Usage and Understanding of Serving Size Information on Food Labels in the United States Yuanting Zhang, PhD; Mark A. Kantor, PhD; WenYen Juan, PhD

Transcription

1 Nutrition Usage and Understanding of Serving Size Information on Food Labels in the United States Yuanting Zhang, PhD; Mark A. Kantor, PhD; WenYen Juan, PhD Abstract Purpose. To investigate consumer understanding and usage of serving size (SS) information on Nutrition Facts (NF) labels. Design. We analyzed three data sources: (1) U.S. Food and Drug Administration (FDA) Health and Diet Survey (HDS) 1994 (n ¼ 1945), 1995 (n ¼ 1001), and 2008 (n ¼ 2584); (2) National Health and Nutrition Examination Survey (NHANES) and (n ¼ 10,750); and (3) 2011 FDA Nutrition Facts Label Experimental Study (NFLES) (n ¼ 9493). Data from FDA are cross-sectional and we focused on usage and meaning of SS. Setting. United States. Subjects. Adults (18þ years). Measures. Both HDS and NHANES addressed how often participants used SS information and HDS also asked how SS is determined. Both NHANES and NFLES contained similar questions on the meaning of SS but NFLES also included an open-ended response option. Analysis. We included both quantitative and qualitative measures. Questions were analyzed by demographic variables and body mass index with frequencies, cross-tabulations, and v 2 statistics reported. Results. HDS showed that the percentage of consumers who used SS information often or sometimes increased from 54% in 1994 to 64% in NHANES and NFLES data indicated that a majority of respondents had misinterpreted the meaning of SS. Women and obese individuals were more likely to use SS often or sometimes, but were also more likely to misinterpret the meaning of SS. A small subsample of NFLES participants expressed a distrust of the SS information. Conclusion. There is a widespread misunderstanding about SS, suggesting the need for clearer NF labels or enhanced education efforts. (Am J Health Promot 2016;30[3]: ) Key Words: Nutrition Label, Serving Size, Survey Research, Nutrition Education, Prevention Research. Manuscript format: research; Research purpose: relationship testing, descriptive; Study design: survey research, qualitative; Outcome measure: cognitive, behavioral; Setting: United States; Health focus: nutrition, weight control; Strategy: education, policy; Target population age: adults; Target population circumstances: all education levels, all income levels, all U.S. locations, all races/ ethnicities INTRODUCTION Since the Nutrition Labeling and Education Act (NLEA) became effective in 1993, most packaged food products sold in the United States have been required to display a Nutrition Facts (NF) label with nutrition information based on the product s serving size (SS). The SS, expressed both in household units (such as cups) and in gram amounts, and the number of servings contained in the entire package are listed near the top of the label. 1 The SS is an approximation of the amount of a particular food typically eaten during a single eating occasion for persons 4 years of age or older (separate calculations are used for infants or children under 4 years of age). 2 The U.S. Food and Drug Administration (FDA) is required by statute to base the SS on an amount of food customarily consumed per eating occasion. To do this, the FDA uses nationally representative data to establish reference amounts customarily consumed (RACCs) for different food product categories and food manufacturers use RACCs to determine the SS of their products. Current RACCs are based on data derived from national food consumption surveys conducted in the 1970s and 1980s. Because newer Yuanting Zhang, PhD, is with the Office of Analytics and Outreach, Center for Food Safety and Applied Nutrition, and Mark A. Kantor, PhD, and WenYen Juan, PhD, are with the Office of Nutrition, Labeling, and Dietary Supplements, U.S. Food and Drug Administration, College Park, Maryland. Send reprint requests to Yuanting Zhang, PhD, Office of Analytics and Outreach, Center for Food Safety and Applied Nutrition, U.S. Food and Drug Administration, 5100 Paint Branch Parkway, HFS-013, College Park, MD 20740; Yuanting.Zhang@fda.hhs.gov. This manuscript was submitted January 17, 2013; revisions were requested April 21, 2014; the manuscript was accepted for publication July 24, Copyright Ó 2016 by American Journal of Health Promotion, Inc /16/$5.00 þ 0 DOI: /ajhp QUAN-30 American Journal of Health Promotion January/February 2016, Vol. 30, No

