Search results: front-of-package

Last week, FDA Commissioner Scott Gottlieb spoke at the National Food Policy Conference in Washington, DC where he announced FDA’s Nutrition Innovation Strategy.

His speech, Reducing the Burden of Chronic Disease, specifies five areas that FDA intends to consider (meaning, at best, proposing suggestions for public comment and going through FDA’s interminable rulemaking process):

• Modernizing health claims
• Modernizing ingredient labels
• Modernizing standards of identity
• Implementing the Nutrition Facts Label and Menu Labeling
• Reducing sodium

The documents:

• Commissioner Speech: https://www.fda.gov/NewsEvents/Speeches/ucm603057.htm
• FDA Nutrition Innovation Strategy: https://www.fda.gov/Food/LabelingNutrition/ucm602651.htm

My immediate reactions: sounds good, but short on commitment.

I was impressed that Gottlieb focused on public health and prevention:

We can’t lose site of the public health basics – better diet, more exercise, and smoking prevention and cessation…The public health gains of such efforts would almost certainly dwarf any single medical innovation or intervention we could discover.

Yes!

I was particularly interested in two initiatives under consideration:

Front-of-package icon for “healthy”

This is to be based on a food-based definition that focuses on the healthful attributes of a food product—not, apparently, on its content of sugar, salt, or saturated fat.  Only healthful attributes?

This sounds like a highly pro-industry position, since research on front-of-package labeling is pretty clear that warning labels about unhealthful attributes (salt, sugar, saturated fat) are most effective in discouraging purchases of “ultraprocessed” foods.  The warning labels used in Chile, for example, are proving to be highly effective.

Gottlieb did not mention the the FDA-sponsored reports on front-of-package labeling performed by the Institute of Medicine early on in the Obama administration.  Those were serious attempts to develop an effective front-of-package labeling system that identified nutrients to be avoided.  The FDA seems to have forgotten about those reports.

Reduce sodium

This is the item that got the most attention.  Gottlieb said: “There remains no single more effective public health action related to nutrition than the reduction of sodium in the diet.”

OK, but if that’s true, how about ensuring that food companies gradually reduce sodium in their products, as was done in the UK.  No such luck.  Instead: “I’m committed to advancing the short‐term voluntary sodium targets” (my emphasis).

I suppose “voluntary” could work, but if sodium reduction isn’t across the board, companies will have little incentive to risk changing their formulas.

In short, Gottlieb’s words reflect modern public health thinking the good news) and it’s great that FDA is considering taking these actions (also good news).  Now, let’s see what the agency actually does.

I’ve been hearing a lot about Canadian food politics lately—lots is going on up there, apparently.

I.  Health Canada is working on guiding principles for healthy diets—dietary guidelines–and is conducting an online consultation for feedback.  The proposed principles:

• A variety of nutritious foods and beverages are the foundation for healthy eating.
• Processed or prepared foods and beverages high in sodium, sugars, or saturated fat undermine healthy eating.
• Knowledge and skills are needed to navigate the complex food environment and support healthy eating.
• Guidelines should consider determinants of health, cultural diversity, and the food environment.

I hope these get a lot of support.

II.  Sodium reduction in processed foods.  Health Canada has just announced the results of its study of how well voluntary sodium reduction is working.  The evaluation results are disappointing, and much more needs to be done.  Mandatory reduction, anyone?   

III.  Front-of-package labels.  Dr. Yoni Freedhoff writes that the Canadian food industry does not like what Health Canada is proposing to do about front-of-package labels.

Health organizations want something like this:

The food industry, no surprise, prefers this:

For more about this dispute, see this article from The Globe & Mail.

IV.  Farm-to-school grants. Yoni Freedhoff also writes that Farm-to-Cafeteria Canada is offering $10,000 grants to Canadian Schools to set up such programs.  Details here.

