Currently browsing posts about: IOM (Institute of Medicine)

I’ve been asked to comment on the HBO series, Weight of the Nation and everything that comes with it: the accompanying book, the auxiliary videos, the distribution plan to schools and other institutions, and the Institute of Medicine’s report, Accelerating Progress in Obesity Prevention.

Because I wanted to look at all of it before commenting, plenty of others have beaten me to it, among them FoodandTechConnect’s infographic summary,   Kerry Trueman on AlterNet and Michele Simon on Grist.

I don’t have HBO but got sent the press kit, the Weight of the Nation book, the disks, and the IOM report.  I watched all four hours of the HBO series, plus the “Rethinkers” video of kids working on a school lunch project in New Orleans (air dates), plus the IOM and HBO books, plus the website.

Overall, Weight of the Nation makes the size, scope, causes, and consequences of obesity alarmingly clear.

The talking heads—many of them my friends, colleagues, and former students—all had plenty to say about what obesity means on a day-to-day basis for individuals and its personal and economic cost to society.

The programs ought to convince anyone that obesity is a big problem and that something big needs to be done to prevent it.

But doing something big, the series makes clear, will be very difficult.

This may be realistic, but it is not inspiring.

We need inspiration.   That’s why I wish the programs had focused as much on social responsibility as they did on personal responsibility.

I wanted to see the programs take leadership on how government can help citizens reduce the social, economic, and business drivers of obesity.

That kind of leadership exists.  To see it in action, watch the video of the New Orleans school “rethinkers.”  Those kids wanted to improve their school lunches.  They got busy, dealt with setbacks, and learned how to make the system work for them.  They “spoke truth to power” and “held feet to the fire.”

Why aren’t adults doing the same?   Politics, the IOM report explains.  Although one of its principal recommendations is critical—Create food and beverage environments that ensure that healthy food and beverage options are the routine, easy choice—its recommendations speak some truth to power but do little to hold feet to the fire.

The IOM report explains the political realities:

The committee’s vision takes into account the need for strategies to be realistic, as well as consistent with fundamental values and principles.  At the same time, however, having a diversity of values and priorities among them is itself a principle of U.S. society.

Potentially competing values and principles must be reconciled, for example, in considering protections needed for individuals versus the community at large or for the public versus the private sector.

Vigilance regarding unintended adverse effects of changes undertaken to address the obesity epidemic is also needed.

“Americans,” the report says, are accustomed to the current obesogenic environment, one “driven by powerful economic and social forces that cannot easily be redirected.”

It may not be easy to redirect such forces, but shouldn’t we be trying?

In 1968 the CBS documentary Hunger in America galvanized the nation to take action to reduce poverty and malnutrition.

The HBO series was equally shocking but I wish it had focused more on how we—as a society—could mobilize public distress about the poor quality of food in schools and the relentless and misleading marketing of sodas and junk foods that it so well documented.

But dealing with the need to address the social and economic forces that promote obesity would, I’m told, be considered lobbying, which the private-public sponsors of the series are not permitted to do.

Mobilizing public support for health is considered lobbying.  Food industry marketing is not.

FoodNavigator-USA.com columnist Caroline Scott-Thomas wrote about the HBO series:

As an industry journalist, I’ll be among the first to admit that industry is stuck in a very hard position here: On the one hand, it wants to be seen to be doing the right things – but on the other, what people say they want to eat, and what they actually do eat are often very different, and after all, food companies are in the business of making money.

But honestly, could industry do more to make healthy choices routine, easy choices? I think so.

Yes it could, but won’t unless forced to.

Without leadership, we are stuck doing what the food industry needs, not what the public needs.

Weight of the Nation did an impressive and compelling job of defining the problem and its causes and consequences.  I wish it—and the IOM—could have risen above the politics and pressed harder for strategies that might help people make healthier choices.

But—if the HBO programs really do help mobilize viewers to become a political force for obesity prevention, they will have been well worth the effort that went into making and watching them.

Ordinarily I find government plans of this type to be soporific but this one is especially well written and well thought out (with some caveats).

The report is a statement of FDA commitment to what it is going to do in the next four years in food areas that affect people and animals.  It includes many promises, among them this one of particular interest: 

Program Goal 4: Provide accurate and useful information so consumers can choose a healthier diet and reduce the risk of chronic disease and obesity

Objective 1. Update the Nutrition Facts label.

• Publish proposed rules updating the nutrition facts label and serving sizes [OK, but by when?].
• Publish final rules updating the nutrition facts label and serving sizes [Ditto].

