1. health and fitness
2. nutrition

1
Front of Pack Nutrition Labelling:
An Emerging Global Perspective
in Public Health Nutrition
CSPI Webinar – Nutrition Labelling for
Public Health Impact
Aril 23, 2015
Mary R. L’Abbé, PhD
Earle W. McHenry Professor and Chair
and Teri Emrich, PhD
Background
2
Burden of diet-related chronic disease1


Account for 60% of deaths worldwide2
Unhealthy diet is a preventable risk factor
 Individuals and
populations should limit1,3:
 Total calories
 Saturated
and trans fat
 Sugar
 Salt
1. WHO. Diet, Nutrition and the Prevention of Chronic Disease (2003); 2. WHO. Preventing chronic diseases: a
vital investment. 2005.; 3. WHOWHO. Global Strategy on Diet, Physical Activity and Health (2005)
Nutrition Information on Foods


A hierarchy of information
about nutrition.
To help consumers make
food choices that will
enhance health and reduce
risk of chronic disease.
Health
Claims
(e.g. SF, Trans
and CVD)
Nutrient
Content Claims
(e.g. high fibre, fat-free)
Nutrition Labelling
(e.g. the Nutrition Facts Table)
Adapted from:
GUIDELINES ON NUTRITION LABELLING
GENERAL STANDARD FOR THE LABELLING OF PREPACKAGED FOODS
GUIDELINES FOR USE OF NUTRITION AND HEALTH CLAIMS
HEALTH CANADA PRESENTATIONS ON NUTRITION LABELLING
4
Countries with Nutrition
Labelling
“Consumers
require accurate,
standardized and
comprehensible
information on
the content of
food items”
-WHO, 2005
Source: EUFIC. Global Update on Nutrition Labelling. 2013
Objectives of Nutrition Labelling
5
Nutrition Facts table




Enable food choices that prevent and/or manage
chronic disease
Standardize presentation to↓ consumer confusion
Allow comparisons among foods at point of
purchase
Support healthier product reformulations
Government of Canada. The Canada Gazette, Part II. 2003
Is Canada meeting these objectives with
current nutrition labelling regulations?
6


Use of Nutrition Label hampered by:

Numeracy challenges

Confusing use of units: %DV, g, mg,

Serving size use and understanding

↓ nutrition knowledge

Can’t interpret the information

Nutrients to limit/encourage not clear
Product reformulation NOT evaluated
The Strategic Counsel. Focus testing of creatives for the nutrition facts education initiative. 2010.
7
FOP labelling –
Can it be a complementary
public health strategy?
Simplified information on the key
nutritional aspects/characteristics of
foods
Types of Front-of-Pack Nutrition
Labelling Systems
8
Nutrient-specific
Summary indicator
Food group information
Basis Underlying different Front-ofPack nutrition labelling systems
9


Fact-based information on
nutrient or food group
content, OR
Meets a nutritional standard
 Qualifying
or disqualifying
threshold criteria
 Relative criteria, i.e. “reduced”
compared to reference, OR

Evaluative or Interpretative
 Ordinal
rating scale, or
 Stars/Colours
Usually for summary systems
Nutrient Profiling – a KEY system
used to set nutritional standards
10
Classification based on nutritional composition 5,7,8
 Considerations:
 Purpose
and target audience,
 Application of criteria (e.g. by category or across the
board?)
 Which nutrients included (e.g. Nutrients to limit
and/or Nutrients to encourage?)
 Reference amount (per serving or per 100 g?)
 Type of model (e.g. thresholds or algorithms?)
 The scientific basis for used criteria (e.g. nutrition
recommendations, DRIs, “better than” etc)
5. IOM. Examination of Front-of-Pack Nutrition Rating Systems and Symbols: Phase 1 Report, 2010; 7. Lobstein & Davies.
Public Health Nutr, 2009, 12(3), 331-340; 8. Stockley. Review of ‘front-of’pack’ nutrition rating schemes, 2007.
Nutrient Profiling System
11
The “science of classifying or ranking foods according to their
nutritional composition for reasons related to preventing disease
and promoting health” [WHO]
Healthy
Unhealthy
Nordic keyhole
Regulatory Applications:
• Front of pack labelling
• Health claims
• Advertising of unhealthy
foods to children
• Food compositional
UK FSA/Ofcom
standards/regulations
model
• Food taxes or subsidies
FOPS in Canada? Food Label
Information Program (FLIP)
12
Food Label Information Program (FLIP)
 Cross-sectional analysis of pre-packaged food
labels in the Canadian marketplace
 Collected
 From
 All
in 2010-2011 and again in 2013
top 4 Canadian grocery retailers (75% of sales)
national and house brands with a NFt collected
 >26,000
foods from 22 food categories
Schermel et al, APMN 2013
Food Label Information Program
13
Data
recorded in
FLIP
14
Nutrition Marketing Appears on
48% of Food Packages
18%
(2011)
Schermel et al, APMN 2013
158 unique FOPS were identified
15
Category
# of symbols Examples
Nutrient-Specific
Systems
80
Summary Indicator
Systems
11
Food Group
Information Systems
47
Hybrids
20
Schermel et al, APMN 2013
Summary Indicatory Systems were
the most prevalent FOPS style
16
Schermel et al, APMN 2013
Current Situation in Canada
17

