A cross-sectional study (Zhang et al., 2025) involving 600 adults in Malta compared comprehension and utilisation of Nutri-Score and Guideline Daily Amounts (GDAs, also known as Reference Intake) front-of-pack nutrition labelling systems (FOPNL) systems. In a country facing some of Europe’s highest obesity and non-communicable disease rates, the findings revealed that although 62.17% of participants do not regularly consult FOPNL, those who do show significantly higher understanding of the simplified Nutri-Score (71–78% accuracy) compared to the more complex GDA/format (47–66%).
Nutri-Score proved more accessible across demographic groups, particularly among men and lower-educated individuali. The study provides strong evidence supporting Malta’s move towards standardised, interpretive labelling like Nutri-Score, coupled with targeted nutrition education to enhance comprehension and support progress towards the 2030 non-communicable disease (NCDs) targets and EU FOPNL harmonisation efforts.
Introduction
The escalating global burden of chronic non-communicable diseases (NCDs) represents one of the most pressing public health challenges of the 21st century. Poor dietary quality has been consistently associated with elevated mortality rates and increased disease burden across diverse age demographics (Wu et al., 2019; Russell et al., 2013). In response to this epidemiological imperative, governments worldwide have implemented various food policy interventions, with front-of-pack nutrition labelling emerging as a widely adopted strategy to facilitate informed consumer decision-making (Lusk & McCluskey, 2018).
Front-of-pack nutrition labelling systems serve dual functions within the public health architecture: they empower consumers to make healthier product selections, as also shown in a recent Italian study from the University of Parma (Andreani et al., 2025) while simultaneously incentivising manufacturers to reformulate products by reducing sodium, sugar, and caloric content (Vyth et al., 2010; Cecchini & Warin, 2016). Research by Egnell et al. (2019) suggests that effective FOPNL implementation could potentially reduce or delay up to 3.4% of diet-related chronic disease deaths, though the magnitude of impact varies considerably across different labelling formats.
The study by Zhang, Cardona, Galea, and Cuschieri (2025) provides further evidence by examining FOPNL comprehension within the Maltese context, a nation confronting among Europe’s highest prevalence rates of obesity and type 2 diabetes mellitus (Cuschieri et al., 2016; Cuschieri, 2020).
Policy context and labelling systems
The European Commission’s 2020 Farm to Fork strategy proposed implementing a universal, mandatory FOPNL system across member States. However, the European Union currently lacks compulsory regulatory frameworks for FOPNL, resulting in considerable heterogeneity in implementation approaches across countries (Kanter et al., 2018). This regulatory inconsistency raises substantive concerns regarding labelling effectiveness, as impact depends fundamentally on consumer comprehension and practical utilisation.
Within Malta, two principal FOPNL systems predominate: the Nutri-Score and the Guideline Daily Amount (GDA), the latter officially referred to as ‘Reference Intake’ (RI) by Food Information Regulation (EU) No 1169/11. The Nutri-Score employs a five-letter classification system (A–E) with corresponding colour gradations to indicate a product’s overall nutritional quality, facilitating rapid comparative assessments (Julia & Hercberg, 2017). Comparative research has demonstrated that individuals generally exhibit superior comprehension of Nutri-Score relative to alternative systems such as Multiple Traffic Lights (MTL) and modified Reference Intakes (mRIs) (Egnell et al., 2020; Aguenaou et al., 2021; Hercberg et al., 2022).
Conversely, the Reference Intake (RI or GDA) system provides quantitative daily recommended intake values, displaying absolute content and percentage contributions for calories, sugars, fats, saturated fats, and salt (Feunekes et al., 2008). While potentially offering more detailed nutritional information, the GDA format necessitates greater numerical literacy and interpretive capacity, potentially creating accessibility barriers for certain demographic segments (Drewnowski & Darmon, 2005; Grunert et al., 2010a).
Methodology
Study design and sampling framework
Zhang et al. (2025) employed a cross-sectional survey design utilising an anonymous, voluntary online questionnaire administered through Google Forms. The research adopted a snowball sampling technique, distributing the survey via the social media platform Facebook. This methodological approach was justified by the substantial proportion of the Maltese population engaging with social media; as of January 2024, approximately 366,500 individuals (68.4% of the population) were registered social media users, predominantly utilising Facebook.
