**4. Nutrition labelling**

Consumer education is an efficient tool for addressing malnutrition challenges. However, it must use effective messages, delivered by effective media and under the right environment. Nutrition labelling on packaged foods is widely used as an educational tool to provide consumers with nutrition information about specific food products. It is intentionally used as

**Figure 6.** From healthy eating recommendations to different interventions for consumer education.

a tool for enabling general consumers to select foods that are appropriate for their health. Ideally, nutritionally educated consumers should be the demand for creating a healthy-food environment. Moreover, nutrition labelling is also used as a marketing tool for the food industry in terms of product reformulation and market expansion of packaged food products around the world [11, 17].

According to the CODEX Guidelines on Nutrition Labelling (CAC/GL 2-1985), the nutrient declaration should be mandated for all pre-packaged foods if nutrition or health claims are made. Two formats exist for the nutrition labelling panel, namely, a traditional format and a graphical format [17]. Nutrition labels using the traditional format are normally located on the back side of food packages, while graphical format panels use a simplified format and are located on the front side of a food package.

#### **4.1. Traditional format nutrition labelling**

dietary fibre and a host of essential non-nutrient substances. The consumption of fruits and

Balanced eating at all life stage, beginning with conception, is crucial for preventing chronic diseases. Over the last two decades, growing evidence has shown that *in utero*, infant and young child under-nutrition are directly linked to vulnerability to adult NCDs [2, 15]. Consequently, public health and nutrition interventions during the first 1000 days of life, or

It is globally accepted that deaths related to NCDs can be partly reduced by investments to promote healthy diets following WHO's recommended eating pattern among populations. Appropriate information via food and nutrition labelling, as well as restrictions on the marketing of unhealthy foods, are major interventions to promote healthy diets [16] (**Figure 6**).

Consumer education is an efficient tool for addressing malnutrition challenges. However, it must use effective messages, delivered by effective media and under the right environment. Nutrition labelling on packaged foods is widely used as an educational tool to provide consumers with nutrition information about specific food products. It is intentionally used as

**Figure 6.** From healthy eating recommendations to different interventions for consumer education.

vegetables can replace foods high in saturated fats, sugar or salt.

from conception to 2 years of age, are encouraged.

200 Adiposity - Epidemiology and Treatment Modalities

**4. Nutrition labelling**

The traditional format normally reports factual information about the nutrients found in a food item. The patterns/panels and nutrients included vary among countries or regions depending upon priority nutrition issues. A basic panel contains a nutrient declaration and supplementary information. For the nutrient declaration, essential key elements include amounts of energy, protein, carbohydrates, sugars, fat, saturated fat and sodium, as well as vitamins and minerals. Under certain circumstances, a nutrient may be declared differently. For example, most nutrition panels identify sodium (in milligrams) as a nutrient, except in the EU nutrition labelling panel that identifies it as a food item in terms of 'salt in grams'. Surprisingly, the explanation for this difference is for the same purpose, which is to avoid consumer confusion and for their better understanding. In fact, in the CODEX Guidelines on Nutrition Labelling, national authorities can choose to use the term 'salt' instead of the term 'sodium'. This issue highlights an interesting challenge for national authorities in developing educational strategies for public awareness, especially in how to understand and use nutritional labelling most effectively (**Figure 7**). Furthermore, the energy value and nutrient amounts can be expressed based on different reference units, i.e. per 100 g or 100 mL or per serving or per package, with percentages of nutrient reference values, particularly for vitamins and minerals. This situation might be due to different logics used during panel development. In fact, different reference units provide consumers with different views of information and usefulness. A reference unit of per 100 g or 100 ml compares nutritional properties between food products of the same category; whereas, a reference unit of per serving or per package is intended to inform consumers about the amounts of energy and nutrients obtained in one eating.

Some nutrition panels also contain information on the percentage that a certain amount of a consumed nutrient can fulfil in terms of daily requirements. Simply put for consumers, 'what percent of my daily requirements does this nutrient fulfil if consumed in a specific amount, recommended serving, or serving size?' This information is shown as percent nutrient reference values (%NRVs) or percent daily intake (%DI). Unfortunately, this information does not always appear in every panel format even though it is a useful guide for consumers.

