To examine the impact of front-of-package (FOP) labels on perceived healthfulness, purchasing intentions and understanding of common FOP systems.

A parallel, open-label design randomised participants to different FOP labelling conditions: ‘high in’ warning labels (WL), multiple traffic light labelling (TLL), health star ratings (HSR) (all displayed per serving) or control with no interpretive FOP labelling. Participants completed a brief educational session via a smartphone application and two experimental tasks. In Task 1, participants viewed healthy or unhealthy versions of four products and rated healthiness and purchasing intention on a seven-point Likert-type scale. In Task 2, participants ranked three sets of five products from healthiest to least healthy.

Online commercial panel.

Canadian residents ≥ 18 years who were involved in household grocery shopping, owned a smartphone and met minimum screen requirements.

Data from 1997 participants (n 500/condition) were analysed. Task 1: across most product categories, the TLL and HSR increased perceived healthiness of healthier products. All FOP systems decreased perceived healthiness of less healthy products. Similar, albeit dampened, effects were seen regarding purchasing intentions. Task 2: participants performed best in the HSR, followed by the TLL, WL and control conditions. Lower health literacy was associated with higher perceived healthiness and purchasing intentions and poorer ranking task performance across all conditions.

All FOP labelling systems, after a brief educational session, improved task performance across a wide spectrum of foods. This effect differed depending on the nutritional quality of the products and the information communicated on labels.

Trial Registration: NCT03290118.

To describe Brazilian parents’ perceptions of non-sugar sweeteners (NSS) in beverages consumed by children and their views for NSS front-of-package labels (FOPL).

A qualitative-driven mixed-methods embedded design was used. Seven focus groups with parents of children explored perceptions of NSS. Qualitative data were coded and analyzed using thematic analysis. Participants also completed a closed-ended survey assessing familiarity with NSS-containing beverages, ability to identify NSS on ingredient labels and perceptions of NSS FOPL. Survey responses were summarised using descriptive statistics.

Public and private schools and early childhood education centres in urban areas of two municipalities in the State of São Paulo, Brazil.

Forty parents of children aged 2–5 and 6–11.

About 35 % of participants reported their children consumed at least one NSS-containing beverage weekly in the past month; 17 % reported daily consumption. Parents expressed a preference for natural products and confusion over the term ‘edulcorantes’ (Portuguese for NSS). They shared concerns about the health effects of both sugar and NSS, particularly for children. NSS were seen as acceptable in specific cases, such as if a child has diabetes. Most parents supported a FOPL like Mexico’s, stating ‘not recommended for children’. In the survey, 85 % of the parents correctly identified beverages with NSS, but 82 % misclassified non-NSS ingredients (e.g. sugar syrup, caramel) as NSS. The Mexico-style FOPL was preferred by 95 % of the parents, who found it helpful and easy to understand.

A FOPL clearly indicating NSS presence, especially one recommending against consumption by children, may help parents make informed choices and reduce children’s intake of NSS-containing beverages.

To examine the labelling status of trans-fat of pre-packaged foods sold in Hong Kong.

Data from 19 027 items in the 2019 FoodSwitch Hong Kong database were used. Ingredient lists were screened to identify specific (e.g. partially hydrogenated vegetable oil, PHVO) and non-specific trans-fat ingredient indicators (e.g. hydrogenated oil). Trans-fat content was obtained from the on-pack nutrition labels, which was converted into proportion of total fat (%total fat). Descriptive statistics were calculated for trans-fat content and the number of specific, non-specific and total trans-fat ingredients indicators found on the ingredients lists. Comparisons were made between regions using one-way ANOVA and χ2 for continuous and categorical variables, respectively.

Cross-sectional audit.

Not applicable.

A total of 729 items (3·8 % of all products) reported to contain industrially produced trans-fat, with a median of 0·4 g/100 g or 100 ml (interquartile range (IQR): 0·1–0·6) and 1·2 %totalfat (IQR: 0·6–2·9). ‘Bread and bakery products’ had the highest proportion of items with industrially produced trans-fat (18·9 %). ‘Non-alcoholic beverages’ had the highest proportion of products of ‘false negatives’ labelling (e.g. labelled as 0 trans-fat but contains PHVO; 59·3 %). The majority of products with trans-fat indicator originated from Asia (70 %).

According to the labelling ∼4 % of pre-packaged food and beverages sold in Hong Kong in 2019 contained industrially produced trans-fat, and a third of these had trans-fat >2 %total fat. The ambiguous trans-fat labelling in Hong Kong may not effectively assist consumers in identifying products free from industrially produced trans-fat.