The target population comprised Maltese adults aged 18 years and above possessing social media accounts. Based on the estimated social media user base, the researchers calculated a minimum required sample size of 384 participants to achieve a 95% confidence interval with a 5% margin of error. The survey remained accessible for a two-week period from 7 August to 21 August 2024, ultimately recruiting 600 participants. Ethical approval was secured from the University of Malta Research Ethical Committee (MED‐2024‐00324).
Questionnaire development and structure
The research instrument comprised 27 items organised into two principal sections. The first section elicited demographic data including gender, age, residential district, educational attainment, employment status, and health status. Residential district classification aligned with Malta National Statistics Office categorisations. Educational level was stratified into four categories: up to secondary school, up to sixth form, undergraduate degree, and postgraduate qualifications or higher.
Health status was operationalised through self-reported chronic disease presence, with participants additionally queried regarding cohabitation with individuals experiencing chronic conditions. This dimension aimed to explore potential influences of chronic disease status on FOPNL understanding and utilisation patterns. The second section assessed participants’ comprehension of both the Nutri-Score and GDA systems, incorporating questions adapted from established instruments (MacKison et al., 2010; Grunert et al., 2010a).
Assessment of Nutri-Score comprehension
To evaluate Nutri-Score understanding, the researchers developed two original questions requiring participants to identify the healthiest product option between paired alternatives (cereal and coffee pods) based on Nutri-Score classifications. Additionally, three adapted questions assessed whether participants could accurately interpret the nutritional implications represented by specific classification letters and numerical values. These questions examined understanding that ‘Nutri-Score A’ signifies very healthy products, ‘Nutri-Score C’ denotes products suitable for moderate consumption, and ‘Nutri-Score E’ indicates products with very poor nutritional profiles.
Assessment of GDA/RI comprehension
GDA/RI system evaluation incorporated two researcher-developed questions requiring participants to compare real-life ravioli and oats products based on their GDA/RI labels. Furthermore, two adapted questions from Grunert et al. (2010a) requested participants to compare three hypothetical ready-made pasta meals, simulating authentic decision-making scenarios. Participants were subsequently asked to identify which nutritional values they considered when selecting the healthiest option and to explain their reasoning through free-text responses.
The questionnaire’s final section, adapted from MacKison et al. (2010) and modified for the Maltese context, explored participants’ perceptions regarding FOPNL usefulness, clarity, and interpretive ease. All product images were sourced from local supermarkets, with brand identifiers obscured to reduce the risk of response bias. The survey was made available in both English and Maltese following rigorous back-translation procedures.
Statistical analysis approach
Data were exported to Microsoft Excel for preliminary processing, with descriptive statistics initially employed to characterise the study population’s sociodemographic profile. Categorical data were stratified into four analytical sub-groups: (i) whether participants consider FOPNLs when shopping, (ii) FOPNL systems participants have encountered, (iii) the FOPNL system with which they are most familiar, and (iv) frequency of considering nutritional information during shopping activities. These sub-groups were compared across gender and educational level dimensions.
For comparative analyses, sub-groups (ii) and (iii) focused exclusively on Nutri-Score and GDA/RI systems, excluding the ‘none’ category due to insufficient comparative utility. In sub-group (iv), responses of ‘always’ and ‘often’ were aggregated as ‘regularly’, whilst ‘never’ and ‘don’t know’ were combined as ‘irregularly’ to facilitate statistical interpretation. Responses of ‘occasionally’ (n=172) were excluded from this specific analysis.
Free-text responses underwent qualitative analysis conducted independently by three researchers who grouped responses based on content similarity to identify predominant themes. The research team subsequently convened to achieve consensus on principal thematic categories. This mixed-methods approach enabled both quantitative assessment of comprehension patterns and qualitative exploration of reasoning underpinning product selection decisions.
Results
Demographic characteristics and sample composition
The study successfully recruited 600 adults in Malta with no questionnaires excluded due to missing data, demonstrating robust data completeness. The sample exhibited substantial female predominance (88%; n=528), with the largest proportion of participants falling within the 40–49 year age group (27.33%; n=164). This demographic distribution proved particularly relevant given that this age cohort frequently assumes primary caregiver responsibilities for children and adolescents, thereby exerting considerable influence over household dietary patterns.