Every now and then I like to try to catch up with the arcane topic of trade agreements (see last week’s post).  Today, I’ll deal with the other one still in play, the Trans Pacific Partnership (TPP).  The U.S. Trade Representative’s Office states the administration’s position on the TPP.  Ballotpedia.org has a helpful summary of where we are on it.

For this one, should you be at all interested, the full text of the TPP is available online.  Like all trade agreements in which the U.S. participates, the TPP is about reducing and eliminating tariffs.  In principle, this is supposed to foster competition and create business opportunities and, as the Trade Representative’s Office says, “leveling the playing field for American workers & American businesses.”

The TPP was signed by the U.S. and the 11 other participating countries in February.  But for us to participate in it, Congress has to ratify the agreement.  It has not yet done so, not least because the TPP is caught up in election-year politics.

Contributing to slow approval is the weak endorsement of the International Trade Commission, which was required to report on the agreement’s economic effects.  Its conclusion: TPP would improve the economy by 2032 (the target year, apparently)—but by less than 1%.  The report gives examples of the increased percentage over baseline in 2032:

• Annual real income: $57.3 billion (0.23 %)
• Real GDP: $42.7 billion (0.15 %)
• Employment would be 0.07 %
• Exports: $27.2 billion (1.0 %)
• Imports: $48.9 billion (1.1 %)
• Agriculture and food output: $10.0 billion (0.5 %)

So TPP has an upside, but a small one.

What about the downside?

For starters, see the letter filed in January by 1500 groups opposing the agreement, and this BMJ paper, just out, about the TPP’s potential to block public health policies such as front-of-package food labels.

Public Citizen also has concerns.  These include, among others, that the TPP would:

• Make it easier for corporations to offshore American jobs.
• Push down domestic wages.
• Flood the U.S. with unsafe imported food.
• Permit big pharmaceutical corporations to keep lower cost generic drugs off the market.
• Tacitly permit human rights violations in partner countries (the agreement does not mention “human rights”).

The Institute for Agriculture and Trade Policy (IATP) has problems with the “fast-track” rules passed by Congress earlier this year.  Under these rules, Congress is only allowed to vote yes or no on the agreement.  It cannot amend it. The IATP says:

Provisions in the chapter on Sanitary and Phytosanitary Standards, for example, would reduce the food safety inspection capacity of food imports, and relegate controversies over GMOs to questions of market access rather than public or environmental health. The inclusion of investor state rules would give foreign corporations new ways to challenge a wide range of environmental and consumer laws around the world for alleged loss of anticipated profits. New rules on patent protections would limit farmers’ ability to save seeds. The agreement fails to acknowledge climate change while expanding an extractive mode of globalization. Like previous failed trade agreements, there are a lot of promises to help farmers that will likely result in the accelerated loss of family farms.

Should you want to do some advocacy on this issue, the IATP has produced a timeline for urging Congress to say no to the TPP, and a handy form for doing so.

Australia has government-sponsored front-of-package nutrient labeling—the Health Star system—that looks a lot like the U.S. grocery industry’s Facts Up Front, but is even more favorable to manufacturers of processed foods.

As I explained a few years ago, Facts Up Front was a successful scheme by the Grocery Manufacturers and Food Marketing Associations to head off the FDA’s attempts to put traffic-light signals on the front of processed food products (here’s more of the back story).

Like the U.S. system, the Australian system is voluntary.  Unlike it, Health Stars are prominent and convey the impression that the more starts, the better.

A year into the program, Australian newspapers are writing about how companies are “gaming” the system:

Deakin University professor of public health nutrition Mark Lawrence said the health star rating system was being exploited as a marketing tool by junk food manufacturers to make consumers think their food was healthy. He said the scheme for packaged food undermined the public health message that people should eat fresh, unprocessed food.

This article quotes a statement by Kellogg that sales of Nutrigrain cereal went up after the company reformulated the product to raise its rating from 2 to 4 stars.

But isn’t reformulation a good thing?  It could be but just because a processed food is “better-for-you,” does not necessarily make it a good choice.

