The findings from the present study showed that significantly more products met the Health Check™ and Sensible Solutions™ nutrition rating systems’ definition of ‘healthy/healthier’ (as described in their respective nutrient criteria) than carried either of these FOP symbols in most food categories. Past research has found that, given two similar foods, one carrying the Health Check™ symbol and one without it, 80% of consumers would perceive the product with the symbol as ‘probably a better choice’ while only 4% of consumers would perceive there was ‘no real difference’ between the two products . Similarly, researchers found that consumers exposed to a FOP symbol on a mousse cake perceived the cake as healthier than consumers who were given the same cake without a symbol (p = 0.004) . The magnitude of perceived differences in the healthiness of foods appears to be influenced by the format of the FOP symbol [16, 20–22]. Given the large number of products that qualify for, yet do not carry these symbols, our findings suggest that the two FOP systems under study may give consumers the erroneous impression that foods carrying the symbols are healthier than a similar product without these symbols – contrary to the Canadian guidance regarding the use of FOP systems .
When absolute threshold nutrient criteria were used, a smaller proportion of products qualified for Sensible Solutions™ than Health Check™. However, when Sensible Solutions™ relative threshold nutrient criteria were used, a larger proportion of products qualified for the Sensible Solutions™ than Health Check™. In fact, the relative threshold criteria appeared poor at differentiating between healthy and less healthy products, with a large proportion of products qualifying for the symbol in most food categories when these criteria were applied (Figure 2). Based on our findings, relative threshold nutrient criteria were less able to discriminate between products based on healthiness. However it should be noted that Kraft designed the relative nutrient criteria to be applied relative to a base product (e.g. a reduced fat Oreo cookie compared to a regular Oreo cookie) or matched with an appropriate reference product. Thus the use of category means as the reference nutrient levels for determining which products qualify based on relative thresholds is a weakness of this analysis. Furthermore, the secondary assessment by Kraft’s Nutrition Department of products that qualify based on relative threshold criteria is not documented, and could not be applied in this study.
With respect to the Health Check™ system, this study found only four subcategories where there was substantial agreement between the number of products qualifying for and carrying symbol. Considering consumers perceive products with the Health Check™ symbol as healthier than similar products without the symbol , our findings suggest that Health Check™ may be a useful guide to choosing healthier products for consumers in very few subcategories. Most subcategories within each of the major Health Check™ categories showed only poor agreement between products qualifying for and carrying this symbol. However, the consumer has no way to determine in which food subcategories the Health Check™ symbol identifies most products that meet the system’s definition of healthy, limiting its utility as a guide to healthier choices. However, universal implementation of a FOP system like Health Check™ or similar threshold based system to all products (not just those that have bought into the program) would allow consumers to better differentiate between healthy and less healthy food choices within all food categories. Indeed, in their 2011 report on FOP nutrition rating systems, the US Institute of Medicine recommended that an ideal FOP system should be applied to all grocery products .
Proponents of FOP systems suggest these systems have the potential to encourage product reformulation by manufacturers to meet their nutrient criteria . The few studies that have examined this issue, including one focused on Health Check™, found that FOP systems successfully encouraged manufacturers to lower the sodium, saturated and trans fat, and calories in their products [23–26]. However, in 24 of 85 Health Check™ subcategories, greater than 75% of products already met the criteria, suggesting that options for reformulation would be minimal [see Additional file 1]. Similarly, when the Sensible Solutions™ relative nutrient threshold criteria were applied, more than 70% of products in many food categories qualified for the systems’ symbol. The results of this study would suggest that, within some product subcategories, the nutrient criteria of Health Check™ and Sensible Solutions™ (especially the relative thresholds) should be strengthened if they are to encourage the reformulation of more food products in a healthful way. Indeed, the Health Check™ program has been continually adjusting its nutrient criteria to encourage manufacturers to reformulate their products to reduce the amount of nutrients such as sodium and trans fat in the food supply [10, 27, 28].
The US Institute of Medicine expert committee recommended in their 2011 report that the model FOP system should be applied universally and be based on absolute thresholds for saturated and trans fat, sodium, and sugar for two food categories, individual foods and main dishes/meal products, to allow for the comparison of foods within and across categories . In contrast to this recommendation, the two systems in this study, Health Check™ and Sensible Solutions™, had different nutrient criteria for up to 85 different subcategories, thereby limiting consumers’ ability to use these FOP systems to compare products across categories. Furthermore, the nutrient criteria used in both of these systems are based on additional nutrients beyond saturated and trans fat, sodium, and sugar, despite the Institute of Medicine’s finding that there is insufficient evidence to suggest that including such nutrients in a FOP system would be useful. Finally, the expert committee proposed that the model FOP system should take a ranked approach to nutritional guidance where, after meeting a minimum eligibility threshold, products could earn and display additional nutritional “points” based on their content of those core three nutrients. However neither system in this study offered additional ranking interpretation of the nutritional quality of products, thereby limiting their full ability to inform consumers and to promote continued product improvements.
In addition to the model FOP system proposed by the Institute of Medicine, a number of single, standardized (mandatory or voluntary) FOP systems are being proposed or adopted by governments, experts, and industry groups in countries such as the US, European Union member states, Australia and New Zealand, and South Korea . The proposed systems are largely nutrient-specific, including nutrients such as saturated fat, sodium, and sugar, and display the amount per serving or per 100 g on the FOP. In addition, the use of traffic light colours to identify high (red), moderate (amber), and low (green) amounts of nutrients is under consideration in a subset of these countries. Summary indicator FOP systems, such as Health Check™ and Sensible Solutions™, are not presently being considered in any jurisdiction for universal implementation. If Canada were to consider adopting a single, standardized FOP system they may want to consider an approach more consistent with what is being proposed internationally, particularly by the Institute of Medicine. The Institute of Medicine proposes two important features that are not covered by current FOP systems; 1) they recommend a graded system with one to three stars or checkmarks awarded depending on nutritional composition; and, 2) products that don't meet the basal criteria, would carry the FOP symbol with zero stars or checkmarks.
Strengths of this study include the large number of food categories and subcategories examined, as well as the inclusion of both a non-profit led and a manufacturer led system. In addition, the FOP systems under study were quantitatively evaluated within the context of the entire food supply and evaluation was not limited to the products of the FOP system’s proprietary manufacturer or the products of manufacturers that have bought into the non-profit FOP system.
There are a few limitations to this study. First, the nutritional composition of products was based on the Nutrition Facts table and data were only available on the 14 core nutrients found in the nutrition label. Both Health Check™ and Sensible Solution™ included some criteria for nutrients and food ingredients not included in the Nutrition Facts table, thus the present study may have underestimated the number of products qualifying for these systems based on the absence of data on these nutrients and food ingredients. Furthermore, the Nutrition Facts table does not differentiate between total and added sugar, which is used in the Sensible Solutions™ system. As we were unable to differentiate between total and added sugar we applied this criteria to total sugar and, as a result, may have underestimated the total number of products that would qualify for Sensible Solutions™. In addition, reliance on nutrient content values reported in the Nutrition Facts table instead of values determined through chemical analysis may have decreased the precision of our results. However, one recent Canadian study of five food categories found no significant differences between nutrient content values reported in the Nutrition Facts table compared to values determined through chemical analysis for saturated and trans fat, indicating that the Nutrition Facts table values are quite precise .