Search results: dietary guidelines

JAMA Internal Medicine has just published an editorial I wrote: Preventing Obesity—It Is Time for Multiple Policy Strategies

As it explains, it is a commentary on a research article by Joshua Petimar, et al, Assessment of Calories Purchased After Calorie Labeling of Prepared Foods in a Large Supermarket Chain  

Both papers are behind paywalls, but here are the key points of the supermarket article:

Question  Was calorie labeling of prepared foods in supermarkets associated with changes in calories purchased from prepared foods and potential packaged substitutes?

Findings  In this longitudinal study of 173 supermarkets followed from 2015 to 2017, calories purchased from prepared bakery items declined by 5.1% after labeling, and calories purchased from prepared deli items declined by 11.0% after labeling, adjusted for prelabeling trends and changes in control foods; no changes were observed among prepared entrées and sides. Calories purchased from similar packaged items did not increase after labeling.

Meaning  Calorie labeling of prepared supermarket foods was associated with overall small declines in calorie content of prepared foods without substitution to similar packaged foods.

I was really interested in this study because the “large supermarket chain” that supplied reams of data was so obviously Hannaford, which has long been ahead of the curve in trying to encourage customers to make healthier food choices.

In 2005, Hannaford initiated a Guiding Stars program that ranked–and still ranks–products by giving them zero to three stars depending on what they contain.

I wrote about the first-year evaluation of this program way back in 2006.  It did help customers to make better choices.

Now, all these years later, the FDA is contemplating doing some kind of front-of-package label.  As I said, Hannaford is way ahead.

But the point of my editorial is that single interventions rarely do better than what this study found.

I argue here for trying multiple strategies at once:

My interpretation of the current status of obesity prevention research is that any single policy intervention is unlikely to show anything but small improvements.

Pessimists will say such interventions are futile and should no longer be attempted.

Optimist that I am, I disagree.  We cannot expect single interventions to prevent population-basedweight gain ontheirown,but they might help some people—and might help even more people if combined simultaneously with other interventions.

….Widespread policy efforts to reduce intake of ultraprocessed foods through a combination of taxes, warning labels, marketing and portion-size restrictions, dietary guidelines, and media education campaigns, along with policies for subsidizing healthier foods and promoting greater physical activity, should be tried; they may produce meaningful effects.

Politically difficult? Of course. Politically impossible? I do not think so.

Unless we keep trying to intervene—and continue to examine the results of our attempts—we will be settling for the normalization of overweight and the personal and societal costs of its health consequences.

Here’s Ted Kyle’s commentary on my commentary on ConscienHealth.

Here’s a good one for my collection:

The Study: TRENDS IN ADDED SUGARS INTAKE AND SOURCES AMONG U.S. CHILDREN, ADOLESCENTS AND TEENS USING NHANES 2001-2018.  Laurie Ricciuto,Victor L. Fulgoni III, P. Courtney Gaine, Maria O. Scott, Loretta DiFrancesco. The Journal of Nutrition, Volume 152, Issue 2, February 2022, Pages 568–578, https://doi.org/10.1093/jn/nxab395 

• Background: Over the past 2 decades, there has been an increased emphasis on added sugars intake in the Dietary Guidelines for Americans (DGA), which has been accompanied by policies and interventions aimed at reducing intake, particularly among children, adolescents, and teens.
  Objectives: The present study provides a comprehensive time-trends analysis of added sugars intakes and contributing sources in the diets of US children, adolescents, and teens …focusing on variations according to sociodemographic factors.
• Methods: Data from 9 consecutive 2-year cycles of the NHANES were combined…Trends were also examined on subsamples stratified by sex, race and ethnicity…income (household poverty income ratio), food assistance, physical activity level, and body weight status.
• Results: From 2001–2018, added sugars intakes decreased significantly…mainly due to significant declines in added sugars from sweetened beverages.
• Conclusions: Declines in added sugars intakes were observed among children, adolescents, and teens…Despite these declines, intakes remain above the DGA recommendation; thus, continued monitoring is warranted.
• Support: The funding for this research was provided by The Sugar Association, Inc. The views expressed in the manuscript are those of the authors and do not necessarily reflect the position or policy of The Sugar Association, Inc. The Sugar Association, Inc. had no restrictions regarding publication.
• Author Disclosures: LR and LD as independent consultants provide nutrition and regulatory consulting to various food manufacturers, commodity groups and health organizations. VLF III as Vice President of Nutrition Impact, LLC conducts NHANES analyses for numerous members of the food, beverage and dietary supplement industry. PCG and MOS are employed by The Sugar Association, Inc.

