Front-of-Package Nutrition Rating Systems and Symbols: Phase I Report (2010)

Growing recognition of the nation’s obesity crisis and the prevalence of chronic disease have led to an array of efforts aimed at increasing physical activity and promoting healthful eating, including changes in the formulation, packaging, labeling, and marketing of food and beverage products that contribute to a healthy lifestyle. In particular, the use of symbols summarizing key nutritional aspects and characteristics of food products has seen substantial growth. These symbols and the nutrition rating systems that underlie them have come to be known as front-of-package (FOP) symbols and nutrition rating systems even though the actual symbol may be found in a variety of locations on the food package or even on retail shelf tags alongside product price information. Systems and symbols have been developed by food manufacturers, retailers, health organizations, and others with the intention of helping consumers make healthier food choices.

While these systems are innovative approaches to nutrition labeling, they are not without controversy. Concerns, particularly over nutrient criteria that vary widely and sometimes conflict among the many systems in the marketplace and over the potential for FOP symbols to encourage purchases, have fueled the current debate on the future use of FOP nutrition rating systems, which has in turn led to new government initiatives to identify better and more consistent approaches for FOP systems.

As a step toward determining how FOP systems should be used as a nutrition education tool in the future, Congress directed the Centers for Disease Control and Prevention to undertake a study with the Institute of Medicine to examine and provide recommendations regarding front-of-package nutrition rating systems and symbols. The Food and Drug Administration (FDA) was also a study sponsor. The study has been undertaken in two phases. This report is the result of the initial phase and focuses on reviewing existing front-of-package systems and their underlying nutrition criteria. A second phase will focus on issues related to consumer understanding and use of FOP systems.

The study task, which guided the committee’s work, is described in Box S-1. Because the committee determined that the same nutritional approach could be applied to both children and adults, it did not consider children and adults separately in Phase I. The committee also developed four guiding principles to assist it in identifying systems and their elements that were most important for improving the health of the American people and in identifying system criteria that could be realistically implemented. The guiding principles are:

• A well-balanced, high-quality diet consistent with the Dietary Guidelines for Americans is essential for the health of Americans, and front-of-package labeling is one tool among many geared toward helping Americans make healthful choices. Other such tools include MyPyramid, the Nutrition Facts panel, and health and nutrient content claims.

• Front-of-package systems will focus on nutrients or food components that are most strongly associated with the diet-related health risks affecting the greatest number of Americans.

• The information highlighted in front-of-package systems will be consistent with the Nutrition Facts panel.

• Front-of-package systems will apply to as many foods as possible.

The committee’s deliberations were also informed by its findings about diet-related health concerns. The findings are:

A number of systems have been or currently are in use in the United States or abroad. The committee chose 20 systems representative of those in the marketplace on which to base its review. General information on these systems by system category is provided in Table S-1. For the purposes of comparing systems and identifying strengths and limitations, the committee categorized systems into the categories described below.

• Nutrient-Specific Systems display on the front of the food package the amount per serving of select nutrients from the Nutrition Facts panel or use symbols based on claim criteria. The information is given in percent daily values (%DV) or guideline daily amounts (%GDA), and the display 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 provided on the front of the food package. Systems using symbols based on claim criteria may award multiple symbols on a product indicating it is “low fat,” “high fiber,” etc.

• Summary Indicator Systems use a single symbol, icon, or score to provide summary information about the nutrient content of a product. No specific nutrient content information is given in these systems. The system may be based on nutrient thresholds or algorithms. 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 (positive and/or negative) into account. Products are given a numeric score (i.e., 1–100) or number of symbols (e.g., 0, 1, 2, 3) to indicate the nutritional quality of the product.

• Food Group Information Systems use symbols that are awarded to a food product based on the presence of a food group or food ingredient. Some symbols indicate the presence of a serving (or partial serving) of a particular food group, while other symbols indicate the presence of ingredients considered to be important dietary components such as whole grains.

Given the number of front-of-package systems on the market and the variety of attributes that future systems may have, it was not possible to conduct an exhaustive evaluation of each system. Rather, the committee characterized the attributes, purposes, strengths, and weaknesses by defined system types (see Tables S-2, S-3, and S-4).

Given that two-thirds of the U.S. adult population and one-third of children and adolescents are overweight or obese, chronic disease levels are high, and a healthy diet consistent with the Dietary Guidelines for Americans is essential for all Americans, FOP labeling would be best geared toward the general population. Thus, children are not considered separately in assessing the nutritional components in Phase I. Whether specific subpopulations, including children, may benefit from FOP labeling, will be explored in Phase II.