Professor Mark Lawrence of Deakin and Christina Pollard of Curtin University write:

Its main design limitation is that it simplistically frames the cause of, and solution to, dietary imbalances in terms of nutrients. This is fundamentally at odds with the latest nutrition advice, which uses a food-based approach…So what the health star rating system ends up doing is encouraging marketing of unhealthy or discretionary foods, as healthy options.

Overall, they point out:

Part of the problem is that the campaign’s main message – “the more stars the better” – is misleading…The actual health message is to eat more of these [recommended healthy] foods; it’s not that we should try to eat food with more stars.

Good advice.

Cheers to the Pan American Health Organization/World Health Organization for releasing nutritional profile standards for making it easier for governments to distinguish fresh and minimally processed foods from ultraprocessed.  The idea here is to encourage populations to consume traditional diets (see press release).

Ultra-processed foods are defined as industrially formulated food products that contain substances extracted from foods (such as casein, milk whey, and protein isolates) or substances synthesized from food constituents (such as hydrogenated oils, modified starches, and flavors). Drawing on the best scientific evidence available, the model classifies processed and ultra-processed foods and beverages as having “excessive” amounts of sugar, salt and fat according to the following criteria:

• Excessive sugar if the amount of added sugars is 10% or more of total calories
• Excessive fat if the calories from all fats are 30% or more of total calories
• Excessive saturated fat if calories from saturated fats are 10% or more of total calories
• Excessive trans fat if calories from trans fats are 1% or more of total calories
• Excessive sodium if the ratio of sodium (in milligrams) to calories (kcal) is 1:1 or higher.

PAHO’s point in setting these standards is to encourage governments to:

• Restrict the marketing of unhealthy food and beverages to children (see PAHO Plan of Action for the Prevention of Obesity in Children and Adolescents)
• Regulate school food environments (feeding programs and food and beverages sold in schools)
• Use front-of-package (FOP) warning labels
• Define taxation policies to limit consumption of unhealthy food
• Assess agricultural subsidies
• Identify foods to be provided by social programs to vulnerable groups.

Yes!

Alas, not everyone is as enthusiastic as I am about the profiles.  The International Council of Beverages Associations released this statement:

We agree that obesity is a global health challenge, and ICBA and its members welcome the opportunity to work with PAHO and other stakeholders to pursue effective and practical solutions. There are some areas, however, where we believe that use of PAHO’s Nutrient Profile Model may not provide helpful guidance to consumers.  There is not current scientific consensus in all areas that the Nutrient Profile Model addresses. It will not be useful if families find that nearly 80% of the foods and beverages in their grocery carts are unacceptable. Such a radical message is not likely to be followed by most individuals…we encourage governments and scientific bodies to offer food and dietary recommendations and national policies that are based on the totality of scientific evidence and provide realistic, positive encouragement to consumers to have a real impact promoting healthful diets and preventing obesity and non-communicable diseases.

The PAHO profiles may need tweaking, but they are a great first step.  Now let’s see how they get implemented.

The first report is from the UK.   Fat Chance? Exploring the Evidence on Who Becomes Obese is a curious example of what happens when a sugar company (AB Sugar) partners with a health organization (2020 Health) to produce a policy document.

The report examines the role of age, gender, socioeconomic factors, the built environment, mental health and disability, sleep, bullying and child abuse, smoking, ethnicity, and religion as factors in obesity—everything except diet and activity levels.

The press release for the report gives key findings, among them:

• Obesity rates are rising rapidly among the poor as well as other groups who experience social instability.
• Uncertainty seems to be a significant factor for weight gain.
• Fast food outlets near working environments have a significant impact on the BMI of men; the lack of green space has an impact on obesity rates particularly among girls.
• Half of all people suffering with psychosis are obese.
• Parental obesity, especially in mothers, is a far more predictive factor in childhood obesity than is ethnicity.