Thanks to a reader in Israel, Yehuda Ben-Hur, for sending this one.

The study: The effect of a high-polyphenol Mediterranean diet (Green-MED) combined with physical activity on age-related brain atrophy: the Dietary Intervention Randomized Controlled Trial Polyphenols Unprocessed Study (DIRECT PLUS) .  Alon Kaplan, Hila Zelicha, Anat Yaskolka Meir, Ehud Rinott, Gal Tsaban, Gidon Levakov, Ofer Prager, Moti Salti, Yoram Yovell, Jonathan Ofer, Sebastian Huhn, Frauke Beyer, Veronica Witte, Arno Villringer, Nachshon Meiran, Tamar B Emesh, Peter Kovacs, Martin von Bergen, Uta Ceglarek, Matthias Blüher, Michael Stumvoll, Frank B Hu, Meir J Stampfer, Alon Friedman, Ilan Shelef, Galia Avidan, Iris Shai.  The American Journal of Clinical Nutrition, nqac001, https://doi.org/10.1093/ajcn/nqac001 Published: 11 January 2022.

Objectives: We aimed to explore the effect of a Mediterranean diet (MED) higher in polyphenols and lower in red/processed meat (Green-MED diet) on age-related brain atrophy.

Methods:  Abdominally obese  participants were randomly assigned to follow one of three diets: (1) healthy dietary guidelines (HDG), (2) MED, or (3) Green-MED diet.  The two MED groups consumed 28 g walnuts/d.  The Green-MED group consumed green tea , mankai (100 g frozen cubes/d as a green shake).  After 18 months, participants got MRI scans.

Results: Indicators of brain atrophy were attenuated in both MED groups, with the best outcomes among Green-MED diet participants.  Therefore, greater Mankai, green tea, and walnut intake and less red and processed meat were significantly and independently associated with reduced atrophy decline .

Conclusions: A Green-MED (high-polyphenol) diet, rich in Mankai, green tea, and walnuts and low in red/processed meat, is potentially neuroprotective for age-related brain atrophy.

Funding: Supported by German Research Foundation, Israel Ministry of Health, Israel Ministry of Science and Technology, and the California Walnut Commission (to I Shai, the senior author). “None of the funding providers were involved in any stage of the design, conduct, or analysis of the study, and they had no access to the study results before publication.”

Comment: I hardly know what to make of this study, which involves so many variables: mankai, (duckweed, supposedly a polyphenol-rich “supergreen”), green tea, walnuts, and low red/processed meat.  The MED groups were instructed to consume a calorie-restricted Mediterranean diet “rich in vegetables, with poultry and fish partly replacing beef and lamb.”  Physical activity instructions (and gym memberships) as well nutrition counseling was also part of this mix.

My questions:

• Why not test the Mediterranean diet on its own without all those polyphenol additives?
• Why walnuts as opposed to any other polyphenol-containing food?  Could sponsorship have anything to do with this choice?
• Why Mankai, which is traditionally a component of Asian diets, not Mediterranean?    Why are Israeli scientists so interested in this plant?
• Don’t classic Mediterranean diets provide enough polyphenols to be protective against brain atrophy?

I will be intersted to see further studies along these lines.

A reader, Effie Schultz, sent this one, with a comment that it comes with the longest conflict of interest statement she had ever seen (I’ve noted one that was two pages long in the first item in a post in 2015).

Association of Low- and No-Calorie Sweetened Beverages as a Replacement for Sugar-Sweetened Beverages With Body Weight and Cardiometabolic Risk: A Systematic Review and Meta-analysis.  McGlynn ND, and 20 other authors.  JAMA Network Open, March 14, 2022. 2022;5(3):e222092.  doi:10.1001/jamanetworkopen.2022.2092

The research question: Are low- and no-calorie sweetened beverages (LNCSBs) as the intended substitute for sugar-sweetened beverages (SSBs) associated with improved body weight and cardiometabolic risk factors similar to water replacement?

