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Background: Suboptimal diets are a leading risk factor for death and disability. Nutrition labelling is a potential method to encourage consumers to improve dietary behaviour. This systematic review and network meta-analysis (NMA) summarises evidence on the impact of colour-coded interpretive labels and warning labels on changing consumers' purchasing behaviour., Methods and Findings: We conducted a literature review of peer-reviewed articles published between 1 January 1990 and 24 May 2021 in PubMed, Embase via Ovid, Cochrane Central Register of Controlled Trials, and SCOPUS. Randomised controlled trials (RCTs) and quasi-experimental studies were included for the primary outcomes (measures of changes in consumers' purchasing and consuming behaviour). A frequentist NMA method was applied to pool the results. A total of 156 studies (including 101 RCTs and 55 non-RCTs) nested in 138 articles were incorporated into the systematic review, of which 134 studies in 120 articles were eligible for meta-analysis. We found that the traffic light labelling system (TLS), nutrient warning (NW), and health warning (HW) were associated with an increased probability of selecting more healthful products (odds ratios [ORs] and 95% confidence intervals [CIs]: TLS, 1.5 [1.2, 1.87]; NW, 3.61 [2.82, 4.63]; HW, 1.65 [1.32, 2.06]). Nutri-Score (NS) and warning labels appeared effective in reducing consumers' probability of selecting less healthful products (NS, 0.66 [0.53, 0.82]; NW,0.65 [0.54, 0.77]; HW,0.64 [0.53, 0.76]). NS and NW were associated with an increased overall healthfulness (healthfulness ratings of products purchased using models such as FSAm-NPS/HCSP) by 7.9% and 26%, respectively. TLS, NS, and NW were associated with a reduced energy (total energy: TLS, -6.5%; NS, -6%; NW, -12.9%; energy per 100 g/ml: TLS, -3%; NS, -3.5%; NW, -3.8%), sodium (total sodium/salt: TLS, -6.4%; sodium/salt per 100 g/ml: NS: -7.8%), fat (total fat: NS, -15.7%; fat per 100 g/ml: TLS: -2.6%; NS: -3.2%), and total saturated fat (TLS, -12.9%; NS: -17.1%; NW: -16.3%) content of purchases. The impact of TLS, NS, and NW on purchasing behaviour could be explained by improved understanding of the nutrition information, which further elicits negative perception towards unhealthful products or positive attitudes towards healthful foods. Comparisons across label types suggested that colour-coded labels performed better in nudging consumers towards the purchase of more healthful products (NS versus NW: 1.51 [1.08, 2.11]), while warning labels have the advantage in discouraging unhealthful purchasing behaviour (NW versus TLS: 0.81 [0.67, 0.98]; HW versus TLS: 0.8 [0.63, 1]). Study limitations included high heterogeneity and inconsistency in the comparisons across different label types, limited number of real-world studies (95% were laboratory studies), and lack of long-term impact assessments., Conclusions: Our systematic review provided comprehensive evidence for the impact of colour-coded labels and warnings in nudging consumers' purchasing behaviour towards more healthful products and the underlying psychological mechanism of behavioural change. Each type of label had different attributes, which should be taken into consideration when making front-of-package nutrition labelling (FOPL) policies according to local contexts. Our study supported mandatory front-of-pack labelling policies in directing consumers' choice and encouraging the food industry to reformulate their products., Protocol Registry: PROSPERO (CRD42020161877)., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: JS is funded, and GAM and FJH are partially funded by the National Institute for Health Research (NIHR) (16/136/77) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK government. GAM is the chair of Blood Pressure UK, Action on Salt, Sugar and Health and World Action on Salt, Sugar and Health (WASSH). FJH is a member of Action on Salt, Sugar and Health and WASSH. Blood Pressure UK, Action on Salt, Sugar and Health and WASSH are nonprofit charitable organizations. GAM and FJH do not receive any financial support from them. MKB is funded by the Medical Research Council/UK Research and Innovation under the Newton Fund Impact Scheme call (grant MR/V005847/1) and Vital Strategies. JW is the Director of the WHO Collaborating Centre on Population Salt Reduction, is supported by a National Heart Foundation Career Development Fellowship (1082924), and through an NHMRC Centre of Research Excellence on food policy interventions to reduce salt (1117300). KT is supported by an NHMRC Early Career Fellowship (1161597) and a Postdoctoral Fellowship (102140) from the National Heart Foundation of Australia. NRCC reports personal fees from Resolve to Save Lives (RTSL), and the World Bank outside the submitted work; and an unpaid consultant on dietary sodium and hypertension control to numerous governmental and non-governmental organisations.

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., Competing Interests: K.M.H., S.P.R. and Z.D. are employees of Consensus Action on Salt, Sugar & Health (CASSH), a non-profit charitable organisation. F.J.H. is a member of CASSH and its international branch World Action on Salt & Health (WASH) and does not receive any financial support from CASSH or WASH. G.A.M. is Chairman of Blood Pressure UK (BPUK), Chairman of CASSH and Chairman of WASH. BPUK, CASSH and WASH are non-profit charitable organisations. G.A.M. does not receive any financial support from any of these organisations.

