**Destigmatizing Carbohydrate with Food Labeling: The Use of Non-Mandatory Labelling to Highlight**

**Christopher P.F. Marinangeli 1,\*, Scott V. Harding <sup>2</sup> , Andrea J. Glenn 3,4, Laura Chiavaroli 3,4 , Andreea Zurbau 3,4 , David J.A. Jenkins 3,4,5,6, Cyril W.C. Kendall 3,4,7, Kevin B. Miller <sup>8</sup> and John L. Sievenpiper 3,4,5,6**

<sup>1</sup> Pulse Canada, 920-220 Portage Avenue, Winnipeg, MB R3C 0A5, Canada

**Quality Carbohydrate Foods**


Received: 30 April 2020; Accepted: 4 June 2020; Published: 9 June 2020

**Abstract:** Dietary carbohydrates are components of healthy foods, but many carbohydrate foods have recently been stigmatized as primary causes of diet-related risk factors for chronic disease. There is an opportunity to enhance efforts within the food landscape to encourage the consumption of higher quality carbohydrate foods. The use of labelling is one strategy that permits consumers to identify healthy carbohydrate foods at the point-of-purchase. This review discusses the regulatory frameworks and examples of associated non-mandatory food labelling claims that are currently employed to highlight healthy carbohydrate foods to consumers. The existing labelling frameworks discussed here align with established measures of carbohydrate quality, such as 1. dietary fibre nutrient content claims and associated dietary fibre-based health claims; 2. the presence of whole carbohydrate foods and ingredients that are intact or reconstituted, such as whole grains; and 3. low glycemic index and glycemic response claims. Standards from Codex Alimentarius, and regulations from Australia and New Zealand, Canada, Europe, and the United States will be used to illustrate the means by which food labelling can be used by consumers to identify quality carbohydrate foods.

**Keywords:** quality carbohydrate; dietary fibre; whole grains; health claims; glycemic index

#### **1. Introduction**

"Quality carbohydrate" is a relatively new term that has been introduced as a means of discussing the contribution of carbohydrate foods to healthy diets. While not formally defined, individual and aggregated measures of carbohydrate quality have been discussed and applied within the literature, and have included one or more criteria, including total dietary fibre, whole versus refined grains, glycemic index (GI) or glycemic response, solid-to-liquid carbohydrate ratio, carbohydrate-to-fibre ratio, whole grain-to-total grain ratio, and sugar content [1–5].

Dietary carbohydrates are components of many healthy foods, including dairy, fruits and vegetables, legumes, seeds and nuts, and whole grains, yet carbohydrate foods are often stigmatized publicly as primary causes of diet-related risk factors for chronic disease. However, similar to dietary fat, the term carbohydrate encompasses various food components that, on their own and within foods, can have a spectrum of benefits on physiological function and health within dietary patterns. Fundamentally, the digestible carbohydrates obtained from foods are a source of energy for cells. Non-digestible carbohydrates, including dietary fibres and resistant starches promote stool regularity, lower circulating LDL-cholesterol, blunt postprandial glycemic responses, encourage mineral absorption in the large intestine, and impose positive effects on the human intestinal microbiome [6]. The fact that carbohydrate-rich foods are emphasized in national dietary guidelines and within dietary patterns shown to reduce cardiovascular and diabetes risk factors demonstrates their value in healthy diets [7–9].

Across jurisdictions, labelling tools exist to help consumers identify foods that align with healthy dietary patterns; this includes foods of higher carbohydrate quality. From a regulatory perspective, many jurisdictions permit the use of nutrient content claims to communicate the presence of nutrients or other healthy food components, including dietary fibre, in foods. Health claims that refer to a physiological function or a health benefit could be supported by the presence of a carbohydrate, such as specific types of dietary fibre. Other claims and labelling programs communicate the presence of intact or reconstituted foods and ingredients, such as whole grains, that contain carbohydrates and other nutrients, but also align with a jurisdiction's nutritional policies. While polarizing, low glycemic index (GI) or glycemic response claims have also been permitted where it has been acknowledged that a lower peak rise in postprandial glucose levels is a physiological benefit to consumers and a nutritional strategy for managing blood glucose levels amongst people with diabetes.

This review provides an overview of the existing regulatory frameworks and examples of associated non-mandatory food labelling claims that are currently employed to highlight high-quality carbohydrate foods to consumers. The labelling frameworks discussed align with established measures of carbohydrate quality, such as 1. dietary fibre content claims and associated dietary fibre-based health claims; 2. the presence of whole carbohydrate foods and ingredients that are intact or reconstituted, such as whole grains; and 3. low GI and glycemic response claims. Standards from Codex Alimentarius, and regulatory frameworks from Australia and New Zealand, Canada, Europe, and the United States (the US) will be used to illustrate the means by which food labelling is used to identify quality carbohydrate foods to consumers. The benefits of expanding labelling regulations to further encourage consumption of higher quality carbohydrate foods will also be discussed.

#### **2. Defining Quality Carbohydrate and Considering Consumer Perception**

The term "carbohydrate quality" can be controversial and is open to interpretation, not only from a scientific perspective, but also from the perspective of the consumer. One common feature is that quality carbohydrate foods refer to those foods that support healthy dietary patterns. Carbohydrates contribute significantly to diets around the world [10]. Indeed, carbohydrate foods are ubiquitous in the food supply, found in many forms (processed and unprocessed) with various physiological and health benefits. Therefore, it is reasonable that carbohydrate quality would not be defined by a single attribute. Often, dietary guidelines have focused on sugar, starch, and dietary fibre to inform the consumption of quality carbohydrate foods [11]. Some of these attributes are often quantified on the nutrition declaration labels of pre-packaged foods. However, in addition to these qualities, there are opportunities to use non-mandatory labelling to highlight attributes that permit the identification of quality carbohydrate foods, that resonate with consumers. For example, emphasizing the presence of whole grains, legumes, and fruits and vegetables within multi-component food products can capture the presence of dietary fibre and complex starch, but also promote vitamin and mineral intakes, along with other plant components (e.g., polyphenols, etc.) with health benefits.

With multiple domains of carbohydrate quality, the next challenge is leveraging labelling tools that encourage consumers to choose higher quality carbohydrate foods over lower quality carbohydrate foods. Increased consumption of refined and rapidly digestible carbohydrates, where dietary fibre, micronutrients, and in some cases, proteins have been removed, has been linked to the development of cardiometabolic diseases and some cancers [4]. Studies demonstrate that diets containing higher levels of dietary fibre and intact carbohydrate foods, such as whole grains, are associated with lower mortality and risk of chronic disease [12,13]. However, it seems that, in some cases, consumers have often extrapolated information referring to refined carbohydrate and negative effects on health to all types of carbohydrate and carbohydrate foods. In a recent study in Canada, when consumers from three major metropolitan cities were asked to use word associations to convey their feelings toward carbohydrates, negative descriptions revolved around overeating, weight gain, risk, and feelings of guilt [14]. In the same study however, participants distinguished between "good" and "bad" carbohydrate foods, where the former was associated with fruits and vegetables, dietary fibre, whole grains, and slowly digestible carbohydrates [14]. These findings mirror a recent consumer survey by the International Food Information Council Foundation, where 23% of US adults believed carbohydrates cause weight gain, which was second to sugar at 27% [15]. Conversely, only 13% of participants believed fats caused weight gain. While these perceptions stigmatize carbohydrates, in the same survey, over 80% of participates identified dietary fibre and whole grains as healthy foods [15].

From the consumer data, there is an opportunity to enhance efforts within the food landscape to encourage higher consumption of quality carbohydrates. As outlined previously, various measures of quality carbohydrates have been applied to foods and diets in a research setting to quantify their characterization as quality carbohydrate foods. While all measures of quality carbohydrates used academically may not be suitable for labelling initiatives, there are broad domains of carbohydrate quality that can and are already used in the marketplace. In 2017, a workshop hosted by the International Life Science Institute North America put forth vision statements that identified three domains of quality carbohydrate foods: 1. a source of dietary fibre; 2. whole food credentials; and 3. low GI or glycemic response. These three domains are closely related to those used in a systematic review and meta-analyses of carbohydrate quality on chronic disease by Reynolds et al. [16]. In addition to dietary fibre and the GI, rather than a broad evaluation of whole foods, whole grain foods were specifically reviewed. Across regions, regulatory frameworks and dietary guidelines already permit the use consumer-facing non-mandatory labelling tools that align with these domains of quality carbohydrates.

The use of labelling is one strategy that permits consumers to easily identify healthy foods at the point-of-purchase. The following sections of this review will discuss and summarize regulations and provide non-mandatory labelling examples that have been used across jurisdictions that have been leveraged to facilitate higher consumption of quality carbohydrates. While some labelling initiatives must follow specific compositional criteria for claims, other labelling initiatives communicate the presence or an attribute of the food. Fundamental to all labelling initiatives, it is imperative that the information communicated to the consumer is not misleading.

#### **3. Labelling Foods for Carbohydrate Quality**

#### *3.1. Dietary Fibre*

#### 3.1.1. Direct Dietary Fibre Claims: Fibre Nutrient Content Claims

The presence of dietary fibre is a commonly identified measure of carbohydrate quality. Although dietary fibre is not a nutrient per se, it is considered to be a beneficial component of dietary patterns. Across regions, Australia and New Zealand, Canada, Europe, and the US have set specific regulatory targets for dietary fibre consumption as well as dietary fibre nutrient content claims (Table 1). In the US and Canada, although a recommended daily allowance (RDA) has not been established, an adequate

intake of 14 g fibre/1000 kcal is recommended and is based on reduced risk for coronary heart disease [17–19]. In Australia and New Zealand, adequate intakes for dietary fibre of 14–30 g/day were derived from median intakes of fibre in populations where issues with laxation did not occur [20]. Similarly, dietary fibre recommendations in Europe are based on effects on laxation with 25 g fibre/day recommended for adults (2–3 g fibre/MJ), and 2 g fibre/MJ for children ≥1 year of age [21]. Given that daily dietary fibre recommendations are relative to energy intake, recommendations can differ between life stages. Note that Codex Alimentarius implements food standards that consider the input from membership countries with different food landscapes, and dietary recommendations for dietary fibre have been left to individual countries [22].

Despite different dietary fibre recommendations across regions, recommendations are based on the observation that dietary fibre can improve physiological function or prevent chronic disease and supports the value of identifying high fibre foods as nutrient content claims. While the criteria differ, nutrient content claims provide a fundamental platform for communicating that foods are a source of quality carbohydrates. However, confusion can arise because of differences in the definition of dietary fibre across regions. As outlined in Table 2, definitions of dietary fibre commonly include indigestible carbohydrates from plants. With the exception of Codex, a degree of polymerization of monomeric units of ≥3 is common among Australia and New Zealand, Canada, Europe, and the US. For extracted and/or novel dietary fibres (including synthetic fibre), a physiological benefit must be demonstrated before the carbohydrate can be considered a dietary fibre. Laxation, cholesterol-lowering, and decreased postprandial glucose and insulin responses are common physiological benefits between countries. However, the US has an expanded list that includes mineral absorption and effects on energy intake from food consumption. Canada and Europe have also included microbial fermentation in the large intestine. However, the directive from the European Commission that outlined the accepted physiological benefits for novel dietary fibres was repealed [28] and replaced by regulation 1169/2011 [29]. It is assumed that the physiological benefits outlined in the previous directive remain as acceptable. Canada explicitly indicates that other benefits not outlined in the dietary fibre policy could also be accepted for novel fibre sources [30].

The common ability to claim that foods are a source dietary fibre is a straightforward opportunity for consumers to identify food sources of quality carbohydrates. For industry, studies to substantiate accepted physiological benefits of extracted, novel, or synthetic dietary fibres can be challenging to demonstrate in healthy populations, but are minimally invasive. However, given that the requirements for dietary fibre claims can differ across jurisdictions, similar foods may not always have the ability to leverage "source of fibre" claims in different countries. Nevertheless, consumers and industry have access to many fibre-containing unprocessed and processed foods, and fibre ingredients, respectively, that can be leveraged as an attribute of quality carbohydrates.

#### 3.1.2. Indirect Dietary Fibre Claims: Function and Disease Risk Claims

Health claims that communicate a functional or health benefit from the presence of a specific type of dietary fibre could also be used to increase the consumption of quality carbohydrates. Functional-type health claims (general level health claims in Australia and New Zealand) refer to a physiological benefit from the food. Therapeutic or disease risk reduction health claims (high-level health claims in Australia and New Zealand) refer to effects of a food or ingredient on chronic disease risk factors such as cholesterol and blood pressure lowering, or disease prevention. Recall that physiological and health benefits can be used to characterize novel carbohydrate ingredients as dietary fibres (see Section 3.1.1.). However, the criteria for leveraging physiological and health benefits as a standalone claim on foods from the inclusion of dietary fibre can require higher standards of evidence, and can differ between regions.


**Table 1.** Summary of dietary fibre recommendations and criteria for nutrient content claims for dietary fibre from Codex and in Australia and New Zealand, Canada, Europe, and the US.


205

meal event [26]. \* US DRV for dietary fiber: Adults and children ≥4 years, 28 g/day; children 1–3 years, 14 g/day; pregnant and lactating women, 28 g/day § US: An RACC is a regulated

serving size consumed

 in a single meal event [27].


**Table 2.** Definitions of fibre from Codex and regulatory agencies in Australia and New Zealand, Canada, Europe, and the US.


**Table 2.** *Cont.*

Abbreviations: DP, degree of polymerization; FDA, US Food and Drug Administration; LDL, low-density lipoprotein; \* DP refers to the number of monomeric units of the carbohydrate molecule.

Table 3 provides examples of physiological function claims that have been identified by regulatory agencies across regions that are based on the presence of dietary fibres. Laxation claims are common. In Australia and New Zealand, all dietary fibres can claim an effect on laxation if the levels of fibre within a food meet the general conditions for a fibre nutrient content claim (Table 1: 2 g/serving). This is reasonable given that dietary fibre recommendations are based on laxation. This is similar to Europe where claims related to increasing fecal bulk, decreased transit time, or normal bowel function can be used if the level of fibre in the food qualifies for a "high in fibre" claim. In Canada, the Canadian Food Inspection Agency (CFIA) has indicated that function claims referring to the effect of wheat bran and psyllium on laxation are permitted. Claims referring to a reduced postprandial glycemic response, maintenance of normal cholesterol levels, and contribution to weight loss in the context of a calorie-restricted diet are also considered to be function-type health claims in Europe and have been approved for a variety of dietary fibres.









reaches the stomach.


