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The Impact of Variations in a Fact-Based Front-of-Package Nutrition Labeling System on Consumer Comprehension

Open AccessPublished:April 10, 2014DOI:https://doi.org/10.1016/j.jand.2014.01.018
      In 1990, when the Nutrition Labeling and Education Act

      Nutrition Labeling and Education Act. 1990. Pub L No. 101-535, 104 Stat 2353. Library of Congress website. http://thomas.loc.gov/cgi-bin/bdquery/z?d101:HR03562:@@@D&summ2=3&|TOM:/bss/d101query.html. Accessed November 30, 2013.

      was enacted, there was a clear need for standardized information on food product packaging. This legislation, an amendment of the Federal Food, Drug and Cosmetic Act of 1938,

      Federal Food, Drug and Cosmetic Act of 1938. 52 USC § 1040. US Food and Drug Administration website. http://www.fda.gov/opacom/laws/fdcact/fdctoc.htm. Accessed November 30, 2013.

      was intended to enable consumers to make more informed food choices to build a healthy diet. In addition to the new requirement for nutrition labeling on most packaged foods, and the creation of uniform definitions used in nutrient content claims, the Nutrition Labeling and Education Act revised health claim regulations allowing manufacturers to print approved health claims on the front of food and beverage product packaging if certain criteria were met.
      The American Heart Association's Heart-Check Food Certification Program,

      American Heart Association. Heart-check food certification program. http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HeartSmartShopping/Heart-Check-Mark-Food-Certification_UCM_300133_Article.jsp. Accessed November 30, 2013.

      launched in 1995, was among the first front-of-package labeling systems. Participating manufacturers who had submitted an application and received approval could place an American Heart Association Heart Check on the front of package if the food met US Food and Drug Administration (FDA) regulations for a heart health claim

      US Department of Health and Human Services, Food and Drug Administration. Code of Federal Regulations, Title 21. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?cfrpart=101. Accessed November 30, 2013.

      and American Heart Association's specific criteria.
      Consumer interest in understanding how to identify healthful foods continues to increase,

      US Food and Drug Administration. 2008 Health and diet survey. http://www.fda.gov/Food/FoodScienceResearch/ConsumerBehaviorResearch/ucm193895.htm. Accessed November 30, 2013.

      Food Marketing Institute and Prevention Magazine
      Shopping for Health.

      International Food Information Council Foundation. 2012 Food & Health Survey: Consumer Attitudes Toward Food Safety, Nutrition & Health. May 2012. http://www.foodinsight.org/Content/3840/2012%20IFIC%20Food%20and%20Health%20Survey%20Report%20of%20Findings%20(for%20website).pdf. Accessed November 30, 2013.

      as manufacturers and retailers have been adding interpretive symbols and fact-based icons (collectively known as “systems”) to product packages and shelf tags. Although these systems were created to help consumers make informed, healthful food choices, the formats, colors, and amount and type of information provided, including summary nutrition ratings, nutrient-specific disclosures about public health concerns, and dietary recommendations, often varied.

      Kellogg's. How to read a nutrition label. http://www.kelloggs.com/en_US/the-benefits-of-cereal/how-to-read-a-nutrition-label.html. Accessed November 30, 2013.

      PepsiCo. Responsible marketing. Nutrition labeling. http://www.pepsico.com/Purpose/Human-Sustainability/Responsible-Marketing. Accessed November 30, 2013.

      Kraft Foods. Healthy living. http://www.kraftrecipes.com/healthy-living-ideas/main.aspx. Accessed November 30, 2013.

      American Beverage Association. Clear on calories. http://www.ameribev.org/nutrition–science/clear-on-calories/. Accessed November 30, 2013.

      NuVal. http://www.nuval.com/scores. Accessed March 14, 2014.

      • Sutherland L.A.
      • Kaley L.A.
      • Fischer L.
      Guiding stars: The effect of a nutrition navigation program on consumer purchases at the supermarket.

      Guiding Stars Licensing Company. http://guidingstars.com/. Accessed November 30, 2013.

      • Sacks G.
      • Rayner M.
      • Winburn S.
      Impact of front-of-pack ‘traffic-light’ nutrition labelling on consumer food purchases in the UK.
      The FDA addressed this reality in 2007 via public hearings and requested research on the effectiveness of front-of-package systems.
      US Food and Drug Administration
      Food labeling: Use of symbols to communicate nutrition information, consideration of consumer studies and nutritional criteria. Public hearing; request for comments.
      US Food and Drug Administration
      Front-of-pack and shelf tag nutrition symbols; establishment of docket; request for comments and information.
      In 2009, Congress directed the Centers for Disease Control and Prevention to evaluate and make recommendations about front-of-package systems and symbols.

      Explanatory Statement Submitted by Mr. Obey, Chairman of the House Committee on Appropriations, Regarding HR 1105, Omnibus Appropriations Act, 2009. Division F-Labor, Health and Human Services and Education, and Related Agencies Appropriations, p. 1398. http://www.gpo.gov/fdsys/pkg/CPRT-111JPRT47494/pdf/CPRT-111JPRT47494-DivisionF.pdf. Accessed December 17, 2013.

      House Report 111-366, Conference Report to accompany H.R. 328, ordered to be printed December 8, 2009, p. 1021. http://www.gpo.gov/fdsys/pkg/CRPT-111hrpt366/pdf/CRPT-111hrpt366.pdf. Accessed December 17, 2013.

      The Centers for Disease Control and Prevention joined forces with the FDA and US Department of Agriculture to commission the Institute of Medicine to address this charge. The resulting Phase I report by the Institute of Medicine in 2010

      Institute of Medicine, Committee on Examination of Front-of-Package Nutrition Ratings Systems and Symbols. examination of front-of-package nutrition ratings systems and symbols: Phase I report. Washington, DC: National Academies Press; 2010. http://www.iom.edu/Reports/2010/Examination-of-Front-of-Package-Nutrition-Rating-Systems-and-Symbols-Phase-1-Report.aspx. Accessed December 17, 2013.

      noted that more work was needed to determine appropriate criteria for front-of-package labeling systems and how best to convey information in such systems. Subsequent to the completion of the study presented in this article, the Institute of Medicine Phase II report

      Institute of Medicine. Examination of front-of-package nutrition rating systems and symbols: Promoting healthier choices. Washington, DC: National Academies Press; 2011. http://www.iom.edu/Reports/2011/Front-of-Package-Nutrition-Rating-Systems-and-Symbols-Promoting-Healthier-Choices.aspx. Accessed December 17, 2013.

      was published, which recommended development and consumer testing of a single, interpretive symbol for the front-of-package combined with fact-based calorie and serving size information.
      The importance of helping consumers make informed food choices and select a healthful diet has never been more vital because the incidence of diet-related disease persists. Obesity is increasing again after reaching a plateau in 2008,

      Fryar CD, Carroll MD, Ogden CL. Prevalence of overweight, obesity and extreme obesity among adults: United States, trends 1960-1962 through 2009-2010. NCHS Health E-Stat. Hyattsville, MD: National Center for Health Statistics; 2012. Centers for Disease Control and Prevention website. http://www.cdc.gov/nchs/data/hestat/obesity_adult_09_10/obesity_adult_09_10.pdf. Accessed November 30, 2013.

      • Ogden C.L.
      • Carroll M.D.
      • Kit B.K.
      • Flegal K.M.
      Prevalence of obesity in the United States, 2009-2010.
      as is diabetes.

      Centers for Disease Control and Prevention. 2011 National Diabetes Fact Sheet: Diagnosed and undiagnosed diabetes in the United States, all ages, 2010. http://www.cdc.gov/diabetes/pubs/estimates11.htm#. Accessed November 30, 2013.

      According to 2010 Centers for Disease Control and Prevention data, 28.5 million people, or 8.3% of the US population, have diabetes (18.8 million diagnosed, estimated 7 million undiagnosed), and 35.7% of the US adult population and 17% (12.5 million) of children aged 2 to 19 years are obese.
      According to 2010 Centers for Disease Control and Prevention data, 28.5 million people, or 8.3% of the US population, have diabetes (18.8 million diagnosed, estimated 7 million undiagnosed), and 35.7% of the US adult population and 17% (12.5 million) of children aged 2 to 19 years are obese.
      Because nutrition information on food product packaging is among the factors that affect consumer purchase decisions

      US Food and Drug Administration. 2008 Health and diet survey. http://www.fda.gov/Food/FoodScienceResearch/ConsumerBehaviorResearch/ucm193895.htm. Accessed November 30, 2013.

