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NUTRITION LABELLING ON PREPACKED FOODS : OPINION AND SUGGESTIONS OF PORTUGUESE FOOD AND NUTRITION PROFESSIONALS

INTRODUCTION: Labelling is an important tool for food and nutrition professionals since it provides information on food safety and nutrition. OBJECTIVES: The aim was to analyse the differences in food and nutrition professionals’ opinions regarding nutrition labelling on prepacked foods. METHODOLOGY: A cross-sectional study was conducted, using a non-probabilistic sample of professionals, by contacting several Portuguese entities in food and nutrition. The eligibility criteria included being 18 years old and over, living and working in Portugal, and having a professional activity in this area. An online self-administered survey was developed, including questions about labelling (importance, reading, use, trust, satisfaction, and influence in food choices). The main changes in the European Union labelling rules about the content, presentation and legibility of the mandatory information were analysed. The present paper focuses on the answers to the open-ended question on suggestions to improve nutrition labelling. RESULTS: From the 297 participants, 33 (11.1%) provided answers to the open-ended question, which were subsequently grouped into six categories. These professionals demonstrated the least satisfaction with the label information namely the specific technical terms, the quantity of information, the symbols used and the nutritional claims. They showed the least agreement with the presentation and content of the nutrition information, implemented by Regulation (EU) No 1169/2011. Two improvements were proposed: the simplification of the labelling information and the understanding of its usefulness as it is currently presented, to provide perceptible and useful information to the consumer. CONCLUSIONS: Nutrition labelling educational tools should be developed, in order to promote nutrition literacy and lead to consumer’s empowerment.


INTRODUCTION
Food and nutrition labelling in prepacked foods is a source of information to the consumer in terms of food safety and nutrition (1,2). The food product label conveys a set of mandatory information that defines it, namely the name of food, the country of origin or place of provenance, the lot number, the net quantity, the name or business name and address of the food business operator, the ingredient list, the allergens information, the type, quality and quantity of the ingredients and categories of ingredients (QUID), the nutrition labelling, the date of minimum durability, special storage conditions and/or instructions for use, as compulsory (3)(4)(5)(6). The nutrition or health claims, the front-ofpack nutrition labelling and others are non-mandatory information (3,7,8). In recent years, labelling has gained significant importance as an effective tool in protecting consumers' health, since it has information that, when properly used, can lead to conscious and healthy food choices (9). The influence of food environments as a collective physical, economic, political, and socio-cultural context can influence individuals' consumption choices and nutritional status, leading to a healthier diet and general well-being through food labelling (4,10,11). Consequently, it must be a requirement to create food labels that are clear and can be trusted. Regarding this situation, the European Parliament and of the Council on the 25 th of October 2011 implemented the Food Information to Consumers (FIC) -Regulation (EU) No 1169/2011 (3,12,13). The focus of the existing guidelines has been changing, in order to safeguard the consumer's well-being through transversal rules in the entire food system and its operators. Since the implementation of the FIC Regulation, food and nutrition labelling rules were harmonized and became necessary to study the possible simplification of the nutrition declaration. Therefore, a smaller risk of the prevalence of non-communicable diseases can be avoided by choosing energydense foods, sugar-sweetened drinks, processed and prepacked foods, encouraged by consumption trends and/or individual food choices (14)(15)(16). While the regulation was in the development stage, a series of investigations were occurring to understand how information can be used and interpreted (17). Labelling is an important tool for professionals in the food and nutrition area (12). However, the reading and usage of the label information may vary, according to the area of activity, professional backgrounds, interests, motivations, and individual knowledge. Nevertheless, there was a need to study the vision and position of the professionals in the food area regarding this matter. It is known that they can be direct or indirect intervenient in the food supply chain, directly in the food production process or in the consumption stage (with an underlining role as food educators, researchers, or regulators), or indirectly in both.

OBJECTIVES
This paper aimed to analyse the differences in food and nutrition professionals' opinions and suggestions regarding nutrition labelling on prepacked foods, established by Regulation (EU) No 1169/2011.

METHODOLOGY
A cross-sectional study was conducted, using an observational design (18,19). Study population: The target population were Portuguese Lastly, a comparison between the group of professionals who make suggestions and those who did not, regarding the survey's answers was done. Statistical data analysis: Different methods and statistical tests were performed, using IBM SPSS ® Statistics version 24 software.
Statistical significance was set at 0.05. A descriptive statistical analysis was carried out. Differences between groups were assessed using the Mann-Whitney U test and the chi-square test.

