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Appendix D
Approach to Literature Review
APPROACH TO GATHERING EVIDENCE
The committee developed an approach to review and evaluate a broad range of evidence generated through
general and focused literature searches. This approach included: (1) establishing research objectives, (2) developing
a literature search strategy, and (3) setting eligibility criteria to evaluate and rate the evidence.
Research Objectives
The committee refined the Statement of Task’s broad study objectives into more specific research goals to
guide the literature search. The Statement of Task identified the following broad study objectives:
• consider the potential benefits of a single, standardized, front-label food guidance system administrated by
the Food and Drug Administration (FDA),
• assess which icons are most effective with consumer audiences, and
• develop conclusions and recommendations about the system/icons that best promote health and how to
maximize their use.
From these objectives, the committee developed research goals, specifically to examine literature relevant to:
• Food package regulation and the regulatory environment, including federal agency jurisdiction over animal-
based food products;
• The context for consumers’ use of nutrition information and product choices;
• Consumer understanding and use of front-of-package (FOP) labeling systems, point-of-purchase labeling,
and shelf tags;
• Impact of the FOP labeling environment, including package design, package clutter, and product claims
on consumer food choice and behavior;
• Design models of FOP symbol systems and influences of symbol systems on consumer food choice and
behavior;
• Nutrients to limit and nutrient thresholds consistent with current dietary guidance; and
• FOP educational and promotional health campaigns.
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142 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS
LITERATURE SEARCH STRATEGY
In order to review the most relevant scientific literature available, study staff initially searched a range of online
bibliographic databases, including ABI/INFORM, Academic Search Premier, AGRICOLA, ASAPII, EMBASE,
New York Academy of Medicine’s Grey Literature Collection, NTIS government documents, PsychINFO, PubMed/
MEDLINE, Science Direct, Web of Science, and WorldCat/First Search. To identify primary literature, staff first
conducted general searches on topics relevant to assessment of consumer information processing, use, and under-
standing of FOP systems and symbols, as well as advertising, marketing, and merchandising of food products.
Using the results of the primary search, staff developed key search terms and then conducted secondary searches.
They chose search terms based on relevance to the study objectives and topic areas identified by the committee.
Searches were limited to English language publications. After the initial search, staff designed a comprehensive
search strategy in consultation with librarians at the George E. Brown Jr. Library of the National Academies.
Search terms incorporated relevant MeSH (Medical Subject Headings) terms as well as terms from the EMBASE
thesaurus. Table D-1 provides an example of how searches were conducted; only a subset of terms from the overall
search are shown because inclusion of the entire search in the report was not practical.
TABLE D-1 Example of Searches Using Key Words to Identify Relevant Literature
Search No. Search Terms Number of Hits
1 Labeling / or food labeling / or percentage ingredient labeling 2,190
2 Consumer information / or health claims 1,348
3 “Product packaging” or “product labeling” 69
4 Packaging material / or packaging 2,708
5 “Package design” or “product claim” or ecolabel* or “ecolabel” or “fair trade” 277
6 “front label” or “front of package” or “net content?” or “ingredient statement” or 23
“statement of identity” or “label component”
7 “nutrition fact? panel?” or “nutrition fact? information” or “NF Panel” or “NF information” 1,405
or “nutrition label”
8 Or / 1-7 7,413
9 Limit 8 to English and years 2000-2011 3,449
10 9 and consumer 996
11 Consumers 1,590
12 “Family and consumer science” / or exp consumer science 15,205
13 Exp consumer behavior / or consumer acceptance / or consumer attitudes / or consumer 7,440
preferences / or consumer satisfaction
14 Consumer economics / or consumer purchasing 537
15 “Consumer perception?” or “consumer decision” or “consumer choice?” 619
16 Consumer surveys 1,535
17 Or / 10-16 16,380
18 9 and 17 1,016
19 “clutter” or “information overload” or “eye tracking” or “package design” 120
20 9 and 19 6
21 10 and 19 2
22 9 and reformulation 3
23 Food choices / or food intakes 15,707
24 9 and 23 220
25 Nutrient intake 11,371
26 Diet 21,358
27 25 or 26 29,564
28 9 and 27 106
29 “agribusiness and business economics” / or marketing 6,227
30 Advertising / or food marketing / or market analysis / or market development / or market 4,799
channels / or marketing strategies / or exp social marketing
31 29 or 30 10,659
32 9 and 31 190
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143
APPENDIX D
TABLE D-1 Continued
Search No. Search Terms Number of Hits
33 Grocery stores / or food purchasing / or supermarkets 2,182
34 9 and 33 114
35 Exp literacy / or readability / or numeracy / or “numer* litera*” 412
36 9 and 35 6
37 Low income households / or poverty 2,958
38 9 and 37 9
39 Exp socioeconomic status 3211
40 8 and 39 35
41 Health beliefs / or food beliefs 1,401
42 9 and 41 62
43 Exp “human health and safety” 19,752
44 9 and 43 211
45 Health promotion / or public health 6777
46 9 and 45 225
47 Education / or health education / or nutrition education 7,952
48 9 and 47 100
49 “National labeling and education act” 3
50 “Laws and regulations” / or “bans and sanctions” / or consumer protection / or deregulation 22,579
/ or labeling / or law enforcement / or market regulations / or ownership / or patents / or
product certification / or “standards and grades” / or trade regulations / or compliance / or
“food law?”
