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Front-of-Package Nutrition Rating Systems and Symbols Promoting Healthier Choices Committee on Examination of Front-of-Package Nutrition Rating Systems and Symbols (Phase II) Food and Nutrition Board Ellen A. Wartella, Alice H. Lichtenstein, Ann Yaktine, and Romy Nathan, Editors
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 200-2005-13434, Task Order 32, between the National Academy of Sciences and the Centers for Disease Control and Prevention, Contract No. HHSF22301021T, Task Order 23, between the National Academy of Sciences and the Food and Drug Administration, and Grant No. CNPP- IOM-11-0001 between the National Academy of Sciences and the U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-21823-8 International Standard Book Number-10: 0-309-21823-3 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. Front-of-Package Nutrition Rating Systems and Sym - bols: Promoting Healthier Choices. Washington, DC: The National Academies Press.
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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advis - ing the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org
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COMMITTEE ON EXAMINATION OF FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS (PHASE II) ELLEN A. WARTELLA (Chair), Professor, Department of Communication Studies, Northwestern University, Evanston, IL ALICE H. LICHTENSTEIN (Vice Chair), Gershoff Professor, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA LINDSAY H. ALLEN, Center Director, USDA, ARS Western Human Nutrition Research Center, Davis, CA JAMES CRIMMINS, Adjunct Professor and Marketing Consultant, Northwestern University, Chicago, IL BRIAN ELBEL, Assistant Professor of Medicine and Health Policy, New York University School of Medicine and Wagner Graduate School of Public Service, New York, NY TRACY A. FOX, Nutrition Consultant and President, Food, Nutrition, & Policy Consultants, LLC, Washington, DC ELIZABETH HOWLETT, Professor of Marketing and Logistics, Sam M. Walton College of Business, University of Arkansas, Fayetteville, AR MATTHEW W. KREUTER, Professor, Health Communication Research Laboratory, Washington University, St. Louis, MO ANUSREE MITRA, Associate Professor, Kogod School of Business, American University, Washington, DC FRANCES H. SELIGSON, Consultant, Hershey, PA MARY T. STORY, Professor, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis VIRGINIA WILKENING, Alexandria, VA (resigned from committee April 2011) Consultants KELLY D. BROWNELL, Rudd Center, Yale University, New Haven, CT CHRISTOPHER CASEY, Washington University, St. Louis, MO LILA RUTTEN, SAIC, Inc., Frederick, MD MARLENE B. SCHWARTZ, Rudd Center, Yale University, New Haven, CT AMY SCOTT, UPBrand Collaborative, and Washington University, St. Louis, MO VIRGINIA WILKENING, Alexandria, VA (as of May 2011) IOM Staff ANN YAKTINE, Study Director ROMY NATHAN, Senior Program Officer JANET MULLIGAN, Senior Program Associate for Research SAMANTHA ROBOTHAM, Senior Program Assistant ANTON BANDY, Financial Officer GERALDINE KENNEDO, Administrative Assistant LINDA D. MEYERS, Director, Food and Nutrition Board v
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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Nancy M. Childs, Department of Food Marketing, St. Joseph’s University, Philadelphia, PA Karen Glanz, Perelman School of Medicine and School of Nursing, University of Pennsylvania, Philadelphia Jeanne P. Goldberg, Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA Edward Groth III, Groth Consulting Services, Pelham, NY Lisa Harnack, School of Public Health, University of Minnesota, Minneapolis Suzanne Harris, International Life Sciences Institute, Washington, DC Joanne R. Lupton, Texas A&M University, College Station Suzanne Murphy, Cancer Research Center of Hawaii, University of Hawaii at Manoa, Honolulu Marion Nestle, Department of Nutrition, Food Studies & Public Health, New York University, New York Sarah Roller, Kelley Drye & Warren, LLP, Washington, DC Bruce A. Silverglade, Washington, DC Linda Van Horn, Feinberg School of Medicine, Northwestern University, Chicago, IL Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Diana Birt, Iowa State University, and Elena O. Nightingale, Washington, DC. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. vii
