Prevalence of Nutrition and Health-Related Claims on Pre-Packaged Foods: A Five-Country Study in Europe

nutrients Article Prevalence of Nutrition and Health-Related Claims on Pre-Packaged Foods: A Five-Country Study in Europe Sophie Hieke 1,*, Nera Kuljanic 1, Igor Pravst 2,3, Krista Miklavec 2, Asha Kaur 4, Kerry A. Brown 5, Bernadette M. Egan 5, Katja Pfeifer 6, Azucena Gracia 7and Mike Rayner 4 1European Food Information Council, rue Paul-Emile Janson 6, 1000 Brussels, Belgium; [email protected] 2Nutrition Institute, Tržaška cesta 40, 1000 Ljubljana, Slovenia; igor[email protected] (I.P.); [email protected] (K.M.) 3Biotechnical Faculty, University of Ljubljana, Jamnikarjeva 101, 1000 Ljubljana, Slovenia 4British Heart Foundation Centre on Population Approaches for Non-Communicable Disease Prevention, University of Oxford, Oxford OX3 7LF, UK; [email protected] (A.K.); [email protected] (M.R.) 5Food, Consumer Behaviour and Health Research Centre, University of Surrey, Guildford GU2 7XH, UK; [email protected] (K.A.B.); [email protected] (B.M.E.) 6Institute for Consumer and Behavioural Research, Saarland University, 66123 Saarbrücken, Germany; [email protected] 7Agrifood Research and Technology Centre of Aragon, 50059 Zaragoza, Spain; [email protected] *Correspondence: [email protected]; Tel.: +32-2-506-8981 Received: 11 December 2015; Accepted: 25 February 2016; Published: 3 March 2016 Abstract: This study is part of the research undertaken in the EU funded project CLYMBOL (“Role of health-related CLaims and sYMBOLs in consumer behaviour”). The first phase of this project consisted of mapping the prevalence of symbolic and non-symbolic nutrition and health-related claims (NHC) on foods and non-alcoholic beverages in five European countries. Pre-packaged foods and drinks were sampled based on a standardized sampling protocol, using store lists or a store floor plan. Data collection took place across five countries, in three types of stores. A total of 2034 foods and drinks were sampled and packaging information was analyzed. At least one claim was identified for 26% (95% CI (24.0%–27.9%)) of all foods and drinks sampled. Six percent of these claims were symbolic. The majority of the claims were nutrition claims (64%), followed by health claims (29%) and health-related ingredient claims (6%). The most common health claims were nutrient and other function claims (47% of all claims), followed by disease risk reduction claims (5%). Eight percent of the health claims were children’s development and health claims but these were only observed on less than 1% (0.4%–1.1%) of the foods. The category of foods for specific dietary use had the highest proportion of NHC (70% of foods carried a claim). The prevalence of symbolic and non-symbolic NHC varies across European countries and between different food categories. This study provides baseline data for policy makers and the food industry to monitor and evaluate the use of claims on food packaging. Keywords: nutrition claims; health claims; health symbols; food supply; monitoring 1. Introduction 1.1. Background The use of nutrition and health-related claims (NHC) on foods and non-alcoholic beverages (henceforth foods and drinks or just foods) is regulated in many developed countries. In the European Union (EU), regulations were harmonized in 2006 by Regulation (EC) 1924/2006 [ 1 ]. The Regulation applies to all nutrition and health claims made on food packaging. The general principle is that NHC Nutrients 2016,8, 137; doi:10.3390/nu8030137 www.mdpi.com/journal/nutrients Nutrients 2016,8, 137 2 of 16 should not be misleading and should be substantiated by generally accepted scientific data [ 1 , 2 ]. Since the EU Register of health claims made on food entered into force in December 2012 [ 3 ], food producers in the EU are allowed to use only authorized health claims and related general non-specific health claims. One exception is claims that are still in the process of scientific evaluation, e.g., botanicals [4]. NHC as well as their symbolic representations (examples of health symbols would be the Dutch Choices logo, the Nordic Keyhole and the Finnish Heart Symbol) may help consumers identify foods that are healthier options, but little is known about how such claims are used by consumers in real-world shopping situations. The pan-European research project “Role of health-related CLaims and sYMBOLs in consumer