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Completed

NCT Number: NCT04172337

Testing the Effects of Singapore's Front-of-Pack Healthier Choice Symbol Label With or Without a Physical Activity Equivalent Label

Poor diets are known risk factors for chronic diseases, and in recent years, food labelling has been increasingly sought-after as a cost-effective intervention to help stem the rising trend in chronic diseases.

In efforts to promote a healthy diet, the Singapore Health Promotion Board (HPB) supplements traditional nutrition labelling with the Healthier Choice Symbol (HCS), which identifies food items within a specific category of foods as healthier choices. The original logos were enhanced to include additional information focusing on particular macronutrients, taking one of two themes; it either indicates that a product contains more of a healthier ingredient, or less of a less healthy ingredient.

However, to date, no published studies have assessed the role of the original and enhanced HCS logos in influencing food choices. There is a lack of scientific evidence on the role of the existing symbols in assisting consumers make healthier food purchasing decisions. There are also concerns over the unintended consequences of health claims made based on a single aspect of nutrient content, without considering other aspects. That is the goal of this effort. Specifically, the investigators

propose to conduct the following:

Use a three arm randomized controlled trial (RCT) and an experimental fully functional web-based grocery store to assess the causal effect of the new HCS logos on measures of diet quality either alone, or in combination with a complementary front-of-package (FOP) label: Physical Activity Equivalents (PAEs), which provides information on how long one would need to engage in a certain activity (e.g., jogging) to burn off one serving of the product.

The investigators hypothesize that the greatest reduction in calories per serving (primary outcome) will occur in the HCS plus PAEs arm, followed by HCS only, and no logo control arm.

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Key information

Conditions

Obesity Body Weight Diabetes Diabetes Mellitus Diet, Healthy Endocrine System Diseases Glucose Metabolism Disorders Metabolic Diseases Nutrition Disorders Nutritional and Metabolic Diseases Overnutrition Overweight Pathological Conditions, Signs and Symptoms Signs and Symptoms

Age range

21 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

Duke-NUS Medical School

Singapore, 169857

Who can participate

Healthy volunteers accepted: Yes

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

  • Singapore residents
  • 21 years of age and above
  • Primary grocery shopper for the household

Exclusion criteria

  • Not residing in Singapore
  • Under 21 years of age
  • Not the primary grocery shopper for the household

Treatment and study plan

Healthier Choice Symbol

Behavioral

The HCS is intended to improve diet quality by signaling to consumers which products are healthier options within a specific category (e.g., which are the healthier biscuits or the healthier beverages). Manufacturers must meet category-specific criteria before a product can display the HCS and an associated tagline. The labels were displayed at the bottom of the product images.

Physical Activity Equivalent label

Behavioral

For the study, we designed a simple PAE logo (Appendix Figure A1) and added a description encoded into the NUSMart user interface to ensure that participants would understand the contents of the label. Participants saw the following description whenever their cursor hovered over the PAE label: "The Physical Activity Equivalent (PAE) refers to the number of minutes that a typical adult would need to jog to burn off the calories associated with one serving of the product." Previous studies have shown this labelling approach to be effective.

The labels were displayed at the bottom of the product images.

Primary outcomes

  1. Change in average calories per serving purchased per shopping trip

    Time frame: Once a week for three weeks

    Calories per serving (kCal per serving) is calculated by dividing the total number of calories purchased in the shopping trip by the total number of servings purchased. The average calories per serving purchased (kcal per serving) is based on mean standardized serving sizes within each subcategory.

Secondary outcomes

  1. Proportion of HCS labelled products purchased (or would have been if not in control arm) per shopping trip

    Time frame: Once a week for three weeks

    Calories per Shopping Trip will be calculated as the sum of all purchased products' total calories.

  2. Total Calories per shopping trip

    Time frame: Once a week for three weeks

    Total calories purchased in kcal.

  3. Diet quality per shopping trip as measured by the Grocery Purchase Quality Index-2016

    Time frame: Once a week for three weeks

    Diet quality per shopping trip as measured by the Grocery Purchase Quality Index-2016 (GPQI-2016). The Grocery Purchase Quality Index-2016 (GPQI-2016) contains 11 different food components with eight components scored based on adequacy and three moderation components. We followed the standard GPQI-2016 scoring methods by mapping NUSMart's subcategories to USDA food plan categories and then to the GPQI components. Each component was scored based on the deviation of the observed expenditure share of each component and the expected expenditure share, and the scores were totaled up to generate the final GPQI-2016 score (minimum possible score = 0, maximum possible score = 75) for each participant's weekly grocery order. A higher score indicates better diet quality of the grocery basket.

  4. Diet quality per shopping trip as measured by weighted average Nutri-Score

    Time frame: Once a week for three weeks

    We applied the standard Nutri-Score algorithm to assign a grade to each product. This algorithm assigns a score of A to E based on nutritional quality, which we recoded to 5 to 1 and then calculated an average score for each participant's weekly grocery order (minimum possible score = 0, maximum possible score = 5), weighted by the number of servings of each product. A higher score indicates better diet quality of the grocery basket.

  5. Sugar per serving per shopping trip

    Time frame: Once a week for three weeks

    Amount of sugar (g) per serving purchased based on mean standardized serving sizes within each subcategory.

  6. Sodium per serving per shopping trip

    Time frame: Once a week for three weeks

    Amount of sodium (mg) per serving purchased based on mean standardized serving sizes within each subcategory.

  7. Saturated fat per serving per shopping trip

    Time frame: Once a week for three weeks

    Amount of saturated fat (g) per serving purchased based on mean standardized serving sizes within each subcategory.

  8. Calories per dollar spent per shopping trip

    Time frame: Once a week for three weeks

    Number of calories per dollar (kcal per dollar) spent

Sponsors and collaborators

Lead sponsor

Duke-NUS Graduate Medical School

Other

Collaborators

  • National Medical Research Council (NMRC), Singapore

Registry information

Official study title

A Randomized Controlled Trial Testing the Effects of Singapore's Front-of-Pack Healthier Choice Symbol Label With or Without a Physical Activity Equivalent Label on Food Purchases and Measures of Diet Quality

Important dates

Study start
2019
Primary completion
2019
Study completion
2019
First posted
Nov 21, 2019
Registry last updated
Nov 21, 2019

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

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This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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