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Summary1 There is a long and rich history of government public health efforts to educate and inform the public about nutrition and healthy eating. The first daily food guide, published in 1916, paved the way for a host of scientific documents, reports, brochures, symbols, and educational campaigns, including the Basic Seven Foods, the Food Guide Pyramid, and the Nutrition Facts panel. As a result of efforts such as these, Americans today have access to more information about nutrition than any previous generation. And yet the nation is facing a crisis of obesity and diet-related chronic diseases. Although there are many factors that influence what and how Americans eat, it is clear that there is a disconnect between dietary recommendations and actual consumption. Most of the front-of-package (FOP) systems that have been developed to date follow in the tradition of providing consumers with nutrition information. The use of such systems implicitly assumes that consumers are receiving appropriate nutrition information, whose impact can be enhanced by making it more prominent (i.e., putting it on the front of packages) and by delivering it more concisely. After reviewing evidence and perspec - tives from a wide range of disciplines, the committee came to a different conclusion. Rather than refining exist - ing informational approaches to communicating with the public about nutrition, the committee believes there is sufficient evidence to recommend that the U.S. Food and Drug Administration (FDA) and the U.S. Department of Agriculture (USDA) consider a fundamental shift in strategy. A new FOP symbol system should move beyond simply informing consumers about nutrition facts. The committee concluded that for a government-sponsored FOP symbol system to help achieve population health benefits, it must not only inform consumers about detailed nutrition content, but also, more importantly, encourage healthier food choices and purchase behaviors. The committee determined that these goals can be better achieved by a simple FOP symbol that serves as a signal or cue to consumers rather than by detailed information about nutrient content on the front of food packages or beverages. Similar approaches, such as the Environmental Protection Agency (EPA) and Department of Energy’s (DoE’s) Energy Star® program, have been highly success- ful in changing consumer purchase patterns for household appliances and electronics. Some nongovernmental organizations as well as food manufacturers have already developed simple FOP symbols. The committee’s rec - ommended approach builds on this foundation, is transparent, and uses the same regulatory criteria consistently across food categories. 1 This summary does not include references. Citations for the findings presented in the Summary appear in the subsequent chapters. 1

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2 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS BOX S-1 Phase I Guiding Principles In evaluating the nutrition science of front-of-package (FOP) systems and symbols, the committee ad- opted four guiding principles to set the stage for the nutritional assessment of FOP systems and symbols. These guiding principles were intended to assist the committee in identifying the systems and elements of systems most important to assisting American consumers in making healthier food choices and the system criteria that could be implemented in the current food environment. The guiding principles are: 1. A well-balanced, high-quality diet consistent with the recommendations of the Dietary Guidelines for Americans is essential for the health of Americans, and FOP labeling is one tool among many geared toward helping Americans make healthful choices. Other such tools include MyPyramid,a the Nutrition Facts panel (NFP), and health and nutrient content claims. 2. FOP systems will focus on nutrients or food components that are most strongly associated with diet-related health risks affecting the greatest number of Americans. 3. The information highlighted in FOP systems will be consistent with the NFP. 4. FOP systems will apply to as many foods as possible. aMyPlate replaces MyPyramid as the primary federal government food group symbol and directs consumers to Choose MyPlate.gov to learn how to apply the Dietary Guidelines. THE COMMITTEE’S TASK AND APPROACH At the direction of Congress, the Centers for Disease Control and Prevention (CDC) asked the Institute of Medicine (IOM) to undertake a study to examine and provide recommendations regarding FOP nutrition rating systems and symbols. The FDA, and later the USDA Center for Nutrition Policy and Promotion, provided support. The study comprised two phases. The Phase I committee focused on evaluating current systems and nutritional criteria and resulted in a report in 2010. The Phase II committee was tasked to: • consider the potential benefits of a single, standardized, front-label food guidance system regulated by the FDA, • assess which icons are most effective with consumer audiences, and • develop conclusions about the systems and icons that best promote health and how to maximize their use. The committee drew on the guiding principles (Box S-1), assessment, findings, and conclusions from Phase I (shown in Box S-1) as a starting point. The committee conducted a comprehensive review and analysis of evidence from several sources directly relevant to its charge. In order to be comprehensive, the committee considered a wide range of material from academic peer-reviewed literature and publicly available industry, government, and market - ing sources as well as evidence and perspectives from a wide range of disciplines. The committee acknowledged the potential shortcomings of any FOP system that were identified during Phase I, and explored whether and how consumers might use the information provided by an FOP symbol system. Although not tasked with making rec - ommendations about food preparation and consumption practices after purchase, the committee recognized that these practices have implications for health. Finally, the committee evaluated only the potential benefits of a single, standardized, front-label, food guidance system regulated by FDA and not the regulatory or related considerations of universally implementing such a system.

