, regulators and professionals, to recommend

changes and adjustments in nutritional front of package labelling with the aim of promoting

healthier nutrition consumption.

patterns. The recently-shown unintended effect on

fat-soluble vitamins deserve attention, but mainly when all

products would be Choices compliant, for example when

the Choices Programme would be obligatory.(2, 13, 15-17)

5.2 Potential impact of the Choices logo on cholesterol Modelling was also used to predict the potential impact

of a diet consisting of Choices-compliant products on

cholesterol levels (18) After replacing all non-compliant

products with compliant products (maximum scenario), the

saturated fatty acids median intake reduced from 14.5 to

9.8%. Trans-fatty acids reduced from 0.95 to 0.57%. The

average predicted changes in low-density lipoprotein (LDL)

and total cholesterol levels were -0.25 and -0.31 mmol/l,

respectively. As high-density lipoprotein (HDL) cholesterol

levels decreased as well (-0.05 mmol/l), overall, the result

was a slightly favorable change in the total cholesterol/

HDL ratio (-0.03).

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8 Other applications of the Choices nutrition criteria8.1 Applications for taxationA study was conducted to examine the effectiveness

of varying taxing and subsidizing schemes to stimulate

healthier food purchases.(22) In this study, the Choices

criteria were used to select the healthier foods. The

authors concluded that price decreases are effective in

stimulating healthy food purchases, but the proportion

of healthy foods remains unaffected. Price increases up to

25% on unhealthier products did not signifi cantly affect

food purchases.

8.2 Label claims on fi ne bakery waresSets of nutrient criteria can be applied to identify fi ne

bakery wares with a signifi cantly better nutritional

composition than the average range of products. More

than 200 commercially available fi ne bakery wares carrying

claims were identifi ed in Germany, France, Spain, Sweden

and United Kingdom.(23) These were evaluated against

fi ve sets of nutrient criteria. Total energy, saturated fatty

acids, sugars, sodium and fi ber were critical parameters for

the categorization of products, with the Choices criteria

being the most restrictive model in this category. Different

sets of criteria for subcategories of fi ne bakery wares did

not seem necessary.

9 Multiple models: research on other FOP programsSince the introduction of nutrition labelling models,

numerous studies have focused on consumer understanding

and effectiveness of different labelling schemes, including

how single, interpretive, positive logos compare with traffi c

lights or GDA-like labelling systems. This chapter highlights

some of the research on other FOP programs, including

some studies comparing these systems to Choices.

9.1 Evidence on consumer use is promising, but more research is neededA comprehensive overview and evaluation of the quality

of the methodology was presented in a review study.

(24) The authors concluded that, at the time, few

methodologically-sound studies were available and there

was a need to measure the health effects of FOP labels

in a real-life setting, using biomarkers in a longitudinal,

randomized controlled design. Very little new evidence

has been added to the published literature since this

conclusion was made in 2014, illustrating the need for

more research in this important area.

However, more recently a between-subjects experiment

of over 160 supermarket shoppers in the United States

sought to determine effectiveness of a FOP label in

aiding consumers in their assessment of the nutrient

density of various products. Researchers concluded

that Facts up Front labels (offering various levels of

nutrient information) and the Health Check FOP label

(interpretative check mark label with no nutrient

information) were effective for nutrition assessment of

snack products compared with products with no label.(25)

A web-based study tested consumer understanding of

different FOP labelling systems.(26) Adult participants (N

= 480) were randomized to one of fi ve groups to evaluate

FOP labels: 1) no label; 2) multiple traffi c light (MTL);

3) MTL plus daily caloric requirement icon (MTL+caloric

intake); 4) traffi c light with specifi c nutrients to limit

based on food category (TL+SNL); or 5) the Choices

logo. Total percentage correct quiz scores were created

refl ecting participants’ ability to select the healthier of

two 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. The fi ndings suggest that both the Choices

and MTL+ caloric intake labels have limitations but that

overall, they perform similarly in educating the consumer.

A new model was developed to compare and visualize

existing front-of-pack nutrient profi ling schemes.(27) They

identifi ed 40 of these front-of-pack systems currently in

use. The various systems are found on all continents, most

of them initiated in North America. 90% of the systems

have criteria based on thresholds, only a few use a scoring

approach. More disqualifying than qualifying criteria are

used. The disqualifying ingredients most often used are

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FIGURE 6: FOP LOGO RELATIVE PLACEMENT: POSITIVE/NEGATIVE AND SIMPLE/COMPLEX Developed in collaboration with the Global Food Research Program of the University of North Carolina

SCANDINAVIA

CROATIA

????????

