Performing evidence-based reviews (EBR) is a growing and important area of research, and more graduate students should be educated in this area. EBRs provide conclusions based on science and follow a specific methodology to decrease bias, consider all pertinent science on the topic, and have transparency. This thesis is two-fold and includes: 1) a faculty course manual on how to facilitate a college course on EBR and 2) an EBR manuscript on the utility of nutrition labeling to affect consumers’ ability to select more nutritious products and whether or not nutrition labeling can affect purchase and consumption of more nutritious products. This EBR is timely in that the US Food and Drug Administration (FDA) has called for a moratorium on Front-of-Pack labeling (FOP) until two Institute of Medicine Committees have produced their reports and FDA has interpreted those reports. The intention of the manuscript is that it will aid in this interpretation. Of 978 articles collected, 699 were excluded using exclusion/inclusion criteria, 253 were identified as secondary articles, and 26 were used for the EBR. Results: Ten studies answered question #1 on whether or not consumers can pick a more nutritious product by reading labels and 21 answered question #2 on whether consumers actually change their purchasing and/or eating behavior by using labels. Studies ranged from simple cross-sectional studies that used survey data to more complex studies that collected sales data or performed in-store observations. In conclusion, consumers are able to use food labels to pick more nutritious products. Preliminary evidence suggests that a subset of health conscious consumers will read food labels to select a healthier product within a product category. Less evidence exists that reading labels actually results in a change of food intake. More intervention rather than survey studies are required to address this issue. In addition, the next stages of investigation should include looking at the whole diet, rather than just individual foods, and finally what affect the whole diet may have on overall health.

BACKGROUND:Health literacy (HL) is an important public health issue. Current measures have drawbacks in length and/or acceptability. The US-developed Newest Vital Sign (NVS) health literacy instrument measures both reading comprehension and numeracy skills using a nutrition label, takes 3 minutes to administer, and has proven to be acceptable to research subjects. This study aimed to amend and validate it for the UK population.METHODS:We used a three-stage process / (1) a Delphi study with academic and clinical experts to amend the NVS label to reflect UK nutrition labeling (2) community-based cognitive testing to assess and improve ease of understanding and acceptability of the test (3) validation of the NVS-UK against an accepted standard test of health literacy, the Test of Functional Health Literacy in Adults (TOFHLA) (Pearson's r and the area under the Receiver Operating Characteristic (ROC) curve) and participant educational level. A sample size calculation indicated that 250 participants would be required. Inclusion criteria were age 18-75 years and ability to converse in English. We excluded people working in the health field and those with impaired vision or inability to undertake the interview due to cognitive impairment or inability to converse in English.RESULTS:In the Delphi study, 28 experts reached consensus (3 cycles). Cognitive testing (80 participants) yielded an instrument that needed no further refinement. Validation testing (337 participants) showed high internal consistency (Cronbach's Alpha = 0.74). Validation against the TOFHLA demonstrated a Pearson's r of 0.49 and an area under the ROC curve of 0.81.CONCLUSIONS:The NVS-UK is a valid measure of HL. Its acceptability and ease of application makes it an ideal tool for use in the UK. It has potential uses in public health research including epidemiological surveys and randomized controlled trials, and in enabling practitioners to tailor care to patient need.

Obesity, the second leading cause of preventable death in the U.S., and related health problems increase people’s concerns about healthy food consumption. The increased prevalence of obesity is a major concern of societies both in developed and developing countries. Nutrition label usage has been increasing due to the link between diet and health. This study intends to provide a framework for describing profiles of consumers who are more likely to use nutrition labels in USA and Turkey, a developing country with increasing obesity rates in recent years. Empirical results present similarities and differences between consumers’ attributes for food label usage in two countries. The main contribution of this study is to investigate the relationship between the importance of serving size, while the number of expanded portion sized products in the market is increasing, and rising obesity rates. Ordered probit model analysis is used to identify the effects of demographics, health status and other components of the nutrition facts panel on selected dependent variables. Better understanding consumers’ responses to nutrition labels may guide consumers and manufacturers to broaden the communication channels through nutrition labels. The findings of this study can provide useful information to policy makers, agribusinesses, manufacturers and marketing professionals.

abstract: This dissertation offers three essays that investigate consumers’ health-related food choices and behaviors from three different, yet complementary, angles. The first essay uses an eye-tracking experiment to examine consumers’ visual attention to the Nutrition Facts Panels for healthy and unhealthy products. In this essay, I focus on how involvement and familiarity affect consumers’ attention toward the Nutrition Facts panel and how these two psychological factors interact with new label format changes in attracting consumers’ attention. In the second essay, I demonstrate using individual-level scanner data that nutritional attributes interact with marketing mix elements to affect consumers’ nutrition intake profiles and their intra-category substitution patterns. My findings suggest that marketing-mix sensitivities are correlated with consumers’ preferences for nutrient attributes in ways that depend on the “healthiness” of the nutrient. For instance, featuring promotes is positively correlated with “healthy” nutritional characteristics such as high-protein, low-fat, or low-carbohydrates, whereas promotion and display are positively correlated with preferences for “unhealthy” characteristics such as high-fat, or high-carbohydrates. I use model simulations to show that some marketing-mix elements are able to induce consumers to purchase items with higher maximum-content levels than others. The fourth chapter shows that dieters are not all the same. I develop and validate a new scale that measures lay theories about abstinence vs. moderation. My findings from a series of experiments indicate that dieters’ recovery from recalled vs. actual indulgences depend on whether they favor abstinence or moderation. However, compensatory coping strategies provide paths for people with both lay theories to recover after an indulgence, in their own ways. The three essays provide insights into individual differences that determine approaches of purchase behaviors, and consumption patterns, and life style that people choose, and these insights have potential policy implications to aid in designing the food-related interventions and policies to improve the healthiness of consumers’ consumption profiles and more general food well-being. / Dissertation/Thesis / Doctoral Dissertation Agribusiness 2018