      Food Marketing Institute and Prevention Magazine
      Shopping for Health.
      —72% of consumers reported seeing the front-of-package symbols or icons and 67% reported they used symbols or icons to inform a food product purchase decision

      US Food and Drug Administration. 2008 Health and diet survey. http://www.fda.gov/Food/FoodScienceResearch/ConsumerBehaviorResearch/ucm193895.htm. Accessed November 30, 2013.

      —and there is a wide range of systems with varying criteria, consumer research is needed to determine an easy-to-use, understandable, accessible format.
      US Food and Drug Administration
      Food labeling: Use of symbols to communicate nutrition information, consideration of consumer studies and nutritional criteria. Public hearing; request for comments.
      US Food and Drug Administration
      Front-of-pack and shelf tag nutrition symbols; establishment of docket; request for comments and information.
      Dietetics practitioners' understanding of outcomes of labeling system research is important, given their critical role in helping consumers make healthful food choices.
      The International Food Information Council Foundation designed a study to examine consumer comprehension, ease of understanding, and interpretation of nutrition information in the uniformly formatted, voluntary front-of-package labeling system that was under consideration by the Grocery Manufacturers Association and the Food Marketing Institute. This research was used to inform the framework for the Facts Up Front

      FactsUpFront.org. http://factsupfront.com/. Accessed November 30, 2013.

      program, which is currently implemented by the two groups.

      Approach

      From August 14 to October 12, 2010, a professional marketing research firm, contracted by the International Food Information Council Foundation, conducted an interactive online survey of primary grocery shoppers. The sample was drawn from a web panel of >4,000,000 people representing hundreds of demographic, socioeconomic, and lifestyle attributes.
      The sample, 7,363 men and women aged 18 to 70 years, was screened to be reflective of the US population (2007-2008 US Census estimates)

      US Census Bureau. American Community Survey. http://www.census.gov/acs/www/. Accessed November 30, 2013.

      with respect to household income, age, and education level (Table 1, available online at www.andjrnl.org). Participants were required to have purchased and consumed both product types from one of two groupings—breakfast cereals and frozen entrées, or salad dressings and savory snacks—within the past 3 months. Respondents received an incentive for participation.
      This survey evaluated the relative effectiveness of four versions of front-of-package nutrition information in one consistently formatted, fact-based system (Figure 1) that mirrors several aspects of the Nutrition Facts label, including use of a neutral background with black print, and focused on nutrients to encourage or limit, per the 2005 Dietary Guidelines for Americans
      US Departments of Agriculture and Health and Human Services
      Dietary Guidelines for Americans, 2005.
      (Figures 1 and 2). This system complied with the current Code of Federal Regulations for nutrition labeling.

      US Department of Health and Human Services, Food and Drug Administration. Code of Federal Regulations, Title 21. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?cfrpart=101. Accessed November 30, 2013.

      Using a fact-based system that presents nutrient values without value judgment helped to ensure that the information would not be deemed misleading. Products were obtained from grocery store shelves. To avoid participant bias for or against particular brands, evidence of branding was removed from product packaging. The serving sizes and the Nutrition Facts label were reviewed to ensure compliance with food labeling regulations.

      US Department of Health and Human Services, Food and Drug Administration. Code of Federal Regulations, Title 21. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?cfrpart=101. Accessed November 30, 2013.

      Version 1 served as the control, displaying no nutrition information on the front of package (Figure 1). Version 2 displayed only calories on the front of package. Version 3 displayed calories and three nutrients to limit (saturated fat, sodium, and sugars) on the front of package. Finally, version 4 displayed calories, three nutrients to limit, and either one nutrient to encourage on savory snack and salad dressing products, or three nutrients to encourage on cereal and frozen entrée products. In order to be displayed on the front of package, nutrients to encourage are required by food labeling regulations to meet at least 10% of the Daily Value (DV). Therefore, with nutrient variability from product to product, it was necessary to display different nutrients to encourage on different products, and to display only one nutrient to encourage on savory snacks and salad dressings (Figure 2, footnote c).
      Figure thumbnail gr1
      Figure 1Front-of-package labeling system (refers to the front-of-package versions tested in the survey).
      Figure 2Rationale and description of information on the four versions of the front-of-package icon system for four product categories for an interactive online survey of primary grocery shoppers.
      Attributes and characteristics of front-of-package versionsLevelDescription
      Load
      All versions presented Nutrition Facts label information. Presentation of the information on the front of package required that the same nutrients be included in the Nutrition Facts label.
      Version 1: ControlNo front-of-package information: Zero icons
      Aligns with US Food and Drug Administration proposal to make calories more prominent on label
      US Food and Drug Administration
      Food labeling; prominence of calories. Advance notice of proposed rulemaking.
      Version 2: Some informationCalories only: One icon
      Aligns with the 2005 Dietary Guidelines for Americans
      US Departments of Agriculture and Health and Human Services
      Dietary Guidelines for Americans, 2005.
      Version 3: More informationCalories+nutrients to limit
      Nutrients to limit did not include trans fat. In 2003, the US Food and Drug Administration began requiring that trans fat be included in the Nutrition Facts label.31 As a result, most products were reformulated to decrease or eliminate it. Therefore, the amount in the food supply was negligible and the amount indicated likely would be zero.
      (saturated fat, sodium, and sugars): Four icons
      Aligns with the 2005 Dietary Guidelines for Americans for nutrients to encourage or limit
      US Departments of Agriculture and Health and Human Services
      Dietary Guidelines for Americans, 2005.
      or the Code of Federal Regulations for required nutrients on the Nutrition Facts label

      US Department of Health and Human Services, Food and Drug Administration. Code of Federal Regulations, Title 21. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?cfrpart=101. Accessed November 30, 2013.

      Version 4: Most informationCalories+nutrients to limit
      Nutrients to limit did not include trans fat. In 2003, the US Food and Drug Administration began requiring that trans fat be included in the Nutrition Facts label.31 As a result, most products were reformulated to decrease or eliminate it. Therefore, the amount in the food supply was negligible and the amount indicated likely would be zero.
      (saturated fat, sodium, and sugars) and nutrients to encourage
      Nutrients to encourage varied by product: fiber, vitamin A, and folate for breakfast cereals; protein, iron, and vitamin A for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks. Nutrients to encourage on the front of package had to meet the definition of a “good source” of the nutrient (ie, contain at least 10% of the Daily Value).4
      (protein, fiber, vitamin A, vitamin C, calcium, iron, or folate): Five to seven icons
      Product packaging tested
      All products were actual products. All front-of-package labeling not related to the front-of-package icon scheme tested, including brand name and any claims, was removed to prevent bias. The name of the product was included. Screen shots included both the front and back panels of the products.
      Products used to display front-of-package nutrient information were consistent with the products the US Food and Drug Administration used in its study methodology

      Fraser LM. US Food and Drug Administration, Center for Food Safety and Applied Nutrition. FDA's consumer research studies of FOP labeling. February 2, 2010. Institute of Medicine website. http://www.iom.edu/∼/media/Files/Activity%20Files/Nutrition/NutritionSymbols/Leslye%20Fraser.pdf. Accessed November 30, 2013.

