Friday, December 08, 2006

Decrypting the Nutrition Label: How the FDA disseminates information without Education – Min Jung Yoon

Introduction

Nutrition is the fuel in which our bodies flourish. Numerous studies have revealed the importance of nutrition, and more members of the general public are recognizing the importance of nutrition (1). There are studies that provide evidence that nutrition habits can exacerbate serious illness (2) or they could enhance health (3). Since 1989 there has been an increased focus on the importance of the nutrition label. The Food and Drug Administration (FDA) has been regulating and enforcing the nutrition labels (4). The FDA has formally begun to advocate for honest, science-based labels. Since then, there have been continuous improvements and modifications of the label, guided by laws such as the Nutrition Labeling and Education Act of 1990.

The purpose of the nutrition label (NL) is to provide systematic, accurate labeling to assist consumers in making healthy food choices. Therefore, the NL consists of valuable information aimed aiding consumer decision by providing information about each product. It is then up to the consumer to digest and compare the nutrients of each product and make an informed decision. The labels also include other valuable information about what to avoid. Although there has been much research devoted to nutrition labels (5), there are even more improvements that should coincide with the current research in order to help serve the purpose of assisting the public to make healthier choices (6). This paper will discuss the other factors that should be improved to help make better use of the nutrition labels. All of these additional factors are related to better education of the public. By educating the public about the nutrition label, we, public health practitioners, are disseminating the knowledge that is necessary to understand the nutrition labels.

Education

The nutrition labels are printed material designed to identify the content of a product. The labels contain basic information to help consumers make informed decisions about their food. However, there are several factors that a consumer must incorporate in order for nutrition labels to play a vital role in the healthy dietary process. A recent study conducted by Rothman et al. (7) illustrates a specific phenomenon. This study divided education factors into: Literacy and Numeracy. The literacy variable measured subjects’ ability to read. Numeracy was measured by the subjects’ ability to do basic math. Rothman et al. (7) found that even some people who had a high level of education had trouble doing some math, which is a crucial skill in calculating how much calories one is consuming. People who do not have the necessary basic education background are at a disadvantage in deciphering nutrition information. This is where the problem lies because, although there is a lot of emphasis on policy and regulation, the intended information is not being comprehended due to lack of education.

One important factor that adds to the difficulty of understanding this complex system is the way the labels are laid out. Rothman et al. (7) found that interpretation of servings size lead to inaccuracy in the consumers’ calculations. This is not the only source of confusion. This study also found that the foot note of daily values for additional information became a source of confusion. The footnote information is written on the bottom of the label to inform the consumer that the recommendations on the label are based on a 2,000-calorie diet. Some participants thought that the footnote information indicated the nutrients contained in the product. These errors of understanding may be a result of lack of health-content based education and lack of consistency in the education that is available (8).

Because each nutrition label communicates condensed factual information, there are many variables to understand in a single product label. It may be hard to depict all the information in a manner that could be understood at a glance. However, the problem is that consumers are not able to read or do simple math to tailor the information to their own needs. There could be other ways to organize the information and make it simpler. However, the problem still remains: literacy and numeracy skills of the public are still not adequate for understanding the labels(7).

Statistic Based variables

A key component to understanding the label comes from knowing how the info is derived. By knowing how the reference numbers are calculated, consumers may make individual judgments on the recommendation’s relevance to them. Since there are many guiding principles, including the estimated average requirement (EAR) or the recommended dietary values (RDA), consumers may be confused about what each acronym means and how it is derived. This could be a problem because different acronyms stand for specific values that represent different numbers. For example, using the EAR makes it hard to plan for specific diets; however, RDA may be more than sufficient for a particular diet (9). While using the nutrition label, consumers must be attentive to the values they are calculating.

Another factor that consumers need to know is that the EAR is based on a weighted average, which is derived from statistical analysis of a skewed population. This is a concept consumers must know and understand because the EAR is geared towards consumers who are 4 years or older and healthy non-pregnant people (10). In order to make decisions about their own personal health based on the labels, consumers need to know that the FDA’s goal in creating the DV% was to ascertain the requirements for the population as a whole, not for each individual. Since certain populations have different recommended requirements for minerals and nutrients, an individual’s needs may or may not be met by the mean recommendation for the population. (11). An individual may be among the outliers, who wouldn’t be included among the mean population. For example, the amount of vitamin B-6 needed by the elderly is different from that which is needed by younger people (11). This means that the DV% calculated for the consumers, which is derived from the RDA, may be inadequate for some people. For example, the daily recommended values of Iron would be different for teenagers and menopausal women. Also, generally, males and females have different needs. Many other factors should be considered in order to determine whether or not daily values should be strictly applied to an individual consumer’s food choices. In order to make a decision, a consumer must know the limitations of the information on the label. Since it is not clear whether consumers are aware of this concept, there needs to be an engagement in teaching this concept and evaluating the usages there of (9). Today’s label is based on a statistical derivative, calculated for the general population. There are many components which are necessary achieve a balanced nutritional diet; consumers should be educated according to the special age groups or needs groups that they fall into. The nutrition label is a tool which tries to tell the consumer a lot of complex information in a simplified format. However, this tool is useless if consumers do not know how to comprehend it.

