The first nutrition labels mandated by the Food and Drug Administration appeared on food packages in 1994. A key update occurred in 2016, informed by new science on the link between diet and chronic disease. Along the way, things like trans fats and added sugars were required, but all along, the labels have been laden with numbers and appear on the back or side of packages. There has long been interest in more succinct and consumer-friendly labeling systems that might appear on the front of packages. Such systems exist outside the US, but for political reasons and lobbying by the food industry, have been blocked in the United States. There's new hope, however, described in a recent opinion piece by Christina Roberto, Alyssa Moran, and Kelly Brownell in the Washington Post. Today, we welcome Dr. Christina Roberto, lead author of that piece. She is the Mitchell J. Blutt and Margot Krody Blutt Presidential Associate Professor of Health Policy in the School of Medicine at the University of Pennsylvania.

Interview Summary

This is a really important topic, and if the nation gets this right, it really could make a difference in the way people make product decisions as they're in the supermarket. So, let's talk first about the importance of labeling on the front of the package. Why is that important when all the information is somewhere else, namely on the side or the back?

I think there's a couple of key reasons why it's good to do front of packaging food labeling specifically. So, as you mentioned, it was a huge deal in 1994 to get this information mandated to be on food packaging to begin with, right? All of a sudden, there was much more transparency about what's in our food supply, but that being said, when you think about the nutrition facts label, it's pretty dense. There's a lot of percentages, there's a lot of numbers, there's a lot of information to process. And when people are actually in the supermarket shopping, they're making these split-second decisions, right? So, it's not to say that some consumers are turning it around and inspecting that packaging, but the reality is, for most people, it's a very habitual behavior. And so, we want to be in a place where that information is prominent, it's easily accessible, and it's easy to understand so that when you're making those snap judgements, they can be informed judgments.

So, you're not talking about taking what's on the back and just moving it to the front. You're talking about a different set of information and symbols that might be available?

That's right. Yeah. What front of package labeling is designed to do is just take some of the key bits of information that we know from science is going to be most important for consumers to base their nutritional decisions on. That's things like saturated fat, sodium, added sugars, right? And moving that to the front of the package and communicating about it in a very simple, clear way. So, no numbers, no percentages, just very straightforward language. And ideally some sort of icon, like an exclamation point, that would draw attention to that symbol and just quickly let consumers know that this product is high in those nutrients that you need to be concerned about and you need to try to limit.

Why is it an important time to be thinking about this issue in the US?

It's an important and it's an exciting time because the FDA right now is highly interested in actually moving forward on a policy that would require these types of front of package labels. And that hasn't been true, as you noted, for about a decade. But last year, the White House convened a very significant conference that hadn't happened in 50 years about nutrition, health, and hunger. And front of package labeling actually made it into their report in that conference as a key objective for this country in terms of a food policy that, under the Biden administration, they want to achieve. What we're seeing the FDA do now is actually undertake a series of research studies to try to understand what should this label look like, and how should it be designed to be consumer friendly. With the hope that actually we'll get a proposed rule on this potentially by June, and even if not by June. There's clear momentum that it looks like this is going to be happening in the near future.

In a few minutes, I'd like to ask you about what's taken place in other countries, but what's been the history of this in the US?

