Recommendations for an educational programme to improve consumer knowledge of and attitudes towards nutritional information on food labels

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Recommendations for an educational programme to improve consumer knowledge of and attitudes towards nutritional information on food labels
+D J Anderson, MDipTech
*D J Coertze, DSc, MBL
+Department of Food and Nutrition, Technikon Natal, Durban
*Centre for Enterprise Development, Technikon Natal, Durban

S A J Clin Nutr 2001 Feb Vol 14 No 1 pp 28-35

Abstract

Background
The needs and objectives of the various groups affected by nutritional labelling illustrate the complex and controversial nature of nutritional labelling and the problems in formulating a simple and easily understood system.

Design
Twenty homogeneous white middle-income suburbs were chosen at random from a total of 39 strata. The multistage cluster method of sampling was used to divide each suburb into smaller clusters. One area was chosen at random from each suburb. Twenty homes were then systematically selected to bring the total sample number of respondents to 400.

Method
White middle-income women completed a questionnaire analysing consumer attitudes towards and knowledge of nutritional labelling in order to identify the objectives needed for the formulation of an educational programme concerning the nutritional labelling of food containers.

Results
The results of the survey suggest that although white middle-income women (N = 388) lacked nutritional labelling knowledge (pass rate < 20%), they had a positive attitude towards nutritional labelling (mean 18.29 ± 4.8). As knowledge scores increased, the following factors became more positive: attitudes towards nutritional labelling (R = 0.2905, P = 0.0000), nutritional education (c2 = 40.9273, P = 0.01), and the use of nutritional labelling in the purchase of food (r = 0.2230, P = 0.0258).

Conclusions
The results of this survey suggest a definite need for a nutritional labelling education programme in South Africa. Although the subject group could be considered representative of the top end of the South African market, a comprehensive needs assessment of the relevant target markets that make up South Africa's diverse population should be undertaken for the formulation of a national nutritional education programme.

The prevalence of chronic diseases of lifestyle has focused attention on the link between diet and disease, with nutritional labelling playing an increasingly prominent role in the prevention and reduction of these diseases.1-3 The role of saturated fatty acid intake in elevating serum low-density lipoprotein (LDL) cholesterol levels as a risk factor for coronary heart disease4-6 has increased the importance of nutritional labelling in informing consumers about fat content, kilojoules and total kilojoules from fat.7,8 The use of food fortification in the prevention of micronutrient deficiency diseases that affect the majority of South African consumers is a strategy that is being encouraged by the World Health Organisation and the Department of Health.10-13 The role of micronutrients in the prevention and treatment of the chronic diseases of lifestyle has also generated much interest, evident in the growth of the functional foods market.14-17 The worldwide furore over the safety of genetically engineered foods has re-emphasised the consumer's need for adequate labelling.18 Nutritional labelling, therefore, has an important part to play in conveying nutritional information to all South Africans to promote a positive change in food choice.

The existing labelling regulations were promulgated in 1993. Substantial changes to these labelling regulations are currently under discussion. The new regulations will introduce five types of claim categories, including nutrition function and health claims.19,20 Although nutritional labelling will not be mandatory, an increasing number of food manufacturers are providing nutritional information on their products in order to maintain their position in the market. The ability of the consumer to use this information effectively or even to comprehend it is, however, questionable.7,20-24 The situation is aggravated by lack of uniformity in the label information format20,25-28 and a lack of enforcement of current labelling legislation which hinders the implementation of consistent, practical labelling legislation.27,28

At present, the largest source of nutritional information for consumers is the media. This information is not always accurately reported and does not necessarily reflect recent overviews of scientific thinking.20,21,29 Although the Department of Health is to distribute an information brochure,27,30 greater emphasis should be placed on education than on information transfer.21,27,29,31,32 Through effective education, the public will be empowered to make informed, rational market choices with confidence.21,32,33

This study identified the recommendations needed for an educational programme to improve consumer knowledge of and attitudes towards nutritional labelling. This was done by evaluating the effectiveness of nutritional labelling in terms of consumer attitudes towards and knowledge of nutritional information on food labels.