The majority of participants (74.4%; n=445) reported employed status, whilst 81.7% (n=490) indicated absence of chronic disease conditions. Regarding residential distribution, the Northern Harbour region represented the largest geographic concentration (35.8%; n=215), followed by the Northern region (30.6%; n=184). Educational attainment demonstrated relatively balanced distribution, with 33.7% (n=202) holding postgraduate qualifications, 27.8% (n=167) possessing undergraduate degrees, 16.2% (n=97) educated to sixth form level, and 22.3% (n=134) completing education at secondary school level.
FOPNL utilisation patterns and engagement
A striking finding emerged regarding baseline FOPNL engagement: 62.17% (n=374) of participants reported that they do not typically consider front-of-pack labelling when conducting grocery shopping. This substantial proportion of non-users represents a critical public health concern, particularly given Malta’s elevated burden of diet-related diseases. The finding suggests that despite FOPNL availability, its potential to influence purchasing behaviour remains substantially underrealised across the population.
Significant gender-based disparities in FOPNL engagement were identified. Female participants demonstrated markedly higher propensity to consider FOPNL when shopping (89.38%; n=202 of those who use FOPNL), whilst male participants were significantly less likely to engage with nutritional labelling. Furthermore, female participants reported consulting FOPNL more regularly than their male counterparts (p=0.007), consistent with established literature indicating women’s greater health consciousness and propensity to seek nutritional information (Campos et al., 2011; Bidmon & Terlutter, 2015; Ek, 2015).
System-specific familiarity patterns
Statistically significant differences emerged between genders regarding familiarity with and exposure to the two FOPNL systems (p=0.031). Female participants exhibited greater likelihood of having encountered and developed familiarity with the GDA/RI system, potentially reflecting preference for detailed, quantitative nutritional data. Conversely, male participants demonstrated greater familiarity with the Nutri-Score system, possibly indicating preference for simplified, interpretive labelling formats. Notably, 29.67% (n=178) of participants reported encountering both FOPNL systems during shopping activities, suggesting coexistence of multiple labelling formats within the Maltese retail environment.
Educational attainment emerged as another critical determinant of FOPNL utilisation. Participants with higher educational qualifications were significantly more likely to consult nutritional labels before purchase (66.37%; n=150), whilst those with lower educational levels demonstrated reduced engagement. Higher-educated participants additionally reported using FOPNL regularly (66.33%; n=197), contrasting sharply with less frequent utilisation among those with lower educational attainment (48.00%; n=60). These findings align with established evidence linking health literacy with educational background (Drichoutis et al., 2005).
Perceptions of FOPNL importance and interpretability
Despite limited actual utilisation, the overwhelming majority of participants (85.83%) recognised FOPNL as important or very important, with 46.5% (95% CI: 42.5%–50.5%) rating it as ‘very important’. This substantial recognition-behaviour gap represents a critical finding, suggesting that whilst consumers acknowledge nutritional labelling’s theoretical value, various barriers prevent translation of this recognition into practical application (Hawley et al., 2013).
Regarding interpretive ease, responses proved more heterogeneous. Whilst 44% (95% CI: 40.0%–48.0%) found FOPNL information generally understandable, a notable proportion perceived interpretation as difficult or very difficult. This variability in perceived comprehensibility likely reflects differential numerical literacy and familiarity with nutritional concepts across educational strata (Cowburn & Stockley, 2005). Concerning information quantity, the majority (53.2%; 95% CI: 49.2%–57.2%) considered the amount of information provided appropriate, though some participants found it excessive whilst others deemed it insufficient, underscoring diverse consumer preferences regarding label detail (Feunekes et al., 2008).
Nutri-Score system comprehension: superior performance
Participants demonstrated generally robust understanding of the Nutri-Score classification system, with notably high accuracy rates across all assessment tasks. When presented with cereal products, 71.17% (n=427) correctly identified the option with highest nutritional quality, whilst 78.17% (n=469) made accurate selections for coffee pod products. These high success rates—substantially exceeding GDA/RI performance—suggest that the Nutri-Score’s simplified, colour-coded format facilitates rapid comparative assessment, consistent with previous European studies (Egnell et al., 2020; Hercberg et al., 2022).
Regarding interpretation of specific classification letters, participants exhibited strong comprehension that ‘Nutri-Score A’ signifies a very healthy product (79.67%; n=478) and that ‘Nutri-Score C’ denotes a product suitable for moderate consumption (85.17%; n=511). However, understanding proved weaker for ‘Nutri-Score E’, with only 57.5% (n=345) correctly identifying this category as representing nutritionally poor products. Despite this relative limitation, the overall comprehension rates for Nutri-Score significantly exceeded those observed for GDA/RI across comparable tasks, particularly among demographic groups typically exhibiting lower nutritional literacy.