Supplementary information located below the nutrition fact information usually consists of certain reference numbers on daily requirements of the nutrients which have been used for



**Figure 7.** Examples of nutrition labelling panels.

evaluating the percent contribution to needs of those nutrients. This supplementary information is optional under the CODEX and can be included if it can provide consumers with better information [11]. Recently, the US has changed its traditional nutrition labelling panel format to remove certain complicated information in the nutrient list [18] (**Figure 8**).

Nutrition labelling is regulated differently in different countries in terms of being mandatory or voluntary. Due to increasing concerns about overweight, obesity and NCDs, many countries are making nutrition labelling mandatory for all packaged food items. This stance is in line with the most current CODEX amendment to the Guidelines on Nutrition Labelling. This amendment recommends that nutrient declaration should be mandatory for all pre-packaged




**Figure 8.** Comparison between original and new nutrition facts label of the United states *Source*:http://www.fda.gov/ Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutrition/ucm385663.htm.

foods, although nutrition or health claims are not made [11, 19]. Such implementation can be found in the United States, Canada, Australia and New Zealand, amongst other countries, where all pre-packaged foods, except for some certain food items, are mandated for nutrition labelling. Under regulation (EU) No. 1169/2011 of the European Parliament and of the Council of 25 October 2011, nutrition labelling will be mandatory for all pre-packaged foods in European Union (EU) countries from December 13, 2016. In ASEAN countries, nutrition labelling is still voluntary unless a nutrition or health claim is made.

evaluating the percent contribution to needs of those nutrients. This supplementary information is optional under the CODEX and can be included if it can provide consumers with better information [11]. Recently, the US has changed its traditional nutrition labelling panel format

Nutrition labelling is regulated differently in different countries in terms of being mandatory or voluntary. Due to increasing concerns about overweight, obesity and NCDs, many countries are making nutrition labelling mandatory for all packaged food items. This stance is in line with the most current CODEX amendment to the Guidelines on Nutrition Labelling. This amendment recommends that nutrient declaration should be mandatory for all pre-packaged

to remove certain complicated information in the nutrient list [18] (**Figure 8**).

**Figure 7.** Examples of nutrition labelling panels.

202 Adiposity - Epidemiology and Treatment Modalities

Traditional nutrition labelling panels are not effective nutrition education tools for general consumers, because consumers rarely use them to make informed food choices [20]. Cowburn and Stockley conducted a systematic review on consumer understanding and use of nutrition labelling. Their research showed that while a high number of consumers read nutrition label panels, in reality the effect of the panels on their food choice decisions was low. In particular, food panels that were more complex in terms of format hindered consumer understanding, interpretation and use of the panels [20]. Similarly, Hammond and co-workers conducted a systematic review of nutrition labels on packaged foods in seven developed and developing countries. They highlighted that while overall prevalence of nutrition label use amongst the general population in each country was generally high, it still varied across subgroups. However, in terms of understanding, many consumers had difficulty in interpreting the quantitative information due to reading frequency, level of education, nutrition knowledge and health status. Moreover, graphical formats were preferred, such as healthy symbols on frontof-pack (FOP) labels. Nevertheless, both systematic reviews concluded that nutrition labelling was a constructive and cost-effective intervention that can contribute to make informed food choices. They also recommended that governments should try to find the most appropriate and effective format that consumers can most easily access and understand [21]. Under these circumstances, national authorities and non-governmental organizations in many countries intend to simplify their current nutrition labelling panels into the easiest formats possible to increase their use and promote healthier food choices and eating habits.

#### **4.2. From 'traditional' to 'graphical'**

Although the number of persons affected by over-nutrition has grown, along with NCDS, few of the most recognized intervention strategies have included providing effective consumer education and creating a healthy food environment. Nonetheless, simplification of the traditional nutrition labelling panels has sparked the interest of many governments and non-governmental organizations. To reduce consumer confusion in using the panels, greater attention has been placed on those nutrients that have proven to be potential risk factors for NCDs and excluding other nutrients usually listed on traditional nutrition labelling panels. Emphasis is being placed on guiding consumers to make quicker, easier and more accurate buying decisions. Likewise, food industries must be inspired and have greater opportunities to develop products with better nutrition profiles and introduce them into the market at affordable prices for consumers. In terms of format, a large area is often times needed to display the traditional nutrition labelling panel that is on the back of a food package or back-of-pack (BOP), which hinders visibility and legibility. As an important consequence, the traditional format may not encourage food industries to reformulate their products to have better nutrient profiles. Consequently, governments and non-governmental organizations have been working towards simplified nutrition labelling to help consumers identify and make healthier food choices at a glance.