Methods
A proportional non-self-weighting sample of 400 white married women between the ages of 18 and 55 years, who had attained at least a standard 10 level of education, and who lived in middle-income areas situated within the Durban magisterial district, was used. Middle income was defined as people who earned between R10 000 and R49 999 per annum (1993 figures).34

The multistage cluster method of sampling was used35 to derive a representative sample of consumers because of the homogeneous nature and size of this sector of South Africa's population as well as the time and financial constraints. These areas were listed alphabetically and 20 middle-income suburbs or strata were chosen at random from a total of 39 strata using the Stat Graphics Plus Version 6 SGPLUS Manugistics, Inc. statistical software programme. The number 20 was chosen to decrease the non- response rate. Ten interviewers interviewed 10 respondents in two areas to make up the total of 400 respondents. A wider area was therefore covered to decrease the non-response rate in order to ensure effective representation of the population.

In the second stage of the sampling selection, each suburb was divided into smaller areas or clusters using the Central Statistical Service area listing for each suburb.36 The areas within each suburb were listed numerically in ascending order and one area was chosen at random from each suburb using the Stat Graphics statistical software computer programme.34,35 Twenty homes were systematically selected within each of the 20 clusters to bring the total sample number of respondents to 400, which was representative of the population.

The multistage cluster method of sampling was preferred, as the consumer was required to use the information on the labels of the cereal boxes in order to answer the questions. Ten interviewers from the human Sciences Research Council (HSRC) were selected to carry out personal interviews in each area of the selected suburb from 13 July 1993 to 9 August 1993. All interviewers participated in the pre- testing as well as in the final survey. Training took place to standardise the methodology of interviewing as well as to report the responses of the consumer.

The 30-minute questionnaire, using a four-point Lickert scale, elicited information on consumer attitudes. The data were processed using the Stat Graphics statistical software programme. Analysis of the responses was made after conversion to a percentage value. The four-point Lickert scale was interpreted by converting these categorical values using a rating scale of 1 - 30. Modal scores were used as the main tool for interpretation and mean scores and standard deviations (SD) were given for each question (Table I). Correlation between consumer attitudes and usage was measured using Pearson's moment correlation. The values reported as P = 0.0000 did not mean that P = zero, but that the significance level was very close to zero. In the statistical analyses using Pearson's moment correlation, correlations with a value of 0.4 - 1 were used with a significance level of less than 0.01. These figures represented correlations at a significant level even if they were at the lower end of the scale. Correlations lower than 0.4 were not reported except where relevant. The McNemar c2 test was used to test for significance between responses and multiple correlation was used to measure the correlation between knowledge and attitudes. Knowledge of nutritional labelling was tested using true and false questions to assess general labelling knowledge. Specific nutritional knowledge was tested using multiple-choice questions and open-ended questions to record the reasons for the answers given. Four cereal boxes differing in content quantity and format of nutritional information were exhibited during the interview. The four selected cereals were Kellogg's All Bran Flakes, Kellogg's Coco Pops, Pronutro and Ideal Mix Muesli. Answers to the knowledge questions were ranked using a scale of 1 - 3 (Table II) and a percentage value and mode were given for each question. The significance between knowledge scores and independent variables was tested using the McNemar c2 test for variance.

Results
The typical survey respondent was an English-speaking white woman between the ages of 18 and 55 years, who earned an income of R10 000 - R49 999, lived in the Durban magisterial district, had a Standard 10 level of education, ate cold breakfast cereal more than once a month, did not follow a special type of diet, and was responsible for the planning and purchasing of household groceries. A total number of 388 questionnaires was accepted for data analysis.

Consumer attitudes towards nutritional labelling on food containers The total mean score was 18.29 ± 4.8 on a scale of 1 - 30, which suggests a positive leaning of consumer attitudes towards nutritional labelling.

