ADA submitted comments on two proposed rules from the FDA modifying the Nutrition Facts label that appears on most packaged foods in the United States and gives consumers information on the nutritional content of the food. The FDA is proposing changes to the content and layout of the Nutrition Facts label.

1. National Office
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Diabetes Information
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June 4, 2014
Philip Spiller
Acting Director
Food and Drug Administration
Center for Food and Safety and Applied Nutrition
Office of Nutrition, Labeling, and Dietary Supplements
5100 Paint Branch Parkway
College Park, MD 20740
Dear Acting Director Spiller:
On behalf of the nearly 26 million Americans living with diabetes, and 79 million more with prediabetes,
the American Diabetes Association (Association) appreciates the opportunity to submit comments on the
Food Labeling: Revision of the Nutrition and Supplement Facts Labels (FDA-2012-N-1210, RIN 0910-
AF22) proposed rule.
Accurate and easily understandable food labels are essential in ensuring individuals with and at risk for
diabetes are able to follow their individualized eating plans and achieve their daily nutrition goals. A
healthful eating pattern, regular physical activity, and often pharmacotherapy are key components of
diabetes management. For many individuals with diabetes, the most challenging part of the treatment
plan is determining what to eat. The Association recommends each person with diabetes be actively
engaged in self-management, education, and treatment planning with his or her health care provider,
which includes the collaborative development of an individualized eating plan.1
There is not a “one-size-
fits-all” eating pattern for individuals with diabetes. However, healthful eating patterns, emphasizing a
variety of nutrient dense foods in appropriate portion sizes, are key in assisting individuals with diabetes
to improve their overall health, and specifically to attain individualized glycemic, blood pressure, and
lipid goals; achieve and maintain body weight goals; and delay or prevent complications of diabetes. In
addition, a healthy diet is a key factor in preventing the onset of type 2 diabetes, even in individuals at
high risk. Studies have shown individuals with prediabetes may be able to reduce their risk of progression
to type 2 diabetes by 58% with modest weight loss through a healthy, low-fat, low-calorie diet and
increased physical activity.2
The Association is pleased the Food and Drug Administration (FDA) has released this proposed rule to
ensure the content and layout of the Nutrition Facts label helps individuals with diabetes and those at risk
for developing diabetes maintain healthy dietary practices. The Association generally supports the
changes FDA proposes, but respectfully offers these comments and recommendations to address key
pieces of information which are of most importance to people with and at risk for diabetes.

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Added Sugars
The Association strongly supports FDA’s proposal to require “added sugars” be declared on the
Nutrition Facts label. There is great confusion in the general public between sugars added to food
during processing and naturally occurring sugars. Eating a well-balanced diet, in addition to monitoring
amounts of carbohydrate, is critical to people with diabetes. While it is true that naturally occurring
sugars and added sugars have the same physiological impact, the difference is significant when
considering dietary quality. Foods high in added sugars (such as sodas and sweets) are nutritionally
inferior to foods high in naturally occurring sugar (such as fruit and milk). The need for Americans to
consume less added sugar is represented in the 2010 Dietary Guidelines for Americans.3
Knowing how
much added sugar a food or beverage contains is key in ensuring individuals are able to make dietary
decisions to reduce their consumption. As such, the Association strongly supports requiring the
declaration of “added sugar” on the Nutrition Facts label to ensure individuals with and at risk for
diabetes are able to follow the 2010 Dietary Guidelines for Americans.
Increased Prominence of “Calories”
The Association supports the FDA’s proposal to continue to require "total calories” be declared on
the label and to increase the prominence of the calorie declaration. For overweight and obese adults
with type 2 diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended.
In many cases, modest weight loss provides clinical benefits for individuals with diabetes. And as
previously noted, weight loss is the key factor in preventing type 2 diabetes. To support individuals with
diabetes and at risk for diabetes in selecting, preparing, and consuming foods and beverages with the
appropriate number of calories to meet their needs for weight management, they must be able to easily see
and understand the number of calories in a serving of a particular food or beverage. Therefore, we
support the proposal to increase the type size for both the “Calories” heading and the numerical value and
to require that the information be highlighted in bold or extra bold type.
In addition to being able to easily identify the number of calories per serving, the Association believes it
is also important for individuals with diabetes and those working to prevent diabetes to be able to easily
identify and comprehend the serving size and number of servings per container. Therefore, we support
the proposal to increase the prominence of the “Servings per container” declaration in a similar
manner as the “Calories” declaration.
Replacing “Total Carbohydrate” with “Total Carbs”
The Association is strongly opposed to FDA’s proposal to replace “Total Carbohydrate” with
“Total Carbs” on the Nutrition Facts label. According to the preamble to this proposed rule, FDA is
proposing this change as a means to maximize the amount of white space and maintain a simple format
which enables the public to easily observe and comprehend the nutrition information presented.
However, for individuals with diabetes, this change would result in confusion.
People with diabetes have a particular interest in the way carbohydrates affect glycemic control and also
the way it affects their need for medications, particularly insulin. A key strategy in achieving glycemic
control for individuals with diabetes is monitoring their carbohydrate intake, including by carbohydrate
counting (grams of carbohydrate or carbohydrate choices). Glycemic control is imperative to avoid the
physically devastating and costly short- and long-term complications of diabetes. As such, it is essential

