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

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.

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 ultra-processed 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 energy-dense, 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 ultra-processed 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.

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 nutrient-specific 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 nutrient-specific 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:

• 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
• 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
• 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, 31, 32, 33, 34, 35, 36, 37

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 government-endorsed 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 low-socioeconomic, 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 low- and 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

The WHO guiding principles and framework manual for front-of-pack labelling for promoting healthy diets has been developed to support countries to develop, implement, and monitor and evaluate an appropriate FOPL system

The document explains that the development, implementation, and monitoring and evaluation of FOPL should be government-led, with input from key stakeholder groups. The development of FOPL should be an iterative and collaborative process. There are some key considerations and steps that need to be taken in developing an FOPL system. Various FOPL systems have already been developed by different countries. Hence, it is important to learn from the experiences of others, adapting approaches where appropriate, and taking into consideration the needs of the country while recognising the importance of global consistency. The aims, scope, and overarching and specific principles of the FOPL need to be confirmed by governments at a national and regional level, because they provide the critical framework for developing the specific details of the FOPL system. The five overarching guiding principles for FOPL that form the basis of the manual are as follows:

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 Nutrient declarations are standardised listings of the nutrient content of a food or beverage, usually positioned on the back or side of the package. In 2012, Codex recommended that nutrient declarations be mandatory on food packages. However, Codex does not have clear and mandatory guidelines for FOPL.

In 2016, the governments of Costa Rica and New Zealand suggested that universal regulations on FOPL should be added to the Codex standards and started the process of amending the Codex guidelines. However, at the time of publications it appears that nothing in the Guidelines will set out a specific recommended format for countries.

A draft standard of the new guidelines is currently being circulated for comments and approval, and once it has been vetted by member nations of the CAC, it will be presented by the Codex Committee on Food Labelling (CCFL) to the commission for adoption into the Codex texts.49

The following FOPL policies were deemed successful based on their effectiveness in increasing consumer nutrition knowledge and/or decreasing the sale of unhealthy foods. Both policies were created by their national governments to avoid any possible conflict of interest and have had an overall positive impact on the populations that use them. These examples may be applicable to relevant regions or local contexts.

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.