Consumers indicated that they read food labelling (64.8%) when purchasing food items, with a higher percentage using labelling in the purchase of a new product (79.2%). More consumers read nutritional labelling at home (57.8%) than during general food purchasing (52.8%). Consumers who read nutritional information also claimed to understand it (r = 0.6654); and use it to assist them in making food purchases (r = 0.6973). Consumers who used nutritional labelling generally when purchasing food read this information more often (r = 0.6973 compared with r = 0.4741), but had a lower understanding of nutritional labelling (r = 0.2230, compared with r = 0.5792) than those consumers who used it when purchasing new products.

Consumers who wanted more nutritional information on food labels (mean (SD) 15 (11), mode 20, N 108) claimed to use nutritional information more often (r = 0.5158) than those who did not want more of this kind of information. A stronger correlation was recorded for consumers who wanted more information on food labels and those who read nutritional labels (r = 0.6412), than for consumers who actually used nutritional information (r = 0.5158) on food labels when purchasing food. Consumers who wanted more information were also correlated with those who wanted a more standardised form of nutritional information (r = 0.5833). Consumers wanted more nutritional information to plan daily nutrient intakes (r = 0.4170), as well as when 'planning meals' (r = 0.4722). Consumers who wanted more information also thought that the food label was the right place for information on diet-related diseases (r = 0.5158). Consumers viewed diet-related disease statements in a positive light and believed that food manufacturers should fully disclose their products, for example, positive statements made about a product should be accompanied by the statement of any negative aspects. Consumers regarded price and habit as important factors in food purchasing (r = 0.5701), but felt that nutritional information for a healthy food choice could rival price under certain conditions (r = 0.5380). Habitual shoppers did not use nutritional labelling in general (r = -0.4787) and did not see the need for more nutritional information on food labels (r = - 0.5788). Consumers concerned about their health (r = 0.4447) and those who ate different types of food in moderation (r = 0.7585) wanted more nutritional education, whereas habitual shoppers concerned with price did not. Consumers who expressed a need for education believed that this would help in food purchase (r = 0.7585) and the reduction of diet-related disease (r = 0.4600). The need for more nutritional education had a moderate positive correlation with consumers who wanted more nutritional education and not only more information on food labels (r = 0.4059). The need for 'more nutritional education' rather than only an increase in nutritional information on food labels was not correlated with nutritional education 'helping food purchase' or nutritional education 'decreasing diet-related disease'. This indicates that consumers not only wanted more education, but also an increase in the amount of nutritional information on food containers.

Consumer knowledge of nutritional information on food labels Most consumers (28.8%) answered between 8 and 9 out of a total of 22 questions correctly. General questions that were well answered (over 60% answered correctly, Table II) included questions on consumer knowledge of types of sugars, definition for the term 'enriched', recommended daily intake of dietary fibre, and what the letters 'RDA' stand for (this was printed on the cereal boxes). Questions that were poorly answered included knowledge of the order ingredients were listed in, the cholesterol content in margarine, whether vegetable oils are saturated, composition and pesticide residue of 'organic' foods, and the definition of RDA. Consumers thought that RDA was the required daily amount of nutrients in the diet instead of the recommended amount.

In the specific category where consumers used the nutritional information on cereal boxes to answer questions, those questions relating to protein content, energy content, reason for choice, and a calculation regarding nutrient intake, were well answered. Most consumers chose the incorrect answer for question 62, which required the consumer to choose the cereal with the highest iron content, but the reason they gave was correct. All Bran Flakes contained the highest amount of iron, and this was clearly stated on the box in the form of a nutritional claim. This indicated that consumers did not take much notice of nutritional claims. The answer to question 66 did not have to be calculated, as the information was on the cereal box. The answer to question 65, which was not answered as well as question 66, had to be calculated using a calculator. Questions that were not well answered included the reason for the particular choice of cereal for heart disease or high blood pressure. Consumers knew about the association between fat and heart disease (not specifically saturated fat), but few knew about the fibre connection, and only 16% answered correctly that both fat and fibre were the significant criteria. Question 64 stated that Pronutro had no sugar content. A total of 43% of consumers agreed with this statement even though sugar was listed as one of the ingredients.

