Nutrition labelling--the DAA perspective. (Conference Paper).

(Nutr Diet 2002;59:48-51)

Introduction

Australians are privileged to have an enormous choice of foods, more than ever before. With our increasingly complex and full lives less time is being devoted to home cooking and the food industry has responded with all kinds of quick, easy and tasty meal solutions.

Along with the rather daunting array of products from which to choose at the supermarket, consumers are exposed to a wealth of information on food package labels which can range from being fairly simple and straightforward to being downright confusing.

Despite predictions in past years that consumer interest in nutrition was a passing phase and taste would win out in the end, surveys still show that nutrition and health concerns join taste and convenience as the top factors in food choices. Witness also the endless stream of fad diets--and now websites--targeting people's health and food concerns.

Consumers and nutrition labelling

People want to know what is in their food. Surveys show that very high proportions of people believe it is important to have nutrition information on food packages (1). The Australia and New Zealand Food Authority (ANZFA) national consumer survey on food labelling (2) found that, depending on the type of food, one-quarter to one-half of people read nutrition information panels--more than one in two people surveyed read panels on breakfast cereals. In this survey 71% stated 'healthy product' was a factor in food choice and 97% claimed to read nutrition information panels at least once. As 80% of people make food purchase decisions at the point of sale (3), nutrition information panels can play a key role in those decisions for many people (4). Supermarkets are, therefore, an important place for influencing food choices.

The literature (5,6) indicates that factors associated with increased reading of labels are: being female; being over 35 years of age; having a higher educational level; eating a diet low in fat and high in fruits, vegetables and fibre; and being more health conscious and less likely to smoke.

Study findings also suggest that people with special needs and those who have been exposed to dietary advice are more likely to check labels for particular nutrition information.

A recent survey conducted through Diabetes Australia's Conquest magazine found that about 90% of the 633 respondents looked for fat and sugar content on nutrition information panels, two-thirds wanted to see glycaemic index on the label and more than half would prefer to see fat types, cholesterol and dietary fibre listed (Barclay A, Diabetes Australia, Sydney, 2001, personal communication).

In the USA (6), a survey of 885 patients from family medicine clinics found significantly more patients with high blood pressure looked for sodium content on the label (but were no more likely to look for other information) and patients with high blood cholesterol concentrations were more likely to look for saturated fat and cholesterol.

But an important question is whether the reading of panels influences the overall diet. One USA study (5) found a significant association between reading of labels and lower fat intakes. This does not necessarily mean that reading of labels led directly to lower fat intakes but it provides evidence that people who wish to lower their fat intakes are using labels to select lower fat foods and effectively to lower their overall fat intakes. Those who usually read labels had a significantly lower proportion of energy from fat (5% lower, adjusting for confounding factors) in their diets.

Other interesting findings from this study were that the key predictors of label use were the belief in the importance of having a low fat diet and knowledge of the relationship between diet and cancer. Those who believed in the importance of low fat intakes for health were ten times more likely to read the nutrition information panel and five times more likely to read the grams of fat on the panel. The most frequently read component of the label was grams of fat, followed by calories, percentage of calories from fat and cholesterol.

Clearly there is a valid role for nutrition information on labels to give people information to help them make food choices to suit their dietary needs.

The USA findings are consistent with earlier studies in Australia that showed that consumers were primarily interested in reading about fats, kilojoules, cholesterol and other 'negatively' perceived items such as additives, sugar, monosodium glutamate and irradiation (1). In one of these studies conducted in 1991 (1), health claims (which in this case was what we would now call nutrient claims) were ranked as the second most important item of health information for a food label, after additives. Several items that nutritionists consider of relevance such as starch, fibre, energy and protein were ranked as least important. According to researcher Tony Worsley, 'the problem for regulators is to adjudicate the conflicting interests of nutritionists, food technologists and various groups of consumers'. We would suggest that these results confirm the pressing need for more public education about dietary priorities and interpretation of nutrition label information.

With the AusDiab study (7) reporting that nearly one in four Australians have diabetes or are at risk of diabetes, and the diet-related conditions of heart disease and cancer accounting for most of the chronic disease in our community, there are compelling reasons to support mandatory nutrition labelling.