2 food intake data show that about 17% of the current RACCs should be changed, the FDA recently proposed to update SS information. 3 Although current RACCs are still valid today, manufacturers may need to change the SS listed on some product labels once the proposed regulation is finalized. Previous research suggests that consumers are unaware that the SS is derived from actual food intake data rather than being a recommended portion size (a portion is the amount of food that one chooses to eat for a meal or snack; it may be larger or smaller than the SS 4 ) and that the nutrient values listed on the NF label are based on one serving. 5 8 This lack of knowledge may potentially impact caloric intake, because the ability to understand and properly use SS information is fundamental in interpreting a product s caloric content per package, which in turn could affect calorie intake. For example, manufacturers currently are allowed to label small food packages (e.g., a small bag of snack chips or a can of soup) that could reasonably be consumed during a single eating occasion as containing two or more servings. Because the NF label lists nutrition information as the amount per serving, consumers who eat the entire contents of such packages at one time would need to multiply the calorie and nutrient levels by a factor of the number of servings per container that is listed to determine the amount of calories and nutrients in the entire package. Individuals who are not aware of this may inadvertently consume twice as many calories or more if they eat the entire contents of a multi-serving food container at one time. Therefore, the FDA recently proposed using a dual-column label format in which nutrition information is listed on both a per serving and per package basis for food packages that are likely to be consumed in one or more sittings or shared, and which contain 200% to 400% of the RACC. 3 Previous authors investigating consumer understanding and use of nutrition labeling concluded that numerical information in general, and SS information in particular, was confusing to consumers. 5 9 In a recent study, Lando and Lo 10 reported that participants were more accurate in assessing nutrition information when product labels listed one serving per container, so that no calculations were required, than when products listed two servings per container. Another factor contributing to consumer misunderstanding of SS information may be portion distortion, which is the gap between what consumers expect a serving to be and the actual SS that appears on the NF label. 11 The possible role of larger portion sizes, especially of popular foods, in the obesity epidemic has been discussed by many authors Because the FDA s proposed revisions to the NF label 16 and to the list of RACCs 3 may affect consumers ability to understand SS information, it is important to collect baseline data on how consumers currently use and understand SS information for assessing the impact of future label changes. Such data may also help inform the design and development of nutrition education programs aimed at improving consumer understanding of SS information. PURPOSE The purpose of this study was to assess consumer understanding and use of SS information on NF labels using multiple population-based surveys. METHODS Data Sources Three surveys, the Health and Diet Survey (HDS), the Nutrition Facts Label Experimental Study (NFLES), and the National Health and Nutrition Examination Survey (NHANES) were used in this study: Health and Diet Survey. This telephone survey, which is periodically commissioned by the FDA, collects and tracks information about consumers knowledge, perceptions, attitudes, and behaviors on a variety of health and nutrition topics. 17 We used HDS data collected from the 1994, 1995, and 2008 surveys, which had sample sizes and response rates of 1945 (49%), 1001 (50%), and 2584 (22.1%), respectively. Nutrition Facts Label Experimental Study. This 2011 FDA study was a randomized, controlled experiment that investigated consumers ability to understand and properly interpret the NF label (n ¼ 9493, cooperation rate ¼ 36%). 