5
Purpose and Merits of Front-of-Package Nutrition Rating Systems

Given the prevalence of obesity and chronic disease in the United States, there is a great need to provide the public with tools that can help them adopt healthier lifestyles, including tools to help select a health promoting diet. The goal of the Nutrition Labeling and Education Act and the standardized label format (Nutrition Facts panel) was to provide useful nutrition information to help consumers make better dietary choices. A recent U.S. Department of Agriculture (USDA) study shows that while the majority of Americans still report using the Nutrition Facts panel, there appears to have been a small decline in use over the ten-year period between 1996 and 2006 (Todd and Variyam, 2008). The authors suggest that for many consumers the difficulty of using this information exceeds the perceived benefits. This is consistent with studies that have shown that even those individuals who use the labels have difficulty interpreting the nutrition information correctly, regardless of their numeracy (the ability to use and understand numbers in daily life) and literacy (Cowburn and Stockley, 2005; Rothman et al., 2006).

A study sponsored by the American Dietetic Association reported that 67 percent of consumers said that diet and nutrition were very important to them, but 41 percent of the respondents said that their poor understanding of diet and nutrition was a key reason that they did not do more to achieve a healthy diet. A majority of respondents reported looking for practical tips to help them eat right, and the percentage of consumers actively seeking information about nutrition and healthy eating doubled from 19 percent in 2000 to 40 percent in 2008 (ADA, 2008).

Based on a systematic review of research on consumer understanding of nutrition labels, Cowburn and Stockley (2005) called for improvements in nutrition labeling so as to provide more useful information at the point of purchase and to promote the selection of healthier foods. FOP rating systems and symbols have the potential to provide such an improvement. While many of the healthiest foods in the supermarket, such as fresh fruits and vegetables, do not bear labels, symbols for these foods could be placed on signage or shelf labels.

CATEGORIZATION OF FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS

As described in Chapter 3, there are a variety of reasons for developing and using FOP nutrition rating systems, and the reasons for use and development vary according to the intended end user, the goals of the rating systems, and the interests of the bodies developing the systems. Because there are dozens of systems in use both in the United States and abroad, the committee chose for its review a set of 20 systems representative of those now in the marketplace. To make it easier to compare and contrast them, the various systems were placed into three categories. Descriptions of these categories are provided in Box 5-1.



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5 Purpose and Merits of Front-of-Package Nutrition Rating Systems Given the prevalence of obesity and chronic disease in the United States, there is a great need to provide the public with tools that can help them adopt healthier lifestyles, including tools to help select a health promoting diet. The goal of the Nutrition Labeling and Education Act and the standardized label format (Nutrition Facts panel) was to provide useful nutrition information to help consumers make better dietary choices. A recent U.S. Department of Agriculture (USDA) study shows that while the majority of Americans still report using the Nutrition Facts panel, there appears to have been a small decline in use over the ten-year period between 1996 and 2006 (Todd and Variyam, 2008). The authors suggest that for many consumers the difficulty of using this information exceeds the perceived benefits. This is consistent with studies that have shown that even those individuals who use the labels have difficulty interpreting the nutrition information correctly, regardless of their numeracy (the ability to use and understand numbers in daily life) and literacy (Cowburn and Stockley, 2005; Rothman et al., 2006). A study sponsored by the American Dietetic Association reported that 67 percent of consumers said that diet and nutrition were very important to them, but 41 percent of the respondents said that their poor understanding of diet and nutrition was a key reason that they did not do more to achieve a healthy diet. A majority of respondents reported looking for practical tips to help them eat right, and the percentage of consumers actively seeking infor- mation about nutrition and healthy eating doubled from 19 percent in 2000 to 40 percent in 2008 (ADA, 2008). Based on a systematic review of research on consumer understanding of nutrition labels, Cowburn and Stockley (2005) called for improvements in nutrition labeling so as to provide more useful information at the point of purchase and to promote the selection of healthier foods. FOP rating systems and symbols have the potential to provide such an improvement. While many of the healthiest foods in the supermarket, such as fresh fruits and vegetables, do not bear labels, symbols for these foods could be placed on signage or shelf labels. CATEGORIZATION OF FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS As described in Chapter 3, there are a variety of reasons for developing and using FOP nutrition rating sys - tems, and the reasons for use and development vary according to the intended end user, the goals of the rating systems, and the interests of the bodies developing the systems. Because there are dozens of systems in use both in the United States and abroad, the committee chose for its review a set of 20 systems representative of those now in the marketplace. To make it easier to compare and contrast them, the various systems were placed into three categories. Descriptions of these categories are provided in Box 5-1. 

