With these considerations in mind, the panel made several key decisions about how the nutrition standards would be structured. These included ranking foods into three tiers, basing the standards around nutrients of concern, (i.e., nutrients that should be limited in the diet), using serving size as the reference amount, and classifying foods into product categories.
Rank foods into three tiers
Nutrition standards commonly use a binary or ternary system to classify the nutritional quality of products based on defined thresholds. A three-tiered approach was chosen over a two-tiered approach for several reasons, despite the potential for more difficult implementation and messaging. First, this approach allows for stricter thresholds for the top and bottom tiers. Second, three tiers can be collapsed into two, if desired by local implementers. Third, this approach recognizes there are numerous nutritional gray areas, and that not all products can be easily classified as “healthy” or “unhealthy.”
The panel recommended a visual traffic light (green, yellow or red) or text-based (
choose often, choose sometimes or
choose rarely) method of communicating the three tiers. The traffic light can be easily communicated regardless of literacy level or English proficiency. There is also evidence that using traffic lights to highlight the nutrition content of products can reduce consumption of red foods [
26‐
28]. Although there has been little research on the use of text-based descriptors as a stand-alone method, evidence shows that using a combination traffic-light and text-based approach may be an effective educational tool for consumers [
29]. In addition, many food banks and pantries already use a similar stoplight-text based approach [
15,
30]. The panel recommends using both approaches as complements to one another, with the option to modify according to local preference.
Base standards on nutrients of concern
Numerous nutrition standards or profile systems exist for ranking foods as ‘healthy’ or ‘unhealthy’ within both the charitable and larger food systems. In developing the standards, the panel favored systems that use nutrient thresholds or cut-offs because the approach is simple to operationalize and requires minimal training. Systems that use algorithms (such as the Nutrient Rich Foods Index) [
31] were not considered due to their complexity.
In existing systems, nutrient thresholds center on beneficial nutrients (such as fiber), nutrients of concern (such as sodium), or a combination. To prioritize feasible implementation, the panel chose to focus on three nutrients of concern (saturated fat, sodium, and added sugars), all of which are found on the NFL. This decision is consistent with recommendations from the DGA, which limit saturated fat, sodium, and added sugars based on strong evidence that these nutrients are commonly found in dietary patterns associated with increased health risks [
32]. Furthermore, foods high in these three nutrients are often associated with poor diet quality [
33]. Overall food product rankings were determined by the lowest tier of any nutrient. For example, a product that is ranked
choose often for saturated fat,
choose sometimes for sodium, and
choose rarely for added sugars would receive a final ranking of
choose rarely.
Although the panel acknowledged the importance of emphasizing beneficial nutrients and encouraging the intake of under consumed nutrients, such as fiber, vitamin D, calcium, and iron, they were ultimately not included in the standards (with some exceptions described below). Algorithms that include both beneficial nutrients and nutrients to limit are more complex to implement, generally requiring additional training and/or calculations. In addition, providing credit for beneficial nutrients may encourage excessive or inappropriate use of fortification in foods that may not be otherwise considered healthy. For example, a heavily fortified cereal that is high in added sugars may be considered healthy under these algorithms, even when a general consumer or a nutrition expert would recognize them as less healthy. This inconsistent messaging creates consumer confusion.
The panel, however, created two exceptions to this general strategy. The first exception was for grains. There is significant and growing evidence to support the consumption of whole grains, although few Americans meet current DGA recommendations. Thus, the panel determined that identification of whole grains from the ingredient list was critical to the nutrition standards. Fiber content, which would have been easily identifiable on the NFL, was considered as a proxy measure of whole grain content but was rejected for two reasons: (1) there are numerous products on the market that may be fortified with functional or isolated fiber, but may not otherwise be considered healthy, and (2) there was often a thin margin between the fiber content of whole grain and non-whole grain products that made it difficult to set an appropriate threshold. While using a product ingredients list to identify a whole grain is more complicated, the panel determined that this would ultimately result in better alignment with the DGA recommendations for a healthy dietary pattern.
The second exception was for 100% juice. Using just nutrients to limit, 100% juice would always be categorized as a
choose often food because there are no added sugars, despite scientific consensus that excessive juice intake contributes to weight gain and obesity. Thus, in these standards 100% juice is automatically categorized in the middle tier, as described in more detail below. This recommendation is consistent with recommendations from the American Academy of Pediatrics (AAP) and a recent consensus statement [
34] on healthy beverage consumption in early childhood from four national health and nutrition organizations including the Academy of Nutrition and Dietetics.
Classify products into eleven categories
The decision to sort products into eleven categories allowed thresholds for nutrients of concern to vary by product category. This product categorization is already routinely done by many food banks and food pantries within the charitable food system, limiting panel concerns about implementation challenges. The panel started its discussion with a review of DGA categories (fruits, vegetables, grains, proteins, and dairy), which would easily align with nutrition messaging provided in other settings. Additional categories, such as mixed dishes (e.g., soups and stews), were added to reflect foods commonly donated to and distributed within the charitable food system and that often defy categorization based on a single ingredient. The eleven final product categories were (1) fruits and vegetables, (2) grains, (3) protein, (4) dairy, (5) non-dairy alternatives, (6) beverages, (7) mixed dishes, (8) processed and packaged snacks, (9) desserts, (10) condiments and cooking staples, and (11) other miscellaneous items.
Product category decisions were multifaceted. The panel sought to create as few categories as possible to limit complexity, but still allow for sensible nutrient thresholds. In some cases, combining products simplified categorization. This was particularly important for the fruit and vegetable category, as there can be confusion over the appropriate categorization of some foods (e.g., tomatoes, avocados, and cucumbers). In this case, combining fruits and vegetables into a single category simplified the nutrient threshold establishment process, because added sugars are the primary nutrient of concern for fruits (and the sodium threshold is rarely relevant), while sodium is the primary nutrient of concern for vegetables (and the added sugars threshold is rarely relevant).
