A total of 63 mothers participated in our study. The mothers were 38.54±5.00 years old. Their education levels were: school graduates (8.2%), high school graduates (36.1%), associates and bachelor’s degree graduates (44%) and graduates of master’s and/or higher degrees (11.7%).
Interviews with ten FQC experts were carried out. Six of them were educated in food industry, two of them in chemistry and one of them in nutrition.
FGDs with experts were conducted with 6 PhD graduates of nutrition and 8 PhD graduates of food industry sciences from universities in Tehran.
1. The stakeholders’ perspectives on PACE labeling
A. Mothers
Most of the mothers’ perspectives on PACE labeling were positive. “If a product has side effects on health, you have the opportunity to know. If you eat a Gaz (an Iranian confection), you should walk for an hour.” (33 year old mother)
Some mothers believed that this type of label would change their food choices but not their physical activity habits. However, if weight reduction was an important aspect of their lives, it could motivate them to increase their physical activities. “We have so many problems with our children. When I feel hungry, I eat something and go back to help them with their lessons. I do not have time to burn calories.”
Some mothers believed that habits played a more important role in everyday life than time limitations.
“I think that anyone can dedicate an hour a day to exercise and walking. Even employed people can set aside half an hour for walking. It’s mostly because of habits, not a busy lifestyle.”
“In my opinion, the physical activity required to burn off the calories of let’s say a cake, can become a habit. So, after eating a cake or an ice-cream, I will try to burn the calories.”
Not all mothers agreed on how these labels would affect their children’s choices. Some mothers were certain that they would improve their children’s food behavior, while others considered them as ineffective. The reasons that were given for these dissimilar opinions were firstly the children’s or their families’ habits and secondly the influence of their peers.
B. FQC experts
Most of the FQC experts provided positive feedbacks on the PACE labels. “I think it would be suitable for people who have weight reduction diets and elders who have a low level of physical activity.” Nevertheless, they believed that pilot studies should certainly be conducted before the implementation of any new type of label. One FQC expert suggested: “You can design a baseline table with information about a physical activity that will burn off 200 calories. At the end of the table you can mention the calorie content.”
One FQC expert was clearly opposed to this label. According to this specialist, producers would not cooperate with its application as it would have a strong negative effect on the sales of high calorie products.
2. The new PACE label’s characteristics:
- The appearance and the nutritional information:
A. Mothers
Table 1 shows the characteristics of the new PACE label. The participants unanimously agreed that graphics were more understandable than digits. They also said that walking was the most accessible form of physical activity, as compared to other exercises such as swimming. Colorful labels were highly recommended, especially for children. In addition, most of the mothers believed that presenting both PACE and traffic light labels would be more effective.
“I think physical activity complements the TLL. I mean that if both of them are put together, it will be complete. They both have information about fat, sugar, carbohydrates, calorie content and physical activity which is sufficient.”(Figure 2-a)
The participants believed “walking duration” was a more appropriate term than “walking distance”.
From the mothers’ point of view, every single nutritional fact was important, such as the general and detailed information about the nutrients and the calorie content. However, this may not be possible, because printing all of this data in the form of colorful graphics can affect the labels’ ligibility.
Taking the mothers’ viewpoints into consideration, with the help of our graphic designer we designed three different physical activity labels by the end of the FGDs (b in figure 2). We simplified the images by excluding certain variables, such as age and gender to produce an applicable label. In order to convert calories into physical activity, walking at 5.6 km/h, an average energy consumption of 6.7 kcal/min and an average weight of 70 kg were considered for the calculations. For example a package of cake with 228 calories needs 34 minutes brisk walking to burn off. The investigators collectively agreed on the second image. However, the walking image was changed to brisk walking in order to better represent the information (c in figure 2).
B. Experts
Some of the food industry experts disagreed with physical activity labels on packaged products. They believed that pre-cooked foods and sweets, because of their high calorie content, should be given preference and labeled instead. However, others suggested the PACE information to be included in the nutrition fact table. On the other hand, the nutritionists agreed with the graphic design of the new label and believed it to be easily understood by the public.
All experts believed that using a single color instead of three would simplify matters for the consumer.
“If I were to declare a product as unhealthy based on the TLL colors, I would have used one single color. I would advise against the use of three colors.”
The nutritionists believed that consumers ought to be provided with vital, yet concise information.
“In my opinion, the calorie content must be included. Fat, be it good or bad, is also an important factor as it results in an intake of calories. I believe, considering our society’s level of nutrition knowledge, the information that is currently being provided about calories, salt and fat is sufficient.”
It was therefore decided to use either one of the green or red colors on the labels. Based on Iran’s Food and Drug Administration guidelines [16], if any of the fat, salt or sugar contents of a product are in the red zone (high), the red label will be used. In addition, the clause "high in fat/sugar/salt" along with calorie content, serving size and recommended physical activity will be included on the label. However, if the abovementioned content levels are in the amber (medium) or green (low) zones, only the green label will be used along with calorie content, serving size and recommended physical activity. Regardless of the label’s color, the minutes of physical activity required to burn off the calories must be provided.
Finally, the new labels were designed in red and green. The red label will provide extra information about the high amount of fat and/or salt and/or sugar (figure 2-d).
After considering expert opinions, and a consensus among the investigators, the labels were sent to the mothers. They were asked to select their preferred label(s) and/or make changes that would improve their food choices. Thus, the second format of the picture (b) (figure 2) was selected. However, the figurative label was slightly changed as per the mothers opinions. They said that walking is a more popular activity, so people may find the information more applicable to their lives. “The picture suggests running instead of walking, which is a limitation and may not be possible for many women in Iran.” (45 year-old mother)