o presente trabalho tem como objetivo realizar uma avaliação crítica da legislação brasileira sobre rotulagem nutricional e compará-Ia com a de outros países, como Canadá, U.S.A., União Européia e as Normas do Codex Alimentarius. Para isso, realizou-se um levantamento sobre a evolução da legislação brasileira, focando as regulamentações sobre rotulagem nutricional durante as últimas quatro décadas. Concisamente, concluiu-se que a legislação brasileira não difere muito da internacional, mas apresenta distinções como a não obrigatoriedade da declaração de ferro, cálcio, colesterol, Vitamina A e C, que em países como os Estados Unidos e Canadá, é obrigatória. A Comunidade Européia e as Normas do Codex Alimentarius estabelecem que a informação nutricional deve ser por 100g ou 100mL de alimento, enquanto no Brasil isso é baseado na quantidade de referência que é consumida costumeiramente. A apresentação por 100g ou 100mL tem a vantagem de não subestimar sistematicamente a real contribuição de certos nutrientes que estão presentes nos alimentos em baixa concentração e por isso não são declarados na porção de referência. Ademais, um levantamento foi conduzido através da avaliação de 460 rótulos de alimentos industrializados no Brasil e o resultado mostrou que 47% estavam irregulares e 41 % apresentavam informações contraditórias. Recomenda-se que o governo incentive as indústrias a manterem a declaração de ferro, cálcio e colesterol nos rótulos de alimentos. De posse da rotulagem nutricional, seria aconselhável esclarecer à população a importância da informação nutricional e como utilizá-Ia em benefício da saúde do consumidor. A introdução desse assunto nas escolas, poderia ser um primeiro estágio. / The present work aims to perform a criticai evaluation of the Brazilian nutrition labeling regulations and to compare them with those of some other countries, like Canada, U.S.A, European Union and those proposed in the Codex Alimentarius. An overview about the evolution of the Brazilian guidelines concerning nutrition labeling over the last four decades is provided. Concisely, it was concluded that the current Brazilian regulations does not differ so much from international ones, but differences like the non-requirement of stating iron, calcium, cholesterol, Vitamins A and C, which is mandatory in countries like the United States and Canada were observed. The European Union and the Norms of the Codex Alimentarius have established that nutrition information should be per 100g or 100mL of food product, while in Brazil it is based on the reference amount customarily consumed . The nutrition facts presented per 100g or . 100mL has the advantage of not systematically under-represent the true contribution of certain nutrients which are present in foods in low amounts and therefore not declared in the reference portion. In addition, a survey was carried out by evaluating 460 labels of foods marketed in Brazil and the results showed that 47% of the labels were incorrect and that 41 % presented contradictory information. It is recommended that the government encourage companies to declare iron, calcium and cholesterol on food product labels. It is advisable to explain to the population about the importance of nutritional information and how it can be used to benefit the health of the consumer. The introduction of this subject at schools could be a first step.