RESULTS
The sample (N=297) of Portuguese professionals who participated in the study included women (81.1%), married (53.2%), with an average age of 39 years (SD=12.1), between 18 and 75 years old, with higher education (99.9%) and 46.0% from the "Food and Nutrition Sciences" course.

Evaluation of the Professionals' Opinion Regarding Accessibility and Clarity of Nutrition Labelling for the Consumer
Out of a total of 297 participants, 10.1% (N=30) strongly disagreed or disagreed that the nutrition labelling changes would favour a better reading and understanding by the consumers, and 11.1% (N=33) replied to the open-ended question, with suggestions for improvements in nutrition labelling.

Analysis of the Suggestions Provided in the Open-ended Question to Improve Nutrition Labelling
The given answers (N=33) were grouped by subject (Table 1) Description of the open-ended question answers by subject (N=33) (free translation) Table 1 1

CLEAR, SIMPLE AND CONCISE LANGUAGE (N =7)
"Firstly, I would require labels to use clear language for any consumer to be able to understand them, thus preventing the use of "substitute foods" that become more harmful to their health. Example: the use of palm oil fats and its derivatives." "The improvement of the information through its simplification and conciseness, by changing the sequence, but it ends up losing information as it broadens, becomes more diversified and specific." "Language." "Greater transparency and clearer language." "Simplify because most consumers don't understand the meaning." "I would simplify -the language since it is too technical and not part of the popular lexical." "If we follow the regulation exactly, we will have to declare "Lipids", for example. Most consumers do not know the meaning of it, so I would turn it mandatory to declare "Fats"."

DIFFICULTY IN INTERPRETING AND TEACHING CONSUMERS (N=8)
"Most consumers have no idea how to read a nutrition declaration." "Most consumers do not have enough knowledge to be able to interpret the information available on the label and make healthy choices." "The quantity/ quality of the information is satisfactory. I think that the consumer does not have enough training to read and interpret this information." "Too much information it is difficult to interpret." "The consumer has a hard time understanding what the label contains and conveys, and how they can use the information to their benefit. The changes are positive for technicians and more transparent communication of the foodstuff information, but difficult for the consumer." "I believe it is necessary to inform the consumer to read the label." "I wouldn't change anything, what I would do is teaching consumers to read the labels because if they knew there would not be a war between the opportunists about sugar and fats." "It will always be difficult for the consumer regarding the reading of the label. More community intervention is needed in this area. I would change -larger letters, specifically in the list of ingredients, nutritional information and allergenic substances. -The traffic light scheme I believe will be the easiest method of reading for the consumer, with a more positive, clear and succinct response. -When appropriate, the nutrition information must be mandatory per serving (ex: biscuit pack)."

PRESENTATION OF NUTRITION LABELLING (N=3)
"The order of the macronutrients and the information of salt makes sense for foods that are high in fat and salt, which means, that it is a measure that focuses solely on obesity and can confuse other categories of products that have nothing to do with obesity. I give a clear example of foods for specific medical purposes, in which it is important to focus on protein and the mention of salt confuses the consumer, since they are products that have no added salt, but sodium, micronutrient." "Not all of the sodium in a food comes from salt, so in my opinion, it should contain the sodium content instead of salt (or both)." "Order of the nutrients, sodium content and fibre content."

TURN OPTIONAL INFORMATION INTO MANDATORY (N=10)
"I would make supplementary information mandatory. The regulation is general for the whole of Europe, not focusing on the deficiencies that may exist in terms of micronutrients per country. If it was mandatory, it would fill this gap." "It should be mandatory to mention the content of hydrogenated fats." "Trans fats, cholesterol and fibre are missing".
"What is in grey should be mandatory".
"I consider the presence of data referring to "one serving" to be important, and it should be mandatory." "What was indicated in the previous points of the survey." "A more detailed list of ingredients."

IMPROVE THE DISPLAY BY USING A SYMBOL (TRAFFIC LIGHT TYPE) (N=3)
"To complement the mandatory information, I would put a more graphic and visual form, universally used (regardless of the brand), more easily perceived by the consumer." "Font size or form of presentation more appealing, clearer and enlightening in the common sense (essential items -fat, salt and sugar highlighting this as an idea (Brilliant! The traffic light should become universal for all products)." "Using the traffic light scheme (which some foodstuffs already have) would be very advantageous for less informed consumers."  (Table 2), except for the geographical area of residency, verifying that the probability of those who made suggestions is greater in the Lisbon metropolitan area and Islands.
The significant differences between groups of professionals who made suggestions (N=33, 11.1%) and those who did not (N=264, 88.9%) are presented in Table 3 (non-significant results were omitted for brevity).