Objective 2.  Implement menu and vending machine labeling regulations.

• Publish final menu and vending machine labeling regulations [OK, but by when?].
• Collaborate with states, localities and other partners to ensure high rates of compliance.

Objective 3.  Improve consumer access to and use of nutrition information.

• Explore front‐of‐pack nutrition labeling opportunities [Explore?  See comment below].
• Collaborate with public/private sector parties on nutrition education [Collaborate?  See comment below].
• Implement updated standards for the labeling of pet food including nutrition and ingredient information [How about a Pet Facts label for pet foods that someone might actually be able to understand?].
• Implement standards for animal feed ingredients.
• Publish final rule defining and permitting use of the term “gluten free” in the labeling of foods.

Goal-setting processes usually include dates by which the objectives are to be completed.  These do not, which suggests that the FDA can continue to delay action until 2016. 

I also do not understand what is meant by “Explore front‐of‐pack nutrition labeling opportunities.”  Explore?  The FDA has already sponsored two Institute of Medicine reports on front-of-pack labeling.  Does this mean the agency is ignoring them and intends further research?

And “Collaborate with public/private sector parties on nutrition education?”  What does the FDA have in mind for the content of such education?  You can bet that no collaborative campaign can focus on “don’t drink your calories.” 

FDA needs to deliver on these items, and sooner rather than later.  This year?  I’m not counting on it.

 

Earlier this week I received a 3-page, single-spaced letter—plus 4 pages of charts and figures–from Andrew Briscoe III, the President and CEO of the Sugar Association.

I opened it with some trepidation because the last letter I got from the Sugar Association threatened to sue me (to read it, click here and scroll down to the Controversies section).

Whew.  This one merely expresses general concerns about:

the misinformation reported on added sugars consumption and the overstatement of added sugars contribution to increased caloric intakes.  Americans do not consume 25 percent of their calories from added sugars. We write to provide you with accurate data….

I don’t think I ever said that the average American consumes 25% of calories from sugars (although some surely do) but I have complained that the Institute of Medicine’s “safe” level of intake of sugars is 25% of calories.  This is higher than public health recommendations to restrict sugars to 10% of calories or less.  It is meant as an upper limit, but is often interpreted as a license to eat this much.

One quarter of daily calories from sugars is too high for something that provides no additional nutritional value.

The letter concludes:

The Sugar Association is committed to ensuring that all advice consumers receive regarding sugar intake is based on the best available scientific evidence and related data.  The American consumer will be better served by dietary advice that is science-based, practical and accurate, no matter the issue.

Can’t argue with that.  But as with all matters concerning nutrition, the issue is which science you choose to cite and how you interpret it.

Mr. Briscoe uses the term sugars, plural, because sucrose, HFCS, syrups, honey, and other such things are all sugars.

How much do Americans actually consume?  Mr. Briscoe was kind enough to provide USDA tables that address this question.  These describe the availability of sugars in the food supply, not necessarily what people are actually eating.

My interpretation of the tables is that they say:

• Sugars comprise 17% of total calorie availability.
• Adjusted for waste, the availability of sugars is about 27.5 teaspoons per day per capita (meaning everyone:  men, women, and tiny babies).
• Translating this into calories: 27.5 teaspoons x 4 grams per teaspoon x 4 calories per gram = 440 calories per day per capita.
• On a 2000 calorie diet, that’s 22% of total energy intake, although it will be lower for people who take in more calories.

The CDC has just released a summary of intake of added sugars among children and adolescents, in calories per day.

At 4 calories a gram, 400 calories is 100 grams or 3.5 ounces.  Can these calories contribute to weight gain or other health problems?

You bet.

As Mark Bittman put it in his New York Times column this week,

Let me state the obvious: there is no nutritional need for foods with added sugar.

All of this is part of the bigger question: How do we regulate the consumption of dangerous foods? As a nation, we’ve accepted the need to limit the marketing and availability of tobacco and alcohol. The first is dangerous in any quantity, and the second becomes dangerous when overconsumed.

And added sweeteners, experts increasingly argue, have more in common with these substances than with fruit.

No wonder the Sugar Association uses its own interpretation of the science to suggest that current levels of intake are benign and that no level of intake poses a risk.  Mr. Briscoe’s letter says:

No authoritative scientific body that has conducted a major systematic review of the scientific literature has a found a public health need to set an Upper Level (UL) for total or added sugars intake.  Every comprehensive review of the scientific literature concludes that, with the exception of dental caries, no causal link can be established between the intake of sugars and lifestyle diseases, including obesity.