o presente trabalho tem como objetivo realizar uma avaliação crítica da legislação brasileira sobre rotulagem nutricional e compará-Ia com a de outros países, como Canadá, U.S.A., União Européia e as Normas do Codex Alimentarius. Para isso, realizou-se um levantamento sobre a evolução da legislação brasileira, focando as regulamentações sobre rotulagem nutricional durante as últimas quatro décadas. Concisamente, concluiu-se que a legislação brasileira não difere muito da internacional, mas apresenta distinções como a não obrigatoriedade da declaração de ferro, cálcio, colesterol, Vitamina A e C, que em países como os Estados Unidos e Canadá, é obrigatória. A Comunidade Européia e as Normas do Codex Alimentarius estabelecem que a informação nutricional deve ser por 100g ou 100mL de alimento, enquanto no Brasil isso é baseado na quantidade de referência que é consumida costumeiramente. A apresentação por 100g ou 100mL tem a vantagem de não subestimar sistematicamente a real contribuição de certos nutrientes que estão presentes nos alimentos em baixa concentração e por isso não são declarados na porção de referência. Ademais, um levantamento foi conduzido através da avaliação de 460 rótulos de alimentos industrializados no Brasil e o resultado mostrou que 47% estavam irregulares e 41 % apresentavam informações contraditórias. Recomenda-se que o governo incentive as indústrias a manterem a declaração de ferro, cálcio e colesterol nos rótulos de alimentos. De posse da rotulagem nutricional, seria aconselhável esclarecer à população a importância da informação nutricional e como utilizá-Ia em benefício da saúde do consumidor. A introdução desse assunto nas escolas, poderia ser um primeiro estágio. / The present work aims to perform a criticai evaluation of the Brazilian nutrition labeling regulations and to compare them with those of some other countries, like Canada, U.S.A, European Union and those proposed in the Codex Alimentarius. An overview about the evolution of the Brazilian guidelines concerning nutrition labeling over the last four decades is provided. Concisely, it was concluded that the current Brazilian regulations does not differ so much from international ones, but differences like the non-requirement of stating iron, calcium, cholesterol, Vitamins A and C, which is mandatory in countries like the United States and Canada were observed. The European Union and the Norms of the Codex Alimentarius have established that nutrition information should be per 100g or 100mL of food product, while in Brazil it is based on the reference amount customarily consumed . The nutrition facts presented per 100g or . 100mL has the advantage of not systematically under-represent the true contribution of certain nutrients which are present in foods in low amounts and therefore not declared in the reference portion. In addition, a survey was carried out by evaluating 460 labels of foods marketed in Brazil and the results showed that 47% of the labels were incorrect and that 41 % presented contradictory information. It is recommended that the government encourage companies to declare iron, calcium and cholesterol on food product labels. It is advisable to explain to the population about the importance of nutritional information and how it can be used to benefit the health of the consumer. The introduction of this subject at schools could be a first step.

Nutrition labeling research suggests consumers want nutrition information on the label; however, many do not comprehend it. The purpose of Phase I was to determine the effect of: 1. two levels of nutrition label formats; 2. three levels of nutrition information load on consumers' preference for product choice using adaptive conjoint analysis. A computer interactive interview was conducted on 252 consumers in Crossroads Mall, Salt Lake City, Utah. label alternatives were printed on soup cans to realistically portray the information. The conjoint analysis compared the attributes, nutrition information format, and nutrition information load in addition to brand and price and determined how the study participants ranked choices within each of these attributes and against the other attributes. There were significant differences (p < .000) among all three mean utility values± Standard Error of the Mean (SEM) of information load, most (.300 ± .03) , more (.154 ± .02), and some (-.231 ± .03). There was no difference between graphical (.093 ± .027) and traditional (.055 ± .020) formats (p = .298). For the other attributes, there were significant differences (p < .000) among all brands, Campbell's (.590 ± .03), Private label (-.007 ± .02) Generic (-.361 ± .03) and all prices, (p < .000), low (.431 ± .03), medium (.022 ± .02), and high (-.230 ± .03). Market simulations were performed and market share was shifted from the major brand when nutrition information was added to a Private label or Generic brand. The purpose of Phase II was to determine the effect of: 1. three levels of nutrition information content load; 2. two levels of nutrition information order; 3. three levels of nutrition information format; and 4. four levels of nutrition information expression on consumers' perceptions of label usefulness in purchase decisions. The methodology was the same as Phase I. There were significant differences (p < .000) among all three mean utility values ± SEM of information load, most (.327 ± .02), more (.091 ± .02) , and some (-.213 ± .03), and between the two mean utility values ± SEM of information order, rearranged (.157 ± .03) and traditional (-.02 ± .02). Consumers significantly preferred (p < .000) the graphical format (.148 ± .02) over the graphical nutrient density (.038 ± .02) and traditional (.018 ± .03) formats. Consumers significantly preferred (p < .000) nutrition information stated in absolute numbers and percentages (.296 ± .03), versus absolute numbers only (.028 ± .03), traditional (-.026 ± .03), and percentages only (-.025 ± .03) expressions. The most useful nutrition label in a purchase decision was one that contained the most information, in a rearranged order, with a graphical format, and an absolute number and percentages expression.

Purpose: Health literacy and obesity are major global issues. Vulnerable populations, such as those with low health literacy, have the highest rates of obesity. Native Hawaiian and other Pacific Islander (NHOPI) nations have the highest prevalence of obesity in the world. This study describes the relationship between health literacy and demographic variables in a sample of NHOPI caregiving adults. Methods: We conducted a correlational study of 364 NHOPI adults. Each was a caregiver of at least one NHOPI child. Data were collected at grocery stores and a preschool in two Hawaiian Islands (n=209) and at NHOPI events in Utah (n=155). Our questionnaire included demographics, the Newest Vital Sign, and questions about caregivers' food-serving and activity promotion. Results: 45% of the sample had limited health literacy. There was no significant difference between participants' health literacy in Hawaii and Utah. Other demographic variables (gender, age, income, BMI, and education) had a significant relationship with health literacy. Conclusions: Many NHOPIs have limited health literacy. This is concerning as limited health literacy can reduce an adults' ability to use health-related materials including nutrition facts labels.Implications for Practice: Health care providers should not assume NHOPIs understand nutrition facts labels. Instruction on nutrition facts labels should be available in schools and communities. Future research should examine effective interventions for this population.