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Preface American consumers today enjoy a wide array of food products from which to choose, but they also face a daunting challenge when trying to make healthful food choices. This challenge is exacerbated by the proliferation of front-of-package and shelf tag nutrition rating symbols and systems intended to communicate information about the healthfulness of the food. Not surprising, consumers trying to make choices in a short amount of time among packages cluttered with information and with different nutrition rating systems may have difficulty choosing more healthful products. During Phase I of the study to examine front-of-package nutrition rating symbols and systems, the committee found that the health risks most strongly associated with diet and affecting the greatest number of Americans are obesity and its associated chronic diseases. The committee also found that Americans consume too many calories, saturated and trans fats, and added sugars, and too much sodium; leaving other important nutrients at risk for inadequacy. Given these findings, the Centers for Disease Control and Prevention (CDC) with additional support from the Food and Drug Administration (FDA) of the U.S. Department of Health and Human Services and the Center for Nutrition Policy and Promotion (CNPP) of the U.S. Department of Agriculture asked the committee to carry out Phase II of the study to consider the benefits of a single, standardized front-label food guidance system; assess which icons or symbols would be most effective with consumers; and develop recommendations about the systems and icons that best promote health and ways to maximize their use. The Phase II committee consisted of the Phase I committee members and three new members, Jim Crimmins, Brian Elbel, and Elizabeth Howlett. The committee conducted an extensive review of both peer-reviewed and non-reviewed evidence. It also conducted a public workshop to gather information from experts outside the com - mittee and to hear from stakeholders. Invited speakers included Chung-Tung Jordan Lin and Alan Levy from the FDA; Kelly Brownell from the Yale University Rudd Center; Regina Hildwine from the Grocery Manufacturer’s Association and Marianne Smith-Edge from the International Food Information Council; Christina Zaradoolas from Mount Sinai School of Medicine; John Kozup from Villanova University; and Christine Johnson from the New York Department of Health. In addition, interviews with representatives from the food manufacturing industry were carried out, and the committee engaged several consultants. Kelly Brownell, Marlene Schwartz, and Lila Rutten served as unpaid consultants to assist the committee in interpreting the evidence. Christopher Casey and Amy Scott developed exemplar graphic representations of front-of-package symbol systems. The contributions of the workshop speakers, industry representatives, and the consultants were invaluable to the committee in guiding ix
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x PREFACE its discussions and developing recommendations. On behalf of the committee, I would like to thank them for their excellent work. I would also like to express my gratitude to the committee members, whose tireless efforts and determination made this report possible. The committee is also grateful to the Institute of Medicine study team: Ann Yaktine, study director; Romy Nathan, senior program officer; Janet Mulligan, Research Associate; Samantha Robotham, senior program assistant; Geraldine Kennedo, administrative assistant; and Anton Bandy, financial officer. I am especially grateful to Linda Meyers, director of the Food and Nutrition Board, who provided guidance to the com - mittee throughout both study phases. The committee’s findings about the current food package environment, together with evidence that consumer food choice behavior has not changed in spite of a myriad of front-of-package nutrition rating systems, clearly suggest that the time has come for a paradigm shift from information-based nutrition rating systems to one that encourages consumers to make more healthful food choices and purchasing decisions. The committee’s recom - mendations are presented as guidance to the study sponsors in developing a front-of-package symbol system that is easily understood and maximizes the opportunity to better inform and guide consumers’ toward more healthful food choices. Ellen A. Wartella, Chair Alice H. Lichtenstein, Vice-Chair Committee on Examination of Front-of-Package Nutrition Rating Systems and Symbols (Phase II)
