Front-Of-Pack Nutrition Labelling: A Position Statement of the European Academy of Paediatrics and the European Childhood Obesity Group

Prevention of childhood obesity is an important priority for public health given the >8-fold increase of the global prevalence of childhood and adolescent overweight and obesity during the last 4 decades [1-3]. In many European countries, this increase has been attenuated or halted, but overweight and obesity rates in children and adolescents remain very high, with major adverse effects on the quality of life, health, and life expectancy of affected individuals [4, 5]. Overweight and obesity predispose to type 2 diabetes and cardiovascular diseases, and they can also contribute to the risk for many types of cancer [6, 7]. Unless preventive and control measures are taken, the number of overweight children worldwide is estimated to reach 70 million by 2025 [8].

The observed increase in the prevalence of childhood obesity is a consequence of environmental and behavioural factors. The choices of food and drink consumption are one of the major modulating factors which have a generally larger effect than variation in physical activity [3, 9, 10]. Therefore, public health efforts include a focus on promoting healthy dietary patterns, including promoting a diet with a modest energy density and a limited dietary intake of saturated fats, salt, sugars, and sugar-containing beverages [11]. The major part of the supply of these less desirable diet components is derived from commercially prepared and marketed foods. In Europe, these foods are labelled with nutrient content tables. However, their impact on consumer choice appears to be limited since it takes considerable time and effort as well as well-informed consumers to use and adequately interpret nutrient content tables [12, 13]. As an alternative measure, simple labels placed on the front-of-packs (FOPs) of food products have been developed with the expectation that they are more effective in improving purchasing behaviour and dietary quality of populations [14]. This is particularly important for families with children and adolescents, as well as for purchases made by children and adolescents who tend to be even more influenced by advertising and packaging appearance [15, 16].

FOP food labels are intended to provide quick orientation on product quality based on nutrient profiles and to a quick decision-making about the relative qualities of different products through a simple and easily interpretable format [17]. The purpose of FOP nutrition labelling is to provide consumers with additional information on healthy dietary choices and to encourage food providers to offer products with a healthier composition. With this statement, we aim at reviewing FOP labelling options for the European Union (EU).

Since 2016, the packaging of all food and drinks sold in the EU must contain a nutrition declaration [18]. European regulations do not impose any obligation to use a simplified and objective indicator on the food industry that would allow easy assessment of the actual nutritional value of products. However, EU countries and the food industry can introduce their own labelling forms. The only restriction is that, according to EU law, the information on the packaging must not be misleading or suggest that the product is healthier than it is in reality.

Voluntary FOP labelling systems are used in 40% (11/27) of EU countries, including Belgium, Croatia, Czech Republic, Denmark, Finland, France, Lithuania, Poland, Slovenia, Spain, and Sweden, and in some countries of the European region (United Kingdom, Iceland, and Norway) [19]. A mandatory system is used only in Finland. Some countries, for example, Germany have announced the intention to introduce regulations on FOP labelling [20]. Currently, over 30 countries worldwide use FOP labelling (Table 1), but it is mandatory only in a few of them (e.g., Chile, Ecuador, Sri Lanka, and South Korea). Chile was the first country worldwide to implement a FOP warning label, and thereafter, several countries have followed this model [21]. The Ecuadorean labelling of packed food products regulation established the inclusion of a traffic light in the package of processed foods for sale in the country for both domestic and imported food products [22]. In 2016, a traffic light labelling system for beverages was implemented in Sri Lanka [23].

There are considerable inconsistencies and incomparability of the FOP systems used by different countries. Given the principle of free movement of goods and people within the EU market, a uniform solution would be advantageous to prevent confusion and enable comparison of all food products. Many different types of FOP labels have been developed, including nutrient-specific labels that display information about the content of a particular nutrient and summary labels that provide an assessment of the overall nutritional value.

Labels specific to nutrients can be divided into 5 categories presented in Table 2. FOP nutrition labelling schemes vary in presentation (e.g., shape, colour, and size), type of public health nutrition message (proscriptive, prescriptive, or both), and nutrient focus (e.g., focus on “critical nutrients” or inclusion of both positive and negative nutrients). To date, the most common “critical nutrients” that have been included in FOP nutrition labelling schemes are sodium, total fats, or saturated and trans-fats, and total sugars. Some but not all of the FOP nutrition labelling schemes include certain nutrient-rich components, such as fibre, whole grains, protein, fruits and vegetables, and nuts [33].

Except for numeric nutrient-specific labels, which have an informative character, all other FOP labels involve a certain level of interpretation of nutritional content through the use of colours, graphics, and/or text elements and can be considered as interpretative labels [13].