FOP labelling not addressed in the
recent Health Canada consultation
document on Nutrition Labelling,
despite consumers’ desire for
Interpretive Labelling
You could colour-code labels or give letter grades for meeting or exceeding
dietary requirements.”
“Create a universal grading system for consumers to know if a food is a
‘choose most often’ or ‘choose sometimes’ food.
The Evidence for FOP systems as
a public health strategy
18
Potential to improve dietary intake and reduce
diet-related chronic disease 1-3
1. Help consumers select healthier foods?
2. Stimulate healthy product development and
reformulation by manufacturers?
1. The Standing Committee on Health, Healthy Weights for Healthy Kids, 2007; 2. IOM. Examination of Front-of-Pack Nutrition Rating
Systems and Symbols: Phase 1 Report, 2010; 3. Stocklet, L. Review of ‘front-of-pack’ nutrition schemes, 2007
1. Helps consumers select
healthier foods
19
27
Mean number of correct healthier choices
25
23
21
19
No label
Tick
Traffic Light
GDA
Coloured GDA
17
15
Borgmeier and Westenhoefer, 2009
Help consumer select healthier
foods?
20

Self-Reported consumer studies (11, 2 with focus groups)


Observational consumer studies (9)


Sales data before and after introduction of FOP program
Reformulation studies (3)


Data: supermarket observations, grocery receipts, …
Sales studies (2)


Consumer surveys on understanding and use of FOPs;
Effects of FOP on product reformulation; most self report by manufacturers
Health Outcome studies (4)

