Food Label Use and Its Relation to Dietary Intake among US Adults

Food Label Use and Its Relation to Dietary Intake among US Adults

RESEARCH Research and Professional Briefs Food Label Use and Its Relation to Dietary Intake among US Adults NICHOLAS JAY OLLBERDING, PhD; RANDI L. WOLF, PhD; ISOBEL CONTENTO, PhD ABSTRACT Rates of diet-related chronic disease combined with the lack of current data on patterns of food label use by the US population warrant re-examination of the use and potential influence of this public health tool. The purpose of this study was to describe the prevalence of food label use and the association between food label use and nu- trient intake in a nationally representative sample of US adults who participated in the 2005-2006 National Health and Nutrition Examination Survey. Data on food label use were collected during the interview portion of the survey, and nutrient intake was estimated using the average of two 24-hour dietary recalls. In this sample, 61.6% of participants reported using the Nutrition Facts panel, 51.6% looked at the list of ingredients, 47.2% looked at serving size, and 43.8% reviewed health claims at least sometimes when deciding to purchase a food product. There were significant differences (PϽ0.05) in food label use across all demographic characteristics ex- amined. Significant differences (PϽ0.05) in mean nutri- ent intake of total energy, total fat, saturated fat, choles- terol, sodium, dietary fiber, and sugars were observed between food label users and non-users with label users reporting healthier nutrient consumption. The greatest differences observed were for total energy and fat and for use of specific nutrient information on the food label. Despite food label use being associated with improved dietary factors, label use alone is not expected to be sufficient in modifying behavior ultimately leading to im- proved health outcomes. J Am Diet Assoc. 2010;110:1233-1237. T he continued rise in rates of obesity and diet-related chronic disease over the past several decades has culminated in a public health crisis that warrants re-examination of approaches designed to combat these disorders. Poor dietary practices, including overconsump- tion of energy (1,2), high intakes of saturated fat and sodium (2), and low intakes of fruits, vegetables, and fiber (2-4) are contributing to diet-related chronic disease and have resulted in speculation that poor diet and physical inactivity will surpass tobacco use as the leading prevent- able cause of death among US adults (5). The 1990 Nutrition Labeling and Education Act al- lowed for the creation of a standardized food label intro- duced in May 1994 with the aim of combating obesity and diet-related chronic disease by providing consumers in- formation at the point of purchase that would assist in selecting foods in accordance with dietary recommenda- tions. Current regulations require all packaged food items regulated by the Food and Drug Administration to display on the label information on serving size, number of servings, total energy, energy from fat, total fat, satu- rated fat, cholesterol, sodium, carbohydrates, dietary fi- ber, sugar, protein, vitamin A, vitamin C, calcium, iron, and trans fat (6), with selection of these nutrients based on their role in chronic disease etiology or nutrient defi- ciency (7). The percent daily value for nutrients reflective of a 2,000-kcal/day diet and a list of ingredients must also be provided for foods with more than one ingredient (6). Health claims must be limited to statements about dis- ease reduction and evaluated by the Food and Drug Ad- ministration before use (6). Previous research indicates that between 45% and 80% of US adults report reading food labels (8-13), and this practice is correlated with improved dietary patterns (12- 16). Various characteristics have also been found to in- fluence food label use (8,9,11-14,16-21), such as age, sex, level of education, income, and household size. Results have not been uniform, with the proportion of adults reporting label use differing between studies and incon- sistencies observed in several characteristics thought to be associated with use. Due to the fact that rates of obesity and diet-related chronic disease have continued to rise since implementation of food label standardization, a timely re-evaluation of the prevalence of use and poten- tial health-related benefits of this public health tool is needed. Therefore, the purpose of this study was to de- scribe the prevalence of food label use among US adults using data from the 2005-2006 National Health and Nu- N. J. Ollberding is a postdoctoral fellow, Cancer Re- search Center of Hawaii, Honolulu; at