Front-of-pack Nutrition Labelling Research Articles

Regulatory approaches to front-of-pack nutrition labelling

Abstract Even though nutrition labelling has been regulated by the EU since the 1990s, the tactics of industry, with the support of a minority of Member States, have prevented effective measures on front-of-pack nutrition labelling (FoPNL). In its Farm to Fork Strategy, the European Commission committed to introduce legislative proposals for harmonised front-of-pack nutrition labelling by the end of 2022. The deadline has passed and no indications appear of matters moving forward. This is even more concerning for public health as the current regulatory framework prohibits interpretive FoPNL, fails to guide Member States towards well-designed schemes, and prohibits schemes becoming mandatory.

Advantages of harmonised front-of-pack nutrition labelling for stakeholders

Abstract The adoption of a harmonised front-of-pack nutrition labelling (FoPNL) scheme has significant advantages from at least four perspectives. From the perspective of consumers, effective FoPNL can help inform them on the nutritional composition of the food they purchase and consume. From the perspective of economic operators, a harmonised FoPNL scheme results in a level playing field, increased legal certainty and reduced labelling costs. From the perspective of Member States, a mandatory, EU-wide scheme will contribute to policies intended to reduce the prevalence of obesity and diet-related diseases, and will facilitate compliance with the commitments they have made at international level to promote healthier food environments. From the perspective of the EU itself, a harmonised FoPNL scheme will promote the proper functioning of the internal market in line with the EU's mandate to ensure a high level of consumer and health protection in all its policies.

Product promotions in online supermarkets: prevalence of 'High Fat Sugar Salt' (HFSS) products and labelling characteristics.

To evaluate the prevalence of 'High Fat Sugar Salt' (HFSS) products and front-of-pack nutrition labelling (FOPNL) characteristics across promoted products in UK online supermarkets. A cross-sectional survey conducted (December 2021-January 2022) on promoted products. Data on ingredients, nutritional composition and display of FOPNL were collected from product webpages. The UK's Nutrient Profiling Model and Multiple Traffic Light criteria were used to determine HFSS status and possession of inherent red traffic lights (iRTL), respectively. Data analysis determined the prevalence (i.e. percentage of products of the total number of products sampled) of HFSS; FOPNL and possession of iRTL. Chi-squared tests explored associations between these. Three major UK online supermarket retailer websites. Product 'multibuy' and 'entrance' promotions, from selected product categories. Among the sampled 625 promoted products, the prevalence of HFSS was greater in entrance (73 %) compared with multibuy (41 %) promotions (χ2 (1) = 34, P < 0·05), with variations in the former across retailers (49-92 %). The prevalence of HFSS products in multibuy promotions offered by two retailers varied by category (i.e. Confectionery 94-97 %, Yogurts 20-20 %, Soft Drinks 16-33 %, Ready Meals 1·4-18 %). Not all promoted products displayed FOPNL on webpages (70 %) or images (52 %). A number of iRTL were found to be possessed by both HFSS and non-HFSS-promoted products. Prior to the 2022 implementation of Regulations restricting these, HFSS products were promoted in online supermarkets with varying display of FOPNL and possession of iRTL. Findings support future policy evaluation and mandatory digital FOPNL.

Implementing front-of-pack nutrition warning labels in Mexico: important lessons for low- and middle-income countries.

To analyse the implementation of front-of-pack nutrition labelling (FOPNL) in Mexico. Review of publicly accessible documents, including legislative websites, news sources, and government, intergovernmental, and advocacy reports. Usage of the policy cycle model to analyse the implementation and evaluation stages of Mexico's General Health Law, amended with FOPNL (2019-2022). In October 2019, the government published a draft modification of the Norma Oficial Mexicana (Official Mexican Standard) to regulate and enforce a new FOPNL warning label system. A 60-d public consultation period followed (October-December 2019), and the regulation was published in March 2020 and implementation began in October 2020. An analysis of nine key provisions of the Standard revealed that the food and beverage industry and its allies weakened some original provisions including health claims, warnings for added sweeteners and display areas. On the other hand, local and international public health groups maintained key regulations including the ban on cartoon character advertisements, standardised portions and nutrient criteria following international best practices. Early implementation appears to have high compliance and helped contribute to reformulating unhealthy products. Continued barriers to implementation include industry efforts to create double fronts and market their cartoon characters on social media and through digitalised marketing. Early success in implementing the new FOPNL system in Mexico was the result of an inclusive and participatory regulatory process dedicated to maintaining public health advances, local and international health advocacy support, and continued monitoring. Other countries proposing and enacting FOPNL should learn from the Mexican experience to maintain scientifically proven best practices, counter industry barriers and minimise delays in implementation.