      US Food and Drug Administration
      Agency information collection activities; submission for Office of Management and Budget Review; comment request; experimental studies of nutrition symbols on food packages.
      Breakfast cerealsProduct 1: Bran flakes (enriched bran flakes cereal)

      Product 2: Crispy honey oats and flakes with almonds (frosted corn and wheat flakes with rolled oat and granola clusters and almonds)

      Product 3: Bunch of cinnamon squares (sweetened wheat and rice cereal)

      Nutrients to encourage: fiber, vitamin A, and folate
      Frozen entréesProduct 1: Sesame chicken (seasoned, white meat chicken on a bed of noodles with green beans and red bell peppers)

      Product 2: Cheese manicotti (in a meaty marinara sauce, topped with mozzarella and parmesan cheeses)

      Product 3: Homestyle macaroni and cheese bake (sharp cheddar cheese, macaroni, and bread crumb topping)

      Nutrients to encourage: protein, vitamin A, and iron
      Salad dressingsProduct 1: Classic Italian—Nutrient to encourage: Vitamin C

      Product 2: Deluxe French—Nutrient to encourage: Vitamin A

      Product 3: Chunky blue cheese—Nutrient to encourage: Calcium
      Savory snacksProduct 1: Multigrain tortilla chips (authentic style)—Nutrient to encourage: Iron

      Product 2: Potato chips (classic)—Nutrient to encourage: Vitamin C

      Product 3: Popcorn (salted)—Nutrient to encourage: Iron
      Nutrition information tiers
      Consistent with FDA methodology,

      Fraser LM. US Food and Drug Administration, Center for Food Safety and Applied Nutrition. FDA's consumer research studies of FOP labeling. February 2, 2010. Institute of Medicine website. http://www.iom.edu/∼/media/Files/Activity%20Files/Nutrition/NutritionSymbols/Leslye%20Fraser.pdf. Accessed November 30, 2013.

      US Food and Drug Administration
      Agency information collection activities; submission for Office of Management and Budget Review; comment request; experimental studies of nutrition symbols on food packages.
      nutrient levels printed on the labels were adjusted (rounded up or down) to clarify high/medium/and low levels of calories and nutrients to encourage represented at least 10% of the DV within product feasibility
      Product 1Lower in calories, saturated fat, total sugars, and sodium

      Higher (good source) in vitamins, minerals, protein, and/or fiber
      Product 2Mid-level in nutrient content
      Product 3Highest in nutrients that should be limited and lowest in nutrients that should be encouraged
      Color
      Color was not used for front-of-package icons in order to prevent biasBlack, white, and grayUsed for the icons to coordinate with the Nutrition Facts label

      US Department of Health and Human Services, Food and Drug Administration. Code of Federal Regulations, Title 21. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?cfrpart=101. Accessed November 30, 2013.

      and to present the information in a neutral/nonbiased, factual format
      Presentation of nutrition information
      Presentation and order of information aligned with the Code of Federal Regulations for presenting information on the Nutrition Facts label

      US Department of Health and Human Services, Food and Drug Administration. Code of Federal Regulations, Title 21. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?cfrpart=101. Accessed November 30, 2013.

      Absolute numbersCalories and sugars
      Percent of Daily ValueVitamin A, vitamin C, calcium, iron, and folate
      Absolute numbers and percent of Daily ValueSaturated fat, sodium, fiber, and protein
      a All versions presented Nutrition Facts label information. Presentation of the information on the front of package required that the same nutrients be included in the Nutrition Facts label.
      b Nutrients to limit did not include trans fat. In 2003, the US Food and Drug Administration began requiring that trans fat be included in the Nutrition Facts label.
      US Food and Drug Administration
      Food labeling: Trans fatty acids in nutrition labeling; consumer research to consider nutrient content and health claims.
      As a result, most products were reformulated to decrease or eliminate it. Therefore, the amount in the food supply was negligible and the amount indicated likely would be zero.
      c Nutrients to encourage varied by product: fiber, vitamin A, and folate for breakfast cereals; protein, iron, and vitamin A for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks. Nutrients to encourage on the front of package had to meet the definition of a “good source” of the nutrient (ie, contain at least 10% of the Daily Value).

      US Department of Health and Human Services, Food and Drug Administration. Code of Federal Regulations, Title 21. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?cfrpart=101. Accessed November 30, 2013.

      d All products were actual products. All front-of-package labeling not related to the front-of-package icon scheme tested, including brand name and any claims, was removed to prevent bias. The name of the product was included. Screen shots included both the front and back panels of the products.