Take-away foods account for a significant proportion of dietary intake among young adults (18–35 years). Young adults want nutrition information at the point-of-purchase (POP); however, it is either unavailable, perceived as ineffective or difficult to use. The present study examined whether symbols on university food outlet menus identifying healthier options would increase their sales and consumer’s awareness of these symbols, purchasing factors and barriers to eating healthy foods.

Repeated-measures, comparison group, quasi-experimental study.

Two carefully matched university food outlets were analysed to determine the targeted items. Tick symbols ✓ were placed next to the targeted items in the experimental outlet. No changes were made at the comparison outlet. Customers were surveyed at the experimental outlet. Food sales were collected for 4 weeks from both outlets at baseline and during the intervention. Food sales were also collected from the experimental outlet 10 weeks later.

Food outlet patrons.

Significant increases in food sales were observed during observation 3 compared with observation 1 (P = 0·0004) and observation 2 (P = 0·0002). Sixty-eight per cent of respondents noticed the symbols, and of that, 30 % reported being influenced. Taste was the most common purchasing factor, and people were less likely to select taste as a factor if they were influenced by the symbols (P = 0·04).

Identifying healthier options with a symbol at the POP increased sales over time. Several purchasing factors (price, taste and healthy food availability) need to be addressed to improve the food selection of young adults.

To analyse the arguments used by the food industry during the early development of the new nutrition front-of-pack labelling (FOPL) in Brazil.

A thematic qualitative analysis was performed using an inductive approach. All data were collected and analysed between December 2018 and April 2019. Data included documents published by the Brazilian government, including industry’s contributions to a technical public consultation, as well as industry material and newspaper articles.

Brazil.

Seven trade associations and one industry group.

During the early stages of the FOPL policy development, food industry actors presented themselves as legitimate actors, by highlighting their economic contribution to the country, their role in safeguarding consumers’ right to choose and their range of solutions in addressing the non-communicable disease epidemic. They also questioned the policy process by criticising the role of the Brazilian Health Regulatory Agency and the science that informed the policy. Finally, food industry actors highlighted the supposedly lack of coherence between national, regional and international policies, as well as other socio-economic risks. A small set of evidence published in non-academic, non-peer-reviewed reports was used by industry actors to support these arguments.

Collectively, these arguments reinforced the position of the food industry as a necessary part of the discussion on FOPL and shifted the blame away from unhealthy products to individual behaviours. It is crucial that public health initiatives, such as the introduction of a new FOPL, are no co-opted and negatively influenced by economic actors who may try to delay the policy process.

Front-of-pack (FOP) nutrition labelling is a globally recommended strategy to encourage healthier food choices. We evaluated the effect of FOP labels on the perceived healthfulness of a sweetened fruit drink in an international sample of adult consumers.

Six-arm randomised controlled experiment to examine the impact of FOP labels (no label control, Guideline Daily Amounts (GDA), Multiple Traffic Lights, the Health Star Ratings (HSR), Health Warning Labels, and ‘High-in’ Warning Labels (HIWL)) on the perceived healthfulness of the drink. Linear regression models by country examined healthfulness perceptions on FOP nutrition labels, testing for interactions by demographic characteristics.

Online survey in 2018 among participants from Australia, Canada, Mexico, United Kingdom (UK) and United States.

Adults (≥18 years, n 22 140).

Compared with control, HIWL had the greatest impact in lowering perceived healthfulness (β from −0·62 to −1·71) across all countries. The HIWL and the HSR had a similar effect in Australia. Other labels were effective in decreasing the perceived healthfulness of the drink within some countries only, but to a lower extent. The GDA did not reduce perceived healthfulness in most countries. In the UK, the effect of HIWL differed by age group, with greater impact among older participants (> 40 years). There were no other variations across key demographic characteristics.

HIWL, which communicates clear, non-quantitative messages about high levels of nutrients of concern, demonstrated the greatest efficacy to decrease the perceived healthfulness of a sweetened fruit drink across countries. This effect was similar across demographic characteristics.

The rapid growth in web-based grocery food purchasing has outpaced federal regulatory attention to the online provision of nutrition and allergen information historically required on food product labels. We sought to characterise the extent and variability that online retailers disclose required and regulated information and identify the legal authorities for the federal government to require online food retailers to disclose such information.

We performed a limited scan of ten products across nine national online retailers and conducted legal research using LexisNexis to analyse federal regulatory agencies’ authorities.

USA.

N/A.