The Dietitians Association of Australia

The Dietitians Association of Australia (DAA) is the largest nutrition-focused body in Australia and the professional association of more than 2200 dietitians working in a range of areas including clinical dietetics, community and public health nutrition, private practice, food industry, education and research. With members working in a wide range of practice areas, DAA is able to bring a broadly-based expert view of the nutritional and public health implications of the nutritional labelling changes that are being introduced whilst maintaining an understanding of the implications for industry.

Part of DAA's mission is to advocate for better food, better health and better living for all. DAA promotes healthy eating by encouraging a wide variety of nutritious foods--including fruit and vegetables--and an understanding of nutritional balance. The association's priority in regard to food labelling is the protection of consumer interests in relation to nutrition information and claims.

Changes to nutrition labelling laws--the DAA perspective

The DAA position on the key aspects of nutrition labelling changes are presented below. All comments are based on the underlying objective that food labels should provide meaningful, accurate and non-misleading information to consumers to help them choose healthy diets.

While allergen labelling and health claims are important parts of the story about nutritional messages to the public, this paper is restricted to consideration of the new requirements for mandatory nutrition information panels, labelling of the percentage of key ingredients, and nutrient claims.

Dietitians, perhaps more than any other group, know how complex nutrition is and, therefore, recognise the considerable challenges that face manufacturers in bringing meaningful and accurate information to consumers and challenges that face consumers in interpreting the information with which they are provided.

In summary, the position of the association is that DAA:

* supports mandatory nutrition information panels;

* supports saturated fat but not sugar content information in the panel;

* believes the reference values for percentage daily intakes could be improved;

* would like to see percentage labelling for all major ingredients; and,

* supports the regulation of nutrient claims, with some modifications to claim definitions.

Nutrition information panels

DAA supports the provision for mandatory nutrition information panels on packaged foods. Dietary guidelines assist consumers to understand the importance of nutrition and the relationship of diets with better health and are the cornerstone of public health nutrition education. However, knowledge of a 'healthy diet' needs to be translated into food choices on a daily basis and, as mentioned before, most food purchase decisions are made at the point of sale. Taking a 'wholistic' or 'whole food' approach to food choices is not always easy, with a wide range of 'meal solution' type foods available and the emergence of more 'functional' and 'novel' foods, so nutrition panels help people with food choice decisions.

Coinciding with increased emphasis on nutrient content information, DAA would like to see significantly more public resources directed to nutrition education. This should include interpretation of label information, health and performance claims (if present), nutrient claims and nutrition panel information.

DAA is particularly pleased to see the introduction of mandatory labelling of saturated fat. It is appreciated that this brings the challenge for ANZFA to update the food composition databases on Australian foods to allow food manufacturers to include saturated fat figures by calculation.

However, with regard to mandatory labelling of total sugar, the DAA position is that this provision does not provide the most meaningful information to consumers. After many years of nutrition research we know that sugars are not strongly or uniquely linked with the major health problems that confront our society and that energy balance and saturated fat intake are higher dietary priorities. While the source of sugars has no bearing on the physiological response to them, consumers are still interested in sugar sources and declaring total sugar content does not address this. DAA believes more meaningful information about sugars would be provided if percentage labelling was required for all major ingredients rather than just the characterising ingredient. It is also important to recognise that the sugar content does not tell people with diabetes how a food affects their blood glucose concentrations. Unfortunately many people with diabetes still incorrectly use total sugar content as a guide to their food choic es.

Nutrition information panels are important, and it is accepted that people need more education to use them properly. One study from the USA (5) found that fewer than 39% of people read 'precentage daily value' on labels after its mandatory introduction in 1994. This is an area that needs special attention to help consumers properly interpret and use this information when present on food packages.

Information about the percentage of daily intake has the potential to be useful, as there are several ways that simple gram amounts on a nutrition information panel can be misinterpreted including the belief there is some sort of maximum amount of a nutrient (e.g. grams of fat) in any food that is acceptable, regardless of food type; the belief that small differences in grams are nutritionally significant when they are not (and due to natural variation in foods, or different analytical methods, etc); a disregard of qualitative aspects of nutrients such as type of fat, glycaemic index of carbohydrate foods; and failure to understand variability in people's needs such as energy requirements, requirements for athletes, and age and gender requirements.