Front of package labeling really came to a head back in 2009. And it's actually quite a delight to share this with you, Kelly, because you and I were doing some research around it at the time. So, what played out then is a labeling system was introduced called Smart Choices. At its face, it seemed to make sense, right? It was going to be a check mark that was going to be put on products that were deemed to be healthy as a smart choice. So, a consumer could look at that and select something they wanted to eat that was relatively healthy. The reality is when that labeling system came out, it was on Fudgesicles and it was on Cookie Crisp cereal, and there was a lot of kind of concern about whether this type of labeling system was systematically problematic and was going to mislead consumers. And at that time, Kelly, I was a grad student at the Rudd Center and you really taught me quite a bit about how to make things happen and how to have a public health impact. Because we were quite concerned about that system, we actually did a study where we randomly sampled 100 products from Smart Choices and we applied an objective nutrition standard - an algorithm to score those products. What we found is that 64% of those Smart Choices products would not meet healthy by this objective nutrition standard. And so, you had the vision to reach out to the New York Times and alert the media to this. And we started to see a lot of kind of concerning reports in the media, like Smart Choices, what's going on? This doesn't seem very smart. We had done this little bit of science, and then at the Rudd Center, you had reached out to the attorney general of Connecticut at the time, Dick Blumenthal, who was quite interested in consumer protection issues and worked a lot on tobacco. And he took this up as a real public health champion to say this is concerning, we have some of this science, and he came out and threatened legal investigation into that program. What was so remarkable to see in that story, particularly for me as a grad student, was wow you can get these different actors coming together, right? Some of that media attention, science playing the role it needs to play, a public health champion who can really make a difference in the attorney general, and all of that can come together and this program literally halted, they stopped it. And I should say, that was a great public health victory. But immediately after that, the Institute of Medicine, so now the National Academy of Medicine, was charged with writing two reports on front of package labeling. And they came out with one that was focused on the nutrition criteria that should underlie a system like that, and one about the design of the label. And they had some great recommendations, very consistent with what you and I have seen in the science, right? It needs to be accessible, simple, easy to understand. Well, what ended up happening is not much. The industry at that point then released their voluntary labeling system that they call Facts Up Front, which is what we have to this day. And as you might imagine, it has percentages and it has grams and milligrams and it's confusing, and they can also highlight positive nutrients on there. So you can have a Cookie Crisp cereal that's also touting the amount of fiber, the amount of protein. And so that's really what we've been stuck with. It's now only over a decade later that we are at this moment where we're finally seeing this progress, and we're at a place where we might get a labeling system that does a really good job of communicating this information to the consumer.

I guess one sort of ironic form of evidence that such a system is likely to really help consumers make decisions is how hard the industry has fought against having such a system. And not to mention the science that exists suggesting that these things might be helpful. A lot of activity has occurred outside the US. Can you describe some of that?

Over 40 countries have front of package labeling systems. Now, some are mandatory, some are voluntary. The mandatory ones, as you might imagine, produce better effects. They range. And many of them are designed really well. So, let's take some of the best examples. Chile, for example, has warning labels that alert consumers to whether products are high in saturated fat, sugars, sodium, and calories, and those symbols are designed in a very intuitive way. They're stop sign shaped, so they really leverage the automatic associations consumers have. They're prominent, they're black, they stand out from the packaging. And these well-designed labels, we now have evidence from scientific evaluations that they're producing effects, right? They're leading consumers to purchase less of these unhealthy nutrients. They're also leading to some reformulation. And by that, I mean the industry is trying to figure out, 'well, can we lower the sodium, so we don't get one of those labels?' The other thing that I think is often overlooked with labeling but is so important is once you decide to label the food supply and you have an agreed upon system, that can support other policies. And that's what we see in Chile as well. Now all of a sudden, you can't market foods with these warning labels to kids, right? And you can't sell those foods with these warning labels to kids in schools. So, it really has even a broader impact than just the behavior change you see from the labeling, and so many other countries have followed suit. Mexico has a very similar labeling system. One thing that they've learned from Chile is, and this is a concern, that as the industry brings down the levels of sugar, for example, in foods in response to labeling, they're increasing the levels of non-sugar sweeteners, right? Things like Sucralose or Stevia or monk fruit, and so that's a worry. Mexico has, in addition, also labeled those non-sugar sweeteners on the food packaging. And then you see other examples. France has a really nice system. It's called Nutri-Score. Very intuitive. There are letter grades. I myself had the chance to go to France. I was trying to buy some turkey for my son. I don't speak a bit of French, and I'm standing in the supermarket and I just see the letter grade A and I think, oh, okay, I'll pick that one.

Great, great example.

Yes, very intuitive systems around the world.

So, are there studies showing which of these systems work and what sort of effects they have? And I know you've done additional work beyond what you mentioned earlier.

Absolutely, and there are a whole range of studies, whether they're randomized controlled trials, lab studies, or online experiments. And then the more compelling, convincing evidence, which comes from natural experiments that are done around the globe, or even research we have from stores that have voluntary implemented these labels and we can look at changes in sales data. And what all that boils down to is labeling will produce behavioral effects. They will get people to purchase healthier foods, they will get people to purchase less of the unhealthy foods. Labels inform consumers, which I think is kind of the first order goal, right? Like let's just make sure people understand what's in the food supply, and then we see this reformulation. And that's been true, even if you look back to trans fat labeling, like requiring trans fat on the labels was also associated with trans fat coming out of the food supply. So, I think we can feel really good and solid that labeling can help people make healthier choices. And as anyone who's worked on issues related to chronic diseases, we're going to need a suite of policies, right? Labels are never going to be the silver bullet. They're not designed to be, but it's a policy that makes a lot of sense. It's a very cost effective policy. It's not very expensive to do labeling, and it can help support many other policies that might produce bigger effects.

