Front-of-Package Nutrition Labelling: September 18, 2017 Stakeholder Engagement Meeting

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Type: Report

Date published: 2017-11-02

Executive Summary
Introduction
Health Canada Introductory Presentations
Panel Discussions: Food Industry Perspectives on FOP Labelling
Panel Discussion: Research Expert Perspectives on FOP Labelling
Key Messages
Discussion on Proposed FOP Symbols
Closing Remarks
Questions from Online Participants and Answers

Please note: This report is intended to summarize the spirit of the proceedings and discussion that took place at the Front-of-Package Nutrition Labelling Stakeholder Engagement Meeting, held in Ottawa on September 18, 2017. Participants may submit clarifications by contacting us at: healthyeating-sainealimentation@hc-sc.gc.ca. These comments will be posted on Health Canada's Openness and Transparency website.

Executive Summary

The incidence of chronic disease in Canada is a major health concern that not only has an impact on mortality and morbidity, but also has a large bearing on the economy in terms of direct health care costs and indirect costs, such as those related to loss of productivity.

In October 2016, the former Minister of Health released the Healthy Eating Strategy as part of the Government's vision of a healthy Canada. A part of the Strategy is a commitment by Health Canada to engage the public and stakeholders to get input on a number of interlocking initiatives to improve the food environment. One of these initiatives includes a front-of-package (FOP) labelling approach aimed at helping Canadians make healthier and more informed food choices, particularly on sugars, sodium and saturated fat.

On September 18, 2017, Health Canada brought together industry and health stakeholders, as well as academic and international experts to share and review evidence and to explore options for FOP symbols for further consultation. Health Canada representatives opened the meeting by indicating that diet-related chronic diseases are a major health problem, specifically diets high in sugars, sodium, and saturated fat. Canadians face a number of healthy eating challenges, which are being addressed by the Healthy Eating Strategy. Part of the Strategy is improving the information on food labels and FOP labelling. Health Canada has proposed FOP 'high in' nutrition symbols that would help consumers identify foods high in sugars, sodium, and saturated fat, and that could drive reformulation of some of these products, so they contain lower levels of these nutrients. Health Canada consulted on proposed symbols for a 'high in' FOP labelling approach through a pre-regulatory online consultation conducted in the fall of 2016.

The Retail Council of Canada (RCC), the Food & Consumer Products of Canada (FCPC) and the Canadian Beverage Association (CBA) each presented proposed FOP symbols that were considered at the meeting. In addition, Abacus Data presented the results of an online survey, co-funded by FCPC and CBA. There were a number of key messages from the industry presentations, including:

A need for coordinated implementation of all the labelling changes.
Consumers should be provided with more information, rather than just a warning label.
A need for education to accompany any FOP system.
Unintended consequences, such as identifying nutrient dense foods as bad, should be avoided.

Academic experts from the Universities of Alberta, Toronto, and Waterloo, as well as an international expert from the Pan American Health Organization, presented research data on FOP labelling and the experiences in other countries. There were several conclusions from these presentations:

There should be a mandatory FOP and not one that simply directs the consumer to the Nutrition Facts table (NFt).
The symbol should be meaningful, intuitive and allow quick decision making.
If colour is included, it should only be one colour (red).

A discussion on the strengths and weaknesses of each symbol proposed by industry, Health Canada and Dietitians of Canada was held. No firm decisions were reached on which ones should be dropped or changed. It was decided that similar ones should be combined and that some positive aspects might be adopted in re-designed symbols that would be subjected to further consultations.

The Minister of Health provided closing remarks. The key message was that discussion is very important and that stakeholders are essential partners in improving the health of Canadians and implementing the initiatives outlined in the Healthy Eating Strategy.

Introduction

Background and Context

Chronic non-communicable diseases, such as type 2 diabetes, cardiovascular disease, and cancer, are a major health concern in Canada. The incidence of Type 2 diabetes continues to increase and cardiovascular disease is one of the leading causes of death in Canada. With high rates of obesity and hypertension, as well as an aging Canadian population, the impact of chronic diseases is likely to continue to increase unless action is taken to reduce modifiable risk factors.

One of the major modifiable risk factors for obesity, type 2 diabetes, cardiovascular disease, and cancer is diet. Poor diet is a primary risk factor for chronic disease and places a high economic burden on the health care system. Costs related to unhealthy diets and other risk factors for chronic disease are estimated to be $26.7 billion annually.

Diets high in sugars, sodium, and saturated fat are strongly linked to obesity and chronic disease risk. Taking action to reduce the intakes of these nutrients in the diets of Canadians can help to reduce the incidence of obesity and chronic diseases, along with the associated economic burden.