#### **4.3. Graphical format nutrition labelling**

Initial interest in simplified nutrition labelling emerged in the late 1960s and was first developed by a non-profit organization (the American Heart Association) in 1987, followed by a government sector (Swedish Food Administration) in 1989 in the form of heart check and green keyhole symbols, respectively (**Figure 9**). The simplified nutrition labelling panel was in a graphical format and located on the front of food packages or front-of-pack. The FOP nutrition labelling panel became interesting and friendly for consumers.

Different FOP nutrition labelling panels were later developed in many parts of the world and managed by different organizations, for example, food industries, government agencies, nonprofit organizations, food retailers and non-industry experts. To reduce panel complexity, Nutrition Labelling: Educational Tool for Reducing Risks of Obesity-Related Non-communicable Diseases http://dx.doi.org/10.5772/65728 205

ing countries. They highlighted that while overall prevalence of nutrition label use amongst the general population in each country was generally high, it still varied across subgroups. However, in terms of understanding, many consumers had difficulty in interpreting the quantitative information due to reading frequency, level of education, nutrition knowledge and health status. Moreover, graphical formats were preferred, such as healthy symbols on frontof-pack (FOP) labels. Nevertheless, both systematic reviews concluded that nutrition labelling was a constructive and cost-effective intervention that can contribute to make informed food choices. They also recommended that governments should try to find the most appropriate and effective format that consumers can most easily access and understand [21]. Under these circumstances, national authorities and non-governmental organizations in many countries intend to simplify their current nutrition labelling panels into the easiest formats possible to

Although the number of persons affected by over-nutrition has grown, along with NCDS, few of the most recognized intervention strategies have included providing effective consumer education and creating a healthy food environment. Nonetheless, simplification of the traditional nutrition labelling panels has sparked the interest of many governments and non-governmental organizations. To reduce consumer confusion in using the panels, greater attention has been placed on those nutrients that have proven to be potential risk factors for NCDs and excluding other nutrients usually listed on traditional nutrition labelling panels. Emphasis is being placed on guiding consumers to make quicker, easier and more accurate buying decisions. Likewise, food industries must be inspired and have greater opportunities to develop products with better nutrition profiles and introduce them into the market at affordable prices for consumers. In terms of format, a large area is often times needed to display the traditional nutrition labelling panel that is on the back of a food package or back-of-pack (BOP), which hinders visibility and legibility. As an important consequence, the traditional format may not encourage food industries to reformulate their products to have better nutrient profiles. Consequently, governments and non-governmental organizations have been working towards simplified nutrition labelling to help consumers identify and make healthier food

Initial interest in simplified nutrition labelling emerged in the late 1960s and was first developed by a non-profit organization (the American Heart Association) in 1987, followed by a government sector (Swedish Food Administration) in 1989 in the form of heart check and green keyhole symbols, respectively (**Figure 9**). The simplified nutrition labelling panel was in a graphical format and located on the front of food packages or front-of-pack. The FOP

Different FOP nutrition labelling panels were later developed in many parts of the world and managed by different organizations, for example, food industries, government agencies, nonprofit organizations, food retailers and non-industry experts. To reduce panel complexity,

nutrition labelling panel became interesting and friendly for consumers.

increase their use and promote healthier food choices and eating habits.

**4.2. From 'traditional' to 'graphical'**

204 Adiposity - Epidemiology and Treatment Modalities

choices at a glance.

**4.3. Graphical format nutrition labelling**

**Figure 9.** Examples of Front-of-Pack nutrition labelling panels. *Source*: (a) http://www.heart.org/HEARTORG/ HealthyLiving/HeathyEating/Heart-CheckMarkCertification/Heart-Check-Mark-Certification\_UCM\_001179\_ SubHomePage.jsp?pid=7bc18bff66f34f909&pcid=MP; (b) http://www.livsmedelsverket.se/en/food-and-content/ labelling/nyckelhalet/; (c) http://healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/content/home; (d) https://www.gov.uk/government/uploads/system/uploads/attachment\_data/file/300886/2902158\_FoP\_Nutrition\_2014. pdf.

they contained information on 'undesirable' or 'disqualified' nutrients including energy, fat, saturated fat, *trans* fat, sugar and sodium. In some cases, more 'desirable' or 'qualified' nutrients were also included, such as dietary fibre or those nutrients that reduce the risks of NCDs. Van Der Bend et al. studied 40 FOP nutrition labelling panels in use around the world and they noted that undesirable nutrients as well as dietary fibre were the most common elements contained in the panels [22] (**Table 4**).

