1. Introduction
obesity, NCD, cancer, diabetes, cardiovascular disease, FOP, WL
OBESITY, CANCER, DISEASES, SHOP
One common strategy for governments to tackle the non-communicable disease (NCD) epidemic is front-of-package (FOP) nutrition labeling. The Kingdom of Saudi Arabia (KSA) is considering implementing a new FOP label that is based on either France’s Nutri-Score (NS), which labels all foods (A = healthiest to E = least healthy) based on overall nutritional quality, or the Chilean warning label (WL) approach, which identifies foods to avoid based on select nutritional characteristics. Using a fully functional online grocery store, this study aimed to test these two promising FOP strategies by randomizing 656 KSA adults into one of the three versions of the store to complete a hypothetical grocery shop: no-label (control), NS, and WL. The NS was modified with a sugar percentage tag given that reducing sugar consumption is one of KSA’s public health goals. We found that both modified NS labels and Chilean warning labels positively influenced food and beverage choices among KSA participants, but there were differential effects across the two labels. Relative to the control, NS improved the overall diet quality of the shopping baskets, measured by the weighted (by the number of servings) average NS point (ranging from 0, least healthy, to 55, healthiest), by 2.5 points [95% CI: 1.7, 3.4; The health and economic burden of non-communicable diseases (NCDs) globally is large and growing [FOP labels can generally be classified as reductive or interpretive. Reductive labels present a subset of relevant information without interpretation, such as calories per serving and calories per day for a healthy diet. Interpretive labels use nutritional information to convey a message to consumers as to the underlying healthiness of the product in the dimensions considered. Interpretive FOP labels can focus solely on identifying foods that are healthier (i.e., positive labels), such as in Singapore’s healthier choice symbol (HCS) labels [Despite the limitations, both graded and warning FOP labels have been shown to be effective relative to a no-label control condition [As with many countries, Saudi Arabia (KSA) has observed a dramatic rise in NCDs. Comparing data between 2008 and 2017, the prevalence of diabetes, cardiovascular disease, and cancer increased to 51%, 47%, and 96%, respectively [We chose a holistic measure of nutritional quality, the weighted average Nutri-Score point, as the primary outcome. Although not free from concerns [We expect that both labels would positively influence food-purchasing patterns relative to a no-label control arm. We hypothesized that the modified Nutri-Score label (NS) would perform best when it comes to overall diet quality, given that is its primary focus. Warning labels (WL) are expected to be more effective at reducing the nutrients (and calories) that are the target of the labels, including sugar intake. This results because the stop sign warning is a stronger signal than simply noting the sugar percentage per serving, as it appears on the NS label. We tested these hypotheses with KSA shoppers using a randomized controlled trial design and a fully functional web grocery store where shoppers completed a one-time hypothetical grocery shop. We investigated the effectiveness of the labels not only on foods and beverages but also on beverages alone, given that sugar-sweetened beverages are a primary contributor to obesity and NCDs [