So, given the different options, the different kind of systems that have been proposed or are out there in use, do you have a sense of what ultimately might be the best system?

I think the FDA has some good options in front of them. Now, if I were to wave a magic wand, I would do warning labels. I would make them more similar to what's done in Chile, just because we have good evidence that warnings in particular, and these kinds of symbols like a stop sign, are probably going to be more effective at educating consumers and shaping behavior. Now, that being said, we have some unique legal challenges in the US for getting a system like that. The FDA is proposing, I think, a totally reasonable, science-based label that essentially would have what it's high in and then indicate whether it's high in added sugar or saturated fat or sodium. I would love to see that label also have some sort of icons, some eye-catching exclamation point or something like that, but that label is great, it's a great option. Let's compare it now to what the industry is pushing for, which is basically what we have now, facts upfront. And as I said earlier, this is a label that has percent daily values, that has grams, that has milligrams, that can highlight positive nutrients that are going to appear on unhealthy foods. I think when you look at those two options, it's just a no-brainer to go with this very simple, very straightforward, high-end label that lists the nutrients and let's put some sort of icon on it.

So are you optimistic about where things might go?

Well, I'm a glass half full kind of person. I would say yes, I try to be very optimistic, but I think there's reason to be. I think we have some good options on the table, FDA is moving forward, research is being done, scientists and others are highly engaged in this process and giving feedback to FDA. And so many other countries have done this. So yes, I am feeling optimistic.

So at the end of the day, a lot of this will come down to how much the FDA can resist pressure from the food industry.

Right, so many things in food policy do come down to that.

That's really true. So true. It's interesting, one of the things that you highlighted, but I'd like to even bring a little more attention to is the issue of the industry reformulating its products so that they don't have to show these negative labels. That's such a potentially powerful public health consequence of this, that it needs to be focused on even more. I'm hoping the valuations are being done of the impact of that on public health. Because you can make an argument, couldn't you, that if these labels don't affect the purchasing behavior of a single individual, they still could have enormous public health benefit just because of the reformulation, do you agree?

Oh, 100%. Yes, absolutely. I would even argue that we have very few mechanisms to hold industry accountable, and to me is just a fundamental right of consumers. Like they have the right to know, there needs to be transparency, and great that they are likely to produce behavior change and great that they are likely to make the industry reformulate, but I just feel like that there's so many reasons to do labeling that it just feels like an obvious policy to pursue.

Hopefully, any system that comes into place can be nimble as much as they can be in these government regulations to take into account new science that occurs. Like at some point, maybe a symbol that notes whether a product is ultra processed would be in order, or as you said, in France, I think it was, where they've labeled the addition of the artificial sweeteners. Was it France or was it another place?

Mexico. Yes.

That's right. Okay. Yeah, thanks for clearing that up. Something like that might enter the system, so having a system that can adjust to the science as it goes forward would be really important too.

Kelly, it's such an important point. I think part of any labeling strategy needs to be monitoring and evaluation, and particularly with the non-sugar substitutes. Like right now, we don't know, it's a very hard thing to track. It's only on the ingredient list. We can't quantify how much is in the food supply. And so I would love to see coupled with labeling some way that that gets disclosed so we can really monitor and ensure how that might be changing in the food supply over time and evaluate, to your point, what's happening in terms of reformulation.

As an aside, we've done a cluster of podcasts on the influence of these artificial sweeteners and the sugar substitutes and the available science on this, on what goes on in the brain, what happens to the microbiome, the impact of health overall is really concerning, so I totally agree with you that having that information disclosed could be really helpful.

Yes, 100%.

BIO

Christina A. Roberto, PhD is the Mitchell J. Blutt and Margo Krody Blutt Presidential Associate Professor of Health Policy at the Perelman School of Medicine at the University of Pennsylvania. She is also an Associate Director of the Center for Health Incentives and Behavioral Economics (CHIBE) at Penn. Dr. Roberto is a psychologist and epidemiologist who studies policies and interventions to promote healthy eating habits and help create a more equitable and just food system. In her work, she draws upon the fields of psychology, behavioral economics, epidemiology, and public health to answer research questions that provide policymakers and institutions with science-based guidance. Dr. Roberto earned a joint-PhD at Yale University in Clinical psychology and Chronic Disease Epidemiology. Dr. Roberto completed her clinical internship at the Yale School of Medicine and was a Robert Wood Johnson Foundation Health and Society Scholar at the Harvard T.H. Chan School of Public Health.