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 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS BOX 5-1 Definition of Front-of-Package System Categories Nutrient-Specific Systems: Systems with symbols that display the amount per serving of select nutrients from the N utrition Facts panel on the front of the food package or use symbols based on claim criteria. Percent daily values (%DV) or guideline daily amounts (%GDA) appear on the front of the package, which may also include traffic light colors or words to indicate that a product contains “high,” “medium,” or “low” amounts of specific nutrients. A declaration of calories per serving may also be on the front of the food package. Systems using symbols based on claim criteria may award multiple symbols indicating that a product is “low fat,” “high fiber,” etc. Summary Indicator Systems: Systems with a single symbol, icon, or score that provides summary information about the nutrient content of a product. No specific nutrient content information is given in these systems. Systems may be based on nutrient thresholds or algorithms. Products that meet the criteria are awarded the system’s symbol. Systems often use different criteria based on food categories (e.g., type of food or food product). Algorithm systems evaluate food products based on an equation that takes nutrients and other components (positive and/or negative) into account. Products are given a numeric score (i.e., 1–100) or number of symbols (i.e., 0, 1, 2, 3) to indicate the nutritional quality of the product. Food Group Information Systems: Systems in which symbols are awarded to a food product based on presence of a food group or food ingredient. Some symbols indicate the presence of a serving (or partial serving) of a particular food group; other symbols indicate the presence of ingredients considered to be important dietary components, such as whole grains. Nutrient-specific systems have been developed largely by food manufacturers and retailers (Wegmans, Harris Teeter, Kellogg’s, General Mills), with the exception of the U.K. Food Standards Agency’s Traffic Light system. Wegmans’ and Harris Teeter’s systems feature symbols to indicate nutrient content—e.g., LF for “low fat,” HF for “high fiber,” etc.—and are based upon Food and Drug Administration (FDA) nutrient content claims. General Mills and Kellogg’s present select information from the Nutrition Facts panel, such as calories and fat per serving, usually accompanied by the percentage of Daily Value (%DV)1 or Guideline Daily Amount (%GDA).2 The systems are aimed at providing consumers with a snapshot of the nutrient content of a food and what that food contributes to their daily diet. If consumers want to consume a specific amount of fiber or limit their sodium intake, this type of system can help them to do so quickly by glancing at a package and selecting or rejecting the product based on its nutrient content. Some of the nutrient-specific systems, such as the UK traffic light characterize the amount of various nutrients by using color, words, or some combination of the two to indicate that the products contains “high,” “medium,” or “low” amounts of each nutrient of interest. Summary indicator systems have been developed by independent (nonprofit) organizations or advisory groups, food manufacturers, and consortiums of those groups. No specific nutrient content information is given in these systems. Generally, a single symbol or score is used. Summary indicator systems may be based on nutrient thresholds or algorithms. Threshold-based systems such as Smart Choices or the Heart Check use a single symbol to indicate that the food product upon which it is featured has satisfied that system’s nutrient criteria. These sys - 1 Daily Values (DVs) were developed by FDA to put the amount of a nutrient in a serving of food in the context of a total daily diet; %DVs are required in the Nutrition Facts panel for those nutrients for which Daily Values were established (21 CFR 101.9(8)). 2 Guideline Daily Amounts (GDAs) are used in Europe on a voluntary basis by food and beverage and retail industries to give context to the energy and nutrient content of foods and beverages. In June 2006 the Confederation of the Food and Drink Industries introduced EU GDAs based on Eurodiet recommendations (available online at http://www.gdalabel.org.uk/gda/background_european.aspx [accessed June 17, 2010]). Nutrition at a Glance (from Kellogg’s) uses the term “GDA” in system descriptions, and uses Daily Values as the basis for the %GDA presented on products sold in the United States.