The scan of products revealed that required information (Nutrition Facts Panels, ingredient lists, common food allergens and per cent juice for fruit drinks) was present, conspicuous and legible for an average of only 36·5 % of the products surveyed, ranging from 11·4 % for potential allergens to 54·2 % for ingredients lists. More commonly, voluntary nutrition-related claims were prominently and conspicuously displayed (63·5 % across retailers and products). Our legal examination found that the Food and Drug Administration, Federal Trade Commission and United States Department of Agriculture have existing regulatory authority over labelling, online sales and advertising, and Supplemental Nutrition Assistance Programme retailers that can be utilised to address deficiencies in the provision of required information in the online food retail environment.

Information regularly provided to consumers in conventional settings is not being uniformly provided online. Congress or the federal agencies can require online food retailers disclose required nutrition and allergen information to support health, nutrition, equity and informed consumer decision-making.

To assess the attitudes and perceived knowledge of health professionals regarding the food product judgemental-labelling reform that began in January 2020 in Israel.

Cross-sectional survey.

An online survey among health professionals working in the Israeli health system.

456 participants (118 physicians, 207 nurses, 131 nutritionists).

Most respondents (89·9 %) were women, 36 % had over 20 years of professional experience. All nutritionists, 96·6 % of physicians and 94·7 % of nurses reported hearing about the reform, and most (88·9 % of nurses, 76·3 % of physicians and 75·6 % of nutritionists) claimed supporting the reform to a great or very great extent. Most respondents believe they should discuss issues related to healthy eating with their patients (91·8 % of nurses, 94·9 % of physicians and all nutritionists), but only about half (47·5 % of physicians and 57·0 % of nurses) reported that they have sufficient knowledge in this field, particularly about food labelling. Almost two-thirds of nutritionists (60·3 %) reported instructing patients to change their food intake according to labelling v. 40·1 % and 34·7 % of nurses and physicians, respectively. Only some respondents felt that they could influence their patients’ nutrition habits. Most participants believe that additional regulatory measures should also be used to promote healthy nutrition.

There is a gap between the desire of physicians and nurses to provide nutritional guidance to the public and their actual knowledge about the labels’ meaning as well as their competencies in providing nutrition counselling. When formulating a reform, policymakers should provide clear guidelines about the expectations of implementing it in therapeutic practice.

To compare the degree of strictness and agreement of different nutrient profiling models (NPM) used to identify which foods would be required to show front-of-package (FOP) warning labels.

Using data of 11 434 packaged foods found in the five largest food retailers in Brazil, we used two published NPM: the Pan American Health Organization (PAHO) model and the NPM used in the Chilean nutritional FOP labelling policy, and compared them with a NPM proposed by the Brazilian National Health Surveillance Agency (Anvisa). The proportion of foods that would be required to show FOP warning labels was calculated overall and by food category. We also tested whether a modified version of the PAHO NPM would behave similarly to the original version.

Brazil.

Two-thirds of the packaged products (62 %) would receive FOP warning labels under the PAHO NPM, as compared with 45 % of products using the proposed Anvisa NPM and 41 % if the Chilean NPM was applied. The PAHO NPM identified more foods high in critical nutrients such as sweetened dairy and non-dairy beverages, canned vegetables and convenience foods. Overall agreement between models was considered good with kappa coefficient ranging from 0·57 to 0·92 but was lower for some food categories.

We found variations in the degree of strictness and agreement between assessed NPM. The PAHO NPM identified more foods and beverages high in sugar which are among the top contributors to sugar and energy intake in Brazil.

To explore on-package formula messaging with reference to legislation and government-issued guidance in Great Britain (GB).

Formula products were identified, pictures of all sides of packs collated and on-package text and images were coded. Compliance with both GB legislation and guidance issued by the Department of Health and Social Care (DHSC) was assessed.

All formula packs that were available for sale over the counter in GB between April and October 2020.

Formula packs (n 71) including infant formula, follow-on formula, growing-up formula and specialist formula were identified, coded and analysed.

In total, 41 % of formula packs included nutrition claims, and 18 % included health claims that may be considered non-permitted, according to DHSC guidance. Additionally, 72 % of products showed images considered ‘non-permitted’. Breast Milk Substitute (BMS) legislation states infant and follow-on formula packs should be clearly distinguishable but does not provide criteria to assess similarity. Based on DHSC guidance, 72 % of infant and follow-on formula packs were categorised as showing a high degree of similarity. Marketing practices not covered by current legislation were widespread, such as 94 % of infant formula packs including advertisements for follow-on or growing-up formula.

