Nutrition labelling, including FOPL, has been identified as one strategy to address growing global concern regarding sub-optimal diet (27). Our analysis identifies opportunities (e.g. consideration of nutrients and/or food groups that align with dietary guidelines, creative and more effective AFH nutrition labeling practices, FOPL schemes that work for all SES groups, etc.) to better leverage the display of nutrition information. However, it also reveals that the potential public health impact of FOPL in the US may be limited as approximately 43% of dietary energy at the population-level is not subject to FOPL. For no sub-population analyzed in terms of socio-demographics, dietary/health behaviors or health status, did FOPL exposure exceed 66%. Except for age and AFH meals, differences in the proportion of dietary energy subject to FOPL by socio-demographics, dietary behaviors and health status were modest indicating that most population sub-groups will have comparable exposure to FOPL. In terms of population-level intakes, some dietary constituents would be impacted by FOPL to a greater or lesser extent, suggesting that if implemented the effects on dietary intakes and health may be uneven.
SES and Food Label Use
Our data showed that individuals with less education and lower incomes had modestly higher exposure to FOPL. Separate research reveals that these populations tend to have a lower level of understanding of traditional nutrition labels and use them less often (6, 28). With ~ 60% FOPL exposure among vulnerable populations, an opportunity exists to improve diet quality by drawing attention to easy-to-comprehend food labeling elements that may promote a higher quality diet. Some FOPL schemes (e.g. scoring-type with summary indicator) are better understood across socioeconomic status levels (29, 30) and should be further explored to ensure they grab consumer attention. Some public health interventions have been shown to inadvertently widen health disparities due to higher-SES individuals being earlier or more ardent adopters (31). While the real-world impact of FOPL implementation on disparities in dietary intakes in the US is uncertain, based on our observation that lower SES individuals have marginally higher exposure to FOPL it is unlikely that such an intervention would widen disparities. On the other-hand, we did observe that adults with the highest quality diets in terms of HEI-2015 had the greatest exposure to FOPL, suggesting that based on current dietary habits those in a position to benefit least from FOPL currently have the greatest exposure. Additional analyses adjusting for AFH meals explained the association between diet quality (HEI-2015) and FOPL exposure, highlighting the importance of AFH foods in any link between FOPL exposure and diet quality.
Away from Home Food Sources
In this analysis, just over half of daily energy came from foods and/or beverages subject to FOPL with the remaining energy coming from AFH sources or store-based purchases of foods not subject to FOPL. The influence of FOPL on overall diet quality is therefore potentially limited given that a third of daily energy comes from AFH sources. The impact of AFH foods on FOPL exposure was strongest for younger adults (20–34 y) who had a 2-fold higher %E from AFH sources and ~ 15% less exposure to FOPL as compared to older adults and young children. While family income and race/ethnicity are both associated with AFH food consumption the previously identified key driver behind food AFH consumption was age (32).
Although nutritional quality can vary between AFH establishments, when compared to meals prepared at home, AFH meals contain higher levels of saturated fat, sodium, and refined grains, lower levels of nutrients to encourage such as calcium and fiber (32), and have been associated with larger portion sizes and higher per meal calorie content (33). As such, more frequent AFH consumption tends to be associated with poor diet quality (32, 34). Further, our analysis identified lower FOPL exposure for people with overweight/obesity, which may be explained by higher AFH consumption (35, 36). In the post-recessionary period, AFH consumption has remained stable but accounts for a substantial proportion of dietary intakes (32). A nutrition labeling strategy that includes AFH food sources, in addition to FOPL, is likely to have a greater impact on diet quality. The US has had mandatory restaurant menu labeling since 2018 but the regulation applies to chain restaurants with ≥ 20 locations and requires that only calories be displayed. Additional written nutrition information (e.g. saturated fat, sodium, sugars, fiber and protein) are available by request (37). Food groups and other nutrients to encourage are not included. Although research on the effectiveness of current AFH labeling is mixed (38), further research exploring novel and creative ways (e.g. contextual, interpretative, digital, etc.) of presenting nutrition information at point of consumption, is warranted (38).