      Questionnaire Description

      The 7,363 participants were randomly assigned to view and answer questions about only one of the four front-of-package versions displayed on six products within one set of product categories (ie, breakfast cereals and frozen entrées, or salad dressings and savory snacks). The resulting groups were found to be demographically similar (Table 1, available online at www.andjrnl.org). The product category pairings allowed respondents assigned to version 4 to see comparable numbers of icons for nutrients to encourage. Three products in each category represented three “tiers” of nutritional content—those meeting higher, medium, and lower levels of nutrients to encourage or limit (Figure 2). (Note: The tiers were not identified for participants.) Within each section, the order of products presented and questions asked was rotated.
      The questionnaire was tested to confirm rotating and skipping patterns worked correctly. It was field tested with 800 subjects to ensure survey language was understood by respondents and to assess internal validity and directionality. Deemed valid, these 800 interviews were used as part of the total sample.
      The questionnaire contained fill-in-the-blank, multiple choice, rating, and open-ended questions. Respondents had to acknowledge receipt of the marketing firm's privacy/confidentiality policy before participating. Participants were informed that their names and responses would remain confidential and study results would be reported in total. The questionnaire began with demographic, socioeconomic, and shopping questions (Table 1, available online at www.andjrnl.org), which doubled as a screening device.
      For one product in each category, five questions addressed identification of nutrient amounts; four questions addressed %DV per serving (Table 2, available online at www.andjrnl.org); two questions addressed product comparisons (Table 3, available online at www.andjrnl.org); and four questions asked about ease of answering identification and comparison questions (Table 4). Participants next answered a multiple-choice question about which product (one of three in the category) they perceived was the best choice with respect to nutritional value (Table 3, available online at www.andjrnl.org); in an open-ended question, respondents were asked to explain their rationale.
      Table 4Percentage of primary household grocery shopper respondents reporting use of four versions of the front-of-package system for four food categories as “very easy”
      The question was stated as follows: “In general, how easy was it for you to figure out the answers you provided for the previous series of questions (eg, number of calories per serving, number of grams of fiber per serving, etc)? Very easy to figure out; somewhat easy to figure out; not too easy to figure out; not at all easy to figure out.”
      in an interactive online survey (n=7,363)
      Survey respondents (n=7,363) were randomized to view and answer questions about six products within two of four product categories (breakfast cereals and frozen entrées or salad dressings and savory snacks) that specifically displayed only one of the four available front-of-package versions.
      Front-of-package versions varied in amount and type of information: version 1 contained no front-of-package information and version 4 contained the most front-of-package information.
      Key evaluation measuresPercentage of Total Sample Who Reported “Very Easy”
      The question was stated as follows: “In general, how easy was it for you to figure out the answers you provided for the previous series of questions (eg, number of calories per serving, number of grams of fiber per serving, etc)? Very easy to figure out; somewhat easy to figure out; not too easy to figure out; not at all easy to figure out.”
      Version 1: None (n=1,832)Version 2: Calories only (n=1,850)Version 3: Calories+nutrients to limit
      Nutrients to limit: saturated fat, sodium, and total sugars.
      (n=1,830)
      Version 4: Calories+nutrients to limit
      Nutrients to limit: saturated fat, sodium, and total sugars.
      +nutrients to encourage
      Nutrients to encourage: fiber, vitamin A, and folate for breakfast cereals; protein, vitamin A, and iron for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks.
      (n=1,851)
      %
      Breakfast cereals
      Nutrition information (on 1 package)71717482
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      % DV
      %DV=percent daily value.
      nutrition information (on 1 package)
      78797590
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Lowest calories per serving (among 3 packages)8690
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      90
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      92
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Lowest sodium per serving (among 3 packages)838088
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      91
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Frozen entrées
      Nutrition information (on 1 package)828287
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      96
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      %DV nutrition information (on 1 package)78798194
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Lowest calories per serving (among 3 packages)8691
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      92
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      93
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Lowest sodium per serving (among 3 packages)86
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      8092
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      94
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Salad dressings
      Nutrition information (on 1 package)929394
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      95
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      %DV nutrition information (on 1 package)8890
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      8788
      Lowest calories per serving (among 3 packages)8995
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      95
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      93
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Lowest sodium per serving (among 3 packages)878893
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      92
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Savory snacks
      Nutrition information (on 1 package)9193
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      94
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      94
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      %DV nutrition information (on 1 package)86888791
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Lowest calories per serving (among 3 packages)868891
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      91
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Lowest sodium per serving (among 3 packages)868691
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      91
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      a The question was stated as follows: “In general, how easy was it for you to figure out the answers you provided for the previous series of questions (eg, number of calories per serving, number of grams of fiber per serving, etc)? Very easy to figure out; somewhat easy to figure out; not too easy to figure out; not at all easy to figure out.”
      b Survey respondents (n=7,363) were randomized to view and answer questions about six products within two of four product categories (breakfast cereals and frozen entrées or salad dressings and savory snacks) that specifically displayed only one of the four available front-of-package versions.
      c Front-of-package versions varied in amount and type of information: version 1 contained no front-of-package information and version 4 contained the most front-of-package information.
      d Nutrients to limit: saturated fat, sodium, and total sugars.
      e Nutrients to encourage: fiber, vitamin A, and folate for breakfast cereals; protein, vitamin A, and iron for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks.
      f %DV=percent daily value.
      x Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      y Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      z Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Respondents rated the front-of-package icon versions on a 5-point scale (where 1=strongly disagree and 5=strongly agree) regarding eight attributes, such as whether the front-of-package information was helpful in making an informed decision (Table 5). Finally, participants answered multiple-choice questions about shopping behaviors and health concerns for their families (Table 1, available online at www.andjrnl.org). Respondents were informed that they had access (via mouse click) to the Nutrition Facts label on the back of the package if they wished to view it.
      Table 5Interpretation of key evaluation measures for four versions of the front-of-package system for four food categories by primary household grocery shoppers to an interactive online survey (n=7,363)
      Survey respondents (n=7,363) were randomized to view and answer questions about six products within two of four product categories (breakfast cereals and frozen entrées or salad dressings and savory snacks) that specifically displayed only one of the four available front-of-package versions.
      Front-of-package versions varied in amount and type of information: version 1 contained no front-of-package information and version 4 contained the most front-of-package information.
      Key evaluation measuresPercentage of Total Sample Who Strongly Agree or Agree
      The question was stated as follows: “Looking at the nutrition information provided on the front of [these] products, please use the scale below to describe how much you agree or disagree with the following statements. Strongly agree, agree somewhat, neither agree nor disagree, disagree somewhat, strongly disagree.” (See product statements under each category.)
      Version 1: None (n=1,832)Version 2: Calories only (n=1,850)Version 3: Calories+nutrients to limit
      Nutrients to limit: saturated fat, sodium, and total sugars.
      (n=1,830)
      Version 4: Calories + nutrients to limit
      Nutrients to limit: saturated fat, sodium, and total sugars.
       + nutrients to encourage
      Nutrients to encourage: vitamin A, fiber, and folate for breakfast cereals; protein, vitamin A, and iron for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks.
      (n=1,851)
      Breakfast cereals
      The nutrition information on the front of the package
       Helps me to understand different nutritional valuesNA
      NA=not applicable.
      5383
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      87
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Helps me make an informed decisionNA6084
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      89
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Is easy to understandNA7989
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      90
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Should be included on other food productsNA6783
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      85
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Takes more time to understand than I am willing to spendNA26
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      2124
       Does not include enough important informationNA64
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      39
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      28
       Is believable and trustworthyNA6577
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      78
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Is accurateNA6574
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      72
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Frozen entrées
      The nutrition information on the front of the package
       Helps me to understand different nutritional valuesNA5484
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      89
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Helps me make an informed decisionNA6387
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      90
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Is easy to understandNA7989
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      90
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Should be included on other food productsNA6985
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      87
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Takes more time to understand than I am willing to spendNA242225
       Does not include enough important informationNA63
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      36
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      27
       Is believable and trustworthyNA6679
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      76
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Is accurateNA6573
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      71
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Salad dressings
      The nutrition information on the front of the package
       Helps me to understand different nutritional valuesNA5187
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      89
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Helps me make an informed decisionNA6088
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      89
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Is easy to understandNA8191
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      91
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Should be included on other food productsNA6784
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      85
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Takes more time to understand than I am willing to spendNA202022
       Does not include enough important informationNA63
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      3030
       Is believable and trustworthyNA6779
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      81
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Is accurateNA6673
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      76
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Savory snacks
      The nutrition information on the front of the package
       Helps me to understand different nutritional valuesNA5087
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      89
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Helps me make an informed decisionNA5787
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      88
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Is easy to understandNA7892
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      92
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Should be included on other food productsNA6785
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      85
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Takes more time to understand than I am willing to spendNA221922
       Does not include enough important informationNA64
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      3231
       Is believable and trustworthyNA6577
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      81
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Is accurateNA6572
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      75
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      a Survey respondents (n=7,363) were randomized to view and answer questions about six products within two of four product categories (breakfast cereals and frozen entrées or salad dressings and savory snacks) that specifically displayed only one of the four available front-of-package versions.
      b Front-of-package versions varied in amount and type of information: version 1 contained no front-of-package information and version 4 contained the most front-of-package information.
      c The question was stated as follows: “Looking at the nutrition information provided on the front of [these] products, please use the scale below to describe how much you agree or disagree with the following statements. Strongly agree, agree somewhat, neither agree nor disagree, disagree somewhat, strongly disagree.” (See product statements under each category.)
      d Nutrients to limit: saturated fat, sodium, and total sugars.
      e Nutrients to encourage: vitamin A, fiber, and folate for breakfast cereals; protein, vitamin A, and iron for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks.
      f NA=not applicable.
      x Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      y Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      z Significantly different from version 4 at P<0.05. Comparisons are made horizontally.

      Statistics

      Descriptive statistics were performed on all variables and statistical analyses were conducted using Quantum software, version 5.8.1 (2010, IBM). Responses to comprehension, ease of use, and interpretation questions about front-of-package versions were compared using a t test on column proportions. Responses to comprehension by education level were compared using a t test on means. The P level was set at 0.05.

      Finding

      Participant Description and Food Label Behaviors

      Of 25,922 consumers who started the survey and were assigned to a front-of-package version, 7,363 (28%) completed it. Mean completion time was 19 minutes (±8.8 minutes standard deviation). If participants took <10 minutes or >45 minutes to complete the survey, their responses were excluded from analysis. There were no significant differences regarding demographics and socioeconomic characteristics among participants assigned to each front-of-package version (Table 1, available online at www.andjrnl.org).
      Overall, 86% of respondents self-reported that they read a product's Nutrition Facts label regularly or occasionally when purchasing it for the first time; 85% self-reported reading labels to compare nutritional values (Table 1, available online at www.andjrnl.org). Among respondents who rarely or never used labels for purchasing decisions, nearly half (48%) were in the lowest income group (<$35,000), 21% had less than a high school education, and 38% had attained a high school education or its equivalent. Regular label users were significantly more likely to be college educated (P<0.05).
      Regarding health concerns for themselves or their families, respondents indicated obesity/overweight was their top health concern, followed by high cholesterol, high blood pressure, and diabetes.

      Increasing Shoppers' Comprehension

      Nine questions assessed respondents' ability to identify absolute numbers (eg, 140 kcal) for nutrient values and %DVs of each product, for a total of 18 questions per respondent. More nutrition information on the front-of-package generally strengthened consumers' comprehension (Table 2, available online at www.andjrnl.org).