The conclusion: This systematic review and meta-analysis found that using LNCSBs as an intended substitute for SSBs was associated with small improvements in body weight and cardiometabolic risk factors without evidence of harm and had a similar direction of benefit as water substitution. The evidence supports the use of LNCSBs as an alternative replacement strategy for SSBs over the moderate term in adults with overweight or obesity who are at risk for or have diabetes.

Comment: Research on artificial sweeteners remains controversial.  I think we will be arguing forever about their safety and efficacy in helping people lose weight.  Studies with conflict of interest disclosures like the excessively extensive one here do not help resolve the research questions.

I strongly support revealing conflicted interests that might influence any aspect of research design, conduct, and interpretation.  For this study, I would be interested in financial ties or arrangements with companies that might either gain or lose sales or marketing advantages from results showing artificial sweeteners or diet drinks to be harmless or beneficial, as these do.  At issue here is whether financial ties to companies with corporate interests in the outcome of such research bias results or interpretation, consciously or unconsciously.

You have to search through this mess of unnecessary and distracting disclosures to find the ones that matter.  They are there.  You have to search for them.

Much of what is disclosed is irrelevant and, therefore, not helpful.

You may well disagree with that assessment.  Judge for yourself.

Conflict of Interest Disclosures: Ms McGlynn reported receiving a Canadian Institutes of Health Research (CIHR)-Masters Award during the conduct of the study and being a former employee of Loblaws Companies Limited outside the submitted work. Dr Khan reported receiving grants from CIHR, International Life Science Institute, and National Honey Board outside the submitted work. Dr Chiavaroli reported being a Mitacs Elevate postdoctoral fellow and receiving joint funding from the Government of Canada and the Canadian Sugar Institute. Mr Au-Yeung reported receiving personal fees from Inquis Clinical Research outside the submitted work. Ms Lee reported receiving graduate scholarship from CIHR and the Banting & Best Diabetes Centre at the University of Toronto outside the submitted work. Dr Comelli reported being the Lawson Family Chair in Microbiome Nutrition Research at the Joannah and Brian Lawson Centre for Child Nutrition, University of Toronto, during the conduct of the study and receiving nonfinancial support from Lallemand Health Solutions, donation to research program from Lallemand Health Solutions, personal fees from Danone, sponsored research and collaboration agreement from Ocean Spray, and nonfinancial support from Ocean Spray outside the submitted work. Ms Ahmed reported receiving scholarship from the Toronto Diet, Digestive tract, and Disease Centre (3D) outside the submitted work. Dr Malik reported receiving personal fees from the City and County of San Francisco, Kaplan Fox & Kilsheimer LLP, and World Health Organization outside the submitted work and support from the Canada Research Chairs Program. Dr Hill reported receiving personal fees from General Mills and McCormick Science Institute. Dr Rahelić reported receiving personal fees from the International Sweeteners Association, Abbott, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Merck, MSD, Salvus, and Sanofi outside the submitted work. Dr Salas-Salvadó reported receiving personal fees from Instituto Danone Spain, nonfinancial support from Danone Institute International, personal fees as director of the World Forum for Nutrition Research and Dissemination from the International Nut and Dried Fruit Council Foundation, financial support to the institution from Fundación Eroski, and financial support to the institution from Danone outside