Consumers’ Reactions to Converting Percentage Daily Energy into Equivalent Walking Time: Results from Qualitative and Qu

1. Consumers’ Reactions to Converting Percentage Daily Energy into Equivalent Walking Time: Resultsfrom Qualitative and Quantitative Measures Brennen Mills, Owen Carter, Steve Pratt

2. Obesity • Worldwide obesity has more than doubled since 1980. (1) • In 2008, more than 1.4 billion adults (20 and older) were overweight. Of these over 200 million men and nearly 300 million women were obese. (1) • In 2009–2010, 35.7% of U.S. adults were obese. (2) • In UK, 26% obese, 37% overweight. (3) • In Australia, 21% obese but 62% Australian adults overweight or obese. (4) • Obesity prevalence in Australia has doubled in the period between 1990 and 2005. (5)

3. Food intake • Most of the worldwide increase in obesity is attributable to a corresponding increase in caloric intake. • (6-8)

4. Mandatory nutrition labels • Consumers are unsure of recommended intake levels against which to compare nutrient content. (9)

5. Quote from Australian Medical Association • “A simple and uniform 'front of pack' system of nutritional labelling for packaged food should be mandated, and supported by an ongoing public education campaign. Clear information about nutrient content should also be provided.” (10)

6. Daily Intake Guide (Australia) TOTAL SUGARS SATURATED FAT SODIUM ENERGY PROTEIN FAT CARBOHYDRATE 960 mg 34.7 g 6.1 g 9.7 g 2000 kJ 25.2 g 25.5 g 36% 23% 50% 40% 11% 7% 42% Percentage Daily Intakes are based on an average adult diet of 8700 kJ. Your daily intakes may be higher or lower depending on your energy needs.

7. Guideline Daily Amount (EU) Facts Up Front (USA)

9. Quote from the Australian Food and Grocery Council • “DIG thumbnails now feature on more than 4000 supermarket products across Australia including on an increasing number of private label products.” (11) • Approximately 2/3 of energy dense/nutrition poor food and beverages used the DIGkJ (Energy alone). (12)

11. Energy only (USA)

12. Study conducted by International Food Information Council Foundation (USA) • Non-peer reviewed • N=7,363 • “Increasing the amount of nutrition information on the front of package served to strengthen consumers’ comprehension and comfort level with such material.” • (13) 15g PROTEIN VIT A IRON

13. Previous research • Qualitative • Participants described the label as being “confronting because it makes them realise how much work it takes to burn off a small amount of calories by walking” (p. 209). [14] • “Some participants said that it evoked a feeling of guilt... flags(FOP labels) should focus on the pleasure of choosing and eating foods.” (p. 209). [14]

14. Equivalent Walking time

15. Equivalent walking time examples 1 burger 2h 01 min 45g packet 57 min 1h 01 min 53g 375 mL 27 min *based upon a 70kg male with average BMR walking at 5 km/h (Naismith’s Rule) (3.5 MET)

16. Food label examples 3

17. Pilot data • 8 focus groups • 1.5 hours duration (approx.) • Stratified by sex, age (18–34 and 35–54 years) and socio-economic status (upper and lower). • Questions proceeded in a naturalistic and semi-structured manner to assess participants’ immediate reactions and overall opinion of each labelling system. • To test for facilitator bias, groups were asked at the end of the sessions which labelling system they thought the facilitator favoured. By consensus, three groups suggested the DIGkJ, two the full DIG and three were undecided.

18. Results - Qualitative (DIGkJ) • % daily intake confusion • “I wasn’t sure what the DI was, that just didn’t hit me.” • “I looked at it and thought ‘5% of what?’” • “I don’t think it has relevance for me, without that prior knowledge and without me being able to work out my daily intake of kilojoules it’s just not something that I’d bother with.”

19. Results - Qualitative (DIGkJ) • After understanding, there were issues with interpretation of the % daily intake information: • “It means you can have 20 [chocolates] in a day and you don’t need anything else.” • “If it’s only 7% out of my whole day than I can have plenty.”

20. Results - Qualitative (Energy Alone) • Label too small to be noticed: • I wouldn’t even notice that, it’s so small.” • “You can’t even see that.” • “There’s eight people in this room and nobody here has even noticed that.” • “You can barely even see it…it’s so tiny no one would even notice that.”