Combating Excessive Food Consumption Through Augmented Reality Packaging: An Explorative Study of Generation Z

In 2020, The Indonesian Food and Drug Authority published Front of Pack Nutrition Labelling to ease consumers decide their diet preferences. In line with this effort, digital campaigns can effectively educate society and reduce the high consumption of Sugar, Salt, and Fat (SSF) in Indonesia. This research discusses the effectiveness of SSF consumption restriction messages delivered using Augmented Reality (AR) technology. This research uses a quantitative descriptive method. The data were collected from randomly selected 100 youngsters living in Jakarta, Bogor, Depok, Tangerang dan Bekasi (Jabodetabek) area and followed by the EPIC (Empathy, Persuasion, Impact, and Communication) model analysis. All four dimensions of EPIC fell on effective category within range 4.23-4.29 out of 5.8. These findings suggest that, in general, the advertisement for limiting the consumption of SSF with Augmented Reality media stands in the very effective category with a final score of 4.25 and represent that AR application in packaging can effectively be used for promoting or advertisising particular information.

Prevalence of Front-of-Pack Warning Signs among Commercial Complementary Foods in Seven High and Upper Middle-Income Countries

Front-of-pack nutrition labelling (FOPNL) can provide a mechanism for communicating the nutritional quality of commercially produced complementary foods (CPCF) to caregivers. To better understand the role FOPNL may provide for CPCF, this study aimed to evaluate CPCFs against national and global FOPNL systems to determine the proportion that would warrant warning or traffic light signs for high levels of concerning nutrients. A cross-sectional assessment was conducted to evaluate the levels of selected nutrients in CPCF available in Australia (n = 266), Brazil (n = 41), Chile (n = 73), Mexico (n = 164), the United States (n = 562), the United Arab Emirates (n = 135), and the United Kingdom (n = 643). The analysis was based on national FOPNL systems and the WHO Regional Office for Europe CPCF nutrient profiling model's 'high sugar' FOPNL warning. A substantial proportion of CPCFs contained excessive levels of total sugar, total fat or saturated fat that would warrant a red/amber traffic light or warning sign on product labels. Additionally, the high prevalence of added sugars and sweeteners identified in CPCFs was concerning. Based on these findings, the use of FOPNL among CPCFs could be beneficial to communicate the nutritional quality of these products to caregivers and trigger the reformulation of CPCFs with inappropriate nutrient profiles.

Informing Consumers: A Bibliometric and Thematic Analysis of Pack Nutrition Labelling

Aim/Purpose: The focus on human well-being has attracted the attention of consumers, organizations, and marketers to understand the various facets of Front of Pack Nutrition Labelling (FOPNL). This study examines the overall research trends in the FPONL domain and identifies the new research areas. Background: FOPNL is becoming increasingly popular and its influence has been widely examined. Different label schemes have been introduced across different regions in the world. Nevertheless, such interventions are limited in developing economies. Methodology: This study uses bibliometric analysis methods to explore Front of Pack Nutrition Labelling (FOPNL) trends using 602 articles published in selected business journals. Contribution: The paper identifies the new FOPNL research avenues. The study indicates that FOPNL has become a crucial research area, and more research is needed at the organization, managerial, and policy levels. Findings: The study identifies four themes. The first theme identified is the effect of harmful nutrients on health and the role of FOPNL nutrition in changing eating habits. The second theme focused on the government's policy and implementation of FOPNL nutrition labeling regulations. The third theme is dedicated to the work on attention, perception, understanding, and influence of multiple traffic light schemes. The fourth theme relates to the Health Star Rating, Nutri Score, and Healthier Choice FOPNL nutrition labeling schemes. Overall, the paper informs consumers, manufacturers, and regulators about the recent trends in the FOPNL research. Recommendation for Researchers: Though FOPNL has been widely examined in the health and nutrition domain, however, limited research has been done in the marketing domain. Research using neuroscientific methods (e.g. eye tracking) should provide more robust findings. Future Research: There is limited research on FOPNL from emerging economies. Future research can examine how FOPNL may influence people, policy, and private entities.