Its authors write:

What is particularly highlighted in recent research, though rarely explicitly stated, is that obesity rates seem to be deeply influenced by social change (not just influences within static social categories). The studies we have compiled for this review show a subtle trend that has become increasingly evident over the last decade. It is highlighted in economic mobility, rising rates of mental illness, technological habits and engagements, and rapidly shifting urban ground. Argued here, broadly speaking, is that many of these categories strongly hint to a meta-structure that remains profoundly under-researched and largely ignored. This is the structure of uncertainty, a type of habitus that influences the terms of emotional engagement between an individual and their daily life. Insidiously, it undermines health seeking behaviour by making daily decision processes cognitively intolerable and emotionally taxing.

They conclude:

…approaches to obesity that recognise and incorporate complexity might impact a host of rising health problems that affect communities across Britain. The same interventions that encourage healthy BMI may improve energy levels through metabolic process and sleeping habits, while reducing risk of mental health problems, diabetes and a range of other comorbidities not discussed in this report.

But they don’t say what those interventions might be.

Could they possibly have something to do with removing sugary drinks and foods from local environments?

For doing just that, the World Cancer Research Fund International has produced Curbing Global Sugar Consumption: Effective Food Policy Actions to Help Promote Healthy Diets & Tackle Obesity.

Examples of actions which have had these effects include school nutrition standards in Queensland, Australia; a vending machine ban in France; a front-of-package symbol that led to product reformulation in the Netherlands; soda taxes in France and Mexico; a programme targeting retail environments in New York City, USA; a programme promoting increased water consumption in schools in Hungary; school fruit and vegetable programmes in Netherlands and Norway; a healthy marketing campaign in Los Angeles County, USA and a comprehensive nutrition and health programme in France.

The first report asks us to solve problems of poverty, instability, and mental health before taking action to prevent obesity, even when actions are known to be effective.  The second calls for such actions now.

Could AB Sugar’s sponsorship possibly have something to do with this difference?

Here is the online version of my commentary in New Scientist, March 14, 2015:24-25.

I submitted an illustration with it, which the editors did not use.  It’s from the Ontario Medical Association.

Cigarettes get plain packets – will junk food be next?

The tobacco industry is fighting moves to sell cigarettes in plain packs by claiming food manufacturers will be hit next. Will they?

ANTI-SMOKING advocates will be delighted. MPs have today voted in favour of introducing uniform packaging for cigarettes in the UK. That plain wrappers will undoubtedly further reduce smoking, especially among young people, is best confirmed by the tobacco industry’s vast opposition to this government measure and positive evidence from Australia, the first country to adopt it.

Along with lobbying and appeals to the World Trade Organization, the tobacco industry, when under attack, inevitably wheels out well-worn arguments about the nanny state, personal freedom, lack of scientific substantiation, and losses in jobs and tax revenues.

So to perk up its tired and thoroughly discredited campaign, the tobacco folks have added a new argument. Requiring plain wrappers on cigarettes, they say, is a slippery slope: next will be alcohol, sugary drinks and fast food. This argument immediately raises questions. Is it serious or just a red herring? Should the public health community lobby for plain wrappers to promote healthier food choices, or just dismiss it as another tobacco industry scare tactic?

Let me state from the outset that foods cannot be subject to the same level of regulatory intervention as cigarettes. The public health objective for tobacco is to end its use. So for cigarettes the rationale for plain wrappers is well established. Company logos, attractive images, descriptive statements, package colours and key words all promote purchases. Plain wrappers discourage buying, especially along with other measures such as bans on advertising, smoke-free policies, taxes and health warnings.

Australia’s pioneering law specified precise details of pack design, warning images and statements. The result: cigarette brands all look much alike. Most reports say plain packaging boosts negative perceptions of cigarettes among smokers and increases their desire to quit. Australia expects plain packaging to further reduce its smoking rate, which, at 12.8 per cent, is already among the world’s lowest. Along with the UK, New Zealand and Ireland are well on the way to adding plain packaging to their anti-smoking arsenal. More nations are considering it.