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3 SUMMARY DEVELOPING A MODEL FOP SYMBOL SYSTEM The committee’s review and analysis of the available evidence (described in Chapters 4 through 6) led to the finding that the various FOP systems in the marketplace predominantly focus on provision of nutrient information at the point of purchase. The evidence about consumer understanding of FOP labeling systems, consumer use of nutrition information, and the effects of food package information on consumer choices suggests that an approach that provides nutrition information only and is not interpretive would have limited success in encouraging healthier consumer food choices and purchase decisions (also discussed in Chapter 6). Thus, the committee concluded that a shift from an informational approach to an interpretive one that quickly and easily provides guidance would encourage healthier food choices. In addition, an effective FOP symbol system would encourage food and beverage companies to provide healthier choices through reformulation or development of new products, and would encourage retailers to highlight healthier products. Given the goal of encouraging healthier food choices, the committee evaluated FOP and shelf-tag nutrition rating systems that have demonstrated some success in the marketplace, but concluded that no FOP symbol system is superior to all others. Furthermore, no FOP systems as currently developed show consistent evidence of dramati - cally influencing consumer choice. However, there is some limited evidence that simple and easy-to-understand FOP systems encourage healthier food selections, particularly in settings where consumers make quick decisions such as in grocery stores with many product choices. Consumers with limited resources are more likely to be concerned about cost instead of nutrition, and consum - ers who find the label difficult to understand are less likely to use the nutrition information. Therefore, it is not surprising that the cognitive approach to providing more nutrition information on labels has not been consistently effective across consumer groups. Placing special emphasis on nutritionally at-risk subpopulations such as those with low incomes, low literacy/numeracy skills, or low levels of education, is an important component of the evaluation process. However, the committee recognizes that any FOP system is likely to have a narrow influence on the food purchase decisions of consumers whose access or resources to purchase healthier foods is impacted by economic and/or geographic limitations. Among consumers with low literacy skills, the evidence reviewed indicates that a simple rating system diminishes the differences in choosing the healthier product between high- and low-literacy adults. FOP labeling, especially using a simple symbol, might serve as a cue or signal for consumers, helping them distinguish between products of greater and lesser nutritional quality. These findings indicate that using simple symbols to summarize complex information about product quality may be especially valuable to low-literacy populations. From its review of existing FOP systems, the committee identified four attributes that are common to most successful FOP systems: 1. simple, understanding does not require specific or sophisticated nutritional knowledge; 2. interpretive, nutrition information is provided as guidance rather than as specific facts; 3. ordinal, nutritional guidance is offered through a scaled or ranked approach; and 4. supported by communication with readily remembered names or identifiable symbols. The EPA/DoE Energy Star® program provides an example of a successful government labeling system. For many consumers, the Energy Star® label signals products that deliver high-quality performance while saving energy and reducing operating costs. Consumer awareness of the label is high, and it appears to be effective in informing consumer purchases. Along with the attributes listed above, key factors that have contributed to the Energy Star® program’s success include partnerships with key stakeholders, widespread market penetration, a dynamic and evolving program, and ongoing and multi-faceted promotions. Each of these factors has relevance for designing and implementing a successful FOP nutrition rating system and, when considered with the totality of the available evidence, informed the committee’s assessment of the characteristics of a successful FOP nutrition rating system. The committee developed a set of eight characteristics that are necessary to the success of an FOP nutrition rating system. Furthermore, the committee determined that the system should carry an identifiable “health mean - ing,” that is, an indication of the extent to which a product contains reasonable amounts of saturated and trans fats,