behaviour” (CLYMBOL) has set out to determine how nutrition and health-related claims and symbols, in their context, can affect consumer understanding, purchase and consumption patterns (for an overview of the project see [5]). As a starting point to the project, the survey reported here aimed to understand what nutrition and health-related claims and symbols consumers are exposed to, i.e., on which food categories such claims and symbols are most common, which types of claims and symbols are used and to which nutrients and health relationships they refer. While some studies on the prevalence of NHC have been conducted in countries where such claims are relatively well regulated, particularly in the US [ 6 , 7 ], Canada [ 8 , 9 ], Australia [ 10 – 13 ] and New Zealand [ 14 ], studies on the European market are scarce and to date no cross-country prevalence study for Europe exists. In 2009, as part of the EU-funded project FLABEL [ 15 ], a study investigated the prevalence of nutrition information, including health claims, for five food categories across all EU Member States plus Turkey [ 16 ]. Significant country-to-country differences were reported regarding the prevalence of nutrition and health claims. However, the study did not analyze the different types of claims found. More in-depth analyses are available for the UK [ 17 ], Ireland [ 18 ] and Slovenia [ 19 ]. However, all of these surveys were completed before the EU Register of health claims came into effect in 2012. Some other studies are also available in which the authors selectively focused on specific food categories, for example dairy foods [ 20 ] and breakfast cereals [ 21 ]. Lastly, the prevalence of nutrition and health claims was also recently investigated in Serbia, a candidate country for EU membership [22]. While monitoring the food supply is an important public health issue, the number of foods available and the diversity of retail environments make this challenging. A global initiative that addresses the harmonization of such data collection is the INFORMAS initiative (International Network for Food and Obesity/Non-Communicable Diseases Research, Monitoring and Action Support). This network has proposed a step-wise approach to surveying food labeling depending on resources, standardized methods for the sampling of retail outlets and foods and priorities for the labeling and related information to be collected [ 22 ]. While the selection of all foods within all food categories might be considered ideal [ 22 ], a huge volume of data is generated when studies attempt to be entirely comprehensive [ 19 ]. Therefore, a sampling approach to the selection of foods is needed particularly for studies investigating different countries. The present study describes a novel approach on how to sample a select number of foods across various countries, using the food categorization scheme [ 23 ] that has been adopted by the Global Food Monitoring Group for future monitoring of the food supply [ 24 ]. 1.2. Research Questions The aim of this study was to investigate the prevalence of nutrition and health claims as found on foods and drinks across five different European countries. The following research questions were identified: ‚ What proportion of pre-packaged foods and drinks available in-store in the five countries carry NHC? ‚What proportion of these claims is symbolic? ‚What types of NHC can be found on pre-packaged foods and drinks? Nutrients 2016,8, 137 3 of 16 ‚To which nutrients or other food components do NHC refer? ‚To which health-relationships do health claims refer? ‚Which types of foods and drinks carry NHC? 2. Methods and Materials Labeling data were collected from pre-packaged foods and drinks sampled in five EU countries: the UK, the Netherlands, Germany, Slovenia and Spain. The selection of countries aimed at a geographical spread across Europe. Three types of stores were selected in each country (with a total of 15 stores overall), with the aim of covering a range of different retail outlets, in order to map consumer exposure to food and drink products across a variety of shopping places: a large supermarket/national retailer, a discounter and a neighborhood store. Differences in the penetration of various food labeling information in different retail outlets were reported recently [ 19 ], confirming the rationale of the approach used in this study. Stores were selected based on