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9 Recommendations INTRODUCTION In Phase I of the study to examine front-of-package (FOP) nutrition rating systems, the committee concluded that such systems are only one among many approaches that provide information to improve the ability of consum - ers to make healthy food choices. In Phase II of the study the committee found that the variety of FOP systems in the marketplace predominantly focused on provision of nutrition information at the point of purchase. The evidence reviewed on consumer use of nutrition information and product choices, understanding FOP labeling systems, and effects of food package information on consumer choices suggested that an approach that provides nutrition information only has had limited success in encouraging healthier consumer food choice and purchase decisions. Importantly, this evidence led the committee to conclude that a shift is needed from an approach that provides infor- mation only to one that encourages consumers to make healthier food choices and purchase decisions. To develop its recommendations for this type of FOP symbol system, the committee identified the characteristics of success - ful FOP systems and then incorporated them into a model FOP symbol system for food packages and shelf tags. RECOMMENDATIONS FOR FOP SYSTEMS AND SYMBOLS As noted in the Phase I report, “The most useful primary purpose of front-of-package rating systems and symbols would be to help consumers identify and select foods based on the nutrients most strongly linked to public health concerns for Americans.” Using the Phase I conclusions as a starting point, the Phase II committee determined that the most critical nutrition components to include in FOP symbol systems are calories, saturated and trans fats, sodium, and added sugars. The Phase I committee concluded that there is insufficient evidence to support inclusion of total fat, cholesterol, total carbohydrate or added sugars, protein, fiber, vitamins, and minerals other than sodium on a FOP label. Furthermore, the committee determined that added sugars should not be a com - ponent 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 informa - tion and including that information on the Nutrition Facts panel (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 105
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106 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS for Americans, which is the federal government’s nutrition policy document, 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 Food and Drug Administration (FDA) fortification policy.1 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 U.S. Department of Agriculture (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 beverages, sugars, and sweets, 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. 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. In considering its task to evaluate the potential benefits of a single, standardized front-label food guidance system regulated by FDA, the committee recognized that it was not constituted to evaluate regulatory or related considerations involving universal implementation of a single, standardized system. Furthermore, the committee recognized that it did not have the expertise to consider possible First Amendment issues that could arise as such a system was developed and implemented as described below. However, because the evidence showed that there are no flawless FOP symbol systems in the marketplace, the committee concluded that a single, standardized system that is easily understood by most age groups and appears on all products would be the best option for encouraging consumers to make healthier food choice and purchase decisions. The committee determined that a single, standardized system for all foods would provide the following spe - cific benefits: • Prominently provide in one symbol system information about calorie content and serving size and targeted information related to nutrients and most foods with added sugars that are strongly associated with public health concerns for Americans; • Facilitate comparisons of nutritional value within as well as across food categories; and • Encourage product reformulation. 1 21 CFR 104.20.
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107 RECOMMENDATIONS The committee therefore makes the following recommendation: 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 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 FOP system appearing on products. For products not meeting the evaluative criteria for an ordinal indicator symbol, the FOP label should still display calorie and serving size information. Examples of symbol systems that are consistent with these recommendations are presented in Chapter 7. RECOMMENDATIONS FOR MONITORING, EVALUATION, AND FUTURE RESEARCH 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. The committee further concluded that, in order to be successful, federal agencies and interested stakeholders, including private and nongovernmental organizations, should support the FOP symbol system, emphasizing its impact on consumer purchase and consumption behavior. 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 system. Monitoring through both process and outcome evaluation is needed to assess the effectiveness and impact and to refine and strengthen program components. Placing special emphasis to 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 food purchase decisions of consumers whose access or resources to purchase healthier foods is impacted by economic and/or geographic limitations. An evaluation of the impact of the FOP symbol system on product refor- mulation is also necessary. Ongoing research will help to guide and strengthen implementation efforts and help inform corrective actions where necessary. Lastly, research should measure success at each stage of the process
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108 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS toward encouraging consumers to make healthier food choices and to guide remedial action where necessary. For example, research could examine whether differentiating between fat, sodium, and added sugars points on the FOP label has any impact on food choices and purchasing decisions. 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. SUMMARY The committee’s recommendations for a single, simple, FOP symbol system are derived from its review and analysis of evidence from the published literature and unpublished reports, as well as from information provided by food manufacturers, consumer organizations, government agencies, nongovernmental organizations, and other stakeholders. The aim of the FOP symbol system is to help consumers identify and choose products that are more consistent than others with the 2010 Dietary Guidelines for Americans for saturated and trans fats, sodium, and added sugars, based on a set of criteria to make that distinction. Based on an evaluation of a limited number of products, the committee found certain criteria for “low saturated fat” and “low sodium” to be overly stringent for products that are consistent with a healthful diet, which suggests that FDA consider alternative criteria devel - oped through the regulatory process to allow certain foods and foods encouraged by the Dietary Guidelines for Americans to receive points as appropriate. 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 a FOP symbol system. Although the committee’s task included developing recommendations for an FOP system that would best promote health and maximize its use, it did not include developing recommendations about consumption practices after purchase. The committee’s recommendations are presented as guidance to the study sponsors for developing a single, standardized FOP symbol system that is easily understood and consistent across food product categories and that encourages consumers to make healthier food choices and purchasing decisions.