In October, 2016, the former Minister of Health released a Healthy Eating Strategy, as part of the Government's vision of a healthy Canada, in response to several food and nutrition commitments outlined in the 2015 Mandate Letter from the Prime Minister of Canada. The Strategy ties Health Canada's ongoing nutrition efforts with new, complementary initiatives to make it easier for Canadians to choose healthier food options. The Strategy states that Canadians 'need to have the right tools to access, understand and use nutrition information to make healthier choices'. For this reason, Health Canada proposed a front-of-package (FOP) labelling approach aimed at helping Canadians make healthier and more informed food choices, particularly with respect to sugars, sodium and saturated fat.

In November of 2016, Health Canada conducted a public consultation on FOP nutrition labelling to solicit input from all interested Canadians, including: consumers; industry members and associated organizations; health professionals and associated organizations; all levels of government; academic and research experts; and non-government organizations. Over 1500 responses were received from interested stakeholders. In December 2016, Health Canada commissioned public opinion research on the symbols proposed for FOP nutrition labelling, the results of which are available on the Library and Archives Canada website. In early 2017, a cost benefit study was undertaken to quantify the proposed benefits and costs of making amendments to the Food and Drug Regulations to, among other things, require a FOP nutrition symbol on foods that contain high levels of sugars, sodium, or saturated fat. In May 2017, Agriculture and Agri-Food Canada hosted a Food Processing Industry Roundtable meeting, where Roundtable members requested that Health Canada convene a stakeholder meeting to share and review evidence and explore options for FOP symbols for further consultation. In response to this request, Health Canada hosted the meeting on September 18, 2017. In the spirit of openness and transparency, the meeting was streamed live and made accessible to other interested parties who could not be physically present.

Purpose of the Report

This report summarizes the proceedings and outcomes of the FOP Nutrition Labelling Stakeholder Engagement Meeting, held in Ottawa on September 18, 2017. The meeting presentations can be ordered from the Health Canada Openness and Transparency website. Some of the views expressed are those of the participants and do not necessarily reflect those of Health Canada or the Government of Canada.

Meeting Objectives

The objectives of the meeting were to bring together a balanced mix of industry stakeholders, scientific experts and health sector representatives to share and review evidence, and to explore additional options for the design of an FOP nutrition symbol for Canada. Stakeholders were invited to submit symbol options that they wished to be included in the discussion. In order for the symbol options to achieve the public health objectives, minimize costs to industry, and align with Health Canada's health protection legislative authority, it was asked that the symbols meet the following three evidence-based criteria:

Follow the 'high-in' approach;
Focus on the three nutrients of public health concern (sugars, sodium and saturated fat); and
Be black and white.

All symbols contributed by participants were included in the discussion on September 18^th, 2017, despite not all meeting the above-listed criteria.

Symposium Participants

Food Industry Representatives:
Participant	Organization
Jim Goetz ׀ President	Canadian Beverage Association
Anthony van Heyningen ׀ Senior Director, Research and Policy	Canadian Beverage Association
Isabelle Neiderer ׀ Director Nutrition	Dairy Farmers of Canada
Jackie Crichton ׀ Chair, Dairy Regulatory/Technical Committee and Director of Regulatory Affairs Canadian Meat Council	Dairy Processors Association of Canada/Canadian Meat Council
Michi Furuya Chang ׀ Vice President Scientific Affairs & Nutrition	Food & Consumer Products of Canada
Carla Ventin ׀ Vice President of Federal Government Affairs	Food & Consumer Products of Canada
Chris Kyte ׀ President	Food Processors of Canada
Alain Brandon ׀ Senior Director, Corporate Social Responsibility and Government Relations	Loblaw Companies Limited
Alison Baxter ׀ Director, Health and Wellness and Industry Relations	Retail Council of Canada
David Wilkes ׀ Senior Vice President, Government Relations and Grocery Division	Retail Council of Canada
Bruce Anderson, Abacus Data	Invited by Food & Consumer Products of Canada and Canadian Beverage Association
Lewis Retik, Gowlings WLG

Health Stakeholder Representatives:
Participant	Organization
Kelly Masotti ׀ Director, Public Issues	Canadian Cancer Society
Jill Skinner ׀ Associate Director, Policy Develoment and Strategic Direction	Canadian Medical Association
Ian Culbert ׀ Executive Director	Canadian Public Health Association
Anne-Marie Morel ׀ Public Policies Advisor	Coalition québécoise sur la problématique du poids
Dr. Seema Nagpal ׀ Epidemiologist and Senior Leader, Government Relations and Public Policy	Diabetes Canada
Pat Vanderkooy ׀ Manager, Public Affairs	Dietitians of Canada
Manuel Arango ׀ Director, Health Policy	Heart and Stroke Foundation of Canada

Scientific Experts:
Participant	Organization
Dr. Fabio Gomes	Pan American Health Organization
Dr. Kim Raine	University of Alberta
Dr. Mary L'Abbé	University of Toronto
Dr. David Hammond	University of Waterloo

Health Canada:
Participant	Organization
Christine Donoghue ׀ Associate Deputy Minister	Health Canada
Pierre Sabourin ׀ Assistant Deputy Minister	Health Products and Food Branch, Health Canada
Kendal Weber ׀ Acting Associate Assistant Deputy Minister	Health Products and Food Branch, Health Canada
Karen Mclntyre ׀ Director General	Food Directorate, Health Products and Food Branch Health Canada

Over 1800 stakeholders registered in Health Canada's Stakeholder Registry were invited to participate in the meeting via live web streaming; there were over 300 registered connections. Viewers could see presentations and hear discussions; a number of them also contributed questions to the discussions. Representatives of other government departments and agencies (Global Affairs Canada, Justice Canada, Agriculture and Agri-Food Canada, Canadian Food Inspection Agency, and the Public Health Agency of Canada) were invited as observers.