**Table 3.**

*Cont.*


Abbreviations: HPMC, hydroxypropyl methylcellulose; NPSC, Nutrient Profiling Scoring Criterion; RACC, reference amount customarily consumed. Australia and New Zealand: A general level health claim refers to a claim that is not considered a high-level health claim. A high-level health claim refers to a serious disease or biomarker for a serious disease. A serious disease is a disease, disorder, or condition that is generally diagnosed, treated, or managed in consultation with or with supervision by a health care professional [38]. † Canada: A reference amount is a regulated serving size that is typically consumed in a single meal event [26]. § Structure/function health claims in the US for conventional foods do not require pre-approval and the US code of the federal registrar does not provide a list of corresponding claims [39].

In Europe, all claims regardless of their scope must be reviewed by the European Food Safety Authority and subsequently added to EU regulation 432/2012 [36]. In the US, structure/function-type health claims do not undergo pre-approval, and thus a list of function claims is not provided within the US Code of Federal Regulations but does not preclude their use on food labels [39]. In some regards, the US is similar to Australia and New Zealand, and Canada, where function-type claims do not require regulatory approval. However, regulatory agencies in these regions will review function-type claims if requested, and subsequently publish their assessment and approval. An example of this has been demonstrated in Canada, where a proprietary combination of viscous fibres characterized as a "polysaccharide complex (glucomannan, xanthan gum, sodium alginate)" was reviewed by Health Canada and accepted as an ingredient that can lower the postprandial glycemic response [35]. In Australia and New Zealand, if a review is not requested prior to utilization, the Chief Executive Officer of Food Standards Australia New Zealand must be notified of the claim [33]. In all three regions, function-type claims used by industry that have not undergone review are required to have adequately substantiated the claim internally and could be asked by regulators to present a claim dossier.

In addition to fibre claims that disseminate an effect on physiological function, various fibres have been reviewed and approved for claims that communicate their ability to decrease cardiometabolic disease risk factors (Table 4). Across the regions included in this review, claims that promote the cholesterol-lowering efficacy of beta-glucan from oats and barely are permitted. For Australia and New Zealand, and Europe, a minimum of 1 g/serving beta-glucan is required to make a cholesterol-lowering claim [23,40,41]. In Canada, at least 0.75 g beta-glucan from oat and 1.0 g beta-glucan from barley per reference amount and serving of the stated size of a food are required [42,43]. In the US, the minimum level of beta-glucan for a lower risk of coronary heart disease claim is 0.75 g per reference amount customarily consumed (RACC) [44]. For all regions summarized, labelling must also communicate a contextual statement that 3 g/day beta-glucan is required. In Europe, it is important to highlight the distinction between the effect of fibres on maintaining cholesterol levels as a function claim (Table 3) and cholesterol-lowering as a risk reduction claim (Table 4). Canada has approved cholesterol-lowering claims for soluble psyllium fibre at 1.75 g/reference amount (and serving of stated size) and 7 g/day [45]. A similar claim referring to a lower risk of coronary heart disease risk is permitted in the US for soluble psyllium fibre at 1.7 g/RACC (US) (and 7 g psyllium fibre/day) [44]. The cholesterol-lowering efficacy of a proprietary polysaccharide complex has also been approved as a cholesterol-lowering ingredient in Canada [46]. The US has authorized health claims for high-fibre grains, fruits, and vegetables for their effects on decreasing the risk of coronary heart disease and cancer, and is based on those grains, fruits, and vegetables that contain at least 0.6 g soluble fibre per RACC [47] and is at least a "good source of fibre" [48] (Table 2), respectively. Regulations indicate that numerous fibre ingredients have been approved for claims relating to physiological benefits and reduced risk for cardiometabolic disease, which are based on the presence of fibre as a quality carbohydrate source.



**Table4.**SummaryoftherapeuticanddiseasereductionclaimssupportedbydietaryfibreinAustraliaandNewZealand,Canada,Europe,andthe



**Table 4.** *Cont*.

disease or biomarker

a health care

consumed

 at a single meal event [27].

 for a serious disease. A serious disease is a disease, disorder, or condition that is generally diagnosed,

professional

 [38]. †

Canada: A reference amount is a regulated serving size that is typically consumed

 treated, or managed in

 in a single meal event [21]. § US: RACC is a regulated serving size

consultation

 with or with

supervision

 by

#### *3.2. Emphasis on Whole Foods*

Whole foods, such as whole grains, or their presence in multicomponent and manufactured foods, can resonate with consumers as healthier food options. When intact foods or all of their components are consumed, it can facilitate the consumption of quality carbohydrates, as well as vitamins, minerals, and other possible bioactives that are often removed when ingredients are refined.

Randomized clinical trials and prospective cohorts studies have demonstrated that higher consumption of whole carbohydrate foods, such as low-fat dairy, legumes, whole grains, nuts, fruits, and vegetables, have been shown to decrease disease risk factors and/or are associated with reduced disease incidence [13,49–64]. Options for labelling that a multicomponent food contains whole food ingredients that are intact or reconstituted to the proportions of their native form are often permitted. This has been demonstrated with labelling programs that highlight whole grains.

The use of food labelling to identify the presence of a broad category of quality carbohydrates within foods, like whole grains, that align with consumer perceptions of a healthy dietary pattern and dietary guidelines could be an effective labelling tool for the consumer. Whole grain cereals and pseudocereals can be consumed as intact cereals, as in the case of brown rice and whole oats (groats), or used as ingredients in multi-component foods. The Cereals & Grains Association (formally the American Association of Cereal Chemists) has defined whole grains as cereals and pseudocereals that "consist of the intact, ground, cracked or flaked caryopsis, whose principal anatomical components—the starchy endosperm, germ and bran—are present in the same relative proportions as they exist in the intact caryopsis [65]." Australia and New Zealand have formally adopted a similar definition of whole grains in the Food Standards Code [66]. Similar definitions of whole grains have been provided by Health Canada and the US as statements or proposed guidance, respectively [67,68]. In Europe, a legal definition of whole grains for use in human food has not been established with different definitions of whole grains being used across countries [69]. The European Food Safety Authority has referenced Cereals & Grains Association's definition in an opinion for health claims related to whole grains [70]. Despite established definitions, without some level of dietary knowledge, it could be difficult for some consumers to identify foods that are indeed whole grains or contribute a meaningful amount of whole grains expected to convey some health benefit. Whole grains are emphasized in most dietary guidelines in Europe, as well as Canada, the US [71], Australia [9], and New Zealand [72], with evidence demonstrating dose-dependent relationships between higher whole grain consumption and reduced risk of all-cause mortality, coronary heart disease incidence, type 2 diabetes, and colorectal cancer [12,13,16].

Messaging that identifies wholes grains within the marketplace, such as oats, could help increase consumption, regardless of whether the consumer is knowledgeable about quality carbohydrate foods. Labelling statements or symbols that indicate that these foods contain a significant level of whole grains can also facilitate increased consumption. As an example, The Oldways Whole Grains Council has developed and implemented a Whole Grain Stamp labelling program that communicates the presence of whole grains in food products in 62 countries, including Canada and the US (Figure 1) [73]. Utilization of the front-of-pack labelling symbol is contingent on a minimum of 8 g/serving of whole grains, which is one-half of the US Department of Agriculture's defined serving of whole grains (16 g) [8]. Similarly, Australia's Grains & Legumes Nutrition Council implemented a voluntary code of practice for claiming that foods are a source of whole grains. The code permits the use of whole grain claims on foods to indicate they contain ≥8 g/serving ("contains whole grain"), ≥16 g/serving ("high level in whole grain"), or ≥24 g/serving ("very high in whole grain") [74]. Additionally, all general and health claims in Australia and New Zealand must comply with the Nutrient Profiling Scoring Criterion (NPSC) [33] outlined in Schedule 4 of the Food Standards Code [23]. A systematic audit of foods in major retail outlets in Sydney showed that utilization of whole grain content claims increased by 71% across food categories evaluated between 2013 and 2019 [75]. Although whole grain labelling has been discussed in detail, similar programs that emphasize the nutritional contribution of other whole quality carbohydrate foods could also be developed. It is also worth noting that

front-of-pack labelling symbols cannot be used in a manner that interferes or detracts from mandatory nutrition labelling [29,76–78].

**Figure 1.** Examples of the Oldways Whole Grains Council's Whole Grains Stamp that assists consumers to identify foods that contain significant levels of whole grains [73]. Reproduced with permission from the Oldways Whole Grains Council.

Although similar, claims that emphasize the presence of a whole food by using "made with" or "contains" claims do not necessarily have the same utility as front-of-pack symbols or claims that are supported by nutritional and dietary guidance. Consumers may not understand that the former is often solely based on the presence of the ingredient and is not necessarily founded on the ingredient's contribution to a healthy dietary pattern, and, in the context of this review, quality carbohydrates. For example, Canada's "Safe Food for Canadians" regulations do not permit the use of words or symbols that falsely communicate the presence of an ingredient [79]. The CFIA's corresponding policy on highlighted ingredients indicates that "it is misleading to over-emphasize the importance, presence or absence of an ingredient or substance in a food because of its desirable or undesirable qualities, or for any other reason [80]." While one could extrapolate this to the presence of an ingredient, such as a quality carbohydrate food or ingredient, ambiguous claims or symbols may not provide sufficient information to the consumer that the claim is referring to nutritional or dietary criteria. For example, an ambiguous claim highlighting the presence of the ingredient could refer to attributes other than nutrition, such as flavour, texture, or the absence of artificial ingredients.

The US and Australia and New Zealand do not have regulations and policies that qualify the use of claims that communicate the presence of particular ingredients. An analysis of fruit and vegetable "presence," "proportion," or "serving" claims in Australia demonstrated that 31%, 52%, and 8% did not meet the cut off from the NPSC, respectively [81]. In some cases, without a reference level, whole food claims could be challenging and, if not implemented correctly, could trigger enforcement from regulatory agencies.

#### *3.3. The Glycemic Index and Glycemic Response*

The GI is a measure of the postprandial glycemic response of a carbohydrate food relative to an equal carbohydrate portion of a reference food as liquid glucose or white bread. Postprandial glycemic responses are measured directly on a glucose scale or converted to the glucose scale when bread is used as the reference food [82]. The test food and reference food are consumed in servings that contain 50 g of available carbohydrates. When levels of carbohydrates are low in the test food, 25 g available carbohydrates is used for both the test and reference food [82]. Given that the GI is determined by using a standardized reference (glucose or bread), foods can be characterized as having a low (<55), medium (56–69), or high (≥70) GI (based on a glucose scale) [82,83]. The GI is only applicable to foods with physiologically relevant levels of available carbohydrates per serving [84]. Many foods with significant levels of carbohydrates that also have a low GI are acknowledged in dietary guidelines

across regions and include specific whole grains, legumes, nuts, dairy, temperate climate fruits, and a variety of vegetables [85].

From a scientific perspective, the GI has been successfully used as part of a diet-based approach to manage blood glucose levels in individuals with diabetes [86–91]. Guidelines for the management of diabetes in Canada, Australia, Europe, the UK, and the US acknowledge that low GI dietary patterns can be used to assist with blood glucose management [92–95]. In Canada, low glycemic index diets have also been acknowledged as a strategy for the prevention and management for cardiovascular disease [96].

From a regulatory perspective, the GI is the most contentious labelling strategy for identifying quality carbohydrate foods. In a recent systemic review and meta-analysis of prospective cohorts, Reynolds et al. [16] concluded that, compared with dietary fibre and whole grains, the GI might not be as useful a measure of carbohydrate quality for the prevention of chronic disease. Conversely, subsequent dose–response meta-analyses of prospective cohorts showed that the risk of coronary heart disease and type 2 diabetes increased by 24% and 27% per 10 unit increase in GI, respectively [97,98]. Food Standards Australia New Zealand permits "low," "medium," and "high" GI claims. However, historically, GI claims have not been permitted in Canada and Europe [99,100]. To our knowledge, there is no regulation in the US that would discourage GI labelling on food.

The rationale for not permitting the use of GI labelling are multifaceted and include the following: perceived challenges with the precision and accuracy of the methods used to measure the GI [101], risk of low-GI foods misaligning with regional healthy eating policies [99], and poor characterization of low-GI foods [100]. Uncertainties around the precision and accuracy of GI values have largely been addressed in the scientific literature [101]. The International Organization for Standardization (ISO) has published an official method for determining the GI of a food [84]. A recent study demonstrated that the ISO method generated accurate GI values with an interlaboratory standard deviation of 5.1% and a coefficient of variation of 8.1% [102]. Results also showed that the ISO GI method was sufficiently precise to distinguish between low- and high-GI foods with 97–99% probability [103]. From a labelling perspective, it is valid that published tables on GI values can demonstrate variability between similar products [85]. However, as with any labelling framework, it is the responsibility of the industry stakeholder using the claim to ensure that the GI of a specific product is assessed using a validated method and confirmed to have a low GI, and not extrapolated from other data sources.

The GI is an attribute of the food. Thus, it is fair that some low-GI foods may or may not align with national dietary policies. Health Canada has outlined concerns that snack-type foods, such as ice cream, and naturally or artificially sweetened beverages could be classified as low-GI foods and mislead consumers to perceiving these foods as healthy and encourage consumption [99]. However, mechanisms can be implemented to mitigate this risk. For example, in Australia and New Zealand, health claims, including GI claims, can only be made if food products meet specific nutritional criteria quantified by the NPSC [23]. The Glycemic Index Foundation (GIF) is an Australia-based non-profit organization supported by the University of Sydney, and Diabetes New South Wales and the Australian Capital Territory, that provides the food industry with a front-of-pack GI symbol program to permit consumers to quickly identify low-GI foods in the marketplace (Figure 2). In addition to regulatory requirements, the GIF has additional nutritional and testing requirements before the symbol program can be used on food products [103]:


**Figure 2.** The Glycemic Index Foundation's low glycemic symbol used by consumers to identify that foods have a low GI [104]. Reproduced with permission from the Glycemic Index Foundation.

