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3 History and Current Status of Front-of-Package Systems A variety of systems have been developed since the first front-of-package (FOP) nutrition rating system appeared more than 20 years ago (Table 3-1). In 1987, aiming to provide consumers with a single symbol that would indicate whether a food was “heart friendly,” the American Heart Association (AHA) created the Heart Guide symbol. Since then, systems and symbols used in food labeling have proliferated. Systems have been developed by food manufacturers, retailers, non-industry experts, nonprofit organizations, industry and non-industry consortia, and government agencies. DEVELOPMENT OF FRONT-OF-PACKAGE SYSTEMS In the late 1980s and early 1990s, when FOP systems were first appearing, they were largely developed by nonprofit health organizations. AHA began its nutrition labeling efforts with the Heart Guide program, but it refocused its energies in 1990 to provide Food and Drug Administration (FDA) with feedback for the Nutrition Labeling and Education Act (NLEA). In 1989 Sweden developed the Keyhole symbol to be used voluntarily by food manufacturers; the use of this symbol has since expanded to Denmark and Norway. In 1995 AHA began a new iteration of its FOP system, the Heart Check program, whose criteria were based on FDA coronary heart disease risk reduction claims, focusing first on levels of total and saturated fat and cholesterol, and later on fiber content. In 1991 Australia and New Zealand’s Heart Foundation created the Tick Programme aimed at improving public health. In 1999 Canada’s Heart and Stroke Foundation created the Health Check program. The program’s goal was to help consumers “identify healthy food choices to achieve an overall healthy diet.”1 Both the Heart Check and the Health Check programs featured a single symbol that could appear on products meeting their respective nutrient criteria, and they were limited in scope to the risk reduction of cardiovascular disease. Food manufacturers were not involved in the development of the criteria for these programs, but they could participate in the appropriate program for a fee and receive the right to use the system symbol on products that met that system’s criteria. In 1992 research by Schucker et al. suggested that consumers purchased more products for which FOP labeling was present on grocery store shelves. In 2002 Wegmans supermarkets developed a series of symbols that were based upon FDA and U.S. Department of Agriculture (USDA) nutrient content and health claims and that were featured on store brand products. A single food item could receive multiple symbols—“low fat,” “excellent source of calcium,” 1 Available online: http://www.healthcheck.org/page/what-health-check (accessed June 15, 2010). 

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 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS TABLE 3-1 Timeline of Selected Activities Related to Front-of-Package Nutrition Rating Systems and Symbols Year Event • AHA launches Heart Guide initiative 1987 • Sweden’s National Food Administration creates Keyhole symbol 1989 • New Zealand Heart Foundation creates Tick Programme 1991 1992 • Study on shelf-tags shows market shares of shelf-tagged products increases (Schucker et al., 1992) 1993 • FDA and USDA publish final rules defining nutrient content claims and providing for health claims • AHA introduces Heart Check program 1995 • Canada’s Heart and Stroke Foundation introduces Health Check program 1999 2002 • Wegmans creates Wellness Keys 2004 • PepsiCo introduces Smart Spot • General Mills introduces Goodness Corner • FDA introduces Calories Count: Report of the Working Group on Obesity 2005 • Whole Grains stamp is launched • FDA publishes an advance notice of proposed rulemaking requesting comments on displaying calories more prominently on food packaging • Kraft Foods introduces Sensible Solution • Heart Check adds an additional certification: whole grains with moderate fat content • President’s Choice launches Blue Menu to designate its healthier products • Naturally Nutrient Rich score introduced (precursor to NRFI) 2006 • CSPI petitions FDA to develop a simple, uniform, science-based rating system • Harris Teeter introduces Wellness Keys • Hannaford introduces Guiding Stars • Confederation of the EU (CIAA) commits to voluntary nutrition labeling scheme across EU member states 2007 • Unilever introduces Choices program • U.K. Food Standards Agency implements Traffic Light system • Kellogg’s