The superior accessibility of Nutri-Score proved especially pronounced among male participants and those with lower educational attainment – precisely the demographic segments demonstrating weakest engagement with quantitative GDA/RI labels. This pattern provides compelling evidence that simplified, interpretive labelling formats reduce health literacy barriers and promote more equitable access to nutritional information across diverse population segments (Shrestha et al., 2023).
GDA/RI system comprehension: variable performance
Assessment of GDA/RI system understanding revealed more heterogeneous comprehension patterns, with performance varying substantially based on comparison complexity. For straightforward two-product comparisons, the majority successfully identified healthier options for ravioli (66%; n=397) and oats (56%; n=334) – accuracy rates notably lower than those observed for equivalent Nutri-Score tasks. In the first pasta ready-meal comparison, 72.5% selected the healthiest product. However, responses became significantly more divided in the second, more complex pasta ready-meal comparison, with only 47.3% choosing correctly.
This substantial performance degradation with increasing complexity – from 72.5% to 47.3% – suggests that while some consumers possess rudimentary GDA/RI interpretation skills, capacity for sophisticated nutritional analysis remains limited across substantial population segments. The quantitative nature of GDA/RI labels, requiring interpretation of absolute nutrient quantities and percentage daily value contributions, necessitates both numerical literacy and understanding of recommended intake thresholds that are not universally distributed across populations (Drewnowski & Darmon, 2005).
Analysis of which nutritional values participants prioritised when determining healthiest products revealed distinct patterns. Calories emerged as the predominant consideration (46.00%; n=276), followed by fat content (27.7%; n=166). Salt (7.0%; n=42), saturated fats (5.67%; n=34), and protein (5.7%; n=34) received moderate attention, whilst carbohydrates (4.5%; n=27), sugar (2.67%; n=16), and fibre (0.8%; n=5) were relatively deprioritised. This calorie-centric approach, while reflecting public awareness of energy balance, potentially overlooks other nutritionally relevant dimensions critical for comprehensive dietary quality assessment.
Discussion
Comparative system performance: Nutri-Score’s clear advantage
The study’s most significant finding concerns the substantial performance differential between Nutri-Score and GDA/RI systems in terms of consumer comprehension and accessibility. Across all assessment tasks, Nutri-Score demonstrated superior comprehension rates (71–78% for product comparisons; 79.67% and 85.17% for category interpretation) compared to GDA/RI (47–66% for product comparisons). This 15–25 percentage point advantage represents a clinically and public health significant difference, particularly when extrapolated to population-level dietary decision-making.
The superior performance of Nutri-Score proved especially pronounced in complex comparison tasks, where GDA/RI comprehension deteriorated markedly (from 72.5% to 47.3%) whilst Nutri-Score maintained relatively consistent accuracy. This pattern suggests that Nutri-Score’s interpretive format – which synthesises multiple nutritional dimensions into a single, colour-coded grade – reduces cognitive burden and facilitates rapid decision-making even when comparing multiple products simultaneously. In contrast, GDA/RI’s quantitative approach, requiring mental calculations and contextualisation of multiple numerical values, overwhelms many consumers’ information processing capacity.
Critically, Nutri-Score’s accessibility advantage proved most pronounced among demographic segments typically exhibiting lowest nutritional literacy: males and individuals with lower educational attainment. Male participants, who showed reduced overall FOPNL engagement, demonstrated greater familiarity with Nutri-Score and superior comprehension of its simplified format compared to GDA/RI’s quantitative approach. Similarly, lower-educated participants – who face elevated chronic disease risk yet possess reduced capacity to interpret complex nutritional information – found Nutri-Score significantly more accessible than GDA labels.
These differential comprehension patterns carry profound equity implications. If the primary objective of FOPNL policy is to facilitate healthier dietary choices across entire populations – not merely among health-conscious, highly-educated consumers – then labelling systems must prove accessible to those with limited nutritional knowledge and numerical literacy. The evidence from this study demonstrates conclusively that Nutri-Score better fulfils this equity mandate than GDA/RI, reducing rather than reinforcing health disparities (Shrestha et al., 2023).