the submitted work. Dr Kendall reported receiving grants and/or in-kind support from Advanced Food Materials Network, Agriculture and Agri-Food Canada, CIHR, Almond Board of California, Barilla, Canola Council of Canada, International Nut and Dried Fruit Council, Peanut Institute, Pulse Canada, Tate and Lyle Nutritional Research Fund at the University of Toronto, and Unilever; receiving nonfinancial support from General Mills, Kellogg, Loblaw Brands Limited, Oldways Preservation Trust, Quaker Oats (Pepsi-Co), Sun-Maid, White Wave Foods/Danone, International Pasta Organization, California Walnut Commission, Primo, Unico, International Carbohydrate Quality Consortium (ICQC), and Toronto Diet, Digestive tract, and Disease Centre (3D) outside the submitted work; receiving personal fees from McCormick Science Institute and Lantmannen; and being a member of the Diabetes and Nutrition Study Group (DNSG) Executive Board and Dietary Guidelines, a member of the expert committee of the DNSG Clinical Practice Guidelines for Nutrition Therapy, a member of the scientific advisory board of the McCormick Science Institute, a scientific advisor for the International Pasta Organization and Oldways Preservation Trust, a member of the ICQC, an executive board member of the DNSG, and being the director of the Toronto Diet, Digestive tract, and Disease Centre (3D) Knowledge Synthesis and Clinical Trials Foundation. Dr Sievenpiper reported receiving nonfinancial support from DNSG of the European Association for the Study of Diabetes (EASD), grants from CIHR through the Canada-wide Human Nutrition Trialists’ Network (NTN), PSI Graham Farquharson Knowledge Translation Fellowship, Diabetes Canada Clinician Scientist Award, CIHR Institute of Nutrition, Metabolism and Diabetes and the Canadian Nutrition Society (INMD/CNS) New Investigator Partnership Prize, and Banting & Best Diabetes Centre Sun Life Financial New Investigator Award during the conduct of the study; receiving grants from American Society for Nutrition, International Nut and Dried Fruit Council Foundation, National Honey Board (the US Department of Agriculture [USDA] honey checkoff program), Institute for the Advancement of Food and Nutrition Sciences (IAFNS; formerly ILSI North America), Pulse Canada, Quaker Oats Center of Excellence, United Soybean Board (the USDA soy checkoff program), Tate and Lyle Nutritional Research Fund at the University of Toronto, Glycemic Control and Cardiovascular Disease in Type 2 Diabetes Fund at the University of Toronto (a fund established by the Alberta Pulse Growers), and Nutrition Trialists Fund at the University of Toronto (a fund established by an inaugural donation from the Calorie Control Council); receiving personal fees from Dairy Farmers of Canada, FoodMinds LLC, International Sweeteners Association, Nestlé, Abbott, General Mills, American Society for Nutrition, INC Nutrition Research and Education Foundation, European Food Safety Authority, Nutrition Communications, International Food Information Council, Calorie Control Council, Comité Européen des Fabricants de Sucre, International Glutamate Technical Committee, Perkins Coie LLP, Tate and Lyle Nutritional Research Fund at the University of Toronto, Danone, Inquis Clinical Research, Soy Nutrition Institute, and European Fruit Juice Association outside the submitted work; serving on the clinical practice guidelines expert committees of Diabetes Canada, EASD, Canadian Cardiovascular Society, and Obesity Canada/Canadian Association of Bariatric Physicians and Surgeons; being an unpaid scientific advisor for the Food, Nutrition, and Safety Program and the Technical Committee on Carbohydrates of IAFNS; being a member of the ICQC, executive board member of the DNSG of the EASD, and director of the Toronto Diet, Digestive tract, and Disease Centre (3D) Knowledge Synthesis and Clinical Trials Foundation; his spouse is an employee of AB InBev. No other disclosures were reported.

