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Front-of-pack nutrition labelling systems: a missed opportunity?

In 2011, the US Institute of Medicine (IOM) called for a standardized, universal Front-of-Package (FOP) nutrition labelling system, "... that encourages healthier food choices through simplicity, visual clarity, and the ability to convey meaning without written information". (1) In 2007, the Canadian Standing Committee on Health called on "The federal government [to]: Implement a mandatory, standardized, simple, front of package labelling requirement on pre-packaged foods for easy identification of nutritional value". (2) However, despite expert consensus on the topic, Canada's Minister of Health dismissed these recommendations, stating that Canadian consumers already have "the tools they need to make healthy food choices when they shop for groceries". (3)

Addressing the burden of diet-related chronic diseases, such as obesity, cardiovascular disease and cancer, has received much attention, leading Canadian public health policy-makers to recommend priority interventions to improve the quality of dietary intakes. (4) FOP systems have been proposed as one such intervention and consist of symbols placed on a food package to provide summary information about the nutritional characteristics of foods. (1) While Canada has some regulated nutrition labelling tools, FOP systems are unregulated and a variety of systems are currently in use.

Below, we briefly review the effectiveness of current Canadian nutrition labelling tools (Table 1), using the nutrition labelling objectives articulated by Health Canada in the Food and Drug Regulations (Table 2), and offer a rationale for why a standardized FOP system should be explored as an additional, regulated food labelling tool.

Regulated food labelling tools

There are a number of existing food labelling tools in Canada, including the following.

Nutrient Content and Health Claims

Nutrient content claims are optional statements that communicate the amount of a given nutrient in a food (i.e., "Low fat"). A food must meet regulated levels of the nutrient to use such statements. (5) Such claims are based on one single nutrient and exclude criteria for other nutrients. For example, a product labelled "low sodium" could also be high in fat, sugar or calories. The other type of claim is diet-related health claims, which communicate the health-related benefits of consuming a product that contains a set amount of a nutrient. For example, to qualify for the claim "A healthy diet with adequate calcium ... may reduce the risk of osteoporosis", a product must contain at least 200 mg of calcium. As per government objectives, both types of claims are consistently worded and based on science; health claims are based on systematic, comprehensive reviews of human evidence of a relationship between a food component and a health effect. (6)

According to consumer research, nutrient content claims and health claims are the least-favoured form of information on food labels. Only 21% and 18% of Canadian consumers, respectively, look for nutrient content claims and health claims on food labels. (7) Indeed, participants in Canadian government-sponsored research reported that on-pack statements about nutritional content and/or product benefits were overrated, misleading, confusing, and the least useful information on the food label. (8) Furthermore, numerous studies examining the use of nutrition-related claims on the front of food labels have found that narrow claims (based on single nutrients) can lead consumers to incorrectly infer that a product is healthy and increase their purchase intentions. (1) These findings suggest that, contrary to their objectives, claims may be deceptive and limited in their ability to help consumers to make informed food choices.

Health professionals have raised concerns that the use of claims on food labels may prioritize food marketing over public health. (8) For instance, manufacturer emphasis on nutrients and claims related to heart disease excludes other important conditions like diabetes and obesity; or, "trendy" claims, like "low fat", exclude claims with broader public health significance, like "lower sodium".

The Nutrition Facts table (NFt)

The mandatory NFt is found on virtually all pre-packaged foods sold in Canada. (5) It presents information on the amount of calories and 13 core nutrients per serving of a food. The NFt also provides information on the contribution of a food to an individual's daily nutrient requirements, expressed as the Percent Daily Value (%DV). In accordance with its objectives, the standardized NFt allows comparisons among foods and greater compatibility with the US system.

Canadian data demonstrate that the NFt does not fully meet its intended objective of enabling consumers to make healthy food choices. (5) Although the majority of Canadians (71%) report using the NFt to support their food choices, (7) studies show that consumer use of nutrition labels is over-reported. (9) Furthermore, NFt use and understanding is not uniform across populations. For example, in the US, women were 2.49 times more likely to use the NFt than men, and college-educated Americans were 2.94 times more likely to use the NFt than those with a high school education. (10) These findings suggest that large segments of the population, including individuals with lower levels of education, are not benefitting from the information presented on the NFt. The NFt's disproportionate reach is particularly concerning as education and literacy, and closely related socio-economic status, are key determinants of health; health status improves with increasing levels of education, income, and social status. (11)

Recent Health Canada-commissioned research demonstrated that individuals had significant confusion concerning the numeric aspects of the NFt, including the %DV, serving size, and quantities for nutrients. (12) Canadians were also uncertain about how to interpret the %DV and contextualize it within the NFt. They were further confused by the use of multiple units (e.g., g, mg, %) to report nutrient amounts, and admitted that they lacked the basic nutrition knowledge required to interpret the NFt (i.e., what is a little or a lot of a nutrient?). These data are consistent with other studies, showing that nutrition knowledge and numeracy skills were major obstacles to the understanding of nutrition labels. (1,9) These findings agree with the IOM recommendations that simplified nutrition labelling, i.e., not requiring complicated nutrition knowledge or numeracy or literacy skills, may be better at guiding food choices.

