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Front-of-Package Nutrition Rating Systems and Symbols: Promoting Healthier Choices (2012)

Chapter:Appendix D: Approach to Literature Review

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Suggested Citation:"Appendix D: Approach to Literature Review." 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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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 understanding 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 “statement of identity” or “label component” 23
7 “nutrition fact? panel?” or “nutrition fact? information” or “NF Panel” or “NF information” or “nutrition label” 1,405
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 preferences / or consumer satisfaction 7,440
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 channels / or marketing strategies / or exp social marketing 4,799
31 29 or 30 10,659
32 9 and 31 190
Suggested Citation:"Appendix D: Approach to Literature Review." 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.
×
 
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 / 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?” 22,579
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

Suggested Citation:"Appendix D: Approach to Literature Review." 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.
×

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

ο United States

ο International

•  Health and safety labeling

ο Health claims

ο Nutrient profiling

•  Package clutter

ο Eye-tracking

ο 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

Suggested Citation:"Appendix D: Approach to Literature Review." 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 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

 ο I—Inclusion criteria are reasonable and appropriate

 ο II—Some criteria missing or not adequate

 ο III—Inclusion criteria absent or not satisfactory

•   Generalizability of the study/Population demographics

 ο 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)

 ο II—Sample is representative of a relevant subgroup of the target population, but not the entire population

 ο III—Sample is representative of a narrow subgroup of subjects only, and is of limited applicability to other subgroups

•   Food product category

 ο I—3 or more products

 ο II—2 or fewer products

 ο 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.

Suggested Citation:"Appendix D: Approach to Literature Review." 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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Suggested Citation:"Appendix D: Approach to Literature Review." 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.
×

Appendix E

Evaluation of Nutrient Content of Selected Example Foods

1 used by the committee to assess strengths and limitations of and regulatory issues associated with nutritional criteria for an FOP symbol system based on current regulations for nutrition and ingredient labeling and nutrient content and health claims.

2 and the USDA Food and Nutrient Database for Dietary Studies, 3.0. Each product is only one of many examples of products within a category and may not be representative of all products in its category. The items are organized by Food and Drug Administration (FDA) product categories for individual foods, then by lowest to highest reference amounts customarily consumed (RACC) within a category.3

Table E-2 displays the FOP points earned by the product examples based on the following two-step approach for evaluation:

Step 1: Determine whether a product should not earn any FOP points for saturated and trans fats, sodium, or added sugars based on eligibility criteria because the product contains an amount of one or more of the stated nutrient components that is not consistent with the Dietary Guidelines.

Step 2: Determine whether a product that meets the eligibility criteria earns FOP points for saturated and trans fats, sodium, and/or added sugars based on qualifying criteria that assess acceptable amounts.

The first step excludes a food or beverage from earning FOP points for saturated and trans fats, sodium, and added sugars because the amount of any one of these components is considered “too high.” For example, a product “high” in sodium but containing no or low levels of saturated fat, trans fat, and added sugars would not be viewed as consistent with the Dietary Guidelines. Such a product should be excluded from earning FOP points for saturated and trans fats and added sugars even if the amounts of these nutrient components otherwise meet qualifying criteria. In the second step, a food or beverage that meets the eligibility criteria can then be evaluated

image

1 It is Institute of Medicine (IOM) policy to not use brand names of products.

2 Available online: http://www.peapod.com/ (accessed on various dates throughout 2010 and 2011).

3 Food product categories as identified in 21 CFR 170.3.

Suggested Citation:"Appendix D: Approach to Literature Review." 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.
×
Page141
Suggested Citation:"Appendix D: Approach to Literature Review." 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.
×
Page142
Suggested Citation:"Appendix D: Approach to Literature Review." 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.
×
Page143
Suggested Citation:"Appendix D: Approach to Literature Review." 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.
×
Page144
Suggested Citation:"Appendix D: Approach to Literature Review." 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.
×
Page145
Suggested Citation:"Appendix D: Approach to Literature Review." 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.
×
Page146
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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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