The GIF symbol program focuses on the identification of "low-GI" foods (GI ≤ 55) and negates the need to linking the symbol to a GI number, which could cause confusion amongst consumers. It is generally accepted that "low-GI" foods have a GI value ≤ 55, which has been used as the cut-off for demonstrating beneficial effects on blood sugar management and reduced cardiometabolic risk. Data from the Australian National Nutrition Survey demonstrated that the GI and glycemic load of diets had decreased by 5% and 12% respectively, from 1995 to 2012 [106]. Combining the GI with nutrition profiling ensures that potential benefits of decreasing postprandial glycemic responses from carbohydrate foods are not counteracted by dietary factors associated with unhealthy dietary patterns.

Regulations in Australia and New Zealand also permit "medium GI" and "high GI" claims on food. However, the latter two claims have little, if any utility for the consumer for identifying quality carbohydrate foods. Again, the benefits of the GI as a tool to facilitate healthy carbohydrate choices are supported by patterns that incorporate foods with a "low GI" designation. Thus, adopting GI as a labeling strategy is only supported by foods with a GI ≤ 55. It is also reasonable that when a food is reformulated, it is retested to ensure that it qualifies for a low GI designation.

Although Canada and Europe do not permit labelling to identify low-GI foods, both jurisdictions have been receptive to the use of postprandial glycemic response claims, which itself is also considered a function-type health claim (Table 3). Similar to the GI, the postprandial glycemic response is determined by measuring the incremental area under the blood glucose curve of the test food. However, rather than indexing against a standardized control, in theory, any food can be used as the reference food. Considered to be a function-type health claim, in 2013, Health Canada published a draft guidance document for postprandial glycemic response claims, where reference foods were suggested to be similar to the test foods [107]. It was also indicated that the postprandial glycemic response should be at least 20% lower than the reference food without a disproportionate rise in insulin levels to make the claim [107]. Few stakeholders in Canada have applied glycemic response labelling to foods as the approach can be limiting to stakeholders. Furthermore, given that the proposed claim is relative to a specific food, the incorporation of "low glycemic response claims" and its efficacy for blood glucose management through the adoption of dietary patterns is arbitrary. While a review for function-type health claims is not required, Health Canada has reviewed and approved a low glycemic response claim for a proprietary polysaccharide complex that contains various viscous dietary fibres (glucomannan, xanthan gum, and sodium alginate) [35]. Reference to the control food has not been identified in the claim statement [35] and is a departure from Health Canada's draft guidance [107]. In Europe, similar to the GI, The European Food Safety Authority (EFSA) has published the opinion that carbohydrate foods that induce a low glycemic response are insufficiently characterized [21]. Nevertheless, since 2010, numerous dietary fibres in Europe that have been appropriately characterized have been authorized to facilitate "a reduction in blood glucose rise after a meal" (Table 2).

An overarching challenge with glycemic response claims is that they are indiscriminate. Labelling and advertising that a food reduces the postprandial glycemic response is only relative to the reference food used. While a significant decrease in the glycemic response might be observed with test food compared with the reference food, the response may not be particularly useful for individuals with diabetes or impaired glucose tolerance. Thus, the utilization of the postprandial glycemic response in the context of a dietary pattern, which would be required to demonstrate meaningful benefits of blood glucose management and decreased cardiometabolic risk over time, can be difficult for the consumer to implement and quantify. On the other hand, low-GI foods, with values ≤55, are characterized by comparing a test food to a standardized reference of glucose (or bread). This enables foods to be definitively labelled as "low-GI foods" and incorporated into dietary patterns that can be adopted and, over time, result in a predictable outcome, which corresponds with the purpose of a claim and quality carbohydrates.

#### **4. Discussion**

There are multiple opportunities to use labelling to promote the consumption of quality carbohydrates. Given that carbohydrate is a macronutrient, high-quality carbohydrate foods can encompass various characteristics. For the most part, source of dietary fibre, dietary fibre-related health claims, whole carbohydrate foods, including whole grains, and low GI and response claims have been implemented internationally into non-mandatory labelling strategies to assist consumers with choosing carbohydrate foods that align with nutrient-dense dietary patterns and/or prevent non-communicable diseases. However, as demonstrated in this review, although the parameters of carbohydrate quality are similar, regulatory frameworks corresponding to quality carbohydrate criteria can differ between regions.

Just as there is no "one-size-fits-all" healthy dietary pattern, this review demonstrates that there are multiple attributes that can be used to highlight carbohydrate quality in foods to the consumer. The laws that underpin regulations and policies that permit the characteristics of foods to be communicated to the consumer are predicated on the fact that food labels and claims cannot be misleading [29,108–112]. Labelling for "source of fibre," fibre-derived health claims, and programs that highlight the presence of whole food credentials are straightforward with similar claims made across jurisdictions, whereas labelling with regard to the GI and glycemic response continues to be debated and varies across regions.

The effects of carbohydrate foods on postprandial glycemia are the most contentious measure of carbohydrate quality. The ongoing polarized debate around "low GI" labelling frameworks is an example of the disconnect between developments in nutrition science and labelling regulations. Jurisdictions have acknowledged the value of managing postprandial glycemia, which, over time, can assist with decreasing the risk of vascular complications linked to diabetes [113]. Australia and New Zealand permit claims that identify foods as "low GI," which has been successfully leveraged and implemented by the GIF. Canada and Europe have been transparent by presenting their rationale for refuting labelling claims that identify low-GI foods or permitting foods that facilitate a lower glycemic response. Although the GI is an attribute of the food that is not presented in the same manner as glycemic response, scientific validity has been presented regarding its benefits when used to help facilitate blood glucose management. This review has highlighted that various metrics of quality carbohydrates exist, and will resonate differently for consumers depending on their food values and needs. Canada's position on GI labelling contradicts Canadian expert opinions for the management of diabetes and cardiovascular disease risk since guidelines recommend low-GI dietary patterns [92,96]. A recent study demonstrated that Canadians would be receptive to GI labelling as a tool to destigmatize carbohydrates and assist with choosing healthy carbohydrate foods [14]. Similar to Australia and New Zealand, when used alongside nutrient profiling, GI labelling can be an efficacious strategy for implementing dietary patterns with higher carbohydrate quality.

Sugar content in foods has not been included as a domain used to identify quality carbohydrate foods. Given that the levels of sugar in specific foods have been raised as a nutritional concern for its effects on cardiometabolic risk, characterizing foods with a high level of sugar as foods of lower quality carbohydrate could be considered. Across regions, policies, including mandatory front-of-pack labelling initiatives, have been used to help consumers choose foods with lower levels of sugar [114]. However, while sugar is a carbohydrate, the absence of sugar is not necessarily a proxy for the carbohydrate quality of foods. Although foods with higher levels of added sugars are linked to cardiometabolic risk, risk is not ubiquitous across all food types. High consumption of added sugars in sugar-sweetened beverages (SSBs) have been consistently shown to be associated with increased risk for diabetes and cardiovascular disease [12,13,115,116]. Conversely, total sugar consumption or intrinsic sugars in solid and liquid foods have not demonstrated the same associations [117–119]. A global review on the effects of dietary factors on the global burden of disease identified higher consumption of SSBs as a significant contributor to disability-adjusted life years (DALYs) and deaths from cardiovascular disease (DALYs: 2.8 million; deaths: 117 thousand) and type 2 diabetes (DALYs: 1.6 million; deaths: 21 thousand) [120]. Other sugar-containing foods were not identified. Comparatively, low consumption of other quality carbohydrate foods, such as fruit (DALYs: 65 million; deaths: 2.4 million), vegetables (DALY: 34 million; deaths: 1.5 million), whole grains (DALYs: 82 million; deaths, 3.1 million), nuts and seeds (DALYs: 50 million; deaths: 2.1 million), legumes (DALYs: 11 million; deaths: 535 thousand), milk (DALYs: 2.7 million; deaths: 126 thousand), and dietary fibre (DALYs: 20 million; deaths: 873 thousand), was ranked higher than increased SSBs consumption as dietary factors that prevent non-communicable diseases [120]. The purpose of mandatory front-of-pack labelling for added sugars in foods, is in part, to prevent high intakes of added sugars that could displace healthy food options from the diet and increase the risk of cardiometabolic disease [121]. However, in the context of labelling for quality carbohydrate foods, sugar on its own, may not be as useful as other domains outlined in this review [122].

It is important to acknowledge that, from an academic perspective, measurements of carbohydrate quality in dietary patterns can be more comprehensive than parameters used to inform consumer food choices. The SUN cohort used a comprehensive approach that combined attributes of carbohydrate quality outlined in this review (dietary fibre and the GI), as well as other indicators (whole grains-to-total grains ratios, solid-to-total carbohydrate ratio) to determine associations with obesity, cardiovascular disease incidence, and micronutrient intake adequacy [1,123,124]. It is undetermined if these approaches are useful as a labelling strategy. Mozaffarian et al. [5] compared various strategies for identifying whole grain foods in grocery stores, which included the Whole Grain Stamp cited in this review. Results demonstrated that using a ≤10:1 ratio of carbohydrate-to-fibre was the most effective at identifying foods with higher levels of dietary fibre, and lower levels of sodium, and sugar. While promising, this approach could require a regulatory assessment. The successful implementation of any labelling strategy by industry would require consumer education and industry support. Labelling concepts that are overly complex may hinder their adoption and usefulness in the marketplace.

Labelling that highlights the quality carbohydrates of a food is not mandatory. It is ultimately up to industry stakeholders to decide on the labelling messages that best align with the foods provided to their consumers, and then for consumers to choose attributes of carbohydrate quality that align with their dietary needs and values. The attributes of a food and corresponding labelling strategy will differ depending on the targeted consumer, and their preferences. Having multiple labelling tools at the industry's disposal across multiple domains of carbohydrate quality can assist with the widespread consumption of quality carbohydrate foods. The scientific community ensures that parameters used to characterize quality carbohydrates, or other attributes, are scientifically valid and applied within a regulatory framework that is not misleading to the consumer. The food environment must enable scientifically valid labelling tools to be accessible to industry to facilitate innovation across multiple parameters of carbohydrate quality.

In the regions discussed in this review, mandatory nutritional information is required on most prepackaged food products. Fresh foods or some single ingredient foods are exempt from nutrition labelling [18,29,125,126]. In Canada and the US, the dietary fibre content of a food per serving is a

mandatory component of nutrient declaration panels [18,125], while it is optional in Australia and New Zealand, and Europe, unless a food presents a dietary fibre nutrient content claim [29,126]. While claims and front-of-pack labelling can be useful for quickly identifying the carbohydrate quality of foods, fundamental nutritional literacy and habitual use of mandatory nutrition information on products could help consumers better evaluate foods for their nutrition value, including quality carbohydrates, and make better selections, and thus enhance the nutritional quality of their diets. Buyuktuncer et al. [127] demonstrated that students that had consistently used nutrition facts tables on food products had higher composite Healthy Eating Index-2005 scores, and higher intakes of total fruit, whole fruit, total vegetables, whole grains, and milk. Consistent users also had higher scores associated with lower intakes of added sugars [127].

#### **5. Conclusions**

Over the last decade, carbohydrate foods have been increasingly stigmatized by consumers. While some types of carbohydrate (i.e., sugar) may not confer a nutritional or health benefit, regulatory agencies and dietary guidelines recognize carbohydrate-rich foods and specific carbohydrate fractions, such as dietary fibre, to be part of healthy dietary patterns. High-quality carbohydrate foods can be identified as those that are high in dietary fibre, contain meaningful levels of whole carbohydrate foods and ingredients that are intact or reconstituted, such as whole grains, or have a low GI or glycemic response. Regulatory agencies around the world permit the use of non-mandatory labelling tools to promote quality carbohydrate foods to consumers across these domains of carbohydrate quality. While not exhaustive, this review provided examples of quality carbohydrate labelling that has been leveraged across Australia, New Zealand, Canada, Europe, and the US. This review does not promote one labelling strategy over another and acknowledges that different facets of carbohydrate quality will resonate differently between consumers. However, as nutrition science continues to evolve, it is crucial that government agencies are equipped to adapt to developments in nutrition science to ensure regulatory frameworks enable the use of labelling to relay messages that destigmatize carbohydrates and steer consumers to healthy quality carbohydrate choices.

**Author Contributions:** Conceptualization: C.P.F.M. and J.L.S.; Investigation: C.P.F.M., S.V.H., A.J.G., L.C., A.Z., D.J.A.J., C.W.C.K., K.B.M., and J.L.S.; Writing—Original draft: C.P.F.M.; Writing—Review and editing: S.V.H., A.J.G., L.C., A.Z., D.J.A.J., C.W.C.K., K.B.M., and J.L.S. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Acknowledgments:** The authors would like to thank Oldways Whole Grains Council for providing pictures of their Whole Grains Stamp (Figure 1) and the Glycemic Index Foundation for providing a picture of their Glycemic Index Symbol (Figure 2).

