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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. 141
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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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