World Heart Federation Policy Brief: Front-Of-Pack Labelling

On World Food Day, the World Heart Federation calls on governments to implement mandatory front-of-pack food labels. The World Heart Federation (WHF) has developed a new policy brief on front-of-pack labelling (FOPL) aimed at improving global standards on nutrition and creating healthy food environments. Poor diet is responsible for more deaths worldwide than any other risk factor, and is a leading cause of obesity, type 2 diabetes, and cardiovascular disease (CVD). Global estimates suggest that almost 2.3 billion children and adults are overweight. The growing availability of ultra-processed foods, which contain high levels of sugars, sodium, saturated fats and refined carbohydrates, is a key contributor to the current obesity epidemic, which is increasingly impacting low- and middle-income countries. The WHF Front-of-Pack Labelling Policy Brief highlights front-of-pack labelling as a way to create environments where consumers are able to make better informed, healthier food choices for themselves and their families. Currently, a wide variety of front-of-pack labelling systems have been implemented by governments and food manufacturers around the world, with varying levels of success. The new WHF Policy Brief provides evidence-based, practical guidance that can be adapted to local contexts. It highlights that in order the be implemented successfully, FOPL systems must take into account consumer literacy and prevailing cultural norms around food and nutrition. FOPL must be mandatory, government-led, and accompanied by broad public nutrition education initiatives. The WHF Policy Brief includes a set of policy recommendations to give governments the tools they need to select the FOPL system that will best meet the needs of their populations, including recommendations on how to develop an effective FOPL programme, how to implement it successfully, and how to monitor and evaluate outcomes.


CVD remains the leading cause of death worldwide
Together with hypertension, tobacco use, and physical inactivity, obesity is a known risk factor for CVD that can make changes to heart structure and function due to build-up of fat tissue. Because of these adverse effects, the World Heart Federation (WHF) works to combat obesity, as it is a barrier in achieving our vision of health justice and heart health for everyone. WHF is dedicated to promoting health behaviours and initiatives that will curb the global obesity epidemic.
Solutions like FOPL are necessary to improve the diets of consumers everywhere and to decrease risk factors for CVD. 1 2

FRONT-OF-PACK LABELLING (FOPL) AND CARDIOVASCULAR DISEASE (CVD)
FOPL can enable consumers to make informed and healthier choices FOPL systems should empower customers to make healthier choices and contribute to the prevention of the most concerning diet-related health conditions in a country. Depending on the priority, the main purpose of FOPL can be achieved by quickly informing consumers about the relative healthiness of products or by warning them when products are excessive in added sugars, total fat, saturated fats, trans fats and/ or sodium, which are the critical nutrients associated with top risk factors for the most burdensome diseases in many countries (e.g. heart disease, high blood pressure, high fasting plasma glucose, and overweight and obesity).

Consumers need help making healthy choices and identifying harmful products
The sheer number of products available makes shopping for food a confusing process for consumers. Having so many different types of foods, from both domestic and foreign manufacturers, makes it difficult for consumers to select nutritious products, even if an increasing number of them want to make healthy choices. 3 Most shoppers spend fewer than ten seconds selecting each item, which does not give them enough time to compare the nutrition facts panels that are found on the backs of packaged foods.
Consumers are instead made to compare different types of FOPL from various manufacturers and regions that can be based on different values or use hard-tointerpret symbols.
Due to lack of understanding of the varied FOPL systems, consumers can be misled to purchase unhealthy options. 4 Additionally, unhealthy products may feature misleading nutrition claims on their packages. Claims related to the amount of a specific nutrient in the food and direct or indirect claims about a food's potential health benefits can give an unhealthy product a "health halo effect" and can cause consumers to misunderstand its nutritional quality.