I’m glad he mentioned dental caries.  Karen Sokal, a physician in California, has been tracking the onset of tooth decay among children in Latin America who are now consuming sodas and candy on a daily basis.  She writes:

Mark Bittman’s excellent editorial, “Regulating our Sugar Habit,” (Feb 27) concludes that eating too much sugar has become “the biggest public health challenge facing the developed world.”  Indeed, it poses a big health challenge for the entire world, especially developing countries.

In my 30 years of global health work, I have seen an explosion in the marketing and consumption of non-nutritious foods and beverages followed by a dramatic rise in childhood tooth decay and obesity. Quarterly business reports praise the food and beverage industry’s increased profits based on increased sales in “emerging markets.” The NY Times article on Kellogg’s purchase of Pringles (Feb 12) stated, “The snack business is growing faster and has greater appeal internationally,” which analysts noted “appears somewhat out of sync with the trends toward better-for-you snacking.”

Governmental regulations to ensure the production and marketing of healthful food and beverages must be applied worldwide and protect the health of the world’s most vulnerable populations.

Indeed, they must.  The Sugar Association has much to answer for in its opposition to public health recommendations to eat less sugar.

FoodNavigator.com reports that the FDA is now supporting the front-of-packaging labeling scheme introduced by the Grocery Manufacturers Association (GMA) and the Food Marketing Institute (FMI).

In previous posts, I wrote that I consider the GMA-FMI Facts-Up-Front scheme to be an end run around the FDA’s front-of-package labeling initiatives, still wending their way through the glacial rulemaking processes.

Why an end run?  GMA and FMI announced their scheme minutes before the Institute of Medicine released its long awaited recommendations for front-of-pack nutrition labeling.

I interpreted this action as evidence that the food industry was trying to head off anything resembling traffic light labels that might discourage people from buying products.

The industry’s position is to support positives, not negatives.  Facts Up Front includes both, thereby confusing the message.  In contrast, the IOM’s proposal focuses only on nutrients to avoid.

According to FoodNavigator,

FDA’s deputy commissioner for foods, Michael Taylor, said that the four standardized basic icons required by industry’s Facts Up Front program – for calories, saturated fat, sodium and total sugars – “would alleviate some of FDA’s concern regarding the potential for product labeling to mislead consumers by presenting only “good news” about nutrient content on the front of the package, which is the concern that the regulations governing nutrient content claims were intended to address.”

Taylor told GMA and FMI executives in the December 13 letter that if the icons were adopted by industry in a uniform manner, they “may contribute to FDA’s public health goals”.

As FoodNavigator further explains

The FDA letter stops short of endorsing the Facts Up Front program (initially called Nutrition Keys), saying that the agency intends to use enforcement discretion for some elements of the scheme, but not if companies use it “in a manner that misleads consumers”.

The use of enforcement discretion means it would be more lenient with food companies about their adherence to other regulations, as long as the Facts Up Front icons are used in a specific way.

Apparently, the FDA no longer considers the demonstrably confusing GMA-FMI labels to be worth opposing.

Could election-year politics have anything to do with the FDA’s leniency on an issue it vowed to address when the Obama administration took office?

Michelle Obama and Tom Vilsack announced new nutrition standards for school meals yesterday, to what seems to be near-universal applause (the potato growers are still miffed, according to the New York Times).

The new standards are best understood in comparison to current standards (see chart).  They call for:

• More fruits and vegetables
• A greater range of vegetables
• A requirement for whole grains
• All milk to be 1% or less
• Only non-fat milk to be permitted to be flavored

This may not sound like much.  But given what it has taken USDA to get to this point, the new standards must be seen as a major step forward.

See, for example, the comparison of an old and new weekly menu (this has not changed since USDA’s original proposal in January last year).

The new one looks so much better.   Now it’s up to schools to make the new standards work, make the foods taste yummy, and get kids to be willing to try new foods.

To review the history: This all started when the USDA asked the Institute of Medicine to design nutrition standards that would:

• Increase the amount and variety of fruits, vegetables, and whole grains
• Set a minimum and maximum level of calories
• Focus more on reducing saturated fat and sodium

The new standards come pretty close to what the IOM recommended (see the earlier chart), with some now-famous exceptions.  The IOM proposed limits on starchy vegetables.  USDA then proposed to limit starchy vegetables to two servings a week.  It also set a minimum for the amount of tomato sauce on pizza that could count toward vegetable servings.

