Allergen labelling: Current practice and improvement from a communication perspective

Abstract Background Allergen information on product labels is crucial in food allergy management, though inadequacy in current labelling practices is one of the major causes for accidental reactions upon consuming prepacked food products. Objective This study analyses current status of communicating allergen information on food labels and provides practical recommendations for improving the label format based on communication theory. Methods Product labels (N 288) of seven food categories from private label products and brands were obtained at three retailers in the Netherlands. Information regarding the 14 EU‐regulated allergens was evaluated by the frequency of emphasizing allergens in the ingredient list, use of precautionary allergen labelling (PAL), icons and an allergen information section. Effectiveness of communication was assessed evaluating readability and findability of information on allergens using principles of Gestalt and Cognitive Load theories. Results As requested by EU regulation 1169/2011, emphasizing allergens in the ingredient list was almost 100%, all other presentations of information on allergens on labels was highly diverse. A separate allergen information section was present on most private label products. This section could, but not necessarily did, repeat allergens from the ingredient list and/or give a PAL. Brands often provided a PAL at the end of the ingredient list. Part of the products displayed an icon at different locations of the label. Label background, a lack of cohesion and variation in location of topics hamper the identification of relevant information on allergens by (allergic) consumers. Recommendations include a standardized order for mandatory and voluntary topics on the label and a separate allergen information section. Conclusion and clinical relevance Overall, consumers encounter a wide and inconsistent range in ways of presentation of allergen information on labels. Standardization according to basic design principles can improve usability and support safe food purchases for allergic consumers.


| INTRODUC TI ON
Food allergy is a worldwide health problem with regional differences in the reported prevalence from 0.3 up to 10%. 1,2 Though prevention of developing a food allergy and development of therapies to cure food allergy are promising, the best option for allergic consumers still is to avoid ingestion of the specific food. 2 Regulation in many regions requires the labelling of allergenic food ingredients when used in food manufacturing. In addition to this, cross-contact with allergens can occur at many stages of the food production chain. Despite all management measures taken, food manufacturers sometimes cannot guarantee the absence of unintended allergens in the final product and may apply a Precautionary Allergen Labelling (PAL).
Unexpected allergic reactions frequently occur and mostly range from mild to severe. 3 Several factors have been mentioned to contribute to the risk of unexpected reactions. Some of these are related to food manufacturing (undeclared ingredients, wrong label on pack, lack of a PAL statement or incomplete PAL statements). Other factors are consumer-related (ignoring or missing PAL, not reading or failure to read labels or missing the allergen as an ingredient). However, the contribution of each factor to the risk of unexpected reactions is not exactly clear. [4][5][6] For food-allergic consumers, the label on food products, and especially the allergen information part, is an important and often crucial communication tool to avoid allergen(s). Regulation Similarly, providing an allergen information box or using icons are not clearly defined in EU Regulation. 7 Further, country-specific interpretations and guidelines exist. [8][9][10] In a global market, an allergic consumer might thus be confronted with different presentation forms of information on allergens.
As with all mandatory communication, there can be a gap between official guidelines and everyday practice. 11 Besides informing customers on the mandatory topics for food safety and quality, food business operators use the label to persuade customers to buy their products. Research shows that allergic consumers experience difficulties to identify, locate, read and understand the allergen information on food labels, but further study is needed on how allergy information might be best provided. 12,13 Studies systematically analysing allergen information on food labels mainly focussed on compliance with legal guidelines, signalling methods of marking allergens on the pack, or the variation of PAL statements used on products. [14][15][16][17] However, steps to improve the functionality of communicating allergen information on food labels for food-allergic consumers and those buying for an allergic consumer have to our knowledge never been investigated.
In the present study, the communication about allergens on food labels is investigated with emphasis on the functionality for (allergic) consumers and on identification of the specific topics for improvement in allergen labelling design. The study does not assess the compliance of allergen information on labels to EU or national regulation; instead, it takes a consumer perspective. First, the allergen information currently provided to (allergic) consumers in The Netherlands is quantitatively analysed for a collection of food labels. Second, a qualitative examination using principles of communication graphic design theory, that is, the basic design principles of Gestalt Theory 18 and Cognitive Load Theory, 19 are used to systematically evaluate the readability and findability of allergen information. The aim is to provide a set of recommendations for providing allergen information on food products to improve labelling.