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Contents SUMMARY 1 1 INTRODUCTION 9 Summary of Phase I Report, 11 Approach to the Study, 11 Findings and Conclusions from Phase I, 11 Statement of Task and Guiding Principles for Phase II, 13 Approach to the Phase II Task, 13 Organization of the Report, 14 References, 14 2 THE FOOD PACKAGE ENVIRONMENT 15 Introduction, 15 Food Packaging, 15 Package Design, 15 Package Information, 16 Prevalence of Product Claims and Other Information on Food Packages, 17 Amount of Information on Packages, 17 Nutritional Quality of Foods Bearing Product Claims and Promotions, 17 Value-Based Labeling, 18 References, 19 3 THE REGULATORY ENVIRONMENT 21 Mandatory Labeling Components, 21 Foods Regulated by the Food and Drug Administration, 21 Foods Regulated by the Food Safety and Inspection Service, U.S. Department of Agriculture, 22 Agency Jurisdiction Over Labeling, 23 xi
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xii CONTENTS Additional Components of Nutrition Labeling, 24 Background, 24 Front-of-Package Symbols in Conjunction with Claims, 28 Regulatory Actions Regarding Front-of-Package Nutrition Rating Systems, 29 Need for Periodic Reassessment of the Nutrition Facts Panel, 29 Findings and Conclusions, 30 References, 30 4 CONSUMERS’ USE OF NUTRITION INFORMATION AND PRODUCT CHOICES 33 Background, 33 Provision of Nutrition Information at the Point of Purchase, 33 The Role of Consumer Education Campaigns, 34 Barriers to Nutrition Label Use, 35 Simplifying Consumer Decisions with Front-of-Package Nutrition Information Labels, 36 Consumer Research Underpinning the Development of Front-of-Package Systems, 37 Consumer Confusion from Divergent Front-of-Package Systems, 38 FDA’s Perspective, 38 Limitations to a Cognitive Approach to FOP Symbol Systems, 39 Findings and Conclusions, 40 References, 40 5 CONSUMER USE AND UNDERSTANDING OF FRONT-OF-PACKAGE LABELING SYSTEMS 43 Introduction, 43 Types of FOP Systems, 43 Literature Review Methodology, 44 Approach to Literature Review, 44 Types of Front-of-Package Symbol System Studies Examined, 44 Applied Marketing Information, 54 Findings and Conclusions, 56 References, 56 6 EFFECTS OF FOOD PACKAGE INFORMATION ON CONSUMER PREFERENCES, CHOICES, AND PROCESSING 59 Introduction, 59 Does Food Package Information Influence Consumers?, 59 Nutrition-Related Claims, 59 Other Package Information, 61 New Methods for Studying Consumer Responses, 61 Effects Vary Among Sub-Groups of Consumers, 62 How Do Consumers Process Product Information in a Cluttered Package Environment?, 63 Insights from Visual Design, 63 Capturing Consumer Attention in a Cluttered Environment, 63 Cues and Signals, 64 Location of Information on Packages, 65 Summary and Conclusions, 67 References, 68
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xiii CONTENTS 7 A MODEL FRONT-OF-PACKAGE SYMBOL SYSTEM INCLUDING CRITERIA FOR EVALUATING NUTRIENTS 71 Introduction, 71 Front-of-Package Model System, 72 Potential for Success, 72 Characteristics of a Model FOP Symbol System, 73 Examples of FOP Symbols, 74 Approach to Evaluating Products for FOP Points, 74 Approach to Evaluating Nutrients to Limit in an FOP Symbol System, 79 Nutritional Criteria, 79 Eligibility Criteria, 79 Qualifying Criteria for Nutrient Component FOP Points, 84 Overall Product Evaluation, 89 Alignment with the Regulatory Environment, 92 Summary and Conclusions, 93 References, 95 8 PROMOTION, EVALUATION, AND MONITORING FOR FRONT-OF-PACKAGE SYMBOL SYSTEMS 97 Introduction, 97 Social Marketing Approach to Changing Health Behavior, 98 Principles of Social Marketing, 98 Rationale for a Social Marketing Approach, 98 Application of Social Marketing Campaigns to FOP Systems, 99 Promotion, Monitoring, Evaluation, and Research, 101 Promotion, 101 Monitoring, Evaluation, and Research, 101 Findings and Conclusions, 101 References, 103 9 RECOMMENDATIONS 105 Introduction, 105 Recommendations for FOP Systems and Symbols, 105 Recommendations for Monitoring, Evaluation, and Future Research, 107 Summary, 108 APPENDIXES A Acronyms and Glossary 109 B History of Nutrition Labeling 115 C FDA Regulatory Requirements for Nutrient Content Claims 135 D Approach to Literature Review 141 E Evaluation of Nutrient Content of Selected Example Foods 147 F Workshop Agenda 157 G Committee Member and Consultant Biographical Sketches 159