      Identifying Nutrient Amounts and %DV by Product Category

      Consumers accurately identified nutritional content more frequently when the relevant information was available on the front of package. For those assigned to different front-of-package versions for breakfast cereals, for example, the total percentage of correct answers to five questions regarding absolute numbers for nutrient values ranged from 87% to 96% and was not significantly different across versions (Table 2, available online at www.andjrnl.org); however, analyzing each question individually, consumers demonstrated significantly increased comprehension when more information was provided. That is, respondents assigned to version 4 had significantly higher correct response rates about absolute values of sodium, saturated fat, sugar, and fiber than respondents assigned to versions 1 and 2. The same finding was observed in the four questions about %DV in breakfast cereals: understanding %DVs for sodium, saturated fat, fiber, and folate was significantly higher among respondents assigned to version 4 than those assigned to versions 1 to 3. Similar results were found for frozen entrées. Scoring for questions regarding the protein grams and the %DV for sodium, vitamin A, and iron was higher among respondents assigned to version 4 compared with respondents assigned to version 3 (Table 2, available online at www.andjrnl.org).
      For salad dressings, identification of cholesterol milligrams and %DV for vitamins A and C was higher in versions 1 and 2 than in versions 3 and 4 (Table 2, available online at www.andjrnl.org). Unlike breakfast cereals and frozen entrées, the front of package for salad dressings in version 4 displayed the answer to only six questions rather than all eight; information about cholesterol values was available to these respondents only via the Nutrition Facts label and the %DV for vitamins A and C was available only via the front of package to one third of these respondents.
      For savory snacks, respondents' correct answers for version 4 were significantly higher than for version 1 for six of the nine questions. Exceptions included protein grams and %DV for vitamin C and iron (Table 2, available online at www.andjrnl.org). The difference was only 3% for vitamin C, but 8% for protein. Protein grams did not appear on the version 4 front of package; therefore, the answer to the question was available only via the Nutrition Facts label. Vitamin C appeared on only one third of the version 4 savory snacks (as noted, one positive nutrient was displayed on each product in this category). Participants showed no difference in identifying the %DV for iron with versions 1, 2, or 4. However, those who viewed version 3 (calories plus nutrients to limit) were less likely to correctly identify nutrients to encourage.
      Initial use of the Nutrition Facts label dropped significantly (P<0.05) when more front-of-package information was displayed. More individuals (63%) who viewed version 1 and version 2 (57%) read the Nutrition Facts label than respondents viewing versions 3 (46%) and 4 (45%).

      Identifying Products with the Lowest or Highest Nutritional Value and Best Perceived Nutritional Value by Product Category

      Correct identification of products with the lowest number of calories per serving was somewhat mixed by product category (Table 3, available online at www.andjrnl.org). But respondents scored higher with versions 2, 3, or 4 compared with version 1, even though the Nutrition Facts label was always available.
      When identifying products with the highest or lowest amount of sodium, participants evaluating breakfast cereals, frozen entrées, and savory snacks had a significantly higher percentage of correct responses for versions 3 and/or 4, which included sodium information; for salad dressings, respondents' scores for versions 2 to 4 were significantly higher than for version 1 (Table 3, available online at www.andjrnl.org).
      With regard to perceived best nutritional value among three products in a category, participants evaluating versions 2 and 4 for breakfast cereal were significantly more likely to answer correctly than those evaluating version 3 (Table 3, available online at www.andjrnl.org). In contrast, for frozen entrées, version 3 respondents performed better than those evaluating versions 1 or 4. For salad dressings, version 3 participants performed better than those viewing version 1. Among individuals evaluating savory snacks, there were no significant differences across versions in perceived best nutritional value.
      When respondents were asked about their rationale for best product choices, answers varied by product type based on nutrient composition (data not shown). Large percentages of respondents within all product categories made selections based on lower amounts of “nutrients to limit” (eg, sodium and saturated fat); however, for breakfast cereals and savory snacks, participants' rationale was often related to more “nutrients to encourage,” for example, fiber and protein, in the product.

      More Nutrient Information Increased Ease of Understanding and Interpretation

      Ratings Ease of Understanding

      Ratings about ease of answering questions were generally significantly higher among participants who evaluated front-of-package labels with more information (versions 3 and/or 4) than those who evaluated front-of-package labels with some or no information (Table 4). In one notable exception, for all products where the front of package included calorie information, respondents reported greater ease of answering questions about lowest calories per serving. Representing another exception, salad dressings rated higher for ease of answering questions about %DV with version 2 than with version 4.

      Interpretation

      Respondents were asked to evaluate the front-of-package nutrition information regarding eight interpretation attributes (Table 5). The percentage of participants who strongly agreed or agreed that the front-of-package's nutrition information (across all four product categories) helped them make an informed decision was significantly higher for version 3 and 4 respondents than for version 2 respondents. This same outcome was noted when participants rated whether the information was easy to understand and should be included on other food product packaging. Regardless of food category, all version 2 participants strongly agreed that the front-of-package “does not include enough important information.”

      Increasing Nutrient Information on Front of Package Improved Comprehension at All Educational Levels

      Comprehension

      When data were segmented by socioeconomic variables, only education level had any consistent, significant impact on comprehension. More front-of-package information improved comprehension scores at all education levels for breakfast cereals and frozen entrées (Table 6).
      Table 6Successful identification of absolute amounts and percent daily values of nutrients on four versions of front-of-package information for four product categories by primary household grocery shoppers who responded to an interactive online survey reported by consumer education level (n=7,363)
      Survey respondents (n=7,363) were randomized to view and answer questions about six products within two of four product categories (breakfast cereals and frozen entrées or salad dressings and savory snacks) that specifically displayed only one of the four available front-of-package versions.
      Front-of-package versions varied in amount and type of information: version 1 contained no front-of-package information and version 4 contained the most front-of-package information.
      Key evaluation measuresNumber of Questions (n=9) Answered Correctly
      Nine questions assessed primary grocery shoppers' comprehension of front-of-package information: Five questions involved identification of absolute numbers and four involved identifying percent daily values on front of package.
      Version 1: None (n=1,832)Version 2: Calories only (n=1,850)Version 3: Calories+nutrients to limit
      Nutrients to limit: saturated fat, sodium, and total sugars.
      (n=1,830)
      Version 4: Calories+nutrients to limit
      Nutrients to limit: saturated fat, sodium, and total sugars.
      +nutrients to encourage
      Nutrients to encourage: fiber, vitamin A and folate for breakfast cereals; protein, vitamin A, and iron A for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks.
      (n=1,851)
      mean±standard deviation
      Breakfast cereals
      Some high school or less7.36±2.167.56±1.917.62±1.708.45±1.29
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      High school graduate7.99±1.617.94±1.738.11±1.308.71±0.73
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Some college8.04±1.598.13±1.428.32±1.17
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      8.72±0.89
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      College graduate8.21±1.328.00±1.618.24±1.27
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      8.61±1.02
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Frozen entrées
      Some high school or less7.35±2.777.71±2.287.69±2.238.44±1.75
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      High school graduate7.92±2.197.80±2.368.15±1.48
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      8.77±0.96
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Some college8.07±2.208.10±1.928.33±1.428.81±0.93
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      College graduate8.27±1.868.00±2.238.41±1.25
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      8.76±0.95
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Salad dressings
      Some high school or less8.22±1.858.39±1.428.44±1.158.68±0.82
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      High school graduate8.67±1.018.70±0.848.71±0.778.69±0.80
      Some college8.70±0.948.70±0.998.68±0.998.72±0.95
      College graduate8.76±0.908.67±0.968.71±0.908.78±0.76
      Savory snacks
      Some high school or less8.06±1.778.07±1.808.34±1.348.52±1.04
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      High school graduate8.49±1.158.47±1.198.48±1.248.45±1.30
      Some college8.50±1.218.54±1.048.48±1.238.60±1.06
      College graduate8.56±1.168.55±1.258.56±1.068.68±0.81
      a Survey respondents (n=7,363) were randomized to view and answer questions about six products within two of four product categories (breakfast cereals and frozen entrées or salad dressings and savory snacks) that specifically displayed only one of the four available front-of-package versions.
      b Front-of-package versions varied in amount and type of information: version 1 contained no front-of-package information and version 4 contained the most front-of-package information.
      c Nine questions assessed primary grocery shoppers' comprehension of front-of-package information: Five questions involved identification of absolute numbers and four involved identifying percent daily values on front of package.
      d Nutrients to limit: saturated fat, sodium, and total sugars.
      e Nutrients to encourage: fiber, vitamin A and folate for breakfast cereals; protein, vitamin A, and iron A for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks.
      x Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      y Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      z Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Notably, more information also improved comprehension scores for those assigned to salad dressings and savory snacks, but only for those with some high school or less. Those with higher levels of education scored higher on version 1 questions; therefore, the difference in scores between versions 1 and 4 was not large enough to show a significant difference in comprehension.

      Interpreting the Web-Survey Findings

      The purpose of food labeling is to assist consumers in selecting foods to build a healthful diet.

      Nutrition Labeling and Education Act. 1990. Pub L No. 101-535, 104 Stat 2353. Library of Congress website. http://thomas.loc.gov/cgi-bin/bdquery/z?d101:HR03562:@@@D&summ2=3&|TOM:/bss/d101query.html. Accessed November 30, 2013.