the time of the study, he was a doctoral degree student, Program in Nutrition, Department of Health and Behavior Studies, Teacher’s College, Columbia, University, New York, NY. R. L. Wolf is an associate professor of human nutrition on the Ella McCollum Vahlteich Endowment, and I. Contento is Mary Swartz Rose Professor of Nutrition and Education, and coordinator, Program in Nutrition, Department of Health and Behavior Studies, Teacher’s College, Columbia University, New York, NY. Address correspondence to: Nicholas Jay Ollberding, PhD, Program in Nutrition, Department of Health and Behavior Studies, Teacher’s College, Columbia Univer- sity, 525 W 120th St, New York, NY 10027. E-mail: njo2105@columbia.edu Manuscript accepted: December 23, 2009. Copyright © 2010 by the American Dietetic Association. 0002-8223/$36.00 doi: 10.1016/j.jada.2010.05.007 © 2010 by the American Dietetic Association Journal of the AMERICAN DIETETIC ASSOCIATION 1233 trition Examination Survey (NHANES) and to examine the association between food label use and nutrient in- take in this nationally representative sample of US adults. METHODS NHANES is a continuous survey of non-institutionalized US civilians conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention that is used to monitor the health and nutritional status of the country (22). During the 2005-2006 NHANES, 10,348 individuals participated in the interview portion of the survey (response rate 80.5%), and 9,950 underwent the physical exam (response rate 77.4%) (23). For this study, only participants who were older than age 18 years and answered questions on food label use (nϭ5,502) were used for prevalence of label use estimations. Participants who were older than age 18 years, answered questions on food label use, and completed two 24-hour recalls with 2-day reported energy values between 500 and 5,000 kcal (nϭ4,454) were used to estimate differences in nutrient intake between food label users and nonusers. This study was deemed exempt by the Teachers College (Columbia University) Institutional Review Board. During the in-home interview, participants were shown a food label model and asked how often they used the Nutrition Facts panel, list of ingredients, serving size information, or health claims when deciding to buy a food product with possible responses being “always,” “most of the time,” “sometimes,” “rarely,” “never,” or “never seen.” For participants reporting use of any section of the label, follow-up questions were asked on the use of specific information related to total energy, total fat, saturated fat, cholesterol, sodium, fiber, or sugars. For this study, those who reported using the food label “always,” “most of the time,” or “sometimes” were deemed food label users and those reporting “rarely,” “never,” or “never seen” as nonusers. The average of two nonconsecutive 24-hour dietary re- calls were used to obtain nutrient estimations. Recalls were conducted using an automated five-step multiple- pass method with three-dimensional measuring guides used to assist in portion size estimation (24). Nutrient composition was calculated from 24-hour recall using the US Department of Agriculture Food and Nutrient Data- base for Dietary Studies (version 3.0, 2008, Agricultural Research Service, Food Surveys Research Group, Belts- ville, MD). Data on participant age, sex, education, family poverty income ratio, race/ethnicity, language of exam, length of residence in the United States if foreign born, and house- hold size were collected on participants during the in- home interview and used in this study. Body mass index, level of physical activity, and smoking status were col- lected during the physical exam. A composite score for physical activity was created for each participant by mul- tiplying the number of times per month leisure time physical activity was reported on the leisure time physi- cal activity questionnaire (25) by the duration of the activity and metabolic equivalent. Participants older than age 20 years who reported smoking cigarettes every day or on some days were classified as current smokers. Because no data were available on the current smoking status of participants younger than age 20 years, smok- ing status for these participants was determined by as- sessing the number of cigarettes smoked in the past 30 days. Participants aged 18 to 19 years who reported smoking one or more cigarettes over the past 30 days were considered current smokers, whereas those who re- ported smoking no cigarettes during the past 30 days were considered nonsmokers. All analyses were performed using STATA software (version 10.1, 2007, STATA Corp, College Station, TX) and accounted for NHANES