Health Canada Introductory Presentations

Christine Donoghue and Karen McIntyre of Health Canada opened the meeting with introductory remarks to frame the agenda for the day and provide background related to the Healthy Eating Strategy.

Chronic diseases such as diabetes, heart disease, stroke, cancer and obesity are leading causes of mortality and disability in Canada. Diets high in sugars, sodium, and saturated fat are strongly linked to these conditions.
Canadians face a number of healthy eating challenges, including the widespread availability of inexpensive foods and beverages high in sugars, sodium, and saturated fat; powerful marketing; difficulties understanding and using nutritional information; and challenges accessing nutritious foods.
Canada ranks among the worst among Organization for Economic Co-operation and Development countries in terms of obesity.
The Healthy Eating Strategy, which is a priority for Minister Petitpas Taylor, presents solutions to help alleviate obesity and diet-related chronic diseases.
The Strategy includes:
- better nutrition guidance through a modernized Canada's Food Guide,
- improved food labels and FOP labelling to help Canadians make informed food choices,
- improved food quality (less sodium, no industrially produced trans fat),
- protected vulnerable populations, by restricting marketing of unhealthy foods and beverages to children, and
- better food access through an improved Nutrition North Canada program.
Product specific information can help Canadians make informed food choices.
Voluntary nutrient content and health claims only highlight positive attributes of foods. The Nutrition Facts table is on the side or back and can be difficult to understand and interpret, particularly by those with limited time, motivation, or health literacy.
The criteria that were selected, i.e., 'High in' and the three nutrients of public health concern, were identified based on a review of the evidence to help consumers make quick and easy decisions about foods they purchase and decrease diet-related disease risk factors.
The symbol would help consumers quickly and easily identify foods high in sugars, sodium, and saturated fat and would encourage reformulation of products where possible to lower levels of these nutrients of public health concern.
The criterion for black and white was selected based on feedback from industry obtained during the cost benefit exercise. In order to minimize the cost burden on small and medium sized enterprises, black and white was chosen instead of colour for the FOP nutrition symbol.
The strengths and weaknesses of different 'High in' symbol options were considered through a pre-regulatory online consultation (> 1500 comments were received), focus group testing, scientific evidence, and a cost benefit analysis with industry.

Panel Discussions: Food Industry Perspectives on FOP Labelling

An overview of the presentations from the three food industry associations specific to their design proposals is provided below, as well as some survey results commissioned by FCPC and the CBA.

Retail Council of Canada (RCC)

RCC expressed concerns about the thresholds and the three-nutrient focus. However, they want to be part of the solution and provided some suggested approaches that still met Health Canada's criteria.
RCC expressed concern that the current HC proposals are similar to a chemical warning and that foods with different levels of nutrients above the threshold will not be differentiated.
RCC's proposed 'Check the NFt' symbols (Figure 1) would meet the Health Canada specified criteria. These symbols have vertical or horizontal variations which allow for design flexibility and refer consumers to the Nutrition Facts table for more information.
RCC added that using the symbol with an enhanced Nutrition Facts table, in which high levels of sugars, sodium, and saturated fat are highlighted, would make it easier to see the key nutrients over the threshold.

**Figure 1: FOP 'Check the NFt' symbol options - proposed by RCC**

Food & Consumer Products of Canada (FCPC)

FCPC expressed concerns with Health Canada's process to develop a FOP nutrition labelling system and feels that the Healthy Eating Strategy initiatives unfairly target the food processing industry.
FCPC expressed concern that Health Canada's proposed symbol appears not to have been modified in light of feedback that was provided by stakeholders in response to the November 2016 consultation. In response to that consultation, FCPC had proposed that Health Canada adopt 'Facts Up Front' (Figure 2), an industry-led FOP approach that has been adopted by a number of multinational companies operating in the United States and Canada.

**Figure 2: 'Facts Up Front' symbol - proposed by FCPC following November 2016 consultation**

FCPC asserted that this system is: fact and science-based; non-discriminatory; supported by consumer research; compatible with the Canadian regulatory framework; widely applicable to packaged food and beverages; supported by a broad array of stakeholders; and accompanied by a robust public education campaign.
FCPC proposed further modification of this system with only nutrients of concern and interpretive elements including options for colours and words (Figure 3). FCPC noted that colour should not be excluded as it is in place in many systems globally and that the FOP footprint should be consistent across packages.