**Conflicts of Interest:** C.P.F.M. is an employee of Pulse Canada and former employee of Kellogg Canada. S.V.H. has received research funding from Natural Sciences and Engineering Council of Canada, Canada Foundation for Innovation, Ocean Frontier Institute and Memorial University. S.V.H. has consulted, and/or received honoraria, and/or travel support from Apotex Canada, Dairy UK, Merck/Seven Seas UK, Unilever R&D Vlaardingen, and MSPrebiotics (Manitoba, Canada). A.J.G. has received funding from the Banting & Best Diabetes Centre Tamarack Graduate Award in Diabetes Research and is a consultant for Solo GI Nutrition. L.C. is a Mitacs-Elevate post-doctoral fellow jointly funded by the Government of Canada and the Canadian Sugar Institute. A.Z. is a part-time research associate at Inquis Clinical Research Ltd., a contract research organization. D.J.A.J. has received research grants from Saskatchewan & Alberta Pulse Growers Associations, the Agricultural Bioproducts Innovation Program through the Pulse Research Network, the Advanced Foods and Material Network, Loblaw Companies Ltd., Unilever Canada and Netherlands, Barilla, the Almond Board of California, Agriculture and Agri-food Canada, Pulse Canada, Kellogg's Company, Canada, Quaker Oats, Canada, Procter & Gamble Technical Centre Ltd., Bayer Consumer Care, Springfield, NJ, Pepsi/Quaker, International Nut & Dried Fruit (INC), Soy Foods Association of North America, the Coca-Cola Company (investigator initiated, unrestricted grant), Solae, Haine Celestial, the Sanitarium Company, Orafti, the International Tree Nut Council Nutrition Research and Education Foundation, the Peanut Institute, Soy Nutrition Institute (SNI), the Canola and Flax Councils of Canada, the Calorie Control Council, the Canadian Institutes of Health Research (CIHR), the Canada Foundation for Innovation (CFI)and the Ontario Research Fund (ORF). He has received in-kind supplies for trials as a research support from the Almond board of California, Walnut Council of California, American Peanut Council, Barilla, Unilever, Unico, Primo, Loblaw Companies, Quaker (Pepsico), Pristine Gourmet, Bunge Limited, Kellogg Canada, WhiteWave

Foods. He has been on the speaker's panel, served on the scientific advisory board and/or received travel support and/or honoraria from the Almond Board of California, Canadian Agriculture Policy Institute, Loblaw Companies Ltd., the Griffin Hospital (for the development of the NuVal scoring system), the Coca-Cola Company, EPICURE, Danone, Diet Quality Photo Navigation (DQPN), Better Therapeutics (FareWell), Verywell, True Health Initiative (THI), Institute of Food Technologists (IFT), Soy Nutrition Institute (SNI), Herbalife Nutrition Institute (HNI), Saskatchewan & Alberta Pulse Growers Associations, Sanitarium Company, Orafti, the American Peanut Council, the International Tree Nut Council Nutrition Research and Education Foundation, the Peanut Institute, Herbalife International, Pacific Health Laboratories, Nutritional Fundamentals for Health (NFH), Barilla, Metagenics, Bayer Consumer Care, Unilever Canada and Netherlands, Solae, Kellogg, Quaker Oats, Procter & Gamble, Abbott Laboratories, Dean Foods, the California Strawberry Commission, Haine Celestial, PepsiCo, the Alpro Foundation, Pioneer Hi-Bred International, DuPont Nutrition and Health, Spherix Consulting and WhiteWave Foods, the Advanced Foods and Material Network, the Canola and Flax Councils of Canada, Agri-Culture and Agri-Food Canada, the Canadian Agri-Food Policy Institute, Pulse Canada, the Soy Foods Association of North America, the Nutrition Foundation of Italy (NFI), Nutra-Source Diagnostics, the McDougall Program, the Toronto Knowledge Translation Group (St. Michael's Hospital), the Canadian College of Naturopathic Medicine, The Hospital for Sick Children, the Canadian Nutrition Society (CNS), the American Society of Nutrition (ASN), Arizona State University, Paolo Sorbini Foundation and the Institute of Nutrition, Metabolism and Diabetes. He received an honorarium from the United States Department of Agriculture to present the 2013 W.O. Atwater Memorial Lecture. He received the 2013 Award for Excellence in Research from the International Nut and Dried Fruit Council. He received funding and travel support from the Canadian Society of Endocrinology and Metabolism to produce mini cases for the Canadian Diabetes Association (CDA). He is a member of the International Carbohydrate Quality Consortium (ICQC). His wife, Alexandra L Jenkins, is a director and partner of Glycemic Index Laboratories, Inc., and his sister, Caroline Brydson, received funding through a grant from the St. Michael's Hospital Foundation to develop a cookbook for one of his studies. C.W.C.K. has received grants or research support from the Advanced Food Materials Network, Agriculture and Agri-Foods Canada (AAFC), Almond Board of California, American Peanut Council, Barilla, Canadian Institutes of Health Research (CIHR), Canola Council of Canada, International Nut and Dried Fruit Council, International Tree Nut Council Research and Education Foundation, Loblaw Brands Ltd., Pulse Canada and Unilever. He has received in-kind research support from the Almond Board of California, American Peanut Council, Barilla, California Walnut Commission, Kellogg Canada, Loblaw Companies, Quaker (PepsiCo), Primo, Unico, Unilever, WhiteWave Foods/Danone. He has received travel support and/or honoraria from the American Peanut Council, Barilla, California Walnut Commission, Canola Council of Canada, General Mills, International Nut and Dried Fruit Council, International Pasta Organization, Loblaw Brands Ltd., Nutrition Foundation of Italy, Oldways Preservation Trust, Paramount Farms, Peanut Institute, Pulse Canada, Sun-Maid, Tate & Lyle, Unilever and White Wave Foods/Danone. He has served on the scientific advisory board for the International Tree Nut Council, International Pasta Organization, McCormick Science Institute and Oldways Preservation Trust. He is a member of the International Carbohydrate Quality Consortium (ICQC), Executive Board Member of the Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD), is on the Clinical Practice Guidelines Expert Committee for Nutrition Therapy of the EASD and is a Director of the Toronto 3D Knowledge Synthesis and Clinical Trials foundation. K.B.M. is a former employee of Novartis, Nestle, and The Kellogg Company. He is a current employee of General Mills Inc. J.L.S. has received research support from the Canadian Foundation for Innovation, Ontario Research Fund, Province of Ontario Ministry of Research and Innovation and Science, Canadian Institutes of health Research (CIHR), Diabetes Canada, PSI Foundation, Banting and Best Diabetes Centre (BBDC), American Society for Nutrition (ASN), INC International Nut and Dried Fruit Council Foundation, National Dried Fruit Trade Association, The Tate and Lyle Nutritional Research Fund at the University of Toronto, The Glycemic Control and Cardiovascular Disease in Type 2 Diabetes Fund at the University of Toronto (a fund established by the Alberta Pulse Growers), and the Nutrition Trialists Fund at the University of Toronto (a fund established by an inaugural donation from the Calorie Control Council). He has received in-kind food donations to support a randomized controlled trial from the Almond Board of California, California Walnut Commission, American Peanut Council, Barilla, Unilever, Unico/Primo, Loblaw Companies, Quaker, Kellogg Canada, and WhiteWave Foods. He has received travel support, speaker fees and/or honoraria from Diabetes Canada, Dairy Farmers of Canada, FoodMinds LLC, International Sweeteners Association, Nestlé, Pulse Canada, Canadian Society for Endocrinology and Metabolism (CSEM), GI Foundation, Abbott, Biofortis, ASN, Northern Ontario School of Medicine, INC Nutrition Research & Education Foundation, European Food Safety Authority (EFSA), Comité Européen des Fabricants de Sucre (CEFS), and Physicians Committee for Responsible Medicine. He has or has had ad hoc consulting arrangements with Perkins Coie LLP, Tate & Lyle, and Wirtschaftliche Vereinigung Zucker e.V. He is a member of the European Fruit Juice Association Scientific Expert Panel and Soy Nutrition Institute (SNI) Scientific Advisory Committee. He is on the Clinical Practice Guidelines Expert Committees of Diabetes Canada, European Association for the study of Diabetes (EASD), Canadian Cardiovascular Society (CCS), and Obesity Canada. He serves or has served as an unpaid scientific advisor for the Food, Nutrition, and Safety Program (FNSP) and the Technical Committee on Carbohydrates of the International Life Science Institute (ILSI) North America. He is a member of the International Carbohydrate Quality Consortium (ICQC), Executive Board Member of the Diabetes and Nutrition Study Group (DNSG) of the EASD, and Director of the Toronto 3D Knowledge Synthesis and Clinical Trials foundation. His wife is an employee of AB InBev.

#### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

*Review*

## **E**ff**ects of Menu Labeling Policies on Transnational Restaurant Chains to Promote a Healthy Diet: A Scoping Review to Inform Policy and Research**

**Sofía Rincón-Gallardo Patiño 1,\* , Mi Zhou <sup>1</sup> , Fabio Da Silva Gomes 2, Robin Lemaire <sup>3</sup> , Valisa Hedrick <sup>1</sup> , Elena Serrano <sup>1</sup> and Vivica I. Kraak <sup>1</sup>**


Received: 30 April 2020; Accepted: 20 May 2020; Published: 26 May 2020

**Abstract:** There is insufficient evidence that restaurant menu labeling policies are cost-effective strategies to reduce obesity and diet-related non-communicable diseases (NCDs). Evidence suggests that menu labeling has a modest effect on calories purchased and consumed. No review has been published on the effect of menu labeling policies on transnational restaurant chains globally. This study conducted a two-step scoping review to map and describe the effect of restaurant menu labeling policies on menu reformulation. First, we identified national, state, and municipal menu labeling policies in countries from global databases. Second, we searched four databases (i.e., PubMed, CINHAL/EBSCO, Web of Science, and Google Scholar) for peer-reviewed studies and gray-literature sources in English and Spanish (2000–2020). Step 1 identified three voluntary and eight mandatory menu labeling policies primarily for energy disclosures for 11 upper-middle and high-income countries, but none for low- or middle-income countries. Step 2 identified 15 of 577 studies that met the inclusion criteria. The analysis showed reductions in energy for newly introduced menu items only in the United States. We suggest actions for governments, civil society organizations, and the restaurant businesses to develop, implement, and evaluate comprehensive menu labeling policies to determine whether these may reduce obesity and NCD risks worldwide.

**Keywords:** food labeling; menu labeling; nutrition declaration; food and nutrition policy; restaurant chains; reformulation; serving size; energy; obesity

#### **1. Introduction**

Unhealthy dietary patterns characterized by the rapid nutrition transition are associated with obesity and diet-related non-communicable diseases (NCDs) [1]. Over the past several decades, dietary patterns have shifted from eating home-cooked meals to eating out more frequently [2,3]. Eating away from home is linked to an increased consumption of ultra-processed food and beverage products with excessive calories, fat, and added sugars and sodium [4–7]. Cafeterias, fast-food restaurant chains, independent take-out-restaurants, and food retailers contribute substantially to the daily energy intake [8,9]. A global survey conducted with 30,000 online respondents across 61 countries found that 48% of participants reported eating away from home weekly or more often with quick-service restaurants (QSRs) and fast-casual restaurants (FCRs) being the most preferred [10].

Evidence suggests that food labeling at point-of-purchase may inform shoppers to choose healthier options [11–13]. The World Health Organization (WHO) has recommended nutrition labeling and reducing portion sizes as strategies to reduce energy intake; however, there is insufficient evidence to show that menu labeling legislation for chain restaurants and food retailers is a cost-effective "best buy" policy to improve diet quality and reduce NCD-related disability and mortality in low- and middle-income countries [14].

The aim of menu labeling policies is to reduce energy intake and improve diet quality by helping consumers make better-informed decisions and to encourage food retailers and restaurant businesses to reformulate menu items and reduce and standardize serving sizes to meet recommended nutrient targets [15,16]. This dual goal has the potential to improve the nutrition and diet quality of individuals who eat away from home frequently because it may impact entire populations and does not require conscious individual behavior changes [17,18].

The restaurant business sector, which includes QSRs, FCRs, and full-service restaurant (FSR) chains and independent restaurants, has the resources and capacity to reformulate menu items or introduce new items [19–21]. United States (US) chain restaurant establishments have demonstrated progress to improve the nutrition composition of items and reduce meal size or portions served to meet recommended nutrient targets of public health experts, namely, the United States Department of Agriculture and the Dietary Guidelines for Americans [20]. A systematic review conducted in 2019 identified trends for restaurant chains to reformulate food and beverage products and reduce or standardize portions in 30 countries across six regions worldwide between 2000 and 2018 [21]. Recommendations by public health practitioners have been issued to downsize and standardize portions to 600–700 calories or 2510–2930 kilojoules/meal as an important strategy for restaurants to help costumers reduce obesity and NCD risks. However, this research found a lack of clear, universal, and internationally accepted standards for transnational restaurant chains to adopt portion or serving sizes for meals, beverages, side dishes, and desserts served to children, adolescents and adults [21]. The studies reviewed (*n* = 50) also revealed wide variation within and across countries, regions, firms, and restaurant chains to reduce energy, saturated fats, trans fats, sodium, and standardized portions. In addition, menu labeling may influence some of the documented progress [21].

The implementation of menu labeling policies in countries has led to 12 published systematic reviews and/or meta-analyses that examined the influence of restaurant menu labeling on consumer dietary behaviors between 2008 and 2018. These studies documented a modest yet statistical reduction in calories purchased and/or consumed at chain restaurants and other food-service settings [15,22–32]. However, only one published literature review examined the restaurant industry's reformulation of menu items [15]. No review has been published on whether menu labeling policies have an effect on reformulation, introduction of new or existing products, or reduction of serving sizes on menus from transnational restaurant chains globally.

Given the lack of published evidence on this topic, a better understanding is needed of the effects of mandatory and voluntary menu labeling on the restaurant sector's businesses. The results may be used to inform governments, civil society organizations, researchers, and the restaurant sector across countries on whether and how to develop comprehensive and robust policies that encourage industry changes to promote healthy dietary choices that will help to reduce obesity and NCD risks worldwide.

#### *Study Purpose*

The purpose of this study is two-fold: (1) to conduct a scoping review to map and describe the menu labeling policies enacted across countries and regions from 2000 to 2020; and (2) and to examine evaluations for any measurable effects (i.e., positive, no, or mixed) that restaurant menu labeling policies have on businesses to reformulate products or introduce new products and reduce the serving size of menus items served and sold to customers. The results are discussed within the context of government actions needed to strengthen policies and invest in external monitoring and evaluations of menu labeling legislation. We also discuss the need to make a compelling business case to encourage restaurant businesses to reformulate menu items to meet recommended healthy nutrient targets. This objective is part of a broader marketing-mix choice-architecture approach to improve their corporate image and attract new customers interested in health and wellness. Finally, we examine the implications for actions for diverse stakeholders, including governments, the WHO, restaurant businesses, private foundations, researchers, and civil society organizations to develop comprehensive menu labeling policies to determine whether these may reduce obesity and NCD risks worldwide.

#### **2. Materials and Methods**

This study was a two-step scoping review, conducted between 1 January and 29 February 2020 to examine the influence of restaurant menu labeling policies on product reformulation and reducing the serving sizes of menu items across countries and regions globally. This study utilized a scoping review, defined by Sucharew as a "research method and strategy to map, describe, and provide an overview of the published literature to identify relevant data and gaps to inform policymaking and research" [33]. The approach differs from a systematic evidence review that gathers, analyzes, and formally assesses the data to draw robust conclusions from the existing evidence for a well-defined issue.