sampling design and study weights. Percentage of food label users by study charac- teristic were calculated for each section of the label and ␹ 2 tests used to examine differences in the proportion of users for each characteristic. Multiple linear regression was used to obtain mean differences in nutrient intake between food label users and nonusers adjusted for age, sex, education, poverty income ratio, race/ethnicity, coun- try of birth, body mass index, recent weight loss attempt, smoking status, leisure time physical activity, and house- hold size. Covariates were chosen a priori and included all available variables thought to potentially confound the association between label use and nutrient intake. All tests were two-tailed with statistical significance set at PϽ0.05. Taylor series linearization was used for variance estimations in all regression models. RESULTS AND DISCUSSION The final sample size for analyses examining the preva- lence of food label use was 5,502 and for analyses exam- ining mean differences in nutrient intake between food label users and nonusers 4,454. The weighted percent- ages of food label users for the total study sample and by demographic characteristics are shown in Table 1. In this sample, 61.5% of adults reported using the Nutrition Facts panel at least sometimes when deciding to pur- chase a food product, 51.6% used the list of ingredients, 47.2% used serving size, and 43.8% used health claims. Examination of the percentage of food label users by demographic characteristics revealed highly discrepant rates of label use for various characteristics including age, sex, education, income, race/ethnicity, language of exam, and length of residence in the United States for those foreign born. These findings indicate that women (8,9,11,13,14,16,18-20,26), participants with greater edu- cation (8-11,16,19), and participants with higher income (9,10,14,16,19) were more likely to report using the food label and have been consistently observed in previous studies. Non-Hispanic whites reported more frequent use of food labels, which is inconsistent with previous re- search showing no observed differences of food label read- ing by race or ethnicity (9,11,16,19). Participants with limited English language skills had greatly reduced rates of label use, whereas label use among foreign-born par- ticipants was found to increase with duration of residency in this sample. This was the first study identified to observe this association with future research in this area needed to better understand the effects of language and acculturation as determinates of food label use. The results of multiple linear regression examining mean differences in nutrient intake between label users and nonusers are shown in Table 2. Users of the Nutri- tion Facts panel were found to have lower reported values 1234 August 2010 Volume 110 Number 8 for total energy, total fat, saturated fat, and sugars; users of the list of ingredients had lower reported values for total fat, saturated fat, and sodium; users of the serving size had lower reported values for total energy, total fat, saturated fat, cholesterol, and sugars; and users of the health claims had lower reported values for total fat and saturated fat. Reported dietary fiber intake was found to be higher among label users for all sections of the food label. Use of specific nutrient information found on the Nutrition Facts panel was associated with the largest difference in mean nutrient intake between label users and nonusers for energy, total fat, cholesterol, and so- dium. Estimates from this sample reveal that differences in reported nutrient intake between label users and non- users was greatest for total energy and fat with less difference observed for other nutrients examined. For example, food label users who use the serving size infor- mation reported eating 150 kcal less per day when com- pared to non–label users. These results support previous studies that have consis- tently observed an association between increased use of the food label and improved nutrient intake (12-15) and health- ier dietary patterns (16), with only one study to date failing to observe this association (9). Analyses revealed that the Table 1. Percentage of food label users a for specific sections of the food label (based on data from the National Health and Nutrition Examination Survey 2005-2006) User characteristic Nutrition Facts Panel Ingredients Serving Size Health Claims %n%n%n%n Total 61.6 3,012 51.6 2,583 47.2 2,358 43.8 2,254 Age (y) 18-34 52.4*** 1,004 38.7*** 768 40.5*** 788 38.6** 767 35-54 66.5 997 56.9 878 50.6 780 45.0 710 55-85 64.3 1,011 57.8 937 49.3 790 47.5 777 Sex Male 49.5*** 