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that individuals with diabetes are able to accurately determine the carbohydrate content of the foods they
consume.
When learning about carbohydrate counting, millions of people with diabetes are taught to use either the
grams of total carbohydrate to adjust insulin, or they can use carbohydrate “choices.” A carbohydrate
choice is defined as a serving of food that contains 15 grams of total carbohydrate. This is frequently
referred to as a “carb choice” or a “serving of carb.”4
(See Appendix A). If the total carbohydrate content
information presented on the Nutrition Facts label is labeled as “Total carbs” as opposed to “Total
Carbohydrate” it could greatly impact individuals with diabetes’ ability to accurately assess the
carbohydrate content of their food and as such their ability to manage their diabetes will be negatively
impacted. For example, if the Nutrition Facts label says a food contains 5 “total carbs,” a person with
diabetes may interpret this to mean the food contains 5 “carb choices” and therefore contains 75 grams of
total carbohydrate. Therefore we strongly urge FDA to continue to require the term “Total
Carbohydrate” on the Nutrition Facts label to avoid any confusion. The extra white space created
by this change is not worth the great disservice this change would do for individuals with diabetes.
Consumer Education
The Association strongly believes a coordinated, multi-component consumer education campaign to
promote and explain the new Nutrition Facts label is necessary to help consumers understand the
information provided by the label and how they can use it to make healthier food and beverage
choices. While it is important for all consumers to know about, understand, and use the revised Nutrition
Facts label, the consumer education campaign should primarily target consumers who are least likely to
understand and use the label, including low-income and low-education consumers more likely to suffer
from many obesity- and nutrition-related chronic diseases, such as diabetes.
The consumer education campaign should integrate with existing consumer education programs and
initiatives, including SNAP-Ed, school-based nutrition education programs, and grocery store labeling
and education initiatives. The education campaign should emphasize calories and serving sizes—since
knowledge of both are important for rolling back the obesity epidemic—and nutrients that will be on the
Nutrition Facts label for the first time, such as added sugars.
Conclusion
The Association appreciates the opportunity to provide comments on this proposed rule. We are pleased
the FDA is proposing changes to the Nutrition Facts label to increase the prominence of the calorie
declaration and require declaration of “added sugars.” These proposed changes will help ensure the
Nutrition Facts labels on packaged foods provide accurate and easily understandable information to help
individuals with and at risk for diabetes follow their individualized eating plans and achieve their daily
nutrition goals. However, we strongly urge FDA to reconsider its proposal to use the term “total carbs” as
it will create confusion for consumers with diabetes.

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If you have any questions, please contact Dr. LaShawn McIver, Managing Director Public Policy and
Strategic Alliances, at lmciver@diabetes.org or (703) 299-5528.
Sincerely,
Shereen Arent
Executive Vice President
Government Affairs & Advocacy
American Diabetes Association
1
Evert AB, Boucher JL, Cypress M, et. al, Nutrition Therapy Recommendations for the Management of Adults with
Diabetes. Diabetes Care, January 2014.
2
DPP Research Group, Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin,
New England Journal of Medicine, February 2002.
3
U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for
Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010. Available at
http://www.health.gov/dietaryguidelines/dga2010/DietaryGuidelines2010.pdf.
4
National Agricultural Library, Carbohydrate Counting and Exchange Lists, U.S. Department of Agriculture, May
2014, available at http://fnic.nal.usda.gov/diet-and-disease/diabetes/carbohydrate-counting-and-exchange-lists.

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Appendix A
Excerpt from “Count your Carbs: Getting Started”
by the American Diabetes Association and the Academy of Nutrition and Dietetics

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