10 Participants were shown various versions of NF label mockups developed specifically for this study and asked to judge the nutritional attributes, including the perceptions of meaning of SS, and overall healthfulness of food products. National Health and Nutrition Examination Survey. Data for adults (18þ years of age) from the combined NHANES and (n ¼ 10,750) and from NHANES (n ¼ 5474) were used for this study. The overall survey response rates were 80.5% and 77.4% for NHANES and , respectively. Survey Questions in Study Questions about SS used in this study fell into the following three categories: How Often Do You Use SS Information? For the 1994 and 1995 HDS (but not the 2008 HDS), the interviewer asked participants to refer to a food package while answering the question about their habitual use of SS information on the NF label. The wording varied slightly in each of the survey years. In the 1994 HDS, participants were first asked if their food package had SS information, and then they were asked: How often do you use this type of information when it is available? Would you say you use the SS information often, sometimes, rarely, or never? For the 1995 HDS, participants were asked: Do you use the SS information often, sometimes, rarely, or never? For the 2008 HDS, the interviewer asked: Now, I would like for you to think about information about SS, which is also found on the food label. Would you say you often, sometimes, rarely, or never use SS information? For NHANES, participants had been provided with a sample of the NF label before the interview. They were asked: How about the information on the SS? How often do you use information on the SS on a food label when deciding to buy a food product? Would you say always, most of the time, 182 American Journal of Health Promotion January/February 2016, Vol. 30, No. 3

3 sometimes, rarely, or never? (The NHANES substituted the phrase size of a serving for SS. ) For this question, HDS data for 3 survey years were compared to the NHANES data for the combined survey years of and In order to make different data sources comparable, the NHANES response categories of always and most of the time were combined into the single category often, and the responses never and never seen were combined into never. What Is the Meaning of SS? We examined consumer perceptions about the meaning of SS only in the NHANES and the NFLES for adults 18þ years of age. The forced choice question, which was identical in both surveys, was: Think about the SS on a food label, what does SS mean to you? The choices available were: The amount of this food that people should eat ; The amount of this food that people usually eat ; Something that makes it easier to compare foods ; and Don t know. In addition, the NFLES provided an other option for this question for which the participant could provide an open-ended response. Who Determines SS? This question was only asked in the HDS. In the 1994 and 1995 HDS, the question was: To the best of your knowledge, how are SSs determined, by manufacturers themselves or by government rules? In the 2008 HDS, the wording was slightly different: To the best of your knowledge, are SSs determined by manufacturers or by government rules? Data Analysis Both quantitative and qualitative measures were used. Qualitative data from NFLES were extracted from an open-ended question addressing the meaning of SS and the responses were categorized into general themes. Questions pertaining to the meaning and the frequency of use of SS information were analyzed by major demographic variables and body mass index (BMI). BMI was calculated based on self-reported weights and heights in the HDS and NFLES, and on actual measured weights and heights of the NHANES participants. Frequencies, Table 1 Weighted Percentage of Serving Size Information Usage and Perceptions about the Source of Serving Size Information on Food Labels by Participants (18þ Years of Age)* cross-tabulations, and v 2 statistics were reported. All data analysis procedures were completed using SAS Descriptive results were weighted when possible (NFLES does not have weights; HDS and NHANES were weighted) in order to provide national representative estimates. RESULTS Table 1 shows the frequency of use of SS information based on data derived from the 1994, 1995, and 2008 HDS and NHANES In comparing HDS data in 1994 vs. 2008, there was a small increase in the proportion of individuals who reported using the SS information often (29% vs. 34%) or sometimes (25% vs. 30%). Results from NHANES were similar to the results from the 1994 and 1995 HDS. However, compared to the 2008 HDS, fewer NHANES participants reported using the SS information often or sometimes and a greater proportion indicated that they never used the SS information. Additionally, Weighted % HDS 1994 HDS 1995 HDS 2008 NHANES n ¼ 1945 n ¼ 1001 n ¼ 2352 n ¼ 10,750 Extent that participants report using the serving size information on food labels Often Sometimes Rarely Never Don t Know/NA Are serving sizes determined by manufacturers