The committee identified a number of purposes, including those set forth by FDA in the Federal Register in April, namely that 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.” ¹ On balance, the latter best reflected the guiding principles and the committee considerations of potential purposes.

Obesity and overweight, which result from calorie consumption in excess of energy expenditure, are critical public health concerns for the majority of the population. Including total calories in nutrition rating system symbols is one way to emphasize the importance of calories in the American diet, and it could help consumers identify lower-calorie foods and track the number of calories consumed. Providing serving size information in household measures gives context to the amount of food associated with the calories per serving displayed in an FOP symbol. Offering serving size information in an easy-to-understand format may help consumers better visualize realistic serving sizes and put the serving size into context with the other foods and beverages they are consuming.

As stated in the committee’s guiding principles, the committee considered it critical that FOP rating systems focus on those nutrients that are most strongly associated with the diet-related health risks affecting the greatest number of Americans. Calories, saturated fat, trans fat, and sodium are four of the most critical nutrients and are also nutrients that are overconsumed in the American diet. Calories are the most critical nutrient to address in reducing obesity and its various co-morbidities, including coronary heart disease and stroke, type 2 diabetes, metabolic syndrome, and certain types of cancer. In addition, reducing sodium intake can reduce blood pressure, which in turn can reduce an individual’s risk of stroke and cardiovascular disease events. Furthermore, reducing saturated and trans fat intake may reduce the risk of cardiovascular disease. Given the adverse health effects of excess calories, saturated fat, trans fat, and sodium intakes, it is critical to include these components in nutrition rating systems so as to help Americans choose foods with lower levels of these nutrients.

Several factors led to the conclusion that it may not be useful to include a number of nutrients in all types of FOP systems. These factors included (1) the relative importance of these nutrients to the most pressing diet-related health concerns among Americans, (2) the potential for some nutrients to track with other nutrients that are considered important to include in FOP rating systems, (3) amounts of the nutrients and food components, except for added sugars, can be found elsewhere on the package label in the Nutrition Fact panel, and (4) challenges for measuring compliance for some nutrients, particularly added sugars. A fifth factor relates to concerns about encouraging overfortification or the addition of these nutrients to food systems in which the nutrient is unstable or not biologically available, which would contradict FDA fortification policy. Issues surrounding added sugars and fiber are challenging and are addressed more fully in Chapter 4 (pages 43–44 and 48) and Chapter 7 (pages 83–85). Monitoring the intake of these nutrients remains important to assembling a healthful diet. However, other tools (e.g., nutrient content claims, education programs) may be more appropriate for addressing these nutrients,

allowing FOP systems to focus on the most critical public health concerns. Brief rationale for not including these nutrients at the current time are listed below.

• Total fat includes beneficial mono- and polyunsaturated fats, whose consumption is encouraged, and saturated and trans fats, whose consumption should be limited. Thus, it is difficult to characterize total fat content as either a positive or negative attribute of a food product.

• Dietary guidance recommendations encourage displacing saturated and trans fats in the diet with unsaturated fats. Since many consumers have a negative view of all types of fat, consumers may avoid products with FOP systems showing higher levels of total fat content, especially those systems that include nutrient-specific information, and this may not be the desired behavior in all cases.

• While cholesterol remains an important concern for certain subgroups of the population, overconsumption of cholesterol is not as significant a problem for the general population as overconsumption of saturated fat, trans fat, or sodium, making it less important to include cholesterol in FOP system criteria.

• Saturated fat criteria may help to address most major sources of cholesterol in the diet since most foods that are high in cholesterol would not be rated well because of a high saturated fat content.

• A variety of compounds that vary greatly in their physiological function, including monosaccharides, disaccharides, starch, fiber, pectins, and gums, are all considered carbohydrates. Because of these compounds’ varied physiological functions, it would be difficult in many types of nutrition rating systems to characterize total carbohydrate content as a positive or negative attribute of a food product.

• There is a lack of scientific agreement about the amount of sugars that can be consumed in a healthy diet and about potential adverse health effects of sugars beyond an effect on dental caries. Thus, it is difficult to conclude that total sugars intake is of sufficient public health concern to be included in FOP rating systems.

• Total sugars include those naturally present in fruits, vegetables, and fat free or low fat dairy products, which are considered foods to encourage.

• Despite the overall increase in calories that they provide to the American diet, at this time evidence and agreement are lacking about adverse health effects of added sugars, the exceptions being the extra calories that they contribute to a diet and their dilution of essential nutrient intake.