#### *2.1. Scoping Review Step 1: Identify Restaurant Menu Labeling Policies*

Step 1 of the scoping review was guided by the following research question: "What restaurant menu labeling policies have been implemented by countries across regions worldwide between January 2000 and February 2020?". The lead investigator (S.R.G.P.) searched the WHO Global database on the Implementation of Nutrition Action (GINA) [34] and the World Cancer Research Fund International's NOURISHING framework [35,36] for national, state, or municipal policies. Then, the data were screened, extracted, compiled and triangulated. The lead investigator used a cross-checked consultation process by reviewing the evidence with other relevant sources (i.e., governmental or health ministry websites and databases, international organizations, and governmental and nongovernmental agency reports) in English and Spanish.

#### *2.2. Scoping Review—Step 2: Identify Evidence for Restaurant Menu Labeling E*ff*ects*

Step 2 of the scoping review step was conducted using the five steps described by Arksey and O'Malley's 2015 framework [37]. To enhance this methodology, we integrated scoping review recommendations by Levac et al. 2010 and Daudt et al. 2012 [38]. The process included identifying the research question, identifying relevant studies that met the inclusion criteria, study selection, charting the data, and summarizing the results. This research followed an iterative approach and used evidence and investigator triangulation to select and analyze the studies.

#### 2.2.1. Identifying the Research Question

The development of the research question was guided by the Population, Exposure, Outcome (PEO) framework that is widely used in qualitative social science or policy research rather than the PICO framework (i.e., population, intervention, comparison, and outcome) framework that is used to assess quantitative research outcomes [39–41]. This review defined population as transnational restaurants, including fast-food or QSR, FCR, and FSR chains; exposure was defined as voluntary and/or mandatory menu labeling policies, and the outcomes as food and beverage product reformulation and serving size reduction of restaurant menu items. Step 2 of the scoping review was guided by the following research question was: "What were the effects of voluntary and mandatory restaurant menu labeling policies on food reformulation and serving size available to restaurant consumers between January 2000 and February 2020?"

#### 2.2.2. Identifying Relevant Studies

The initial search was conducted using four electronic databases, including PubMed, CINAHL, Web of Science, and Google Scholar for peer-reviewed literature and gray literature. Only the first 100 hits sorted by relevance were considered for the Google Scholar database search. The databases were selected to be comprehensive and cover a broad range of disciplines, with guidance from a university research librarian. The PEO framework guided the identification of appropriate Medical Subject Headings (MeSH) terms and a combination of synonyms (Table 1; Table S1 provides MeSH terms definitions, and Table S2 provides the search details on each database). The reference sections of relevant articles were handsearched to identify further evidence not captured in the electronic database search.


**Table 1.** Systematic search strategy for the scoping review.

PEO framework: (P) Population—transnational restaurants; (E) Exposure—voluntary and mandatory policies; (O) Outcome—food reformulation and serving size reductions.

#### 2.2.3. Study Selection

The evidence selection was based on a priori inclusion and exclusion criteria. This scoping review was limited to peer-reviewed and gray literature published between 1 January 2000 and 29 February 2020 for English and Spanish-language studies and publications that explored the effect of menu labeling for restaurant chains that measured or evaluated the effects of menu labeling on product reformulation and serving size reductions. Studies were excluded for non-restaurant settings including cafeterias, laboratory settings, vending machines, schools, supermarkets, or independent food-retail establishments. Other evidence excluded was based on other outcomes related to consumers, purchase or consumption of nutrients, sales, pricing data, or described prevalence of business compliance. Literature reviews and studies based on packaged food labeling or other marketing strategies were considered to be different interventions and not included. Exclusion criteria also included literature reviews (i.e., scoping reviews, systematic reviews, and meta-analysis), which were removed and classified as the wrong type of study. All citations were imported into an EndNote X9 citation manager system and uploaded to the Covidence software, Cochrane's primary screening and data extraction tool to support scoping and systematic reviews [42]. The screening process used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Figure 1) guidelines that enabled the systematic searching, selection, and synthesis of the identified evidence [43]. The primary investigator (S.R.G.P.) removed duplicates, and a co-investigator (M.Z.) independently reviewed the title, abstract, and the full text of studies for inclusion against the eligibility criteria. A third co-investigator (V.I.K.) resolved any disagreements related to study inclusion.

#### 2.2.4. Charting the Data

From each selected study, two investigators (S.R.G.P. and M.Z.) extracted data on the author, year, country, study design, study purpose, sample, setting, data source, main outcomes, and disclosure of conflicts of interest. The data extraction was compiled in a single Microsoft Excel sheet. To assess the study quality, two investigators (S.R.G.P. and M.Z.) used the Johanna Briggs Institute's critical appraisal eight-item checklist for analytical observational studies [44] and assigned a quality score ranging from poor, fair, or good. A third co-investigator (V.I.K.) was consulted to resolve any discrepancies to reach consensus through investigator triangulation.

#### 2.2.5. Collating, Summarizing and Reporting Results

We used a narrative synthesis [45] to report and summarize the evidence compiled for restaurant menu labeling policies related to the reformulation and serving size reductions of restaurant menu items, and to compare similarities, differences, and patterns among the evidence. A thematic analysis was also completed during the examination of the studies to identify topics and categorize the main results [46]. We disassembled the evidence to identify relevant themes based on the main outcomes. Thereafter, we reassembled the data across studies and organized it by positive effect if results showed a statistically significant *p*-value, no effect if results showed no statistically significant *p*-value or negative effects, and mixed-effects if results showed both findings for the effects of menu labeling.

#### **3. Results**

The search identified 3 voluntary and 8 mandatory menu labeling policies in 11 upper–middle and high-income countries defined by The World Bank classification. No policies were identified for low- or middle-income countries. Out of 577 screened studies, 15 studies met the inclusion criteria. Eleven studies were conducted in the Americas region (i.e., Canada and the US), two studies were conducted in the European region (i.e., the UK and Ireland), and two studies were conducted in the Western Pacific region (i.e., Australia) (Table 2).


**Table 2.** Two-step scoping review results across countries by world region\*.

US: United States; UK: United Kingdom. \* World Health Organization regional groups [60].

#### *3.1. Scoping Review Results for Step 1: Identify Restaurant Menu Labeling Policies*

The implementation of voluntary or mandatory menu labeling policies has become popular throughout upper–middle and high-income countries of the world by region including the Americas *n* = 2, Europe *n* = 2, Eastern Mediterranean *n* = 3, Western Pacific *n* = 4; including Australia, Bahrain, Canada, Ireland, Malaysia, Saudi Arabia, South Korea, Taiwan, United Arab Emirates, the UK and the US (Table 3). No policies were found in the Africa and South-East Asian regions.

We identified eight mandatory menu labeling policies across 11 countries. The US was the first country that enacted a mandatory national menu labeling law in 2010 that became effective on 1 May 2018 [61]. The Food and Drug Administration (FDA) has oversight for implementing the law and provided compliance guidance for industry. Section 4205 of the 2010 Affordable Care Act, Public Law 111-148 (HR 3590) mandated that restaurant chains and other retail establishments (i.e., convenience stores, coffee shops, grocery stores, cafeterias) with 20 or more US locations disclose calories on menus and menu boards and make other nutrition information available to customers upon request [61].

Several countries implemented a mandatory policy at national, state/provincial/territorial levels, including Australia [62], Canada [63], and the United Arab Emirates [64]. Between 2011 and 2018, the Australian government and Obesity Policy Coalition implemented various menu labeling schemes throughout four states and one territory. The current legislative schemes provide detailed requirements for chain food outlets, which include displaying the energy content in kilojoules for items on the menus, drive-through boards, tags, and other materials that display the name or price of products [62].

While mandatory policies have emerged, other countries have launched voluntary recommendations and guidelines to encourage restaurant chains and food industry businesses to display menu labeling for food and beverage items, which include Malaysia in 2008, followed by Bahrain in 2010, and the UK in 2011 [36]. These three countries are moving towards mandatory policies, and initiatives are being debated or incorporated into national plans. In 2016, the Malaysian government included the menu labeling strategy into its National Plan of Action for Nutrition 2016–2025, and plans to have a mandatory menu labeling policy by 2025 [65]. In 2018, Bahrain submitted a proposal to the Ministerial Cabinet that is currently under review for restaurants and cafes to voluntarily display calories [66]. Since 2015, mandatory menu labeling in Ireland has been under consideration and is now included in the National Obesity Policy and Action Plan 2016–2020 [67]. In 2011, the UK government released the voluntary policy for the Out of Home Calorie Labeling pledge as part of The Public Health Responsibility Deal, where businesses voluntarily committed to display the calorie content on menus [68]. The UK government is currently undertaking a consultation to implement menu labeling as a mandatory national policy [69–71].

All the policies across countries require the disclosure of energy content as calories or kilojoules. The US, Australia, and Dubai have mandatory policies that also require the display of daily energy intake statements so a customer can compare specific menu items to 2000 calories/day or 8700 kilojoules/day. Malaysia, Bahrain, and Korea expanded the nutrients that restaurants are required to report to include fat, protein, sodium, and added sugars. Taiwan is the only country that has a mandatory policy that requires the disclosure of caffeine and added sugars for beverages.


*Nutrients* **2020**, *12*, 1544

#### *3.2. Scoping Review Results for Step 2: Identify Evidence for Restaurant Menu Labeling E*ff*ects*

The search yielded 560 articles across four electronic databases, and 17 additional records identified manually were included. After removing 58 duplicates, 519 records were screened. Of these, 369 records were excluded by title. Thereafter, 150 records were screened by abstract, 19 selected for full-text assessment, and 15 studies were included in the final scoping review (Figure 1).

**Figure 1.** PRISMA flow diagram of the systematic study identification, screening, and selection of the studies for the scoping review.

Table 4 summarizes the studies that met all the inclusion criteria for the scoping review. Despite the search strategy including a wide range of years (from 2000 to 2020), all the included studies were published between 2012 and 2020, and more than half of the studies were published from 2018 to 2020. Eleven studies were conducted in the US, two in Australia, one in Canada, and one in the UK. A majority of studies (*n* = 14) were observational (i.e., longitudinal, case-control, and cross-sectional); and one study was a quasi-experimental design. The analyzed studies (*n* = 14) were conducted in diverse QSR, FCR and FSR chain settings, and a single study included convenience stores [55]. Diverse evidence sources were used across studies to assess the potential effects of menu labeling on food reformulation of food and beverage menu items and the serving reductions. Most of the studies

used either the MenuStat Database (i.e., a free nutritional database provided by the New York City Department of Health and Mental Hygiene that provides nutritional information on menu items offered by the largest US chain restaurants; *n* = 7) or consulted business websites, visited establishments, or requested information via email and telephone (*n* = 7) to obtain nutrition content and serving size on menu items offered by restaurants chains. A single study for Canada used the Menu-FLIP database developed by the University of Toronto that provides nutrition data for chain restaurants [73]. The thematic analysis identified three main outcomes: (1) menu items, (2) the nutrition composition of menu items, and (3) newly introduced versus common or regular menu items. No conflicts of interest were found between the studies that could potentially influence the results. Table S3 shows the results of the study quality assessment. No studies were judged as being poor quality, four studies scored fair quality, and 11 studies were considered good quality.

#### 3.2.1. Changes to Menu Items by Food and Beverage Category

The classification of menu items across studies varied. Most of the studies included appetizers and side dishes, main courses or entrees, and desserts. Six studies included children's meals [49,50,52,56,59,74] and six studies examined beverages [19,48–50,53,57]. The evidence suggests that most of the changes made by restaurants were for appetizers and side dishes. Four studies showed statistically significant positive effects for calorie reduction [16,49,50,55], and two studies from the UK and the US reported mixed results [52,57].

Positive effects: Tran et al. (2019) conducted a study in the US during the period leading up to the federal menu labeling implementation date of May 2018 and found a reduction on calories mainly in entrees and dropping higher-calorie appetizers, sides, entrees, and desserts from the menus of pizzeria chains [55]. Bleich et al. (2017) described trends in calories from 19,391 US restaurant chain items that found differences in toppings: 93 kcal in 2008 to 84 kcal in 2015 (*p*-value for trend = 0.001) [50]. Bleich et al. (2016) found that calories declined between 2012 and 2014 for the main course items and children's menu items at QSR, FCR, and FSR chains that suggested restaurants had voluntarily reduced calories in advance of the national menu labeling law [49]. Bruemmer et al. (2012) examined the calorie content of menu items in King County, Washington, and demonstrated statistically significant differences for the calorie content of entrees between 6 and 18 months of the menu labeling county law enactment. These results were presumably due to the reformulation of menu items for selected QSR and independent restaurant chains [16].

Mixed effects: A UK study assessed the effects of a national voluntary menu labeling guidelines for the top 100 UK chain restaurants ranked by sales [57]. Theis and Adams (2019) showed that while there was a reduction of calories and sodium for pizza, sandwiches, and toppings, baked goods items were higher in nutrients of concern (i.e., calories, fat, sugar, and sodium) in restaurants that provided menu labeling for customers [57]. Namba et al. (2013) found evidence that despite the increase in healthier entrees sold by US chain restaurants, a limited improvement was observed for the nutritional content of children's entrees [52].


Positive

 Positive

**E**ff**ect \***

Positive

Bleich et al.

2018 [19]

USA

Observational,

longitudinal

Compare mean

calories for items that

remained on

27,238 menu items

from restaurant

Restaurant

MenuStat

Appetizers and sides,

Calories. Items that

the menu in all years

had fewer calories than those items that

Positive

were dropped (448

calories vs. 733

calories)

> were dropped had 71

more calories

main courses,

desserts, and

beverages

chains

chains

restaurant menus with items dropped

from the menu



chains and SD chains

**Table4.***Cont.*

*Nutrients* **2020**, *12*, 1544


**Table 4.** *Cont.*


**E**ff**ect \***

 No effect

*Nutrients* **2020**, *12*, 1544

2010 - 2017

2017. Significant increase in serving sizes among sit-down

restaurants of 12 g per

serving between 2010

and 2017

foods in 2013 and

2016

No effect





**Table4.***Cont.*

*Nutrients* **2020**, *12*, 1544



**Table 4.** *Cont.*

**\***Effect: positive (if results showed a statistically significant *p*-value), no effect (if results showed no statistically significant *p*-value or negative effects), and mixed-effects (if results showed both) on menu labeling. QSR: quick-service restaurants; FCR: fast-casual restaurants; FSR: full-service restaurant. kJ: kilojoules.

