Wednesday, June 8, 2016

Food Labels – Do They Properly Inform Consumers?

The unsurprising and non-controversial role of food labels is to present the ingredients and elements of a food product both independently and in the context of dietary guidelines to ensure consumers are informed to what they are purchasing and how “healthy” the product. In the United States the National Labeling and Education Act (NLEA) in 1990 required the inclusion of nutrition information on packaged foods, with a few exceptions, and set the standard for how the information should be presented. This legislation was important because before the NLEA nutritional information was only required when producers wanted to make claims about specific nutritional benefits derived from consuming their product. However, the lack of standardization in presentation of nutritional information made it difficult to contrast and compare even when the information was available. Thus the famous standardized side panel conveying nutritional information for food products was born.

Interestingly enough very little has changed in the presentation and information of this standard U.S. labeling since the NLEA up until now. Recently the Food and Drug Administration (FDA) released information regarding how this food label would change by 2018; this news was met with cheers from some health circles and jeers from others. Overall the changes are rather uneventful with an increased font size for calorie count, elimination of calories from fat, more nuanced language for per serving and per package identifiers including more empirically based serving sizes, gram amounts in addition to percentages for vitamins (this change seems rather meaningless), Vitamin D and potassium switch required status with Vitamin A and C and more clarification regarding the % Daily Value footnote. The one supposed “big ticket” change is that labels are now required to breakdown the sugar content between natural sugars and added sugars.

The level of usefulness for the consumer within the divergence between natural and added sugars is questionable because without specifically breaking down the sugar content into its molecular complements: glucose, fructose, maltose, etc. the total sugar amount is still the only real meaningful piece of information. Knowing how much sugar was added versus how much sugar naturally occurs in the product is rather irrelevant regarding how the body will process it. Is someone really going to buy product A over product B because it has 28 grams of natural sugar versus 14 grams of natural sugar and 14 grams of added sugar? For some the answer will be yes, although most will not have a good reason why (the only real valid reason would be the contention that added sugars have a higher probability of being simple sugars and negative for health), but for most the answer will be no.

Some individuals could counter-argue that various groups like the AHA, AAP, WHO and Institute of Medicine have recommended decreasing intake of added sugars with general estimates that only about 10 percent of total daily calories should come from added sugar. While all of this is true, the problem is that differentiation between added sugar and natural sugar is more propagandized than meaningful. Again without differentiating between the specific molecules that make up the sugar content, total sugar is the only metric regarding sugar that actually matters. The propaganda stems from individuals promoting the reduced consumption of processed foods, which are more likely to have added sugars. Certainly it is true that added sugars do nothing positive to the nutritional content of the food, but again total sugar is what matters without specific differentiation.

The “debate” about added vs. natural sugar aside, in reality this new label certainly falls short of Michelle Obama’s endorsement “you will no longer need a microscope, a calculator, or a degree in nutrition to figure out whether the food you’re buying is actually good for our kids…” It is difficult to support the accuracy of that statement based on the changes; a sentiment shared by many other individuals who think the food labeling requirements should have been much more substantial.

For example applying the labeling itself is only a part of the battle for the information on the label is only meaningful when consumers read and understand it. There is some question to whether or not the label needs to change for studies have demonstrated that while a vast majority of individuals in the U.S. read food labels, this information does little to influence their food choices.1-3 However, in the EU, which has a more intensive and thorough labeling system, food labels do influence consumer choice.4

While it is difficult to directly determine if the critical factor in this difference in behavior is born from the food labeling methodologies due to cultural differences between the U.S. and the EU, it is also difficult to dismiss the differing labeling strategies as playing an influencing factor. The key difference between the two labeling systems is that the U.S. system places a greater emphasis on the consumer to understand the nutritional context of both product A and how it may differ from the nutritional context of product B versus the more categorized labeling system of the EU in general.

