Nutrient-Content Claims — Guidance Or Cause for Confusion? Allison C

PERSPECTIVE Toward More Comprehensive Food Labeling

Figure 2. Possible New Front-of-Package Labeling.

with little more than fat, sugar, powerful impact not only on con- 2. Supermarket facts: industry overview 2012. Arlington, VA: Food Marketing Institute and salt. sumer behavior, but perhaps more (https://www.fmi.org/research-resources/ That won’t be easy. The food important, on the decisions man- supermarket-facts). industry is expert at promoting ufacturers make about the foods 3. Todd JE, Variyam JN. The decline in consum- er uses of food nutrition labels, 1995-2006. its food in a captivating manner, they create for the marketplace. Washington, DC: Department of Agriculture so the FDA has very heavy com- Disclosure forms provided by the author Economic Research Service, August 2008. petition for the consumer’s eye. are available with the full text of this article 4. Proposed changes to the Nutrition Facts at NEJM.org. label. Silver Spring, MD: Food and Drug But we are riding a tide of Administration (http://www.fda.gov/Food/ change, with obesity experts in- From the Departments of Pediatrics and GuidanceRegulation/GuidanceDocuments creasingly recognizing the value Epidemiology and Biostatistics, School of RegulatoryInformation/LabelingNutrition/ of healthy eating and consumers Medicine, University of California, San Fran- ucm385663.htm). cisco, San Francisco. 5. Nestle M. IOM releases tough report on eager to make smarter food front-of-package labeling. Food Politics blog, October 20, 2011 (http://www.foodpolitics choices. A revised Nutrition Facts 1. Kessler DA, Mande JR, Scarbrough FE, .com/2011/10/iom-releases-tough-report-on Schapiro R, Feiden K. Developing the “nu- label combined with a stream- -front-of-package-labeling). lined, comprehensible ingredient trition facts” food label. Harvard Health Policy Review 2003;4:13-24 (http://www.hcs DOI: 10.1056/NEJMp1402971 list and trustworthy front-of- .harvard.edu/~epihc/currentissue/fall2003/ Copyright © 2014 Massachusetts Medical Society.

iStockphoto.com/padnpen/Kevin Grady/Elizabeth Drye package labeling can have a kessler_et_al.pdf).

Nutrient-Content Claims — Guidance or Cause for Confusion? Allison C. Sylvetsky, Ph.D., and William H. Dietz, M.D., Ph.D.

utrient-content claims, such ulated in accordance with spe- United States presented such Nas “sugar-free,” “high in oat cific requirements of the Food nutrient-content claims.1 The prev- bran,” or “contains 100 calories” and Drug Administration (FDA). alence of these claims has in- — any “claims on a food prod- According to the 2000–2001 creased in recent years,2 as the uct that directly or by implica- Food Label and Package Survey food and beverage industry has tion characterize the level of a (FLAPS), half of all packaged launched myriad new products nutrient in the food” — are reg- foods and beverages sold in the to offer palatable, lower-calorie

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Definitions of Sugar- and Calorie-Related Nutrient-Content Claims and Examples of Nonnutritive-Sweetener–Containing Foods and Beverages Bearing Each Claim.*

Claim Definition Example Sugar-free <0.5 g of sugar per RACC and per labeled serving Sugar-free strawberry preserves Sugar-free instant pudding No sugar added No sugar or sugar-containing ingredient added during processing; does not No-sugar-added canned peaches include sugar alcohol No-sugar-added ice cream Reduced or lower sugar ≥25% less sugar per RACC than an appropriate reference food (or for meals and Reduced-sugar tomato ketchup main dishes, ≥25% less sugar per 100 g) Lower-sugar oatmeal Low sugar Not defined; may not be used Not applicable Light If ≥50% of the calories in an appropriate reference food are from fat, fat must be Light lemonade reduced by ≥50% per serving; if <50% of calories in the reference food are Light yogurt from fat, fat must be reduced by ≥50% or calories reduced by at least one Light English muffins third per serving Low calorie ≤40 kcal per RACC (and per 50 g if RACC is small; for meals and main dishes, Low-calorie syrup ≤120 kcal per 100 g) Low-calorie gelatin snacks

* Definitions are from the Food and Drug Administration (FDA; www.fda.gov/food/guidanceregulation/guidancedocumentsregulatory information/labelingnutrition/ucm064911.htm). RACC denotes reference amount customarily consumed.