Front-of-pack nutrition labelling systems

Considering the limitations of the NFt and claims, FOP systems have been proposed as an ideal means to achieve the core objective of nutrition labelling--enabling consumers to make informed food selections to reduce the onset of chronic disease. FOP systems are found on selected pre-packaged foods in Canada and provide summary information on the nutrition profile of a product. (1) Environmental scans have identified at least eight proprietary FOP systems in the Canadian marketplace, developed by manufacturers, food retailers, and nonprofit health groups, each with their own nutritional criteria. (13,14)

[FIGURE 1 OMITTED]

There are some data to suggest that FOP systems may promote healthier diets by encouraging consumers to make healthier choices and manufacturers to provide healthier offerings. Sales data from field experiments in supermarkets have shown that FOP systems influence consumer purchases. (1) Although data are limited in amount and scope, such studies give the best evidence of how FOP systems would operate in the real world. Moreover, studies have demonstrated that manufacturers enrolled in FOP programs improved the nutritional profile of their products in order to qualify to carry the FOP symbol. (15,16) However, since these studies did not include controls, it is unclear whether non-participating manufacturers similarly improved the nutritional quality of their products. While additional research is needed, FOP systems appear to be a promising intervention to improve the quality of dietary intakes.

In the most comprehensive review of FOP systems to date, the IOM concluded that symbols that are simple and easily understood are most effective at encouraging the selection of healthier foods. (1) While no single FOP system emerged as the 'best', the IOM drew on food package and marketing research to suggest an approach to FOP labelling that would be noticeable and accessible to a range of consumers. According to the IOM, a model FOP system would be simple (i.e., requires no nutrition knowledge to be understood), interpretive (i.e., provides guidance rather than information), and ordinal (i.e., uses a scaled or ranked approach) (Figure 1). Furthermore, the IOM found that a single, standardized FOP system is preferable to multiple, proprietary systems, based on data showing that the coexistence of multiple systems causes confusion among consumers and makes interpreting nutrition information and comparing products difficult. While informed by research, the IOM's approach is untested and would benefit from additional studies to confirm its effectiveness.

CONCLUSION

The use of a single FOP system in Canada could ensure that this tool is more consistent with the objectives of good nutrition labelling outlined by the Canadian government. A standardized FOP system would ensure that Canadians see a consistent symbol, one based on scientific criteria, which research suggests may enable consumers to select the healthiest foods. Furthermore, more individuals may benefit from a FOP system than from the NFt, if the FOP system did not require literacy, numeracy, or nutrition knowledge. Together, these data suggest that a standardized FOP system merits Canadian research and consideration as a potential intervention to enhance Canada's existing nutrition labelling tools.

Received: March 20, 2012

Accepted: May 21, 2012

REFERENCES

(1.) Committee on Examination of Front-of-Package Nutrition Ratings Systems and Symbols (Phase II), Institute of Medicine. Front-of-Package Nutrition Rating Systems and Symbols: Promoting Healthier Choices. Washington, DC: The National Academies Press, 2011.

(2.) The Standing Committee on Health. Healthy Weights for Healthy Kids. Ottawa, ON: Communications Canada, 2007.

(3.) Schmidt S. Aglukkaq pans U.S. nutrition recommendations. Postmedia News. 2011 October 20.

(4.) The Secretariat for the Intersectoral Healthy Living Network in partnership with the F/P/T Healthy Living Task Group and the F/P/T Advisory Committee on Population Health and Health Security. The Integrated Pan-Canadian Healthy Living Strategy. Ottawa: Minister of Health, 2005.

(5.) Government of Canada. Regulations Amending the Food and Drug Regulations. The Canada Gazette, Part II 2003;137(1):154.

(6.) Bureau of Nutritional Sciences. Guidance Document for Preparing a Submission for Food Health Claims. Ottawa: Health Canada, 2009.

(7.) Canadian Council of Food and Nutrition. Tracking Nutrition Trends VII. Mississauga, ON: Canadian Council of Food and Nutrition, 2008.

(8.) The Strategic Counsel. Consumer Understanding of Health Claims. Toronto, ON: Health Canada, 2009. Report No.: HC POR 8-16.

(9.) Cowburn G, Stockley L. Consumer understanding and use of nutrition labelling: A systematic review. Public Health Nutr 2005;8(1):21-28.

(10.) Blitstein JL, Evans WD. Use of nutrition facts panels among adults who make household food purchasing decisions. J Nutr Educ Behav 2006;38(6):360-64.

(11.) What makes Canadians healthy or unhealthy? Ottawa: Public Health Agency of Canada, 2003. Available at: http://www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php#unhealthy (Accessed May 5, 2012).

(12.) The Strategic Counsel. Focus Testing of Creatives for the Nutrition Facts Education Initiative. Toronto: Health Canada, 2010. Report No.: HC POR 09-16.