Demographic determinants of FOPNL engagement
The study’s findings illuminate substantial demographic variation in FOPNL familiarity and engagement, with gender and educational attainment emerging as principal determinants. The pronounced female predominance in FOPNL utilisation accords with established literature documenting women’s greater health consciousness and propensity to seek nutritional information (Campos et al., 2011; Bidmon & Terlutter, 2015).
The study’s participant demographic – with majority representation from the 40–49 year age group – proves particularly relevant from a public health perspective.
This cohort frequently assumes primary responsibility for household food purchasing and preparation, thereby exerting substantial influence over family dietary patterns. Consequently, enhancing FOPNL literacy within this demographic segment could generate multiplicative benefits by improving dietary quality across multiple household members, including children and adolescents during critical developmental periods.
Educational attainment and health literacy
The strong association between educational level and FOPNL engagement corroborates extensive literature documenting education as a fundamental determinant of health literacy (Drichoutis et al., 2005). Higher-educated participants demonstrated both greater propensity to consult nutritional labels and more frequent engagement, suggesting that formal education cultivates skills and knowledge facilitating nutritional information utilisation. This educational gradient in health literacy represents a significant equity concern, as lower-educated populations – who often experience elevated chronic disease burden – simultaneously demonstrate reduced capacity to leverage nutritional labelling as a health protection tool.
The finding that higher-educated participants exhibited greater familiarity with the quantitative GDA/RI system while lower-educated individuals showed preference for the interpretive Nutri-Score format provides compelling evidence that labelling system accessibility varies across educational strata. This pattern strongly supports arguments for implementing simplified, interpretive labelling formats like Nutri-Score, which reduce health literacy barriers and promote more equitable access to nutritional information (Shrestha et al., 2023). The coexistence of multiple labelling systems within the retail environment may generate confusion, potentially undermining effectiveness of either approach.
The substantial proportion of participants reporting limited FOPNL engagement despite recognising its importance reveals a critical intention-behaviour gap. This disconnect likely reflects multiple barriers including time constraints during shopping, information overload, cost considerations, and habitual purchasing patterns (Hieke & Taylor, 2012). Addressing this gap necessitates multifaceted interventions extending beyond mere information provision to encompass behavioural economics insights, point-of-purchase prompts, and broader environmental modifications facilitating healthy choices.
Nutri-Score implementation: opportunities and challenges
The generally strong Nutri-Score comprehension observed in this study, particularly relative to GDA/RI performance, provides robust empirical foundation for policy recommendations favouring standardised Nutri-Score adoption. The high accuracy rates for identifying healthiest products across different food categories (71–78%) demonstrate that the system’s colour-coded, letter-grade approach successfully communicates nutritional quality in an accessible format. This comprehension pattern proved relatively consistent across demographic subgroups, though with notable accessibility advantages for typically underserved populations.
However, the comparatively weaker understanding of Category E products (57.5% accuracy) represents a significant limitation requiring targeted intervention. Category E encompasses foods with poorest nutritional profiles, characterised by high levels of unfavourable nutrients and low beneficial component content (Merz et al., 2024). Inadequate recognition of these products’ nutritional inadequacy may fail to discourage consumption, thereby undermining one of FOPL’s primary objectives: steering consumers away from least healthy options.
This comprehension deficit becomes particularly significant within Malta’s epidemiological context. With approximately 69.75% of Maltese adults classified as overweight or obese – substantially exceeding the EU average – and circulatory diseases representing the leading mortality cause (29.5% of deaths in 2021), Malta confronts exceptional cardiometabolic disease burden (Cuschieri et al., 2016). Consumption of Category E products likely contributes substantially to this disease burden, rendering enhanced public understanding of this classification a policy priority.
Malta’s relatively recent adoption of Nutri-Score may partially explain suboptimal public awareness. Whilst the system was developed by French researchers in 2014 and officially adopted in France in 2017, Malta’s implementation occurred more recently (Merz et al., 2024). This temporal lag suggests that public education campaigns specifically targeting Nutri-Score interpretation – particularly Category E recognition – could yield substantial comprehension improvements and maximise the system’s public health impact.
GDA/RI system limitations and accessibility barriers
The GDA/RI system assessment revealed fundamental accessibility limitations that raise serious questions regarding its suitability as a primary nutritional labelling format, particularly for populations with elevated chronic disease burden. The substantial performance degradation with increasing task complexity – from 72.5% accuracy in straightforward comparisons to 47.3% in complex multi-product assessments – demonstrates that GDA/RI’s quantitative format overwhelms many consumers’ cognitive capacity.