Reference: For a summary of research on the “funding effect”—the observations that research sponsored by food companies almost invariably produces results favorable to the sponsor’s interests and that recipients of industry funding typically did not intend to be influenced and do not recognize the influence—see my book, Unsavory Truth: How Food Companies Skew the Science of What We Eat.

The American Journal of Public Health has just published a first look—ahead of its print in June—at my most recent article, Regulating the Food Industry: An Aspirational Agenda [if you are not a member of the American Public Health Association, this will be behind a paywall, alas].

It begins:

I end it with policy recommendations for:

• Dietary guidelines
• Mass media campaigns
• Taxes
• Warning labels
• Marketing restrictions
• Portion size restrictions
• Farm subsidies

Hence, aspirational.

And, I say,

While we are thinking in aspirational terms, let us not forget root causes. We must also demand policies that link agriculture to public health, keep corporate money out of politics, reduce corporate concentration, and require Wall Street evaluate corporations on the basis of social as well as fiscal responsibility.  In comparison with those challenges, takin gon the food industry should be easy.

Let’s get to work.

The Center for Food As Medicine and the Hunter College NYC Food Policy Center have released their first-ever academic narrative review and report of the food-as-medicine movement: Food as medicine review and report: how food and diet impact the treatment of disease.

As the press release puts it,

Food has always been a part of medical practice, going back millennia; however, as medical procedures and treatments became more sophisticated, modern societies began to disregard the role of food in the treatment of disease. Using food to treat disease was viewed as an uncivilized approach. This led to a gap between modern medicine and the use of food to treat disease, and a lack of acceptance of food-based interventions in modern treatment plans.

the report has five parts:

1. Background information on the history of using food to treat disease,
2. Modern challenges to widespread use and acceptance of food as medicine practices,
3. Current evidence about contemporary food as medicine practices (such as medically tailored meals, produce prescriptions, and functional foods),
4. Literature review of food as treatment for specific disease states, and
5. Recommendations to stakeholders (including policymakers, health care professionals, and academics) to contribute to a healthier, more equitable health care system.

Here are the report’s key findings (my paraphrase)

• Medical schools do not often require nutrition instruction.
• Social media makes food as medicine appear pseudoscientific.
• Websites confuse the public about role of food in disease prevention and treatment.
• Supplements cause confusion.
• Dietary Guidelines are influenced by food companies and do not always reflect current science.
• The FDA allows misleading marketing and health claims on packaged foods.
• Research funded by food companies misleads the public.
• Nutrition incentive programs (e.g., NYC’s Health Bucks) can help combat food and nutrition insecurity.
• The government should support food as medicine interventions such as medically tailored meals and produce prescription programs.

See Food Tank: 22 Global Medical Professionals Practicing Food as Medicine

Here are 22 medical professionals working to use food as a critical tool for treating, controlling, and healing from illness and maintaining health.

Along those lines, The Rockefeller Foundation Commits USD 105M to Making Healthy and Sustainable Foods More Accessible Around the World.

Today The Rockefeller Foundation launched its new Good Food Strategy, which will invest USD 105 million over three years to increase access to healthy and sustainable foods for 40 million underserved people around the globe. The program will support a shift in public and private spending toward foods that are nutritious, regenerate the environment, and create equitable economic opportunity for people at every step of the food supply chain.

And here is Dr. David Katz on this theme.

We could transition from the dual costs of medication to fix only partly all the parts of us food keeps breaking. Food as the medicine long ago invoked by Hippocrates could save lives, vitality, biodiversity — and a vast fortune into the bargain. The drumbeat tolls of necessity in the guise of diabetes, heart disease, obesity, cancer, dementia, climate change — and the acutely calamitous toll of COVID, as well. We may, whenever so inclined, invoke the will to invent the better way.

And let’s not forget the Food is Medicine Initiative from the Aspen Institute. which I wrote about previously here.

Comment: I prefer to think of food as food (a pleasure) and medicine as medicine (a pain) and not conflate them, but there s no question that eating healthfully is a good health habit along with being active, getting enough sleep, and not smoking, or overdoing on alcohol or recreational drugs.  If food-as-medicine initiatives help people eat more healthfully, it’s hard to argue with them, and I won’t.

Remember the fight over setting standards for reimbursible meals and a la carte products offered to kids in schools?

Michelle Obama’s Let’s Move! campaign set healthier standards for school foods.   Although you might think that serving healthy food to kids in schools would get lots of bipartisan support (who could possibly be against it), the standards got lots of pushback (too hard to implement, kids won’t like the food, too much food waste, too much nanny state).

Some aspects of the standards—less salt and more fruits, vegetables, and whole grains—survived, but “relaxed” during the Trump administration.  Recall USDA Secretary Sonny Perdue’s “Make School Meals Great Again”

That was then and this is now with pandemic-induced obesity rates rising among children, and supply chains making it hard for schools to feed kids in any way.

That has not stopped the Center for Science in the Public Interest, the American Heart Association, and the American Public Health Association from petitioning the USDA to put a limit on added sugars in school meals, to bring them into compliance with the Dietary Guidelines.  By law, the USDA must have school meals follow the guidelines, but this means rulemaking, and rulemaking takes time—lots of it.

USDA has now taken Step #1: transitional standards for milk, whole grains, and salt.

• Milk: Schools and child care providers serving participants ages six and older may offer flavored low-fat (1%) milk in addition to nonfat flavored milk and nonfat or low-fat unflavored milk;
• Whole Grains: At least 80% of the grains served in school lunch and breakfast each week must be whole grain-rich; and
• Sodium: The weekly sodium limit for school lunch and breakfast will remain at the current level in SY 2022-2023. For school lunch only, there will be a 10% decrease in the limit in SY 2023-2024. This aligns with the U.S Food and Drug Administration’s recently released guidance that establishes voluntary sodium reduction targets for processed, packaged, and prepared foods in the U.S.