alternatives to full-calorie items. It’s important to recognize labeled as low-fat, negating any Many new products, regardless that providing children with difference in caloric intake per of their actual nutritional value, sugar- or calorie-modified foods volume. Similarly, sugar- and make sugar- and calorie-related and beverages will not necessar- calorie-related claims on foods claims that appeal to consumers ily reduce their caloric intake or and beverages may lead parents (see table). risk of obesity or improve their to underestimate the products’ Concurrently, the FDA is con- long-term health. Research has energy content and allow their sidering changes to the Nutrition shown that consumers perceive children to consume more than Facts label to help consumers foods and beverages labeled with they otherwise would. In effect, make healthier choices. The pro- nutrient and health claims as the calories assumed to be “saved” posed changes will update serv- “healthier” than foods without by providing a sugar- or calorie- ing sizes, specify added sugar such claims,3 yet many of these modified alternative will be negat- content, and prominently high- products are heavily processed ed if children consume greater light the number of calories per and may not produce health ben- quantities of these highly pro- serving and the number of serv- efits. The presence of front-of- cessed yet seemingly healthier ings in a container. However, they package nutrient and health claims items. do not address nutrient-content reduces the likelihood that con- Moreover, reducing sugar intake claims or ingredient lists. We be- sumers will pay attention to the by selecting sugar- and calorie- lieve that if we are to improve detailed Nutrition Facts label dis- modified alternatives will not consumers’ — especially parents’ played on the back of the package.3 necessarily promote a more nutri- — understanding of nutrient and Sugar- or calorie-modified tious or less sweet diet. Although calorie content, other labeling products usually contain fewer sugar- and calorie-modified prod- changes are necessary to support calories per serving than their ucts contain less sugar than their consumers in selecting whole- counterparts. But factors other counterparts, the use of nonnutri- some and nutritious foods and than calories influence the quan- tive sweeteners in these prod- beverages; one key concern is tity consumed and ultimately the ucts may still foster the develop- sugar- and calorie-related claims, total calories ingested. For exam- ment of a “sweet tooth” because especially with regard to non­ ple, we have long known about nonnutritive sweeteners are hun- nutritive sweeteners and product the “low-fat phenomenon” where- dreds of times sweeter than table sweetness. by people overconsume snacks sugar by weight. Studies in ani-

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mals and preliminary data from content claims,4 most parents into 100 mg of sucralose for an humans suggest that exposure to reported strikingly negative atti- average-weight 6-year-old boy sweet taste early in life promotes tudes toward giving their children (weighing approximately 20 kg); long-term preferences for sweet foods containing nonnutritive this ADI would be met by the in- foods and beverages. The contri- sweeteners. Yet the same parents take of 1.5 cans of an average bution of sweet (and often high- preferred sugar-modified products, sucralose-sweetened soda (60 to calorie) foods and beverages to which often contained nonnutri- 70 mg per 12-oz [355-ml] can), a excess energy intake and obesity tive sweeteners. Parents’ selection quantity of sweetened beverage has been well described. Nutrient- of foods and beverages contain- that is frequently exceeded by content claims such as “sugar- ing the precise ingredients that children in this age group. free” and “no sugar added” offer they report avoiding was also Whereas U.S. consumers can- a seemingly easy solution for seen in the Sweetener360 study not easily obtain detailed infor- parents who want to avoid sugar- (www.cornnaturally.com/Sweetener mation about nonnutritive sweet- laden snacks and soft drinks, yet -360) and indicates that despite eners, Canada, for example, has surprisingly, such products are labeling efforts, parents often do regulations requiring a statement often sweeter than their sugar- not understand what they are se- on the front of a food or bever- sweetened counterparts. lecting. age package indicating that it Nonnutritive sweeteners and The FDA requires that the in- contains one or more nonnutri- other food additives are docu- gredient lists of all nonnutritive- tive sweeteners (e.g., “contains mented on the ingredient lists of sweetener–containing products in- aspartame”). In addition, Cana- packaged foods, but their chemi- clude the specific sweetener name, dian regulations require that the cal names may not be recognized but the amount that has been amount of the sweetener or even by educated consumers. added to the product remains sweeteners expressed in milli- Furthermore, parents may choose proprietary information. Thus, grams per serving and a state- “lower-sugar oatmeal” or “no- even if motivated parents have ment describing the sweetness sugar-added canned fruit” for explored the acceptable daily in- per serving, expressed as the their children under the assump- take (ADI) of a particular non- amount of sugar needed to pro- tion that these products contain nutritive sweetener (the amount duce an equivalent degree of less sugar than the alternatives, that can be ingested daily over a sweetness, be present on the pack- but they often do not realize that lifetime without appreciable risk), age and grouped with the ingre- such products frequently contain they cannot determine how much dient list.5 nonnutritive sweeteners — typi- cally, sucralose and acesulfame In our pilot study of parental selection potassium. Most consumers are also unaware that foods and bev- of grocery items bearing sugar-related erages may contain ingredients that counterbalance sweetness nutrient-content claims, most parents (e.g., the sweet-taste–receptor an- reported strikingly negative attitudes toward tagonist lactisole). Thus, even the most health-conscious parent may giving their children foods containing not understand the information provided in ingredient lists and nonnutritive sweeteners. Yet the same may rely instead on short and parents preferred sugar-modified products, uncomplicated nutrient-content claims for guidance. which often contained nonnutritive sweeteners. In fact, current FDA labeling regulations may promote rather of a beverage containing that We believe that adopting a than prevent parental confusion. sweetener their children can safe- more straightforward and easily In our own pilot study of paren- ly consume. For example, the ADI understandable ingredient-labeling tal selection of grocery items for sucralose of 5 mg per kilo- system in the United States and bearing sugar-related nutrient- gram of body weight translates educating parents in the inter-