or government rules? By manufacturers By government rules Don t know/refused * HDS indicates Health and Diet Survey; NHANES, National Health and Nutrition Examination Survey; and NA, not answered or refused. Data sources: HDS 1994, 1995, and 2008; NHANES and combined. Percentages may not add up to 100% because of rounding. For NHANES data, often included combined responses for always and most of the time and never included combined responses for never and never seen. participants in the 1994, 1995, and 2008 HDS were more likely to report that the label SS was determined by manufacturers rather than by government rules (Table 1). However, the weighted percentage of respondents indicating that SS was determined by government rules increased in both survey years following implementation of NLEA in Table 2 shows the overall weighted percentages for SS usage by demographic variables and BMI. The best indicators for using the SS information often for both the NHANES and HDS data were being female and having more education. The frequency of use of SS information increased with age in the NHANES , but this effect was not seen in the 2008 HDS data. Among the different BMI categories, obese participants (BMI 30) were most likely to use SS information often or sometimes in both the NHANES (58%) and the 2008 HDS (67%). With regards to race, Hispanics (especially Mexican-Americans) in the NHANES were most likely to report never using the SS, followed by non- American Journal of Health Promotion January/February 2016, Vol. 30, No

4 Table 2 Weighted Row Percentage of Serving Size Information Usage by Participants (18þ Years of Age) Stratified by Demographic Data and Body Mass Index* NHANES (n ¼ 10,750) 2008 HDS (n ¼ 2352) Often Sometimes Rarely Never Often Sometimes Rarely Never Gender Female Male Age þ Education,High school High school/ged Some college Collegeþ Race NH white NH black Mexican-American Other Hispanics Other race v 2,0.0002, Body mass index Underweight Normal Overweight Obese v 2,0.039, * NHANES indicates National Health and Nutrition Examination Survey; HDS, Health and Diet Survey; GED, general equivalency diploma; and NH, non-hispanic. Data sources: NHANES and U.S. Food and Drug Administration 2008 HDS. NHANES separated Hispanics into Mexican-American and other Hispanics; HDS classified all Hispanics into one category. Body mass index was calculated as weight (kg)/height (m) 2 and was based on measured height and weight in NHANES and self-reported height and weight in HDS. Underweight (,18.5), normal ( ), overweight ( ), obese (30). In addition to the three response choices for the question regarding the meaning of the label SS, NFLES participants also had the option of selecting other and providing their own interpretation of SS. About 11% of the 9493 NFLES participants chose this option. These open-ended responses were independently and subjectively analyzed by the investigators and three general themes emerged, as listed below along with representative quotations for each theme. Theme 1. An arbitrary number decided upon by the food manufacturer to deliberately deceive consumers. to mislead people on total amounts (in the package) to make it (the food) look healthier (than) it really is to make an unhealthy product look not so bad Theme 2. An amount of food that is recommended by someone (or some organization or agency) but that is not realistic. just a way of keeping (you) stressed about what (you) eat the amount that experts think you should eat even if it is an unsatisfying amount Theme 3. The amount of food in the package that can feed a certain number of people. how many people (the product) will serve/feed how many people can eat from the product Hispanic (NH) blacks. In the 2008 HDS, the other race respondents and NH blacks were most likely to report never using the SS. Of the three explanations provided for the question regarding how individuals perceive the meaning of the term SS, about half of the participants in both the NHANES and 2011 NFLES selected the amount of this food that people should eat. As seen in Table 3, participants who were male, older, with more education (collegeþ), and who identified themselves as being in the other race group were more likely than those in other demographic groups to answer correctly (i.e., they either answered that SS was the amount of food that people usually eat or something that makes it easier to compare foods). In contrast, female participants, those in a younger age bracket, those with a high school diploma or general equivalency diploma (but