The next steps:

• Stakeholder briefing today: 11:45am-12:30 pm ET.  Register to attend here. 
• USDA will start working on standards that bring the meals into full compliance with the Dietary Guidelines.

Call for Comments:  The USDA invites comments on these transitional standards and on the next steps.

• Federal eRulemaking Portal: Go to http://www.regulations.gov. Follow the online instructions for submitting comments.
• Mail: Send comments to Tina Namian, Chief, School Programs Branch, Policy and Program Development Division—4th Floor, Food and Nutrition Service, 1320 Braddock Place, Alexandria, VA 22314; telephone: 703-305-2590.

Resources

• Press release
• USDA’s website on school meals 
• Federal Register: Child Nutrition Programs: Transitional Standards for Milk, Whole Grains, and Sodium
• Webpage: Building Back Better with School Meals
• Fact Sheet: Child Nutrition Programs: Transitional Standards for Milk, Whole Grains, and Sodium
• Infographic: The Road Ahead: Building Back Better with School Meals 
• Infographic: Ten Reasons to Build Back Even Better with School Meals!

Last week was a busy time for high-level thinking about nutrition.

I’ll start with this from Chef José Andrés.

A message from @WCKitchen's @chefjoseandres on child #nutrition: Child nutrition programs play an essential role in ensuring food and nutrition security for the nation's youth. pic.twitter.com/kZ4i7JGYVK

— Bipartisan Policy Center (@BPC_Bipartisan) January 27, 2022

For the rest, I am indebted to Politico Morning Ag for gathering all this in one place.

Nutrition research: Last week, Sens. Cory Booker (D-N.J.) and John Cornyn (R-Texas) appeared at an event focused on “sustainable nutrition science” hosted by the Union of Concerned Scientists and Tufts University’s Friedman School of Nutrition Science and Policy.  The are sponsors of the Food and Nutrition Education in Schools Act.  I watched Booker’s remarkably inspiring talk and wish I could find a video or transcript of it.

Booker held hearings on nutrition last year.  I have a transcript of his opening remarks.  Here is an excerpt:

Now let’s be clear about something: the majority of our food system is controlled by a handful of big multinational companies. These big food companies carefully formulate and market nutrient-poor, addictive, ultra-processed foods — ultra-processed foods which now comprise 2/3 of the calories in children and teen diets in the U.S — and then these companies want us to believe that diet related diseases such as obesity and diabetes are somehow a moral failing, that they represent a lack of willpower or a failure to exercise enough.
That is a lie.
It is not a moral failing, it is a policy failure.

Food is Medicine: Food and Society at the Aspen Institute and Harvard’s Center for Health Law and Policy Innovation released a Food is Medicine Research Action Plan, a lengthy report detailing recommendations for how to bolster nutrition interventions in health care.

Food is the leading cause of poor health in the United States. Over half of American adults suffering from at least one chronic, diet-related disease. This health crisis has devastating effects for individuals and their and families and places an immense burden on our health system and economy. Though food is the culprit, it can also be the cure. Food and nutrition interventions can aid in prevention and management, and even reverse chronic disease. Introduced at large scale, proven interventions could save millions of lives and billions in healthcare costs each year.

Universal free school meals: The Bipartisan Policy Center released recommendations from its Food and Nutrition Security Task Force.   The report has recommendations for strengthening nutrition education and security in and out of school.  For example:

• Ensure all children, regardless of household income, have access to nutritious foods to allow them to learn and grow by providing school breakfast, school lunch, afterschool meals, and summer meals to all students at no cost.
• Make Summer EBT a permanent program and allow students to access EBT benefits during school breaks, holidays, closures, and other emergencies.
• Maintain and, if possible, strengthen nutrition standards for all programs to better align them with the latest Dietary Guidelines for Americans.

Pandemic EBT program: The Government Accountability Office recommended that USDA do a better job on nutrition assistance during emergencies and of implement the Pandemic-EBT program, which was supposed to give eligible school children charge cards for buying foods, but never worked well.