| Data collection
Packaged food products were collected for evaluation of (precautionary) allergen labelling regarding the 14 EU-regulated allergens. 7 Six graduate students of Utrecht University were recruited to collect anaphylaxis, food allergy, prevention, quality-of-life, regulatory aspects Fast foods 40 10 10 10 10 Breakfast products 41 10 10 10 11 Snacks 56 10 10 10 26 Soup products 39 10 10 10 9 Desserts 42 10 10 10 12 Dinner meal products 41 11 11 10 9 TA B L E 1 Number of collected food labels per food category and manufacturer the labels. The collection was performed in May and June 2018. The students were instructed to take photographs of the label with specific emphasis on the ingredient list and the possible additional separate allergen information, either a PAL statement, an icon and/or an allergen information section. They registered the product name, category and manufacturer type (either retail or brand). Digital photographs were taken of at least nine products per food category (Table 1) and manufacturer type. Labels from private label products from three major retailers were collected for the selected seven food categories. Together, these retailers are covering 60% of the food store market in the Netherlands. Similar types of products were collected from brands for each of the food categories. Photographs were made at three food stores in the city of Utrecht, and at one store, labels from individual brands were collected.

| Food categories
Seven categories were defined with food products that are consumed on a regular basis and at specific eating moments during a day. These categories were as follows: breakfast products such as cereals, rusk, flakes; products typically eaten as a snack (including crisps, nuts, chocolate bars and cookies); fast foods (including pizza, fried shrimp, quiche, sausage roll and cheese soufflé); soup products (including soup, soup powders and soup vegetables); desserts (yoghurts, custards, ice creams and small cakes); dinner meal products (frying oil, wraps, rice, sauces and meal boxes); and bread toppings (including cheese, sweet sprinkles, peanut butter, salads and meat products). If possible, similar types of products were selected for the private label products of the different retailers and the brands. Table 1 presents the distribution over these categories of 301 collected food labels.

| Qualitative evaluation
A qualitative analysis was performed on the current allergen labelling practice in order to evaluate the functional communication of food labels for (allergic) consumers. Several of the basic design principles of Cognitive Load Theory 19 and Gestalt Theory 18 were applied (Table 2) to describe the communication and to formulate the recommendations for improvement.

| Data set
In total, 301 unique labels of manufactured food products were collected. In 288 of the labels, information relevant for the allergic consumer was present, for example an ingredient list, an allergen information section, a PAL or an icon. Thirteen labels did not contain any information on any of the 14 EU-regulated allergens and were excluded from further analysis.

| Emphasizing allergens in the ingredient list
There was a significant preference (80%) for emphasizing the allergenic ingredients using bold-face type (Table 3). Capital font was used significantly less. Among the brands, more variation was observed, including the use of a combination of bold and capital font type and underlining. Retailers did not use underlining. There was one case where a product contained an allergenic ingredient without any highlighting. Further, retailer 1 occasionally highlighted allergenic ingredients in blue and bold to stand out to the other ingredients in black letter type. Italic font of allergenic ingredients was never used.

| Use of PAL statements
Half of the collected labels (52.1%) contained a PAL statement to warn for a possible unintended presence of allergens, and these were placed either following the last ingredient in the ingredient list or in a separate allergen information section. For those labels with a PAL, the 'may contain traces'-statement was used most frequently (76% overall score). Retailers 2 and 3 only used this statement, whereas retailer 1 also used the 'factory/production' statement on 48% of its labels with a PAL. Both statements were used within the same product categories. In contrast to this observation, within the brands, all three different PAL statements were found, 58% was a 'may contain traces of X' statement followed by 'may contain X' (36%) and the 'factory/production' statement in just 6%. One product label even contained two different formulations of a PAL statement: 'This product may contain peanut and traces of egg, gluten and nuts'.

| Presence of allergen icons
The icons present on labels mentioned whether a product was 'free from' milk or gluten, that is none of the icons were used to indicate the (possible) presence of milk or gluten. Icons for other allergens were not used at all. Icons were present on 21.9% of all 288 labels. This was due to private label products of retailers 1 and 3 that displayed an icon on 49.3% and 38.6%, respectively, of their product labels. Retailer 2 and almost all brands were consistent in not using icons for allergens. Only one brand label displayed a gluten-free icon.

| Presence of a separate allergen information section
In 71% of all labels (204 out of 288), a separate allergen informa-

| Content of the allergen information section
Most, but not all, allergen information sections repeated the allergenic ingredients from the ingredient list (Table 4). This means in case such labels displayed only a PAL in the allergen information section, two situations: either allergens were not present as an ingredient (products of retailers 1 and 2) or allergens were present and marked in the ingredient lists (products of retailer 3 and brands).
Allergenic ingredients were repeated in the allergen information section, but they could be named and/or highlighted differently.
An example: the ingredient list sometimes mentioned wheat flour; cream, soybean, and the allergen information section cited this as wheat gluten, lactose, milk protein and soy. Sometimes, these were emphasized in bold as well.
A few brands used the allergen information section to refer to the ingredient list. An example: 'For allergens, including cereals containing gluten, see bold ingredients'. The category 'other' contained a PAL and a reference to a website for more allergen information, and a combination of a list of allergens including a gluten-free statement.

| Qualitative evaluation of the label design
The quantitative results do not give a complete insight into the use- This theory was developed in the domain of instructional psychology in order to analyse the factors that complicate learning a new task and to develop guidelines for designers of instructional material in order to optimize performance.