Food labelling

Abstract The Commission has undertaken to regulate the information provided to consumers on food. In particular, it intends to propose mandatory front-of-pack nutrition labelling (FoPNL) for food by the end of 2022. Even though nutrition labelling has been regulated by the EU since 1990, the tactics of industry, with the support of a minority of Member States, have prevented, so far, the adoption of a single, EU-wide, mandatory FoPNL scheme. Questions therefore arise regarding the extent to which the EU may secure agreement for the adoption of an EU-wide scheme which could effectively contribute to a high level of public health protection.

Mortality prediction of the nutrient profile of the Chilean front-of-pack warning labels: Results from the Seguimiento Universidad de Navarra prospective cohort study.

Front-of-Pack (FoP) nutrition labelling has been established as a policy, empowering consumers to choose healthy food options for preventing diet-related non-communicable diseases. This study aimed to evaluate the association between the nutrient profile underlying the Chilean warning label score and all-cause mortality and to conduct a calibration with the Nutri-Score in a large cohort of Spanish university graduates. This prospective cohort study analysed 20,666 participants (8,068 men and 12,598 women) with a mean (standard deviation) age of 38 years (±12.4) from the SUN cohort. Dietary food intake was assessed by a validated semi-quantitative food-frequency questionnaire at baseline and after 10 years of follow-up. The warning label score was calculated by considering the threshold of nutrients (sugar, saturated fat, and sodium) and energy density per 100 g/ml of product, as established by Chilean Legislation. Participants were classified according to quartiles of consumption of daily label score: Q1 (≤5.0), Q2 (>5.0-7.1), Q3 (>7.1-9.8), and Q4 (>9.8). Time-dependent, multivariable-adjusted Cox models were applied. To compare the performance of the warning label score and Nutri-Score to predict mortality, we used the Akaike information criterion (AIC) and Bayesian information criterion (BIC) methods. During a median of 12.2 years of follow-up, 467 deaths were identified. A higher score in the warning label values (lower nutritional quality) was associated with an increased risk of all-cause mortality [HR (95% CI) Q4 vs. Q1: 1.51 (1.07-2.13); p-trend = 0.010] and cancer mortality [HR (95% CI) Q4 vs. Q1: 1.91 (1.18-3.10); p-trend = 0.006]. However, no statistically significant association was found for cardiovascular mortality. Furthermore, the warning label score and Nutri-Score exhibited comparable AIC and BIC values, showing similar power of prediction for mortality. A diet with a higher warning label score (>9.8 per day) was a good predictor of all cases and cancer mortality in a large Spanish cohort of university graduates. Also, the warning label score was capable to predict mortality as well as the Nutri-Score. Our findings support the validity of the warning label score as a FoP nutrition labelling policy since it can highlight less healthy food products.

Comment on Muzzioli et al. Are Front-of-Pack Labels a Health Policy Tool? Nutrients 2022, 14, 771.

As scientists working and publishing in the field of front-of-pack nutrition labelling (FOPNL) for many years, we have read with interest and concern the narrative review regarding their effectiveness by Muzzioli et al. [...].

232The Impact of Australasian Voluntary Front of Pack Nutrition Labelling on Packaged Food Reformulation

Abstract Background Front-of-pack nutrition labelling (FoPL) of packaged foods can promote healthier diets. Australia &amp; New Zealand (NZ) adopted the voluntary Health Star Rating (HSR) scheme in 2014. We studied the impact of voluntary adoption of HSR on food reformulation overall, and for more- versus less-healthy foods. Methods Annual nutrition information panel data was collected for non-seasonal packaged foods sold in major supermarkets in Auckland from 2013-19, and Sydney from 2014-18. We used difference-in-differences to estimate reformulation associated with HSR adoption. Results Healthier products adopted HSR more than unhealthy products: 35% of products that achieved four or more stars displayed the label compared to 15% of products that achieved two stars or less. Products that adopted HSR were 6.5% &amp; 10.7% more likely to increase their rating by ≥ 0.5 stars in Australia and NZ, respectively. Labelled products showed a -4.2% [95% CI -6.5% to -1.9%] relative decline in sodium content in NZ, but there was no sodium change in Australia. There was a -2.3% [-3.7% to -1.0 %] change in sugar content in NZ and a -1.1% [-2.2% to 0.0%] difference in Australia. Initially unhealthy products showed larger reformulation when adopting HSR than healthier products. Conclusions Overall, introduction of HSR had a small effect on product reformulation. The voluntary nature of the HSR program lowers effectiveness because labels were mostly placed on already healthy products. These already healthy products had limited scope for reformulation. Key messages HSR adoption by unhealthy products should be incentivized, or mandated, by governments to maximise reformulation