the accessibility of their network within the respective country, as well as comparable store characteristics (e.g., store size). A food or drink (henceforth only referred to as “food”) was defined as a single item available for sale in the selected store. This definition meant that the same food in different sized packaging could be included in the survey, on the basis that the packaging for the same food in different sized packages may carry different health-related claims. Within-country, exact duplicates, however, were removed from the database. Only pre-packaged foods were considered. The EU Regulation on the provision of food information to consumers (EC) 1169/2011 defines a pre-packaged foodstuff as “any single item for presentation as such to the ultimate consumer and to mass caterers, consisting of a foodstuff and the packaging into which it was put before being offered for sale, whether such packaging encloses the foodstuff completely or only partially, but in any case in such a way that the contents cannot be altered without opening or changing the packaging” [25]. 2.1. Data Collection In each of the five countries, approximately 400 foods were sampled i.e., purchased using a randomized sampling approach. A power calculation was conducted to estimate the sample size required. An assumed 50% prevalence rate for NHC was selected in order to ensure an adequate sample size, for the detection of NHC prevalence with 5% precision. The sample size needed for an estimation of prevalence is at maximum when the measured prevalence is 50%. Hence, after adjustment for a finite population and assuming a prevalence rate of 50% for NHC, 400 foods for each country would produce confidence intervals of ˘ 5%, sufficient for distinguishing a 10% difference in prevalence between countries. In each of the five countries approximately 250 foods were sampled from the supermarket/ national retailer, 75 foods were sampled from the discounter and 75 from the neighborhood store. Details of the whole sample are provided in Table 1. Table 1. Sample overview (sampling method and number of foods). UK Netherlands Germany Slovenia Spain Total Large supermarket/ national retailer floor plan, n= 248 store list, n= 252 store list, n= 248 store list, n= 260 store list, n= 251 1259 (62%) Discounter floor plan, n= 75 store list, n= 81 store list, n= 76 store list, n= 78 store list, n= 78 388 (19%) Neighborhood store floor plan, n= 75 store list, n= 83 floor plan, n= 75 store list, n= 78 store list, n= 76 387 (19%) Total no of foods 398 (20%) 416 (20%) 399 (20%) 416 (20%) 405 (20%) 2034 (100%) Foods were sampled from retail outlets in two ways: either using a store/stock list or failing that a floor plan. Nutrients 2016,8, 137 4 of 16 Retailer’s store/stock lists were converted to Microsoft Excel spreadsheets, if not already in that format. The following types of product were then excluded: (a) non-food items; (b) food supplements; (c) alcoholic drinks; and (d) unpackaged foods. The remaining foods were assigned an ID number and the appropriately sized sample randomly selected using the RAND function in Excel. The sample of foods was then purchased. For four of the stores, a store/stock list could not be obtained. In these cases a floor plan was created which mapped the layout of the store (including the location of promotional stands or other non-aisle displays). Each section/aisle was then assigned a number and the number of foods in each section/aisle was estimated using a tally counter. The total number of foods in the store was then estimated and each food location assigned an ID number. Again, an appropriately sized list of food locations was randomly generated using the RAND function in Excel. The researchers then returned to the store and purchased the foods using the list of locations. Exclusion of products also occurred post sampling. Post-sampling exclusion occurred for unpackaged products selected inadvertently. Foods were selected and purchased in the same time frame (July–August 2013) for all countries. For perishable foods, the packaging was removed. Photographs were taken of all sides of packages carrying at least one claim. Two pilot studies were carried out: one in Germany at a large supermarket and the other in the UK at a neighborhood store. Feedback from the pilots resulted only in minor changes to the final protocol for data collection. 