Objective: To evaluate the changes in sugar and energy labelling of carbonated sugar-sweetened soft drinks after the implementation of a tax on sugar-sweetened drinks in the United Kingdom of Great Britain and Northern Ireland., Methods: We visited nine main supermarkets before (May 2014) and after (April 2018) the tax came into effect and obtained data from product packaging and nutrition information panels of carbonated sugar-sweetened soft drinks. We used the paired t -test to assess differences in sugar and energy content of the same products between 2014 and 2018., Findings: We obtained data from 166 products in 2014 and 464 products in 2018, of which 83 products were the same in both years. Large variations in stated sugar content were found between the different carbonated sugar-sweetened soft drinks in both 2014 and 2018 for all products and for the 83 products. The mean sugar content of the 83 products decreased by 42% between 2014 and 2018, from 9.1 g/100 mL (standard deviation, SD: 3.3) to 5.3 g/100 mL (SD: 3.5; P  < 0.001). The mean energy content decreased by 40%, from 38 kcal/100 mL (SD: 13) in 2014 to 23 kcal/100 mL (SD: 15) in 2018 ( P  < 0.001)., Conclusion: The significant decreases in the labelling of sugar and energy content of carbonated sugar-sweetened soft drinks after the levy came into effect suggest this tax has been effective. The sugar content of drinks still varied considerably in 2018, suggesting further reductions in sugar content of these drinks is possible. The levy thresholds should be reduced and the tax increased to drive further reformulation of soft drinks to reduce their sugar content., ((c) 2019 The authors; licensee World Health Organization.)

Cakes and biscuits contribute to energy, total and saturated fat and sugar in British diets. So far, the UK government has prompted manufacturers to reduce energy density in these products through a reduction of their sugar content. We conducted a cross-sectional survey of the fat content of cakes and biscuits available in nine UK supermarket chains. In cakes ( n = 381), the mean total fat content was 17.9 ± 5.2 g/100 g (39% of the overall energy); range (1.4-35.6 g/100 g) and the average saturated fat content in cakes was 5.9 ± 3.4 g/100 g (13% of the overall energy); range (0.3-20 g/100 g). In biscuits ( n = 481), the mean total fat content was 21.8 g ± 6.3 g/100 g (40% of the overall energy); range (0.7-38.9 g/100 g) and the average saturated fat content was 11.4 ± 4.9 g/100 g (23% of the overall energy); range (0.3-22.3 g/100 g). In both cakes and biscuits, total and saturated fat content was positively correlated with energy density. Our results show that cakes and biscuits sold in UK supermarkets are high in total and saturated fat, and that fat content contributes substantially to product energy density. Fat reformulation in these products would effectively reduce energy density, calorie intake and help prevent obesity. Fat reformulation should be implemented simultaneously with sugar reformulation and be focused on saturated fat, as this will have the additional effect of lowering LDL cholesterol., Competing Interests: F.J.H. is a member of Action on Salt (AOS) and its international branch Word Action on Salt and Health (WASH). F.J.H. does not receive any financial support from AOS and WASH. G.A.M. is Chairman of Blood Pressure UK (BPUK), WASH and Consensus Action on Salt, Sugar and Health (CASSH). K.M.H.’s role is funded by CASSH. All the other authors declare no competing interest

Objective: To investigate the sodium content in sauces sold in Malaysian supermarkets., Methods: A cross-sectional market survey was conducted in 2017 of 233 sauces sold in Malaysian supermarkets. Information on the sodium content was collected from the product packaging and nutrient information panels of the sauces sold in the seven top supermarkets in the capital of Malaysia., Results: Of the 233 sauces surveyed, 116 did not include sodium content information on the nutrient information panel (49.8%). Soy sauce (particularly sweet soy sauce) and ketchup (particularly chilli sauce) were found to be the highest number of products surveyed in the analysis (N=54 and N=48, respectively). The highest sodium content information was displayed by fish/prawn sauce (budu/cencalok) (5192±3228 mg/100 g) which was followed by the light/thin soy sauce (5116±2084 mg/100 g), and followed by salty soy sauce (4780±988 mg/100 g). The sodium content information of the imported sauces was higher compared with local products produced in Malaysia. However, for sweet soy sauce, the sodium content information of the local products was higher compared with the imported products. Of the 116 sauces which displayed information regarding their sodium content, only 18.2% of the salty soy sauce and 25% of the light/thin soy sauce were found to be below the 2017 Malaysian sodium guidelines. Furthermore, only 21.7% of chilli ketchup and no tomato ketchup were below the 2017 UK salt guidelines., Conclusions: Almost half of the sauces surveyed did not include sodium content information on the nutrient information panel. It is recommended that sodium content information is provided on all sauces sold in Malaysia. Also, manufacturers should be urged to reduce the sodium content level of their sauces to a minimum of 5%., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To estimate the proportion of products meeting Indian government labelling regulations and to examine the Na levels in packaged foods sold in India., Design: Nutritional composition data were collected from the labels of all packaged food products sold at Indian supermarkets in between 2012 and 2014. Proportions of products compliant with the Food Safety Standards Authority of India (FSSAI) regulations and labelled with Na content, and mean Na levels were calculated. Comparisons were made against 2010 data from Hyderabad and against the UK Department of Health (DoH) 2017 Na targets., Setting: Eleven large chain retail stores in Delhi and Hyderabad, India., Subjects: Packaged food products (n 5686) categorised into fourteen food groups, thirty-three food categories and ninety sub-categories., Results: More packaged food products (43 v. 34 %; P<0·001) were compliant with FSSAI regulations but less (32 v. 38 %; P<0·001) reported Na values compared with 2010. Food groups with the highest Na content were sauces and spreads (2217 mg/100 g) and convenience foods (1344 mg/100 g). Mean Na content in 2014 was higher in four food groups compared with 2010 and lower in none (P<0·05). Only 27 % of foods in sub-categories for which there are UK DoH benchmarks had Na levels below the targets., Conclusions: Compliance with nutrient labelling in India is improving but remains low. Many packaged food products have high levels of Na and there is no evidence that Indian packaged foods are becoming less salty.