In the WHO Eastern Mediterranean Region half the Region’s adult women (50.1%) and more than two in five men (43.8%) are overweight or obese and more than 2.2 million lives are lost each year to noncommunicable diseases (NCDs) [1
]. Unhealthy diets are a major contributor to this burden, estimated to be responsible for over 20% of adult deaths in the Region [2
]. All available policy tools should be leveraged to improve diets, and policies to improve access to nutrition information—including on food labels—are an important element of such efforts.
The provision of nutrition labelling on prepackaged foods has long been recognized as being one means of empowering consumers to make healthier food choices. WHO has recommended countries use food labelling to tackle malnutrition in all its forms and to help meet the global targets on nutrition and NCDs [3
]. In the Eastern Mediterranean Region, the Regional Framework for Obesity Prevention, adopted by WHO Member States in 2018, recommends implementation of front-of-pack nutrition labelling for all prepackaged foods [7
To date, nutrition information has largely been implemented as a detailed nutrient content declaration (sometimes known as a nutrition information panel), which declares the amount of key nutrients in the food, usually in small print size, on the back or side of food packages. The international food standards body, the Codex Alimentarius Commission, recommends that Member States make labelling with nutrient declarations mandatory [8
] and it is estimated that more than 50 countries have now legislated to make such labelling mandatory [9
Such information is particularly important given the major role of highly processed, packaged foods in modern diets in the Region [10
] and the greater difficulty that may pose for consumers to determine how much saturated or trans fats, sugars or salt such foods contain. Most of the countries in the Eastern Mediterranean Region have seen a transition from traditional diets to more “Westernised” diets and higher intakes of highly processed and fast foods [12
There is consistent research to suggest an association between use of nutrition labels, whether on the front or back of food packages, and healthier diet [13
], but actual use of labels is relatively low and certain groups—particularly women, people on higher incomes, and/or with more education, as well as those who already have a specific interest in diet and health—are more likely to use nutrition labels [13
]. Widespread problems with understanding and interpretation of the relatively complex numerical information on back-of-pack nutrition information panels are also reported [13
], particularly among people with lower socioeconomic status [13
]. There are concerns, therefore, that reliance on back-of-pack nutrient declarations alone could widen socioeconomic inequalities in health.
Hence, there has been growing interest in the provision of supplementary, simplified nutrition information, in a prominent place on the front of package to help consumers understand the nutritional quality of foods. Such front-of-pack nutrition labelling is intended to supplement, rather than replace, more detailed nutrition information on the back or side of packs.
Globally, it is estimated that, by 2017, 1.5 billion people were living in countries where front-of-pack nutrition labelling schemes have been implemented or officially proposed [19
]. Many different front-of-pack labelling schemes have emerged, with no one scheme regarded as being as optimal. To help make sense of this complex picture, some conceptual frameworks have been developed to categorize the different types of schemes [20
This paper summarizes the current status of implementation of front-of-pack nutrition labelling in the WHO Eastern Mediterranean Region and explores how lessons from international experience could guide further implementation in the Region.
In order to build a picture of the state of implementation of front-of-pack nutrition labelling in the WHO Eastern Mediterranean Region and to inform its future implementation, a literature review was conducted for development of a background document for discussion at a WHO Technical Consultation held in Beirut, Lebanon, between 11 and 13 September 2018.
This paper builds on four elements:
An initial scoping literature review which identified, through PubMed, review articles on nutrition labelling which were published in English after 2000 [13
]. Only reviews which included any explicit consideration of front-of-pack nutrition labelling were included. In addition, relevant grey literature—including reports from official bodies such as WHO, the Codex Alimentarius Commission and the European Commission—was identified [19
]. Further specific references were identified from these reviews to enable more in-depth exploration of some of the issues highlighted in the discussion section.
Presentations and discussions during the Technical Consultation in September 2018.
Information on implementation in the Eastern Mediterranean Region, identified through follow-up communication with experts about ongoing research and with nutrition or food regulatory officials in the relevant countries.
Inclusion of new reviews published since the original literature review and technical consultation in 2018 [36
The term “front-of-pack labelling” refers to supplementary information which is designed to assist in interpreting the information in nutrient declarations on the back of packages.