21. Results – Qualitative (Energy Alone) • Confusion when using kilojoules as a measurement of daily intake: • “I don’t know what a high number for energy is...anything over 1000 is pretty high isn’t it? Or is that for calories?” • “To me 169kJ is just gibberish. Even if I knew the average I wouldn’t be thinking if I’ve done 500kJ I’ve still got 750 left…I wouldn’t even think like that. This is pointless to me.”

22. Results – Qualitative (Energy Alone) • The concept of high ‘energy’ being associated with poor nutrition was lost on a number of participants: • “Well I know that it’s good for kids when it’s got a high energy content.” • “Energy is a good thing, you give them [kids] energy that they can use for sport.” • “Energy means power. I guess it is kind of like a burst of power or energy.” • “If I drink a carton of beer that will give me good energy.”

23. Results – Qualitative (EWT) • The majority of participants described the EWT as instantly understandable, difficult to ignore, and helps people truly appreciate the implications of consuming EDNP foods: • “It’s an easy concept to understand straight away.” • “It puts everything into perspective.” • “People can easily relate to exercise time rather than working with statistics and percentages.” • “It’s more meaningful because it shows the direct impact on what we need to do.” • “It would help control portion sizes.” • “I’d second guess whether I bought it or not.”

24. Results – Qualitative (EWT) • Participants also mentioned that it would most likely be easy for children to understand: • “He [my son] would definitely prefer that [EWT label] because he would see walking time and understand it.”

25. Results – Qualitative (EWT) • However, some people that expressed fat or sugar, not energy, was their primary focus when selecting foods • Therefore neither the DIGkJ (Energy alone) or EWT appealed to them. • “I would usually go try and find the three main ones, the sugar, the fat and the salt, I don’t really look at the energy.”

26. Methods - Quantitative • Commercial survey company • N=1000 participants from all states and territories throughout Australia • Sampling quotas set to ensure equal numbers of males and females, equal numbers from lower and higher socio-economic strata, and equal numbers from lower and upper age-groups (18–34 and 35–65 years). • Online questionnaire

27. Methods – Quantitative (Materials) • Thirty packaged foods and beverages were selected for the study. • They were classified into three categories of ‘green’, ‘amber’ or ‘red’ based on the nutrient cut-offs from the Food Standards Authority (Australia and New Zealand) (24) • Biscuits and crackers, snack bars, crisps and snack foods, milk drinks, and soft drinks made five food/beverage categories.

28. Methods – Quantitative (Materials) • In order to minimise confounding from participants’ pre-existing familiarity with the foods and beverages, products that are not marketed or available in Australia were sourced from other countries.

29. Methods – Quantitative (Procedure)

30. Methods – Quantitative (Procedure)

31. Methods – Quantitative (Procedure)

32. Methods – Quantitative (Procedure)

33. Methods – Quantitative (Procedure)

34. Methods – Quantitative (Procedure)

35. Methods – Quantitative (Procedure)

36. Methods – Quantitative (Procedure) • Interpretability of label • Understandability of label • Likelihood consumer would pay attention to label • Act as a deterrent to purchasing unhealthy ‘snack foods’

37. Methods – Quantitative (Procedure)

38. Results - Quantitative Mean difference in overall ratings from ‘no label’ condition .8 .650 .6 .4 .355 .2 0 -.094 -.2 DIGkJ DIG EWT

39. 10 DIGkJ EWT 9 Mean rating (1= lowest, 10 = highest) 8 7.34 7.14 6.90 7 6.95 6 5.55 5.52 5.24 5.05 5 4 3 2 1 Useful Understand Attention Deterrent Properties Results - Quantitative Subjective results • * All differences were statistically significant (p<0.05)

40. Discussion (Main findings) • Participants found the DIGkJ difficult to understand or apply in any practical sense. • The EWT was found to be more useful in identifying energy dense/nutrition poor (EDNP) foods • The EWT label may be a viable alternative to the DIGkJ, while depicting the exact same energy information in a different way, that satisfies the ‘at a glance’ criterion of a FOP food label and also allows consumers to correctly identify EDNP foods.

41. Discussion (Study Limitations) • Additional images on packages were removed (e.g. “diet, 99% fat free). • Questions in quantitative survey were posed in terms of consumption of the product on a daily basis. • Study was based on five food/beverage categories.