The quantitative nature of GDA/RI labels, providing absolute nutrient quantities and percentage daily value contributions, necessitates both numerical literacy and understanding of recommended intake thresholds. These cognitive requirements create substantial accessibility barriers, particularly for individuals with limited educational attainment or mathematical anxiety (Drewnowski & Darmon, 2005). The finding that higher-educated participants demonstrated significantly greater GDA familiarity and utilisation supports this interpretation, suggesting that effective GDA engagement demands educational foundations that are not universally distributed across populations.
Moreover, the nutritional priorities participants employed when assessing GDA labels – with predominant focus on caloric content (46.0%) and relatively limited attention to sugar (2.67%), fibre (0.8%), and other important nutrients – suggests that many consumers employ overly simplistic heuristics when interpreting quantitative labels. This calorie-centric approach, whilst reflecting widespread awareness of energy balance, potentially overlooks nutritionally relevant dimensions critical for comprehensive dietary quality assessment (Cuschieri, 2020).
The GDA/RI system’s complexity and associated interpretation difficulties carry significant equity implications. If nutritional labelling primarily benefits highly-educated, numerically-literate consumers whilst remaining inaccessible to vulnerable populations, it risks reinforcing rather than reducing health disparities. In contrast, Nutri-Score’s superior accessibility across educational and gender segments positions it as a more equitable policy instrument for promoting population-level dietary improvement.
Policy implications and recommendations
The study’s findings provide compelling empirical evidence supporting several policy recommendations for Malta’s nutritional labelling framework. First and foremost, the substantial comprehension advantage demonstrated by Nutri-Score relative to GDA/RI – particularly among demographic segments with lowest baseline nutritional literacy – argues strongly for standardised adoption of Nutri-Score as Malta’s primary FOPNL system. This recommendation aligns with growing scientific consensus supporting interpretive, simplified labelling formats as most effective for facilitating healthy dietary choices across diverse populations (Egnell et al., 2020; Hercberg et al., 2022).
Standardisation on a single labelling format would additionally address the confusion potentially generated by coexisting multiple systems within the retail environment. Currently, 29.67% of participants report encountering both Nutri-Score and GDA/RI labels, which may undermine comprehension and reduce practical utility of either approach. A unified, mandatory Nutri-Score system would provide consistent nutritional signalling, facilitate cross-product comparisons, and reduce cognitive burden associated with interpreting multiple labelling formats.
However, labelling system optimisation represents merely one component of comprehensive strategies needed to leverage FOPNL’s public health potential. The substantial recognition-behaviour gap – with 85.83% acknowledging FOPL importance yet 62.17% not consulting labels during shopping – demonstrates that system presence alone proves insufficient. Complementary interventions must address practical barriers including time constraints, cognitive effort requirements, economic accessibility, and entrenched purchasing habits through behavioural insights, point-of-purchase prompts, and environmental modifications.
Targeted public education campaigns assume critical importance, particularly for enhancing understanding of Nutri-Score Category E products and engaging demographic segments with lowest current utilisation: males, lower-educated individuals, and those without chronic disease conditions. Such campaigns should employ diverse channels including mass media, social media, point-of-purchase materials, healthcare provider communication, and school-based nutritional literacy programmes to maximise reach and effectiveness across population segments.
Equity considerations and vulnerable populations
The study’s findings illuminate critical health equity dimensions of FOPNL policy that warrant explicit attention in system design and implementation. The associations between limited FOPNL engagement and lower educational attainment, male gender, and absence of chronic disease suggest that labelling systems may inadvertently reinforce health inequalities if not designed with explicit attention to accessibility. Lower-educated populations, who typically experience elevated chronic disease burden and face greater economic constraints on food choices, simultaneously demonstrate reduced nutritional literacy and decreased FOPNL utilisation (Drewnowski & Darmon, 2005).
This pattern risks creating an ‘inverse care law’ phenomenon wherein those who could benefit most from nutritional guidance prove least able to access and utilise it effectively. The superior accessibility of Nutri-Score among these vulnerable populations – males and lower-educated individuals – represents a compelling equity argument for its adoption. By reducing cognitive and literacy barriers, simplified interpretive formats enable more equitable access to nutritional information, potentially reducing rather than reinforcing health disparities (Shrestha et al., 2023).