WHY IS FOPL IMPORTANT?
Ultra-processed food products (UPP) have become increasingly available across the world UPP are frequently high in calories and have little nutritional value. The great majority of these pre-packaged foods are ultraprocessed with high levels of added sugars, sodium (salt), saturated fats, and refined carbohydrates. 5 While sometimes they may have added vitamins and minerals, these generally do not justify consumption of these energydense, nutrient poor products. 6 These nutrients, and the packaged foods they are found in, are all associated with diet-related noncommunicable diseases (NCDs) and are connected to the growing global obesity epidemic . 7 8 9 Besides having a bad nutrient profile, UPP are linked to nonrecommended dietary practices, including overeating, mindless eating, and fast eating, as they increase the speed of eating rate, worsen satiety, and promote excessive energy intake. 10 11 A considerable body of research highlights the large and significant impact of consuming ultraprocessed foods on the major NCDs, including obesity, 12 diabetes and hypertension. The latest link was a randomized control trial conducted by Hall KD and researchers at the US National Institutes of Health (NIH) in 2019. This NIH work is supported by a wide range of over 19 cohort studies from Europe, the US, Brazil and elsewhere. These studies show that increased proportions of ultra-processed food in the diet are linked with increased risk of obesity, and heart and circulatory diseases (CVD) (diabetes, hypertension, stroke).
As of 2016, more than 1.9 billion individuals have been estimated to have overweight or obesity, and without intervention, this global health epidemic will continue to grow.

BILLION
There is a consensus among the research community that FOPL systems can impact consumers' choices by increasing their understanding and use of nutrition information Several of these label systems have been shown to affect the most nutritionally at-risk populations who may have less education and nutritional knowledge. 13 14 15 16 17 There is currently a wide variety of FOPL systems that have been implemented or are in the process of being created by governments around the world. Examples of existing systems include nutrientspecific warning labels, which alert customers when products contain excessive amounts of nutrients associated with the top risk factors for CVD and other NCDs; e.g. saturated fat and sodium; the traffic light system, which uses green, amber and red colours associated with the relative low, medium or high levels of critical nutrients in a product is another example of a nutrientspecific system; and summary indicators that rate the overall nutritional quality of a product based on algorithms that include both negative and positive nutrients and ingredients.

Which type of label is the most effective?
While some FOPL systems are generally helpful at improving shoppers' use and understanding of nutritional information, the success or effectiveness of a labelling system is dependent on the specific context and desired objectives. 18 In some countries, FOPL systems seek to nudge consumers towards more healthful choices without providing nutrient-specific information. In other countries, FOPL seeks to help populations easily identify products that are excessive in critical nutrients: n Summary score systems, such as the Nutri-Score and the Health Star Rating systems, are designed to provide consumers with an overall summary score about the (un) healthfulness of the product. It has been demonstrated that they can assist shoppers to correctly rank products from the least to the most healthful one. 19 20 21 n Nutrition warning labels are designed to allow consumers to quickly, easily and correctly identify products that are excessive in nutrients associated with high blood pressure, high fasting blood glucose and/or overweight/ obesity; i.e. sugars, totals fats, saturated fats, trans fats, and sodium. Evidence is consistent in demonstrating this system effectively fulfils this purpose, improving use and understanding of information as well as the purchase intention and purchase decisions of consumers. 22 23 24 25 26 27 28 29 n Traffic light labelling systems add colours and sometimes text to the Guideline Daily Amount (GDA) scheme, providing an interpretation to the critical nutrient values as being low, medium, or high, so compared to (GDA) systems they perform better as they add interpretative elements, improving the use of information. However, conflicting valences/coding and colours can undermine the understanding of the information and weaken the impact on purchase intention or purchase decisions, so they perform worse than directive systems such as warning labels and summary scores. 30

Diversity in existing systems and nutritional standards
Many countries feel that harmonising guidelines might be technically challenging due to the diversity of existing systems and nutritional profiles. Creating a global scheme would require agreeing upon a set of standards for nutritional value and measurement. Countries have expressed concern that an FOPL program might be unable to make a distinction between good or bad foods and good or bad diets due to a lack of worldwide scientific consensus on the topic. 39

Food industry push-back
The food manufacturing industry for the most part has been against the creation of government-endorsed FOPL systems. The Food Industry has also been more vocal in their opposition to labelling programs that are mandatory rather than voluntary. Many times, if a system is made voluntary by a country, the Food Industry will not print the labels at all or will attempt to resist and/or implement the labels very slowly. In addition to being vocal in their resistance to governmentendorsed FOPL systems, food manufacturers have also tried to discourage their implementation by creating their own systems of labelling. Having the Food Industry create their own FOPL systems presents a conflict of interests, as manufacturers do not want to alert their consumers to the (un)healthfulness of their products as this transparency will impact their sales.
The Food Industry has been promoting a voluntary GDA FOPL system to meet the growing consumer demand. Although this means that manufacturers are labelling their products more often, research shows the GDA is the least impactful and effective FOPL system. It is hard to understand for consumers and does little to change purchasing patterns and decrease the sales of unhealthy products.