#### 3.2.2. Changes in the Nutritional Composition by Nutrients of Concern

The effects of menu labeling were measured by changes in the nutrition composition of menu items for four nutrients of concern, including calories (*n* = 14), sodium (*n* = 5), saturated fat (*n* = 3), and sugar (*n* = 3). A single US study from Washington state did not use these nutrients; rather the authors classified healthy versus unhealthy items based on 10 items examined by the Nutrition Environment Measures Surveys—Restaurant version (NEMSR) [54]. Two studies from the US and one from Canada assessed serving size reductions of menu items [16,47,54].

Positive effects: Bleich et al. (2020) reported the results of a longitudinal study (2012–2018) that examined nutrient trends for 28,238 food and beverage menu items from 28,238 US chain restaurants. The results found less calories in food items, and less calories and saturated fat in beverages, with results attributed to the US national menu labeling law [51]. Similar results were noted for six US studies that documented a significant decline in calories of certain items [19,48–50,53,55]. Besides energy, positive changes were reported for reducing the saturated fat and sodium content of menu items after the menu labeling implementation period in King County, Washington, that had more stringent menu labeling requirements before the national menu labeling law was passed in 2010 [16].

No effects: Two studies in Canada and Australia did not show significant results [47,58]. Saelens et al. (2012) reported that the availability of reduced portions actually decreased in King County, Washington, where menu labeling was implemented [54].

Mixed effects: Wu and Sturm (2014) assessed the energy and sodium changes from items offered by US chain restaurants after the national menu labeling law was passed in 2010 and in 2011. Results showed that QSR chains reduced the mean energy content of children's menu entrees by 40 calories; however, upscale restaurants had increased the mean energy content of children's menu entrees by 46 calories [56]. Similarly, Namba et al. (2013) examined the nutrient content of menu items after the national menu labeling law was passed in 2010 and in 2011, and found that the proportion of healthier menu items was higher in locations implementing restaurant labeling despite the mean calories of items that did not change [52]. Wellard-Cole et al. (2019) conducted a study in New South Wales, Australia, and found minimal decreases in energy, saturated fat, and sodium by specific QSR chains but and an increase in energy, sugars, and sodium from the QSR franchise called Hungry Jack's (Burger King) [59].

#### 3.2.3. Newly Introduced Menu Items Versus Common or Regular Menu Items

Seven studies conducted in the US and Canada [47–49,51,52,55,56] compared the differences between newly introduced menu items after the baseline year of the implementation of a menu labeling policy in 2018 with those that were dropped and/or stayed the same over the years. Five studies found positive effects [48,49,51,55,56], one study mixed effects [47], and one study found no effects [52].

Positive effects: Five US studies found significant changes made for newly introduced menu items that had fewer calories (from −57 kcal to −285 kcal) relative to popular menu items that were offered regularly and consistently at the chain restaurants [48,49,51,55,56].

No effects: Scourbutakos et al. (2019) investigated the early impact of the mandatory menu labeling law in the province of Ontario, Canada, that documented opposite results from the US studies that measured similar outcomes. The study found that newly introduced food items in 2017 contained more energy per serving compared with the newly introduced food items in 2016. The newly introduced menu items in 2017 also had significantly higher serving sizes compared with the newly introduced items from 2013 and 2016 [47].

Mixed effects: Namba et al. (2013) reported the results of a case-control study that examined five QSR chains that had voluntarily implemented menu labeling before the US national menu labeling law was passed in 2010. Three of the chains had improved the nutritional quality of items with healthier profiles of side dishes and children's meals. However, two chains showed no reduction in calories of any menu items [52].

#### **4. Discussion**

This is the first comprehensive review published to document the number of countries that have enacted menu labeling policies, to compare the features of these policies, and to examine evaluations about the effect of menu labeling policies on the business practices of transnational restaurant chains globally. Step 1 of the scoping review identified 11 menu labeling policies or laws enacted by national, state or provincial, and/or municipal authorities in upper–middle and high-income countries between 2010 and 2020. The governments in eight countries had enacted mandatory policies (i.e., Australia, Canada, Ireland, Saudi Arabia, South Korea, Taiwan, United Arab Emirates, and the US). The governments in three countries had enacted voluntary policies (i.e., Bahrain, Malaysia, and the UK). Step 2 of the scoping review summarizes the results and evidence gaps from 15 published studies (2012 to 2020) on existing menu labeling policies across four countries (i.e., Australia, Canada, the UK, and the US). Overall, the studies found mixed results, and only the US studies showed positive effects of restaurant menu labeling policies to reformulate items or introduce new healthier items ranging from 57calories to 285 fewer calories/item. Studies conducted in Australia, Canada, and the UK found either no effect or mixed effects of menu labeling policies on businesses to reformulate or introduce new menu offerings.

Step 2 of the scoping review revealed a major lack of published evidence for the effects of menu labeling on restaurant business for other regions of the world that have policies in place identified in step 1 (Table 2). No studies were found on the effects of menu labeling policies on restaurant food reformulation and serving sizes in the Asian region (i.e., Malaysia, South Korea, and Taiwan); Middle East region (i.e., Bahrain, Dubai, Saudi Arabia, and the United Arab Emirates); and European region (i.e., Ireland). This may have been due to no evaluations conducted, evaluations that were not available in the public domain, or published in languages other than English or Spanish.

The mandatory restaurant menu labeling policy compliance rate for disclosing energy (calories or kilojoules) was high in the US (94% after May 2018) [75] and in New South Wales, Australia (95%) [76]. However, subsequent evaluations in New South Wales showed that this compliance had not translated into restaurants making significant reductions in energy for menu items by 2016 [59]. A 2018 evaluation of restaurant menu labeling compliance across four Australian states (including New South Wales) and one territory showed high menu labeling compliance reported by 11 chain restaurants [77]. However, independent evaluations are needed to verify industry-reported results.

The menu labeling policies reviewed were found across upper–middle and high-income countries. However, the existing evidence highlights that eating away from home is increasing among populations creating room for menu labeling policies. The 2015 Nielsen Global Out-of-Home Dining Survey conducted among more than 30,000 adults in 61 countries found that about half of respondents (48%) reported eating out one or more times weekly (REF). Consumers (22%–26%) in the Asia-Pacific region (i.e., Hong Kong, Taiwan, Malaysia and Thailand) reported eating out daily, and other countries with menu labeling legislation (i.e., Saudi Arabia and the US) reported rates of eating away from home daily (12%–15%) that exceeded the global average of 9 percent [10]. The survey found that three out of the top five countries with the highest percentage of respondents that eat lunch away from home are in Latin America: Chile, Brazil, and Colombia [10]. Popkin and Reardon (2018) confirmed that since 1995, people are increasingly spending more of their income on eating out of home, with higher significant increases in Brazil, Chile, and Colombia [78]. A Nielsen Global Survey of food labeling trends among 25,000 consumers in 56 countries found that 80 percent of respondents expressed that fast-food restaurants should include calorie labeling and other nutrition information either sometimes or always, and, support was strongest in Latin America, North America and Europe [79]. Given these trends, there is a need to evaluate menu labeling policies of countries in these regions.

The small number of studies that assessed other nutrients of concern (i.e., saturated fats, trans fats, sodium, and added sugars) [16,51,56,57,59] rather than just energy might be the consequence of policies limiting the regulation to reporting the energy content. All 11 countries that have implemented restaurant menu labeling policies require the disclosure of energy (i.e., calories or kilojoules). Only three countries (i.e., Australia, United Arab Emirates, and the US) require contextual information to display the daily energy intake recommended for the average adult (i.e., 2000 calories/day or 8700 kilojoules/day). Of these three countries, no evaluation was available for Dubai, and only two published evaluations were available for New South Wales, Australia, that found no significant effects. Results showed that two voluntary policies (Malaysia and Bahrain) and one mandatory policy (South Korea) included disclosure of fat, protein, sodium, and sugar besides calories. However, no evaluations were available to assess industry changes to reduce the availability of nutrients of concern (i.e., sodium, saturated fat, trans fat, and added sugar) linked to obesity, and diet-related NCDs have not been assessed yet.

It is important to note that the US studies showed a positive effect of menu labeling on restaurants to reduce calories for newly introduced items, especially appetizers and side dishes, may have been related to a longer time frame between the legislation enactment in 2010 and the published studies with positive effects (2015–2020) [16,19,48–51,53,55]. It is possible that the US restaurant sector had a longer period of time to implement changes that complied with the national law. Two US studies showed mixed results where the time factor could have influenced. Namba et al. (2013) evaluated the effect of menu labeling on QSR chain menus from 2005 through 2011, and most of the assessed years were before the national menu labeling law was passed [52]. In contrast, the menu labeling legislation passed in 2015 in Ontario, Canada, was implemented in January 2017. The Canadian study showed baseline data (2010–2016) no effects of menu labeling on the chain restaurants reformulating to offer healthier items [47]. Australia initiated mandatory menu labeling legislation in New South Wales in 2011, which was expanded to the Australian Canberra Territory and three states, including Victoria, which enacted mandatory menu labeling in 2018. The studies conducted in Australia showed both mixed [59] and no effect [58] of food reformulation or serving size reductions.

The type of policy might have influenced the study outcomes besides the time factor. The UK implemented a voluntary menu labeling policy that could have played a role in the mixed-effects found by Theis and Adams 2019 [57]. Several challenges are associated with mandatory policies enacted at the state or territorial levels (Australia) or the provincial level (Canada) that may lead to inconsistencies in legislation between jurisdictions and across the outlet threshold (chain versus non-chain), variations in the provision of voluntary, readable and standardized nutritional information to customers, and inability to customize menu ordering [77].

The study design may also explain the results from this review since the studies showing positive effects in the US were observational and longitudinal. The availability of longitudinal data from the MenuStat database could justify why the US studies showed positive effects for national menu labeling over eight years (2010–2018) compared to other countries that had a shorter time frame from the enactment of legislation. Experimental, quasi-experimental, and observational, case-control studies that compared non-regulated periods or jurisdiction versus regulated ones found no or mixed effects, respectively. This may indicate that industry changes may have happened for other reasons and/or policies independently from the menu labeling policy. In addition, studies that found positive effects have analyzed changes among items, and those that assessed effects among menus instead, have found no or mixed effects. These findings suggest that industry may have introduced positive changes to some items but kept the overall nutritional quality of the menu as a whole unchanged. The majority of study designs from the reviewed articles were observational, which cannot determine causation, and reverse causality needs to be explored. Restaurants could have changed their products before implementing menu labeling, or food businesses and non-restaurant businesses could have adopted pledges and commitments on items that are often offered in restaurants. Some recent US voluntary initiatives to improve the nutritional content of food and beverage products are the Healthy Weight Commitment [80] and the Children's Food and Beverage Advertising Initiative [81] in the US.

A robust body of evidence has shown that food reformulation may reduce or eliminate sodium and trans fats, both of which are identified by the WHO as a cost-effective strategy used across different countries to improve diet quality and reduce obesity and diet-related NCD risks [82–90]. Food and beverage product reformulation may have a greater impact on the entire population than strategies that encourage healthy choices that may or may not influence consumer behavior change because the decline in energy (calories or kilojoules) is distributed across populations that frequently consume the modified products [88,91,92].

Our scoping review results identified several challenges. First, evaluations were published for only four of 11 countries that had passed legislation between 2010 and 2020. This suggests that policymakers are not investing adequate resources to monitor and evaluate the effects of menu labeling policies. Second, only the US studies that evaluated the effects of a mandatory national policy showed that restaurants had reduced calories for some newly introduced menu item categories, but did not reduce calories or the serving sizes of popular items frequently consumed. This is a challenge because expert bodies have recommended nutrient targets for menu item categories that are not being used as reference points to evaluate industry progress [21]. Third, while the WHO has recommended nutrition labeling and reducing portion sizes as strategies to reduce energy intake, our study found no evidence to support menu labeling legislation as a cost-effectiveness "best buy" strategy to reduce NCD-related disability and mortality in low- and middle-income countries [14].

#### *4.1. Implications for Policy, Practice, and Research*

Our results suggest that menu labeling legislation in the absence of other supportive strategies is unlikely to produce a meaningful change among restaurant practices to expand healthy menu items for all customers. Menu labeling is one of eight marketing-mix and choice architecture strategies that restaurant businesses can use to nudge customers toward healthy food environments 20 [93,94]. A compelling business case must be made to persuade chain restaurants to adopt these strategies to improve their corporate image and attract new customers who want healthy meals [95].

Table 5 suggests several actions for stakeholders, including governments, the WHO, restaurant businesses, private foundations, researchers, and civil society organizations to develop, implement, and evaluate comprehensive restaurant menu labeling policies.


**Table 5.** Recommended actions for stakeholders to develop, implement, and evaluate comprehensive restaurant menu labeling policies.

Government action is needed to implement national comprehensive menu labeling policies to have a significant effect on food reformulation and serving size reduction. Evidence still needs to be stronger to confirm these positive effects, and it is clear that voluntary efforts by industry are not enough. Only one study [57], based on the UK voluntary policy, discussed that food business initiatives and goodwill are insufficient for restaurant menu labeling to become a cost-effective strategy to address obesity and diet-related NCDs. Littlewood et al. (2016) have suggested that restaurants are more likely to improve their performance to offer healthier options with mandatory government requirements [25].

Digital technologies (i.e., online ordering through apps and digital menu boards) are being used more frequently to reach more customers that may either support or undermine the positive effect of menu labeling. The coronavirus or COVID-19 pandemic has created a new trend where restaurant businesses have moved to digital online and delivery, in response to the economic crisis that the pandemic has caused worldwide. Future policies and research should examine how restaurants change menu items based on customers' online ordering experience, use of onsite digital technology computerized touch screens and smartphones, use of algorithmic nudging to influence customers' choices, and how customers use digital technologies available through third-party delivery apps and businesses such as UberEats and DoorDash. Research could also examine how to leverage digital technology to encourage menu item reformulation and serving size reductions while encouraging customers to purchase the healthiest menu items [96].