42. Conclusions • “There is no scientific or government research to demonstrate that any food labelling system is substantially better than others.” (2009) (15)

43. Conclusions • Evidence from Australia alone: • Carter, O., B. Mills, and T. Phan, An Independent Assessment of the Australian Food Industry's Daily Intake Guide 'Energy Alone' Label. Health Promotion Journal of Australia, 2011. 22(1): p. 63-67. • Blewett, N., et al., Labelling logic: review of food labelling law and policy. Canberra: Commonwealth of Australia; 2011 • Kelly. B, et al., Consumer testing of the acceptability and effectiveness of front-of-pack food labelling systems for the Australian grocery market. Health PromotInt, 2009. 24(2): p. 120-9. • Kelly, B., et al., On behalf of a Collaboration of Public Health and Consumer Research Groups. Front-of-Pack Food Labelling: Traffic Light Labelling Gets the Green Light. Cancer Council: Sydney. 2008.

44. Conclusions • “Industry is always looking at ways to better inform consumers and assist them to select healthy diets” (p.17). (16)

45. Funding and resources

46. Contact Details • Brennen Mills - Edith Cowan University, Western Australia. • b.mills@ecu.edu.au • Owen Carter - Edith Cowan University, Western Australia. • o.carter@ecu.edu.au • Steve Pratt – Cancer Council Western Australia • spratt@cancer.wa.asn.au

47. References • 1. World Health Organisation Obesity Fact sheet no. 311. • http://www.who.int/mediacentre/factsheets/fs311/en/ • 2. Prevalence of Obesity in the United States: Data from the National Health and Nutrition Examination Survey, 2009–2010. NCHS Data Brief ■ No. 82 ■ January 2012 • http://www.cdc.gov/nchs/data/databriefs/db82.pdf • 3. The NHS Information Centre, Lifestyles Statistics. Statistics on obesity, physical activity and diet: England, 2012 • 4. Australian Bureau of Statistics. 4364.0 - 2007-08 National Health Survey: Summary of Results [report on the Internet]. Canberra (AUST): ABS; 2009 [cited 2011 Mar 8]. Available from: http://www.ausstats.abs.gov.au/Ausst\ats/subscriber.nsf/0/9FD6625F3294CA36CA25761C0019DDC5/$File/43640_2007-2008%20(reissue).pdf. • 5. Australian Bureau of Statistics 2008, Overweight and Obesity in Adults, Australia, 2004-05, ABS Cat No. 4719.0. • 6. Swinburn, B. Sacks, G. Ravussin, E. Increased food energy supply is more than sufficient to explain the US epidemic of obesity. Am J ClinNutr. 2009 90(6) 1453-56 • 7. Swinburn BA,  Sacks G,  Lo SK,  et al. Estimating the changes in energy flux that characterize the rise in obesity prevalence. Am J ClinNutr 2009;89:1723–8. • 8. Hall KD, Chow CC. Estimating the quantitative relation between food energy intake and changes in body weight. Am J ClinNutr March 2010 vol. 91 no. 3 816 • 9. Cowburn, G. and L. Stockley, Consumer understanding and use of nutrition labelling: a systematic review. Public Health Nutr, 2005. 8(1): p. 21-8. • 10. Australian Medical Association 2008. AMA Position Statement on Obesity. Canberra: Australian Medial Association. • 11. Daily Intake Guide gets thumbs up from Woolworths. • http://docs.noodls.com/viewDoc.asp?filename=104517/EXT/89C01E4DCE6159AE3F143603F42B5BA15AEDB78E_A55E34169B0555695D20B402B22D777B1DB77ACA.PDF • 12. Carter, O, Mills B, Llyod E, Phan T. An independent audit of the Australian food industry's voluntary front-of-pack nutrition labelling scheme for energy-dense nutrition-poor foods. Accepted for Publication17/10/2012. European Journal of Clinical Nutrition. • 13. . International Food Information Council Foundation. Front of Pack Lbaeling: Consumer Research Project. • 14. van Kleef, E., et al., Consumer preferences for front-of-pack calories labelling. Public Health Nutr, 2007. 11(2): p. 203-213. • 15. 25. Palmer, D., Food Labelling Debate Flares Up [news page on the Internet]. Melbourne (AUST): Australian Food News; 2009 [cited 2010 Nov 4]. Available from: http://www.ausfoodnews.com.au/2009/04/06/food-labelling-debate-flares-up.html. • 16. 26. Australian Food and Grocery Council. Australian Food and Grocery Council Submission to the Department of Health and Ageing Food Regulation Secretariat in Response to the Review of Food Labelling Law and Policy [submission on the Internet]. Canberra(AUST): AFGC; 2009 [cited 2010 Nov 4]. Available from: http://www.afgc.org.au/doc-library/category/11-general-documents.html?download=140%3Aafgcsubmission-to-the-review-of-food-labellign-law-and-policy.