Effectiveness for lowsocioeconomic, limited education, and at-risk populations
Studies have shown that some FOPL schemes are especially useful in educating consumers on the healthfulness of pre-packaged foods, while some are very effective in helping consumers quickly, easily and correctly identify products excessive in CVD-related critical nutrients. Some schemes are good at reaching consumers with different nutrition knowledge, education and socio-economic levels, 40 41 42 while others are considerably more useful when the consumer already possesses a baseline level of nutrition knowledge. 43 As obesity is a more prevalent problem among lower-income groups 44 and is increasing in lowand middle-income countries, 45 it is important to determine whether creating a FOPL policy will be able to have a serious impact on such groups. 46 WHAT ARE THE CHALLENGES?

The Codex Alimentarius Commission (CAC) sets international food standards that serve as a guideline for packaging and food safety for all 188 of its member nations
The CAC standards currently identify three types of nutrition labelling: nutrient declarations; nutrition and health claims; and supplementary nutrition information, which includes FOPL. 48

WHAT ARE THE PROPOSED DRAFT CODEX GUIDELINES ON FOPL?
n FOPL programs should use a combination of text and symbols to present nutrition information quickly and simply.
n The FOPL systems under consideration should be evaluated based on desired impact to select the better one for a given country, and to defend the selection during implementation.
n Labels should be based on national health values and be easy to see and understand so that they can meet their purpose, whether this is improving ease of comparison of different products and/or the ability to identify products that are excessive in critical nutrients.
o If a country does not currently have national dietary guidelines, the system could be aligned with global or regional dietary guidance, such as those systems designed by the WHO and its Regional Offices.
n One system should be used in each country.
o See the WHO guiding principles and framework manual for front-ofpack labelling for promoting healthy diets for further information. 13 n There should be an education program to help consumers understand and use labels n FOPL programs should be evaluated periodically and improved as needed.
n The WHO guiding principles and framework manual for front-of-pack labelling for promoting healthy diets should be an important resource for the Codex. Furthermore, it will be important to make sure that the Codex guidelines and the WHO guiding principles complement one another.

SUCCESS STORIES
The

CHILE
In 2012, Chile adopted some of the strongest mandatory FOPL regulations to warn consumers if products were high in either sugar, sodium, saturated fats, or calories. 50 Evidence from several evaluation studies and impact assessments conducted since the legislation was enacted have demonstrated that consumers in Chile are aware of and understand the Chilean FOPL, and that they are using the labels to make decisions about food purchases. 51 52 The labels are also contributing to a shift in social norms and attitudes towards purchasing nutritious food. 53 Because the labelling system is relatively simple and has been used by all types of consumers in Chile, it has an impact across different socioeconomic and education levels, and greatly impacts the purchasing pattern of all Chileans. It has also contributed to the reformulation of some products. 54

FRANCE
In France, a voluntary FOPL system was created and has been implemented since 2017. It displays a nutritional summary score of products using five colours (from green to red) and a grading system from A to E. The score is computed by accounting for the amount of positive nutrients and ingredients (fruits, vegetables and nuts, fibres, and proteins) and the product's negative nutrient and caloric concentration (too many calories, saturated fat, sugars, and/ or sodium), resulting in an overall score of the product.
This scheme, known as "Nutri-Score," has been found to be particularly useful and effective for educating and informing nutritionally at-risk individuals in France. The labelling system is justified on public health grounds based on the positive impact it has had on French consumers and their overall nutrition.

WHAT ARE THE POLICY RECOMMENDATIONS?
While the WHO guidelines give specific recommendations for many aspects of the FOPL programme, there are some areas of the system that are flexible. This allows countries to tailor their FOPL system to the needs of their populations. Listed below are some of these flexible areas, as well as the corresponding WHF policy recommendations.