Principles used to analyse the food labels
• The intrinsic cognitive load is the level of inherent complexity of the task: learning to cook an egg is easier than learning to prepare lasagna. • The extraneous cognitive load refers to the often unnecessary complexity of the instructional material. Finding out whether there are any allergens in the boiled egg is easier than for lasagna: assessing the safety of food may create extraneous load when buyers have problems locating allergen information and need to find out whether the lasagna does not contain an allergen. • Germane cognitive load refers to cognitive activity of the learner that is used to develop schemes in order to process information on a higher level and thus make free capacity in working memory, which is limited in both capacity and duration.A central notion in the Cognitive Load Theory is the differentiation between three types of cognitive load. When all food labels would have the same order of information, consumers would gradually construct a scheme of relevant food topics, which means only a temporary increase of germane load. At the same time, long-term extraneous load would decrease, because locating allergen information would become the easiest part of reading food labels.

The Gestalt Theory 18
This theory was developed in the early 20th century by three German psychologists (Wertheimer, Koffka and Kohler) who tried to formulate some basic principles of interpreting visual stimuli. These principles played an influential role in thinking about graphic design, 32 and help to organize the visual field of the food label in ways that support the main goals of food product information Principles used to analyse the food labels when objects are located within the same region of the food label, consumers will perceive these elements as belonging semantically together. These elements may share common aspects or purpose. • The principle of Proximity, which is related to the second principle: elements presented closely together appear to be more related than elements that are spaced apart. So, within one group the order of the topics is meaningful. This principle helps to think about the structure of the different topics presented on the food label. In several food labels, the lack of contrast between background and text hampers to distinguish bold ingredients from other ingredients ( Figure 1). The two labels in Figure 1A are printed on transparent packaging, causing low contrast between figure and ground. The label in Figure 1B has text printed on a creative background design, causing a cluttered background with different white and orange regions.
The decision for packaging in transparent plastics does not automatically need to result in low figure-ground discrimination of ingredient lists, as can be seen in Figure 2A. A smooth white background is used to discriminate the text from the coated peanuts inside the package, providing sufficient figure-ground contrast for reading the ingredient list with allergens presented in bold.

| Grouping of allergen information
The Gestalt Principle of Grouping or Common Region states that information units that are visually grouped together are interpreted as belonging semantically together. Readers expect some connection between these units. For (food-allergic) consumers the ingredient list, a separate allergen information section, a PAL statement and an icon, are best understood and located when they are presented in a common region of the visual space of the food label. Figure 2 shows two food labels with a separate allergen information section clearly standing out, and visually connected with the ingredient list because of their proximity to each other. Overall, in 86% of the labels, this allergen information section was in proximity to the location of the ingredient list (Appendix S1 Table A1, Figure A1). But for all food manufacturers, we observed that on some of their product labels the allergen information section was separated or interrupted by other information, such as preparation instructions, text explaining No marking 1 (<1%) 1 (1.5%) 0 (0%) 0 (0%) 0 (0%) a Eight labels had an ingredient list without any allergens, but either a precautionary allergen statement or an allergen icon. Four labels were from single ingredient products without other ingredients in an ingredient list, but with a separate allergen information section. These twelve labels were excluded from the set of 288 labels for this part of the analysis.

TA B L E 4 Presence and content of the allergen information section
the origin of ingredients or the product, or mentioning sustainability ( Figure 2C, Appendix S1 Figure A2).
Most brand labels (77%) did not have a distinct allergen information section (Table 4). These labels marked the allergens in the ingredient list, and if they provided a PAL, it followed directly after the last ingredient (Appendix S1 Figure A3). Although this meets the Grouping principle, without a visual clue, this PAL may be easily overlooked.
Most icons (80%) were displayed in close proximity to the ingredient list, but the location varied: the icon was either above or below the ingredient list and could be in or separate from the allergen information section (Appendix S1 Figure A1). In one case, the icon was on a different side of the package ( Figure A1-G). The images used differed between the producer types but were standardized within a retailer.

