Disclosures

1. Effects of different front-of-pack labelling formats on the healthiness of food purchases – a randomized trial

2. Disclosures None

3. Rationale for front-of-pack food labelling • Poor diet the leading cause of disease burden worldwide • Nutrient declarations technically informative but difficult for most to use • Front-of-pack labelling may facilitate healthier food choices by consumers • In 2014 the Australian government commenced implementation of ‘Health Star Rating’ (HSR) system

4. Many possible label formats Multiple Traffic Lights Daily Intake Guide Health Star Rating Warnings or recommendations

5. 1 month follow-up of all packaged food purchases Design Registration and 1 week run-in

6. 1 month collection of all packaged food purchases Design Registration and 1 week run-in HEALTHY CHOICE

7. Flow chart Randomised (n=1,578)

8. Analysis • Mixed models and analysis of variance • Primary - non-inferiority • Secondary - superiority • Primary outcome - mean healthiness of packaged foods (nutrient profile score) • Secondary outcomes - sugar, sodium, saturated fat, energy density, spend, user perceptions of utility

9. Participant characteristics

10. Intervention and outcome metrics

11. Healthiness of food purchases HSR compared to alternatives

12. Healthiness of food purchases HSR compared to alternatives

13. Healthiness of food purchases HSR compared to alternatives

14. Healthiness of food purchases HSR compared to alternatives • Secondary outcomes – non-inferiority also demonstrated for sugar, saturated fat, energy density and spend (all p<0.05) but not for sodium (all p>0.08)

15. Healthiness of food purchases HSR compared to alternatives • No differences across subgroups (age, gender, education, etc.) except self-reported baseline nutrition knowledge (p=0.001)

16. User perceptions HSR compared to alternatives • All p non-inferiority <0.001

17. User perceptions HSR compared to alternatives • All p non-inferiority <0.001

18. User perceptions HSR compared to alternatives • All p non-inferiority <0.001

19. Healthiness of food purchases Active compared to NIP control • Secondary outcomes: 20 comparisons, one p=0.04 (MTL, sugar) and one p=0.05 (WARN, price), no clear pattern of differences

20. Healthiness of food purchases Active compared to NIP control • Secondary outcomes – 20 comparisons, one p=0.04 (MTL, sugar) and one p=0.05 (WARN, price), no clear pattern of differences

21. User perceptions Active compared to NIP control

22. User perceptions Active compared to NIP control

23. User perceptions Active compared to NIP control

24. Strengths and weaknesses Strengths • Randomised, blinded, controlled, large, real-world setting Weaknesses • Limited use of smartphone intervention, use of app as surrogate for on-pack labelling, incomplete reporting of purchases, only addresses packaged foods Likely impact • Bias towards the null, underestimated or missed real effects

25. In context • NZ Starlight trial – AJCN 2017; 105:695-704 • n=1,357 • HSR vs NIP • MTL vs NIP HSR vs NIP • Directly comparable methods and outcome evaluations MTL vs NIP

26. Conclusions • Strong likelihood that HSR, MTL or WARN will result in healthier food choices than NIP. But not DIG • HSR clearly superior to other formats in terms of user perceptions • HSR is now the labelling format with the strongest evidence base • Australian government choice of HSR was reasonable • Modifications that strengthen HSR might improve effectiveness

27. Strengthening the HSR with colours and descriptors 1.5 UNHEALTHY CHOICE 4.5 HEALTHY CHOICE

28. Acknowledgements NHMRC Bupa National Heart Foundation of Australia Michelle Crino, Elizabeth Dunford,Annie Gao, Rohan Greenland, Nicole, Cliona Ni Mhurchu, Audra Millis, Simone Pettigrew,Gary Sacks, Jacqui Webster, Jason HY Wu

29. bneal@georgeinstitute.org.au