Multiple studies have demonstrated the helpfulness of FOP nutrition labelling in raising awareness and consumer understanding of the nutritional quality of pre-packaged foods [12, 14-16, 34-39]. In recent years, there has been a significant increase in the number of studies comparing the efficacy of different approaches to labelling. The number of labelling methods compared in each study is usually small and newer models (such as warning labels or total rating) are underrepresented [13]. However, all schemes improve a consumers’ ability to correctly interpret the nutritional quality of food compared to a control situation with no labelling [18, 40].

Studies have shown that FOP nutrition labels have a stronger influence on the ability to identify healthier products than the individual characteristics of consumers. The effect of the Nutri-Score outweighed the differences observed across socio-demographic subgroups, showing its applicability to vulnerable populations [13]. In contrast, understanding numeric and purely informational nutritional labels appears to be linked to the socio-economic and health status of the consumers, and disadvantaged groups with a higher obesity and disease risk are less effectively reached [41].

Global and colour-coded FOP labels effectively attract consumer attention and require less processing time and fewer fixations than nutrition facts labels [42, 43]. Studies on elements of design that more attract consumer attention and influence their purchasing choices have shown that a triangular symbol containing the word “high” on a white background worked better than an octagon with the word “a lot” [44]. It also turns out that there are differences in the perception of positive labelling. Interestingly, the star system seems more polarized in consumer perception than the system of multiple traffic lights [45].

Based on the available research and literature reviews, it seems that the best solution is ample, colour-coded global FOP labels that are easy-to-understand and quickly interpretably by all consumer and allow quick guidance of health-promoting purchasing decisions at the point of sale, regardless of the consumer’s socio-economic background [46, 47]. The Nutri-Score fulfils these criteria and was shown to be an effective labelling tool, and it has, therefore, been chosen as the method of FOP labelling in several European countries including Belgium, France, Germany, Luxembourg, Spain, and Switzerland [12, 48].

In 2015, WHO recommended governments to introduce easy-to-understand or interpretative FOP labels that help consumers to identify healthier options [49]. Also, the World Cancer Research Fund International recommends that policymakers from around the world should take up the challenge of implementing FOP food labelling [20]. The European Consumer Organization suggests the introduction of a coloured system on the front of food packaging that limits situations in which confused consumers choose unhealthy products [50]. Moreover, 7 associations affiliated with European Consumer Organization organized a petition for the introduction of the Nutri-Score system on the labelling of all food and drink products in the EU [51]. Also, the American Medical Association believes that food packaging should include more transparent information about the contents within food, so the healthy choice can be the easy choice for consumers [52]. The latest position paper of the Global Federation of International Societies of Paediatric Gastroenterology, Hepatology, and Nutrition also recommends introducing societal standards that protect the health of children and adolescents, which may include easy-to-understand colour-coded FOP labelling of food products [3]. The Commission to The European Parliament and The Council stated that thanks to the potential of FOP schemes to help consumers make health-conscious food choices it seems appropriate to introduce a harmonized mandatory FOP nutrition labelling at EU-level [53].

We recommend that a consistent, easily interpretable colour-coded FOP food labelling system is introduced as a mandatory labelling requirement for packaged foods marketed in European countries, as one element of a broader obesity prevention strategy. We strongly support the EU-wide mandatory introduction of the Nutri-Score. We are aware of the limitations of this labelling system, which does not cover all food products (e.g., fresh fruits, vegetables, herbs, and spices) and is based on a uniform reference amount rather than on portion sizes, but its universality and comprehensibility significantly outweigh the imperfections.

European countries should take coordinated action to stop the childhood obesity epidemic. Appropriate labelling of food products with the Nutri-Score can provide an important contribution to increasing awareness of consumers and families, support health-promoting purchasing choices, and improve dietary quality.

EU authorities should introduce an EU-wide mandatory requirement for colour-coded FOP labelling for packaged foods and beverages.

FOP labels should be consumer-friendly, interpretative, and easy-to-understand to enable consumers to make health-adequate decisions intuitively and quickly. The FOP labelling system should use simple, standardized symbols and colours that effectively illustrate the nutrition declaration. The Nutri-Score fulfils these requirements was positively evaluated in numerous studies and should be introduced as a mandatory labelling requirement in the EU.

The authors have no conflicts of interest to declare.

The authors did not receive any funding.

K.D., Ł.D., and A.M. were the project managers and conceived the manuscript design; D.W., A.H., and B.K. participated in the design of the manuscript and collected data; K.D., Ł.D., J.W., and E.Ł. analyzed the literature; Ł.D. and K.D. drafted the manuscript; J.W., A.M., D.W., E.Ł., A.H., and B.K. revised the content of the manuscript.