(13.) Reza Z. Defining "Healthy" Foods Environmental Scan of the Situation in Canada. Ottawa: Food Directorate, Health Canada, 2009.

(14.) Dietitians of Canada. Diabetes, Obesity and Cardiovascular Disease Network. Evidence-Based Background Paper on Point-of-Purchase Nutrition Programs. Dietitians of Canada, 2006.

(15.) Vyth EL, Steenhuis IHM, Roodenburg AJC, Brug J, Seidell JC. Front-of-pack nutrition label stimulates healthier product development: A quantitative analysis. Int J Behav Nutr Phys Act 2010;7.

(16.) Young L, Swinburn B. Impact of the pick the tick food information programme on the salt content of food in New Zealand. Health Promot Int 2002;17(1):13-19.

Teri E. Emrich, MPH, RD, JoAnne Arcand, PhD, RD, Mary R. L'Abbe, PhD

Author Affiliations

Department of Nutritional Sciences, University of Toronto, Toronto, ON

Correspondence: Mary R. L'Abbe, Earle W. McHenry Professor and Chair, Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, FitzGerald Building, Room 315, 150 College Street, Toronto, ON M5S 3E2, Tel: 416-978-7235, Fax: 416-971-2366, E-mail: mary.labbe@utoronto.ca

Acknowledgements: Stipend support to Teri Emrich funded by the Cancer Care Ontario and the CIHR Training Grant in Population Intervention for Chronic Disease Prevention: A Pan-Canadian Program (Grant #53893). Stipend support to JoAnne Arcand funded by CIHR Strategic Training Program in Public Health Policy. Additional funding from the Earle W. McHenry Research Chair Award to Mary L'Abbe.

Conflict of Interest: None to declare.
Table 1. Nutrition Labelling Tools in the Canadian Marketplace

                      Definition                 Examples

Regulated

Nutrition labelling   "Refers to the             Nutrition Facts table
                      standardized
                      presentation of the
                      nutrient content of a
                      food." (5)

Nutrient content      "A claim that describes    "Low calorie."
claims                the amount of a            "Trans fat free."
                      nutrient in a              "Reduced sodium."
                      food." (5)

Health claims         "A statement that          "A healthy diet with
                      describes the              adequate calcium
                      characteristics of a       and vitamin D, and
                      diet associated  with      regular physical
                      the reduction of the       activity help to
                      risk of developing a       achieve strong
                      diet-related disease       bones and may
                      or condition." (5)         reduce the risk of
                                                 osteoporosis.
                                                 (Name of food) is a
                                                 good source of
                                                 calcium." (5)

Unregulated

Front-of-pack         "Systems that use          Heart and Stroke
labelling systems     nutrient criteria and        Foundation's Health
                      symbols to indicate          Check[TM] logo
                      that a product has         Kraft's Sensible
                      certain nutritional          Solutions
                      characteristics.           Pepsi's Smart Spot[R]
                      Symbols are often          Whole Grains
                      placed on the                Council's Whole
                      principal display            Grain Stamp[TM]
                      panel of the product,      PC[R] Blue Menu[TM]
                      but may also be found
                      on the side, top, or
                      back panels or on self
                      tags." (1)

Table 2. Objectives of Regulated Nutrition Labelling Information in
Canada

                   Objectives (5)

Nutrition          * To enable consumers to make appropriate food
Facts table          choices in relation to reducing the risk of
                     developing chronic diseases and permitting
                     dietary management of chronic diseases of public
                     health significance.
                   * To encourage the availability of foods with
                     compositional characteristics that contribute to
                     diets that reduce the risk of developing chronic
                     diseases.
                   * To advance compatibility with the US system and
                     further work towards mutual acceptance by Canada
                     and the US of their respective nutrition
                     labelling requirements.
                   * To provide a system for conveying information
                     about the nutrient content of food in a
                     standardized format which allows for comparison
                     among foods and prevents consumers' confusion in
                     respect of the nutrient value and composition of
                     a food at   point of purchase.

Nutrient content   * To ensure that nutrient content claims for foods:
claims               --Enable consumers to make informed dietary
                       choices in order to prevent injury to health;
                     --Are consistent and not deceptive;
                     --Are based on recognized health and scientific
                       criteria; and
                     --Take into account the economic and trade
                       considerations where possible and when not in
                       conflict with health and safety criteria.

Diet-related       * To ensure diet-related health claims:
health claims        --Are useful to consumers in making informed
                       choices to prevent injury to health by reducing
                       the risk of developing chronic diseases;
                     --Are consistent and not deceptive;
                     --Are based on recognized health and scientific
                       criteria; and
                     --Describe the characteristics of a diet
                       associated with reduced risk of developing the
                       chronic disease identified in the health claim.
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Title Annotation:COMMENTARY
Author:Emrich, Teri E.; Arcand, JoAnne; L'Abbe, Mary R.
Publication:Canadian Journal of Public Health
Geographic Code:1CANA
Date:Jul 1, 2012
Words:2466
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