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 PURPOSE AND MERITS OF FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS tems are aimed at providing consumers with a way to select foods of higher nutritional quality without having to process nutrition information in detail. Summary indicators based on algorithms like Guiding Stars and NuVal use a mathematical equation, which may include a combination of positive and negative values reflecting the various nutrients as well as other factors to score the nutritional quality of a food. A numerical or symbol-based score is used as the summary symbol. Food group information systems emphasize particular food groups or components in a food product, such as fruits and vegetables or whole grains. ConAgra is the main food manufacturer using this type of system, which it applies in combination with USDA’s MyPyramid. ConAgra’s target audience is consumers who want the convenience of prepared meals and foods but who are concerned about the healthfulness of those prepared foods (ConAgra, 2010). In addition, the Whole Grains Council developed a Whole Grain Stamp for council members to use on package labels when the product contains at least 8 g of whole grains, the amount that is equivalent to half a serving of whole grains according to MyPyramid guidelines. GENERAL PURPOSES OF FRONT-OF-PACKAGE SYSTEMS In 2010, the FDA announced an overarching goal for FOP nutrition rating systems: The goal of an FOP nutrition label is to increase the proportion of consumers who readily notice, understand, and use the available information to make more nutritious choices for themselves and their families, and thereby prevent or reduce obesity and other diet-related chronic disease.3 FDA also identified a number of other potential purposes of FOP systems, including providing “a more con - venient and effective information tool for consumers seeking quick and accurate information about the nutritional quality of the food they are purchasing and accessing,” helping to educate consumers and aid them in making healthier food choices,4 and encouraging industry reformulation of products.5 The committee’s review of existing systems identified a number of purposes for FOP systems. As described in Chapter 3, some of them were intended to encourage the purchase of more nutritious products belonging to an individual company’s portfolio. Others were introduced specifically to help consumers make choices consistent with reduced CVD risk. Still others were designed to encourage the reformulation of packaged foods. Many other purposes were identified as well. In addition to examining the purposes of the various FOP rating systems that have been introduced to the marketplace, the committee also found it useful to try to identify as many potential purposes of FOP rating systems as possible, regardless of whether a particular purpose had driven previous system development. In this exercise, the committee identified ten potential purposes of FOP rating systems. Table 5-1 identifies purposes that are currently or could potentially be achieved by the broad categories of FOP system types defined in Box 5-1. The description of the purposes provided below also includes some examples (although not an exhaustive list) of current systems identified by the committee as serving a particular purpose. Provide Prominent Calorie Content Information At present, the major health challenge in the United States is overweight and obesity, and energy content is arguably the most important information that should be presented as a component of an FOP system or symbol. Calorie content can be presented in various ways: (1) per serving, (2) percentage of a 2,000-calorie reference total daily intake, (3) calories per package for items that are likely to be consumed for a single meal or snack, or (4) per serving and per package (regardless of size). As an example of the third approach, the beverage industry announced 3 75 FR 22602. 4 75 FR 22602. 5 75 FR 22602.