2.2. Data Extraction Labeling data were taken from packaging and entered into a database. All NHC were identified and characteristics of the claims were recorded, i.e., whether the claim was worded, pictorial or a combination (both worded and pictorial) and whether it qualified as a symbolic claim. Worded claims were recorded verbatim and translated into English. Pictorial claims (or claims which were a combination of words and picture(s)) were briefly described. The type of health symbol was noted. Other labeling and food composition data were also collected (e.g., whether the package had front-of-pack nutrition labeling and information about nutrient content from the nutrient declaration). Additional characteristics of the NHC recorded included their position on pack and the number of times they appeared on one packet. For health claims, it was also noted whether it was a specific health claim, meaning whether a specified nutrient, other substance or health-related ingredient was stated to have a specific health effect, or a non-specific health claim. 2.3. Analysis Once identified, claims were classified into nutrition claims (including nutrient content claims and nutrient comparative claim), health-related ingredient claims and health claims (including reduction of disease risk claims, nutrient and other function claims, general health claims and children’s development and health claims). All claims were categorized as being either symbolic or non-symbolic. A symbolic claim was defined as a health-related claim (whether a nutrition, health-related ingredient or health claim) that was pictorial or combined words and pictures and for which the criteria for use of the symbol have been published. An example of a symbolic general health claim is the Dutch “Choices” logo [ 26 ]. An example of a symbolic nutrient and other function claims is the “Toothfriendly” logo [ 27 ]. See Figure 1. Nutrients 2016,8, 137 5 of 16 Nutrients 2016,8,1375of17  Allclaimswerecategorizedasbeingeithersymbolicornon‐symbolic.Asymbolicclaimwas definedasahealth‐relatedclaim(whetheranutrition,health‐relatedingredientorhealthclaim)that waspictorialorcombinedwordsandpicturesandforwhichthecriteriaforuseofthesymbolhave beenpublished.AnexampleofasymbolicgeneralhealthclaimistheDutch“Choices”logo[26].An exampleofasymbolicnutrientandotherfunctionclaimsisthe“Toothfriendly”logo[27]. Symbolicgeneral healthclaim Symbolicnutrientand otherfunctionclaim DutchchoiceslogoToothfriendlylogo Figure1.Examplesofsymbolicclaims. Color‐codednutritionlabels(e.g.,trafficlightor%GDAlabeling)didnotqualifyasasymbolic claimbecausetheypresentnutritionalinformationbutdonotsuggestahealthrelationship[28].All NHCdefinitionsareconsistentwithEURegulation: 1. Anutritionclaimwasdefinedas“anyclaimwhichstates,suggestsorimpliesthatafoodhas particularbeneficialnutritionalpropertiesdueto(a)theenergy(calorificvalue)it(i)provides; (ii)providesatareducedorincreasedrate;or(iii)doesnotprovide;and/or(b)thenutrientsor othersubstancesit(i)contains;(ii)containsinreducedorincreasedproportions;or(iii)doesnot contain”[1]. 2. Nutritionclaimswereclassifiedaseitheranutrientcontentclaimwhenit“describesthelevelof anutrientcontainedinafood(oritsenergyvalue)”(e.g.,“highinfibre”and“lowfat”)ora nutrientcomparativeclaim“whenitcomparesthecompositionofthefoodinquestionwiththe compositionofotherfoods”(e.g.,“higherinfibre”and“reducedsugar”)[1]. 3. Ahealth‐relatedingredientclaimwasdefinedasaclaimcommunicatingthepresenceofan ingredient(s)whichisnotanutrientorothersubstanceasdefinedintheEURegulation[1]but whichimplieshealthbenefits.Inmostcases,theseclaimsrelatedtothecontentofingredients thatareconsideredasahealthy(e.g.,“Containsoneofyourfiveaday”)oratleastahealthier alternative(e.g.,“Sweetenedonlywithbrownsugar”). 4. Ahealthclaimwasdefinedas“anyclaimthatstates,suggestsorimpliesthatarelationshipexists betweenafoodcategory,afoodoroneofitsconstituentsandhealth”[1]. 5. Ageneralhealthclaim(coveredbyArticle10(3)oftheEURegulation[1])wasdefinedasaclaim referringtobenefitsforgeneralhealthorwell‐being.Atypicalexampleofsuchaclaimis“Good foryourhealth”or“Healthierchoice(withinthisproductgroup)”. 6. Anutrientandotherfunctionclaim(ascoveredbyArticle13oftheEURegulation[1])was definedasahealthclaimthatdescribesorreferstooneofthefollowing:(a)theroleofanutrient orothersubstanceingrowth,developmentandthefunctionsofthebody;(b)psychologicaland behavioralfunctions;or(c)slimmingorweight‐controlorareductioninthesenseofhungeror anincreaseinthesenseofsatietyorareductionoftheavailableenergyfromthediet.Typical examplesofsuchaclaimare“Calciumbuildsstrongteeth”and“Fibrehelpsmaintainahealthy digestivesystem”. 