NIGERIA

THAILAND

AUSTRALIA

SINGAPORE

FRANCE????

THE NETHERLANDS/BELGIUM

MALAYSIA

CHILE

GLOBAL

Negative Positive

For IRI, 25-9-2017

Sim

ple

Co

mp

lex

LOW Fat7.7g per serving

LOW Saturates2.0g per serving

HIGH Sugars42.2g per serving

MED Salt2.0g per serving

LOW Fat7.7g per serving

LOW Saturates2.0g per serving

HIGH Sugars42.2g per serving

MED Salt2.0g per serving

saturated fatty acids (SFA), total fat, trans fatty acids

(TFA), sugar, sodium, energy and cholesterol. Dietary

fi ber is the most frequently used qualifying ingredient in

the FOP- systems. The funnel model provides an easy-to-

use overview of the differences and similarities between

systems like Choices, Keyhole, Heart logos, single-color or

color-coded GDA and many more, based on eight different

characteristics.

Eye-tracking studies were used to measure whether and

how attention to nutrition information mediates consum-

ers’ choice.(28) The study demonstrates that color-coded

and monochrome GDA’s result in more attention and

more product selection compared to the Choices logo. This

effect can be explained by the time it takes the consumer

to process the labelling information. The authors there-

fore propose to distinguish between attention-getting

and attention-holding properties of the nutrition label

format. As the Choices logo has a simple format, the

attention-holding time might be lower compared to GDAs.

However, authors did not state how many of the studied

persons did know the meaning of the Choices logo or if

the logo was explained. The study concludes that studies

in real shopping environments are needed. The authors

suggest that it is not unlikely that these studies might

demonstrate that a simple logo such as Choices could have

more infl uence on consumer choice.

However, a systematic literature review of various FOP

formats suggested that consumers prefer different systems

depending on their dominant method of processing

information, which refl ects their personal variables

12

(nutrition knowledge, time pressure, motivation). These

authors called for more “real-life” research to understand

this important interplay.(29)

9.2 Is simpler better?Other experiments to compare programs were conducted

in the past. For example, a comparison of simple logos,

such as the Choices logo, with more complex labelling

systems, such as traffi c lights and GDA, was made in 2008.

(30) The authors found that simple logos (including the

Choices logo) were found to require less time to interpret,

making them more suitable for use in supermarkets, where

people must make rapid decisions about which products to

purchase. Figure 6 represents relative comparison of some

FOP logos based on positivity/negativity and simplicity/

complexity.

9.3 Understanding and credibilityQualitative research on Australian consumers around

the National Heart Foundation’s (NHF) Tick program – in

place for more than 25 years – showed that consumer

awareness and understanding of the program was high.

However, views have been mixed over the program’s role

and credibility in light of certain commercial licensing

agreements.(31)

9.4 Effect on product reformulation and consumer recognitionStimulating reformulation while providing consumer

guidance is no small feat. Recently, technology-based data

collecting initiatives have been recommended in order

to achieve both goals of most FOP programs: stimulating

improvements in product composition while providing

consumers with understandable guidance.(32)

In New Zealand’s NHF Tick program, research shows that

the program and FOP logo do have a positive impact on

the food supply, motivating manufacturers to reformulate

and innovate towards products with better nutrient

profi les. Over time, researchers stressed that these changes

will likely result in improvements in population nutrient

intakes and reduced risk for cardiovascular disease.

