In recent decades, greater availability of low nutritional quality foods and decreased consumption of nutrient-dense foods have negatively impacted the nutrient profile of Canadian diets. (1,2) Canadian diets are high in sodium, free sugars, * saturated fats, and red and processed meats, and low in fruits, vegetables, whole grains and legumes. (2,3) Consequently, poor diet is now the leading risk factor for chronic disease and premature death in Canada. (4)

To prevent diet-related chronic diseases, a comprehensive approach is required, including communication of reliable, consistent nutrition information. (5) Nutrition labelling is one policy tool for communicating nutrition information. In Canada, notable shortcomings exist with the implementation and enforcement of nutrition labelling regulations. For example, consumers have identified the Nutrition Facts table (NFt) as confusing or difficult to interpret. (6) Relatively strong literacy and numeracy skills are needed to interpret percent daily value information and compare nutrient profiles across similar products. (6,7) Food labels currently provide little information about ingredient amounts, merely rank-ordering ingredients by weight and without stipulating the direction or size of the impact of those ingredients on disease risks. (8) More than 158 front-of-package (FOP) labelling systems have been documented in Canada, (9) which are applied inconsistently and to foods with dubious nutritional quality, adding to consumer confusion. (11) Moreover, current nutrition labelling systems predominantly focus on pre-packaged and processed foods, leaving Canadians with no regulated labelling system when choosing fresh foods, or when eating in out-of-home settings, such as restaurants. (6)

Further government action on nutrition labelling, including FOP, shelf, and menu labelling, is needed to help Canadians navigate the complex food environment. FOP and shelf labelling refers to simple, easily identifiable labels on FOP or shelf tags beside product prices, which can be organized into nutrient-specific or summary systems. (12,13) Menu labelling refers to the provision of nutrition information directly on menus. (14)

In May 2016, we convened a consensus conference in Vancouver, British Columbia, with experts from research, policy and practice fields, to reach consensus on recommendations for action on FOP, shelf, and menu labelling in Canada. Prior to the conference, we conducted an evidence synthesis (15) to collate the best available evidence. The conference was followed by teleconferences and circulation of drafts before finalization of recommendations. Here, we examine the evidence, opportunities and challenges surrounding nutrition labelling, and present our recommendations.

EVIDENCE

FOP and shelf labelling

The United States' National Academy of Medicine ([dagger]) recommends a single, standardized FOP labelling system. (16) Research suggests that systems aligned with these recommendations can beneficially impact the nutritional quality of consumer food purchases. (17,18) Although more research is needed comparing different labelling formats, the use of interpretive systems, such as traffic-light or star-based labelling systems, appears promising in terms of improving consumers' ability to identify nutritious products. (12,18,19) Shelf labelling research is also limited. However, evidence suggests that such labels may promote healthier choices, especially if they do not compete for shoppers' attention with other promotions. (12,19,20) Further, FOP and shelf labelling, if well designed, may encourage industry to provide more nutritious foods through product reformulation, contributing to improved diets at the population level and benefiting consumers regardless of their use of labelling. (18) However, there are concerns that product reformulation may unintentionally promote a reductive focus on nutrients, rather than highlighting the holistic quality of foods. (21) Overall, the research findings on FOP and shelf labelling should be interpreted with caution, given several limitations of available literature, including over-reliance on self-reported data and a lack of real-world studies with time constraints. (18,20,22) A process for implementing mandatory FOP labelling is underway in Bolivia, Chile, Ecuador and Peru, (23) but the fact that few, if any, countries have fully implemented mandatory FOP labelling systems to date has limited long-term impact studies. Regardless, the potential for public health impact is sufficiently strong to warrant government efforts to innovate.

Menu labelling

Reviews exploring the impact of menu labelling on outcomes, such as sales or intent to purchase, have reported relatively small impacts, with evidence suggesting effectiveness varies across population subgroups. (22,24,25) With that said, a recent meta-analysis, including real-world and experimental studies, found that menu labelling can reduce calories purchased in some contexts and for some food types. (26) In other words, it works in some restaurants, for some people, some of the time. Menu labelling has also been found to be cost-effective, with economic benefits of prevention outweighing costs. (11,27) Similar to FOP and shelf labelling research, existing menu labelling research is not without limitations (e.g., lack of real-world studies, use of few controls, small and non-representative samples), making it difficult to draw firm conclusions. (22,24,27)

OPPORTUNITIES AND CHALLENGES

Consumer confusion and protection

"Noise" from untrustworthy sources, such as media headlines and advertisements, has confounded consumers' understanding of the relationship between diet and health. With this in mind, Canada's major health and scientific organizations, such as the Hypertension Advisory Committee, (28) Dietitians of Canada, (29) Canadian Diabetes Association, (30) Heart and Stroke, (31) and the Centre for Health Science and Law, (32) have called for improvements to nutrition labelling in the name of consumer protection.