1,189 41.1*** 1,026 34.2*** 868 32.5*** 843 Female 72.8 1,823 61.4 1,557 59.3 1,490 54.3 1,411 Education ϽHigh school 39.6*** 586 37.0*** 540 31.6*** 481 30.8*** 477 High school 53.2 668 44.5 589 40.5 538 40.1 534 Some college 67.0 980 55.5 828 52.4 780 47.8 738 College graduate 79.2 757 64.5 625 58.8 558 51.9 504 Income (PIR) b Ͻ1.3 47.6*** 655 43.0*** 597 39.5*** 540 37.8** 524 1.3-3.5 55.7 1,043 48.0 917 43.6 823 42.6 837 Ͼ3.5 72.8 1,174 58.8 960 54.3 897 47.8 802 Race/ethnicity Non-Hispanic white 65.2*** 1,602 53.4*** 1,313 49.2** 1,213 45.0** 1,115 Mexican American 41.4 477 35.4 406 32.9 376 33.5 395 Other Hispanic 58.7 93 50.5 82 40.3 63 45.1 70 Non-Hispanic black 55.4 707 52.4 664 46.3 597 44.3 572 Multi-racial/other 58.5 133 51.1 118 47.7 109 41.2 102 Language of exam English 63.1*** 2,797 52.9*** 2,231 48.4*** 2,186 44.8*** 2,080 Spanish 34.3 213 29.4 191 25.7 172 25.5 174 Length of residence in the United States c Ͻ5 y 44.5** 88 37.0** 78 32.3** 66 33.7 70 5-20 y 44.5 221 38.4 201 32.4 163 32.3 178 Ͼ20 y 61.5 198 52.7 177 49.4 161 43.1 146 Household size Ͼ1 person 60.4*** 2,532 50.1*** 2,148 46.7 1,993 43.4 1,903 Live alone 68.8 480 60.3 435 49.9 365 46.1 351 a Food label users are those who reported “always,” “most of the time,” or “sometimes” using the section of the food label when deciding to buy a food product. Analyses were restricted to participants who were older than age 18 years and answered questions on food label use during the interview portion of the survey (nϭ5,502). Asterisk denotes significant ␹ 2 value for within-group differences on each demographic characteristic and aspect of label use. b PIRϭpoverty-to-income ratio. PIR Ͻ1.3 considered low income, 1.3-3.5 middle income, and Ͼ3.5 high income. c If foreign born. **PϽ0.01. ***PϽ0.001. August 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1235 Table 2. Differences in mean nutrient intake between food label users and nonusers, based on data from the National Health and Nutrition Examination Survey 2005-2006 a Nutrient ␤ ؎standard error P value R 2 (%) ⌬R 2b (%) Total energy intake (kcal/d) Covariates only c 29.10 Use of Nutrition Facts panel c Ϫ113.47Ϯ35.040 0.006 29.49 0.39 Use of list of ingredients c Ϫ66.25Ϯ33.194 0.064 29.25 0.15 Use of serving size c Ϫ149.60Ϯ27.495 Ͻ0.001 29.88 0.78 Use of health claims c Ϫ57.21Ϯ31.792 0.092 29.22 0.12 Use of energy information de Ϫ163.61Ϯ25.901 Ͻ0.001 29.79 0.69 Total fat intake (g/d) Covariates only c 20.43 Use of Nutrition Facts panel c Ϫ4.71Ϯ1.382 0.004 20.74 0.31 Use of list of ingredients c Ϫ4.41Ϯ1.810 0.028 20.75 0.32 Use of serving size c Ϫ7.95Ϯ1.191 Ͻ0.001 21.45 1.02 Use of health claims c Ϫ4.74Ϯ1.699 0.014 20.8 0.37 Use of total fat information de Ϫ9.01Ϯ1.429 Ͻ0.001 21.35 0.92 Saturated fat intake (g/d) Covariates only c 17.39 Use of Nutrition Facts panel c Ϫ2.48Ϯ0.468 Ͻ0.001 18.0 0.61 Use of list of ingredients c Ϫ2.04Ϯ0.678 0.009 17.87 0.48 Use of serving size c Ϫ3.50Ϯ0.417 Ͻ0.001 18.81 1.42 Use of health claims c Ϫ2.28Ϯ0.706 0.006 18.01 0.62 Use of saturated fat information de Ϫ3.05Ϯ0.480 Ͻ0.001 17.92 0.53 Cholesterol intake (mg/d) Covariates only c 10.63 Use of Nutrition Facts panel c Ϫ13.75Ϯ8.376 0.122 10.74 0.11 Use of list of ingredients c Ϫ6.71Ϯ7.726 0.399 10.66 0.03 Use of serving size c Ϫ24.05Ϯ5.431 Ͻ0.001 11.01 0.38 Use of health claims c Ϫ14.80Ϯ8.504 0.102 10.78 0.15 Use of cholesterol information de Ϫ28.96Ϯ9.577 0.009 11.49 0.86 Sodium intake (mg/d) Covariates only c 22.05 Use of Nutrition Facts panel c Ϫ38.44Ϯ59.009 0.525 22.06 0.01 Use of list of ingredients c Ϫ162.02Ϯ74.388 0.046 22.33 0.28 Use of serving size c Ϫ148.03Ϯ72.531 0.059 22.29 0.24 Use of health claims c Ϫ83.89Ϯ56.999 0.162 22.12 0.07 Use of sodium information de Ϫ203.89Ϯ53.533 0.002 23.25 1.2 Total fiber intake (g/d) Covariates only c 12.57 Use of Nutrition Facts panel c 1.24Ϯ0.339 0.002 13.05 0.48 Use of list of ingredients c 1.24Ϯ0.391 0.006 13.12 0.55 Use of serving size c 0.66Ϯ0.297 0.044 12.73 0.16 Use of health claims c 1.13Ϯ0.399 0.013 13.04 0.47 Use of fiber information de 1.13Ϯ0.458 0.026 14.53 1.96 Sugar intake (g/d) Covariates only c 13.22 Use of Nutrition Facts panel c Ϫ17.94Ϯ3.541 Ͻ.001 14.64 1.42 Use of list of ingredients c Ϫ5.50Ϯ3.309 0.117 13.38 0.16 Use of serving size c Ϫ14.20Ϯ2.801 Ͻ0.001 14.25 1.03 Use of health claims c Ϫ2.20Ϯ3.142 0.494 13.25 0.03 Use of sugar information de Ϫ12.13Ϯ2.709 Ͻ0.001 13.3 0.08 a Nutrient values were obtained using the average of two 24-hour recalls. All values were obtained using multiple linear regression adjusted for age, sex, education, poverty income ratio, race/ethnicity, country of birth, body mass index, recent weight loss attempt, smoking status, leisure time physical activity, and household size. Analyses were restricted to participants who were older than age 18 y, answered questions on food label use during the interview portion of the survey, and completed two 24-hour dietary recalls with an average caloric intake between 500 and 5,000 kcal (nϭ4,454). b Variance explained by label use beyond that explained by covariates converted to a percentage. c Use of information on that nutrient found on the Nutrition Facts panel. d nϭapproximately 3,956. e nϭapproximately 3,062. 