Addressing equity challenges requires multipronged approaches including: standardised adoption of simplified labelling formats with minimal cognitive demands; extensive public education campaigns employing diverse media and community channels; school-based nutritional literacy programmes building foundational knowledge from early ages; and potentially differential pricing policies or subsidies making healthier products economically accessible to lower-income populations. Only through such comprehensive approaches can FOPNL fulfil its potential as an equitable public health intervention benefiting entire populations rather than privileged segments.
Limitations and methodological considerations
The study exhibits several methodological limitations warranting acknowledgement. The online survey distribution via social media, whilst achieving substantial reach, may not fully represent the general adult population, particularly older individuals with limited digital literacy or social media engagement. The marked female predominance (88%) in the sample limits generalisability of findings to males and may have influenced overall results regarding comprehension and attitudes, though this gender imbalance paradoxically strengthens findings regarding male preference for Nutri-Score given the limited male representation.
The relatively modest sample size (n=600), whilst meeting calculated requirements, nonetheless limits statistical power for detecting small effects and conducting comprehensive subgroup analyses. The cross-sectional design precludes causal inference regarding relationships between demographic characteristics and FOPNL engagement, as directionality cannot be definitively established. The anonymous survey format prevented verification that all participants met eligibility criteria, introducing potential selection bias.
Self-reported data introduces potential recall bias and social desirability bias, particularly regarding questions about FOPNL consultation frequency and nutritional knowledge, where participants may overestimate behaviours perceived as socially valued. The grouping of response categories whilst facilitating statistical analysis may have introduced misclassification bias and reduced analytical precision. Future research employing objective behavioural measures such as eye-tracking studies or actual purchasing data would strengthen evidence regarding real-world FOPNL effectiveness.
Conclusions and future directions
This comprehensive study makes valuable empirical contributions to understanding FOPNL comprehension and utilisation in Malta, with findings carrying significant implications for national policy and broader European Union debates regarding mandatory labelling harmonisation. The research demonstrates conclusively that Nutri-Score exhibits substantial superiority over GDA/RI in terms of consumer comprehension, accessibility across demographic groups, and equity implications—providing robust evidence supporting standardised Nutri-Score adoption within Malta’s regulatory framework.
The 15–25 percentage point comprehension advantage demonstrated by Nutri-Score, particularly among males and lower-educated populations typically exhibiting lowest nutritional literacy, represents a clinically and public health significant difference. This accessibility advantage positions Nutri-Score as a more equitable policy instrument capable of facilitating healthier dietary choices across entire populations rather than merely among health-conscious, highly-educated consumers. In a nation confronting exceptional cardiometabolic disease burden, implementing the most accessible and effective nutritional labelling system constitutes a strategic public health imperative.
However, labelling system optimisation represents merely one component of comprehensive strategies needed to leverage FOPNL’s public health potential. The substantial recognition-behaviour gap – with majority acknowledgement of FOPNL importance yet limited practical utilisation – demonstrates necessity for multifaceted interventions addressing time constraints, cognitive demands, economic accessibility, and entrenched purchasing habits. Targeted educational campaigns, particularly enhancing Category E understanding and engaging underserved demographic segments, assume critical importance for maximising Nutri-Score’s population-level impact.
Future research should address current evidence gaps through longitudinal studies tracking FOPNL engagement evolution, experimental studies employing objective behavioural measures, qualitative research exploring barriers and facilitators in greater depth, and studies examining actual purchasing behaviour and dietary intake rather than merely comprehension. Such evidence would strengthen understanding of FOPNL’s real-world effectiveness and inform evidence-based refinements to policy and implementation strategies.
From a policy perspective, Malta’s preparation for the United Nations High-Level Meeting on Non-Communicable Diseases and commitment to 2030 targets renders FOPNL optimisation a strategic priority. Evidence-based recommendations include: implementing standardised, mandatory Nutri-Score labelling across packaged foods; launching comprehensive public education campaigns targeting lowest-engagement segments; integrating nutritional literacy into school curricula; providing healthcare provider training; and conducting regular monitoring enabling adaptive policy refinement. These measures, implemented comprehensively, position Malta to maximise public health returns from nutritional labelling investment while contributing valuable evidence informing European Union-wide policy harmonisation debates.
Dario Dongo
Cover image: composition based on image by jimmy_ktm on Pixabay
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Dario Dongo, lawyer and journalist, PhD in international food law, founder of WIISE (FARE - GIFT - Food Times) and Égalité.