The standards for these nutrients in foods or food products can be interpreted based either on serving size, 100 g/ml, 100 kcal/kJ, daily value or a combination. Which standard is used depends upon the one that consumers best understand and/or the one that is most agreeable to the food industry. The design in terms of message, size, characteristics and panel location should be one that consumers can easily see, remember and understand. However, it should not make false or exaggerated claims about a product. The values used to establish criteria are normally based on internationally recognized health guidelines as well as the unique characteristics of food products. The established criteria usually are found as either independent qualifying/disqualifying thresholds or relative to what is found in commercial products. The different designs used in FOP nutrition labelling panels may require consumer input to determine what is absolutely (non-directive), partly (semi-directive) or not at all (directive) needed [22].


**Table 4.** Percentages of nutrients normally found mentioning on the FOP nutrition labelling panels.

According to The Strategic Counsel, Toronto, Canada, at least 158 FOP nutrition labelling panels are being implemented and these are divisible into four types, nutrient specific, summary indicator, food group information and hybrids [23]. Examples of these FOP nutrition labelling panels are shown in **Table 5**.


Nutrition Labelling: Educational Tool for Reducing Risks of Obesity-Related Non-communicable Diseases http://dx.doi.org/10.5772/65728 207


**Table 5.** Examples of each type of FOP nutrition labelling panels..

According to The Strategic Counsel, Toronto, Canada, at least 158 FOP nutrition labelling panels are being implemented and these are divisible into four types, nutrient specific, summary indicator, food group information and hybrids [23]. Examples of these FOP nutrition

**Table 4.** Percentages of nutrients normally found mentioning on the FOP nutrition labelling panels.

**Nutrient Percentage (%) use in FOP nutrition labelling panels**

**1.** *Nutrient specific*: This type of FOP panel contains four to five types of nutrients that should be limited in order to reduce the risk of NCDs, that is energy, fat, saturated fat, sugar and sodium. The information shown is generally in amounts of nutrients per serving, which is not always the case and depending on a country's context. In some instances, per 100 g or 100 ml or per package are also used. Percentages of daily requirement or maximum consumption limits per day of the nutrients are additional information shown on these panels. The presentation pattern can be shown as a sequence of rows or as a pie chart. The pattern is presented either in monochrome or multi-chrome (normally consisting of three

**2.** *Summary indicator*: A summary indicator is represented only by a symbol that may or may not imply good health. To have a summary indicator shown on the front of a food package, the nutrient profile of the food must pass the established nutrition standard for that food, usually through comparisons on the nature of such food or food product. The criteria mostly depend on the amount of undesirable nutrients removed, reduced or contained. **3.** *Food group information*: This type of FOP nutrition labelling panel is based on the existence of certain food groups or food items that should be consumed in greater amounts to reduce the risk of NCDs. The terminologies used for identifying food items on the panel are normally similar to those recommended in a country's food-based dietary guidelines and aim-

**4.** *Hybrids*: More than one type of FOP nutrition labelling panel can be shown on the same package, which should provide additional information on different aspects to increase

labelling panels are shown in **Table 5**.

Dietary fibre 62.5 Protein 35 Calcium 30 Saturated fatty acids 75 Total sugar 62.5 Total fat 62.5 Sodium 62.5 Energy 52.5 *Trans* fatty acids 37.5 Cholesterol 30

206 Adiposity - Epidemiology and Treatment Modalities

colours similar to a traffic light).

ing for better consumer understanding.

consumer understanding. For example, a summary indicator panel provides information for purchasing decisions, while an additional nutrient specific type panel explains the beneficial nutrient profile of the product.

Within the same type of FOP nutrition labelling panel, messages can provide different levels of information. A deeper informative message should have a higher impact on consumer decision-making, especially for those with health concerns. However, such a message must be developed through a process of evaluation, interpretation and conclusion as provided by different sectors, that is government, NGOs, food businesses, consumer protection agency and academics.

The degree of informativeness can be ranked at three levels.