**Figure 3: Modified 'Facts Up Front' symbol options - proposed by FCPC**

Canadian Beverage Association (CBA)

CBA outlined principles that they believed should underpin any FOP system, including: science-based; compatible with the regulatory framework; applied uniformly; consistent visually; and informative to consumers.
CBA indicated that fact-based FOP labelling has already been implemented, or proposed, in many countries on a voluntary basis. Fact-based FOP labelling is mandatory in Mexico and Thailand - only Chile has a mandatory interpretive system.
CBA felt that the symbols proposed in the 2016 consultation paper are similar to poisonous, corrosive, and explosive hazard symbols.
CBA believes that Canada should align itself with major trading partners, taking into account that guiding principles for Codex FOP labelling will be developed shortly.
Because CBA feels that it is critical to understand the views and understandings of Canadians for a variety of labelling options, FCPC and CBA co-funded a consumer survey on preferences for 3 FOP systems, conducted by Abacus Data.

Abacus Data

Abacus Data presented the results of the Canadian Attitudes on Food and Beverage Initiatives, which was an online survey of 1500 people, aged 18 and over, drawn from a Research Now panel and statistically weighted to match the Canadian population.
The results indicate that Canadians:
- Feel they have a healthy diet and are well-served by the market.
- Don't necessarily think they will change their choices, knowing that there are healthier options available.
- Are split on whether or not the Government is doing enough to promote healthy eating.
- Are able to get the nutritional information that they need, and that they are aware enough of what is healthy and what is not. In the case of sugars, sodium, and saturated fat, over 60% felt that the information that is currently available on food labels is clear enough.
- More than 59% preferred the colour-coded 'Facts up Front' model compared to the Health Canada's 'High in' symbol (Figure 5) and the non-colour coded 'Facts Up Front'. This was consistent over gender, age, income level, and political preference.
- Respondents in both Split A and B thought that the colour coded Facts Up Front symbol was clearest about the health aspect of the product and that it tells them what they want to know and is most likely to affect their choices.

Table Discussion Regarding Information Presented by Panellists

Key points relevant to the presentations included:

Industry associations were divided on the use of colour in a FOP symbol. Some expressed concerns about the use of colour because it increases package design and printing costs. FCPC responded that these costs are not the only consideration. Manufacturers would rather spend more to colour-code information in Facts Up Front than display a black and white or one-colour interpretive system like those proposed by Health Canada or RCC.
Industry felt strongly that there needs to be a clear link with the information in the NFt and that this should remain the principle source of balanced information for consumers to make informed choices. There was concern that HC's proposal could divert attention from the NFt by providing too much of a shortcut to making purchase decisions. A counterpoint was made that nutrient content and health claims also divert attention from the NFt, particularly when consumers are making choices very quickly while shopping.
Clarification is needed on the methodology used by Abacus Data for their survey. There are important limitations inherent to public opinion research. There was discussion on studies which look at what people prefer or say they understand versus testing to see if they understand a concept or how they actually use the concept. No functional tasks were asked of participants in the Abacus Data survey. The Abacus study did not test consumer understanding of a mix of colours in a symbol.
If a colour-coded scheme such as the one proposed by FCPC (Figure 3- modified 'Facts Up Front') was to be put into place, a graded set of thresholds would be required that would also align with nutrient content claims. Health Canada was asked to consider extending the timelines for the regulatory project in order to do further focus group testing with RCC's proposal (Figure 1- FOP 'Check the NFt' symbol options).
There was general agreement around the table that accompanying education campaigns will be crucial no matter which system is chosen.

Panel Discussion: Research Expert Perspectives on FOP Labelling

Dr. Kim Raine, University of Alberta

Front-of-Package Labelling as a Policy Tool for Chronic Disease Prevention: Essential Elements

There is a public health crisis with diet outranking tobacco as the number one risk factor for developing disease.
Two thirds of the Canadian population is overweight or obese.
A comprehensive approach is needed to prevent diet-related chronic disease, including communication of consistent reliable nutrition information.
Nutrition labelling is a key policy tool for providing consumers with information to help them reduce their consumption of less healthy nutrients.
The NFt is difficult to interpret and needs strong literacy and numeracy skills, and it does not convey the impact of nutrients on disease risk.
More than 158 FOP labelling systems have been documented in Canada. These are applied inconsistently and to foods with dubious nutritional quality.
Based on 13 reviews that dealt with FOP labelling, FOP labelling is a suitable policy option for helping consumers make healthier food choices. It is more effective that side/back labelling and consumers are more likely to identify healthier foods with it.
The consensus recommendation is for a single, standardized FOP labelling system, which prevents competition from competing messages. It should be implemented as part of a standardized, coordinated, multi-pronged approach.
Specific recommendations are that the FOP label should be standardized, simple, interpretive, ordinal, visually prominent, consistently located, and supported by ongoing, regularly updated promotion.