      The purpose of a front-of-package system, especially a fact-based one, is to help consumers quickly and easily compare products while shopping. The versions of the front-of-package system with more information, for example, version 3 and 4, tested in this study, generally enabled grocery shoppers to demonstrate improved comprehension of nutrient content of food products tested. These more robust versions also increased ease of understanding nutrition information and assisted with interpreting nutrition information on the products included in the study.

      Reported Food Label Behaviors

      More than 80% of the 7,363 participants reported reading the Nutrition Facts label when purchasing a product for the first time. Although this percentage is comparable with FDA findings

      US Food and Drug Administration. 2008 Health and diet survey. http://www.fda.gov/Food/FoodScienceResearch/ConsumerBehaviorResearch/ucm193895.htm. Accessed November 30, 2013.

      for this behavior, other surveys about shoppers' label-reading habits report that approximately 65% read labels in the store.

      International Food Information Council Foundation. 2012 Food & Health Survey: Consumer Attitudes Toward Food Safety, Nutrition & Health. May 2012. http://www.foodinsight.org/Content/3840/2012%20IFIC%20Food%20and%20Health%20Survey%20Report%20of%20Findings%20(for%20website).pdf. Accessed November 30, 2013.

      Food Marketing Institute
      US Grocery Shopper Trends 2012.

      Increasing Shoppers' Comprehension

      In general, increasing the amount of nutrition information on the front of package improved accuracy and lessened the need to use the Nutrition Facts label. Consumers obtained the information they needed from the front-of-package label and therefore did not need to take time studying the Nutrition Facts label. Notably, the increased comprehension was seen for those at the lower educational levels. This finding is especially important because these consumers usually have a lower comprehension of the Nutrition Facts label.
      • Levy A.S.
      • Fein S.B.
      Consumers' ability to perform tasks using nutrition labels.
      This front-of-package labeling system, especially version 4, assisted them in making more accurate assessments about the nutrient content of the food.
      In general, consumers who were presented with the most front-of-package information on breakfast cereal and frozen entrée packaging had higher accuracy scores. However, consumers were occasionally just as accurate in understanding nutrient information when provided fewer or no front-of-package details for salad dressings and savory snacks. This result may be because the Nutrition Facts labels for salad dressings and savory snacks were much less complicated—that is, listed fewer nutrients—compared with breakfast cereals and frozen entrées (Table 2, available online at www.andjrnl.org). The front-of-package labeling system was most helpful when a significant amount of information was in the Nutrition Facts label. The front-of-package system also resulted in more accurate assessments of nutrition quality if nutrients to encourage are included (version 4), which was also found by Roberto and colleagues.
      • Roberto C.A.
      • Bragg M.A.
      • Schwartz M.B.
      • et al.
      Facts Up Front versus traffic light food labels: A randomized controlled trial.
      Notably, scores for identifying %DV for nutrients to encourage were significantly lower among respondents assigned to version 3 compared with versions 1, 2, or 4 in almost all product categories. When asked to identify information about nutrients not displayed on the front of package, those viewing versions 1 or 2 largely turned to the Nutrition Facts label for information. However, those viewing version 3, which included calories and nutrients to limit, were less likely to find information about nutrients to encourage. This finding is concerning because encouraging nutrients and, therefore, foods needed to build a healthful diet, is critical to long-term health.
      The US Dietary Guidelines encourage nutrient-dense/-rich foods and identify which to limit.
      US Departments of Agriculture and Health and Human Services
      Dietary Guidelines for Americans, 2005.
      US Departments of Agriculture and Health and Human Services
      Dietary Guidelines for Americans, 2010.
      A front-of-package labeling system on the product package should assist in communicating this information and more fully represent the nutrient contribution—not just nutrients to limit—of a food or beverage product. Nutrient-dense foods and beverages help consumers achieve healthful diets without overconsuming energy.
      • Miller G.D.
      • Drewnowski A.
      • Fulgoni V.
      • et al.
      It is time for a positive approach to dietary guidance using nutrient density as a basic principle.
      A disproportionate focus on nutrients to limit may lead consumers to restrict healthful foods, such as tree nuts and avocado-based products, which are high in fat but provide significant amounts of nutrients to encourage. A recent survey showed that although 33% of consumers are limiting calories, sugar, fat, and salt, they are also looking for healthier versions of foods they eat every day.
      Food Marketing Institute and Prevention Magazine
      Shopping for Health.
      Consumers are trying to make more of their calories count for better overall health.
      Food Marketing Institute and Prevention Magazine
      Shopping for Health.
      Therefore, it is important to include nutrients to encourage and limit on the front of package.

      Increasing Ease of Understanding and Interpretation Ratings

      Consumers agreed that more nutrition information on the front of package assisted them in comprehension and that such information should appear on more products. Other studies have shown that more information is usually preferred.
      • Geiger C.J.
      • Wyse B.W.
      • Parent C.R.M.
      • Hansen R.G.
      Bar graph, informative nutrition labels deemed most useful for consumer purchase decisions using adaptive conjoint analysis.
      In this study, presentation of the front of package with nutrients to encourage and limit and including some nutrients in both absolute numbers and %DV likely satisfied consumers' needs.
      Among consumers who evaluated front-of-package versions 2, 3, or 4, there was greater agreement that the nutrition information aided in decision making and understanding than when given just the number of calories.
      The ideal front-of-package system should be transparent and science based.
      • Miller G.D.
      • Drewnowski A.
      • Fulgoni V.
      • et al.
      It is time for a positive approach to dietary guidance using nutrient density as a basic principle.
      The system tested is consistent in appearance with the Nutrition Facts label, which consumers consider trustworthy,

      International Food Information Council Foundation. Food label consumer research project: Qualitative research findings. Food Insight, January 8, 2010. http://www.foodinsight.org/Resources/Detail.aspx?topic=IFIC_Foundation_Food_Label_Consumer_Research_Project. Accessed November 30, 2013.

      is fact based and not interpretive, complies with the Code of Federal Regulations,

      US Department of Health and Human Services, Food and Drug Administration. Code of Federal Regulations, Title 21. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?cfrpart=101. Accessed November 30, 2013.

      and has received enforcement discretion from the FDA for general use on the front of package

      US Food and Drug Administration. Letter of enforcement discretion to GMA/FMI re “Facts Up Front.” December 13, 2011. http://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm302720.htm. Accessed November 30, 2013.

      (Figures 1 and 2). With this type of system, at-a-glance product comparisons can occur on the shelf. Such easy access to this information can be crucial to increasing consumer use of nutrition information on product packaging, especially for those with a lower education level. Interpretation of information for any front-of-package system will depend on consumer understanding and education.

      Study Limitations

      This study examined only one front-of-package system and did not compare it with other systems. The survey was cross sectional and measured consumers' reactions at one point in time. Many factors beyond nutrition information that affect food purchase and consumption decisions, such as cost and brand, were not assessed as part of the study design. Results may vary for other food categories.

      Implications for Practice and Research

      If a front-of-package labeling system is widely available, dietetics practitioners can use front-of-package information to provide clients a shortcut in making purchase decisions to build a healthful diet. When instructing clients with a high school education or less, front-of-package information is especially useful in improving understanding of nutrient information. Clients with higher education levels are likely to be able to accurately assess a product's nutritional value with or without additional front-of-package information. However, having front-of-package information on food and beverage products facilitates product comparisons.
      Well-designed and tested front-of-package labeling has the potential to positively affect the health of Americans. Any front-of-package system should be tested at baseline and then monitored and evaluated over time for impact on awareness, comprehension/understanding, purchase decisions, usage/incorporation into consumers' everyday lives, and, ultimately, effect on health. Consumer response to this front-of-package system, which is the basis for the Facts Up Front program, should be monitored and evaluated to assess its impact. This front-of-package system provides concise, factual information in a format that consumers can understand and incorporate into their everyday lives.
      Any system should be accompanied by a consumer education campaign promoted by health professional organizations, consumer groups, government agencies, commodity groups, and the food industry in order to effectively disseminate consistent messages and encourage informed food choices for an overall healthful diet.