who did not attend college), and obese participants were more likely than their counterparts to believe that SS indicates an amount of food that people should eat. DISCUSSION Frequency of Use of SS Information We found that between 1994 and 2008, 14 years after the NF label became mandatory on commercial food products, there was an increase in the weighted proportion of consumers who reported using the label SS information often or sometimes, and a decline in those who said they never used the information. By 2008, consumers had been exposed to the NF label for more than a decade and presumably had adequate time to become familiar with it and to gain 184 American Journal of Health Promotion January/February 2016, Vol. 30, No. 3

5 Table 3 Consumer Perceptions of the Meaning of Serving Size Stratified by Demographics and Body Mass Index* Serving size is... NHANES (n ¼ 5281), Weighted % 2011 NFLES (n ¼ 9493), Unweighted % Amount People Should Eat Amount People Usually Eat or Makes It Easier to Compare Foods Refused or Don t Know Amount People Should Eat Amount People Usually Eat or Makes It Easier To Compare Foods Refused or Don t Know or Other Overall Gender Female Male Age þ Education,High school High school/ged Some college Collegeþ Race NH white NH black Mexican-American Other Hispanics Other race v 2,0.026, Body mass index Underweight Normal Overweight Obese v 2,0.130, * NHANES indicates National Health and Nutrition Examination Survey; NFLES, Nutrition Facts Label Experimental Study; GED, general equivalency diploma; and NH, non-hispanic. Data sources: NHANES data and 2011 U.S. Food and Drug Administration NFLES. Response choices were not mutually exclusive; subjects who provided more than one answer were excluded. Only NFLES offers other option. NHANES separated Hispanics into Mexican Americans and other Hispanics. Body mass index was calculated as weight (kg)/height (m) 2 and was based on measured height and weight in NHANES and self-reported height and weight in NFLES. experience in using the SS information. The NHANES data for the combined survey years indicated less frequent use of SS information compared to the 2008 HDS results, the year of HDS data collection closest to the NHANES. However, the NHANES and HDS data were not directly comparable because they had different sampling frames (complex multistage probability sampling vs. simple random sampling) and survey answers to the questions (always, most of the time, never, and never seen vs. often, never). Because the 2008 HDS used a random-digit-dialing protocol that reached landlines only, the results may be limited to such individuals, excluding those who solely used cell phones. It is noteworthy that for all three HDS years and the NHANES, approximately 35% to 45% of participants reported rarely or never using the SS information. Because knowledge of the SS is necessary for estimating the number of calories consumed, this finding suggests that many consumers might have misperceptions regarding their caloric intake from packaged food products or have no interest in knowing how many calories they consume. Similar results on the use of SS information among participants in NHANES were described by Ollberding et al., 20 who found that 47% of survey participants reported using the label SS, and those who used American Journal of Health Promotion January/February 2016, Vol. 30, No

6 SS more frequently reported lower intake of total calories (150 fewer kcal consumed per day) compared to nonusers. Because Ollberding and associates 20 did not focus on the relationship between usage of SS information and BMI, their results cannot be compared to ours directly. Although we do not have consumption data, we found that in both the 2008 HDS and NHANES , participants who were obese were more likely to report using the SS information often or sometimes compared to other participants; however, they were also more likely to misunderstand the meaning of SS information. We found that more frequent use of SS information was associated with being female and having more education. Similar findings, as well as the observation that label users were more likely to have higher socioeconomic status and to be aware of relationships between nutrition and health, were previously reported. 21,22 These authors suggested that compared to men, women were more likely to use food labels because they were typically responsible for household shopping 22 and were more health conscious in general. 