1236 August 2010 Volume 110 Number 8 proportion of variance in nutrient intake explained by food label use alone was small (0% to 1.99%) and similar to values obtained in the only other study identified to report on this value (13). Despite the limited amount of variance explained by label use, mean differences between users and nonusers for several nutrients were of sufficient magnitude to be of potential public health importance. There were several study limitations. First, this study was cross-sectional, precluding temporal ascertainment for many associations and some measures seen as proxies for constructs of interest since questionnaires were not de- signed specifically for this study. Second, caution should be taken in interpreting results due to the exploratory nature of this study and large number of statistical tests conducted with no adjustments for cumulative error increasing the risk of type I error. Third, selection bias may have been incompletely controlled for in this study. CONCLUSIONS If food labels are to have greater influence on public health, rates of use will likely need to be increased among US adults. Dietetics educators and practitioners may be uniquely capable to train individuals on the use of the food label and to increase awareness in the need for better pop- ulation-wide nutrition monitoring practices. Low rates of label use also suggest that national campaigns or modifica- tion of the food label may be needed to reduce the proportion of the population not using this information. Possible changes to the current label that have been suggested in- clude using boldface type for energy information (27); re- porting the total nutrient intake for foods likely to be con- sumed in a single sitting (27); and using more intuitive labeling that requires less cognitive processing such as a red, yellow, and green “traffic light” sign on the front of the label (28). The food label alone is not expected to be suffi- cient in modifying behavior ultimately leading to improved health outcomes but may be used by individuals and dietet- ics practitioners as a valuable and motivating tool in our efforts to combat obesity and diet-related chronic disease. STATEMENT OF POTENTIAL CONFLICT OF INTEREST: No potential conflict of interest was reported by the authors. References 1. Wright JD K-SJ, Wang CY, McDowell MA, Johnson CL. Trends in intake of energy and macronutrients—United States, 1971-2000. MMWR Morbid Mortal Wkly Rep. 2004;53:80-83. 2. Nutrient intakes: Mean amounts consumed per individual, one day, 2005-2006. US Department of Agriculture, Agricultural Research Ser- vice Web site. www.ars.usda.gov/ba/bhnrc/fsrg. Posted 2008. Accessed August 8, 2009 3. Guenther PM, Dodd KW, Reedy J, Krebs-Smith SM. Most Americans eat much less than recommended amounts of fruits and vegetables. J Am Diet Assoc. 2006;106:1371-1379. 4. 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National Health and Nutrition Examination Survey Physical Activity Questionnaire. Centers for Disease Control and Prevention, National Center for Health Statistics Web site. http://www.cdc.gov/nchs/ nhanes/nhanes2005-2006/quex05_06.htm. Accessed Novemeber 15, 2009. 26. Kristal AR, Levy L, Patterson RE, Li SS, White E. Trends in food label use associated with new nutrition labeling regulations. Am J Public Health. 1998;88:1212-1215. 27. Philipson T. Government perspective: Food labeling. Am J Clin Nutr. 2005;82(1 suppl):262S-264S. 28. Silver L, Bassett MT. Food safety for the 21st century. JAMA. 2008;300:957-959. August 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1237 . RESEARCH Research and Professional Briefs Food Label Use and Its Relation to Dietary Intake among US Adults NICHOLAS JAY OLLBERDING, PhD; RANDI L. WOLF, PhD; ISOBEL CONTENTO, PhD ABSTRACT Rates. fiber, and sugars were observed between food label users and non-users with label users reporting healthier nutrient consumption. The greatest differences observed were for total energy and fat and. and fat and for use of specific nutrient information on the food label. Despite food label use being associated with improved dietary factors, label use alone is not expected to be sufficient in