WHO defines front-of-pack labelling as referring to nutrition labelling systems that:
Are presented on the front of food packages (in the principle field of vision) and can be applied across the packaged retail food supply;
Comprise an underpinning nutrient profile model that considers the overall nutrition quality of the product and/or the nutrients of concern for NCD;
Present simple, often graphic information on the nutrient content and/or nutritional quality of products to complement the more detailed nutrient declarations usually provided on the back of food packages [20
This paper deals with nutrition labelling on prepackaged foods. There is clearly, however, also scope for provision of simplified nutrition information on retail shelves or on unpackaged foods, as well as on menus or at point-of-purchase in restaurants and other food service outlets.
Front-of-pack nutrition labelling generally has two specific objectives:
To provide consumers with nutrition information in a more understandable format, with a view enabling them to make healthier food choices;
To encourage food manufacturers to develop new products and reformulate their existing products towards healthier food products.
Some additional objectives are sometimes also considered:
To improve consumer understanding about the links between the nutrient content of foods and health, particularly for the prevention of NCDs;
To facilitate health professional advice on nutrition and healthy eating;
To reduce consumer confusion and deception about food products, particularly in relation to misleading use of health and nutrition claims.
In relation to these objectives, the most relevant outcomes are:
Effects on consumer understanding of the nutritional quality of foods;
Effects on consumer purchasing behaviour;
Changes in the nutritional composition of foods (fat, saturated fat, sugars, and salt levels).
Implementation of front-of-pack labelling in the Eastern Mediterranean Region remains limited, but three types of scheme were identified as having been implemented or at an advanced stage of development. The advantages and disadvantages of the three types of scheme—traffic lights; Nutri-Score; health logos—are summarized in Table 3
. It is important to note that this discussion is limited to the types of scheme under development in the Eastern Mediterranean Region and there are many other types of front-of-pack nutrition labels in use, globally. Warning labels on foods which are high in energy, saturated fat, sugars, or sodium, for example, were introduced in Chile in 2016, and have since been adopted in Peru and Uruguay. In addition, the interpretive Health Star Rating system in use in Australia and New Zealand is not discussed in detail in this paper.
There is a growing evidence base in support of front-of-pack nutrition labelling and an increasing number of country examples of effective implementation. With all schemes, the effectiveness depends on exactly how it is implemented, including the governance and transparency of the development and implementation, and, to a large degree, on the validity of the nutrient profile model which underpins the labelling scheme.
Gaps remain in the evidence base, however, and as yet there remains little research in real world settings and there is no definitive evidence on which specific scheme is most effective. The most appropriate front-of-pack labelling scheme may vary from country to country, therefore, and policy makers need to choose the scheme most suitable to the particular national context.
The current proliferation of schemes and mixed evidence base can be confusing for policymakers and for this reason WHO is developing global guiding principles for front-of-pack labelling and Codex is discussing front-of-pack labelling and is expected to produce guidance.
Examination of the existing evidence base and country experience with implementation of front-of-pack labelling may provide some pointers for consideration by policymakers seeking to take action in this area in the Eastern Mediterranean Region.
Consumers appear to prefer interpretive labels to informative (or reductive) labelling [34
]. Research suggests that labels which help consumers interpret nutrition information are more likely to have an impact on consumer understanding and food choices than informative labels [13
]. Continued exposure to interpretive labels also has the potential to improve people’s literacy about the nutritional quality of foods [66
] and interpretive labels may be able to reach groups with poor nutritional knowledge and unhealthy diets [42
Research also suggests that consumers are most concerned to have information about which foods to consume less of or which foods have high levels of nutrients for which consumption should be limited [14
]. Labels that include indications of the presence of high levels of fat, sugar or salt, or which give a graded overall score, are more likely to be effective than labels which only highlight healthier foods (positive judgement only) [34
Front-of-pack labels should be designed to enable at-a-glance decisions about potential purchases. It is important that front-of-pack labels simplify the complex information provided in nutrient declarations, which is known to be difficult to comprehend [13
]. Previous research tended to suggest that nutrient-specific schemes were better, but emerging evidence suggests that summary systems are easy to understand across all groups [39
Inclusion of an aid to interpretation such as colour-coding, graphics, or interpretive text is likely to improve comprehension of the labels [13
]. Green and red colours have been shown to be a key aspect to enhancing understanding [24
] and the incorporation of red appears to have a more powerful influence than appearance of green [59
]. There are concerns, however, that the information must be accessible to people who suffer from colour-blindness, which means that dependence on colour alone can be problematic.