21 With respect to BMI and reported use of SS information, we found that being obese was the best indicator of using SS often and sometimes in the NHANES and a good indicator of using SS sometimes in the 2008 HDS. It is possible that obese individuals with a BMI over 30 who may have been trying to lose weight could have been more conscious of calorie information and therefore more likely to pay attention to the SS information on the package. However, in the 2008 HDS, underweight and normal-weight participants reported using SS most often. The differences in the results between the two surveys may be because height and weight were self-reported in the 2008 HDS compared to the actual measurements in the NHANES. Perceptions of the Meaning of Serving Size We found widespread misinterpretation about the meaning of SS, with about 51% to 55% of the 2011 NFLES and NHANES respondents indicating that the label SS was the amount of this food that people should eat (i.e., a recommendation) rather than an amount that people usually eat or that makes it easier to compare foods. This finding was consistent across all demographic groups and suggests either a fundamental misunderstanding of the label SS or confusion stemming from outdated RACCs that may no longer reflect the SS of certain products. Interestingly, male participants in both surveys were more likely than females to give a correct answer to this question, although, as indicated above, women used SS information more frequently and were previously reported to have a greater awareness of nutrition and health. Targeted nutrition education effort, coupled with the updated SS information from the rule-making process will improve the consumers understanding of the SS and, perhaps, the consumers use of the information to build a healthful dietary practice. Open-ended responses to the question What does SS mean to you? suggest that consumers may harbor suspicion or mistrust toward the SS information appearing on food labels. Some respondents considered it to be an arbitrary number whereas others seemed to believe that manufacturers make it deliberately misleading. Although the majority of these participants provided brief comments, their responses conveyed the impression that they either distrusted the SS or were frustrated with SS information and struggled to use it. Barriers to understanding the meaning of SS information and using the information have been previously discussed. 12,23,24 In particular, consumers have difficulty understanding the difference between SS and portion size, as these terms are often used interchangeably. As mentioned, portion sizes have become larger, whereas the label SS has not changed since Moreover, SS recommendations by government agencies have been inconsistent, as the SS used in the U.S. Department of Agriculture s Food Guide Pyramid during the 1990s was not necessarily the same as the SS appearing on packaged food products. 25 Although misunderstanding the meaning of SS may not necessarily lead to a misinterpretation of calories or affect the amounts of nutrients consumed, correct understanding of nutrition information on the NF label may help consumers follow healthful dietary practices. Determination of Serving Sizes We found widespread misunderstanding with regards to who is responsible for the SS information on food labels. A majority of the HDS participants consistently and incorrectly responded that manufacturers determine the SS. Between 1994 and 2008 there was a slight increase in the proportion of participants who correctly indicated that SSs are determined by government rules, perhaps as a result of the public becoming more knowledgeable about the NF label in general. However, 22% to 24% of participants either indicated that they did not know the answer to this question or refused to answer it. If consumers realized that the FDA establishes the basis for the label SS, they might perceive the SS differently. Lack of Consumer Education Consistent with previous reports, we found that a large proportion of consumers neither understand nor use the SS information on NF labels, suggesting that efforts aimed at increasing consumer use and understanding of the SS information are warranted. Although Congress clearly intended that the NLEA would include a public education component, as the title of the law indicates, the overall scope of educational efforts since 1993 has been limited and fragmented, despite evidence that consumers are interested in such programs. 26 The need for consumer education regarding the revised NF label was recognized in the FDA s proposed regulation. 16(p11883) Education programs should provide clear information on the meaning and proper use of SS, and help motivate consumers to use the new label. The FDA has previously developed educational materials and programs targeted to various audiences, including children, that have been favorably received based on informal evaluations. 27 However, we were not able to locate published studies in which education programs aimed at increasing consumer use and understanding of the NF label, particularly 186 American Journal of Health Promotion January/February 2016, Vol. 30, No. 3

