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JAMA
June 06, 2016
A Step Forward and More Room for Improvement
As the obesity epidemic continues unabated in the United States, costing more than $190 billion per year in health care expenditures,1 a public health crisis is unfolding that warrants careful reevaluation of existing policies to combat obesity and related chronic diseases. Recently, the US Food and Drug Administration (FDA) announced the first major amendment of the Nutrition Facts Label in more than 2 decades, to be implemented in the next 2 to 3 years, to reflect the evolving evidence related to dietary factors and risk of chronic diseases. The collective changes update the list of nutrients that are required or permitted to be declared, provide reference Daily Values based on current dietary recommendations or consensus reports, adjust serving sizes and labeling requirements for certain package sizes, and revise the overall format and appearance of the label for enhanced interpretability.2
Vasanti S. Malik, ScD1; Walter C. Willett, MD, DrPH2,3; Frank B. Hu, MD, PhD2,3
The Nutrition Facts label was introduced in May 1993 with the passage of the Nutrition Labeling and Education Act of 1990 and has become an iconic fixture on food packaging. The label provides point-of-purchase nutrition information in a standardized format to help guide consumers’ food and beverage choices. All packaged food items regulated by the FDA—everything from breads and cereals to canned and frozen foods, snacks, desserts, and beverages—are required to display information on the label pertaining to serving size, number of servings, total energy, and a selection of nutrients based on their role in chronic disease etiology or nutrient deficiency: energy from fat, total fat, saturated fat, cholesterol, sodium, carbohydrates, dietary fiber, sugar, protein, vitamin A, vitamin C, calcium, iron, and, most recently, transfat. With more than 61% of US adults reporting that they use the Nutrition Facts panel when deciding to purchase food, these labels have great visibility and potential to be important tools for public education and policy.3
Prior to the current ruling, the only amendment to the original label was the addition of a required line fortrans fat content, implemented in 2006 in response to substantial evidence linking intake of trans fat to adverse cardiometabolic health. This provided a strong incentive for manufacturers to eliminate trans fat; together with city- and state-level regulatory action limiting trans fat use in restaurants it has been largely eliminated from the US food supply. The FDA recently announced removing trans fat from the “generally regarded as safe” category, setting a 2018 deadline for the US food industry to eliminate it from all products. The substantial reduction in trans fat intake, from 4.6 to 1.3 g/d,4 accounted for about half of the improvement in US diet quality since 2000 and is likely a major factor contributing to improvements in blood lipid levels5 and a decline in type 2 diabetes in the United States.6
The new changes will further align the label with current dietary guidelines.7 One important change is the addition of a line disclosing “added sugar” content. The Daily Value (% DV) for added sugar is 10% of calories, representing a limit of 50 g (roughly 12 teaspoons) of added sugar for a 2000-calorie diet, a typical daily intake for adults (Figure). Although intake of added sugar has decreased in recent years in the United States, consumption still exceeds recommendations, with the average adult consuming 22 teaspoons of added sugar per day. Sugar-sweetened beverages alone account for 39% of all added sugar intake.7 Intake of sugar-sweetened beverages and added sugar is associated with weight gain and increased risk of type 2 diabetes and cardiovascular disease.8 Based on these data, the 2015-2020 Dietary Guidelines for Americans recommend limiting added sugar intake to less than 10% of daily calories.7 Once the changes are implemented, the label on a 20-oz (591 mL) bottle of soda, for example, would indicate that individuals are consuming 130% of their added sugar limit for the day (for a 2000-calorie diet).