Digital Education

Although there have been continuous changes in education since the Nutrition Labeling and Education Act of 1990, there was no budget set for the ‘Education’ portion (12). However, there have been efforts to educate via printed educational materials, press, and research (12). Last month, the FDA released an online educational module and brochure, specifically the “Label Man” and “Nutrition Facts Label brochure (13)” to improve skills needed to read the labels. Although future investigation would be needed to evaluate the effectiveness of the new website materials, I would like to express some concerns about factors that may impede their purpose of educating the public.

The Label Man is an online based interactive learning program that helps the consumers get acquainted with the nutrition facts (13). This program has several different components that could help the consumers learn valuable information. For example, it goes through exercises that help consumers compare nutrition values of two products. It is a practice module to learn how to calculate serving sizes and calories, decide which product is more nutritious than the other product based on a nutrient such as calcium, and prepare consumers to be able to incorporate different factors to consider two similar products (13). This would be a good module for people who are able to access it on the Internet. Access can be a problem, however. There are studies that show the discrepancies between consumers of different socioeconomic status and their access to the Internet (14). In their study, Hoffman et al examined demographic patterns and usage and access to the Internet. It is not surprising that this study found inconsistencies in Internet access by race, occupation, and education. In addition, the United States Census in 2000 found that only 51% of the homes had computers; moreover, households with Internet access were lower, at 41.4% (15). Using the Internet as the medium may be a problem to those who do not have access to the Internet. The FDA’s attempt to educate the public through use of the Label Man is limited in how much information it could diffuse because of access.

There are usually community based technology centers that may be useful for individuals who do not have computers or Internet access at home. However, in these cases, mere access to a computer might not be the solution. There are skills that need to be acquired in order to effectively use the internet to learn how to interpret the nutrition labels. Lack of computer literacy would be a barrier for those who might gain access to a computer but not know how to use it. For example, one would need to know how to navigate the desktop to find access to browser with a mouse and type in the URL to find the page that has the link to the FDA Label Man. There are several steps that are required for one to gain mere access to the module.
In addition to learning keyboarding and basic computer skills, consumers may need to learn or improve English language skills. Most of the digital information on the FDA Label Man site is in English, non-English speakers weren’t considered. In a diverse country like America, there are many minorities who don’t speak English (16). Although majority of the public indeed speak literacy (17), more than 15 million people have difficulty with English (16). The FDA’s outreach program is limited because of barriers such as access to internet and English literacy.

Conclusion

This paper is not arguing in support of a particular guiding principle such as EAR or RDA. Regardless of the decision that the FDA makes, consumers must be educated to interpret the information that is presented to them. The problem arises when not everyone is exposed when young to health education that would help them understand nutrition labels. Although some health education classes are offered in K-12 Education, many curricula are inconsistent across grades, and many teachers are under qualified (8). Another limitation is that many of the products with recommendation labels are based on a 2,000-calorie intake. To utilize this information, individual consumers must know how many calories they require. For the people who do not fit in the recommended 2,000 calorie per day intake category, the daily recommended value percentages that are calculated for them need to be recalibrated in order to fit their needs. If they eat more than 3,000 calories, then their amount of intake for nutrients should be greater than the amount indicated on the labels. Consumers need to know these basic concepts in order to interpret the information and adapt the information to their own diets.
Since the Nutrition Labeling and Education Act of 1990, there has been an intense focus on consumer education. The FDA’s use of labeling as an approach to help consumers decide their nutritional intake is a great tool for consumers to make informed decisions. Before an average consumer can make informed choices, however, there are phenomenal factors that need to be taken care of. It is useless to merely put the nutrition label in front of the consumer. The consumer needs to understand how to use the labels. When the necessary education is done, the public will be able to use the information given in the labels. Adequate education could take decades if the FDA did it alone, but with a conjoined project with the Department of Education, far more people could be reached. When the FDA educates the public with other organizations, consumers will be able to utilize what they have learned in their daily lives.