7 the SS information, were rigorously evaluated. We expect that the FDA s proposed regulations on revising and updating the NF label, when finalized, will provide a fresh opportunity for such renewed education and outreach efforts. SO WHAT? Implications for Health Promotion Practitioners and Researchers What is already known on this topic? Many consumers do not use serving size (SS) information on Nutrition Facts (NF) labels, or understand the difference between SS and portion size. What does this article add? Our analysis of national survey data suggests that consumer use of SS information has been increasing, but half the population has a fundamental misunderstanding of SS. Although women reported using SS information more frequently than men, we found that women and participants who were younger, less educated, and obese were more likely to incorrectly believe that SS indicates a recommended portion of food. Subjects who volunteered to express their opinion indicated a general distrust of information on NF labels. What are the implications for health promotion practice or research? There is clearly a need for enhanced public education efforts focusing on the proper use and understanding of SS information on the NF label. Using SS information incorrectly may result in misjudging the caloric and nutrient content of a packaged food, possibly leading to overconsumption and contributing to obesity and other health problems. More efforts are needed to encourage the consumer to use the NF labels and also make the NF labels understandable and usable. References 1. Food and Drug Administration. Food labeling: mandatory status of nutrition labeling and nutrient content revision, format of nutrition label. Final rule. Fed Regist. 1993;58: Food and Drug Administration. Food labeling; serving sizes. Final rule. Fed Regist. 1993;58: Food and Drug Administration. Food labeling: serving sizes of foods that can reasonably be consumed at one-eating occasion; dual-column labeling; updating, modifying, and establishing certain reference amounts customarily consumed; serving size for breath mints; and technical amendments. Proposed rule. Fed Regist. 2014;79: National Institute of Health. Serving sizes and portions. Available at: nhlbi.nih.gov/health/public/heart/ obesity/wecan/eat-right/distortion.htm. Accessed June 16, Campos S, Doxey J, Hammond D. Nutrition labels on pre-packaged foods: a systematic review. Public Health Nutr. 2011; 14: Cowburn G, Stockley L. Consumer understanding and use of nutrition labelling: a systematic review. Public Health Nutr. 2005;8: Misra R. Knowledge, attitudes, and label use among college students. J Am Diet Assoc. 2007;107: Pelletier AL, Chang WW, Delzell JE, McCall JW. Patients understanding and use of snack food package nutrition labels. J Am Board Fam Pract. 2004;17: Rothman RL, Housam R, Weiss H, et al. Patient understanding of food labels. The role of literacy and numeracy. Am J Prev Med. 2006;31: Lando AM, Lo SC. Single-larger-portionsize and dual-column nutrition labeling may help consumers make more healthful food choices. J Acad Nutr Diet. 2013;113: National Institute of Health. Portion distortion! Do you know how food portions have changed in 20 years? Available at: portion/. Accessed August 15, Young LR, Nestle M. Expanding portion sizes in the US marketplace: implications for nutrition counseling. J Am Diet Assoc. 2003;103: Brogden N, Almiron-Roig E. Estimated portion sizes of snacks and beverages differ from reference amounts and are affected by appetite status in non-obese men. Public Health Nutr. 2011;14: Ello-Martin JA, Ledikwe JH, Rolls BJ. The influence of food portion size and energy density on energy intake: implications for weight management. Am J Clin Nutr. 2005; 82(suppl):236S 241S. 15. Levitsky DA, Pacanowski CR. Free will and the obesity epidemic. Public Health Nutr. 2011;15: Food and Drug Administration. Food labeling: revision of the nutrition and supplement facts labels. Proposed rule. Fed Regist. 