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Suggested Citation:"Front Matter." Institute of Medicine. 2012. Front-of-Package Nutrition Rating Systems and Symbols: Promoting Healthier Choices. Washington, DC: The National Academies Press. doi: 10.17226/13221.
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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

INSTITUTE OF MEDICINE

    OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

WASHINGTON, D.C.

www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Front-of-Package Nutrition Rating Systems and Symbols: Promoting Healthier Choices. Washington, DC: The National Academies Press. doi: 10.17226/13221.
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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.

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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 Symbols: Promoting Healthier Choices. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Front-of-Package Nutrition Rating Systems and Symbols: Promoting Healthier Choices. Washington, DC: The National Academies Press. doi: 10.17226/13221.
×
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe

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INSTITUTE OF MEDICINE

OF THE NATIONAL ACADEMIES

Advising the Nation, Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Front-of-Package Nutrition Rating Systems and Symbols: Promoting Healthier Choices. Washington, DC: The National Academies Press. doi: 10.17226/13221.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering and Medicine

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 advising 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

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Front-of-Package Nutrition Rating Systems and Symbols: Promoting Healthier Choices. Washington, DC: The National Academies Press. doi: 10.17226/13221.
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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

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Front-of-Package Nutrition Rating Systems and Symbols: Promoting Healthier Choices. Washington, DC: The National Academies Press. doi: 10.17226/13221.
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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.

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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 committee 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

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Front-of-Package Nutrition Rating Systems and Symbols: Promoting Healthier Choices. Washington, DC: The National Academies Press. doi: 10.17226/13221.
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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 committee 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 recommendations 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)

Suggested Citation:"Front Matter." Institute of Medicine. 2012. Front-of-Package Nutrition Rating Systems and Symbols: Promoting Healthier Choices. Washington, DC: The National Academies Press. doi: 10.17226/13221.
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Additional Components of Nutrition Labeling

Background

Front-of-Package Symbols in Conjunction with Claims

Regulatory Actions Regarding Front-of-Package Nutrition Rating Systems

Need for Periodic Reassessment of the Nutrition Facts Panel

Findings and Conclusions

References

4 CONSUMERS’ USE OF NUTRITION INFORMATION AND PRODUCT CHOICES

Background

Provision of Nutrition Information at the Point of Purchase

The Role of Consumer Education Campaigns

Barriers to Nutrition Label Use

Simplifying Consumer Decisions with Front-of-Package Nutrition Information Labels

Consumer Research Underpinning the Development of Front-of-Package Systems

Consumer Confusion from Divergent Front-of-Package Systems

FDA’s Perspective

Limitations to a Cognitive Approach to FOP Symbol Systems

Findings and Conclusions

References

5  CONSUMER USE AND UNDERSTANDING OF FRONT-OF-PACKAGE LABELING SYSTEMS

Introduction

Types of FOP Systems

Literature Review Methodology

Approach to Literature Review

Types of Front-of-Package Symbol System Studies Examined

Applied Marketing Information

Findings and Conclusions

References

6  EFFECTS OF FOOD PACKAGE INFORMATION ON CONSUMER PREFERENCES, CHOICES, AND PROCESSING

Introduction

Does Food Package Information Influence Consumers?

Nutrition-Related Claims

Other Package Information

New Methods for Studying Consumer Responses

Effects Vary Among Sub-Groups of Consumers

How Do Consumers Process Product Information in a Cluttered Package Environment?

Insights from Visual Design

Capturing Consumer Attention in a Cluttered Environment

Cues and Signals

Location of Information on Packages

Summary and Conclusions

References

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TABLES

2-1 Selected Types of Information Commonly Found on Front of Food Packages
 
3-1 Mandatory Labeling Components on Retail Packages
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)
 
5-1 Examples of Peer-Reviewed Studies Evaluating Front-of-Package (FOP) Systems
 
7-1 Saturated Fat Content of Example Foods That Exceed the Food and Drug Administration (FDA) Disclosure/ Disqualifying Level for Saturated Fat
7-2 Sodium Content of Example Products That Exceed the Food and Drug Administration (FDA) Disclosure/ Disqualifying Level for Sodium
7-3 Examples of Products Categorized as Sugars, Sweets, or Beverages
7-4 Criteria for Nutrient Content Claims That Characterize the Amount of Saturated Fat
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
7-6 Criteria for Nutrient Content Claims That Characterize the Amount of Sodium
7-7 Sodium Content of Selected Example Foods That Meet the Sodium Criteria for “Low” and/or “Healthy,”
7-8 Potential Qualifying Criteria for a Front-of-Package Added Sugars Point for Individual Foods
7-9 Sugars Content of Selected Example Foods That Do and Do Not Meet Potential Front-of-Package Criteria for Added Sugars
7-10 Potential Criteria for a Front-of-Package Symbol System for Individual Foods
7-11 Potential Nutritional Criteria for a Front-of-Package Symbol System for Main Dishes and Meal Products
7-12 Front-of-Package (FOP) Points for Examples of Bakery Products Evaluated Against Potential Eligibility and Qualifying Criteria
 
8-1 The Marketing Mix of the Four Ps
8-2 Ongoing Monitoring, Evaluation, and Improvement of the New Front-of-Package System
 
B-1 Milestones in Nutrition Labeling
 
D-1 Example of Searches Using Key Words to Identify Relevant Literature
 
E-1 Reference Amounts Customarily Consumed and Nutrient Content of Select Individual Example Foods in Amount per Labeled Serving
E-2 Front-of-Package Points for Examples of Individual Foods Evaluated Against Potential Eligibility and Qualifying Criteria
E-3 Front-of-Package Points for Example Fish and Poultry Products Evaluated Against Various Criteria for Saturated Fat Content
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During the past decade, tremendous growth has occurred in the use of nutrition symbols and rating systems designed to summarize key nutritional aspects and characteristics of food products. These symbols and the systems that underlie them have become known as front-of-package (FOP) nutrition rating systems and symbols, even though the symbols themselves can be found anywhere on the front of a food package or on a retail shelf tag. Though not regulated and inconsistent in format, content, and criteria, FOP systems and symbols have the potential to provide useful guidance to consumers as well as maximize effectiveness. As a result, Congress directed the Centers for Disease Control and Prevention (CDC) to undertake a study with the Institute of Medicine (IOM) to examine and provide recommendations regarding FOP nutrition rating systems and symbols.

The study was completed in two phases. Phase I focused primarily on the nutrition criteria underlying FOP systems. Phase II builds on the results of Phase I while focusing on aspects related to consumer understanding and behavior related to the development of a standardized FOP system.

Front-of-Package Nutrition Rating Systems and Symbols focuses on Phase II of the study. The report addresses the potential benefits of a single, standardized front-label food guidance system regulated by the Food and Drug Administration, assesses which icons are most effective with consumer audiences, and considers the systems/icons that best promote health and how to maximize their use.

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