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TABLE 5-1 Comparison of Front-of-Package Scheme Types According to Attribute or Potential to Fulfill Specific Purposesa  Nutrient Specific Information Summary Indicator Food Group Information Nutrient Symbol Based Based on Calories Amount on FDA/USDA Nutrient Based on Food Food Purpose per Serving per Serving Claim Criteria Thresholds Algorithm Groups Ingredient ¸ ¸ ¸ ¸ ¸ ¸ ¸ Provide prominent calorie content information ¸ ¸ ¸ ¸ ¸ ¸ ¸ Provide prominent serving size information ¸ ¸ Provide targeted nutrition information ¸ ¸ ¸ Indicate whether product is high or low in specific nutrient(s) ¸ ¸ Summarize overall nutritional value of a product ¸b ¸b ¸b ¸c ¸c Facilitate comparisons of nutritional value within food categories ¸b ¸b ¸b Facilitate comparisons of nutritional value across food categories ?d ?d ¸ ¸ Provide information about contribution to recommended food ¸e groups ¸b ¸b ¸b ¸c ¸c Provide guidance on products suitable for marketing to children ¸ ¸ ¸ ¸ ¸ ¸ ¸ Encourage product reformulation aA checkmark indicates a system subtype either currently does or potentially could be developed to fulfill the specified purpose. b Only specific nutrient content can be compared, e.g., sodium, saturated fat, etc. c Only overall nutritional value can be compared. d The ability to compare products across categories would depend on how the nutrient thresholds or algorithm are set. e Some summary indicator systems include criteria for food groups, but food group contribution is not depicted on FOP.

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 PURPOSE AND MERITS OF FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS it will declare calories per container as part of an FOP system on packages up to and including 20 fl. oz. 6 It might be possible for all types of FOP systems to include prominent calorie content information if this were incorporated into the FOP symbol. Provide Prominent Serving Size Information As with calorie information, FOP nutrition rating systems could also provide descriptive information about serving size in order to reinforce with consumers the actual quantity of food that is associated with the declared calorie content. None of the reviewed FOP systems specifically indicates serving size, but, if found useful through consumer research, serving size could be indicated alongside or incorporated within the system symbol. An addi - tional metric that could help consumers associate calorie content and serving size is the number of servings per package for packages that contain three or more servings. Provide Targeted Nutrition Information By design, nutrient-specific systems provide information on targeted nutrients. These systems all include nutrients identified by the system developers as nutrients that should be limited in the diet, but not all of them necessarily include nutrients to encourage. In addition to amount per serving, some U.S. systems provide the percent of the Daily Value (%DV) per serving, and UK systems may provide the percent of the Guideline Daily Amount (%GDA).7 Indicate Whether a Product Is High or Low in Specific Nutrients Some systems use symbols that indicate whether a product meets the criteria for a nutrient content or health claim defined by FDA or USDA, e.g., “low fat” cheese or “lean” beef. Similarly the Heart Check symbol (American Heart Association) includes text to indicate that an item is “low” in saturated fat and cholesterol (non-meat items) or “extra lean” (meat and seafood). UK labeling schemes may include a text descriptor of “high,” “medium,” or “low” or a color indicator of “high” (red), “medium” (amber), or “low” (green) for nutrients that should be limited in the diet. Summarize Overall Nutritional Value of a Product By definition, summary indicators purport to assess the overall nutritional value of a product. As described in Box 5-1, a food product may be evaluated based upon (1) a specific set of criteria for various nutrients (threshold) or (2) a mathematical equation—commonly referred to as an algorithm—that takes nutrients and other factors (positive or negative or both) into account and generates a score or other symbol to indicate the product’s nutri - tional quality. Facilitate Comparisons of Nutritional Value Within Food Categories A merit of systems based on nutrient-specific information—and, to some extent, summary symbols based on nutrient thresholds and algorithms—is that consumers can compare the nutritional value of items within a product category, such as within the category of crackers. For example, the sodium content of crackers can be compared on the basis of weight (expressed in mg) or %DV per serving. These comparisons can also be made with the Nutrition Facts panel, but moving sodium information to a more prominent location on the package may allow for more convenient decision making. Sodium content could also be evaluated if the products carried a nutrient content claim, such as “low sodium,” or a claim-based FOP symbol for “low sodium.” However, for this comparison to be 6 Available online: http://www.ameribev.org/news--media/news-releases--statements/more/180 (accessed June 1, 2010). 7 As stated in footnote 2, Kellogg’s Nutrition at a Glance uses the term “GDA” in system descriptions, but actually uses FDA Daily Values for calculating the percentage contribution to a 2,000-calorie daily diet.

