Potential for Front of Pack Labeling Exposure to Impact US Dietary Choices: a Population-based Cross-sectional Study Using NHANES 2017-2018

Abstract Background: Although front-of-pack nutrition labeling (FOPL) schemes have proliferated as a strategy to help improve population-wide dietary intakes in recent years, the proportion and elements of the diet subject to FOPL have not been described in population-based data. This study sought to quantify the proportion of the US diet in terms of dietary energy that would be subject to FOPL and what aspects of the diet would be more or less impacted by FOPL.Methods: This cross-sectional study used data from 7,121 participants age≥2y who completed a 24-hour dietary recall as part of the nationally-representative 2017-2018 National Health and Nutrition Examination Survey (NHANES). From the 24-hour dietary recall, foods/beverages that would be subject to FOPL were identified from food composition and ingredients tables. The proportion of dietary energy subject to FOPL was estimated overall and by population sub-group in terms of socio-demographics, dietary/lifestyle factors and health status. The proportion of dietary intakes for key macronutrients, micronutrients and food groups subject to versus not subject to FOPL was also estimated. Survey-weighted proportions and 95% confidence intervals were calculated, and Wald tests were used to assess the statistical significance of differences.Results: Overall, 57% of dietary energy would be subject to FOPL and a u-shaped pattern was observed with age (lowest exposure among those 20-34y). Socio-demographic differences in exposure to FOPL were modest. Individuals consuming more away-from-home meals had significantly lower exposure to FOPL (65.1%E vs. 45.5% comparing individuals with ≤1 to ≥6 meals not home prepared in the past week). Adults with a healthy weight had greater exposure to FOPL than adults who are overweight or obese. Dramatic differences in the sources of key dietary constituents were observed. Specifically, protein, sodium, potassium, whole fruit, vegetables, and unprocessed meats were less subject to FOPL as compared to total sugars, added sugars, calcium, fruit juice, milk, yogurt, nuts/seeds and whole grains that were more subject to FOPL. Conclusion: FOPL may have limited reach for the US diet and demonstrates some inconsistencies with current dietary guidance regarding the under and over-representation of key food groups and nutrients.