Evaluation of nutrition label reading habits and knowledge levels among Turkish consumers: Implications for healthier food choices

habits and


INTRODUCTION
According to the World Obesity Atlas 2022 published by the World Obesity Federation, it is estimated that one billion people worldwide will live with obesity by 2030, one out of every five women and one out of seven men [1]. "Nutrition labels" are increasingly seen as an important component in comprehensive strategies to combat obesity caused by increased energy intake as a result of the widespread consumption of processed ready-to-eat foods [2,3].
Nutrition labels are an important communication tool between food manufacturers and consumers [4]. Nutrition labels encourage consumers to make healthier food choices [5]. In a meta-analysis evaluating the effects of nutrition labels on consumers' eating habits; it has been determined that nutrition labels lead consumers to healthier food choices [6].
It is stated that nutrition labeling can contribute to the improvement of health with its effects on the food industry as well as the effects on the food choices of consumers [5,6]. For example, the requirement to specify the trans-fat content on the labels of packaged foods necessitated the development of food technologies that will reduce the trans-fat content in the food industry [6]. It is important to the presence of nutritional labels in packaged foods as well as how the nutrition labels are designed is also very important [5]. It is reported that when well-designed, nutritional labels can potentially have a positive impact on the national diet [5,7]. On the other hand, poorly designed nutrition labels and information confusion on nutrition labels adversely affect the level of consumers' benefit from these labels [8].
Nutrition claims describe the amount of a nutrient in a food (e.g., "low in sodium") and/or the health or disease-related properties of a food product or food ingredient (for example, a healthy diet low in saturated and trans fats may reduce the risk of heart disease) [9][10][11]. The correct application of nutrition claims on nutrition labels can lead consumers to make healthier food choices [10].
Healthy diet and food choices are the main modifiable factors for healthy aging and the prevention of chronic diseases [12]. Therefore, investigating the factors that influence food choices and nutritional status is crucial to efforts to improve the health of populations. Nutrition labels have an important place among the factors that affect nutritional behavior and food preference [6]. Furthermore, learning the habits of consumers to read nutrition labels, their level of knowledge and expectations about these labels will contribute to better design of nutrition labels. In this study, it is aimed to evaluate the nutritional label reading habits of Turkish adults and their knowledge levels about nutrition labels and nutrition claims.

Study Design and Participants
This study was conducted on 1,195 participants, 597 men and 598 women, aged between 18-65 years. Individuals with a diagnosis of neurological disease were excluded from the study due to the difficulty of establishing healthy communication and the concerns of not answering the questions correctly. In the study, a questionnaire form was applied to the individuals by the face-to-face interview method. With the questionnaire, the descriptive information of the participants (age, gender, marital status, education level, occupation, and number of households), nutrition label reading habits, information levels about nutrition labels and the information and claims they prefer to be on the food label were questioned.

Determination of Participants' Nutrition Label Reading Habits, Information Levels About Nutrition Labels, and Preferred Information and Claims to be on Nutrition Labels
Within the scope of the research, 11 questions were asked to the participants under the sub-title of "information on nutrition label reading habits" via a questionnaire, and the participants' nutritional label reading habits, the importance they attach to nutrition label reading and their level of knowledge about food packaging were questioned. In the survey, within the scope of the sub-title of "information on nutrition labels", seven questions were asked and the information about the nutrition claims on the nutrition labels, the most read nutrition claims, and health claims of the participants were questioned. In addition, participants were asked to fill in three tables within the scope of "preferred information and claims on nutrition labels" subheading in the survey; the frequency of paying attention to some phrases on nutrition labels, which of the statements on the packaging are more important, and the level of knowledge about food additives, probiotics, prebiotics, and symbiotics was determined.

Statistical Analyses
Statistical package for the social sciences (SPSS, version: 23.0) statistical package program was used for the statistical evaluation of the data obtained from the study. Number and percentage (%) values were calculated for the variables obtained from individuals. The correlation between categorical variables was examined by the chi-square test. Statistical significance rates were given in 99% and/or 95% confidence intervals in all analyses.