**3.** *Conclusive or directive*: A holistic nutrition standard for each food or food product is developed at this level of informativeness in either a positive or negative direction with the aim of reducing the risks of NCDs. Similar to the evaluative and interpretative levels, development must involve academicians and stakeholders. However, the criteria implemented at this level must provide a clear judgment in terms of qualified/disqualified or pass/non-pass in order to allow the use of a specific symbol on a product's FOP. Normally, the nutrition standard is specifically developed for each food product with regard to its nature, which may be as a threshold value or ability to reduce the undesirable nutrient(s) associated with NCDs risk that are normally high in such food or food product. Criteria can be developed based on reference values found in food products of the same type or group that are available in the market. These can be single or multiple criteria depending on the nature of the product. In practice, the criteria can be ideal, but they must also be feasible for food industries. For example, the nutrition standard for fish sauce is <6000 mg of sodium per 100 ml, which is a 30% reduction from what is normally found in the market (9000 mg per 100 ml). The nutrition standard for beverages is <6% sugar, which is a 50% reduction from 12% in generally marketed beverages. Sodium and sugar represent single criterion that have been developed relative to commercial products. An example of multiple criteria is milk, wherein the nutrition standard includes no sugar added and <1.5% fat. These criteria are independently developed as threshold values. The input of this informativeness level results in products that are deemed to be nutritionally healthier than others of the same type or group that are available in the market. Only products that pass screening with their nutrition standards qualify for these specific symbols. Most summary indicator types are developed at this level of informativeness.

#### **4.4. A note of caution**

consumer understanding. For example, a summary indicator panel provides information for purchasing decisions, while an additional nutrient specific type panel explains the ben-

Within the same type of FOP nutrition labelling panel, messages can provide different levels of information. A deeper informative message should have a higher impact on consumer decision-making, especially for those with health concerns. However, such a message must be developed through a process of evaluation, interpretation and conclusion as provided by different sectors, that is government, NGOs, food businesses, consumer protection agency

**1.** *Non-evaluative or non-directive*: The information shown on monochrome FOP nutrient specific and food group information panels are based on this level of informativeness. Fact-based information on nutritive values of the selected nutrients is shown. The input is only on selecting certain information from traditional BOP nutrition labelling panels and reporting it in a simplified format or indicating what beneficial natural food group the product contains. Consequently, all foods can have a monochrome nutrient specific type of FOP panel with no need for further screening or evaluation by any party, as long as a complete data set for the required nutrients exists. At this level of informativeness, a FOP nutrient specific panel is suitable for more knowledgeable consumers since there is limited guidance. Additional information, such as percent contribution to the recommended daily intake, may not be understandable by most consumers as well. For food group information panels, the food group that is recommended for greater consumption is already visible.

**2.** *Evaluative or interpretative or semi-directive*: Nutrition criteria are normally developed for categories of foods based on the FAO/WHO recommendations for energy, protein and nutrient requirements and using the nutrition criteria of four to five undesirable nutrients for meals, snacks and beverages. The criteria are usually developed into three levels of risk classification for each nutrient of each food category, that is high risk, potentially high risk and low risk. The multi-chrome FOP nutrient specific type panel is an example of a product at this level of informativeness. The amount and percent recommended daily intake of nutrients are listed with the NCDs risk evaluation. The risk evaluation result is indicated as colours, and usually as traffic light colours where red, amber and green indicate high, potentially high and low risk, respectively. Consumers can classify a food or a food product as good or bad depending upon the numbers of red, amber and green colours presented. The FOP summary indicator panel at this level is being implemented in Australia and the USA. Australia's Star® and the United States' Nu Val® are good examples of the use of this level for ordinal rating, wherein the risk evaluation is presented as number of stars or a full score of 100, respectively. The more stars there are, or the higher the score, the healthier the products. The application of this level of informativeness, either in the FOP nutrient specific or summary indicator type, still requires consumers to make independent

eficial nutrient profile of the product.

208 Adiposity - Epidemiology and Treatment Modalities

The degree of informativeness can be ranked at three levels.

Hence, it should be easy for consumers to make a decision.

and academics.

judgments.