Dr. Mary L'Abbé, University of Toronto

Evidence Regarding Consumer Behaviour Towards Front-of-Pack Labelling

FOP labelling has a strong foundation; it is supported by a number of authoritative scientific bodies.
Foods with 'positive' FOP symbols are perceived to be better. About half of all foods sold in Canada have FOP messages, mainly in the form of nutrient content claims.
A labelling system that provides information on nutrients of public health concerns is needed, in addition to those that show positive nutrients.
Increased cognitive skills are required to interpret the information as the label becomes more complex.
The information should be interpretive. Symbols that show guideline daily amounts (non-interpretive) (for example, the 'Facts Up Front' labels shown in Figures 2 and 3) are out-performed by more interpretive ones. For traffic light labelling (semi-interpretive), it has been shown that foods that have a red are avoided and that two greens out-performs a red. With star rating systems (semi-interpretive) there is confusion about the meaning of no stars (is it good or bad). Warning labels (most interpretive) allow consumers to make faster decisions.
Interpretive labelling, such as that used in Chile, is better understood by consumers, encourages reformulation, and has a public health benefit.

Dr. David Hammond, University of Waterloo

Front-of-Package Labelling - Evidence & Effective Principles

Consumers rely on the NFt, but do not really understand the information. Only 24% correctly identified the calorie amount. Canadians that need the information the most cannot understand it. The proposed changes to the NFt will not address this issue.
Current FOP systems emphasize positive information, resulting in some poor nutritional quality foods having positive labels.
Effective labels must be salient and visible, and the content must be understandable.
The label should be on the top of the front of the package, have a border and contrasting colour, feature a symbol and make use of colour to enhance the message.
The label should be simple, so that no nutritional knowledge is required, and it should be interpretive, with information provided as guidance, rather than specific facts. The 'Facts Up Front' label (Figures 2 and 3) is neither simple nor interpretive, while the magnifying glass (Figure 1) just points back to the NFt, which is troublesome to understand. One third to one half of consumers do not understand health star ratings. The traffic light symbol is interpretive, but could provide misleading information if there are two greens and one red.
The 'high in' symbol, used in Chile, is the simplest and most interpretive. It is the most effective for avoiding unhealthy foods and rated highest amongst consumers when asked what additional information they would like to see on food products (79% would support a government policy that would require a symbol for 'high in sugar' on the front of package labels).

Dr. Fabio Gomes, Pan American Health Organization

Front-of-Package Labelling - evidence, policy and action

As a result of different package and portion sizes, it is difficult to make comparisons between similar products, as well as between products in different categories, when using numerical nutrition information.
While shopping, consumers do not use extended cognitive effort in selecting a product, thus the major goal is to make a satisfactory choice with not thinking about it too much.
A decision on a food purchase is made in 4 to 8 seconds. Persuasive elements on the label include characters from children's stories, images and references to fresh fruit and vegetables, and nutrient content and health benefit claims.
With traffic light symbols, green and yellow increase the appeal for these products.
It is quicker to identify foods high in sodium with a warning label, compared to the traffic light and Guideline Daily Amounts labels that are complex, requiring education and time.
Black and white labels are most effective as they provide the greatest contrast for the human eye.
In Chile, warning symbols, plus the elimination of licensed characters from food labels, became mandatory in 2016. Also products labelled 'high in' are banned from schools and have advertising restrictions.
Surveys have shown that 91.6% of consumers are influenced by the warning symbols and as a result, 18% of products have already been reformulated to avoid the symbols.

Table Discussion Regarding Information Presented by Panellists

Key points relevant to the presentations included:

Although the interpretive FOP symbols are simple, they provide enough information for the consumer to make the decision to eat less of this food.
Consumers want information to make an easier choice. For those that want more detailed information, the NFt is still on the package.
Research shows that these systems change consumer behaviour. There likely will not be a risk of desensitization to the symbols. Consumers will likely come to rely on these more often.
A number of participants expressed concern that warning symbols do not discriminate between nutrient-dense foods and others. There could be unintended consequences, such as children under 2 years old being fed low fat milk.
It was noted that it could be a challenge to compare foods within a category if all, or none, have FOP symbols. In some products there are already 5 to 10-fold differences in the nutrient levels.

Key Messages

Industry

There needs to be a coordinated implementation of all labelling changes.
Some supported a link to the NFt in the FOP symbol.
Some prefer more nuanced information in the symbol, such as the % DV.
There are concerns related to the criteria. More information needs to be provided and unintended consequences should be avoided.
There were mixed views on the use of colour in the symbol. Some stakeholders supported the use of multiple colours (green, amber, red) while others preferred black and white.
People should be able to have a treat without facing a warning label.
There was agreement that education is a key component of nutrition labelling.