Experience also demonstrates the importance of front-of-pack labelling schemes being underpinned by robust nutrient profile models, appropriate to the national context. Nutrient criteria need to reflect up-to-date guidelines if any changes in consumer behaviour are to result in healthier diets and be translated into health benefits, particularly reducing the risk of diet-related NCDs. The criteria underpinning the scheme also need to be transparent—a lack of transparency about the nutrient criteria can undermine confidence in the schemes.
Unless there are standardised serving sizes, there is the potential for consumers to be misled by figures expressed on a per serving basis if declared serving sizes set by manufacturers are smaller than actual portions consumed and vary across brands. This suggests that nutrient criteria should be based on nutrients per 100 g, rather than per serving, where countries do not have standard serving sizes.
Governments can choose to require companies to adopt front-of-pack labelling through legislation, or they may decide to define a scheme but leave implementation optional (or only mandatory in certain conditions or for some foods). Experience suggests that voluntary schemes do not always achieve sufficient coverage of the products on the market [34
]. Five years after adoption of the government-led voluntary Health Star Rating in Australia the logo featured on 31% of products [69
], while after two years in New Zealand only 5.3% of the products on retail shelves were labelled with the logo [45
]. According to official estimates, by September 2019, two years after adoption, companies voluntarily applying the Nutri-Score label in France covered 25% of processed food products on the market [70
]. Even in countries where a voluntary scheme has higher penetration, there can be distortion because less healthy products are less likely to carry front-of-pack labels. In the United Kingdom, for example, the Department of Health estimates that the voluntary scheme has been adopted by two-thirds of the packaged food and drink market [43
], and historically penetration has been lower in categories where there are more foods high in fat, sugar or salt (meat products, pastry products, pizza, and prepared meals) [71
]. Similarly, in Australia more than three quarters (76.4%) of foods displaying a Health Star Rating label had three or more stars [72
]. Where voluntary approaches are pursued, there are approaches that can be used to maximize effectiveness and/or ensure widespread uptake and penetration of the scheme (e.g., defining only one single type of front-of-pack label to be permitted; setting a condition that any use of the front-of-pack label requires manufacturers to use the label across their brand and product range).
Irrespective of whether a scheme is mandatory or voluntary, the process to develop it should be transparent and government-led to ensure independence and maximize credibility. It is important that research and testing findings are published and that the scope, aims, and objectives of front-of-pack labelling are transparent. The process clearly requires engagement with industry, consumers and other stakeholders, but governmental processes should incorporate robust safeguards from conflicts of interest.
It is important for front-of-pack nutrition labelling to be implemented as part of a comprehensive strategy to promote healthy diets and prevent obesity and diet-related NCDs. In the Eastern Mediterranean Region, the countries that have introduced, or are in the process of introducing, front-of-pack labels are doing so as part of a broader approach to promoting healthy diets. These programmes also include, variously, nutrition labelling on menus, taxation of sugar-sweetened beverages, regulatory limits on trans fatty acids, nutrition standards for food in schools, and/or hospitals, government-led reformulation programmes and behaviour change communication. The effectiveness of front-of-pack labelling is likely to be enhanced by nutrition education, while front-of-pack labels can in themselves be educational and may help people to translate learning into action. Consumer understanding of front-of-pack labels is likely to increase over time and will be enhanced if there is one single front-of-pack labelling scheme to minimize confusion.
As countries prepare to introduce a front-of-pack labelling scheme, there are a number of steps that can help to pre-empt any trade complaints [73
]. It is important for policy makers to engage with the legal sector to ensure that policy objectives are framed in a strategic way—as part of a comprehensive response to a public health problem—and that the justification for why the measure is necessary, effective, and proportional is clearly set out. Inclusion of explicit references to WHO guidelines, guiding principles, and recommendations is advisable and it may be useful to cite the precautionary principle.