Health equity and ethical concerns

There are concerns that a focus on nutrition labelling will detract from broader issues of health equity, shifting responsibility away from government and industry actions promoting the healthfulness of the food supply, towards consumers. Our recommendations are made within the spirit of recognizing that labelling is only one tool within a larger tool kit promoting improved food environments. Prior to implementing labelling interventions, broad cross-sectoral engagement is critical to plan for unintended negative consequences, particularly from an equity perspective. There is also a need to explore potentially beneficial indirect effects of nutrition labelling, such as product reformulation.

The Canadian regulatory environment is already moving

In February 2016, the Standing Senate Committee on Social Affairs, Science and Technology called for stricter nutrition labelling regulations, including mandating the use of FOP labelling on foods required to display an NFt. (33) Seven months after our consensus conference (December 2016), Health Canada announced a consultation on a proposed FOP labelling system, ([double dagger]) whereby warning symbols highlight nutrients with negative health impacts in packaged foods, but not yet fully embracing the importance of ingredients for promoting health. (34) The proposed system takes a health protection approach, focusing on removing negative influences on health, rather than a broader health promotion approach, which would strive to provide individuals with the necessary tools to take charge of their health. Without a single, standardized approach, consumers will be faced with FOP labels in addition to existing health logos, amplifying confusion. (6) Further, in January 2017, restaurant menu labelling (calories) was mandated in Ontario with the Healthy Menu Choices Act. (35) There is potential synergy between labelling and other food environment policies identified in Canada's Healthy Eating Strategy, including changes to the NFt and food reformulation targets. (36) By acting on this moving regulatory environment, windows of opportunity exist to improve the status quo.

GENERAL RECOMMENDATIONS

To help Canadians make healthier food choices that align with current dietary guidance, we recommend that:

* Nutrition labelling, including FOP, shelf, and menu labelling, be implemented as part of a standardized, coordinated and multi-pronged approach to promote consumption of nutritious foods. We recommend that such labelling systems be:

** Supported by a robust, evidence-based nutrition profiling system, which classifies foods based on nutritional composition for purposes related to disease prevention and health promotion (37)

** Based on and aligned with information on NFts and ingredient lists

** Monitored for adherence to regulations

** Accompanied by education and communication efforts, including technological innovation (e.g., phone apps), to support consumers' right to know and increase uptake and use of nutrition information

* The Government of Canada implement evidence-based recommendations for nutrition labelling previously developed by expert organizations (e.g., Sodium Working Group, (38) World Health Organization (10))

* Key stakeholders be identified and involved throughout nutrition labelling policy development, implementation and evaluation, at stages of the process where they can avoid conflict of interest. This includes:

** Government regulators or other regulatory bodies, during all stages

** Health groups (e.g., Heart and Stroke, Dietitians of Canada, Centre for Health Science and Law), during all stages

** Independent experts, during development

** The food industry, during implementation

** Independent experts, during all stages

* In the absence of federal and provincial legislation, municipal and regional governments implement healthy food policies and initiatives involving shelf and menu labelling.

SPECIFIC RECOMMENDATIONS

Specific to FOP and shelf labelling, menu labelling, and research, we recommend that:

FOP and shelf labelling

* The Government of Canada mandate a single, standardized labelling system, whereby labels are displayed on FOP or on shelf tags

** This system extend to all grocery food products (including deli, bakery, prepared foods, and produce), thereby encouraging consumption of nutritious whole foods

** This system align with National Academy of Medicine (2012) recommendations, (16) which call for labels that are:

* Standardized: uniform provision of nutrition information, concerning content and format

* Simple: advanced nutrition knowledge is not needed for understanding; for example, calories are displayed based on servings measured in common household measure serving sizes

* Interpretive: logo summarizes and distills the overall meaning of information on NFts and ingredient lists, rather than simply restating it

* Ordinal: graduated scale or ranking system is used to represent nutritional guidance, enabling consumers to compare foods across a variety of categories

* Visually prominent: adequate in size to attract attention and contrast in appearance with existing packaging elements

* Consistently located: easy-to-find placement on all food packages

* Supported by ongoing, regularly updated promotion: complementary nutrition education campaigns guide consumers in their usage