The new regulations for Australia permit voluntary inclusion of information about the 'percentage of daily intake', and they specify reference intakes. While DAA supports the concept of defining reference values for consistency and simplicity, the values in Volume 2 of the Food Standards Code (8) are inconsistent with current recommendations for the proportion of macronutrients in a diet. The value for protein, in particular, is too low, for total carbohydrate is too high and for sugars is too low.

Nutrient claims

While consumers are increasingly seeking nutrition information and they report reading nutrition information panels, it is clear there is still a large proportion who experience difficulty interpreting the figures.

DAA believes that well defined and monitored nutrient content and comparative claims, such as 'high fibre', 'low fat' and 'reduced sodium' provide an opportunity to assist consumers to understand the role and relative nutritional attributes of products.

The USA experience was that, three years after the implementation of the Nutrition Labelling and Education Act in 1994, 39% of all products sold carried a nutrient content claim on the label (4). Reflecting the strong consumer focus on fat in recent years, nearly one in four of all products with nutrient claims had a claim related to total fat--the next most common claims were calorie-related claims and sodium claims (both on 7% of products). Fluid milk was the most common product with fat claims, followed by sandwich spreads and meat substitutes, refrigerated spreads and cereals.

For consistency and maximum compliance, DAA supports the regulation of nutrient claims within the Food Standards Code. Improvements in adherence to these definitions by food marketers should assist in reducing consumer confusion about some nutritional issues and reducing the likelihood of inadvertently misleading claims on food products. Additional resources for enforcement agencies will be necessary to increase compliance with regulations concerning nutrient claims and to reduce the current large numbers of breaches in the marketplace.

DAA also believes the current Code of Practice (9) definitions need some modifications including:

* removal of permission to use certain claims that are commonly misunderstood and/or lack nutritional significance such as 'x% fat free', 'low cholesterol', 'reduced cholesterol' and 'no added sugar';

* addition of more positive claims such as definitions for 'high protein', 'high carbohydrate' and 'source or good source of whole grains';

* 'low saturated fat' claims being allowed on foods that are not 'low fat';

* definition of the terms 'excellent', 'very high' and 'very low'; and,

* stricter requirements for the use o of the term 'light' - that is, to specify, in close proximity to the term, the characteristic in which the product is 'light'.

Nutritional science moves forward continuously, so it is also critical that the range and nature of definitions is reviewed regularly as further knowledge concerning the amounts of nutrients and bioactive sub stances in foods is available. This will allow meaningful definitions to be provided for substances, such as isoflavones and probiotics, that have high consumer awareness.

DAA also believes that it could be useful for ANZFA to consider the derivation of definitions of nutrient claims for specific food groups, including a range of separate claims for meal-type products. For example 'low fat' in relation to a meat product should not need to have as low a fat content as a 'low fat' cereal should have.

Percentage labelling

The position of DAA on percentage labelling is that more complete percentage labelling will provide consumers with more information to guide food choices. The Association suggests that if an ingredient is present at 5% or more of food weight, then its percentage must be declared.

The current requirement for percentage labelling of the characterising ingredient only is useful to help reduce false representations of products. However, it does not give consumers as much information (for example, about the source of sugars) as would be available from percentage labelling of main ingredients.

Opportunities and challenges

The new nutrition labelling regulations will provide consumers with more information about the composition of the foods they eat and have the potential to help them make more informed food choices. But information on food labels alone is not enough. using nutrient information is a reality in nutrition education, particularly for people with special dietary needs, but there is a place for both nutrition labelling and more wholistic nutrition education. Nutrition education needs to he evidence-based and consistent with the Australian dietary guidelines.

Such education should encompass not only the traditional approach of diet and health relationships but also: assessing nutrient content information and claims in the context of overall dietary pattern and health needs; getting the balance right, that is showing how to select a range of tasty and nutritious foods to create an eating pattern that will enhance health; and identifying priorities for achieving the best nutritional outcomes. The private sector, health professionals and government cam all play a role to maximise education opportunities.