DISCUSSION OF RESULTS
The professionals' suggestions given by the open-ended question regarding nutrition labelling on prepacked food were analysed, resulting in six categories which were grouped by subject. From these categories, two sets of suggestions were proposed. The first one was to simplify the information of the nutrition labelling, in order to promote the reading and usage by the consumers with low nutritional literacy (subject 1, 2 and 5). These professionals suggested that it is necessary to turn the language into a clearer, simpler, and more concise one as presented "would simplify the language" (subject 1) and improve the display by using a symbol as cited "The traffic light should become universal for all products" (subject 5) since the current form of presentation is difficult to interpret (subject 2). This information has to be explained to the consumer "to inform the consumer to read the label" (subject 2) or the consumer should be instructed on how to read, interpret and use the information available "I would do is teaching consumers to read the labels" (subject 2). Both suggested actions focus on the consumer's education and its empowerment regarding the use of food and nutrition labelling, as it had already been mentioned (1,12,20). The difficulties on label usage have been previously reported, mainly in studies with consumers (21)(22)(23)(24).
While the EU regulation harmonizes food labelling rules, it is necessary to improve the reading, usage and understanding of the available information to the consumer. Given the complexity of the information and the low nutritional literacy, the most favourable option becomes a symbol on the front-of-pack, as a means of simplifying nutritional information and leading conscious food choices (25,26).
The second improvement included the need to promote the accuracy and the usefulness of the nutrition labelling as it is currently presented (subject 3, 4 and 6). In this case, it was advocated the adjustment of the presentation of the nutrition labelling (subject 3), to turn optional *Analyse Descriptive Statistics -Mann-Whitney Test. 1 The values presented correspond to the sum of all positive answers namely "satisfied" and "highly satisfied". 2 The values presented correspond to the sum of all positive answers namely "agree" and "strongly agree".
A comparative analysis of the positive survey answers between those professionals' who suggested and those who did not suggest in the open-ended question   (25,27). The previous studies before the implementation of the regulation raised a series of needs, expectations and uses regarding the information available to the consumers (28)(29)(30). It was assumed that having unanimous information would be difficult, but the commitment would be to simply the information considered most important on a first phase. In the second phase, the public health goal was the priority, it aimed to provide accurate and easy-to-understand front-of-pack nutrition information (26,31). The analysis of the mandatory information on labelling became a secondary matter (25). In this study, a relevant concern was "the nutritional composition varies a lot, such as traditional Regarding the differences between the group of food and nutrition professionals who made suggestions and those who did not, it was found that those who gave suggestions were less satisfied with the current information on the label, namely the specific technical terms, the quantity of information, the used symbols, and the nutritional claims.
Comparably, this group of professionals showed less agreement with the changes implemented by Regulation (EU) No. 1169/ 2011, such as the presentation order of the mandatory nutrition information and the optional indication of the fibre content. They also presented less agreement with the alterations in the presentation and in the content of the back-of-pack nutrition labelling, which may provide a more accessible and enlightening reading for the consumer. Some professionals are not still that satisfied with its presentation because it may provide too much detail for the consumers (the specific technical terms, the quantity of information, the used symbols, and the nutritional claims), possibly because they may have low nutrition literacy.
This study had several methodological considerations.
In the study design, the collection of data resulted in a convenience sample, thus non-probabilistic. Since the total number of professionals working in the food and nutrition area in Portugal is unknown and there is no practical way to contact them, it is not possible to guarantee that all professionals were reached. Nevertheless, the main entities in this area were contacted to reach the largest possible number of professionals. The choice of entities in the food and nutrition area was done by researching the ones that would be relevant and representative of the sector, authorities, and food' associations, which could reach a larger spectrum of professionals.
Limitations regarding the data collection procedure were related to using an online self-administered survey since the comprehension errors could not be clarified. This might constitute an accessibility limitation for some professionals, on one hand, but on the other hand, as an advantage, an online procedure allowed the collection of a larger sample from different geographic locations of the country quickly and conveniently (1,32).