For example in the UK labeling follows four core principles enumerated by the UK Food Standards Agency (FSA) for front of the package:5,6

1) Separate information must be provided on fat, saturated fat, sugars and salt; (this is also a guideline in the U.S. via Facts Up Front, but it is a voluntary program)

2) A red, amber or green color coding, similar to traffic lights, must be utilized to indicate whether the levels of those elements outlined in the first principle are high, medium or low respectively per 100 g (or ml for liquids) of product content;

3) Color metrics are established by nutritional criteria set forth by the FSA;

4) Provide portion ratios relative to the elements outlined in the first principle for color coding;

When this proposal was first made in 2006 there was significant resistance regarding the traffic light identification system as numerous food manufactures and producers questioned the use of the traffic light system and instead favored more of a U.S. style system using percentage of daily recommended values.5 Furthermore food manufactures also disagreed with the use of 100 g/ml as a standard invoking the argument that consumers think more in portions of the consumed product. It would be difficult for consumers to deduce a gram weight-based portion size. This complaint produced an alternative system using the needlessly large number of portion sizes by various food products creating a much more difficult comparison environment for consumers; such was ironic because it produced the result that was exactly the rational used by food companies to argue against the 100 g/ml standard, an overly complicated system.

Regardless of the bumpy road to establishing a universal labeling system and the lack of ideal standardization in the UK (note the confliction between points 2 and 4 from above), numerous studies have demonstrated that front of the package simple signal (like color coding) labeling of the “healthiness” of a food product does influence consumer choice both by increasing the probability that the customer purchases healthier products and increasing the probability that food producers create healthier products;7-10 also traffic light systems have proven superior to other systems like single compounded numbers or guiding star type systems.8,11 Therefore, clearly creating regulations regarding the nutritional or “health value” of a food for the front of the package is a meaningful step to increasing the probability of an informed consumer.

Part of the battle for the front of the package (FOP) is not just to produce a standardized system to convey the health of the product, but to ensure genuine portrayal of the product itself. For example advertising for some food products tends to mislead consumers that the product may contain a larger quantity of a component than in reality. Such is common with fruit juice products; for example in an attempt to draw attention away from the top ingredients commonly being concentrated water and high fructose corn syrup with pictures of fruit. One means that helps support such trickery is that ingredients are only listed in order of percent amount, but the percentages are not given. Actually requiring the percentages may help limit the impact of this type of advertising.

Ensuring proper labeling design is important because studies have demonstrated that simple, transparent and clear labeling engage subconscious emotional elements in the brain including the amygdala.12-14 Therefore, the FDA may need to properly regulate front of the box labeling because the side panel may be at a psychological disadvantage to the “health proclamations” that commonly adorn the front of the box in stylized and eye-catching presentations.

In the past some parties have acknowledge the importance of the front of the box and lamented the U.S. government’s acquiescence of its power to corporations. These parties have proposed taking back the front of the box in such a way to “inform” consumers of whether or not their choice is a healthy one. For example one proposal is that the upper right portion of the box should contain the three most prevalent ingredients in the product, the calorie count and the number of total ingredients beyond those first three in bold and clear font.15

The proponents of such a system believe that it will produce a fast means for consumers to identify healthy food versus unhealthy food that is so easy it is impossible to ignore. However, the problem with such a system is that it can be easily manipulated where producers can fine-tailor their produces where 3 seemingly healthy ingredients can be the 3 most plentiful ingredients by an incredibly small amount before the “unhealthy” ingredients.

Also calorie counts in such a system would have to identify serving size to be placed in proper context and even then such counts may prove to complicate the issue. Note that the above proposition suggests posting the calories per serving on the front of the package. However, if all similar products do not have standardized serving amounts (all listing 100 grams for example vs. ½ cup or 8 to a box) then listing the calories is not simplistic strategy to optimize food choices on the basis of health. Varying serving amounts force the consumer to undertake some general arithmetic. For example suppose Cereal A has 120 calories per ½ cup (10 servings) and Cereal B has 160 calories per ¾ cup (7 servings), front of the box labeling would imply that Cereal A has fewer calories, but that is not the case in either equivalent serving calories or total calories for the entire box. Therefore, front of the package labeling must be less simplistic unless a standardized serving metric is established. Facts Up Front suffers from this serving difference problem limiting its effectiveness.

The possible problems with the above differing option notwithstanding, it is clear that the EU, including the U.K., has a better labeling system than the U.S. with regards to helping consumers acquire and understand nutritional information. So why does so little change in the “updated” U.S. labeling system? Most would argue, probably correctly, that lobbying by food companies prevents the FDA from going further thanks to interference from Congress. If the FDA had the “freedom” to make any changes what changes should they make?