RESULTS
The distribution of the general characteristics of the participants in the study is given in Table 1. There was no difference between the genders in terms of age groups (p>0.05). When the education level is evaluated, 19.9% of the male gender is pre-high school, 44.4% is high school and 35.7% is university or higher graduate, while respectively %23.5, %46.2, and %30.3 in female gender (p<0.05). When the occupational status was evaluated, it was determined that the highest rate of 28.9% was government employees in the male gender and a housewife with the rate of 42.5% in the female gender (p<0.05).
The distribution of information about the nutrition label reading habits of the participants is also shown in Table 2. While the status of being a food that is given up after reading the label information is 23.6% in the male gender, it is seen that this situation is 29.8% in the female gender (p<0.001). However, there is no significant difference between genders in terms of finding label information important when purchasing food (p>0.05).
It was determined that the rate of reading the packaging information, buying unpackaged food and the need to research a substance in the composition of that food after reading the nutrition label was higher in the male gender and in the total participants (male+female gender) who found the label information important when purchasing food than those who did not find it important (p<0.05), but the rate of knowing the health claims on the label was lower (p<0.05) ( Table 3).
It was found that the rate of reading the packaging information and the need to research a substance in the composition of that food after reading the nutrition label was higher in the female gender who found the label information important when purchasing food than those who did not find it important (p<0.001).
The distribution of the most frequently read nutrition claims by the participants according to their knowledge of the nutrition claims on the nutrition labels is given in Table 4.  It was determined that those who know the nutrition claims on the nutrition labels in all groups prefer more "reduced energy", "low fat/fat free", "saturated fats free", "trans-fats free", "omega-3 enriched", "cholesterol free", "no salt/low salt", "high fiber", and "full of vitamins/minerals" among the most read nutrition claims compared to those who do not know (p<0.001).
The state of hearing some terms according to whether the participants find the label information important when purchasing food is shown in Table 5.

DISCUSSION
Nutrition labels act as a bridge in the communication between food producers and consumers and are effective in shaping the food choices and dietary habits of consumers [13]. For this reason, it is very important to determine the factors that affect food label reading habits. Among the factors thought to be effective are socio-demographic characteristics [13][14][15]. It was determined that young, female, married, working, high-income and highly educated individuals are more likely to read and use nutrition labels when purchasing foods [14]. It was also found that the rate of reading habits on food labels is higher in highly educated, single, working individuals, physically active adults, and non-smokers [13]. In this study, it is seen that there is a significant difference between the genders (23.6% in the male gender, 29.8% in the female gender) in terms of being a food that is given up after reading the label information (p<0.001) ( Table 2).
Although this result indicates that female individuals find the information on food labels more important, it should not be ignored that no significant difference was found between the sexes in terms of finding label information important when purchasing food (p>0.05) ( Table 2). In addition, in the present study, it was determined that there was a difference between the genders in terms of education and occupational status (p<0.05 and p<0.001, respectively) ( Table 1). However, the relationship between these sociodemographic characteristics and nutrition label reading habits was not evaluated in the study. For this reason, it is not possible to interpret the effects of education and occupation status on the habit of reading nutrition labels from the current study data. Investigating this relationship in future studies will help to better understand which sociodemographic characteristics are effective in gaining the habit of reading nutrition labels.
Globally, daily dietary energy (kcal) intake is increasing day by day, and processed ready-to-eat foods, whose consumption is becoming more widespread, are held responsible for this situation [2,3]. Obesity, one of the consequences of unhealthy nutrition caused by these nutritional trends, has become a crucial public health problem today [16]. Nutrition labels are increasingly seen as a crucial strategy to combat diet-related chronic diseases, especially obesity [3]. Nutrition labels provide considerable information to the consumer regarding the content of the food, nutrition claims, and nutritional benefits [17]. Nutrition claims are also important tools used in the food industry to help consumers make healthy food choices [18]. In a meta-analysis, it was found that nutritional labels decreased the total energy and total fat intake of consumers and increased the consumption of vegetables [6]. Data obtained from another meta-analysis also suggest that nutrition labels may lead consumers to choose healthier and less calorie-containing foods [3]. In addition, nutrition labels can contribute to a healthy diet by increasing the choice of some health-promoting foods (such as fiber-rich foods) and reducing the choice of some harmful foods (such as foods high in sugar, fat, and cholesterol) at purchase [19][20][21]. It is also stated that nutrition claims on nutrition labels have a positive effect on consumers' food purchase preferences [10,18,22]. It was found that most consumers are willing to pay for two nutrition claims, "high fiber" and "reduced in saturated fat", and that these nutrition claims on nutrition labels lead individuals to choose healthier foods [18]. In this study, it was determined that the rate of reading the packaging information and the need to research a substance in its composition after reading the nutrition label of those who found the label information important while purchasing food in all groups was higher (p<0.001) ( Table 3). Additionally, the rate of buying unpackaged food in the male group and total participants who found the label information important was higher than in those who did not find it important (p<0.05), but the rate of knowing the health claims on the label was lower (p<0.05) ( Table 3). These results suggest that finding nutritional label information important will lead individuals to choose healthier food by increasing the rate of reading the food label, the need for research on the content of nutrients, and the rate of buying unpackaged food. However, the fact that those who find the nutritional label information important have a lower rate of knowing the health claims on the label creates a contradiction. For this reason, this situation should be investigated again with new studies to be done. Another result of the study is that those who know the nutrition claims on the nutrition labels in all groups prefer more "reduced energy", "low fat/fat free", "saturated fats free", "trans-fats free", "omega-3 enriched", "cholesterol free", "no salt/low salt", "high fiber", and "full of vitamins/minerals" among the most read nutrition claims (p<0.001) ( Table 4). Taking this data into consideration, it is thought that knowing the nutrition claims on the nutrition labels leads individuals to read more about the nutrition claims they attribute as healthier (such as "trans-fats free"). Furthermore, the habit of reading food labels is likely to contribute to awareness of these nutritional claims. The data obtained from the literature and this study suggest that explaining the importance of nutrition labels and nutrition claims at the societal level can lead consumers to make healthier food choices and gain eating habits.
Increasing the nutritional knowledge level of consumers and the rate of reading food labels are considered crucial tools to encourage their orientation towards healthier food choices [23]. It is stated that people are generally willing to improve their health and control their body weight by increasing their nutritional knowledge [21]. It is also reported that there is a relationship between the level of nutritional knowledge and the status of reading food labels [23]. It was found that individuals with high nutritional knowledge had a higher rate of reading the food label (p<0.0001) and the effect of the food label on purchase intention (p<0.05) [23]. Another result is that individuals with low nutritional knowledge do not or rarely look at nutrition labels to check whether their food is low in fat [23]. In this study, it was found that the rate of hearing some terms frequently used in the food industry (such as colorants and preservatives) of those who find the label information important when purchasing food is higher than those who do not find the label information important (p<0.05) ( Table 5). Individuals who think that nutrition label information is important are more likely to have heard/know some terms frequently used in the food industry due to selective perception and the increasing need for research. These results suggest that the habit of reading nutrition labels can contribute to increasing the level of nutritional knowledge and healthy food choices.