Scientific Experts

Specific recommendations are that the FOP label should be standardized, simple, interpretive, visually prominent, consistently located, and supported by ongoing, regularly updated promotion.
There should be a mandatory FOP system.
The FOP system should not simply direct to the NFt.
The symbol should be meaningful, interpretive and allow quick decision making. Facts Up Front is not interpretive.
If colour is included, it needs to be only one colour.

Discussion on Proposed FOP Symbols

**Figure 5: FOP symbol options presented for discussion**

The symbols submitted by both Health Canada and other organizations were presented for discussion (Figure 5). The strengths and weaknesses of each were discussed. The following summaries include comments from online participants.

Discussion on FOP Nutrition Symbol Strengths and Weaknesses

Symbol 1: 'Check the NFt' symbol, with no % DV - proposed by RCC
Strengths	Weaknesses
Gives consumer information on the front of package and encourages them to look further on the back, with key nutrients bolded Ties in with previous consumer education campaign - consumers are familiar with the magnifying glass and bolded text - there is evidence that the consumer understands the symbol Highlights nutrients of concern on the FOP without scaring them Greater flexibility in design for packaging (vertical and horizontal) Inference that because the information on the nutrients is presented on the front of pack, these are nutrients of concern (no consensus on this)	Does not tell you why - are these nutrients to seek out or to avoid? Is not sufficiently interpretive (questionable) Symbol would be easier to understand if it included 'high in' on the inside of the magnifying glass Does not convey an 'alert' ---- there is no clear communication of risk Drawing attention to the Nutrition Facts table may also be a weakness because the NFt requires more time and interpretation For some, the magnifying glass does not make the link to the NFt Will do nothing to reduce current disparities Adds a new complexity to nutrition claims

Symbol 2: 'Check the NFt' symbol, with % DV - proposed by RCC
Strengths	Weaknesses
See Symbol 1 plus: By adding %DV, this ties in even more strongly with the original education campaign	See Symbol 1 plus: % DV can add to consumer confusion

Symbol 3: 'Facts Up Front' symbol - proposed by FCPC
Strengths	Weaknesses
The symbol is in black and white The focus is on the nutrients of concern It provides information on calories, an important additional element that enhances understanding It is factual and non-judgmental It allows people to think about daily consumption by giving minimal information It has been tested in other jurisdictions and is similar to those used by other NAFTA partners It does not trigger 'alarm'	Calories without portion size is not useful There is a lot of data, but nothing to nudge people in any direction It fails the criteria of simplicity and interpretation In research studies, this system performed the least well It provides data, but not information for those at the highest risk It does not allow for comparisons of products with different portion and package sizes* It requires more time to interpret It requires more education to interpret It is less likely to encourage reformulation *Note that serving sizes will be standardized under the new regulations.

Symbol 4: 'Facts Up Front' symbol, with colour and descriptive interpretation - proposed by FCPC
Strengths	Weaknesses
There is an added focus on calories It is interpretive, fast and does not rely strictly on numbers It can easily be dove-tailed into an education campaign It complements existing nutrition education campaigns It provides a nice balance between having too much and not enough information It is universally understood, with red, yellow and green colours It provides two levels of information, numerical and symbolic (colour) It provides information for food literate individuals Colour blind individuals can still get the message by reading the symbol It behaves more as an alert to avoid red	It is not good for colour blind/visually impaired individuals It repeats the NFt information There is a large cognitive burden, with 4 or 5 different levels of information It slows the decision making process There is the potential for confusion with green alongside red It is a complicated system for comparison of products The symbols might get lost on a colourful package On small packages, it will be difficult to read The take-home message is lost in the way that this is presented. It should be: a lot, moderate, and a little. It does not provide an interpretation for calories The green increases the appetite for the product It would have to be a universal system that is applied to all foods Colour will add additional cost if applied to all food products - there is a range of application issues

Symbol 5: 'High in' symbol, with stop sign shape and exclamation point - proposed by Health Canada
Strengths	Weaknesses
It is clear what the symbol is about - stop signs and exclamation marks indicate nutrients of concern It is black and white with high contrast The use of the Health Canada identification provides additional credibility It is smaller, therefore more practical It has a border and distinct colour It uses straight lines which help with finding the label on food packages It required less time to interpret It requires less knowledge to use It is simple and does not require high cognitive skills It would drive reformulation It is attention-grabbing and conveys an alert It facilitates comparisons. The logo is either there or not	A red stop sign would be more powerful It would be more salient if there was a symbol for each nutrient of concern It is oversimplified There is no evidence that this symbol will encourage reformulation or gradual reduction It is a blunt statement that does not facilitate comparisons of similar products that display the symbol, but that have different levels of the nutrient It is alarming as opposed to alerting The stop sign means that the product is damaging Stop and yield signs are used as warning labels on hazardous products (chemical hazard symbols)

Symbols 6: 'High in' symbols, with exclamation point but no stop sign shape - proposed by Health Canada
Strengths	Weaknesses
See Symbol 5	See Symbol 5 plus The explanation mark without context is meaningless Presentation of tiered nutrients is confusing (highest tier highest in product?)