References:
1 Morreale SJ, Schwartz NE. Helping Americans eat right: Developing practical and actionable public nutrition education messages based on the ADA survey of American Dietary Habits. J Am Dietetic Association. 1995; 95:305 – 308.
2 Bonnefont-Rousselot D. The role of antioxidant micronutrients in the prevention of diabetic complications. Treatments in Endocrinology 2004; 3(1):41-52.
3 Kushi LH., Byers T., Doyle C., Bandera EV., McCullough M., Gansler Ted., Andrews KS., Thun MJ., American Cancer Society Guidelines on Nutrition and Physical Activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity. 2006; 56(5):254-81.
4 Philipson, T. Government perspective: Food Labeling. Am J of Clinical Nutrition 2005; 82(suppl):262S-4S.
5 Kristal AR, Levy L, Patterson RE, Li SS, White E. Trends in Food Label Use Associated with New Nutrition Labeling Regulations. Am J of Public Health. 1998; 88(8):1212-5.
6 Neuhouser ML, Kristal AR, Patterson RE. Use of food nutrition labels is associated with lower fat intake. American Journal of the American Dietetic Association 1999; 99:45-50,53.
7 Rothman RL, Housam R, Weiss H, Davis D, Gregory R, Gebretsadik T et al. Patient Understanding of Food Labels: The Role of Literacy and Numeracy. Am J Prev Med 2006; 31 (5):391-98.
8 Institute of Medicine of the National Academics. Health Literacy: A Prescription to End Confusion. Washingtong, DC: The National Academies Press, 2004.
9 Murphy SP, Barr SI. Recommended Dietary Allowances should be used to set Daily Values for nutrition labeling. Am J Clin Nutr 2006; 83(suppl):1223S-7S.
10 The National Academies Press. Dietary Reference Intakes: Applications in dietary Assessment. http://www.nap.edu/books/0309071836/html/19.html, accessed November, 2006.
11 Yates AA. Which Dietary Reference Intake is Best suited to serve as the basis for Nutrition Labeling for Daily Values. J Nutr. 2006; 136:2457-2462.
12 Allen AM. The new Nutrition Facts label in the print media: A content analysis. Journal of the American Dietetic Association 1995; 95(3):348-351.
13 U.S. Food and Drug Administration. Food Labeling and Nutrition. http://www.cfsan.fda.gov/label.html, accessed November 2006.
14 Hoffman DL, Novak TP, Schlosser A. Journal of Computer-Medicated Communication. 5(3) March 2000. http://jcmc.indiana.edu/vol5/issue3/hoffman.html#Abstract
(accessed November, 2006)
15 US Census Bureau. Home Computers and Internet Use in the United States: August 2000. http://ict.cas.psu.edu/resources/Census/PDF/Comp_in_Households_Aug00.pdf, accessed November, 2006.
16 US Census Bureau. Language Use and Linguistic Isolation: Historical Data and Methodological Issues. http://www.census.gov/population/socdemo/language/li-final.pdf, accessed November, 2006.
17 Wiley TG. Myths about Language Diversity and Literacy in the United States. ERIC Educ Reports. http://findarticles.com/p/articles/mi_pric/is_199704/ai_2007898816/pg_1 (accessed November, 2006).
18 National Research Council, Committee on Diet and Health, Food and Nutrition Board. 1989. Diet and Health: Implications for Reducing Chronic Disease Risk. National Academy Press, Washington, DC.

3 Comments:

Blogger Michael Siegel said...

This is a great critique and offers a novel insight into a strategy that has previously been widely accepted in public health. But you compellingly show that it makes little sense to provide people with information that they cannot or are unable to use in a meaningful way. I hope that your ideas are considered, including by those at FDA, in the modification of our approach to informing consumers so that they are able to make their own informed food choices. As you show, having information on content is not necessarily equivalent to being truly informed.

4:58 PM  
Anonymous Anonymous said...

In addition to critiquing the use of NL, Min, extends her argument noting that the FDA has realized this failure themselves and attempted to correct it through programs like the Label Man module. Then Min explains how this attempt at improvement remains insufficient. I think it strengthens her piece that she addressed the FDA's attempts at education - a great example of how a public health intervention is useless if the public isn't educated on how to utilize it.

2:20 PM  
Anonymous Anonymous said...

I was looking forward to reading your critique after it was briefly discussed in class, and this is certainly an example of how important it is to look at those who you want to target with an intervention and how to most effectively educate and reach those who you are trying to help. It's great if information is disseminated and displayed, but if it's not understandable or easily applied to an individual for use, then the intervention fails in its attempt.

8:43 AM  

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