Which is all bad news for the tobacco industry. So it ramps up the slippery slope argument, hoping the food industry will support its fight against plain wrappers. It cites examples such as the regulation of infant formula in South Africa, where pictures of babies on labels are forbidden; that’s a big problem for the Gerber food brand – Gerber’s company logo is a smiling baby.

But those peddling the slippery slope idea ignore the fact that the health message for tobacco is simple: stop smoking. But beyond tobacco, it is more complex. For alcohol it is a little more nuanced: drink moderately, if at all. For food it is much more nuanced. Food is not optional; we must eat to live. Nutritional quality varies widely. Foods are spread across a spectrum from unhealthy to healthy, from soft drinks (no nutrients) to carrots or fish (many nutrients). Most fall somewhere in between. What’s more, an occasional soft drink is fine; daily guzzling is not. So the advice is to choose the healthy and avoid or eat less junk, both in the context of calorie intake and expenditure.

Is there any evidence that plain packaging for unhealthy foods would reduce demand? Research has focused on marketing’s effect on children’s food preferences, demands and consumption. Brands and packages sell foods and drinks, and even very young children recognise and desire popular brands. When researchers compare the responses of children to the same foods wrapped in plain paper or in wrappers with company logos, bright colours or cartoon characters, kids invariably prefer the more exciting packaging.

But the problem is deciding which foods and beverages might call for plain wrappers. For anything but soft drinks and confectionery, the decisions look too vexing. Rather than having to deal with such difficulties, health advocates prefer to focus on interventions that are easier to justify – scientifically and politically.

We know that some regulations and market interventions –analogous to, if not the same as those aimed at smoking cessation – are essential for reducing the damage from harmful products. If not plain packaging, then what? Studies suggest small benefits from a long list of interventions such as taxes, caps on portion size, front-of-package traffic-light labels, nutrition standards for school meals, advertising restrictions, and elimination of toys from fast food meals and cartoons from packaging. Rather than dealing with the impossible politics of plain wrappers on foods, health advocates increasingly favour warning labels.

These first appeared on cigarette packs in the 1960s and have been considered for food products since the early 1990s. Heart disease researchers suggested that foods high in calories and fat should display labels such as: “The fat content of this food may contribute to heart disease.” More recently, health advocates in California and New York proposed warning labels on sugary drinks. The Ontario Medical Association takes a similar view: “To stop the obesity crisis, governments must apply the lessons learned from successful anti-tobacco campaigns.” It has mocked up examples of warnings on foods.

Although no warning label law has passed so far, such messages are the logical next step in promoting healthy food choices, in the same way that plain wrappers are the next logical step for all cigarette packages. Health advocates should recognise the slippery slope argument for the typical tobacco ploy that it is.

The 2015 Dietary Guidelines Advisory Committee (DGAC) issued its more than 500-page report yesterday.

Before I say anything about it, please note that this report informs, but does not constitute, the Dietary Guidelines. The agencies—USDA and HHS—write the actual Guidelines and are not expected to do so until the end of this year.

Here are what I see as the highlights (these are direct quotes)

• A healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meat; and low in sugar-sweetened foods and drinks and refined grains.
• A diet higher in plant-based foods…and lower in calories and animal-based foods is more health promoting and is associated with less environmental impact than is the current U.S. diet.
• It will take concerted, bold actions…to achieve and maintain the healthy diet patterns, and the levels of physical activity needed to promote the health of the U.S. population. These actions will require a paradigm shift to an environment in which population health is a national priority and where individuals and organizations, private business, and communities work together to achieve a population-wide “culture of health” in which healthy lifestyle choices are easy, accessible, affordable, and normative.

Some facts and statements from the report (not direct quotes).