• An analytical test that can accurately determine added sugar content is unavailable, leaving the sharing of proprietary product formulations as the only apparent option for monitoring product compliance with established criteria.

• Added sugars are not included in the Nutrition Facts panel, so including added sugars in FOP system criteria would lead to inconsistencies between the Nutrition Facts panel and FOP symbols.

• Protein is not currently considered a nutrient of public health concern in the United States.

• For many vitamins and minerals, there is no public health need for the general population to increase intake.

• In the case of fiber and those vitamins and minerals for which there is a public health need to increase intake, inclusion in an FOP rating system could lead to practices that may not be beneficial to consumers, such as excessive or inappropriate uses of fortification, or might inadvertently drive consumers away from foods that do not contain these components but which are otherwise considered nutritious food choices.

For each of the potential systems, the committee identified ways in which criteria might be set for calories, saturated fat, trans fat, and sodium. Given ongoing consumer research by FDA and others, as well as the plans for examination of consumer use of FOP labeling in the second phase of the committee’s work, the committee decided that it would be premature at this time to try to determine the type of FOP symbol or system that would be most useful in informing consumers and facilitating dietary changes. Because of the diversity of system types, the committee was unable to suggest a universal set of criteria that can be used across all FOP rating systems. However, the committee did examine how criteria might be set for various system types. These considerations might serve as a basis for setting future FOP criteria once consumer research and testing results can determine which formats are most appropriate.

The committee identified six options for setting criteria for two system types: four options for setting criteria for nutrient-specific information systems and two options for a summary indicator based on threshold systems (see Chapter 7). The committee did not find readily apparent options for setting criteria for the other types. Algorithm-based summary indicators would not be ideal because they would need to assume that the effects of saturated fat, trans fat, and sodium are additive for overall health outcomes, which is not the case. For systems based on food group information, no options could be identified that would provide sufficient information on the nutrients of concern.

All options include a declaration of calories and serving size, which is consistent with Conclusion 3. The four options for nutrient-specific information systems have varying levels of complexity in providing specific information on saturated fat, trans fat, and sodium. In characterizing “low” levels of nutrients, government-regulated definitions for “low” can be used. “High” levels could be set using regulated criteria already in place for determining when disclosure statements must accompany nutrient content claims because a given food exceeds prescribed levels for nutrients of concern. Since no claim criteria or disclosure levels exist for trans fat and because saturated fat and trans fat are both fats of concern, it might be reasonable to combine these components and use their combined content for characterizing levels. The two options identified for developing a nutrient threshold-based summary indicator are (1) to set the same criteria across all foods to allow for comparison of foods across the supermarket and (2) to develop varied criteria across food categories to make the criteria more or less stringent based on the characteristic attributes of the food category.

The second phase of this study focuses on assessing consumer use and understanding of FOP symbols. The committee will draw on this first-phase report as it considers (1) which systems and symbols are most effective with consumer audiences and best promote health, (2) how to maximize their use, and (3) the potential benefits of a single, standardized front-label food guidance system regulated by the Food and Drug Administration.

The approach to the task includes gathering information from relevant consumer behavior literature and experts in relevant fields, including new research on FOP undertaken by FDA as well as from available research from the United States and internationally. Information-gathering will include a workshop in October 2010 on Consumer Behavior Research and Front of Package Nutrition Rating Systems and Symbols—What do consumers know, understand, and use? Questions of interest to the committee are given in Chapter 7. The committee will be attentive to research related to consumer literacy and numeracy, as well as usability of labels by various subgroups in the population including children and adolescents. The report of the second phase is due in fall 2011.

No front-of-package system is perfect—each has strengths and limitations that must be weighed against the purposes of FOP systems. Given current public health needs, FOP systems may have the greatest potential benefit if the nutrition components included are limited to those most closely related to prominent public health conditions. As implied throughout this report, decisions about which nutrients to include in FOP systems and about the underlying nutrition criteria would benefit from grounding in nutrition science as based on current consensus documents on the dietary needs of the U.S. population. Because nutrition science and labeling regulations change, it would be useful to consider developing a formalized process for reassessment of a system’s nutrient criteria. Further, to ensure that labeled products actually meet FOP nutrition criteria, it will be important that the criteria be transparent and publicly available, with analytical detections methods included.

Additionally, research is needed to determine the most effective way of presenting the ratings to consumers so they can make food choices that contribute to a healthy diet. As noted, some research is currently being conducted by the FDA, academic institutions, and industry and can factor into future FOP system development and adjustments. The committee welcomes such information and data as it gathers information for the second phase.