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Meta-Analysis
. 2018 Feb 27;2(2):CD009315.
doi: 10.1002/14651858.CD009315.pub2.

Nutritional labelling for healthier food or non-alcoholic drink purchasing and consumption

Rachel A Crockett  1 , Sarah E King, Theresa M Marteau, A T Prevost, Giacomo Bignardi, Nia W Roberts, Brendon Stubbs, Gareth J Hollands, Susan A Jebb
Affiliations
Meta-Analysis

Nutritional labelling for healthier food or non-alcoholic drink purchasing and consumption

Rachel A Crockett et al. Cochrane Database Syst Rev. .

Abstract

Background: Nutritional labelling is advocated as a means to promote healthier food purchasing and consumption, including lower energy intake. Internationally, many different nutritional labelling schemes have been introduced. There is no consensus on whether such labelling is effective in promoting healthier behaviour.

Objectives: To assess the impact of nutritional labelling for food and non-alcoholic drinks on purchasing and consumption of healthier items. Our secondary objective was to explore possible effect moderators of nutritional labelling on purchasing and consumption.

Search methods: We searched 13 electronic databases including CENTRAL, MEDLINE and Embase to 26 April 2017. We also handsearched references and citations and sought unpublished studies through websites and trials registries.

Selection criteria: Eligible studies: were randomised or quasi-randomised controlled trials (RCTs/Q-RCTs), controlled before-and-after studies, or interrupted time series (ITS) studies; compared a labelled product (with information on nutrients or energy) with the same product without a nutritional label; assessed objectively measured purchasing or consumption of foods or non-alcoholic drinks in real-world or laboratory settings.

Data collection and analysis: Two authors independently selected studies for inclusion and extracted study data. We applied the Cochrane 'Risk of bias' tool and GRADE to assess the quality of evidence. We pooled studies that evaluated similar interventions and outcomes using a random-effects meta-analysis, and we synthesised data from other studies in a narrative summary.

Main results: We included 28 studies, comprising 17 RCTs, 5 Q-RCTs and 6 ITS studies. Most (21/28) took place in the USA, and 19 took place in university settings, 14 of which mainly involved university students or staff. Most (20/28) studies assessed the impact of labelling on menus or menu boards, or nutritional labelling placed on, or adjacent to, a range of foods or drinks from which participants could choose. Eight studies provided participants with only one labelled food or drink option (in which labelling was present on a container or packaging, adjacent to the food or on a display board) and measured the amount consumed. The most frequently assessed labelling type was energy (i.e. calorie) information (12/28).Eleven studies assessed the impact of nutritional labelling on purchasing food or drink options in real-world settings, including purchases from vending machines (one cluster-RCT), grocery stores (one ITS), or restaurants, cafeterias or coffee shops (three RCTs, one Q-RCT and five ITS). Findings on vending machines and grocery stores were not interpretable, and were rated as very low quality. A meta-analysis of the three RCTs, all of which assessed energy labelling on menus in restaurants, demonstrated a statistically significant reduction of 47 kcal in energy purchased (MD -46.72 kcal, 95% CI -78.35, -15.10, N = 1877). Assuming an average meal of 600 kcal, energy labelling on menus would reduce energy purchased per meal by 7.8% (95% CI 2.5% to 13.1%). The quality of the evidence for these three studies was rated as low, so our confidence in the effect estimate is limited and may change with further studies. Of the remaining six studies, only two (both ITS studies involving energy labels on menus or menus boards in a coffee shop or cafeteria) were at low risk of bias, and their results support the meta-analysis. The results of the other four studies which were conducted in a restaurant, cafeterias (2 studies) or a coffee shop, were not clearly reported and were at high risk of bias.Seventeen studies assessed the impact of nutritional labels on consumption in artificial settings or scenarios (henceforth referred to as laboratory studies or settings). Of these, eight (all RCTs) assessed the effect of labels on menus or placed on a range of food options. A meta-analysis of these studies did not conclusively demonstrate a reduction in energy consumed during a meal (MD -50 kcal, 95% CI -104.41, 3.88, N = 1705). We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies.Six laboratory studies (four RCTs and two Q-RCTs) assessed the impact of labelling a single food or drink option (such as chocolate, pasta or soft drinks) on energy consumed during a snack or meal. A meta-analysis of these studies did not demonstrate a statistically significant difference in energy (kcal) consumed (SMD 0.05, 95% CI -0.17 to 0.27, N = 732). However, the confidence intervals were wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence as low, so our confidence in the effect estimate is limited and may change with further studies.There was no evidence that nutritional labelling had the unintended harm of increasing energy purchased or consumed. Indirect evidence came from five laboratory studies that involved mislabelling single nutrient content (i.e. placing low energy or low fat labels on high-energy foods) during a snack or meal. A meta-analysis of these studies did not demonstrate a statistically significant increase in energy (kcal) consumed (SMD 0.19, 95% CI -0.14to 0.51, N = 718). The effect was small and the confidence intervals wide, suggesting uncertainty in the true effect size. We rated the quality of the evidence from these studies as very low, providing very little confidence in the effect estimate.