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4 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS sodium, and added sugars, which are considered harmful when consumed in excess or above a certain threshold. The eight characteristics are incorporated into its recommendation for an FOP symbol system. RECOMMENDATIONS FOR FRONT-OF-PACKAGE SYSTEMS AND SYMBOLS From its review of the available evidence, the committee concluded that no flawless FOP symbol systems exist in the marketplace—each has strengths and limitations that must be weighed against the system’s intended purposes. The committee also concluded that a single, standardized system that is easily understood by most age groups and appears on all food products would best maximize the effectiveness in encouraging consumers to make healthier food choice and purchase decisions. Such a system would: • Prominently provide in one symbol system information about calorie content and serving size and targeted information related to nutrients that are strongly associated with public health concerns for Americans and foods with added sugars that the Dietary Guidelines recommends reducing or eliminating; • Facilitate comparisons of nutritional value within and across food categories; and • Encourage product reformulation. The approach and criteria for evaluating nutrients to limit in a FOP symbol system should be transparent and nonproprietary, that is, based on and/or consistent with FDA’s labeling regulations. After reviewing and analyzing the totality of the available evidence and weighing the benefits of and limita - tions to a single, standardized FOP system, the committee developed the following recommendation for a system that incorporates the characteristics described above: Recommendation 1 FDA and USDA should develop, test, and implement a single, standardized FOP system to appear on all food and beverage products. The system should have the following eight characteristics: • One simple, standard symbol translating information from the Nutrition Facts panel (NFP) on each product into a quickly and easily grasped health meaning, making healthier options unmistakable; • Displaying: o Calories in common household measure serving sizes (shelf tags to be used on bulk items such as fruits and vegetables as well as packaged goods), and o Zero to three nutritional “points” (for saturated and trans fats, sodium, and added sugars); • Appearing on all grocery products, allowing consumers to compare food choices across and within categories (universal implementation must be preceded by consumer testing and conducted in conjunction with an education and promotion program); • Appearing in a consistent location across products; • Practical to implement by being consistent with nutrition labeling regulations; • Integrated with the NFP so that the FOP symbol system and the NFP are mutually reinforcing; • Providing a nonproprietary, transparent translation of nutrition information into health meaning; and • Made prominent and useful to consumers through an ongoing and frequently refreshed program of promotion integrating the efforts of all concerned parties. Implementation of this system will require modifications of and/or exemptions to current FDA regulations and development of both new regulations and food group specifications, for establishing evaluative criteria. Because the NFP does not declare added sugars, the total sugars declaration could be footnoted with a statement such as “Contains no added sugars” or “Contains a qualifying amount of added sugars.” A single, standardized FOP symbol system should be the only system appearing on products. For products not meeting the evaluative criteria for an

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5 SUMMARY ordinal indicator symbol, the FOP system should still display calorie and serving size information. Examples of symbol systems that are consistent with these recommendations are presented in Chapter 7. An approach to deter- mining the number of points displayed on the FOP system is described in the following section. APPROACH TO EVALUATING PRODUCTS AND SETTING CRITERIA FOR NUTRIENT LIMITS As a critical component of the FOP symbol system, all products would display calories per serving size in common household measures and points2 for saturated and trans fats, sodium, and added sugars. The Phase I committee concluded that added sugars should not be a component of an FOP nutrition rating system because of insufficient evidence about the contribution of added sugars beyond calories to the most pressing diet-related health concerns among Americans; the inability to distinguish analytically between added and naturally occurring sugars in foods without obtaining proprietary product information and including that information on the NFP; and the relatively small number of food categories with high amounts of added sugars. This committee reconsidered this Phase I conclusion in light of events occurring after the release of the Phase I report, specifically the release of the 2010 Dietary Guidelines for Americans and the development of an approach to evaluating added sugars content. The 2010 Dietary Guidelines for Americans, which is the federal government’s nutrition policy docu- ment, strongly recommends reducing intakes of calories from added sugars and consumption of foods containing added sugars. These products contribute to energy intake; generally contain no or low amounts of saturated and trans fats and sodium; and provide little or no essential nutrients unless fortified, which is not consistent with FDA fortification policy.3 A relatively small number of food and beverage categories contribute more than half the added sugars in the American diet. The committee developed an approach to evaluating added sugars based on products categorized as Sugars, Sweets, and Beverages in the USDA Food and Nutrient Database for Dietary Studies that addresses previous concerns about analyzing foods for added sugars content. Simply stated, any product that is categorized as Sugars, Sweets, and Beverages in the USDA Food and Nutrient Database for Dietary Studies and contains added sugars would not be eligible to earn FOP points. As a consequence, major contributors of added sugars to diets, such as sugars, sweets, and beverages, would erroneously appear as being healthy because they are low in saturated and trans fats and sodium. The strong recommendation from the 2010 Dietary Guidelines for Americans, along with the development of this approach to evaluating added sugars, led the committee to conclude that added sugars are an important com - ponent that should be included in a FOP nutrition rating system. This conclusion is consistent with the principle that an FOP symbol system should not inadvertently promote products that are inconsistent with current federal dietary guidance. Evaluation of Nutrients for FOP Points The process to evaluate saturated and trans fats, sodium, and added sugars in a product occurs in two steps. In the first step, determining eligibility for inclusion in the FOP system (for earning any points), a food or beverage is excluded from earning FOP points if it does not meet specified eligibility criteria (see Chapter 7 for details). In the second step, a product that meets the eligibility criteria is evaluated for FOP points for saturated and trans fats, sodium, and/or added sugars based on qualifying criteria that assess acceptable amounts. The more points displayed, the more the food or beverage helps the consumer avoid less healthy levels of those nutrients identified as being associated with diet-related health risks. For example, a food or beverage product could earn one point for an acceptable level of sodium, one for an acceptable level of saturated and trans fats, and/or one point for an acceptable level of added sugars. Saturated and trans fats are considered together to facilitate communication about limiting consumption of foods containing solid fats, as recommended in the 2010 Dietary Guidelines for Americans. Points for a nutrient component would be displayed using a ranked or scaled (ordinal indicator) symbol 2 The term “points” is used to indicate that a critical component nutrient met its defined criteria. 3 21 CFR 104.20.