A simplified FOP nutrition labelling panel aims to ease the lives of consumers by providing decision-making guidance based on scientific evidence. However, consumers tend to interpret panels that contain higher levels of informativeness in terms of 'claims'. Consequently, the processes used for nutrition standard development, as well as consumer communication, must be conducted carefully and take into account the available international standard found in the Codex Alimentarius on nutrition and health claims. For example, the green colour on a multi-chrome FOP nutrient specific type panel can be understood as a 'nutrition claim'. An FOP summary indicator can be understood either as a nutrition or health claim in terms of its environmental factors. An FOP summary indicator with a description of a food category and dominate nutrient (either higher or lower) can be interpreted as a nutrition claim, while ones with no description can be understood either way. Take, for example, the first two symbols on the green key hole and heart check symbol FOP nutrition labelling panels. Even though these two different symbols might have been developed from the same criteria found in a nutrient profile, they may affect consumer recognition differently. Since the green keyhole symbol was issued by the government authority that controls food quality and safety, it may be interpreted by consumers as a nutrition or health claim. Consequently, it is necessary for the government or issuing organization to either provide adequate information that the symbol has been issued based on the product's nutrient profile, not health impact, or indicate the FOP nutrition labelling panel is a hybrid type comprised of other types of FOP nutrition labelling, such as GDAs. Furthermore, consumers may interpret a symbol issued by a professional health association as a health claim. For the heart check symbol, the product might be interpreted in terms of lowering the risk for cardiovascular diseases. Consequently, harmonization of established standards with local and international standards and regulations should also be taken into consideration.

#### **4.5. Outcome and expectation**

While traditional BOP nutrition labelling panels are mandatory in most countries, the FOP nutrition labelling panels are implemented mainly on a voluntary basis. The exception is the monochrome Guideline Daily Amounts (GDAs) panel that is preferred by the food industry and has become mandated in some countries. After nutrition standards have been developed and accepted, the food industry is the first stakeholder that is actively involved. Products that have met their nutritional standards should be promoted first. Product development research should be performed continuously in order to offer more product choices in the market by changing composition and/or reformulating using new ingredients and/or replacers. In addition, new products with acceptable nutrient profiles can also be introduced into the market. **Figure 10** indicates the numbers of food products that have been sorted, reformulated and developed with regard to the Choice International® criteria.

Reduction in packaging size to fit with minimum serving size can also improve a product's nutrient profile as well as consumer behaviour. Consumers tend to eat a larger amount of food if that food is served/packaged in a larger serving size. To launch a qualified food

**Figure 10.** Total numbers of products that were newly developed, reformulated or already complaint with the Choice International® criteria (slide 26 Canada slide). *Source*: Ellis L Vyth et al. (2010) [24].

product (original, reformulated, newly developed) in the market, costs due to labelling changes is unavoidably increase. Hence, there must be a grace period for utilizing left-over packages and printing new ones. The concept used for advertising and promoting the FOP nutrition labelling panel must then include NCD risk, the purpose of which is for consumer education. For most consumers, sensory quality is an important issue and oftentimes more important than nutritional quality. The most conservative strategy is to improve the nutrient profile of a product but still maintain its original sensory quality. This may involve replacing normally-used ingredients with substitutes or replacers for salt, sugar or fat. Consumer behaviours may not change for the better if those undesirable nutrients are not replaced with acceptable ones. Since change in consumer eating behaviours towards better nutrition is the paramount goal, the promotion message sometimes must guide consumers to partly modify their sensory preference in order to gain better nutrition. However, this is a difficult process and takes time, but it must be urgently started. Marketing and logistics strategies are equally important as part of the promotion strategy, since the products must be widely available for consumers at affordable prices. If both main players—consumers and the food industry—satisfactorily respond to a program, the outcomes should have beneficial impacts for health and marketing.

has been issued based on the product's nutrient profile, not health impact, or indicate the FOP nutrition labelling panel is a hybrid type comprised of other types of FOP nutrition labelling, such as GDAs. Furthermore, consumers may interpret a symbol issued by a professional health association as a health claim. For the heart check symbol, the product might be interpreted in terms of lowering the risk for cardiovascular diseases. Consequently, harmonization of established standards with local and international standards and regulations should also

While traditional BOP nutrition labelling panels are mandatory in most countries, the FOP nutrition labelling panels are implemented mainly on a voluntary basis. The exception is the monochrome Guideline Daily Amounts (GDAs) panel that is preferred by the food industry and has become mandated in some countries. After nutrition standards have been developed and accepted, the food industry is the first stakeholder that is actively involved. Products that have met their nutritional standards should be promoted first. Product development research should be performed continuously in order to offer more product choices in the market by changing composition and/or reformulating using new ingredients and/or replacers. In addition, new products with acceptable nutrient profiles can also be introduced into the market. **Figure 10** indicates the numbers of food products that have been sorted, reformulated and

Reduction in packaging size to fit with minimum serving size can also improve a product's nutrient profile as well as consumer behaviour. Consumers tend to eat a larger amount of food if that food is served/packaged in a larger serving size. To launch a qualified food

**Figure 10.** Total numbers of products that were newly developed, reformulated or already complaint with the Choice

International® criteria (slide 26 Canada slide). *Source*: Ellis L Vyth et al. (2010) [24].

be taken into consideration.

