Effect of Front-of-Package Information, Fruit Imagery, and High–Added Sugar Warning Labels on Parent Beverage Choices for Children

Abstract

ImportanceFruit drinks are widely consumed by young children, and many parents mistakenly believe that these drinks are healthy, potentially due to front-of-package claims and imagery. Research is needed on the influence of this marketing and how labeling regulations could change behavior.ObjectiveTo assess the effects of a front-of-package 100% vitamin C claim, fruit imagery, percentage juice and teaspoons of added sugar disclosures, and high–added sugar warnings on parents’ choices, knowledge, and perceptions of beverages.Design, Setting, and ParticipantsThis randomized clinical trial was conducted May to July 2021 as a single-exposure (no follow-up) online survey of primary caregivers of children ages 0 to 5 years throughout the US.InterventionsParticipants were shown no–, low–, and high–added sugar beverages and asked to choose 1 for their child. Participants were randomized to see high–added sugar beverages with 1 of 7 front-of-package conditions: (1) claim and imagery (control); (2) no claim; (3) no imagery; (4) no claim or imagery; (5) claim, imagery, and percentage juice disclosure; (6) claim, imagery, and warning; or (7) claim, imagery, warning, and teaspoons of added sugar disclosure.Main Outcomes and MeasuresPrimary outcomes were type of beverage chosen (eg, high–added sugar beverage) and resulting calories and added sugar (in grams). Secondary outcomes were fruit drink knowledge (added sugar and percent juice) and perceptions.ResultsThere were 5005 participants included in the final analysis (mean [SD] age, 31.5 [8.3] years; 3587 female participants [71.7%]), including 714 participants in group 1, 717 participants in group 2, 710 participants in group 3, 717 participants in group 4, 708 participants in group 5, 729 participants in group 6, and 710 participants in group 7. Compared with participants in the control group, who had a mean (standard error [SE]) of 9.4 (0.5) g of added sugar and 81.9 (1.6) kcal in chosen beverages, only participants who saw warnings with teaspoons of added sugar disclosures had significantly reduced added sugar (−1.3 g; 95% CI, −2.6 to −0.1 g [−14.2%; 95% CI, −26.7% to −1.8%]; P = .04) and calories (−5.3 kcal; 95% CI, −9.8 to −0.9 kcal [−6.5%; 95% CI, −11.8% to −1.3%]; P = .02) in selected beverages. In warning conditions (ie, 6 and 7) compared with the control group (mean [SE] 41.0% [1.8%]), the proportion of participants choosing high–added sugar beverages was significantly reduced, by 5.5 percentage points (95% CI, 0.5 to 10.5 percentage points [13.4%; 95% CI, 1.2% to 25.6%]; P = .03) and 6.4 percentage points (95% CI, 1.4 to 11.4 percentage points [15.6%; 95% CI, 3.3% to 27.8%]; P = .01), respectively. The no claim or imagery condition (4) significantly reduced the proportion of parents choosing high–added sugar beverages (−7.6 percentage points; 95% CI, −12.6 to −2.6 percentage points [−18.4%; 95% CI, −30.6% to −6.3%]; P = .003). Percentage juice disclosures did not affect beverage choice.Conclusions and RelevanceThese findings suggest that added sugar warnings and prohibitions of front-of-package claims and imagery may reduce parents’ purchases of high–added sugar beverages for their young children but that percentage juice disclosures may not change behavior.Trial RegistrationClinicalTrials.gov Identifier: NCT04811690

Effects of a front-of-package disclosure on accuracy in assessing children’s drink ingredients: two randomised controlled experiments with US caregivers of young children

“…Moreover, the present research shows that even when claims and fruit imagery were present on product packages, the disclosure corrected misperceptions about ingredients and healthfulness of sweetened drinks. Similar to our findings, previous research shows that warning labels were effective in reducing parents’ sugary drink selection for their children when added to packages that also contained fruit imagery and marketing claims (24) . Therefore, FOP disclosures alone may provide enough information to counteract common claims, such as ‘good source of Vitamin C’, ‘all natural ingredients’ and ‘no high fructose corn syrup’, that may lead caregivers to believe that sweetened children’s drinks are healthful choices for children (20) .…”

“…These findings are similar to studies that have examined effects of warning labels. FOP warnings, including symbols to highlight 'high-in' ingredients to avoid or statements about health harms related to consumption, have been found to correct misperceptions about the healthfulness of fruit drinks and reduce selection for their children (24)(25)(26) . The results assessing caregivers' base-level understanding of ingredients in children's sweetened and unsweetened drinks when viewing packages without disclosures (i.e.…”

“…However, research in this area is somewhat inconsistent. One study found that removing claims did not reduce parents' selection of sweetened fruit drinks for their child if a fruit image remained on the package (24) . The same study showed that either adding warnings or removing both claims and fruit imagery on product packages reduced parents' selection of sugar-sweetened fruit drinks for their child but did not test a condition with warnings added and claims removed (24) .…”

“…One study found that removing claims did not reduce parents' selection of sweetened fruit drinks for their child if a fruit image remained on the package (24) . The same study showed that either adding warnings or removing both claims and fruit imagery on product packages reduced parents' selection of sugar-sweetened fruit drinks for their child but did not test a condition with warnings added and claims removed (24) . Research is needed to understand the relative contribution of adding warnings or disclosures and/or removing claims and imagery in reducing parents' purchases of sweetened drinks for their children.…”

Effects of marketing claims on toddler food products on parents’ product preferences, perceptions and purchasing intentions: an online experiment

“…Additionally, Government could require that warning labels be displayed on products high in nutrients of concern, as warning labels have been found to mitigate but not eliminate ‘health halo’ effects of nutrition-related content claims on product perceptions and preferences [ 20 , 26 , 42 ]. More specifically, studies with US parents have found that displaying added sugar warning labels on sugary snacks and drinks encourages parents to choose healthier options for their children [ 39 , 43 ]. Overall, available evidence suggests that stricter regulation surrounding the marketing and labelling of toddler foods needs to be introduced to protect parents against potentially misleading claims and encourage healthier choices.…”