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 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS made accurately, the consumer must be able to assume that products that do not contain the claim do not qualify as “low sodium,” which may not always hold true. In contrast to focusing on a single nutrient, threshold- and algorithm-based systems attempt to evaluate the overall nutritional value of a given product by considering the content of many different nutrients that should be either limited or encouraged. Thus, a cracker that contains a summary symbol based on nutrient thresholds will have met specific criteria not only for sodium but also for other nutrients and will theoretically have a better overall nutritional value than a cracker that does not have the symbol. Crackers evaluated by an algorithm can be compared by, for example, the number of stars they contain (as in Guiding Stars) or by the numerical value of their scores (as in NuVal). Facilitate Comparisons of Nutritional Value Across Food Categories All FOP systems based on nutrient-specific information allow consumers to compare the nutritional value of food and beverage items across product categories. Assuming that crackers and cookies would be viewed as two different product categories, for example, consumers could compare the sodium content of crackers to the sodium content of cookies on the basis of amount expressed as mg or %DV per serving. Cookies and crackers can also be compared for sodium content based on the presence of nutrient content claim–based symbols because the criteria for claims such as “sodium-free,” “very low sodium,” and “low sodium” are the same for all product categories (except main dishes and meals8). For comparisons to be made accurately, the consumer must be able to assume that products that do not contain a claim or symbol indicating “low sodium” are indeed not low in sodium, which is not always true. FOP systems using summary indicators based on thresholds could allow for comparison of nutritional value across product categories if the systems have one set of nutrient criteria for all food categories. However, current threshold systems have different nutrient criteria for different food categories, which are themselves defined dif - ferently for each system. For example, the overall nutritional value of a breakfast cereal and yogurt could only be compared in a threshold-based system if the nutrients included and the criteria for evaluating the nutrient content were the same. The same limitations for comparing products across food categories apply to algorithm-based systems. For the general population (i.e., not including infant and toddler foods), Guiding Stars has three broad food categories which differ enough in their algorithms to preclude comparison of a breakfast cereal and a yogurt based on the number of stars assigned. The NuVal system uses one general algorithm but applies many different “universal adjustors,” “weighting coefficients,” and other adjustors that are category-specific (Katz et al., 2009), and that have the potential to lead to inconsistencies in across-category comparisons. The Nutrient Rich Food Index applies only one algorithm across all product categories (Fulgoni et al., 2009), but consumers would not know how the content of individual nutrients influenced the final score. Provide Information About Contribution of Recommended Food Groups The committee reviewed two FOP nutrition rating systems that describe a product’s contribution to the intake of specific food groups or food ingredients. The Start Making Choices symbol (ConAgra) shows how much one serving of a given product contributes to the recommended daily intakes of MyPyramid food groups such as fruits, vegetables, dairy, and meat and beans. Similarly, the Whole Grains Council developed a stamp symbol to com - municate the whole grain (i.e., a food ingredient) content of products. 9 8 21 CFR 101.61. Depending on the claim, the sodium criteria for main dishes and meals are expressed per labeled serving or per 100 g. The sodium criteria for all other foods regardless of product category are expressed per reference amount customarily consumed (RACC) for sodium free, very low sodium, and low sodium as well as per labeled serving for low sodium. Special rules apply if the RACC is small, i.e., 30 g or less or 2 tablespoons or less. 9 Available online: http://www.wholegrainscouncil.org/files/US_StampUsageGuide.pdf (accessed June 1, 2010). Products must contain at least 8 g of whole grain per labeled serving to use the basic Whole Grain Stamp. Products that contain at least 16 g of whole grain and in which all the grains are whole grains may use the 100% Whole Grain Stamp.