Effective policy actions require regulatory oversight to ensure accountability [97]. The engagement of diverse sectors will help to strengthen the accountability process. Civil society organizations should mobilize efforts to support restaurant menu labeling initiatives and can perform independent evaluations that are shared with industry actors and government regulatory bodies. It is common for the industry sector to oppose these initiatives based on evidence from Ireland [67] and in the UK [69], where national menu labeling has been under consideration by Congress since 2015.

This research adds to the literature by identifying the knowledge gaps about the effects of restaurant and fast-food chain menu labeling on food reformulation and serving size reductions. Further research is needed to assess ongoing restaurant menu labeling policies from the Americas region (especially Latin and Central American countries), European, Eastern Mediterranean, African and Western Pacific regions for the short-term, mid-term, and long-term effects. More research is needed to explore whether restaurant menu labeling can reduce serving sizes of menu items in middle-and low-income countries. Experimental studies are needed to explore reverse causation and whether restaurant menu labeling policies will be effective in different countries by context. Finally, the WHO has clearly stated that obesity and NCDs are risk factors for COVID-19 [98]. Governments are implementing "new guidelines" for re-opening business and reset the economy and should prioritize in their political agenda policies that encourage healthier food environments to ensure that nutritious food is available for all populations as an integral strategy.

#### *4.2. Study Strengths and Limitations*

This scoping review has several limitations common to the nature of the study (i.e., map, describe, and provide an overview of the published literature to identify relevant data to inform policymaking and research). The exploratory scope of this review does not enable conclusions about the topic. However, these results may provide valuable insights for research and policy actions, especially regarding the monitoring and evaluation of implemented policies within and across countries to rigorously understand whether and under what conditions menu labeling could have an effect on restaurant businesses. It is possible that the use of additional literature databases would have yielded further articles. Given the involvement of an expert librarian, it was anticipated that the selected databases were appropriate to capture the breadth of research on this topic. In addition, this review also assessed the quality of the selected studies. We limited the search date to 2000. No studies that met the inclusion criteria were found between 2000 and 2011; therefore, we believe that our search captured the majority of relevant articles for the topic. Literature in other languages than English and

Spanish were excluded, so research for countries that had legislation and evaluations published in other languages may have been missed. Lastly, all the selected studies were conducted in high-income countries; therefore, these results cannot be generalized to middle- or low-income country settings.

#### **5. Conclusions**

The trend of increased eating away from home across countries is a call for mandatory menu labeling policies to improve healthy offerings to support a healthy diet worldwide. The overall evidence from this review is mixed on the effect of menu labeling policies for transnational restaurants and fast-food chains on food reformulation. The positive effects were from observational and longitudinal studies conducted within the period the legislation was enacted in the US and mainly for food reformulation of the energy content of menu items, and the introduction of new healthier menu items, not for overall changes among the menus. Case-control and quasi-experimental studies found no or mixed effects. Considerable gaps in the evidence remain, particularly regarding the effects of the implemented policies across regions at mid- and long-term, research in middle- and low-income countries, and reverse causation of restaurant menu labeling policies. Moreover, while all the enacted policies across countries request to display energy content, additional nutrients of concern could be included to have a greater impact. These results may inform governments, civil society, academics, and the restaurant industry to develop comprehensive and robust restaurant menu labeling policies that promote healthy dietary choices to reduce obesity and NCD risks worldwide.

**Supplementary Materials:** The following are available online at http://www.mdpi.com/2072-6643/12/6/1544/s1. Table S1: MeSH terms definitions. Table S2: Search details on each database. Table S3: Quality assessment results based on the Johanna Briggs Institute critical appraisal checklist.

**Author Contributions:** S.R.-G.P. led the study conception, methodology, data collection, formal analysis, and original draft manuscripts. The co-authors contributed as follows: Conceptualization, V.I.K., V.H., and E.S.; methodology, M.Z.; validation, M.Z. and V.I.K.; writing—review and editing, M.Z., V.H., E.S., R.L., F.D.S.G., and V.I.K. F.D.S.G. is a staff member of the Pan American Health Organization. The authors alone are responsible for the views expressed in this publication, and they do not necessarily represent the decisions or policies of the Pan American Health Organization. All authors have read and agreed to the published version of the manuscript.

**Funding:** We are grateful for the financial support provided by Virginia Tech Library's Open Access Subvention Fund to cover the publication and open access costs for this manuscript. In any use of this publication, there should be no suggestion that PAHO endorses specific organizations, products, or services.

**Acknowledgments:** The authors greatly appreciate Erin Smith for her guidance and input on developing the research question, finding the appropriate MeSH terms for the scoping review, and selecting the appropriate databases. We thank Sara Hendery and Jessica Agnew for their help in proofreading the manuscript.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

*Article*

### **Prevalence of Product Claims and Marketing Buzzwords Found on Health Food Snack Products Does Not Relate to Nutrient Profile**

#### **Maddison Breen** †**, Hollie James** †**, Anna Rangan and Luke Gemming \***

Nutrition & Dietetics Department, Charles Perkins Centre, School of Life and Environmental Sciences, The University of Sydney, Sydney, NSW 2006, Australia; mbre6607@uni.sydney.edu.au (M.B.);

holliejamesdietitian@gmail.com (H.J.); anna.rangan@sydney.edu.au (A.R.)

**\*** Correspondence: luke.gemming@sydney.edu.au; Tel.: +61-286-275-209

† Maddison Breen and Hollie James should be considered joint first author.

Received: 18 April 2020; Accepted: 20 May 2020; Published: 22 May 2020

**Abstract:** Growth in the consumer health and wellness industry has led to an increase of packaged foods marketed as health food (HF) products. In consequence, a 'health halo' around packaged HF has arisen that influences consumers at point-of-purchase. This study compared product claims (nutrient content claims (NCC), health claims and marketing 'buzzwords') displayed on packaged HF snack products sold in HF stores and HF aisles in supermarkets to equivalent products sold in regular aisles (RA) of supermarkets. Product Health Star Rating (HSR), nutrient profile and price were also compared. Data were collected for 2361 products from three supermarket chains, two HF chains and one independent HF store in Sydney, Australia. Mann-Whitney U tests compared the product claims, HSR, nutrient composition and unit (\$) price. HF snacks displayed significantly more product claims per product compared to RA foods (HSR ≤ 2.5), median (IQR) 5.0(4.0) versus 1.0(2) and (HSR > 2.5) 4.0(4.0) versus 3.0(4), respectively (*p* < 0.001). A significantly different HSR was evident between HF and RA snack products, median 2.5(0) versus 2.0(1.5), respectively (*p* < 0.001). HF snacks cost significantly more than RA snack foods, irrespective of product HSR (*p* < 0.001). These findings support the recommendation for revised labelling regulations and increased education regarding consumers food label interpretation.

**Keywords:** health food; nutrient content claims; health claims; food labelling; nutrient profile; health star rating

#### **1. Introduction**

Since 2004, the sales of packaged foods in Australia have nearly doubled and are predicted to continue to climb at a steady rate [1]. Likewise, in the past decade, ready-to-eat snack foods have increased in popularity amongst the Australian population [2]. Packaged, ready-to-eat snack foods can be defined as foods that have undergone a degree of processing and are designed to be consumed in the original state purchased [3,4]. Most fall within the discretionary food category (junk food) characterised by their high energy, saturated fat, added sugar and sodium content [2,5–7]. Thus, daily consumption should be limited due to their link with overweight and obesity, cardiovascular disease, diabetes and other co-morbidities [2,5,8].

Contrary to the rise in non-communicable diseases, such as obesity [9], consumer awareness of diet related health consequences has advanced [10]. It is evident that consumers are making a deliberate effort to modify certain dietary behaviours with the aim of improving their overall health and wellbeing [11–14]. According to a Nielsen report, sales of packaged health food (HF) products increased by 82% in supermarkets from 2012–2014, and most HF consumers report they shop in specialty retail stores that stock HF products [15]. In response, food manufacturers are constantly developing new HF products to capitalise on consumer demand [1]. These products are predominantly sold in HF aisles of supermarkets and specialty HF stores, which typically market themselves as food retailers in the health and wellness sector. In both locations, HF products are marketed and labelled as being nutritionally beneficial and often natural, organic or environmentally sustainable. Between 2012–2014, the sales of products with 'natural' or 'organic' claims grew by 24% and 28%, respectively [15]. Correspondingly, the value of 'natural' products has been influenced by consumer choice, with natural non-sugar sweetened product sales increasing by 186%, due to perceived health benefits, while artificially sweetened product sales decreased by 12% [15].

While the term healthy is defined as "beneficial to one's physical, mental, or emotional state: conducive to or associated with good health or reduced risk of disease" [16], the measured healthfulness of a product is difficult, given the differing attributes associated with health by consumers. Research indicates that consumers choose products that advertise 'healthy' qualities to attempt a more nutritionally balanced lifestyle [13]. Research also shows that consumers believe organic, gluten free and/or more expensive products to be healthier than the alternative [11–13,17,18]. Thus, a 'health halo' can exist [19,20], where consumers assume foods that are perceived to be 'healthy' have greater health benefits, more nutrients and fewer health risks than may actually be true [21–24].

With the aim to assist consumers in interpreting food labels more appropriately, the Health Star Rating (HSR) was implemented in Australia as a voluntary front of pack labelling (FoPL) scheme in 2014 [25]. Consumers prefer FoPL, including HSR and nutrition content claims (NCCs) over nutrition information panels (NIPs), because of their simplicity [24,26,27]. NCCs and health claims are images or words on product packaging that highlight particular properties and/or their health impact. Although the FoPL labels are strictly controlled by Food Standards Australia New Zealand (FSANZ), they may also contribute to the health halo effect when placed on products with other marketing messages with little to no restrictions, otherwise known as 'buzzwords', or when placed on products that are not necessarily healthier [21,23,26,28–32]. As such, questions have been raised regarding the use of NCCs and the HSR on packaged foods [33–37].

Due to the consumer confusion and vagueness of the term 'health' or 'healthy', products in the UK are not permitted to be labelled as such [38], while FSANZ does not mention this term specifically in nutrient and health claim regulations, neither permitting nor preventing its use [28]. Thus, a climate exists in food labelling where people who want to make healthier choices, by seeking healthy food products, may find it difficult to appropriately determine their value [39–42]. Concurrently, there has been significant growth in HF snack products sold in supermarket HF aisles and specialty HF stores. However, as there are no governing criteria of what can be stocked in these locations, the true health benefits of these products are largely unknown.

Accordingly, the primary aim of this study was to examine and compare the use of NCC, health claims and marketing 'buzzwords' on packaged HF snack products sold in supermarkets and specialty HF stores to equivalent products sold in RA of supermarkets. A secondary aim was to compare the nutrition profile and cost of these products.

#### **2. Materials and Methods**

#### *2.1. Data Collection*

Ethics approval was not required for the completion of this study. Data were collected from March 2018 to August 2019 as part of an audit of commercially available packaged snack foods in Australia [43]. Data were collected from the four major Australian supermarkets in the Sydney metropolitan area: Woolworths, Coles, Aldi and IGA. To capture additional HF snack products not sold in the major supermarkets, data were also collected from two national HF store chains, Go Vita and Healthy Life. To ensure data collection had reached saturation of the market, one large independent HF store was chosen at convenience for data collection. Several other HF stores across Sydney were subsequently

visited to verify completeness of data collection. Assessment of the HF store's products indicated saturation was reached and therefore not used in the study. Not all supermarkets had entire dedicated HF aisles. Thus, HF aisle was defined as the aisle (complete or partly) that contained 'health foods', 'gluten free products' or 'sports nutrition products' as per aisle signage. Products located in all other aisles of supermarkets that contained a gluten free label were classified as RA foods.

Researchers captured images of the front and back packaging, ingredient list, Nutrition Information Panel (NIP) and barcode of all products using smartphones in-store. The products were classified into seven main categories and thirteen sub-categories (detailed in supplementary material Table S1). Once the data for HF snack foods was recorded, equivalent or 'like' products were sourced from the regular aisles (RA) of the supermarkets.

Product claims were divided into three categories; nutrient content claims (NCC), health claims and 'buzzwords'. Nutrient content and health claims were defined using the FSANZ definitions [28]. All other claims were categorised as 'buzzwords' (claim descriptions in supplementary material Table S2). Nutrition information from the NIP and full unit price values (\$AUD) of all products were recorded and standardised per 100 g. Where the same products were available across multiple supermarkets or stores, price was taken from Coles or Woolworths, the first location where the product was recorded. All data were manually entered into an online database. Ready-to-eat packaged snack foods that were still wholefoods and/or were only minimally processed were excluded from collection, e.g., dried fruit and nut snack packs.

Data cleaning was carried out and duplicates of the same product within the same store type and duplicate products with different package sizes were removed from the database. The smallest package size was kept in the database and the unit cost was calculated from this. All outliers were checked against the original images. Any NIP values that stated nutrient content as <X, values were input as X - 1 for analysis, e.g., < 10 g was input as 9 g.

For those products that did not specify an HSR, the HSR was calculated using the Australian Government's HSR calculator (HSRC) [44]. Negative nutrients include energy (kJ), saturated fat, sugar and sodium, which accrue points, while positive nutrients such as protein, fibre and fruit, vegetable, nut and legume (FVNL) content deduct points; the higher the product score, the lower the HSR. Although, as many products did not declare ingredient percentage of product weight, the FVNL scores were estimated using a previously tested method [8]. As per other systematic analyses of the Australian food supply [37], for those products that did not specify fibre content in the NIP, a value was estimated from the nearest matched product from the AUSNUT 2011–2013 Food Nutrient database [45]. A sensitivity analysis was performed to determine whether these methods affected the derived fibre values and the derived HSR outcome.