The primary challenge for food manufacturers is to ensure that the information on food labels is accurate, deals with issues of relevance to public health, is not misleading and is well understood by consumers. As the owners of food labels, manufacturers face additional specific challenges that cannot be ignored, including the difficulties inherent in deriving nutrient content information; limitations of methodologies to measure nutrient content; natural variability in nutrient content; and sampling and analytical quality control. The biologically-active substances of relevance to consumers must be identified, and efforts to quantify them and decisions about their inclusion in the panel must be made. It must be ascertained what the product's characterising ingredient is. The nutritional benefits must be communicated without stepping into the realm of health claims. Development and provision of detailed information such as ingredient-free lists for health professionals to assist clients with special needs, s uch as coeliac disease, allergies and food intolerances, are additional challenges.

For health professionals, the main challenges--and opportunities--are to educate consumers on interpretation and use of labels in choosing a healthy diet; and to work with manufacturers to ensure label information is as accurate and meaningful as possible. Dietitians must acquire up-to-date knowledge of the new labelling laws in order to assist their clients to understand how to maximise the opportunities presented by this increased level of information. This is an area in which DAA hopes to assist its members with continuing education.

Dietitians can also become more proactive in identifying breaches of the regulations, or labels which they feel are potentially misleading, and bringing these to the attention of food manufacturers. Working together with industry to improve consumer understanding of food labels, diet and heath, and the role of food companies in providing this information, is an opportunity that has probably been under-realised to date.

In conclusion, DAA would like to call on ANZFA to ensure a knowledge base for future changes to food labels by closely monitoring consumer understanding as the new system comes into place, and evaluating the usefulness of labelling in helping people to select foods consistent with healthier diets. For effective evaluation, it is vital that baseline data are collected during the transition period. DAA would also like to see monitoring of the uptake by industry, and accuracy of nutrient claims following the new regulatory mechanism, whatever that may be.

Lastly, but probably most importantly of all, DAA urges health departments, federal, state and territory, to provide increased resources for nutrition education of the public. Not only do consumers need to understand key diet and health relationships but they also need to understand that all published nutrition and dietary advice is not necessarily based on sound science. Nutrition education should help people assess the credibility of information sources and should raise awareness of the best nutrition information sources such as DAA and other reputable nutrition organisations and information underwritten by Accredited Practising Dietitians in all environments-- media, government, non-government organisations, professional organisations and the food industry. Sound nutrition education is not an easy or inexpensive pursuit, but it is a vital tool for improving the health of Australians.

Acknowledgments

Assistance from members of the Dietitians Association of Australia Food Standards Advisory Committee, Peter Williams and Leigh Reeve, is acknowledged.

References

(1.) Worsley A. Which nutrition information do shoppers want on food labels? Asia Pac J Clin Nutr 1996;5:70-8.

(2.) Australia New Zealand Food Authority. National consumer survey on food labelling. Canberra: Australian Government Publishing Service; 1996.

(3.) Light L, Portnoy B, Blair JE, Smith JM, Brown Rodgers A, Tuckermanty E, et al. Nutrition education in supermarkets. Pam Community Health 1989; 12(l):43-52.

(4.) Brecher SJ, Bender MM, Wilkening VL, McCabe N, Anderson EM. Status of nutrition labeling, health claims, and nutrient content claims for processed foods: 1997 Food label and package survey. J Am Diet Assoc 2000;100:1057-62.

(5.) Neuhouser ML, Kristal AR, Patterson RE. Use of food nutrition labels is associated with lower fat intake. J Am Diet Assoc 1999;99:45-50,53.

(6.) Kreuter MW, Brennan LK, Scharff DP, Lukwago SN. Do nutrition label readers eat healthier diets? Behavioural correlates of adults' use of food labels. Am J Prey Med 1997;t3:277-83.

(7.) Diabesity and associated disorders in Australia 2000. The accelerating epidemic. Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Melbourne: International Diabetes Institute; 2001.

(8.) Australia New Zealand Food Authority. Food standards code volume 2. South Melbourne: Anstat; 2001.

(9.) National Food Authority. Code of practice--nutrient claims in food labels and in advertisements. Canberra: Australian Government Publishing Service; 1995.

This paper is based on a presentation on behalf of the Dietitians Association of Australia at the IBC Conference on Food Labelling, on 13 December 2001 in Sydney. It has not been subject to the Journal's normal peer review process.

T. Irwin, MPH, BSc, DipNutrDiet, APD, Chair, DAA Food Standards Committee

Correspondence: T. Irwin, 3 Kawana Street, Frenchs Forest, NSW 2086.

Email: [e-mail]