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Boxes, Figures, and Tables BOXES S-1 Phase I Guiding Principles, 2 1-1 Statements of Task for Phase I and II, 10 1-2 Obesity and Diet-Related Health Concerns in America, 12 Energy Guide and Energy Star® Programs, 66 6-1 7-1 Definition of Terms Used in Setting Nutritional Criteria, 78 7-2 Purposes, Strengths, and Limitations of the Described Approach for Evaluating Nutrients to Limit in the Model Front-of-Package (FOP) Symbol System, 80 7-3 Limitations Associated with Criteria for Limits on Nutrient Components in a Front-of-Package (FOP) Symbol System Based on Current Regulations and Potential Solutions, 94 D-1 Research Taxonomy, 144 FIGURES 4-1 Cumulative increase in the total number of front-of-package symbol systems during the past three decades in the United States, 36 7-1 Front-of-package symbol system example 1, 75 7-2 Front-of-package symbol system example 2, 76 7-3 Front-of-package symbol system example 3, 77 7-4 Evaluation criteria for a front-of-package symbol system, 81 8-1 Application of social marketing to a front-of-package symbol system, 100 B-1 Nutrition Facts panel, 123 xv
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xvi BOXES, FIGURES, AND TABLES TABLES 2-1 Selected Types of Information Commonly Found on Front of Food Packages, 16 3-1 Mandatory Labeling Components on Retail Packages, 23 3-2 Summary of Jurisdiction Overlap for Commercial Products Regulated by the Food and Drug Administration (FDA) and the U.S. Department of Agriculture (USDA), 26 5-1 Examples of Peer-Reviewed Studies Evaluating Front-of-Package (FOP) Systems, 46 7-1 Saturated Fat Content of Example Foods That Exceed the Food and Drug Administration (FDA) Disclosure/ Disqualifying Level for Saturated Fat, 82 7-2 Sodium Content of Example Products That Exceed the Food and Drug Administration (FDA) Disclosure/ Disqualifying Level for Sodium, 83 7-3 Examples of Products Categorized as Sugars, Sweets, or Beverages, 84 7-4 Criteria for Nutrient Content Claims That Characterize the Amount of Saturated Fat, 84 7-5 Saturated Fat Content of Selected Example Products Compared to Criteria for “Low in Saturated Fat” and Content of Trans Fat and Partially Hydrogenated Vegetable Oil, 86 7-6 Criteria for Nutrient Content Claims That Characterize the Amount of Sodium, 87 7-7 Sodium Content of Selected Example Foods That Meet the Sodium Criteria for “Low” and/or “Healthy,” 87 7-8 Potential Qualifying Criteria for a Front-of-Package Added Sugars Point for Individual Foods, 88 7-9 Sugars Content of Selected Example Foods That Do and Do Not Meet Potential Front-of-Package Criteria for Added Sugars, 89 7-10 Potential Criteria for a Front-of-Package Symbol System for Individual Foods, 90 7-11 Potential Nutritional Criteria for a Front-of-Package Symbol System for Main Dishes and Meal Products, 91 7-12 Front-of-Package (FOP) Points for Examples of Bakery Products Evaluated Against Potential Eligibility and Qualifying Criteria, 92 8-1 The Marketing Mix of the Four Ps, 98 8-2 Ongoing Monitoring, Evaluation, and Improvement of the New Front-of-Package System, 102 B-1 Milestones in Nutrition Labeling, 129 D-1 Example of Searches Using Key Words to Identify Relevant Literature, 142 E-1 Reference Amounts Customarily Consumed and Nutrient Content of Select Individual Example Foods in Amount per Labeled Serving, 149 E-2 Front-of-Package Points for Examples of Individual Foods Evaluated Against Potential Eligibility and Qualifying Criteria, 152 E-3 Front-of-Package Points for Example Fish and Poultry Products Evaluated Against Various Criteria for Saturated Fat Content, 156