7. Areductionofdiseaseriskclaim(coveredbyArticle14.1(a)oftheEURegulation[1])was definedasaclaimcommunicatingthattheconsumptionofafoodcategory,afoodoroneofits constituentssignificantlyreducesariskfactorinthedevelopmentofahumandisease.Typical examplesofsuchaclaimare“Plantsterolsreducebloodcholesterol.Highcholesterolisarisk Figure 1. Examples of symbolic claims. Color-coded nutrition labels (e.g., traffic light or % GDA labeling) did not qualify as a symbolic claim because they present nutritional information but do not suggest a health relationship [ 28 ]. All NHC definitions are consistent with EU Regulation: 1. A nutrition claim was defined as “any claim which states, suggests or implies that a food has particular beneficial nutritional properties due to (a) the energy (calorific value) it (i) provides; (ii) provides at a reduced or increased rate; or (iii) does not provide; and/or (b) the nutrients or other substances it (i) contains; (ii) contains in reduced or increased proportions; or (iii) does not contain” [1]. 2. Nutrition claims were classified as either a nutrient content claim when it “describes the level of a nutrient contained in a food (or its energy value)” (e.g., “high in fibre” and “low fat”) or a nutrient comparative claim “when it compares the composition of the food in question with the composition of other foods” (e.g., “higher in fibre” and “reduced sugar”) [1]. 3. A health-related ingredient claim was defined as a claim communicating the presence of an ingredient(s) which is not a nutrient or other substance as defined in the EU Regulation [ 1 ] but which implies health benefits. In most cases, these claims related to the content of ingredients that are considered as a healthy (e.g., “Contains one of your five a day”) or at least a healthier alternative (e.g., “Sweetened only with brown sugar”). 4. A health claim was defined as “any claim that states, suggests or implies that a relationship exists between a food category, a food or one of its constituents and health” [1]. 5. A general health claim (covered by Article 10(3) of the EU Regulation [ 1 ]) was defined as a claim referring to benefits for general health or well-being. A typical example of such a claim is “Good for your health” or “Healthier choice (within this product group)”. 6. A nutrient and other function claim (as covered by Article 13 of the EU Regulation [ 1 ]) was defined as a health claim that describes or refers to one of the following: (a) the role of a nutrient or other substance in growth, development and the functions of the body; (b) psychological and behavioral functions; or (c) slimming or weight-control or a reduction in the sense of hunger or an increase in the sense of satiety or a reduction of the available energy from the diet. Typical examples of such a claim are “Calcium builds strong teeth” and “Fibre helps maintain a healthy digestive system”. 7. A reduction of disease risk claim (covered by Article 14.1(a) of the EU Regulation [ 1 ]) was defined as a claim communicating that the consumption of a food category, a food or one of its constituents significantly reduces a risk factor in the development of a human disease. Typical examples of such a claim are “Plant sterols reduce blood cholesterol. High cholesterol is a risk factor in the development of coronary heart disease” and “Reduces the risk factor for development of dental caries”. Nutrients 2016,8, 137 6 of 16 8. A children’s development and health claim (covered by Article 14.1(b) of the EU Regulation [ 1 ]) was defined as a health claim where children’s development and/or health was specifically mentioned. Typical examples of such a claim are “Calcium is needed for normal growth and development of bones in children” and “For your baby’s safe and balanced diet”. Claims where children were not specifically mentioned, even if these claims were found on foods intended solely for use by children, were not considered children’s development and health claims. Claims such as “natural”, “organic” and “halal” were not considered NHCs on the basis that they refer to the method of the production rather than the content. Similarly, information on the presence of additives, preservatives, flavorings, etc. was not considered a health-related claim. Allergy advice (e.g., “contains nuts”) was not considered to be an NHC nor were references to the presence of a food or food group in the product where there was no clear relationship to its health benefits, e.g., references to milk content. Claims relating to the endorsement of a health-related organization were also not included, e.g., “[Product] supported by the [health association]”. 