#### *2.2. Data Analysis*

Data analysis was conducted using IBM SPSS Statistics Version 24 (2016), Armonk, NY, USA. The proportion (%) of products displaying NNC claims, health claims and buzzwords on HF snack products and equivalent RA foods was calculated and presented using descriptive statistics. The HSR was used to broadly classify product 'healthfulness'; products were classified as having an HSR ≤ 2.5 or >2.5 for NCC, health claim and buzzword comparisons. The data were checked for normality and found to be non-normal distribution; therefore, the median and interquartile range were used. The product claims, nutrient composition and unit price (\$) per 100 g were compared between HF snack products and equivalent RA foods using Mann-Whitney U tests. A *p*-value of <0.001 was considered statistically significant due to the large number of tests undertaken. The HSR was used to group products for unit price comparisons using descriptive statistics.

#### **3. Results**

A total of 2361 snack products were collected; 1251 sold in RA and 1110 HF products sold in "health food" aisles of supermarkets and specialty "health food" stores; 621 products from HF aisles and 489 products from HF stores. The HSR was derived for 80% of RA products and 82% HF products. The fibre content was derived for 53% of RA and 11% of HF snack products. The sensitivity analysis revealed no apparent differences between original and derived fibre and HSR values; therefore, derived HSR values were used in the analysis. The largest category for HF snacks was snack bars (35%) and for RA products was confectionary (19%).

#### *3.1. Nutrient Content Claims, Health Claims and 'Buzzwords'*

A total of 8155 product claims were recorded, 5626 for HF snack products (2726 from HF aisles and 2900 from HF stores) and 2529 for RA snack products. Overall, 94% of the HF snack products and 73% of RA snack products reported/displayed NCC, health claims or 'buzzwords'.

Table 1 shows the proportion that different NCC, health claims or 'buzzwords', directly or indirectly related to health, were displayed on HF and RA snacks products (number of NCC, health claims and buzzwords/total HF or RA snack products).

**Table 1.** The proportion (%) of snack products that display nutrient content claims, health claims or 'buzzwords' on health food (HF) snack products sold in supermarkets and specialty HF stores, and equivalent products sold in regular aisles (RA) of supermarkets. FSANZ: Food Standards Australia New Zealand.


\* Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols.

'Gluten free' was the most common NCC displayed on both HF and RA snack products. 'Vegan' was the most common buzzword used on HF snack products and 'no artificial' was the most common

for RA snack products. Other buzzwords, including 'no artificial', 'natural', 'dairy free', 'organic' and 'allergen free', were also frequently displayed (>25%) on HF snack products. 'Dairy free' was the only other buzzword displayed frequently (>25%) on RA snack products. Due to small individual numbers, a wide range of "other claims" were grouped together. At least one of these "other claims" were present on 100% of HF snack products and 39.6% of RA snack products.

Table 2 compares the proportion of HF and RA snack products with an HSR ≤ 2.5 or > 2.5, with 50% of HF and 25% RA snack products scoring an HSR > 2.5. Overall (all categories), HF snack products displayed significantly more NCC, health claims and buzzwords per product compared to RA products, median 5.0 versus 1.0 (HSR ≤ 2.5) and 4.0 versus 3.0 (HSR > 2.5), respectively (*p* < 0.001). For those products with an HSR ≤ 2.5, HF snacks displayed significantly more product claims per product for all categories. Similarly, for those products with an HSR > 2.5, HF snacks displayed significantly more product claims per product for all categories excluding chips and sweet biscuits was significantly lower. Small sample sizes (*n* < 10) for these two categories, chocolate and confectionary, were evident.


**Table 2.** Comparison of the median (IQR) product claims displayed on health food (HF) snack products sold in supermarkets and specialty HF stores to equivalent products sold in regular aisles (RA) of supermarkets, by product category for products with an HSR ≤ 2.5 and products with an HSR >2.5. Differences in median (IQR) claims displayed were assessed via Mann-Whitney U tests.

Product claims include all nutrient content claims, health claims and 'buzzwords'. Health Star Rating abbreviated to HSR. Regular aisles abbreviated to RA. Health foods Abbreviated to HF. \* Denotes *p*-value < 0.001.

#### *3.2. Nutrient Composition and HSR*

Table 3 shows the median HSR and nutrient composition of HF and RA snack products. Overall ('all categories'), the median HSR for HF snack products was significantly higher than RA products, 2.5 versus 2.0, respectively (*p* < 0.001). Compared to RA snacks, the median HSR for HF snack products was significantly higher for all categories, except beverages and confectionary. Overall ('all categories'), HF snack products were significantly higher in protein, total fat and fibre and RA snack products were significantly higher in carbohydrates and sugar (*p* < 0.001). No difference in energy, saturated fat or sodium was evident. For HF snack products, all categories, except beverages and confectionary, were significantly higher in fibre than RA products (*p* < 0.001).


**Table 3.** Comparative analysis of the differences in median (IQR) for HSR and nutrient content between health food (HF) snack products sold in supermarkets and specialty HF stores compared to equivalent products sold in regular aisles (RA) of supermarkets. Differences in median (IQR) nutrient values were assessed via Mann-Whitney U tests.


#### *3.3. Price*

Figure 1 shows HF snack products in all food categories were substantially more expensive than RA foods. The largest overall price difference was between HF snack products and RA products was confectionary (253%). Median unit price (\$) of HF snack products was significantly higher than RA products for all product categories (supplementary material Table S3).

**Figure 1.** Median unit cost (\$) per 100 g percent difference (%), per product category, between health food (HF) snack products sold in supermarkets and specialty HF stores compared to equivalent products sold in regular aisles (RA) of supermarkets.

Figure 2 shows unit cost (\$) differences between product types, per HSR category. Health foods were substantially more expensive for all HSR categories. No clear trend between unit price (\$) and HSR was evident. The greatest price difference was between HF and RA snack products scoring highest HSR of 5.0 (579%), followed by products scoring the lowest three HSR of 1.5, 1.0 and 0.5.

**Figure 2.** Median unit cost per 100 g percent difference (%), per HSR category, between health food (HF) snack products sold in supermarkets and specialty HF stores compared to equivalent products sold in regular aisles (RA) of supermarkets.

#### **4. Discussion**

This study sought to examine and compare NCC, health claims and 'buzzwords' displayed on pre-packaged snack HF products sold in supermarkets and specialty health food stores to equivalent products sold in RA of supermarkets. Secondary aims were to compare the nutrition profile and cost. The main findings of this study revealed manufactures of HF snack products use significantly more NCC, health claims and buzzwords to market their products compared to equivalent products sold in RA of supermarkets irrespective of their overall 'healthfulness'. Surprisingly, the greatest use of NCC, health claims and buzzwords was found on HF snack products with HSR ≤2.5 (median five claims per product). In contrast, equivalent products sold in RA only displayed one NCC, health claim or buzzword per product, revealing the presence and quantity of claims often does not relate to product healthfulness, and particularly for HF snack products, may instead encourage consumption of foods associated with increased health risks misleading consumers [8,21,23,26,33,46,47]. Furthermore, it must also be noted that the health halos that NCC may help create, also applies to the absence of misunderstood constituents, such as gluten. In the current study, a substantially higher proportion of HF snack products were labelled gluten free, despite 50% of products displaying an HSR ≤ 2.5. This is not surprising considering consumers often consider gluten free foods to be more beneficial to health [11,48].

The HSRC algorithm was used as a proxy to estimate a foods 'healthfulness' [44]. Overall, HF snack products were marginally superior to equivalent products sold in RA with a small but significant difference evident, median 2.5 versus 2.0, respectively. The slightly higher HSR achieved by HF snack products is likely attributed to greater fibre and lower sugar found across several categories, but no differences were evident for energy, saturated fat or sodium, all noted to be of concern by the World Health Organisation as detrimental to human health [9]. The significantly higher total fat and lower carbohydrate content in HF snack products was also notable and likely attributed to increased use of plant-based fats, nuts and seeds evident from the product ingredient lists. While our research used the mid-point of HSR system 2.5/5 to broadly classify foods into two distinct groups when examining differences in product labelling, a higher HSR cut-off ≥ 3.5 has been used by others to more clearly distinguish 'healthier' food choices and reduce the likelihood of discretionary foods being classified as healthy foods [7,37,49]. Accordingly, neither HF snacks nor equivalent RA products would meet this cut-off. This may be expected for products in RA, which are not always manufactured or viewed as the healthier options, but emphasises the concern surrounding HF snack products. Thus, the median HF score of 2.5/5 should be considered a minimum passing grade at best, a marked difference from the health halo surrounding products marketed as health foods [34].

Despite the limited research in this area, overall, these results were consistent with previous findings. Studies that have examined a range of products with and without NCC and health claims, or claimed to be 'organic', found that most products showed no difference in overall nutrient profile [8,21,23,26,33,46,47,50]. Pertinent to our own findings, Hughes et al. [33] found that a large number of NCC and health claims used on Australian products did not meet FSANZ nutrient profiling criteria [51] and this is likely true for a proportion of products examined in this study.

Previous literature has sought to determine appropriate FoPL to improve consumer perception of a products nutrition, without the strong influence of NCC, health claims and buzzwords, though not specifically for HF products [21,52–59]. Research shows that consumers have a poor understanding of food labels and cannot appropriately interpret the NIP [39,40], especially when a product claim is present [41,42]. In addition, qualitative literature has consistently found that consumers believe labels such as 'organic' [12,17,60], 'natural' and 'not artificial' [13] indicate that products are more nutritious [17] and are lower in sugar, fat and sodium [13]. Likewise, the placement of snack products within HF aisles and specialty HF stores marketed as 'health foods' (for which there is limited regulation) may act as a buzzword itself influencing consumer purchases. Evidence suggests the "reductive style" [55] of the HSR reduces consumer inclination to buy unhealthy products and guide more accurate interpretations [21,47,59,61]. However, our data show most products did not display HSRs. Due to the voluntary nature of HSR, manufacturers may preferentially display HSRs on healthier products, therefore increasing consumer reliance on other product labels and claims [62]. Additionally, in agreement with other research, our data show that discretionary foods can obtain HSR scores >2.5, potentially distracting from the consumption of foods from the five food groups and showing poor alignment with the Australian Dietary Guidelines [34–37,49]. Together, these findings provide strong evidence for revised labelling regulations, and increased education initiatives for consumers on how to interpret nutrition labels, to make informed purchasing decisions [14,54].

Though the number of NCC, health claims and buzzwords that HF snack products displayed did not correlate to a higher HSR, they may partly explain the higher price of HF products. The majority of HF snack products in some categories claimed to be vegan, organic, environmentally conscious or made 'good sugar' claims. Thus, in conjunction with (likely) smaller production, the cost of organic and alternative ingredients such as coconut oil, increased use of nuts, wheat and cane sugar alternatives are likely more expensive. However, the large price differences observed are not likely due to production costs alone. In addition, the price premium for purchasing HF products was not related to the HSR. Other research has reported similar findings, with foods labelled 'organic' found to have a similar nutrition profile but cost significantly more than those that are not [50,63,64]. This is of significance as the use of 'buzzwords', along with higher price points, have been found to strongly influence consumers and generate a misleading health halo effect [13,15,17,29,31,32,65]. Consumers should have the right to seek and pay a premium for ethical, organic and sustainable food options, though this should not be confused with purchasing healthier choices.

When interpreting these data, limitations must be considered. The study was limited to snack foods, and therefore did not assess all products found in HF stores and aisles, such as cereal products. However, the remaining products (excluding whole foods e.g., nuts) do represent most other products found in HF stores and HF aisles. Over 80% of the HSR for all products from all store types were derived using the HSRC [44]. Furthermore, some fibre values also had to be derived for HSR calculation. Despite the sensitivity analysis conducted, and a validated approach used by others [8,62], the derived values are only estimates and might differ from the true values. Additionally, several researchers have raised concerns regarding the HSRC to appropriately assess foods 'healthfulness' [34–37]; thus, the system is not without limitations. 'Buzzwords' regarding environmentally conscious claims were grouped within the overall results for interpretation but do not directly imply a product is healthier. Some values may also be skewed due to the placement of supermarket products. For example, gluten free sections are often contained within HF aisles; thus, our HF data contains both formulated gluten free product alternatives such as gluten free biscuits and other HF products simply marketed as gluten free along with other buzzwords. Thus, the marketing intent of the gluten free label may be different between products. Due to nutrition labelling regulations in Australia, added sugars were not distinguished from natural sugars. Future research could analyse the difference between added and natural sugars between these store types using other datasets. Finally, these data are a snapshot of products from the Sydney metropolitan area, across a certain time. Due to constant fluctuation in product availability and pricing, the packaged food supply may have changed at time of publication. However, with over 2000 products analysed, the study has provided a reliable sample, and thus comparison, of packaged snack foods in HF stores, HF aisles and regular aisles in 2019.

#### **5. Conclusions**

The main findings of this study revealed manufactures of HF snack products use substantially more NCC, health claims and 'buzzwords' to market their products compared to equivalent products sold in RA of supermarkets irrespective of their overall 'healthfulness', and may actually encourage the consumption of foods associated with increased health risks, misleading consumers. Although the nutrition profiles of HF snack products were marginally better than equivalent products found in RA, overall, the HF snack products examined in the study often received low HSR ≤ 2.5, with most being discretionary choices, a marked difference from the consumer perception and health halo surrounding

HF products. Health food snack products were also found to be substantially more expensive, but this was not consistent with the 'healthfulness' of a product. If consumers pay a premium for ethical, organic and sustainable foods, they should not be confused with purchasing foods that are healthier. Thus, the findings of this research provide strong evidence to support recommendations for revised labelling regulations, particularly surrounding HF snack products. Increased efforts to educate consumers on label reading are required to help consumers make informed and healthy choices.

**Supplementary Materials:** The following are available online at http://www.mdpi.com/2072-6643/12/5/1513/s1, Table S1. Product category and subcategory descriptions. Table S2. Product claim categories. Table S3. Comparative analysis of median unit cost (\$/100g) between health food (HF) snack products sold in supermarkets and specialty HF stores compared to equivalent products sold in regular aisles (RA) of supermarkets.

**Author Contributions:** Conceptualization, M.B., H.J., A.R. and L.G.; Formal analysis, M.B. and H.J.; Investigation, M.B. and H.J.; Methodology, M.B., H.J., A.R. and L.G.; Supervision, A.R. and L.G.; Writing—original draft, M.B., H.J. and L.G.; Writing—review and editing, M.B., H.J., A.R. and L.G. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external financial funding.

**Acknowledgments:** The authors would like to thank Clare Chow and Angela Lau for their contribution in data collection.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


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*Article*