Nutrient / Food Group Intake & FOPL Exposure
Nutrient profile models that underpin FOPLs should ideally complement current government advice on a healthy diet (10). It is therefore important that nutrients and food groups to limit and encourage are considered in FOPL schemes. Our data reveals major differences between these key nutrients and those eligible for FOPL leading to potential inconsistencies between FOPL and current dietary guidance. The DGA recommends limiting consumption of sodium, saturated fat and added sugars. Consistent with prior work showing added sugars preferentially come from stores, more than three-quarters of added sugars is subject to FOPL. Saturated fat is well covered (57.5%) by FOPL. However, less than half of sodium intake is subject to FOPL. If FOPL is effective at steering people towards healthier foods, the population-level impact on sodium intakes may be more muted. Although sodium reduction efforts for packaged foods should continue, the impact of these reductions is limited due to two key sources not subject to FOPL: AFH foods and table salt used during cooking or eating. Those ≥ 20y reporting eating at least one meal at a restaurant consumed 53% of their daily sodium intake from AFH food sources, resulting in an additional 605 mg/day compared to those not consuming restaurant food (39).
The DGA has identified potassium, calcium, vitamin D, and dietary fiber as being “shortfall” nutrients in the US diet. In our analysis, 40–50% of potassium and fiber intakes are subject to FOPL. Fresh fruits and vegetables, which are exempt from nutrition labeling, are key sources of both nutrients and explain their under-representation. Our data show that > 60% of calcium intake is subject to FOPL and is driven by the FOPL exposure of dairy, especially milk and yogurt. While just over half of cheese intake is subject to FOPL, AFH pizza consumption is a key contributor to cheese intake which explains the difference with other dairy forms (40). Since calcium is a mandatory nutrient for nutrition labeling in US, including calcium or dairy content in FOPL could help draw attention to food sources delivering this shortfall nutrient. At present, most NP/FOPL schemes do not include dairy or calcium. Americans also fail to meet the recommendations for key food groups, including fruit and vegetables (80–90% shortfall), dairy (90% shortfall) and whole grains (98% shortfall) (1). Apart from fruit juice, fruit and vegetable intakes were less subject to FOPL. Vegetables and fruit are both important components of some FOPL algorithms, including Nutri-Score and Health Star Rating (HSR), but a potential discrepancy exists at the population level for these food groups, as a very low proportion of their intake is subject to FOPL. Innovating ways to conveniently incorporate fruits and vegetables into FOPL eligible foods and beverages may be one way to address the fruit and vegetable intake challenge. Education on the nutrient content of frozen and canned fruits and vegetables, specifically how they are comparable to fresh may also help Americans meet recommended intakes. Further, inclusion of meaningful fruit and vegetable quantities into FOPL algorithms would further draw consumer attention to FOPL eligible fruit and vegetables sources. Additionally, Americans are recommended to increase the variety of consumption of protein subgroups (seafood, beans, peas and lentils) and our analysis found that while less than 50% of protein intake is subject to FOPL, plant-based sources of protein, legumes and nuts/seeds, are more subject to FOPL, warranting a discussion as to whether these identified foods groups to encourage should be included in FOPL schemes.
Nearly 90% of whole grain intake is subject to FOPL; however, whole grains are not typically included in the NP models that underpin the FOPL (41, 42). While fiber is a purported surrogate for whole grains, our analysis shows fiber and whole grains intakes at the population-level to have differing proportions subject to FOPL indicating that fiber may not be an appropriate surrogate for whole grain content. This finding is consistent with prior research examining the HSR system which showed that fiber was not an adequate proxy for whole grain content (42). Whole grains are an excellent source of fiber, but the fiber content of one full serving (16 g) of whole grains can vary from about 1 to 3 grams. While some whole grains deliver less fiber, they still provide other valuable nutrients (e.g. antioxidants, iron, B vitamins, etc.). Fiber alone is therefore not enough to assess whether a product is in fact a whole grain food (43).