introduces Nutrition-at-a-Glance • General Mills implements Nutrition Highlights to replace Goodness Corner • Keystone Food and Nutrition Roundtable studies the various FOP systems in the United States • FDA public hearing on front-of-package and other nutrition symbols • NuVal system is developed 2008 • ConAgra introduces Start Making Choices symbol using MyPyramid • Smart Choices program is developed • Mars International launches Guideline Daily Amount (GDA) labeling of its foods and snacks in the United States • Nutrient Rich Food Index articles are published in the scientific literature 2009 • Healthy Ideas is launched at Giant Foods and Stop & Shop supermarkets • Sara Lee introduces Nutritional Spotlight; similar to recent efforts by Mars and Kellogg’s • FDA releases “Comments on Symbols Public Hearing and Current Plans for Addressing Issues,” from the 2007 hearing • Smart Choices is formally launched • FDA issues letter to Smart Choices • Most industry participants suspend use of Smart Choices; program is put on hold • FDA designs and begins to implement a plan to conduct research on FOP nutrition rating systems and symbols • Institute of Medicine Nutrition Rating Systems and Symbols committee is formed 2010 • FDA requests comments and data on front-of-pack labeling • U.K. Food Standards Authority announces that Traffic Light system will not be mandatory

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 HISTORY AND CURRENT STATUS OF FRONT-OF-PACKAGE SYSTEMS “gluten free,” and so on—with the intention that a consumer could quickly look at a product and decide if it met his or her needs. By featuring this system only on the grocery’s own store brand products, Wegmans provided consumers with an incentive to purchase the house brand. Over the next several years additional manufacturers followed suit. PepsiCo and Kraft Foods developed two sep - arate FOP systems, SmartSpot in 2004 and Sensible Solution in 2005. Both were aimed at guiding health-conscious consumers to the “healthier” versions of their products according to the standards of the time (for example, baked potato chips vs. original potato chips or “low fat” ranch dressing vs. original ranch dressing). In 2005 President’s Choice in Canada launched a similar program, Blue Menu, to direct consumers to its “healthier” food products. In 2006 the first algorithm-based summary symbol indicator was introduced into the marketplace. The Guiding Stars system was developed by Hannaford Supermarkets by a scientific advisory panel convened for this purpose. Using a proprietary algorithm that took into account both positive and negative nutrients, the system gave ratings of zero to three stars to foods that met minimum Hannaford nutrient criteria. The star ratings were then displayed on the shelf tags of participating retail stores. Shortly afterwards, in 2007, the NuVal Nutritional Scoring System was introduced and is part of a joint venture of Topco Associates LLC and Griffin Hospital in Connecticut. Similar to the Guiding Stars system, it was based on a proprietary algorithm (Overall Nutritional Quality Index) that took into account—and weighted—both positive and negative nutrients. The NuVal system presented the end result as a number between 1 and 100 which allowed consumers to gauge the nutritional value of a food product: The higher the value, the “healthier” the choice. In 2008 and 2009 several new FOP systems entered the marketplace, including ConAgra’s Start Making Choices, Giant’s Healthy Ideas, and the Keystone Roundtable Smart Choices program. Vastly different in their approaches to rating foods, Start Making Choices was a manufacturer-developed program (based on USDA crite - ria) designed to illustrate food group contributions; Giant’s Healthy Ideas was a retailer-developed system using nutrient criteria; and the Smart Choices Program was a nutrient-criteria-based system developed by a consortium of industry, public health, and academic nutrition leaders. While each program had its own goal and target consumers in mind and used different criteria and approaches to rate foods, the overarching intent of each was to provide consumers with the ability to quickly determine if a food was a nutritious choice, to compare foods within a category, and to determine if the food met their spe - cific nutrient needs (for instance, if it provided 20% Daily Value [%DV] calcium or was “low” in saturated fat). Manufacturer- and retailer-developed FOP systems tended to focus on providing consumers targeted information regarding more