The significance between knowledge scores and the independent variables was tested using the McNemar c2 test for variance. Age was significant at P = 0.04. The tabulation showed that the 18 - 25- year-old age group had the least nutritional knowledge (17.6%), but that the 26 - 35-year-old age group had a better knowledge score (35.7%) than the 36 - 45-year-old and the 46 - 55-year-old age groups. Level of income was also significant at P = 0.09, which indicated that as the level of income rose, so did the level of nutritional knowledge. Level of education was not shown to be significant in this study. Correlation between consumer attitudes towards and knowledge of nutritional information on food labels Questions 10 - 42 and 43 - 58 measured the correlation between consumer attitudes and knowledge respectively (Fig. 1). Questions 10 - 42 were summed to make a single variable. A rating scale of 1 - 30 was used for each question, the total possible score ranging from 34 to 1 020. The mean score for the 34 questions was 616.3008 ± 40.8. The knowledge questions (questions 43 - 58) were grouped into five classes to make five variables according to their frequency distribution. This was done to obtain classes with similar means, which were used to measure the correlation between consumer attitudes towards and knowledge of nutritional information on food labels. The responses to the questions were only taken as correct if a correct answer could be given to the succeeding question, e.g. question 56 asked the respondent to choose the most correct cereal for a person suffering from heart disease. Question 57 then asked the respondent to give a reason for the answer given in question 56. As nutritional knowledge increased, attitudes towards nutritional information on food labels became more positive.7,24 The low positive multiple correlation of R = 0.2905 was significant at P = 0.0000. Even though the correlation coefficient was low, it was significantly different from zero. The sample size of 388 people also rendered this correlation significant.

Significant relationships were tested for using the McNemar c2 test for variance between knowledge treated as a single variable, and the attitude questions. The results indicated that those consumers who had high nutritional knowledge scores were more inclined to read nutritional labels, which helped in the purchasing of food. The findings also showed that the higher the consumers' nutritional knowledge scores, the more important they regarded the education of consumers to be in terms of nutritional labelling for food purchasing and disease prevention.

Discussion
Consumer attitudes towards nutritional information on food containers Although consumers used nutritional labelling as an information source, there was no guarantee that they understood the information. Because more consumers claimed to read nutritional information on food labels at home than in the supermarket, this implies that when the consumer has more time available the information is processed more extensively. There was greater reference to nutritional labelling when purchasing new foods than routine food items. This suggests that beliefs that were important when initially purchasing food later gave way to habit. This is to be expected because of the time constraints on consumers when purchasing food.7,24

The need for more information, and also for more standardised information, was evident. This indicated that certain labelling issues were not being addressed. Consumers who wanted more nutritional information on food labels seemed to be inclined to use this information to a greater extent, e.g. for planning daily energy intake and when planning meals at home. This underlies consumers' need for more nutritional information and also for personalised information. Those consumers who wanted more nutritional information favoured the food label as the appropriate place for diet-related disease statements.

The influence of factors such as price, habit, health consciousness, and eating in moderation on food purchase indicated that consumers were generally price conscious. This was to be expected in the light of the current economic situation. These findings correspond with a report on South African consumers,21 which also stated that price was more important to consumers who habitually purchased food items than to health-conscious consumers. Health-conscious consumers played an active role in seeking product information and indicated their desire for education regarding nutritional labelling. Although the perceived risk for food choice (i.e. the harmful effect of food substances on health) was not as great for consumers who 'eat food in moderation' as it was for health-conscious consumers, it was nevertheless significant.