Figure. The Revised Nutrition Facts Label Side-by-side comparison of the original nutrition label (left) and new label (right). From the FDA website and Final Rule.2
The new labeling requirement for added sugar is timely and accompanies other policy initiatives aiming to reduce intake of sugar-sweetened beverages and added sugars. For example, in 2015 Berkeley, California, implemented an excise tax of 1¢ per ounce on sugar-sweetened beverages, and San Francisco, California, recently passed a ruling to issue health warning labels on sugar-sweetened beverages. Boston, Massachusetts, has prohibited the sale of sugar-sweetened beverages on city property, and many school districts have banned sales and vending of these beverages as strategies to help curb childhood obesity. Similar to the case of trans fat, these collective legislative actions to reduce added sugar intake can create an environment that fosters and supports behavioral change toward more healthful choices and are more effective and efficient at reducing dietary risk factors than actions that depend solely on voluntary behavioral change. Consumer perceptions of added sugar may be particularly effective at motivating behavioral change, as illustrated in a recent analysis in which health warning labels on sugar-sweetened beverages improved parental understanding of their harms and may potentially reduce parent purchasing habits.9 In addition to helping consumers make more informed decisions about food and beverage choices, the new disclosure of added sugar may also motivate food manufacturers to reduce sugar in their products. However, an unintended consequence, discouraged by the Dietary Guidelines, may be the addition of noncaloric artificial sweeteners to preserve sweetness, particularly in items marketed to children. This would be of concern given the lack of long-term data on the health effects of artificial sweeteners.
In addition to highlighting added sugar, the Nutrition Facts label updates are also consistent with current dietary guidelines in the removal of the line for “calories from fat,” reflecting evidence that fat quality is more important that quantity.7 However, a line for “total fat” will still appear, with a corresponding %DV assuming a limit of about 35% of daily calories. It is unclear why this is retained because there is no scientific basis for the % DV and it is inconsistent with the new Dietary Guidelines,7 which did not set an upper limit for total fat intake. Declarations of potassium and vitamin D will now be required on the labels and reflect current recommendations to increase intake of these nutrients. Calcium and iron will continue to be required while vitamins A and C will no longer be required but permitted on a voluntary basis. Inclusion of potassium and vitamin D on the labels should be useful because they are underconsumed by much of the population.
However, the Daily Values, which are generally regarded as a goal for essential nutrients, for potassium and calcium are based on outdated or misleading evidence. For example, the Daily Value for potassium, 4700 mg/d, is unrealistically high for most people to attain and was based on a small study of salt-loaded men who were treated with potassium supplements.10 There is an urgent need to reevaluate the Recommended Dietary Allowances (RDAs) for key nutrients, especially potassium and calcium.
Another change to the Nutrition Facts panel is the inclusion of nutrition information both “per serving” and “per package” for products that could be consumed by one person, such as pints of ice cream or bags of chips. Previously, information was only given per serving, which was often misleading because a package consumed by one person often contained multiple servings. The new label also highlights caloric content per serving and adjusts serving sizes based on amounts typically consumed. For example, the serving size for soda will increase from 8 to 12 oz and a 20-oz bottle of soda will be labeled as 1 serving.
Most manufacturers will be required to implement the new label by July 26, 2018. However, those with less than $10 million in annual food sales will have an additional year to comply. While these changes will likely be supported by most consumer groups, some industry representatives claim that the inclusion of added sugar lacks scientific justification. A central argument is that calories from added sugar do not differ from calories from natural sugar or other sources. Thus, overconsumption of calories from carrots would be no different from overconsumption of calories from soda. However, the evidence linking higher intake of added sugar and sugar-sweetened beverages to adverse health is compelling; thus, reducing consumption of added sugars—especially sugar-sweetened beverages—is a major public health priority.7,8
Some food manufacturers have managed to exploit the food label in ways not addressed in the current revision. For example, purified additives such as inulin and cellulosic fiber (“functional fibers”) are allowed to be included in the “fiber” line to convey a healthy product, even though there is little evidence that they have the same benefits as fibers contained in foods.
The changes to the FDA Nutrition Facts label are an important step forward, especially with the inclusion of added sugar, but like the nutritional sciences and dietary recommendations on which they are based, they need to evolve and reflect advances in the field as well as changes in consumer behaviors. Careful monitoring of how food manufacturing changes in response to the label changes will be an important step in ensuring nutritional quality of food products.
Nutrition labeling and other regulatory actions have the potential to shift cultural norms and create food and social environments that support healthful choices with long-lasting benefits for the public’s health.