Abstract
BackgroundBulgaria continues to lag behind other EU Member States with respect to chronic disease morbidity and mortality prevention.MethodsIn line with efforts targeting the improvement of dietary practices, this comparative study assessed objective understanding of five different front-of-package labels (FOPL) (Reference Intakes, Multiple Traffic Lights, Warning label, Nutri-Score, and Health Star Rating) in a sample of 1010 Bulgarian adults. Objective understanding was assessed by comparing the results of two nutritional quality ranking tasks (with and without FOPL) in an online randomized experiment featuring three food categories (pizza, cakes, breakfast cereals). Multivariable ordinal logistic regression models within and across food categories were fit.ResultsCompared with the Reference Intakes group, participants randomized to Nutri-Score exhibited the largest improvement in product ranking ability across food categories (OR = 2.33; 95% CI: 1.55–3.51), followed by those randomized to Health Star Rating (OR = 1.99; 95% CI: 1.32–3.00). Nutri-Score also performed best within two (pizza and breakfast cereals) of the three food categories. The Multiple Traffic Lights and Warning label groups did not display any significant improvement in objective understanding either within or across food categories compared with the Reference Intakes group.ConclusionNutri-Score, which is a summary, interpretive, polychromatic FOPL, emerged as the most effective model in the Bulgarian context, with the potential to help consumers better understand the nutritional quality of food. The findings are of particular interest to public health policymakers in the region and across Europe, as the debate about an EU-wide FOPL model continues to gather momentum.Trial registrationRegistration number ACTRN12618001221246. Trial registered at the Australian New Zealand Clinical Trials Registry.
Highlights
Bulgaria continues to lag behind other European Union (EU) Member States with respect to chronic disease morbidity and mortality prevention
In the analysis combining all three food categories, compared with the Reference Intakes (RI) group, participants randomized to Nutri-Score exhibited the largest improvement in product ranking ability (OR = 2.33; 95% confidence intervals (CI): 1.55–3.51), followed by those randomized to Health Star Rating (HSR) (OR = 1.99; 95% CI: 1.32–3.00)
Among the five front-of-package labels (FOPL) conditions HSR, Multiple Traffic Lights (MTL), Nutri-Score, Warning label, and RI - participants randomized to Nutri-Score exhibited the largest improvement in product ranking ability across food categories
Summary
Bulgaria continues to lag behind other EU Member States with respect to chronic disease morbidity and mortality prevention. The proposal, which featured taxation of foods and beverages containing quantities of sugar, salt, trans-fatty acids, caffeine, or taurine exceeding pre-defined limits, was rejected by the National Assembly following a vigorous debate [6]. This outcome is alarming and could be viewed as reflecting opposition by food industry advocates, and with respect to the broader context reflecting the population’s generally low level of awareness about chronic disease prevention. Evidence from a recent nationally representative survey showed that, among Bulgarian adults aged 20 years and older, knowledge about risk factors and causes of serious diseases was markedly insufficient and often inaccurate [7]
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