      Supplementary Data

      Table 1Demographic, socioeconomic, health, and food label usage characteristics of household primary grocery shoppers who responded to an interactive online survey reported by total sample and by version of the front-of-package system viewed (n=7,363)
      Survey respondents (n=7,363) were randomized to one of the four available front-of-package versions. The versions varied in amount and type of information: version 1 contained no front-of-package information and version 4 contained the most front-of-package information.
      CharacteristicsTotal (n=7,363)Version 1: None (n=1,832)Version 2: Calories only (n=1,850)Version 3: Calories+nutrients to limit
      Nutrients to limit: saturated fat, sodium, and total sugars.
      (n=1,830)
      Version 4: Calories+nutrients to limit
      Nutrients to limit: saturated fat, sodium, and total sugars.
      and nutrients to encourage
      Nutrients to encourage: fiber, vitamin A, and folate for breakfast cereals; protein, vitamin A, and iron for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks.
      (n=1,851)
      mean±standard deviation
      Age (y)41.55±13.9841.58±14.0241.46±13.9741.49±14.0041.68±3.95
      Body mass index26.70±5.0426.60±5.0426.60±5.0626.75±5.0126.85±5.04
      Self-reported health status
      Health perceived as excellent (4), good (3), fair (2), poor (1).
      3.00±0.732.99±0.733.00±0.733.01±0.723.00±0.73
      Household income ($)52,353±28,12252,234±28,05252,920±28,12151,832±28,17952,419±28,149
      No. of people living in household2.97±1.482.96±1.522.94±1.422.95±1.483.01±1.50
      n (%)
      Sex
      Female4,963 (67)1,236 (67)1,246 (67)1,237 (68)1,244 (67)
      Male2,400 (33)596 (33)604 (33)593 (32)607 (33)
      Marital status
      Married3,851 (52)932 (51)968 (52)947 (52)1,004 (54)
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Living with someone949 (13)235 (13)245 (13)243 (13)226 (12)
      Single1,515 (21)389 (21)367 (20)380 (21)379 (20)
      Divorced/separated/widowed1,027 (14)269 (15)265 (14)255 (14)238 (13)
      Other/refused to answer21 (<1)7 (<1)5 (<1)5 (<1)4 (<1)
      Ethnicity
      White6,048 (82)1,493 (81)1,552 (82)1,504 (82)1,529 (83)
      African American582 (8)152 (8)148 (8)141 (8)141 (8)
      Asian282 (4)68 (4)79 (4)69 (4)66 (4)
      Other451 (6)119 (6)101 (5)116 (6)115 (6)
      Hispanic origin (can be any race)827 (11)214 (12)204 (11)213 (12)196 (11)
      Education
      High school or less2,702 (37)667 (36)680 (37)660 (36)695 (38)
      Some college2,406 (33)603 (33)604 (33)604 (33)595 (32)
      College graduate1,501 (20)375 (20)376 (20)373 (20)377 (20)
      Postgraduate754 (10)187 (10)190 (10)193 (11)184 (10)
      Employment status
      Working full time3,095 (42)770 (42)789 (43)777 (42)759 (41)
      Working part time938 (13)236 (13)221 (12)227 (12)254 (14)
      Full-time student324 (4)85 (5)84 (5)76 (4)79 (4)
      Full-time homemaker1,100 (15)266 (15)284 (15)268 (15)282 (15)
      Retired790 (11)205 (11)181 (10)194 (11)210 (11)
      Unemployed1,116 (15)270 (15)291 (16)288 (16)267 (14)
      Health problems of concernn (%)
      Obesity/overweight3,034 (35)739 (40)781 (42)728 (40)786 (42)
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      High cholesterol2,591 (35)660 (36)641 (35)622 (34)668 (36)
      Hypertension/high blood pressure2,570 (35)649 (35)
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      591 (32)641 (35)
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      689 (37)
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Diabetes1,590 (22)399 (22)380 (21)396 (22)415 (22)
      Heart disease1,167 (16)301 (16)285 (15)275 (15)306 (17)
      Osteoporosis1,066 (14)264 (14)263 (14)256 (14)283 (15)
      Cancer847 (12)215 (12)204 (11)208 (11)220 (12)
      Stroke654 (9)180 (10)
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      148 (8)167 (9)159 (9)
      Not reported2,595 (35)615 (34)666 (36)684 (37)
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      630 (34)
      Children in household (0 to 17 y)4,615 (63)1,116 (61)1,153 (62)1,121 (61)1,225 (66)
      Portion of household's grocery shopping performed personally by respondent
      All5,200 (71)1,325 (72)
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      1,277 (69)1,299 (71)1,299 (70)
      Half or more2,163 (29)507 (28)573 (31)
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      531 (29)552 (30)
      Self-reported frequency of reading food labels when buying products for first time
      Regularly4,369 (59)1,034 (56)1,079 (58)1,128 (62)
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      1,128 (61)
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Occasionally2,003 (27)498 (27)513 (28)488 (27)504 (27)
      Rarely727 (10)220 (12)
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      185 (10)163 (9)159 (9)
      Never264 (4)80 (4)
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      73 (4)51 (3)60 (3)
      Self-reported frequency of reading food labels to compare nutritional values when shopping
      Regularly3,668 (50)848 (46)906 (49)961 (53)
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      953 (51)
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Occasionally2,585 (35)656 (36)645 (35)639 (35)645 (35)
      Rarely858 (12)248 (14)
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      237 (13)
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      176 (10)197 (11)
      Never252 (3)80 (4)
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      62 (3)54 (3)56 (3)
      n (%)
      Self-reported frequency of reading food labels when buying food products regularly
      Regularly2,663 (36)599 (33)671 (36)
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      697 (38)
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      696 (38)
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Occasionally2,958 (40)742 (41)719 (39)753 (41)744 (40)
      Rarely1,424 (19)405 (22)
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      371 (20)
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      317 (17)331 (18)
      Never318 (4)86 (5)89 (5)
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      63 (3)80 (4)
      a Survey respondents (n=7,363) were randomized to one of the four available front-of-package versions. The versions varied in amount and type of information: version 1 contained no front-of-package information and version 4 contained the most front-of-package information.
      b Nutrients to limit: saturated fat, sodium, and total sugars.
      c Nutrients to encourage: fiber, vitamin A, and folate for breakfast cereals; protein, vitamin A, and iron for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks.
      d Health perceived as excellent (4), good (3), fair (2), poor (1).
      w Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      x Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      y Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      z Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      Table 2Comprehension and identification of absolute amounts and percent daily values of nutrient measurements for four food categories by primary household grocery shoppers who responded to an interactive online survey reported by version of the front-of-package system (n=7,363)
      Survey respondents (n=7,363) were randomized to view and answer questions about six products within two of four product categories (breakfast cereals and frozen entrées or salad dressings and savory snacks) that specifically displayed only one of the four available front-of-package versions.
      Front-of-package versions varied in amount and type of information: version 1 contained no front-of-package information and version 4 contained the most front-of-package information.
      Key evaluation measures
      The number of Nutrition Facts label nutrients and percent of Daily Value listings per product category: breakfast cereals, 57; frozen entrées, 27; salad dressings, 21; savory snacks, 21.
      Percentage of Correct Answers for Total Sample
      Version 1: None (n=1,832)Version 2: Calories only (n=1,850)Version 3: Calories+nutrients to limit
      Nutrients to limit: saturated fat, sodium, and total sugars.
      (n=1,830)
      Version 4: Calories+nutrients to limit
      Nutrients to limit: saturated fat, sodium, and total sugars.
      +nutrients to encourage
      Nutrients to encourage: fiber, vitamin A, and folate for breakfast cereals; protein, vitamin A, and iron for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks.
      (n=1,851)
      Breakfast cereals
      Absolute number identification
       Calories9195
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      96
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      98
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Sodium (mg)848492
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      94
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Saturated fat (g)888795
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      97
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Sugars (g)93
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      9095
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      97
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Fiber (g)808387
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      93
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Total87889496
      %DV
      %DV=percent daily value.
      identification
       Sodium908894
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      96
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Saturated fat898693
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      98
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Fiber84
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      81
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      7292
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Folate91
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      90
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      8397
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Total88868696
      Frozen entrées
      Absolute number identification
       Calories8996
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      97
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      98
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Sodium (mg)878596
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      97
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Saturated fat (g)87
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      8396
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      97
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Sugars (g)908897
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      98
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Protein (g)87
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      87
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      7898
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Total88879397
      %DV identification
       Sodium908995
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      97
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Saturated fat868592
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      94
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Vitamin A92
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      91
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      8797
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Iron90
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      88
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      8397
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Total90888996
      Salad dressings
      Absolute number identification
       Calories9597
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      98
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      98
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
       Sodium (mg)969497
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      97
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Sugars (g)979698
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      98
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Cholesterol (mg)97
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      96
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      8988
       Saturated fat (g)929196
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      97
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Total96959596
      %DV identification
       Vitamin A97
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      97
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      9393
       Vitamin C96
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      98
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      9393
       Sodium93949597
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Calcium97
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      96
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      9191
       Total96969394
      Savory snacks
      Absolute number identification
       Calories9698
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      98
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      98
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
       Sodium (mg)929397
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      97
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Saturated fat (g)908997
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      96
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Sugars (g)979798
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      98
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Protein (g)96
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      95
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      8888
       Total94949595
      %DV identification
       Sodium (DV%)939396
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      96
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Saturated fat (DV%)888891
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      93
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Vitamin C (DV%)96
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      95
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      9292
       Iron (DV%)95
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      94
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      9095
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Total93929294
      a Survey respondents (n=7,363) were randomized to view and answer questions about six products within two of four product categories (breakfast cereals and frozen entrées or salad dressings and savory snacks) that specifically displayed only one of the four available front-of-package versions.
      b Front-of-package versions varied in amount and type of information: version 1 contained no front-of-package information and version 4 contained the most front-of-package information.
      c The number of Nutrition Facts label nutrients and percent of Daily Value listings per product category: breakfast cereals, 57; frozen entrées, 27; salad dressings, 21; savory snacks, 21.
      d Nutrients to limit: saturated fat, sodium, and total sugars.
      e Nutrients to encourage: fiber, vitamin A, and folate for breakfast cereals; protein, vitamin A, and iron for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks.
      f %DV=percent daily value.
      w Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      x Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      y Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      z Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      Table 3Identification of products with the lowest or highest nutritional value and best perceived nutritional value for four food product categories performed by primary household grocery shopper respondents to an interactive online survey reported by version of the front-of-package system (n=7,363)
      Survey respondents (n=7,363) were randomized to view and answer questions about six products within two of four product categories (breakfast cereals and frozen entrées or salad dressings and savory snacks) that specifically displayed only one of the four available front-of-package versions.
      Front-of-package versions varied in amount and type of information: version 1 contained no front-of-package information and version 4 contained the most front-of-package information. Those respondents assigned to versions 1 and 2 needed to refer to the Nutrition Facts label to answer all or some of these questions, respectively.
      Nutrient questionsPercentage of Responses of Individuals by Front-of-Package Version
      Version 1: None (n=1,832)Version 2: Calories only (n=1,850)Version 3: Calories+nutrients to limit
      Nutrients to limit: saturated fat, sodium, and total sugars.
      (n=1,830)
      Version 4: Calories+nutrients to limit
      Nutrients to limit: saturated fat, sodium, and total sugars.
      +nutrients to encourage
      Nutrients to encourage: fiber, vitamin A, and folate for breakfast cereals; protein, vitamin A, and iron for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks.
      (n=1,851)
      Breakfast cereals
      Which of these three breakfast cereal products contains the lowest number of calories per serving?
      Product 1
      Product number that carried the correct answer is underlined.
      9093
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      9395
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
       Product 23433
       Product 33
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      122
       Don't know/not sure4
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      23
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      1
      Which of these three breakfast cereal products contains the lowest amount of sodium per serving?
       Product 1912
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      78
      Product 284
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      7988
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      88
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Product 33222
       Don't know/not sure4
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      6
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      32
      Now looking at all three of these breakfast cereal products, please select which product you believe is the best choice with respect to nutritional value.
      Product 17071
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      6773
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Product 2131217
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      12
       Product 33322
       None8789
       Don't know/not sure6
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      6
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      7
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      3
      Frozen entrées
      Which frozen entrée product contains the lowest number of calories per serving?
      Product 1899294
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      94
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Product 224
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      33
       Product 34
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      222
       Don't know/not sure4
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      211
      Which frozen entrée product contains the highest amount of sodium per serving?
       Product 129
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      29
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      2222
       Product 24
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      323
      Product 3636374
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      74
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
       Don't know/not sure4
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      5
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      11
      Now looking at all three of these frozen entrée products, please select which product you believe is the best choice with respect to nutritional value.
      Product 1757881
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      76
       Product 29
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      7610
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
       Product 33333
       None7767
       Don't know/not sure6555
      Salad dressings
      Which salad dressing product contains the lowest number of calories per serving?
      Product 19496
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      96
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      96
       Product 21112
       Product 33
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      211
       Don't know/not sure2
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      111
      Which salad dressing product contains the lowest amount of sodium per serving?
       Product 130
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      26
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      2224
       Product 23222
      Product 36469
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      74
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      73
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
       Don't know/not sure3
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      2
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      11
      Now looking at all three of these salad dressing products, please select which product you believe is the best choice with respect to nutritional value.
      Product 1808384
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      83
       Product 23323
       Product 33222
       None11
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      898
       Don't know/not sure4434
      Savory snacks
      Which savory snack product contains the lowest number of calories per serving?
      Product 1899094
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      92
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
       Product 22212
       Product 34544
       Don't know/not sure4
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      3
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      22
      Which savory snack product contains the highest amount of sodium per serving?
      Product 1899094
      Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      92
       Product 23
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      323
       Product 34
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      323
       Don't know/not sure3423
      Now looking at all three of these savory snack products, please select which product you believe is the best choice with respect to nutritional value.
      Product 186858887
       Product 21212
       Product 34
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      Significantly different from version 4 at P<0.05. Comparisons are made horizontally.
      4
      Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      22
       None5545
       Don't know/not sure4433
      a Survey respondents (n=7,363) were randomized to view and answer questions about six products within two of four product categories (breakfast cereals and frozen entrées or salad dressings and savory snacks) that specifically displayed only one of the four available front-of-package versions.
      b Front-of-package versions varied in amount and type of information: version 1 contained no front-of-package information and version 4 contained the most front-of-package information. Those respondents assigned to versions 1 and 2 needed to refer to the Nutrition Facts label to answer all or some of these questions, respectively.
      c Nutrients to limit: saturated fat, sodium, and total sugars.
      d Nutrients to encourage: fiber, vitamin A, and folate for breakfast cereals; protein, vitamin A, and iron for frozen entrées; vitamin A, vitamin C, or calcium for salad dressings; and vitamin C or iron for savory snacks.
      e Product number that carried the correct answer is underlined.
      w Significantly different from version 1 at P<0.05. Comparisons are made horizontally.
      x Significantly different from version 2 at P<0.05. Comparisons are made horizontally.
      y Significantly different from version 3 at P<0.05. Comparisons are made horizontally.
      z Significantly different from version 4 at P<0.05. Comparisons are made horizontally.