| Cohesion of different topics
The Gestalt Principle of Proximity suggests that perception is facili- buying for an allergic person to locate relevant information most efficiently (see Table 5 for the complete list of all topics-mandatory and optional-found on food labels). In our data sets, retailer 1 creates a relatively high level of consistency for the topic order in the design of their private label products, but also within this group of products, the location of the allergen information is not consistently placed directly below the ingredient list (see examples in Appendix S1 Figure A1).
The group of brands consists of many different food manufacturers. Consequently, this group shows a large variety in presentation formats. Although the name of the product is almost always presented on top of the label, all other mandatory and optional topics were found in any order (examples in Appendix S1 Figure A4).

| D ISCUSS I ON AND RECOMMENDATI ON S FOR ALLERG EN L AB ELLING
Based on an analysis of nearly 300 labels, we conclude that allergic Our study shows that label designs of brands varied largely between brands and deviated from the label designs of the three private labels. The brand labels are from a highly miscellaneous group of food manufacturers, each with their own labelling policies. In contrast, labels of each of the retailers were a rather homogenous group, very likely because a retailer prescribes one labelling policy for their range of different private label food products. Still, within private labels variation in allergen information is present. A different selection of labels in our study, with more labels of brands, or of other retailers, would probably have altered the proportions found in our study. But this is not expected to change the general findings of our study regarding the variability in what and how allergen information is communicated. The three retailers have 60% of the market store share in the Netherlands, and they represent a considerable part of the food information that is offered to customers in The Netherlands. The study therefore provides a good overview of the range of labels (allergic) consumers encounter when buying food.
Our study is the first to investigate the allergen information provided on labels from a communication perspective. Besides a relatively clear standardization of emphasizing allergens in the ingredient list using a different font type, our study shows that content, location and design of allergen information on the label is very diverse. Previously, allergic consumers have expressed that they experience many difficulties in reading and interpreting food labels, and that standardization of allergen information is very important to them. 12,13,[22][23][24] Still the communication of allergen information present on the examined labels proved to be far from optimal. Based on our evaluation of the current labelling practices using communication theories, we propose six recommendations in order to improve the communication of allergen information.
1. Ensure all food information is readable (good figure-ground). For good readability, visual clutter on background should be avoided and in case of transparent packaging, a white background is preferred for optimal visibility/discrimination.

Presenting allergens in the ingredient list in bold is highly preferred.
In information design, bold is seen as more appropriate than italics for headings by making words stand out. 25 Also in the design of nutrition labels, the bold presentation of nutrition information and presentation on a white background were shown to be important to improve the uptake of the information by consumers. 26 3. Provide grouping of related topics and a uniform topic order on the label. A basic communication principle in label design is that related topics should be grouped in order to improve information retrieval. 18 This can be obtained if all topics on allergens are connected in the design of the food label. Additionally, a uniform topic order is preferred. Figure 3 presents an example of a topic order for a label that could be preferred from a communication perspective. This example presents all mandatory topics as well as closely related additional allergen information currently not implemented in EU 1169/2011 regulation yet (PAL, icons, allergen information section). These related topics should not be interrupted or separated by any optional information on the product.
Our study suggests that labels may be improved from an allergen information communication perspective by restructuring the order as proposed in Figure 3. It would be interesting to conduct user tests among (allergic) consumers for this proposed format. Currently, the same information is repeated in multiple languages for products marketed in various countries, which is highlighted as a source of irritation by consumers. 22 The use of pictograms will reduce this repetition and can have the advantage of a more efficient use of valuable space on the label. Several local initiatives to develop allergen icons have been published (https:// www.foodp rotec tion.org/resou rces/food-aller gen-icons/ or by https://www.aller genen consu ltancy.nl/produ cten/icone n-enstickers). However, development of specific icons for allergenic foods needs further investigation to ensure a global common understanding to avoid the risk for an allergic reaction 31 and avoid confusion with the way free from icons are currently used.

| Final remarks
Several of the above recommendations can be applied relatively easily by individual food business operators to improve their communication (provide a good figure-ground, group all allergen information in proximity and do not place unrelated other information in between).
For other recommendations, like the standardized topic order, the use of universal icons, or the use of a separate allergen information section, and the preferred PAL statement, further studies should help to determine the optimal content and design. The preferences and needs of all stakeholders involved, including (allergic) consumers, food business operators and regulators, should be taken into account, and would need regulatory acceptance and harmonization to implement.
Overall, we conclude that standardization and application of basic design principles would considerably improve usability of allergen information and would support safe food purchases for allergic consumers.

ACK N OWLED G EM ENTS
The students of the MA Communication & Organization 2018 who took part in the seminar group Allergy Communication are acknowledged for construction of the materials and data collection of the studies. The analysis and interpretation of data were supported by a Future Food grant at the Utrecht University.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The labels analysed during the current study are not publicly available due to copyright, but are available from the corresponding au-