• Half the energy intake in U.S. diets comes from a combination of burgers and sandwiches (~14%), desserts and sweet snacks (8.5%), sugary beverages (6.5%), mixed dished made with rice, pasta, and other grains (5.5%, savory snacks (~5%), pizza (4.3%), and meat, poultry and seafood mixed dishes (~4%).
• Nearly half of total sugar intake comes from beverages other than milk and 100% fruit juice

The report comments on issues under current debate.

• Saturated fat: “replacing SFA with unsaturated fats…significantly reduces total and LDL cholesterol…Strong and consistent evidence…shows that replacing SFA [saturated fatty acids] with PUFA [polyunsaturated fatty acids] reduces the risk of CVD [cardiovascular] events and coronary mortality…For every 1 percent of energy intake from SFA replaced with PUFA, incidence of CHD [coronary heart disease] is reduced by 2 to 3 percent. However, reducing total fat (replacing total fat with overall carbohydrates) does not lower CVD risk.”
• Sugars: “Strong and consistent evidence shows that intake of added sugars from food and/or sugar sweetened beverages are associated with excess body weight in children and adults…Strong evidence shows that higher consumption of added sugars, especially sugar-sweetened beverages, increases the risk of type 2 diabetes among adults and this relationship is not fully explained by body weight.[Theae findings are] compatible with a recommendation to keep added sugars intake below 10 percent of total energy intake.”
• Food labels: “Consumers would benefit from a standardized, easily understood front-of-package (FOP) label on all food and beverage products to give clear guidance about a food’s healthfulness.” [This refers to the recommendations of the Institute of Medicine that I’ve written about previously; they disappeared without a trace.]
• Soda taxes: “Economic and pricing approaches, using incentives and disincentives should be explored to promote the purchase of healthier foods and beverages. For example, higher sugar-sweetened beverage taxes may encourage consumers to reduce sugar-sweetened beverage consumption.”
• SNAP: “Policy changes within the federal Supplemental Nutrition Assistance Program (SNAP), similar to policies in place for the WIC program, should be considered to encourage purchase of healthier options, including foods and beverages low in added sugars. Pilot studies using incentives and restrictions should be tested and evaluated.”

The DGAC recommends (these are direct quotes but not necessarily complete):

• Establish local, state, and Federal policies to make healthy foods accessible and affordable and to limit access to high-calorie, nutrient-poor foods and sugar-sweetened beverages in public buildings and facilities.
• Set nutrition standards for foods and beverages offered in public places.
• Improve retail food environments and make healthy foods accessible and affordable in underserved neighborhoods and communities.
• Implement the comprehensive school meal guidelines (National School Lunch Program) from the USDA that increase intakes of vegetables (without added salt), fruits (without added sugars), and whole grains.
• Limit marketing unhealthy foods to children.
• Make drinking water freely available to students throughout the day.
• Ensure competitive foods meet the national nutrition standards (e.g., Dietary Guidelines for Americans).
• Eliminate sugar-sweetened beverages [from schools].
• Nutrition Facts label should include added sugars (in grams and teaspoons).

And for all federal nutrition programs, the DGAC recommends:

• Align program standards with the Dietary Guidelines for Americans so as to achieve the 2015 DGAC recommendations and promote a “culture of health.”

Congratulations to this committee for its courageous recommendations.

Why courageous?  See my previous comments on the objections to such advice.

The next step: public comment:

The public is encouraged to view the independent advisory group’s report and provide written comments at www.DietaryGuidelines.gov for a period of 45 days after publication in the Federal Register. The public will also have an opportunity to offer oral comments at a public meeting in Bethesda, Maryland, on March 24, 2015. Those interested in providing oral comments at the March 24, 2015, public meeting can register at www.DietaryGuidelines.gov. Capacity is limited, so participants will be accepted on a first-come, first-served basis.

Here’s your chance to support this committee’s excellent ideas and demonstrate public approval for diets that promote the health of people and the planet.

Note: the reactions to the report are pouring in and I will deal with them next week.  Enjoy the weekend!