Obviously it is important for there to be some form of comparison information that goes beyond Facts Up Front. A traffic light system certainly holds promise due to its successful application in the UK. However, it is understandable that food companies would balk at such a condition, especially those with significant “red” light products. The proper response to such complaints is two-fold: first, who cares if the food companies have complaints again the proper utilitarian construct of ensuring transparent information. Second, one could attempt to lessen the impact of the traffic light system in the context that a primarily “red” food should not be viewed as something that should never be consumed, otherwise no one would ever eat something like a piece of cheese cake, but instead a food that should be consumed rarely in the context of good health. Thus, the green, yellow and red lights simply transition into anytime, once-a-day and rare, food choices.

Another interesting idea would be to establish a standardized declaration system for the front of the package involving commonly referred health terms against an empirically derived metric. Basically it is commonplace for food producers to put labeling on the front of a package that states: “high in fiber”, “low sodium”, “x number of essential vitamins and minerals”, etc. This newly proposed system would eliminating that ability of food producers to make such claims and instead replace this system with a five or six bullet point checklist in the upper right corner of the package confirming a given “positive health feature”. A check would be earned by meeting a standard floor or ceiling for the given attribute per 100 g of product; where the FDA would establish the standard. For example the “high fiber” box would be checked if a food contained 3 grams of fiber per 100 g of product, not checked otherwise. Five possibilities for such a checklist are shown below.

1) High Fiber;
2) Low Sodium;
3) Whole Grain;
4) Low Sugar;
5) Low Saturated Fat

In the end both of these strategies: the traffic lights and the checkbox, should significantly increase the probability that consumers are informed about the general nutritional value of their food product choices without an unreasonably long analysis period. Overall there is no good reason that the FDA and its surrogates should not establish and enforce such a labeling system.

Citations –

1. Cha, E, et Al. “Health literacy, self-efficacy, food label use, and diet in young adults.” Am. J. Health. Behav. 2014. 38(3):331-339.

2. Campos, S, Doxey, J, and Hammond, D. “Nutrition labels on pre-packaged foods: a systematic review.” Public Health Nutr. 2011. 14(8). 1496-1506.

3. Huang, T, et Al. “Reading nutrition labels and fat consumption in adolescents.” J. Adolesc. Health. 2004. 35(5):399-401.

4. Storcksdieck, G, and Wills, J. “Nutrition labeling to prevent obesity: reviewing the evidence from Europe.” Curr Obes. Rep. 2012. 1(3):134-140.

5. Lobstein, T, and Davies, S. “Defining and labelling ‘healthy’ and ‘unhealthy’ food.” Public Health Nutrition. 12(3):331-340.

6. Food Standards Agency. Board Agrees Principles for Front of Pack Labelling. 2006. Food Standards Agency.

7. Lobstein, T, Landon, J, and Lincoln, P. “Misconceptions and misinformation: the problems with guideline daily amounts (GDAs). A review of GDAs and their use for signaling nutritional information on food and drink labels.” National Heart Forum. 2007.

8. Temple, N, and Fraser, J. “Food labels: a critical assessment.” Nutrition. 2014. 30:257-260.

9. Hersey, J, et Al. “Effects of front-of-package and shelf ntrition labeling systems on consumers.” Nutr. Rev. 2013. 71:1-14.

10. Hawley, K, et Al. “The science on front-of-package food labels.” Public Health Nutr. 2013. 16:430-439.

11. Sutherland, L, Kaley, L, and Fischer, L. “Guiding Stars: the effect of a nutrition navigation program on consumer purchases at the supermarket.” Am. J. Clin. Nutr. 2010. 91:1090S-1094S.

12. Grabenhorst, F, et Al. “Food labels promote healthy choices by a decision bias in the amygdala.” NeuroImage. 2013. 74:152-63.

13. Pessoa, L, and Adolphs, R. “Emotion processing and the amygdala: from a ‘low road’ to ‘many roads’ of evaluating biological significance.” Nat. Rev. Neurosci. 2010. 11:773-783.

14. Seymour, B, and Dolan, R. “Emotion, decision-making, and the amygdala.” Neuron. 2008. 58:662-671.

15. Kessler, D. “Toward more comprehensive food labeling.” N. Engl. J. Med. 2014. 371(3):193-195.

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