nutritious varieties of their own product lines, while nonprofit and academic groups comprised of dietitians, physicians, nutritionists, and so forth tended to score many or all food products, regardless of brand, and often, to offset administrative costs, charged manufacturers a fee to participate. Typically, the aim of these systems has been to provide consumers with a method to select more nutritious foods at the grocery store on any brands that choose to participate in the program. Purposes and merits of types of systems are discussed in Chapter 5, and Table 5-1 compares FOP types according to potential to fulfill specific purposes. REACTION TO FRONT-OF-PACKAGE SYSTEMS As retailers and manufacturers continued to develop and launch FOP systems, concerns were raised about what a variety of systems might mean to consumers. In 2006 the Center for Science in the Public Interest petitioned the FDA to develop a single, consistent FOP system that would present nutrition information graphically on the front of the package.2 In response, FDA held public hearings in 2007 and in 2008 issued guidance for industry about FOP systems and implied nutrient content claims. The guidance stated that if a product claims to “provide” or “have a low percent of” a specific nutrient, it must meet the current claim regulations for using terms such as “low” or “good source of,” including the use of disclosure statements for products that contain more than a certain amount of total fat, saturated fat, cholesterol, or sodium.3 2 Available online: http://www.cspinet.org/new/pdf/healthy_symbol_petition.pdf (accessed June 15, 2010). 3 Availableonline: http://www.fda.gov/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocuments/FoodLabelingNutrition/ ucm120274.htm (accessed June 15, 2010).

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0 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS By 2009 FOP systems and symbols were abundant, and concerns increased about consumers being confused or even misled. After much attention was given to a Smart Choices symbol appearing on a popular, sugar-sweetened breakfast cereal, in August 2009 FDA and the USDA’s Food Safety and Inspection Service sent a joint letter to Sarah Krol,4 general manager of the Smart Choices program. The letter stated that the agencies “would be concerned if FOP labeling systems used criteria that were not stringent enough to protect consumers against misleading claims; were inconsistent with the Dietary Guidelines for Americans; or had the effect of encouraging consumers to choose highly processed foods and refined grains instead of fruits, vegetables, and whole grains.” With increasing criticisms and concerns about consumer confusion, FDA Commissioner Margaret Hamburg and the FDA Office of Nutrition, Labeling and Dietary Supplements followed up with open letters to industry announcing the FDA’s plan of action to clear up consumer confusion and propose new standards for nutrient criteria to minimize inconsistencies among FOP systems.5 FDA also issued guidance to industry regarding FOP labeling.6 In 2010, with the inception of the Let’s Move campaign7 and the White House’s concern about obesity and health, interest in FOP systems has remained strong. FDA has taken a more active role in assessing consumer response to FOP systems, has initiated consumer testing of possible FOP symbols, and has announced a request for comment, information, and data on FOP labeling.8 While this Institute of Medicine study was congressionally mandated and initiated prior to the most recent FDA activities, it is considered by FDA as one component of the work the agency is supporting to gain additional perspective from nutrition and consumer experts on how to best proceed in potential regulation of FOP systems. REFERENCE Schucker, R. E., A. S. Levy, J. E. Tenney, and O. Mathews. 1992. Nutrition shelf-labeling and consumer purchase behavior. Journal of Nutrition Education 24:75–81. 4 Available online: http://www.fda.gov/Food/LabelingNutrition/LabelClaims/ucm180146.htm (accessed August 4, 2010). 5 Available online: http://www.fda.gov/Food/LabelingNutrition/LabelClaims/ucm120274.htm (accessed September 20, 2010). 6 Available online: http://www.fda.gov/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocuments/FoodLabelingNutrition/ ucm187208.htm (accessed July 7, 2010). 7 Available online: http://www.whitehouse.gov/the-press-office/first-lady-michelle-obama-launches-lets-move-americas-move-raise-a-healthier- genera (accessed June 16, 2010). 8 75 FR 22602.