Symbol 7: 'Facts Up Front' symbol, with colour interpretation - proposed by FCPC
Strengths	Weaknesses
See Symbol 4 plus: There is one level less of information for consumers - this could be a strength or a weakness To resolve the universality issue, threshold above or below which the symbol would not have to be used could be established	See Symbol 4

Symbol 8: 'Facts Up Front' symbol, with descriptive interpretation - proposed by FCPC
Strengths	Weaknesses
See Symbol 4 plus: Removes the colour blindness issue	See Symbol 4 plus: There is no indication of risk - it only provides information Calories without portion size is a shortcoming There are legibility concerns

Symbol 9: 'High in' symbol, with inverted triangle (i.e. yield sign) point only - proposed by Health Canada

Please refer to strengths and weaknesses of Symbol 6.

Symbol 10: 'Attention!' symbols, with stop sign shapes - proposed by Dietitians of Canada

An additional proposal, (Symbol 10) was developed and presented at the meeting by the representative from Dietitians of Canada (Figure 6).

**Figure 6: Symbol proposed by the Dietitians of Canada representative**

Symbol 10: Symbol proposed by the Dietitians of Canada representative
Strengths	Weaknesses
N/A	It does not give Canadians enough to make informed decisions Too busy, cannot be interpreted quickly

The question of whether or not any of the designs should be dropped or changed was posed. The following key points came out of the discussion:

Revisions to the symbols would be subject to a short timeline. It should be possible to take the positive points heard in the discussions and design something that meets the need.
Revisions should take into account cost considerations and concerns that the stop sign could be interpreted to mean that the food is unsafe and should not be eaten.
The caution sign could be removed from the Health Canada proposals to make them less 'alarming', but this would take away the impact.
Concerns about interpretation of warning / traffic symbols should not be presumed, but tested.
Most consumers are not versed enough in nutrition to understand what the numbers mean, thus it is better to stay away from them. For those who want the information, the NFt is there.
The alignment between the FOP labelling criteria and the public policy objective was re-emphasized.
The public policy goal of FOP labelling is to reduce harm from chronic disease, which has both a human and economic impact. An unhealthy diet is very costly to every Canadian in the form of healthcare.
The criteria for the FOP symbol should first and foremost reflect the public policy goal while putting in place measures to mitigate industry's concerns.
There needs to be a clear decision on colour, either one colour or black and white, as these would be the only options that align the 'high in' criterion.
Education is a very important component of the implementation, regardless of which symbol is selected.

Closing Remarks

Minister of Health and Assistant Deputy Minister

The Minister of Health, Ginette Petitpas Taylor, addressed the participants at the meeting. She made the following points:

The organizations represented by those present at the meeting are essential partners with the Government in improving the health of Canadians.
Health Canada is looking for insights into how to implement the Healthy Eating Strategy.
Good health is fundamental to a good quality of life and is critical to Canada's prosperity as well.
One-fifth of Canadians suffer from chronic diseases, with some now showing up in kids; type 2 diabetes has doubled over the last decade.
The cost of chronic disease is approximately $26 billion per year.
A ban on industrial trans fat has been announced and will reduce heart disease risk.
In the past year, there have been consultations on updating Canada's Food Guide, restricting the marketing of unhealthy foods to children, and FOP labelling.
There are countless FOP statements on the benefit of foods, but there is no equivalent information on foods that are high in sugars, sodium, and saturated fat.
Discussion is very important in moving this forward and we need to get it right.

Pierre Sabourin, Assistant Deputy Minister, concluded the meeting by re-emphasizing the public health imperative, the objectives of FOP nutrition labeling, and the next steps. Mr. Sabourin indicated that participants would receive a letter inviting them to submit revised symbols that are compatible with the evidence-based criteria discussed during the meeting. These evidence-based criteria are intended to help ensure the FOP approach achieves the public health objectives and align with Health Canada's health protection legislative authority. Symbol submissions will be reviewed by Health Canada and used to form the basis of the next formal stakeholder engagement on the Health Eating Strategy, planned for November. Mr. Sabourin thanked all of the participants for their contribution as well as those who helped plan and organize the meeting.

Meeting presentations will be available on the Health Canada Openness and Transparency website.

Questions from Online Participants and Answers

In the spirit of openness and transparency, the meeting was streamed live and made accessible to interested parties who could not be physically present at the meeting. There were over 300 registered connections. Viewers could see presentations and hear discussions; a number of them sent in questions and comments. Most of the comments on symbols received from online participants were captured as part of the discussions and are reflected in this report. Below are the questions received that were not addressed during the meeting, and the corresponding responses from Health Canada.

1. Abacus data seemed to imply that Canadians have all the information they need/want. Does Health Canada have evidence that Canadians need information about nutrients of concern on the front of the package?