Similarly, the protein category includes both animal and plant proteins. Although the nutritional composition of plant and animal proteins are very different, grouping them into one category allows users of the system to recognize the overall healthier nutrient profile of lean animal proteins and plant-based proteins compared to red meats and processed meats. Although dairy is also a good source of protein, it is typically treated as a separate meal component (e.g., milk in school meal programs and DGA) so the panel elected to keep dairy in its own category.
For other products, dividing into multiple categories simplified the ranking process and allowed for important nutrient threshold distinctions. In particular, non-dairy alternatives presented a challenge. The panel considered ranking products such as soy, almond, cashew and oat “milks” with the dairy category, the protein category, and the beverage category before ultimately deciding to establish a separate category for them. The composition and bioavailability of nutrients in non-dairy alternatives render them nutritionally dissimilar to cow’s milk, making nutrient thresholds difficult to establish when combining dairy and non-dairy foods. The panel elected not to include non-dairy alternatives in the protein category because there is significant variation in the protein content of many of these products, with some having virtually no protein at all. Finally, the panel chose not to include these products in the beverage category because of complexity in categorizing yogurt, cheese, and other foods also created from non-dairy alternatives. Thus, the final decision to place non-dairy alternatives in their own category allows for more specificity in the nutrient thresholds, accommodates culturally and medically appropriate items in the top tier, and allows for identification of more and less healthy non-dairy alternative products.
Mixed dishes, such as soups, stews, frozen dinners, and boxed meals, are common in the charitable food system. Most other nutrition standards do not include separate categories for mixed dishes because the assumption is that such foods can be categorized into a primary food group component (such as dairy, protein, or grain). However, the task of categorizing a mixed dish into a primary food group component can be challenging, particularly for untrained volunteers. The decision to create a separate mixed dishes category allows staff or volunteers to easily categorize products that do not neatly fit into another category. In addition, this decision allows for a more tailored sodium threshold. Sodium is the key nutrient of concern in most mixed dishes, and because these items are generally consumed as an entire meal rather than a meal component, the sodium threshold could be moved upward with fewer concerns about exceeding daily sodium recommendations.
The processed and packaged snacks and the desserts categories are two other examples of creating separate categories rather than grouping products into an existing food category based on their primary ingredient (e.g., cookies grouped as a grain or potato chips grouped as a vegetable). These products are consistently higher in saturated fats, sodium, and added sugars making them less healthy choices. However, product reformulations in recent years have meant that there are some processed and packaged snack foods and desserts that could end up being ranked as
choose often in their primary ingredient category, especially if they are packaged in small serving sizes. To prevent this, the panel created two separate categories for processed and packaged snacks and desserts. Similar to the Go, Slow, Whoa system [
35], no items in these categories can be categorized as
choose often. Notably, the processed and packaged snack category does not include minimally processed foods from other categories that can be eaten as snacks, such as yogurt (dairy), apple slices (fruit), or nuts (protein). Many food banks have programs, such as backpack programs providing weekend food for school children, that prioritize small packages of shelf-stable snack items. Creating a separate category for processed and packaged snack foods allows these programs to choose healthier packaged snacks, while also acknowledging that these products should be consumed in moderation.
The panel decided to separate desserts from the processed and packaged snacks category because, unlike snacks, the consensus was that desserts are, by definition, a treat and are typically high in added sugars and saturated fat. As a result, all products in this category are automatically ranked as
choose rarely. Although there are a number of fat-free and sugar-free products on the market, there is still reason to take caution when consuming these products. Low- or fat-free items often contain higher added sugars to compensate for flavor. In addition, many sugar-free products contain artificial sweeteners, which have unclear impacts on obesity and other health outcomes. While the panel acknowledges that desserts, when consumed in moderation, can have a place in a healthy diet, it is important to note that research shows people using the charitable food system are not generally accessing the food pantry to obtain dessert items. In fact, products such as candy, cookies, and brownies consistently are ranked at the bottom of clients’ priority lists [
8,
25]. Moreover, clients at food pantries in general have greater access to desserts (and other processed and packaged snacks) than access to healthier alternatives.
The condiments & cooking staples category includes items such as vinegar, oils, butter, sugar, ketchup, sauces, salad dressing, syrup, and other products that are typically used for cooking/baking or to enhance the flavor of meals. These items are combined into one category that is not ranked; rather, a focus is placed on consumer education and other messaging strategies regarding the frequency and appropriate serving sizes for these items. There were multiple panel discussions about the advantages and disadvantages of ranking these items, especially concerning overconsumption of certain condiments like salad dressing and mayonnaise. However, research has shown that consuming food that was prepared at home is associated with improved diet quality, and the panel reasoned that not ranking these items would promote home cooking and greater consumption of otherwise healthy food items (such as salad with dressing). The panel also recognized the importance of promoting the inclusion of condiments that are often used in preparing cuisines from a range of different cultures. For example, soy sauce and fish sauce are important ingredients in many Asian cuisines, but they would likely be classified as “use rarely” in any ranking system due to the sodium content. The inclusion of culturally relevant ingredients has also been recognized as an important element of ensuring the acceptability of nutrition interventions in food banks and pantries [
36]. The intention of this approach is to encourage food banks and pantries to discover the cuisines that are important to their client population and provide culturally inclusive and relevant nutrition education to support home meal preparation.
The panel also created a miscellaneous category to categorize items such as nutrition supplements and baby food. These items are meant to fulfill the nutrition needs of specific subpopulations and are therefore not ranked.