Text and images considered non-permitted according to DHSC guidance for implementing BMS legislation were widespread on formula products available in GB. As terms such as ‘similarity’ are not defined in BMS legislation, it was unclear if breaches had occurred. Findings support the WHO call for loopholes in domestic legislation to be closed as a matter of urgency.

Childhood obesity is on the rise in South Africa (SA), and child-directed marketing (CDM) is one of the contributing factors to children’s unhealthy food choices. This study assessed CDM on packaged breakfast cereals available in SA supermarkets and their nutritional quality.

Photographic images were examined in a descriptive quantitative study. A codebook of definitions of CDM was developed for this purpose. REDCap, an online research database, was used for data capturing, and SPSS was used for data analyses including cross-tabulations and one-way ANOVA.

The current study was set in the Western Cape province of SA.

Photographic images of all packaged breakfast cereals sold in major retailers in the Western Cape province of SA in 2019 were studied.

CDM strategies were classified as direct (to the child) or indirect (through the parent). A total of 222 breakfast cereals were studied, of which 96·9 % had a nutritional or health claim, 95·0 % had illustrations, 75·2 % had product and consumption appeals, 10·8 % had characters, 10·8 % consisted of different appeals, 8·6 % alluded to fantasy and 7·7 % had role models. In breakfast cereals with direct CDM, the protein and fibre content was significantly lower than in breakfast cereals without direct CDM. This study found a significantly higher total carbohydrate and total sugar content in breakfast cereals with direct CDM than those without direct CDM.

CDM was highly prevalent in breakfast cereals sold in SA. Regulations to curb the marketing of packaged foods high in nutrients of concern is recommended.

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.

To examine differences in noticing and use of nutrition information comparing jurisdictions with and without mandatory menu labelling policies and examine differences among sociodemographic groups.

Cross-sectional data from the International Food Policy Study (IFPS) online survey.

IFPS participants from Australia, Canada, Mexico, United Kingdom and USA in 2019.

Adults aged 18–99; n 19 393.

Participants in jurisdictions with mandatory policies were significantly more likely to notice and use nutrition information, order something different, eat less of their order and change restaurants compared to jurisdictions without policies. For noticed nutrition information, the differences between policy groups were greatest comparing older to younger age groups and comparing high education (difference of 10·7 %, 95 % CI 8·9, 12·6) to low education (difference of 4·1 %, 95 % CI 1·8, 6·3). For used nutrition information, differences were greatest comparing high education (difference of 4·9 %, 95 % CI 3·5, 6·4) to low education (difference of 1·8 %, 95 % CI 0·2, 3·5). Mandatory labelling was associated with an increase in ordering something different among the majority ethnicity group and a decrease among the minority ethnicity group. For changed restaurant visited, differences were greater for medium and high education compared to low education, and differences were greater for higher compared to lower income adequacy.

Participants living in jurisdictions with mandatory nutrition information in restaurants were more likely to report noticing and using nutrition information, as well as greater efforts to modify their consumption. However, the magnitudes of these differences were relatively small.

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.

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.

The Keyhole is an internationally recognised front-of-pack nutrition label, guiding consumers to healthier food options. It indicates products in accordance with specific criteria for dietary fats, sugars, fibres, salt and wholegrains. The objective of this study was to simulate the potential impact of the Keyhole on adolescents’ energy and nutrient intakes by modelling a shift from reported food intakes to foods meeting the Keyhole criteria.

Self-reported dietary intake data were derived from a cross-sectional survey. Multiple replacement scenarios were calculated, where foods meeting the Keyhole criteria replaced reported non-compliant foods with varying proportions of replacement.

Dietary survey ‘Riksmaten Adolescents 2016–2017’ in schools across Sweden.

A nationally representative sample of 3099 adolescents in school years 5, 8 and 11 (55 % girls).

Overall, replacement with foods meeting the Keyhole criteria led to more adolescents meeting nutrition recommendations. Largest median intake improvements were seen for wholegrains (+196 %), SFA (-13 %), PUFA (+17 %) and fibres (+15 %). Smallest improvements were seen for free sugars (-3 %) and salt (-2 %), partly explained by the ineligibility of main food sources of free sugars for the Keyhole, and non-inclusion of ready meals that are often high in salt. Most micronutrient intakes were stable or improved. Unintentional effects included decreases in vitamin A, MUFA and energy intakes. Largest potential improvements in fat and fibre sources were observed in the youngest age group.

A shift to Keyhole alternatives for everyday foods would improve adolescents’ nutrient intakes, even with smaller exchanges.