There is an urgent public health need to confront obesity and chronic diseases. Canadians eat too much sodium, sugars and saturated fat. This increases their risk of obesity and chronic diseases such as heart disease, diabetes and some cancers. FOP labelling is one of several initiatives that Health Canada is undertaking to help Canadians make healthier food choices. Along with improvements to the Nutrition Facts table and revisions to Canada's Food Guide, FOP labelling will provide information that consumers need to make healthier choices.

In addition, during the nutrition labelling consultations in 2014 and 2015, consumers and public health advocates expressed interest in having one government-led FOP system to help Canadians make healthy food choices.

In his presentation, Dr. David Hammond cited a study that indicated that 80% of consumers consulted would like to support government policy that would require 'high in sugars' symbols on the front of food packages.

2. Why does Health Canada expect FOP nutrition labelling to be effective at helping consumers make healthier choices?

Research has shown that information on the front of packages influences food purchases and the perception of how healthy a food is.

FOP labelling is not new. Manufacturers have been using symbols and nutrition claims-such as 'excellent source of fibre' and 'trans-fat free'-on the front of food packages for many years. FOP labelling has helped manufacturers highlight the positive attributes of food and to market their products.

Health Canada wants to ensure that the negative attributes of food products are also represented on the front of the package. This will help Canadians make informed choices.

There is evidence to support the role of front-of-package labelling in helping consumers identify healthier food options. In addition, nutrient-specific and interpretive approaches most consistently help consumers to do so.

Based on a review of consumer research studies and international experience, Health Canada concluded that a mandatory 'high in' front-of-package labelling system is the most appropriate labelling tool to help address the burden of chronic disease in Canada.

3. What can we learn from Chile's experience?

There is increasing international momentum for front-of-package as a regulatory initiative to address the global human and economic burden of chronic, non-communicable diseases. Other countries, such as Chile and Ecuador, have started implementing front-of-package warning symbols.

Chile implemented 'high in' FOP labelling in 2016. An evaluation post implementation indicated that 92.9% of consumers recognize the symbols. In addition, 91.6% of consumers said it influences their purchase in some way (choose product with less warning, don't buy, or purchase less). This study also determined that since implementation, 18% of products have been reformulated (e.g. 65% of dairy, 48% of processed meat products).

4. Will Health Canada's proposed approach say that nutrient-dense foods are unhealthy?

Many factors-such as taste, price, marketing and nutritional value-affect food choices. FOP labelling is just one tool that can help Canadians make healthier food choices when comparing similar products at the grocery store.

Within food categories, some foods would carry the FOP symbol, while others would not. For example, flavoured milk and yogurt, seasoned potato chips and regular soft drinks would carry the FOP symbol, whereas plain milk and yogurt, some potato chips and diet soft drinks would not. This would encourage consumers to choose foods without the FOP symbol more often.

5. Why is Health Canada proposing to introduce front-of-package labelling only on packaged foods, but not on foods sold behind the counter and in restaurants?

Health Canada is proposing to require front-of-package labelling on foods that have a Nutrition Facts table. Foods sold behind the counter and in restaurants are currently exempt from nutrition labelling requirements for a variety of reasons, including costs, lack of standardization of recipes (which make generating accurate nutrient values challenging)

Health Canada recognizes that this is a gap and will examine this issue in the future and continue to work with provincial and territorial counterparts to find the best way to provide nutrition information in restaurants and other food service establishments.

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Date modified:: 2017-11-02

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Front-of-Package Nutrition Labelling: September 18, 2017 Stakeholder Engagement Meeting

Table of Contents

Executive Summary

Introduction

Background and Context

Purpose of the Report

Meeting Objectives

Symposium Participants

Health Canada Introductory Presentations

Panel Discussions: Food Industry Perspectives on FOP Labelling

Retail Council of Canada (RCC)

Food & Consumer Products of Canada (FCPC)

Canadian Beverage Association (CBA)

Abacus Data

Table Discussion Regarding Information Presented by Panellists

Panel Discussion: Research Expert Perspectives on FOP Labelling

Dr. Kim Raine, University of Alberta

Dr. Mary L'Abbé, University of Toronto

Dr. David Hammond, University of Waterloo

Dr. Fabio Gomes, Pan American Health Organization

Table Discussion Regarding Information Presented by Panellists

Key Messages

Industry

Scientific Experts

Discussion on Proposed FOP Symbols

Discussion on FOP Nutrition Symbol Strengths and Weaknesses

Closing Remarks

Minister of Health and Assistant Deputy Minister

Questions from Online Participants and Answers

1. Abacus data seemed to imply that Canadians have all the information they need/want. Does Health Canada have evidence that Canadians need information about nutrients of concern on the front of the package?

2. Why does Health Canada expect FOP nutrition labelling to be effective at helping consumers make healthier choices?

3. What can we learn from Chile's experience?

4. Will Health Canada's proposed approach say that nutrient-dense foods are unhealthy?

5. Why is Health Canada proposing to introduce front-of-package labelling only on packaged foods, but not on foods sold behind the counter and in restaurants?

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