51 9 and 50 585
52 “Purchase behavior” or “purchase intention” 83
53 9 and 52 12
Staff limited the searches to English language and to publication dates of 2000 and later. The initial search
retrieved more than 4,900 citations, including more than 1,000 business citations, which were then sorted into
predefined topics identified by the committee. The topical search terms included
• Advertising/marketing
• Brand names
• Brand preferences
• Choice behavior
• Clutter
• Consumer behavior
• Diet/nutrient intake
• Education
• Food choice
• Food law and legislation
• Health promotion
• Health/food beliefs
• Health/safety
• Literacy/numeracy
• Low income/poverty
• Nutrition labeling information
• Purchase intention
• Reformulation
• Retail/purchasing
• Socioeconomics
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144 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS
BOX D-1
Research Taxonomy
Intervention studies
Includes randomized trials, field experiments, quasi-experimental studies
• Consumer behavior
• Consumer choice
• Diet and nutrient intake
• Education and food choice
• Food choice and behavior
• Health and food beliefs and attitudes
• Health literacy
• Nutrition Facts panel and nutrition information
• Purchase intent
Observational studies
Includes surveys, descriptive studies
• Brand preference
• Food law and legislation
o United States
o International
• Health and safety labeling
o Health claims
o Nutrient profiling
• Package clutter
o Eye-tracking
o Purchase intent
• Product reformulation
• Socioeconomic factors in food availability and choice
Reviews
Includes narrative reviews, evidence-based reviews, meta-analyses on any search topic
Relevant references obtained from the initial search were then screened and categorized according to the
research taxonomy shown in Box D-1, and then annotated by staff. The committee was provided reference lists
of key citations in tabulated format for evaluation and rating.
EVIDENCE RATING
Studies were segregated by design into the first level of the literature review and evaluation process as follows:
• Experimental studies, including randomized controlled trials, field experiments, online or lab experiments
• Descriptive/observational studies, including cohort, cross-sectional, and ecological designs
• Reviews
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145
APPENDIX D
The committee rated experimental studies, including field, laboratory, and online experiments as the strongest
type of evidence, but also considered observational and descriptive research. To evaluate this type of evidence, the
committee considered the quality of the research design as well as whether the evidence was supportive of any
experimental research. Reviews were included but not rated. To evaluate the literature for further consideration
and inclusion in the report, the committee assessed the evidence according to the following factors:
• Inclusion criteria, based on methodological approach, including adequate control group, blinding or no
blinding, appropriate statistics
o I—Inclusion criteria are reasonable and appropriate
o II—Some criteria missing or not adequate
o III—Inclusion criteria absent or not satisfactory
• Generalizability of the study/Population demographics
o I—Sample is representative of the target population. Sufficiently large to cover both sexes, wide age
range, and other important feature of the target populations (e.g., diet)
o II—Sample is representative of a relevant subgroup of the target population, but not the entire population
o III—Sample is representative of a narrow subgroup of subjects only, and is of limited applicability to
other subgroups
• Food product category
o I—3 or more products
o II—2 or fewer products
o III—No products in the study
Staff maintained and posted on the committee’s portal a reference database of the evaluated evidence. The
database was searchable by keywords, annotations, or other criteria. Bibliographies were updated throughout the
study and as committee members requested journal articles and other resources.
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