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 PURPOSE AND MERITS OF FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS While the information is not depicted on the FOP symbol, some summary indicator systems based on nutri - ent thresholds include criteria for encouraging the inclusion of MyPyramid food groups or a food ingredient such as whole grains. Several product categories in Sensible Solutions (Kraft) and Smart Choices include the criterion that at least a one-half serving of fruits, vegetables, whole grains, or fat-free or “low fat” milk products should be included. Provide Guidance on Products Appropriate for Marketing to Children In response to concerns about the high prevalence of overweight and obesity in children and teens, there are growing efforts to develop nutrition standards for determining which products might appropriately be marketed to children. In 2006 the Council of Better Business Bureaus launched the Children’s Food and Beverage Advertising Initiative (CFBAI) to provide companies that advertise foods and beverages to children under age 12 years with a transparent and accountable advertising self-regulation mechanism. Part of a participant’s pledge to CFBAI is a guarantee that nutrient criteria are consistent with established scientific and government standards, such as the Dietary Guidelines for Americans, MyPyramid food group recommendations, and FDA standards for nutrient con- tent and health claims.10 The CFBAI pledge approach is similar to FOP systems based on nutrient thresholds, but it does not require products to carry an FOP symbol. Each company participating in this self-regulation program has established a different set of nutrition criteria on which to evaluate its products and marketing practices. Con - ceivably, an appropriately designed FOP nutrition rating system for the general population might also be useful in advising industry on products that may be appropriate for marketing to children ages 4 years and older and could provide for a more consistent set of nutrient criteria for all companies that participate. Encourage Product Reformulation FOP rating systems can encourage food manufacturers to reformulate products or develop new products in order to meet specific nutrient targets. Several supporters of the CFBAI have either reformulated existing products or developed new products to be consistent with their pledged nutrition criteria. 11 However, it should be noted that at times, such as during the “low fat” trend in the 1990s, encouraging product reformulation can have unintended consequences. In addition, for certain nutrient criteria one must consider various issues related to the potential encouragement of overfortification of the food supply. REFERENCES ADA (American Dietetic Association). 2008. Nutrition and you: Trends 00. Chicago, IL: ADA. ConAgra. 2010. MyPyramid Labeling Program. Presented at the Public Information-Open Session for the Committee on Examination of Front- of-Package Nutrition Rating Systems and Symbols. Washington, DC. April 9, 2010. Cowburn, G., and L. Stockley. 2005. Consumer understanding and use of nutrition labelling: A systematic review. Public Health Nutrition 8:21–28. Fulgoni, V. L., III, D. R. Keast, and A. Drewnowski, A. 2009. Development and validation of the nutrient-rich foods index: A tool to measure nutritional quality of foods. Journal of Nutrition 139:1549–1554. Katz, D. L., V. Y. Njike, Z. Faridi, L. Q. Rhee, R. S. Reeves, D. J. A. Jenkins, and K. T. Ayoob. 2009. The stratification of foods on the basis of overall nutritional quality: The Overall Nutritional Quality Index. American Journal of Health Promotion 24(2):133–143. Rothman, R. L., R. Housam, H. Weiss, D. Davis, R. Gregory, T. Gebretsadik, A. Shintani, and T. A. Elasy. 2006. Patient understanding of food labels: The role of literacy and numeracy. American Journal of Preentie Medicine 31(5):391–398. Todd, J. E., and J. N. Variyam. 2008. The decline in consumer use of food nutrition labels, 1995–2006. Economic Research Report No. (ERR–). 32 pp. 10 Available online: http://www.bbb.org/us/children-food-beverage-advertising-initiative (accessed July 8, 2010). 11Available online: http://www.bbb.org/us/storage/0/Shared%20Documents/finalbbbs.pdf (accessed June, 18, 2010). The Children’s Food and Beverage Advertising Initiative: A Report on Compliance and Implementation During 2008 (see Appendix H, p. 78).

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