3. Results Where confidence intervals are provided in tables, they will not be reported in the text. Results are discussed by country, claim type and product category. 3.1. What Proportion of Pre-Packaged Foods and Drinks Available In-Store in the Five Countries Carry NHC? Twenty-six percent of foods carried at least one nutrition, health-related ingredient or health claim (including symbolic versions of such claims) (Table 2). There were almost twice as many foods carrying nutrition claims as there were foods carrying health claims (21% and 11% respectively). Just 4% of foods carried a health-related ingredient claim. General health claims appeared on 7% of the foods. Only 5% of foods carried a nutrient and other function claim. Just 0.6% of foods carried a reduction of disease risk claim and 0.7% of foods carried children’s development and health claims. Products could carry more than one claim. Thirty percent of foods sampled in the UK carried a nutrition claim, followed by Spain (23%), Slovenia (19%), the Netherlands (17%) and Germany (16%). There was less variation across countries in the number of foods carrying health claims; the highest prevalence was observed in the Netherlands (14%) and the lowest in Spain (7%). The foods sampled in the Netherlands had more instances of general health claims (12%), compared to 4%–6% for the remaining countries. The highest proportion of foods carrying a nutrient and other function claim was found in Slovenia (9%), followed by the UK (7%), Germany (5%), Spain and the Netherlands (both 3%). Overall, the prevalence of reduction of disease risk claims was very low across all countries; it was highest in the UK (1%) and lowest in the Netherlands (0.2%). Similarly, the prevalence of children’s development and health claims ranged from 0% (in the Netherlands) to 1.3% (in Germany). Foods carrying claims tend to carry multiple claims; the average number of NHC per product carrying any claim across the five countries was 2.6 (Table 3). The highest number of claims seen on a product was 17, observed on two baby food products in Spain and Germany. The mean number of nutrition claims per product carrying any claim was slightly higher than the mean number of health claims (2.0 and 1.9, respectively). A Kruskal-Wallis test was used to determine if there were any significant country differences in the number of nutrition claims, health claims or any claims (NHC) of foods that carry such claims. There was a significant country difference in the number of health claims, but the country differences in the number of nutrition claims or NHC claims overall were not statistically significant. The highest number of health claims observed on a single product was 15, found on a baby food, and for nutrition claims, 13 claims found on a confectionery product, both in Germany. Nutrients 2016,8, 137 7 of 16 Table 2. Prevalence of nutrition claims, health claims, and symbols in five European countries. Country Claim Type No. of Claims . . . of Which Are Symbolic No. of Foods with a Claim % of Foods with Claim (95% CIs) All Countries N = 2034 Foods Nutrition claim 865 1 423 20.8% (19.0%–22.5%) Nutrient content claim 797 1399 19.6% (17.8%–21.3%) Nutrient comparative claims 68 049 2.4% (1.7%–3.1%) Health-related ingredient claim 105 6 72 3.5% (2.7%–4.3%) Health claim 392 74 222 10.9% (9.6%–12.3%) General health claim 153 64 137 6.7% (5.6%–7.8%) Nutrient and other function claim 185 9 106 5.2% (4.2%–6.2%) Reduction of disease risk claim 21 1 12 0.6% (0.2%–0.09%) Children’s development & health claims 33 0 15 0.7% (0.4%–1.1%) Any type of claim (NHC) 1362 81 528 26.0% (24.0%–27.9%) UK N = 398 foods Nutrition claim 247 0 118 29.6 (25.1%–34.1%) Health-related ingredient claim 65 3 40 10.1% (7.1%–13.0%) Health claim 85 2 44 11.1% (8.0%–14.1%) General health claim 30 0 23 5.8% (3.5%–8.1%) Nutrient and other function claim 38 2 26 6.5% (4.1%–9.0%) Reduction of disease risk claim 10 0 4 1.0% (0.0%–0.2%) Children’s development & health claims 7 0 4 1.0% (0.0%–2.0%) Any type of claim (NHC) 397 5 140 35.2% (30.4%–40.0%) Nether-lands N = 416 foods Nutrition claim 154 0 70 16.8% (13.2%–20.4%) Health-related ingredient claim 12 0 12 2.9% (1.3%–4.5%) Health claim 73 50 60 14.4% (8.9%–15.2%) General health claim 52 49 50 12.0% (8.9%–15.2%) Nutrient and other function claim 19 1 12 2.9% (1.3%–4.5%) Reduction of disease risk claim 2 0 1 0.2% (0.0%–0.1%) Children’s development & health claims 0 0 0 0.0% Any type of claim (NHC) 239 50 103 24.8% (20.6%–29.0%) Germany N = 399 foods Nutrition claim 123 0 64 16.0% (12.4%–19.7%) Health-related ingredient claim 19 1 13 3.3% (1.5%–5.0%) Health claim 82 0 37 9.3% (6.4%–12.1%) General health claim 29 0 23 5.8% (3.5%–8.1%) Nutrient and other function claim 45 0 20 5.0% (2.9%–3.2%) Reduction of disease risk claim 1 0 1 0.3% (–0.2%–0.7%) Children’s development & health claims 7 0 5 1.3% (0.1%–0.2%) Nutrients 2016,8, 137 8 of 16 Table 2. Cont. Country Claim Type No. of Claims . . . of Which Are Symbolic No. of Foods with a Claim % of Foods with Claim (95% CIs) Slovenia N = 416 foods Nutrition claim 144 0 78 18.8% (15.0%–22.5%) Health-related ingredient claim 3 1 2 0.5% (–0.2%–1.1%) Health claim 88 7 52 12.5% (0.9%–15.7%) General health claim 24 1 23 5.5% (3.3%–7.7%) Nutrient and other function claim 58 6 36 8.7% (5.9%–11.4%) Reduction of disease risk claim 4 0 3 0.7% (–0.1%–1.5%) Children’s development & health claims 2 0 1 0.2% (–0.2%–0.7%) Any type of claim (NHC) 235 8 103 24.8% (20.6%–28.9%) Spain N = 405 Nutrition claim 196 1 93 23.0% (18.8%–27.1%) Health-related ingredient claim 6 1 5 1.2% (0.2%–2.3%) Health claim 64 15 29 7.2% (4.6%–9.7%) General health claim 18 14 18 4.4% (2.4%–6.5%) Nutrient and other function claim 25 0 12 3.0% (1.3%–4.6%) Reduction of disease risk claim 4 1 3 0.7% (–0.1%–1.6%) Children’s development & health claims 17 0 5 1.2% (0.2%–2.3%) Any type of claim (NHC) 266 17 100 24.7% (20.5%–28.9%) Bold is for main claims we looked at and the total claims. Italic is for the sub-categories of all these claims. Regular font size was only used for the description of the countries to the left. Nutrients 2016,8, 137 9 of 16 Table 3. Number of claims per product. Mean Number of Nutrition Claims 1 Highest Number of Nutrition Claims on a Single Product Mean Number of Health Claims 1 Highest Number of Health Claims on a Single Product Mean Number of Any Claim 1 Highest Number of Any Claims on a Single Product All countries 2.0 13 1.9 15 2.6 17 UK 2.1 11 1.9 5 2.8 15 Netherlands 2.2 8 1.2 6 2.3 9 Germany 1.9 13 2.2 15 2.7 17 Slovenia 1.8 8 1.7 5 2.3 11 Spain 2.1 12 2.2 11 2.7 17 pvalue 0.94 <0.01 0.52 NOTE: per product carrying a claim. 3.2. What Proportion of These Claims is Symbolic? Substantial differences were observed in the prevalence of symbolic claims between the countries (Table 2). The highest prevalence was found in the Netherlands (12%, (9%–14%)), followed by Spain (4%, (2%–6%)), Slovenia (2%, (1.0%–3.0%)), the UK (1%, (0%–2%)), and Germany (0.3%, (0%–1%)). Almost all of the general health claims in the Netherlands were symbolic—the majority of which comprised of the Choices logo. Spain had a similarly high level of symbolic general health claims, including logos of health organizations such as the Spanish Association for Pediatricians. However, it should be noted that in general the prevalence of symbolic claims was quite low; altogether only 3.88% (3%–5%) of foods were labeled with a symbolic claim. 3.3. What Types of NHC Can Be Found on Pre-Packaged Food and Drinks? 64% of the claims were nutrition claims of which 92% (90%–94%) were classified as nutrient content claims and just 8% (6%–10%) were nutrient comparative claims (Table 2). Health claims accounted for 29% (26%–31%) of the claims recorded. Of these, almost half (47%, (42%–52%)) were nutrient and other function claims, 39% (34%–44%) were general health claims, 8% (6%–11%) were children’s development and health claims and the remaining 5% (3%–8%) were reduction of risk claims. The remaining claims fell into the category of health-related ingredient claims (8%, (6%–9%)). The proportion of nutrition claims was highest in Spain (74% of all claims were nutrition claims), followed by the Netherlands (64%), the UK (62%), Slovenia (61%), and Germany (55%). The proportion of health claims showed slightly less variation across the five countries: it was highest in Slovenia and Germany (both 37%), followed by the Netherlands (31%), Spain (24%) and the UK (21%). Only 14% (12%–15%) of the NHC were nutrient and other function health claims. The highest proportion was found in Slovenia (25%, (19%–30%)) and lowest in the Netherlands (8%, (5%–11%)). Spain had the highest proportion of children’s development and health claims (6%, (3%–9%)) while none were found on foods sampled in the Netherlands. The UK had the highest proportion of disease risk claims (3%, (1%–4%)) whereas Germany had the lowest (only one such claim was found, out of a total of 224 claims identified) (Table 2). 