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6 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS as discussed above in the Model for a Symbol System and illustrated in Chapter 7 with hypothetical examples. If a food or beverage product contains any one of the nutrient components of concern in amounts exceeding speci - fied criteria limits, then the product would not be eligible for points and its label would display only calories per serving (examples are illustrated in Chapter 7). Labels of products that do not meet the eligibility and qualifying criteria for points would display only calorie and serving size information. A similar system could be developed for shelf tags for unpackaged or bulk items such as fruits and vegetables as well as packaged goods. From a nutrient perspective, this two-step process would mean that for each nutrient there are potentially two levels of evaluation, one to determine if the product is eligible to earn any points at all ( eligibility criteria) and, if so, one to determine how many points the product can earn (qualifying criteria). For example, 100 percent whole wheat bread would earn three FOP points, graham crackers two points (one each for saturated and trans fats and sodium), oat and peanut butter bars one point (for sodium), and soup crackers no points (because it exceeds the disclosure/disqualifying level for sodium). The determination of threshold values for a product to earn FOP points, based on regulations for nutrition label- ing and nutrient content claims, is explained in Chapter 7. The committee evaluated the nutrient content of a limited number of example foods and beverages in consideration of developing eligibility and qualifying criteria based on current regulations for nutrition labeling and nutrient content claims; these products are shown in Appendix E. Alignment with the Regulatory Environment The committee recognized that there should be alignment between eligibility and qualifying criteria for an FOP symbol system and federal regulations for nutrient content claims. However, the eligibility and qualifying criteria for the FOP symbol system described in this report are not entirely consistent with current regulations for nutrient content claims. As part of developing and testing an FOP symbol system, inconsistencies between potential criteria and current regulations will need to be addressed. The committee views the described criteria as starting points for extensive computer modeling to determine if the criteria are consistent with appropriate ratings for saturated and trans fats, sodium, and added sugars across a wide variety of foods and beverages. The com- mittee recognized that the criteria must balance restrictiveness with practicality to allow products to earn FOP system points appropriately. As with all regulatory actions, public input will be required for implementation of a new FOP symbol system and its criteria. PROMOTION, EVALUATION, AND RESEARCH Promotion There are a number of ways in which social marketing strategies and theory can be applied to FOP labeling to influence nutrition-related awareness, knowledge, attitudes, and behaviors. Based on its review of existing public health campaigns, the committee concluded that implementation of an effective FOP system must be a well-funded, sustained effort that is dynamic, refreshed on a regular basis, and carried out by a public-private partnership. Campaigns should carefully attend to specific behavioral goals that are effective and actionable. Comprehensive, multi-level approaches that attend to pertinent environmental and policy constraints, socio-cultural influences, and individual-level factors relevant to dietary behavior change in the target population are encouraged. Monitoring, Evaluation, and Research The committee acknowledges that certain federal agencies will incur costs to implement the recommendations for an FOP symbol system and that an additional investment will be needed to support an education and promotion campaign, along with evaluation of the campaign and research to test and refine educational messages. Neverthe - less, the committee concluded that implementation of its recommendations offers the best option to maximize the effectiveness of an FOP symbol system in encouraging consumers to make healthier food choices and purchase decisions. There should be ongoing monitoring and periodic evaluation of a new FOP symbol system. This program should include the following components:

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7 SUMMARY • Identifying the steps toward reaching the goal of making healthier choices; • Conducting research designed to assess success in reaching each step; and • Enhancing system components and taking corrective action where necessary. Research should be conducted to assess the needs and preferences of target audiences to better understand factors that influence consumer food choice and purchase behavior. In addition, formative research is necessary to test and refine messages and to determine the best approaches and channels to promote an FOP symbol system. Monitoring through both process and outcome evaluation is needed to assess the effectiveness and impact and to refine and strengthen program components. An evaluation of the impact of the FOP symbol system on product reformulation is also necessary. Ongoing research will help to guide and strengthen implementation efforts and help inform corrective actions where necessary. Placing special emphasis on nutritionally at-risk subpopulations, such as those with low incomes, low literacy/numeracy skills, or low levels of education, is an important component of these processes. Based on these conclusions the committee makes the following recommendation: Recommendation 2 Implementation of a new FOP symbol system should include a multi-stakeholder, multi-faceted aware - ness and promotion campaign that includes ongoing monitoring, research, and evaluation. CLOSING REMARKS After reviewing the available evidence, the committee determined that there is a need for an FOP symbol system designed to encourage consumers to make healthier food choices and that a single, simple FOP symbol system, aligned with current dietary guidance and consistently applied across food product categories, would be most useful to achieving that goal.

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