Evolution not revolution – what might the future hold for front‐of‐pack nutrition labelling in the UK?: A British Nutrition Foundation roundtable

AbstractObesity and diet‐related chronic diseases remain a serious public health concern across the globe. As part of an integrated package of policies to tackle obesity, many countries use front‐of‐pack nutrition labelling (FOPNL), which can provide at‐a‐glance information to help consumers make healthier food choices. The UK government has recently run a consultation (July 2020–October 2020) on FOPNL to gather views and evidence on the current ‘multiple traffic lights’ (MTL) label scheme, and to compare other FOPNL schemes (such as the Chilean Warning and Nutri‐Score labels) in respect of their impact on consumer and industry behaviour. To identify and explore the strengths and limitations of different FOPNL systems, the British Nutrition Foundation hosted a virtual roundtable event with a wide range of stakeholders in October 2020. The ensuing discussions considered the effectiveness of FOPNL in guiding food purchases and healthier eating choices and in driving product reformulation; as well as the potential advantages, disadvantages, opportunities and challenges of different systems including MTL and Nutri‐Score. This report describes some of the key points emerging from the discussions.

Looking Ahead: Health Impact Assessment of Front-Of-Pack Nutrition Labelling Schema as a Public Health Measure.

This study aimed to describe the underlying process, used methods and major recommendations emerging from a comprehensive and prospective health impact assessment of the endorsement of a front-of-pack nutrition labelling (FOP-NL) system by the Portuguese health authorities. A mixed-methods approach was used to gather information on the impact of four FOP-NL schemes on consumers’ selection of food products according to the perception of their nutritional quality, combining a systematic literature review, focus groups (FG), in-depth individual interviews, and an open-label crossover randomized controlled study. The relevance of FOP-NL as a public health promotion policy has emerged as a consensual idea among either FGs’ participants (i.e., consumers and experts), or interviewed stakeholders. Although all of the evaluated FOP-NLs result better than no system on promoting the choice of the healthiest product, the effectiveness of easy-to-interpret FOP-NL among vulnerable groups raised concerns related to the need of integrating specific nutritional information to promote a better self-management of chronic diseases, and related to the level of literacy of consumers, which could impair the usage of FOP-NL. Educational campaigns addressing skills to use FOP-NL is recommended. Furthermore, a monitoring strategy should be considered to evaluate the long-term effectiveness of this policy in promoting healthier food choices, and in reducing diet-related non-communicable diseases burden.

The impact of voluntary front-of-pack nutrition labelling on packaged food reformulation: A difference-in-differences analysis of the Australasian Health Star Rating scheme.

Front-of-pack nutrition labelling (FoPL) of packaged foods can promote healthier diets. Australia and New Zealand (NZ) adopted the voluntary Health Star Rating (HSR) scheme in 2014. We studied the impact of voluntary adoption of HSR on food reformulation relative to unlabelled foods and examined differential impacts for more-versus-less healthy foods. Annual nutrition information panel data were collected for nonseasonal packaged foods sold in major supermarkets in Auckland from 2013 to 2019 and in Sydney from 2014 to 2018. The analysis sample covered 58,905 unique products over 14 major food groups. We used a difference-in-differences design to estimate reformulation associated with HSR adoption. Healthier products adopted HSR more than unhealthy products: >35% of products that achieved 4 or more stars displayed the label compared to <15% of products that achieved 2 stars or less. Products that adopted HSR were 6.5% and 10.7% more likely to increase their rating by ≥0.5 stars in Australia and NZ, respectively. Labelled products showed a -4.0% [95% confidence interval (CI): -6.4% to -1.7%, p = 0.001] relative decline in sodium content in NZ, and there was a -1.4% [95% CI: -2.7% to -0.0%, p = 0.045] sodium change in Australia. HSR adoption was associated with a -2.3% [-3.7% to -0.9%, p = 0.001] change in sugar content in NZ and a statistically insignificant -1.1% [-2.3% to 0.1%, p = 0.061] difference in Australia. Initially unhealthy products showed larger reformulation effects when adopting HSR than healthier products. No evidence of a change in protein or saturated fat content was observed. A limitation of our study is that results are not sales weighted. Thus, it is not able to assess changes in overall nutrient consumption that occur because of HSR-caused reformulation. Also, participation into labelling and reformulation is jointly determined by producers in this observational study, impacting its generalisability to settings with mandatory labelling. In this study, we observed that reformulation changes following voluntary HSR labelling are small, but greater for initially unhealthy products. Initially unhealthy foods were, however, less likely to adopt HSR. Our results, therefore, suggest that mandatory labelling has the greatest potential for improving the healthiness of packaged foods.