Limitations
One of the important limitations of the study is that anthropometric measurements such as the body weight of the participants were not questioned in the current study. Moreover, the most important limitation of the study is that the relationship between the habit of reading nutrition labels and healthy-unhealthy food choices was not questioned. Taking anthropometric measurements and questioning the specified relationships in future studies will provide a clearer presentation of the effects of nutrition label reading habits on food selection.

CONCLUSIONS
In conclusion, it was found in the study that finding nutritional label information important can increase the rate of reading the food label, The need to research a substance in the composition of foods, and the rate of buying unpackaged food. Another result of the study is that knowing the nutrition claims encourages individuals to read some nutrition claims more (such as "trans-fats free"). Furthermore, the study found that finding nutritional label information important may increase the likelihood of hearing some terms used frequently in the food industry. In line with these results, it is suggested that instilling the importance of reading nutrition labels and teaching nutrition claims to individuals in the community may be a cost-effective intervention to encourage consumers to make healthier food choices and acquire healthier eating habits. In this context, it can be ensured that public service announcements emphasizing the importance of reading nutrition labels in the media are increased, education is given to students on nutrition labels and claims in schools, and the information and claims on nutrition labels can be made more visible.
Author contributions: All co-authors have been involved in all stages of this study while preparing the final version. They all agree with the results and conclusions.

Funding:
No funding source is reported for this study.

Declaration of interest: No conflict of interest is declared by the authors.
Ethical statement: Ethics committee approval of the study was obtained from Amasya University Non-Interventional Clinical Research Ethics Committee with decision number 2023/06 dated 19 January 2023. Signed informed consent was obtained from all participants and the study was conducted in accordance with the Declaration of Helsinki.
Data sharing statement: Data supporting the findings and conclusions are available upon request from corresponding author.