Consumers expressed their need for more nutritional education to equip them to read food labels, which would help in the purchase of food and ultimately in the prevention of disease. Consumers seemed to believe that more emphasis should be placed on education than on the provision of more information, but that more information was needed. In the past greater emphasis has been placed on the dissemination of nutritional information than on dietary behaviour.37 The literature reports that nutritional information that is perceived as self-relevant elicits voluntary attention and is processed more extensively.29,38,39 The provision of nutritional information that actively involves consumers in problem-solving tasks is more likely to be successful in motivating a change in food choice and the attainment of the US dietary guidelines used in south Africa.37,40,41

Consumer knowledge of nutritional labelling
Overall, nutritional knowledge questions were not all well answered. Questions based on the nutritional labelling format printed on the cereal box revealed that most consumers did not use the list of ingredients or nutritional claims as an informational tool. Comparisons using the numerical method of 100 g (ml) were not well received.22,25 The calculation involving the conversion (question 65, Table II) was poorly executed. The difference in the serving sizes or the way in which the information was given could have influenced three of the questions specific to the cereal label. These questions, which were not well answered, related to the fat, fibre, sodium and iron content of the cereals. Consumers had some idea what the purpose of the recommended daily allowance (RDA) was, but the perception that the RDA represented the 'required' and not the 'recommended' level of nutrients to be used as a guideline for nutrient consumption was evident.

Respondents had some knowledge of nutritional terminology, for example the different terms used to indicate the presence of sugar in food. The South African regulations concerned with labelling of food containing sugar were amended at the time of the survey42 to prevent manufacturers from misleading the consumer. In the past, consumers were unaware that 'sugar' is the common name for sucrose,20 with other forms of sugar being exclusive of this term. The media coverage during the period when the regulations were changed could have had an impact on increasing consumer knowledge in this respect. The term 'sodium', which commonly appears on food labels, was not well known, whereas the term 'enriched' was known by 72% of the respondents. A high confusion rate was noted as far as the composition of organic foods was concerned.21,22,42 Reports of confusion regarding terms such as 'polyunsaturated' and 'saturated' fat, 'RDA', 'natural', 'fresh', '0% cholesterol', 'sodium', 'kilojoules', 'carbohydrates', and 'sugar' have been made in this country and overseas.21,22,29,43 As far as the function of nutrients was concerned, consumer knowledge was fairly good except for the function of fibre in preventing heart disease and the association between salt and high blood pressure. This was consistent with reports on British consumers.22 Sources of nutrients, such as cholesterol and saturated fats, were not well known. Although Pronutro was recognised for its high energy content, it seems very likely that consumers drew on their past experience in answering this question. Reasons for this may be that nutrient claims and information listed as numerical values were not well understood, and that Pronutro has been well advertised as a high-energy breakfast cereal in the past. Another indication of consumers relying on their own knowledge and not reading the label is that All Bran cereal is widely advertised as a high-fibre cereal but not as being high in iron. Consumers did not know that this cereal had the highest iron content.

Although consumers had some nutritional knowledge, they did not have good nutritional knowledge in any particular area, such as sources or functions of nutrients. Reports from the HSRC interviewers who the conducted the interviews together with the results of this study indicate that consumers relied on television advertisements for a substantial amount of their product knowledge. Although the media can be used as a source of nutritional information to educate consumers both at home and at point of purchase,44 commercials broadcast on television often promote foods high in fat and/or sugar, with a relatively low nutrient intake.45 Consumer complaints regarding misleading commercials have also been reported in the literature.46-48 Cognisance therefore needs to be taken of the impact of these commercials on food choice.20,29,45,49

The results of this study indicate that although consumers do use nutritional labelling when purchasing food, this does not mean that they understood the information on the food label. This may explain the difference in the results between a positive consumer attitude towards nutritional labelling, and poor consumer nutritional knowledge. As consumer knowledge increased, so did label usage and the desire for more nutritional education to aid food purchase and disease prevention. The positive correlation between attitude and knowledge, which has also been widely reported in the literature,23,24,43,50 indicates that an effective nutritional educational programme can motivate consumers to make more use of nutritional labelling to make healthier food choices and subsequently change their eating habits. In order for the consumer to follow the dietary guidelines, for example reducing salt intake, nutritional labels must provide this information and the consumer needs to be educated as to the minimum amount of salt needed per day. The argument that standardised information should precede an educational programme to be of any real benefit is flawed as consumers become confused by the proliferation of information, their confidence in the food industry and their attitude towards healthy eating weaken, and medical costs rise.