Trade, standards and politics: global pressures on front-of-pack nutrition labelling interventions

Abstract Although interpretive front-of-pack (FOP) nutrition labelling is rightly considered a national health policy decision, it is also influenced by global trade agreements and international standards. Over the past decade, Specific Trade Concerns have been repeatedly raised at the World Trade Organization (WTO) regarding potential impacts of FOP nutrition labelling initiatives on trade. One of the common concerns raised was regarding the consistency of the measures with international standards. The Codex Alimentarius Commission (Codex), which makes global food standards, is currently developing global guidance for FoP nutrition labelling, which will almost certainly influence national policy making. This presentation draws on qualitative policy analysis research on trade concerns and international standards work regarding FOP nutrition labelling. Two challenges are evident at the global policy level. The first is the potential for constraints on policy space for innovative FOP nutrition labelling due to binding trade agreements. The second is the potential for significant industry input into standard development at Codex, which then constitute the reference point for WTO discussions on labelling. Historically, Codex standards have focussed primarily on acute risks, for example, from foodborne disease. This shift in Codex's activities towards standards to address NCDs presents new risks for achievement of public health goals, as a result of the high level of industry involvement in this forum and thus potential commercial conflict of interest. It is imperative that public health actors engage with Codex processes to ensure policy space for national governments to implement strong and effective regulation and allow scope for innovation. At the national policy level, strategic framing of nutrition labelling policy objectives and proactive policy engagement between trade and health can also minimise trade issues.

The emergence of nutrition warning labels in Latin America

Abstract Over the last decade, Latin American countries have become leaders in the emerging policy field of front-of-pack nutrition labelling (FOPNL). Recommended by public health experts and the World Health Organization, FOPNL regulations seek to improve the healthiness of population diets and thereby reduce the incidence of overweight and obesity and associated non-communicable diseases, such as diabetes, cancer, and heart diseases. In 2011, Chile passed the world's first comprehensive nutrition labelling law and now prohibits school sales and daytime advertisement of any product labeled “high in” sugar, salt, saturated fats, or calories. Ecuador introduced a mandatory traffic-light labelling scheme in 2014, while Peru, Uruguay, and Mexico introduced Chile-style warning labels since 2018. Several other Latin American countries, including Argentina and Brazil, are currently debating the introduction of mandatory front-of-pack warning labels. In contrast, most countries in the Global North have so far failed to introduce mandatory FOPNL and the European Union even banned its member states from doing so in 2011. This presentation will trace and explain this emergence of FOPNL in Latin America.

Front-of-pack nutrition labelling to promote healthier diets: current practice and opportunities to strengthen regulation worldwide

Abstract Unhealthy diets are a leading cause of death and disability globally. The WHO recommends Member States implement front-of-pack (FOP) nutrition labels to guide consumers towards healthier food choices, as part of comprehensive strategies to prevent diet-related non-communicable diseases. Interest in FOP nutrition labelling is increasing, but there is limited guidance for policymakers developing regulations necessary for effective implementation. A rapidly evolving evidence base, limited regulatory capacity and possibility of legal challenge by affected food industry stakeholders can create ‘regulatory chill', whereby governments are dissuaded from progressive public health policymaking. We use a framework for analysing public health law and available best-practice guidance to evaluate key components of 31 FOP nutrition labelling regulations endorsed by governments up to June 2019. Analysis of regulatory form shows recent rapid uptake of label formats that are easier for consumers to understand and increasing use of mandatory legislation. However, policymakers must decide much more than whether to apply ‘stars', ‘traffic lights' or ‘stop signs'. The substance of effective regulation must contain strategic regulatory objectives, clear specifications for displaying the label on pack, a valid scoring mechanism and a justified scope for including foods. While there are limited data on current practice, good governance of FOP nutrition labelling regulation also requires transparency and accountability in processes of label development, implementation, evaluation and enforcement to promote continuous improvement and withstand undue commercial interference. Whether developing new FOP nutrition labels or reforming existing ones, our findings support policymakers to design and implement best-practice, evidence-informed regulation.