2014;79: Food and Drug Administration. Consumer behavior research; Available at: FoodScienceResearch/ ConsumerBehaviorResearch/default.htm. Accessed August 20, Centers for Disease Control and Prevention. National Health and Nutrition Examination Survey; Available at: nhanes.htm. Accessed August 22, SAS Institute Inc. Base SASt 9.3 Procedures Guide [computer program]. Cary, NC: SAS Institute Inc; Ollberding NJ, Wolf RL, Contento I. Food label use and its relation to dietary intake among US adults. J Am Diet Assoc. 2010; 110: Blitstein JL, Evans WD. Use of nutrition facts panels among adults who make household food purchasing decisions. J Nutr Educ Behav. 2006;38: Chen X, Jahns L, Gittelsohn J, Wang Y. Who is missing the message? Targeting strategies to increase food label use among US adults. Public Health Nutr. 2012; 15: Faulkner GP, Pourshahidi LK, Wallace JMW, et al. Serving size guidance for consumers: is it effective? Proc Nutr Soc. 2012;71: Gans KM, Risica PM, Kirtania U, et al. Dietary behaviors and portion sizes of black women who enrolled in SisterTalk and variation by demographic characteristics. J Nutr Educ Behav. 2009;41: Britten P, Haven J, Davis C. Consumer research for development of educational messages for the MyPyramid Food Guidance System. J Nutr Educ Behav. 2006; 38(suppl 6):S108 S Haldeman L, Perez-Escamilla R, Ferris AM, et al. Development of a color-coded bilingual food label for low-literacy Latino caretakers. J Nutr Educ. 2000;32: Food and Drug Administration. Nutrition facts label programs & materials; Available at: IngredientsPackagingLabeling/ LabelingNutrition/ucm htm. Accessed August 20, American Journal of Health Promotion January/February 2016, Vol. 30, No

8 EDITOR IN CHIEF Michael P. O Donnell, PhD, MBA, MPH ASSOCIATE EDITORS IN CHIEF Jennifer E. Taylor, PhD Jennie Jacobs Kronenfeld, PhD Kwame Owusu-Edusei Jr., PhD* Kerry J. Redican, MPH, PhD, CHES The Wisdom of Practice and the Rigor of Research The American Journal of Health Promotion provides a forum for that rare commodity practical and intellectual exchange between researchers and practitioners. Kenneth E. Warner, PhD Dean and Avedis Donabedian Distinguished University Professor of Public Health School of Public Health, University of Michigan The contents of the American Journal of Health Promotion are timely, relevant, and most important, written and reviewed by the most respected researchers in our field. David R. Anderson, PhD, LP Senior Vice President & Chief Health Officer, StayWell Health Management Be the first to know. Available exclusively to ONLINE SUBSCRIBERS The American Journal of Health Promotion is now publishing all articles online, ahead of print. Articles are available as a PDF document for download as soon as they have completed the review process. This means you can access the very latest papers in the field of health promotion in some cases up to a year before they appear in print. Subscribe Today. 6 Issues/Year ISSN (PRINT) ISSN (ONLINE) *Kwame Owusu-Edusei, Jr. is serving in his personal capacity. The views expressed are his own and do not necessarily represent the views of the Centers for Disease Control and Prevention or the United States Government. Subscribe Online at CUSTOMER SERVICE (US only) or ANNUAL SUBSCRIPTION RATES (Effective through ) SUBSCRIPTION USA CANADA/ OTHER AGENCY MEXICO COUNTRIES DISCOUNT Individual Print & Online* $145 $154 $163 N/A Institutional Print Only** $191 $200 $209 10% Tier 1: Institutional Print & Online $373 $382 $391 10% Institutional Online Only $373 $373 $373 10% Tier 2: Institutional Print & Online $477 $486 $495 10% Institutional Online Only $477 $477 $477 10% Tier 3: Institutional Print & Online $581 $590 $599 10% Institutional Online Only $581 $581 $581 10% University w/archive Posting Privileges*** $895 $904 $913 10% *Individual Subscriptions must be set up in the name of a single individual and mailed to a residential address. ** Print subscriptions are one print copy per issue. For multi-site institutions wishing to have a copy sent to each location, additional subscriptions are required. Tier 1 Most Employers and Corporations except Health Organizations, Libraries and Schools Tier 2 Health Organizations including Hospitals, Clinics, Health Promotion Providers, Insurance Companies and Voluntary Health Agencies Tier 3 Libraries, Colleges and Universities ***University w.archive Posting Privileges Allows an unlimited number of faculty, students and staff to post an unlimited number of typeset accepted manuscripts on the school s internal archive website. Includes print and online.