3.4. To Which Nutrients or Other Food Components Do NHC Refer? More than one third of the nutrition claims referred to vitamins and/or minerals (e.g., “Enriched with important vitamins and minerals”) (Table 4). More specifically, 22% referred to vitamins, of which vitamin C was the most common vitamin referenced (e.g., “High in vitamin C”) and 13% to minerals, of which calcium was the most common mineral (e.g., “A source of calcium”). Almost a quarter of nutrition claims (24%) referred to the fat content of a food in some way, 12% to the sugar content and 9% to fiber. Nutrients 2016,8, 137 16 of 16 18. Lalor, F.; Kennedy, J.; Flynn, M.A.T.; Wall, P.G. A study of nutrition and health claims—A snapshot of what’s on the Irish market. Public Health Nutr. 2010,13, 704–711. [CrossRef] [PubMed] 19. Pravst, I.; Kušar, A. Consumers’ exposure to nutrition and health claims on pre-packed foods: Use of sales weighting for assessing the food supply in Slovenia. Nutrients 2015,7, 9353–9368. [CrossRef] [PubMed] 20. Menard, C.; Dumas, C.; Gillot, N.; Laurent, L.; Labarbe, B.; Ireland, J.; Volatier, J.-L. The French OQALI survey on dairy products: Comparison of nutrient contents and other nutrition information on labels among types of brands. J. Hum. Nutr. Diet. 2012,25, 323–333. [CrossRef] [PubMed] 21. Debeljak, K.; Pravst, I; Košmelj, K.; Kaˇc, M. “Healthier” and “less healthy” classifications according to three nutrient profiling systems relative to nutrition and health claims on food labels. Acta Aliment. 2015 ,44, 561–565. 22. Davidovic, D.B.; Tomic, D.V.; Paunovic, K.Ž.; Vasiljevic, N.D.; Jorga, J.B. Nutrition labelling of pre-packaged foods in Belgrade, Serbia: Current situation. Public Health Nutr. 2015,18, 1969–1978. [CrossRef] [PubMed] 23. Dunford, E.; Webster, J.; Metzler, A.B.; Czernichow, S.; Mhurchu, C.N.; Snowdon, W.; L’Abbe, M.; Li, N.; Maulik, P.K.; Barquera, S.; et al. International collaborative project to compare and monitor the nutritional composition of processed foods. Eur. J. Prev. Cardiol. 2012,19, 1326–1332. [CrossRef] [PubMed] 24. Dunford, E.; Webster, J.; Metzler, A.; Blanco, S.; Ni Mhurchu, C.; Wolmarans, P.; Snowdon, W.; L’Abbe, M. International collaborative project to compare and track the nutritional composition of fast foods. BMC Public Health 2012,12, 1–7. 25. Regulation (EU) No 1169/2011 on the Provision of Food Information to Consumers. Available online: http://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:02011R1169-20140219 (accessed on 29 February 2016). 26. Roodenburg, A.J.C.; Popkin, B.M.; Seidell, J.C. Development of international criteria for a front of package food labelling system: The International Choices Programme. Eur. J. Clin. Nutr. 2011 ,65, 1190–1200. [CrossRef] [PubMed] 27. Cinar, A.B.; Murtomaa, H. A holistic food labelling strategy for preventing obesity and dental caries. Obes. Rev. 2009,10, 357–361. [CrossRef] [PubMed] 28. Rayner, M.; Wood, A.; Lawrence, M.; Mhurchu, C.N.; Albert, J.; Barquera, S.; Friel, S.; Hawkes, C.; Kelly, B.; Kumanyika, S.; et al. Monitoring the health-related labelling of foods and non-alcoholic beverages in retail settings. Obes. Rev. 2013,14, 70–81. [CrossRef] [PubMed] 29. World Health Organisation. International Classification of Functioning, Disability and Health (ICF). Available online: http://www.who.int/classifications/icf/en/ (accessed on 29 February 2016). 30. Raats, M.M.; Malcolm, R.N.; Lähteenmaki, L.; Pravst, I.; Gage, H.; Cleary, A.; Klopˇciˇc, M. Understanding the impact of European Regulation on the substantiation and use of claims on food and drinks: Design of the REDICLAIM project and initial results. Nutr. Bull. 2015,40, 340–348. [CrossRef] © 2016 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons by Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/).