'I had never seen so many lobbyists': food industry political practices during the development of a new nutrition front-of-pack labelling system in Colombia.

To identify and monitor food industry use of political practices during the adoption of nutrition warning labels (WL) in Colombia. Document analysis of publicly available information triangulated with interviews. Colombia. Eighteen key informants from the government (n 2), academia (n 1), civil society (n 12), the media (n 2) and a former food industry employee (n 1). In Colombia, the food industry used experts and groups funded by large transnationals to promote its preferred front-of-pack nutrition labelling (FOPL) and discredit the proposed warning models. The industry criticised the proposed WL, discussing the negative impacts they would have on trade, the excessive costs required to implement them and the fact that consumers were responsible for making the right choices about what to eat. Food industry actors also interacted with the government and former members of large trade associations now in decision-making positions in the public sector. The Codex Alimentarius was also a platform through which the industry got access to decision-making and could influence the FOPL policy. In Colombia, the food industry used a broad range of political strategies that could have negatively influenced the FOPL policy process. Despite this influence, the mandatory use of WL was announced in February 2020. There is an urgent need to condemn such political practices as they still could prevent the implementation of other internationally recommended measures to improve population health in the country and abroad, nutrition WL being only of them.

Nutrition Profile of Products with Cartoon Animations on the Packaging: A UK Cross-Sectional Survey of Foods and Drinks.

Background: Marketing, including the use of cartoon animations on packaging, has been shown to influence the food children choose to eat. This paper aims to determine the nutritional quality of UK food and drink products featuring child-friendly characters on pack. Methods: A comprehensive cross-sectional survey of food and drink with packaging appealing to children available in the UK. Products were classified high in fat, salt and/or sugar (HFSS) according to the UK nutrient profiling model and guidance for front of pack nutrition labelling. Logistic regression was used to determine whether there was a significant relationship between nutritional quality of products, and animation type. Results: Over half (51%) of 532 products with animations on packaging were classified as HFSS. Food products featuring unlicensed characters were significantly more likely to be deemed HFSS than those with licensed characters, according to both the nutrient profiling model (odds ratio (OR) 2.1, 95% CI: 1.3 to 3.4) and front of pack nutrition labelling system (OR 2.3, 95% confidence interval CI: 1.4 to 3.7). Conclusions: The use of cartoon characters on HFSS products is widespread. Policies to restrict the use of such marketing tactics should be considered to prevent children being targeted with unhealthy foods and drinks.

Perceived healthiness of food items and the traffic light front of pack nutrition labelling: choice‐based conjoint analysis and cross‐sectional survey

Although traffic light labelling (TLL) is designed to aid the selection of healthier choices, consumers often have to make trade-offs between (un)desirable attributes. With the current emphasis of public health on sugar reduction, the present study aimed to investigate the relative influence of sugar on the perceived healthiness of products. A choice-based conjoint analysis (CBC) survey was designed to assess the relative importance of the macronutrients commonly used in TLL, as well as the rescaled utilities of three attribute levels (red, amber and green), which involved 858 participants aged ≥18years, who were recruited from the general population of Nottingham. An additional cross-sectional online survey was completed by another 901 participants to assess public knowledge about the intake recommendations underpinning the TLL. Usable data for CBC analysis showed that, when deciding upon the healthiness of items, sugar was significantly the most important macronutrient (mean 0.34, 95% confidence interval=0.32-0.35) among the 641 participants. Red labelling was significantly more influential than green across macronutrients. In the substudy, 13.3% of participants correctly identify the maximum recommended intake of free sugars. Moreover, 42.8% of the total sample could not identify whether the sugar information on TLL refers to the total or free sugar content. Despite a lack of knowledge about the recommendations underpinning the TLL criteria, decisions made by participants concerning the healthfulness of food products were significantly influenced by sugar content. TLL appears to guide consumer beliefs in the absence of deep knowledge. The dominance of sugar in decision making is unsurprising in the current public health climate.