Estimated effects of FOP on nutrient intakes or health outcomes using national
food databases and population intake survey data
Vyth et al, Nutrition Reviews 2012
2. Stimulates product reformulation
and new product development
21
Vyth et al. Int J Behav Nutr Phys Act, 2010, 7(65)
22
Problems with Current
Voluntary and Unregulated FOP
System in Canada
1. Many more Foods Qualify than
Carry symbol, e.g. Health Check
23
100%
80%
60%
Qualify
†
†
†
Carry
†
†
†
40%
†
20%
0%
All Products Vegetables
and Fruit
Grain
Products
Milk and
Meat and
Alternatives Alternatives
Oils and
Fats
Combination
Foods
† Differ significantly from the proportion of food products carrying the front-of-pack symbols p<.01.
2. Foods with FOP symbols do NOT
have superior nutrient profiles
24
Food Category
FOP
status
N
Calories (kcal)
Median [Q1, Q3]
Saturated fat (g)
Median [Q1, Q3]
Sodium (mg)
Median [Q1, Q3]
Sugar (g)
Median [Q1, Q3]
Bakery Products
No
1254
144 [120, 183]
1.2 [0.3, 3.4]
169 [91, 250]
6 [1, 13]
Yes
382
126 [91, 140]
0.5 [0.3, 1.3]†
148 [92, 205]
2 [1, 8]†
Cereals and Other Grain
Products
No
548
300 [164, 302]
0.2 [0.0, 0.3]†
1 [0, 57]†
2 [1, 4]†
Yes
229
209 [156, 300]†
0.3 [0.2, 0.5]
109 [2, 200]
6 [3,11]
Combination dishes
No
852
300 [230, 340]
3.0 [1.3, 4.7]
709 [509, 880]
4 [2, 7]†
Yes
192
261 [212, 295]
1.5 [0.7, 2.5]†
561 [468, 660]
5 [3, 9]
Dairy Products and
Substitutes
No
741
109 [81, 130]
3.5 [1.5, 6.0]
160 [100, 220]
1 [0, 9]†
Yes
98
110 [84, 132]
1.5 [0.4, 3.2]†
126 [100 ,210]
7 [1, 14]
Fats and Oils
No
395
80 [70, 100]
1.0 [0.8, 2.0]
120 [0, 300]
0 [0, 2]
Yes
81
70 [35, 80]
1.0 [0.3, 1.0]
135 [70, 260]
0 [0, 2]
No
611
120 [100, 130]
0.0 [0.0, 0.0]
10 [0, 25]†
25 [21, 29]
Yes
189
120 [86, 130]
0.0 [0.0, 0.0]
20 [6, 35]
25 [19, 28]
Meat, Poultry, Their
Products and Substitutes
No
557
147 [90, 223]
2.9 [1.1, 4.9]
522 [425, 640]
1 [0, 1]
Yes
86
127 [91, 154]
0.6 [0.4, 1.5]†
356 [256, 437]†
1 [0, 1]
Snacks
No
384
260 [230, 270]
1.5 [1.0, 3.0]
288 [151, 390]
2 [0, 3]
Yes
87
214 [179, 240]
0.7 [0.0, 1.3]†
233 [74, 360]
2 [0, 4]
No
244
90 [60, 150]†
0.5 [0.0, 1.5]
740 [650, 898]
2 [1, 4] †
Yes
90
120 [90, 150]
0.5 [0.2, 1.0]
625 [480, 650]
4 [2, 7]
No
489
25 [16, 40]
0.0 [0.0, 0.0]
180 [34, 290]
2 [0, 4] †
Yes
134
30 [20, 50]
0.0 [0.0, 0.0]
71 [15, 290]†
3 [1, 5]
Fruits and Fruit Juices
Soups
Vegetables
Emrich et al, Appetite 2014
Consumer Understanding and Use
of FOP - Mock Package Experiment
25
5X2
No
FOPS
No
NFT
1
2
3
4
5
NFT
6
7
8
9
10
Emrich et al., App Physiol Nutr Metab 2014
Mock Packages
26
27
5
Foods with a FOP symbol perceived as
healthier with no NFt
4
a
3
bcd
cd
2
1
ab
cd
cd
bc
cd
cd
d
No NFt
NFt
No FOP
system
Emrich et al. Appl Physio Nutr Metab. 2014.
Liking
28
Nutrition Facts table
conditions
5
No Nutrition Facts table
conditions
Mean rating
4
3
2
1
0
a
No FOP
systems
c
c
b
b
Not rated
No FOP
systems
b*
b
a
a
Credibility
29
5
No Nutrition Facts table
conditions
Nutrition Facts table
conditions
Mean rating
4
3
2
1
0
a
No FOP
c
d
c
b
Not rated
No FOP
b*
c
b
a
Most Canadians support a single,
mandatory FOP symbols for Canada
30
Q. In your opinion there should be:
9%
5%
A single, mandatory FOPS*
8%
A single, voluntary FOPS
Multiple FOPS
No opinion
78%
n=3029 (missing 92)
*p<.0001
Emrich et al. Appl Physio Nutr Metab. 2014.
Preferred FOP system format
31
60
Percent of Respondents
50
40
(n = 2924)
30
20
10
0
None of the
above
Emrich et al. Appl Physio Nutr Metab. 2014.
32
Effectiveness of FOPS formats –
Varies widely by country
4.4
4.2
4
Mean score
No FOPS
has been
consistently
found most
effective
across
studies.
3.8
3.6
3.4
UK
Germany
Italy
Netherlands
Overall mean
3.2
3
Adapted from: Feunekes et al Appetite, 2008;50
Thank You - Questions!
33
Mary R. L’Abbe, PhD
Department of Nutritional Sciences
Faculty of Medicine, University of Toronto
FitzGerald Building, 150 College Street
Toronto, ON, Canada M5S 3E2
mary.labbe@utoronto.ca
Acknowledgements