Many countries are considering the implementation of front-of-pack nutrition labels as a strategy to address high and increasing levels of overweight and obesity. A growing body of work demonstrates the superiority of labels that use colour and/or provide a summary indicator of product healthiness to enhance comprehension. However, previous studies have been confounded in determining the relative effectiveness of these two attributes by comparing labels that also differ in other ways. The present study tested labels that varied only on use of colour and/or reliance on a summary indicator across an international sample to provide unique insights into the relative importance of these attributes.

Participants were randomised to see one of four variations of the Health Star Rating label that differed on the basis of use of colour and sole provision of a summary indicator.

Australia, Canada, China, India, New Zealand, the UK and the USA.

Adults (n 7545) in seven countries were exposed to online choice tasks requiring them to select a preferred breakfast cereal and then nominate the healthiest cereal.

Overall, the coloured versions, and particularly the one with just a summary indicator, outperformed the monochrome version that included nutrient-specific information. However, there were some differences by country, with results from Canada and China indicating superior outcomes for monochrome labels and those providing nutrient-specific information.

The results highlight the importance of colour, but suggest that the introduction of front-of-pack nutrition labels should be preceded by country-specific formative testing to identify potential differences in outcomes.

To explore how some of the largest food companies involved in producing alternative proteins (AP) use health and nutrition claims to market their products.

We identified the largest food manufacturers, meat processors and AP companies selling plant-based AP products in the USA. Using publicly available data, we analysed the voluntary health and nutrition claims made on front-of-pack labels (FOPL) and company webpages. We also analysed company websites for further nutrition and health-related statements about their products or AP more generally. Claim classification was guided by the INFORMAS (International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring, and Action Support) taxonomy for health-related food labelling.

USA.

Not applicable.

1394 health and nutrition-related FOPL claims were identified on 216 products, including 685 nutrition claims and 709 ‘other health-related’ claims. No FOPL health claims were identified. Most nutrient claims were for nutrients associated with meat, with 94 % of products carrying a protein claim and 30 % carrying a cholesterol claim. 74 % of products carried a GMO-free claim, and 63 % carried a plant-based claim. On their websites, some companies expanded on these claims or discussed the health benefits of specific ingredients.

Companies involved in this category appear to be using nutritional marketing primarily to position their products in relation to meat. There is a focus on nutrient and ingredient claims, with discussion of processing largely avoided. The findings highlight the challenges companies face in positioning AP products as healthy against the backdrop of debates about ultra-processed foods.

There is a lack of qualitative research developing sugar-sweetened beverage (SSB) warning labels with their intended end users. We sought to identify promising SSB warning elements for improving label effectiveness and for future testing in policy and institutional settings.

Mixed methods design using ten focus groups, a design task and a survey. The design task was used to generate ideas for an icon that would dissuade SSB consumption. The survey and focus group guide assessed participant perceptions of SSB warning label mock-ups of text (loss frame, gain frame and loss frame with attribution), colour and icon options.

Three large public universities in California from February to March 2018.

Young adult SSB consumers (n 86) enrolled in one of three diverse California public universities.

Participants perceived the following elements as most effective for reducing SSB consumption: loss-frame text with attribution to a credible source, yellow and red colour for label background and an image or icon to accompany the text. Preferred images included sugar near or inside of an SSB, intuitive shapes like a triangle with exclamation mark or octagon and a visual indicator of SSB sugar content compared with recommended limits. Support was high for using SSB warning labels in university cafeterias and on bottles/cans.

Loss-frame text with a credible source, yellow or red label colour and icons could potentially enhance effectiveness of SSB warning labels and warrant further testing.

To analyse the process for the development and implementation of mandatory nutritional warning labels in Uruguay, in order to inform future nutrition policy making and strategic engagement by public health actors.

The study design drew on policy analysis methodology and case study research methodology. Two main sources of information were selected and analysed for the current study: eighteen official documents from the Uruguayan government and 259 news reports, published between June 2017 and February 2021.

Uruguay, Latin America.

The Uruguayan Ministry of Public Health led a cross-sectoral working group composed of diverse governmental stakeholders, international organisations and the academia to develop the front-of-package nutrition labelling policy. A robust evidence-based approach, based on rigorous scientific knowledge generated in the country, was followed. However, changes in the systemic governing coalition as a consequence of a change in government led to a delay in the entry into force and changes in the regulation. The food industry was the main opponent to the warning label regulation and relied on widely reported corporate political activities to influence the policy process: information and messaging, legal action, policy substitution, opposition, fragmentation and destabilisation.

Key insights to inform future policy action in Uruguay and other jurisdictions were derived. Results stressed the importance of an evidence-based approach for policy design and the early engagement with actors from all the political system.