Authors' conclusions: Findings from a small body of low-quality evidence suggest that nutritional labelling comprising energy information on menus may reduce energy purchased in restaurants. The evidence assessing the impact on consumption of energy information on menus or on a range of food options in laboratory settings suggests a similar effect to that observed for purchasing, although the evidence is less definite and also of low quality.Accordingly, and in the absence of observed harms, we tentatively suggest that nutritional labelling on menus in restaurants could be used as part of a wider set of measures to tackle obesity. Additional high-quality research in real-world settings is needed to enable more certain conclusions.Further high-quality research is also needed to address the dearth of evidence from grocery stores and vending machines and to assess potential moderators of the intervention effect, including socioeconomic status.

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Conflict of interest statement

Rachel Crockett: none known. Sarah King: none known. Theresa Marteau: none known. AT Prevost: none known. Giacomo Bignardi: none known. Nia Roberts: none known. Brendon Stubbs: none known. Gareth Hollands: none known. Susan Jebb: Chaired the Public Health Responsibility Deal Food Network (2011‐2015) which encouraged the adoption of front of pack nutritional labelling and energy labelling on menus.

Figures

1
1
Examples of nutritional labels used in practice
2
2
Logic model of the process by which nutritional labelling may have an impact on diets and health
3
3
Study flow diagram
4
4
Risk of bias summary
5
5
Forest plot of comparison: Labelling on menus vs no labelling in restaurants, and energy (kcal) of food purchased
6
6
Forest plot of comparison: Labelling on menus or placed on a range of food options vs. no labelling in laboratory settings, and energy (kcal) consumed
1.1
1.1. Analysis
Comparison 1: Labelling on menus vs no labelling in restaurants, Outcome 1: Energy (kcal) of food purchased
2.1
2.1. Analysis
Comparison 2: Labelling on menus or placed on a range of food options vs no labelling in laboratory settings, Outcome 1: Energy (kcal) consumed during a meal
3.1
3.1. Analysis
Comparison 3: Labelling on menus vs no labelling in laboratory settings (studies with a low risk of bias), Outcome 1: Energy (kcal) consumed during a meal
4.1
4.1. Analysis
Comparison 4: Labelling of a single food or drink option vs no labelling in laboratory settings, Outcome 1: Energy (kcal) consumption
5.1
5.1. Analysis
Comparison 5: Labelling of a single food or drink option vs no labelling in laboratory settings (studies at low risk of bias), Outcome 1: Energy (kcal) consumption
6.1
6.1. Analysis
Comparison 6: Consumption in laboratory settings: subgroup analysis by dietary restraint (studies providing a range of food options), Outcome 1: Energy (kcal) consumed during a meal
7.1
7.1. Analysis
Comparison 7: Consumption in laboratory settings: subgroup analysis by dietary restraint (study providing a single food option), Outcome 1: Energy (kcal) consumed during a snack
8.1
8.1. Analysis
Comparison 8: Consumption in laboratory settings: subgroup analysis by study country (studies providing a range of food options), Outcome 1: Energy (kcal) consumed during a snack/meal
9.1
9.1. Analysis
Comparison 9: Consumption in laboratory settings: subgroup analysis by study country (studies providing single food option), Outcome 1: Energy (kcal) consumed during a snack/meal
10.1
10.1. Analysis
Comparison 10: Low fat (or energy) labelling vs no labelling on high‐energy foods, Outcome 1: Energy (kcal) consumed during a snack/meal in laboratory settings
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD009315

References

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References to ongoing studies

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References to other published versions of this review

Crockett 2011
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Publication types