(33) In fact, this same group of researchers found that

the presence of the Tick “infl uenced food companies

to remove approximately 16 tonnes of salt through the

reformulation and formulation of 52 Tick-approved

breakfast cereals, edible oil spreads, cooking sauces and

processed poultry products.” In addition, companies

reported additional programs targeting reformulation

and as well as increased consumer interest in healthier

products, reinforcing the credibility and effectiveness of

the Tick on local consumers.(34)

When the Heart Check, a voluntary nutrition labelling

program by the Heart and Stroke Foundation of Canada,

was studied for its use in restaurants, researchers found

that consumers noticed the logo and used nutrition

information during meal selection at greater rates

compared to consumers in restaurants that did not use

the Heart Check. However, due to menu complexities,

researchers were unable to decipher whether the

restaurants using the Heart Check had more favorable

nutritional profi les compared with restaurants not using

the Heart Check.(35)

A study about adolescent attitudes around snacks with

nutrition labels in Norway showed that the Keyhole sym-

bol increased health perceptions without infl uencing taste

perceptions. Researchers commented that these fi ndings

illustrated the Keyhole’s importance in promoting healthy

snack choices among adolescents.(36)

9.5 Potential effect on nutrient intakeIn Finland, researchers examined the potential effect

revising food compositions according to the national Heart

Symbol criteria would have on fat, sugar, sodium and

saturated fat intakes. Results were promising: “the mean

intake of saturated fat decreased from 14.3 energy% to

less than 10 energy%. The mean daily intake of sodium

decreased by more than 10%.” This led researchers to

conclude that there is great potential for use of the Heart

Symbol, a positive logo based on the same principles

as Choices, to stimulate decreases in saturated fat and

sodium.(37)

9.6 Potentially greater impact when part of a comprehensive program Some studies, such as a systematic review of research

published between 2003-2015, indicate that combination

approaches – including elements of price, labelling,

information and easy access healthy foods – will help

consumers make healthier choices.(38) A supermarket

intervention made up “multiple components,

implemented simultaneously”, including an emphasis on

labelling healthy foods, helped low-income consumers

identify healthier foods.(39)

Focus group research in the UK about foodservice

environments showed that consumers wanted a “simple

uncomplicated label placed next to the target meal or on

menu boards to signpost healthy choices” in addition to

complementary informative messages.(40)

13

10 Summary of research fi ndings10.1 Innovation and reformulationIn relation to product innovation and reformulation,

research suggests a strong sodium and sugar reduction

of Choices-compliant products over time, while the fi ber

content has increased.

10.2 Consumer researchPreliminary results of EU-funded CLYMBOL research shows

that the introduction of FOP logos in the Netherlands and

Denmark, respectively, may drive purchasing decisions.

During the fi rst years after the introduction of the Dutch

Choices logo, Dutch consumers gave a high degree of

recognition and credibility to the Choices logo, which

they say is easy to interpret and therefore suitable for

people who need to shop quickly. Scientifi c research

points out that people who pay attention to healthier

diets buy more products with the Choices logo, but

it is unclear whether this is solely due to the logo, or

whether other factors are more important (such as

increased publicity). Most consumers indicate that they

do not consume more of a certain product when it bears

a Choices logo, and this is confi rmed by the results of a

practical study.

In terms of catering, the Choices logo has only had a

marginal infl uence on point-of-sale purchases, with only

those respondents motivated by health indicating that

they make use of it. This demonstrates, however, that

individual motivation to eat more healthily is a major

incentive for using the logo. An experiment in a full-

service restaurant indicated that a small majority (54%)

opted for Choices-labelled menus.

10.3 Potential impact on diet and nutrient intakeUsing the Daily Menu Method, Research revealed that

if consumers were to consistently select products that

comply with the Choices criteria, their daily diet would be

more in line with international dietary guidelines. Indeed,

their intake of nutrients which negatively impact health

would be noticeably reduced, while their intake of most

benefi cial nutrients would increase. It was also shown that

a small benefi cial effect on cholesterol can be expected. A

calculated reduction of fat soluble vitamins due to a shift

towards lower fat products has been found in the latest

model study. This would be of concern when all products

consumed comply with the criteria.

10.4 FOP-labelling researchAs Vyth et al. concluded from their review on the quality of

FOP-labelling studies, few methodologically sound studies

are currently available. However, some national programs

have been evaluated and do show widespread recognition

and understanding over time. Recommendations for future

research include the need for measuring the health impact

of FOP-labels in a real-life setting by using biomarkers in a

longitudinal, randomized-controlled design.

10.5 Comprehensive programs may have greater effectEvidence points to the usefulness of front-of-pack logos

in conjunction with complementary activities to have a

greater effect. Such comprehensive programs, including

education, pricing incentives and accessibility of healthy

foods may lead to greater improvements in nutrient intake

and health outcomes.

14

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16

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