Response to ‘Front-of-package nutrition labels need to be assessed on their nutrition science rigour’ by Lawrence and Woods

Madam

We thank Lawrence and Woods for their letter^{( 1 )} in response to our overview of front-of-package (FOP) nutrition labelling policy^{( 2 )}. We agree that FOP nutrition labels need to be evaluated regarding their nutrition science rigour, preferably prior to their implementation within formal public policies, and we see this as an ongoing area of research. The focus of our editorial was to provide an overview of existing FOP nutrition labelling systems and areas for further research. However, it does not mean that we fully support all the systems that we included in our overview. We strongly agree that the nutrient profiling methods underpinning FOP nutrition labels are an important focus for future research.

There are a myriad of non-scientific factors influencing the development and implementation of public policies, including FOP nutrition labels^{( 3 , 4 )}. To our knowledge, the Health Star Rating (HSR) system is designed to compare products within groups rather than across groups^{( 5 )}, and includes nutrients of concern as well as positive components within its scoring system. The result is a system that permits ‘the display of 3, 3·5 and 4 health stars on foods such as ice confections and chocolate covered-muesli bars’, as Lawrence and Woods assert^{( 1 )}. Nutrition science research has recently been conducted that suggests that when added sugars are used to calculate the HSR instead of total sugars, the performance of the HSR improves for packaged foods in Australia^{( 6 )}, thus also supporting the initiative in the USA to include added sugars on nutrition facts labels^{( 7 )}. There is currently a formal review underway with the aim to evaluate the performance of the HSR, its algorithm and its implementation^{( 8 )}. Both in Australia and New Zealand, respectively, public health experts have recommended that their governments urgently address the existing anomalies in the HSR algorithm, and that the HSR be made mandatory if there is not widespread uptake by 2019^{( 9 , 10 )}. More broadly, research comparing the nutrient profiling capabilities of the different FOP labelling schemes, such as comparing the HSR with other FOP labelling schemes, will elucidate which of these systems will be most effective for the public and which of these systems may be most resistant to industry exploitation for marketing purposes.

While greater research regarding ‘whole foods/dietary patterns and health outcomes’^{( 1 )} will strengthen our understanding of what constitutes a ‘healthy’ diet, it is the juxtaposition between what is ‘good’ and ‘bad’, or truly nutritious, for health that has made nutrient profiling schemes confusing^{( 11 , 12 )}. Various FOP nutrition labelling systems, while at times crude and based on a limited number of nutrients, have the ability to help consumers identify ‘more healthful’ and ‘less healthful’ food items in an increasingly complex food system^{( 2 , 12 , 13 )}. We feel that a thorough examination of consumer understanding, interpretation and use of each of the various FOP nutrition labelling systems and impacts on the food industry are equally as important for understanding FOP nutrition labelling as a public health nutrition tool as Lawrence and Woods’ suggestions of improved nutrient profiling science^{( 1 )}, to advance this policy space. FOP nutrition labels need to continue to be assessed based on the most current and rigorous nutrition science, not just as a means to evaluate current FOP nutrition labelling policies, but well before a FOP nutrition label is implemented into public policy.