210 Adiposity - Epidemiology and Treatment Modalities

**4.5. Outcome and expectation**

developed with regard to the Choice International® criteria.

**Table 5** also indicates that external factors (i.e. community, culture) and internal factors (i.e. individual) can influence expected outcomes. Inputs from government and non-governmental agencies on several important issues, such as nutrition education, preventive medical care policy, support for nutritious food production and promotion in relationship to the food culture, are examples of external factors that can significantly influence to stakeholders. For consumers at the demand side, their buying decisions can also be influenced by individual factors, such as educational background, socioeconomic status, health status and awareness.

The program's outcomes should initially benefit consumers and food industries in terms of availability of nutritious foods in the market and increased product sales, respectively. In the long-term, it is expected that the information that is provided through the FOP nutrition labelling panel should serve as a nutrition education tool for changing consumers' eating behaviours, especially in terms of preference for undesirable nutrients.

A number of studies have evaluated the impacts of FOP nutrition labelling on consumer and industrial sides. Methodologies, such as self-reporting and focus groups, have been used to evaluate understanding and use of the FOP nutrition labelling panel among consumers in terms of their food purchasing decisions. Observational studies estimated the impact of FOP nutrition labelling panel on consumers' selection. Indicators, such as increased numbers of qualified product sales as well as reformulated and newly developed products in the market, were used to determine the impact of FOP nutrition labelling among industries. In addition, the impact of FOP nutrition labelling on nutrient intake and health outcomes can be evaluated from national food consumption and national nutrition surveys [25].

Many studies have shown that the FOP nutrition labelling panel has been quite helpful to consumers and their food choice decisions [25, 26]. Moreover, the simpler format for FOP nutrition labelling panels (e.g. Healthier Choice Tick, Smileys and Stars) is more effective than complex ones (e.g. Multiple Traffic Light, Wheel of Health, GDA scores), since consumers can more




**Table 6.** Examples of the implemented front- of pack nutrition labelling panels.

quickly select healthier food choices [27]. Furthermore, FOP nutrition labelling panels implemented by national authorities have more credibility. The wide variety of FOP nutrition labelling panels of different designs and criteria that are being implemented worldwide, however, can be confusing for consumers, which leads to misinterpretation and hinder their effectiveness [28]. Consequently, it has been suggested that a single format should be implemented. Before beginning the panel harmonization process, the use of a simple visual model, the so-called 'Funnel Model' that was developed by Van Der Bend et al. can be effectively used to evaluate available FOP nutrition labelling panels on the market worldwide. The model aims to illustrate, describe and compare all existing FOP nutrient profiling systems based on qualifying and disqualifying ingredients, reference units, purposes of use, methodological approaches, types of organizations and directivity [22]. Moreover, it also provides an overview of the different characteristics of each FOP in use. The model then can be used as a tool for situation analysis and provide efficient information for establishing a single format of FOP nutrition labelling panel (**Table 6**).

#### **4.6. Range of applications**

The main purpose of FOP nutrition labelling panel is to enable consumers to select pre-packaged food products that have better nutrient profiles in reducing the risks of NCDs. Another indirect benefit, which should also be a main purpose, is to educate consumers and improve their daily eating behaviours. Industries can use established nutrition standards as one of the criteria for product development. Since NCDs have become a global nutrition challenge, international and national government agencies tend to implement certain strategies for controlling unhealthy food products in the market, especially those high in fat, sugar and sodium. High taxation for food products that contain excessive amounts of fat, sugar or sodium is one strategy that has been used in some countries. Policy-makers can use the standard in the FOP nutrition labelling panel as a guideline to impose higher taxes, such as sugar a tax on sugary drinks. Regarding WHO concerns on the marketing of foods and beverages to children, the FOP nutrition labelling panel can be used as a screening tool for foods and beverages to be sold in schools and areas nearby, as well as for advertisements aimed at children. Foods and beverages that pass the nutrition standard can be included in the country's FBDGs, which is the guideline for the general population. Moreover, the FOP nutrition labelling panel can also be used for product promotion in international trade, wherein a better nutrient profile can add value to exported products, especially since the panel has been mutually recognized.