Recommendations for a nutritional education programme
The results of this study suggest that the following nutritional attitudes and knowledge need to be addressed in a nutritional educational programme on the labelling of food containers. Nutritional attitudes should aim: (i) to motivate consumers to make use of nutritional information on food labels in order to choose foods that will contribute to a balanced diet, thus maintaining their health; (ii) to encourage consumers to take responsibility for their health by choosing foods that have nutritional values stated on the container, to communicate their need for this information to the manufacturer and to motivate consumers to report and act on discrepancies they encounter with food labels; (iii) to urge consumers to assess critically the nutrient content of new foods added to their diet; (iv) to make consumers aware of 'actual' risks, for example high fat intake, and to reduce 'perceived' risks that are unreasonable, such as concern about certain additives; and (v) to urge consumers who are pressurised for time to make random checks on the nutrient content of their diet using the information on food labels. Nutritional knowledge should aim: (i) to help consumers to understand the format used to present nutritional information, e.g. the list of ingredients, how measures of nutrients given per weight and percentage of RDA relate to the dietary guidelines, and nutritional claims; (ii) to increase consumer understanding of terminology used on food labels, and to inform them of the functions and sources of nutrients present in processed foods and other foods that contribute to a balanced diet; (iii) to inform consumers how to compare products in similar categories using limited information, including how to convert information given per 100 g (ml) to the serving size used by the consumer; (iv) to increase consumer understanding of the relationship between diet and disease; (v) to inform the consumer of the cost-benefit relationship in food choice, e.g. fresh fruit is perceived to be expensive, but this is not the case in relation to snack food; (vi) to provide information on key issues such as reduction in body weight, fat, and salt, and the increase of fibre in the diet; (vii) to teach the consumer how to include food groups that have become health issues such as red meat, dairy products and indulgence foods within a balanced diet; (viii) to teach consumers to weigh the positive attributes of a product claimed by the manufacturer against negative points not emphasised by the manufacturer; (ix) to equip consumers with the necessary knowledge so that they can critically evaluate nutritional information from sources prone to bias in order to raise awareness of misinformation; (x) to personalise nutritional information, focusing on the most important messages for each audience, resulting in the development of more cost-effective educational programmes - a comprehensive needs assessment of the relevant target groups would need to be conducted to achieve this objective; and (xi) to provide nutritional education that actively involves consumers in problem-solving tasks, using self-relevant information, in order to lead the consumer to a greater understanding of dietary goals.

Conclusion
Although this study was completed in 1993, the results are still relevant as legislation has not changed. In addition, no nutritional labelling educational programme has been implemented to date by the Department of Health. The sample of consumers used in this study could be considered as representative of the top end of the South African market;51,52 they have a higher level of education and are more likely to use food labels during food purchase.37,52,53 A comprehensive needs assessment of the relevant target markets that make up South Africa's diverse population should be undertaken. Tailoring an educational programme to a particular target market28,29,38,39 and actively involving consumers in problem-solving tasks are more likely to be successful than the information channels currently used, i.e. leaflets, magazines and television.37,40,41 Educational information on the use of food labels should be offered at school level in a cross-curricular fashion, to the general public at point-of-purchase outlets, and through the media. Nutrition education on the use of labels in the management of medical conditions should be provided by medical practitioners, clinics and hospitals.28,54,55 Ongoing and expanded nutritional labelling educational programmes are recommended.

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