Aspects to be considered
What are the WHF recommendations?
What is the reasoning?
What should be the principal message to consumers?
Consumers should avoid ultra-processed foods and instead focus on "real food"; that is, less processed, high-nutrient, preferably fresh foods.
There is a significant negative impact of consuming excessive ultra-processed foods on cardiovascular health, including obesity, diabetes, hypertension, and other conditions.
Should the system provide a nutritional summary or talk about levels of specific nutrients?
The system should be aligned with national public health and nutrition policies (dietary guidelines) and food regulations, as well as with relevant WHO guidance and Codex guidelines.
It should allow for easy and quick identification of ultra-processed and processed products that have an excess of energy and key nutrients of concern, including sugar-sweetened beverages and high-fat or salty snacks, to contribute to the prevention of overweight and obesity and dietrelated NCDs.
The purposes of FOPL can vary. In some countries, they seek to allow consumers to better rank products according to their healthfulness (without necessarily allowing them to identify which products are excessive in critical nutrients) and in other countries they seek to help the population easily identify products that are excessive in critical nutrients. Summary scores, such as the Nutri-Score system, meet the first purpose only, not the second. Warning labels meet the second purpose, not the first.
When many purposes are pursued, it is unlikely that any one will be fully achieved. Healthy nutrients in a product can work as claims that stimulate the consumption of unhealthy products. For example, a cracker high in sodium with significant amounts of fibre should not be encouraged as a source of fibre. If this conflict is present, it will undermine the achievement of the objective.
FOPL systems that are in line with or exceed the minimum requirements and recommendations of Codex and WHO are likely to be better positioned to achieve their health objectives.

Aspects to be considered
What are the WHF recommendations?
What is the reasoning?
Is WHF in favour of one system over than another?
WHF does not privilege one system over another and encourages governments to consider their situation and the objectives that best correspond in selecting an FOPL system. Whichever option is used, WHF believes that a comprehensive system should be put in place, rather than reliance on the less effective GDA.
WHF is aware that some countries favour summary systems (such as Nutri-Score) to help their population to be able to rank products according to their healthfulness.
WHF is also aware that other countries favour warning labels because they want to help their population to easily identify products that are excessive in critical nutrients. The research on warning labels is very consistent in demonstrating that warning labels meet the regulatory objectives these countries are seeking; namely, helping consumers to easily, quickly and correctly identify products that are excessive in critical nutrients and that are linked to the three risk factors of the most burdensome diseases (high blood pressure, high fasting blood glucose, and overweight and obesity).

What foods should be labelled?
Pre-packaged processed and ultraprocessed food products (UPP).
Pre-packaged processed and UPP foods apply several persuasive elements to their labels that drive consumers to purchase products that are excessive in critical nutrients and reduce the relevance of nutrition information and the capacity of consumers to make informed decisions. When a government is addressing its responsibilities and mandates towards reducing obesity and improving public health, civil society should support it. However, when a government does not provide the required leadership, civil society should organize and advocate for improved policies and strategies to address malnutrition in all its forms.
To advance the WHF vision of a world where heart health for everyone is a fundamental human right and a crucial element of global health justice, it is necessary to address major risk factors such as obesity and overweight.
Front-of-pack labelling is an acknowledged part of an effective strategy to address dietrelated risks.
What should the education program look like?
Consumer FOPL education must make individuals aware of the existence of new labels and the objectives they pursue. An effective education programme should also help consumers understand what is considered a healthy diet and how the FOPL relate to national dietary guidelines.
Consumers should understand why the labels were developed and how to read them. They should also learn what is considered a healthy diet in order to use the labels to make more nutritious purchases. How will the system be evaluated?
The FOPL system should be regularly monitored by the national government for uptake, impact on purchasing patterns, and efficiencies and improved as necessary. Sciencebased civil society organizations and/ or academic institutions may wish to conduct additional reviews or research that are independent of the government.
Evaluation and success can be based on improvements in consumer nutritional knowledge and changes in consumer spending on food, i.e., is there a higher rate of healthy food being purchased? Because the purposes of FOPL can vary, studies and evaluations should make sure that they evaluate results against the specific objectives of a system; studies that compare Nutri-Score systems and warning label systems cannot evaluate their respective effectiveness well if they only examine issues related to the purpose of one or the other. For example, if a study is designed to examine an FOPL system's success by asking consumers to correctly identify which products are excessive in any of the critical nutrients, the survey would find good results for warning label systems but poor performance from Nutri-Score, simply because the latter was not designed for that purpose.