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pretation of sugar- and calorie- ers that have been added would on processed, packaged foods. J Am Diet Assoc 2004;104:952-8. related nutrient-content claims help parents understand what 2. Colby SE, Johnson L, Scheett A, Hoverson through transparent food market- they are feeding their children. B. Nutrition marketing on food labels. J Nutr ing are needed steps to empower Disclosure forms provided by the authors Educ Behav 2010;42:92-8. parents to make informed choic- are available with the full text of this article 3. Williams P. Consumer understanding and at NEJM.org. use of health claims for foods. Nutr Rev es. If the FDA revised the current 2005;63:256-64. 4. Sylvetsky AC, Greenberg MJ, Rother KI. labeling requirements for foods From the Department of Exercise and Nu- Parental recognition and perception of com- trition Sciences (A.C.S.) and the Sumner M. and beverages bearing sugar- and mercially available foods and beverages con- Redstone Global Center for Prevention and calorie-related nutrient-content taining non-nutritive sweeteners. FASEB J Wellness (W.H.D.), Milken Institute School 2013;27:Suppl:232.4. abstract. claims in this way, the replace- of Public Health, George Washington Uni- 5. Chapter 9: supplementary information on versity, Washington, DC. ment of added sugars with other specific products. In: Guide to food labelling sweet ingredients would be clear- and advertising. Canadian Food Inspection ly highlighted. And a statement 1. Legault L, Brandt MB, McCabe N, Adler Agency, 2011. C, Brown AM, Brecher S. 2000-2001 Food about product sweetness and the Label and Package Survey: an update on DOI: 10.1056/NEJMp1404899 quantity of nonnutritive sweeten- prevalence of nutrition labeling and claims Copyright © 2014 Massachusetts Medical Society.

Culturally and Linguistically Appropriate Services — Advancing Health with CLAS Howard K. Koh, M.D., M.P.H., J. Nadine Gracia, M.D., M.S.C.E., and Mayra E. Alvarez, M.H.A.

he United States continues improve health equity but also (beyond traditional consider- Tto grow more diverse. Cur- increase client satisfaction, im- ations of race and ethnicity) and rently, about 20% of the U.S. prove quality and safety, gain a health (including mental health population speaks a language market advantage, and meet leg- as well as physical health, for ex- other than English at home, and islative and regulatory stan- ample). They apply to organiza- 9% has limited English profi- dards. Although many providers tions focused on prevention and ciency. By 2050, the United are personally committed to im- public health as well as health States will be a “majority minor- proving cultural and linguistic care organizations. To guide ity” nation, with more than half competence, their organizations and encourage adoption, the the population coming from may remain uncertain about how OMH released a blueprint high- ­racial or ethnic minority back- best to become welcoming to all. lighting promising practices and grounds. Diversity is even great- To address this need, in 2013, exemplary programs.1 er when dimensions such as ge- the HHS Office of Minority Although adherence is volun- ography, socioeconomic status, Health (OMH) released the en- tary, many organizations have disability status, sexual orienta- hanced National Standards for committed to some or all of the tion, and gender identity are Culturally and Linguistically Ap- 15 standards, which fall under considered. Attention to these propriate Services (CLAS) in Health three themes.1 The first, “Gover- trends is critical for ensuring and Health Care (see box). These nance, Leadership, and Work- that health disparities narrow, standards provide a framework force,” emphasizes that the rather than widen, in the future. for organizations seeking to of- ­responsibility for CLAS imple- The U.S. Department of Health fer services responsive to indi- mentation rests at the highest and Human Services (HHS) has vidual cultural health beliefs and levels of organizational leader- long promoted cultural and lin- practices, preferred languages, ship. Prominent groups have en- guistic competence as one way to health-literacy levels, and com- dorsed this concept. For exam- address health disparities. Boost- munication needs.1 Building on ple, the National Quality Forum ing such competence among standards released in 2000, the identifies leadership as one of health care providers and organi- enhanced standards employ the seven primary domains for zations could not only help them broader definitions of culture measuring and reporting cultural

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