* In addition to providing a standardized system, government-mandated stipulations prevent manufacturers and stores from presenting competing health messages or engaging in other labelling and shelving practices that undermine the usage of FOP labelling by consumers

Menu labelling

* The Government of Canada or provincial/territorial governments mandate displaying the following information on menus:

** Calorie and sodium content with appropriate formatting features to facilitate optimal use

** An evidence-based contextual statement to help consumers understand nutritional merits of menu items compared to dietary requirements, and, where children's menus are used, age-appropriate daily targets for nutrients

* Nutrition information (not just calories) and ingredients be provided for menu items on publicly available websites and supplementary documents in restaurants

* The impact of Ontario's Healthy Choices Menu Act, 201535 be monitored and evaluated

* Menu labelling be eventually extended to most restaurants and cafeterias, not just large national chain restaurants

Research

* Robust, independent research and evaluations regarding nutrition labelling in Canadian contexts be conducted. Specifically, conduct research:

** In applied real-world settings, where time constraints can affect food purchasing decisions and decision-making time is a measured variable

** With diverse population groups, including improved subgroup analysis to assess equity impacts (e.g., children, parents, nutritionally vulnerable groups, including persons from varying socio-economic backgrounds and new immigrants)

** Examining the intended and unintended impacts of food labelling on food purchasing behaviours, dietary intake and health outcomes

** Monitoring and evaluating changes to food availability, including the impact on product reformulation and introduction of new, healthier products, as well as pricing practices by retailers.

CONCLUSION

This consensus reflects a synthesis of available evidence and conference discussions regarding nutrition labelling in Canada as of January 2017. To date, the current regulatory environment has observed incremental shifts. Moving forward, we encourage government to consider more novel policy solutions, with the aim of reducing consumer confusion and promoting health. Implemented as part of a comprehensive approach, our recommendations have the potential to improve the nutrition information environment and to support Canadians in making healthier choices.

doi: 10.17269/CJPH.108.6076

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Received: January 12, 2017

Accepted: April 21, 2017

Kim D. Raine, PhD, RD, [1] Alexa R. Ferdinands, BSc, RD, [1] Kayla Atkey, MSc, [1] Erin Hobin, PhD, [2] Bill Jeffery, LLB, [3] Candace I.J. Nykiforuk, PhD, [1] Lana Vanderlee, PhD, [4] Ellen Vogel, PhD, RD, [5] Barbara von Tigerstrom, LLB, PhD [6]

Author Affiliations

[1.] School of Public Health, University of Alberta, Edmonton, AB

[2.] Public Health Ontario, Toronto, ON

[3.] Centre for Health Science and Law, Ottawa, ON; International Association of Consumer Food Organizations, Ottawa/London/Washington; and the Geneva Global Health Hub (G2H2), Geneva, Switzerland

[4.] Department of Nutritional Sciences, University of Toronto, Toronto, ON

[5.] Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON

[6.] College of Law, University of Saskatchewan, Saskatoon, SK

Correspondence: Kim D. Raine, PhD, School of Public Health, University of Alberta, 4-077 Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, AB T6G 1C9, Tel: 780-492-9415, E-mail: kim.raine@ualberta.ca

Acknowledgements: The authors acknowledge Manuel Arango, Norm Campbell, Kate Chidester, Mary Collins, Andre Corriveau, Lucie Granger, David Hammond, Mary L'Abbe, Janice Macdonald, Soultana Macridis, Rachel Prowse, Kelly Stott, Jim Talbot, Mark Tremblay and Pat Vanderkooy for participating in the consensus conference process. This study was supported by the Canadian Partnership Against Cancer through a Coalitions Linking Actions and Science for Prevention grant. C. Nykiforuk received support as an Applied Public Health Chair from the Canadian Institutes of Health Research in partnership with the Public Health Agency of Canada and Alberta Innovates--Health Solutions (2014-2019). L. Vanderlee is a CIHR Banting Postdoctoral Fellow.

Conflict of Interest: None to declare.

* "Free sugars include monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates". (10, p1)

([dagger]) Formerly known as the Institute of Medicine.

([double dagger]) This system is capable only of shifting consumers away from foods highest in these nutrients with negative health impacts (sodium, sugar, saturated fat); however, it is not consistent with the National Academy of Medicine's recommendations for effective FOP systems. As the labels are not listed on all foods in a supermarket, they will likely only appear on a small proportion of packaged foods. This system is unable to support consumers in identifying the healthiest packaged foods, or in shifting consumers away from packaged foods to whole foods.