      References

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      2. Federal Food, Drug and Cosmetic Act of 1938. 52 USC § 1040. US Food and Drug Administration website. http://www.fda.gov/opacom/laws/fdcact/fdctoc.htm. Accessed November 30, 2013.

      3. American Heart Association. Heart-check food certification program. http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HeartSmartShopping/Heart-Check-Mark-Food-Certification_UCM_300133_Article.jsp. Accessed November 30, 2013.

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        • Food Marketing Institute and Prevention Magazine
        Shopping for Health.
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      7. Kellogg's. How to read a nutrition label. http://www.kelloggs.com/en_US/the-benefits-of-cereal/how-to-read-a-nutrition-label.html. Accessed November 30, 2013.

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        • Sutherland L.A.
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        • 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
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        • Sacks G.
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        Food labeling: Use of symbols to communicate nutrition information, consideration of consumer studies and nutritional criteria. Public hearing; request for comments.
        Fed Reg. 2007; 72: 39815-39818
        • US Food and Drug Administration
        Front-of-pack and shelf tag nutrition symbols; establishment of docket; request for comments and information.
        Fed Reg. 2010; 75 (22, 602-622, 606)
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      23. US Food and Drug Administration. Letter of enforcement discretion to GMA/FMI re “Facts Up Front.” December 13, 2011. http://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm302720.htm. Accessed November 30, 2013.