Under pressure from potato growers and suppliers of school pizza, Congress weighed in and overruled the USDA on both counts.

The result: pizza now counts as a vegetable.

To give some idea of the extent of lobbying on all sides of this issue, USDA’s January proposal elicited 132,000 public comments (these are someplace at www.regulations.gov and are addressed in the Federal Register notice).

I asked in a previous post whether this kind of congressional micromanagement made sense (absolutely not, in my view).  I also wrote previously about the intense lobbying efforts to make sure these standards would never be released.

Despite congressional and industry opposition, the standards are out.

Applause is very much in order for Mrs. Obama’s leadership on this issue.

Good work.  Now let’s get busy on the next challenges:

• Set nutrition standards for competitive foods in schools—those sold outside of the lunch program as snacks and meal replacements.
• Teach kids where food comes from
• Teach kids to cook

For the record:

The initial press release: It is headlined “First Lady to Announce New Nutrition Standards for Meals Served in America’s Schools: Public-Private Partnership Aims to Connect More Kids to Nutrition Programs.”  I’m not sure where the Public-Private Partnership comes into this.

USDA’s actual press announcement provides links to the Nutrition Standards home page and other relevant documents.

Additions: Dana Woldrow sends this link to shed some light on the curious business of private-public partnerships.  Here’s one where Goya foods is giving out teaching materials in schools.

My monthly (first Sunday) Food Matters column in the San Francisco Chronicle appears today.  This time, it’s about the fuss over front-of-package labels.

Q: I’m completely confused by all of the little check marks and squares on food packages telling me they are healthy. Do they mean anything?

A: The Food and Drug Administration feels your pain. It sponsored two studies by the Institute of Medicine to rationalize front-of-package nutrition ranking systems.

The institute released its second report last month; it advises the FDA to allow front-of-package labels to state nothing but calories and nutrients to avoid: saturated and trans fat, sodium and sugar (go to sfg.ly/sUptQR).

The institute’s proposal gives products one point for not containing too much of each of these nutrients. It suggests displaying the points like Energy Stars on home appliances with zero to three stars, depending on how well the product meets nutritional criteria.

This is a simple system, instantly understandable. I think it is courageous. The institute’s proposal benefits consumers. It does not help companies sell junk food.

Selling or educating?

No food company wants to display nutrients to avoid. For the food industry, the entire point of front-of-package labels is to market products as healthy or “better for you” no matter what they contain. Front-of-package labels are a tool for selling, not buying. They make highly processed foods look healthier.

Will companies accept a voluntary labeling scheme that makes foods seem worse? Doubtful.

Nutrition ranking symbols began appearing on food packages in the mid-1990s, when the American Heart Association got companies to pay for displaying its HeartCheck.

Food companies then established their own systems for identifying “better-for-you” products. PepsiCo, for example, developed its own nutritional standards and proclaimed hundreds of its snacks and drinks as “Smart Choices Made Easy.”

In an attempt to bring order to this chaos, food companies banded together to develop an industry-wide system. Unfortunately, their joint Smart Choices checkmark appeared first on Froot Loops and other sugary cereals. The ensuing ridicule and legal challenges forced the program to be withdrawn.

At that point, the FDA, backed by Congress and other federal agencies, asked the Institute of Medicine for help.

The institute released its first report last year. It revealed inconsistencies in the 20 existing ranking schemes from private agencies, food companies and supermarket chains. Toasted oat cereal, for example, earned two stars in one system, a score of 84 (on a scale of 100) in another, and a score of 37 in a third.

The report said labels should display only calories and to-be-avoided nutrients. Labels should not display “good-for-you” nutrients – protein, fiber, and certain vitamins and minerals – because these would only confuse consumers and encourage companies to unnecessarily add nutrients to products for marketing purposes.

Although the FDA was waiting for the second institute report before taking action, the food industry wasted no time. The Grocery Manufacturers Association and Food Marketing Institute introduced their own system.

Complicated approach

They got their members to agree to a more complicated system, “Nutrition Keys,” based on nutrients to avoid but also including up to two “good-for-you” nutrients.

Food companies immediately put Nutrition Keys’ symbols – well established to be difficult for consumers to understand – on package labels where you can see them today. Now called Facts Up Front, the symbols are backed by a $50 million “public education” campaign.

The reasons for the industry’s preemptive strike are obvious. The second Institute of Medicine report gives examples of products that qualify for stars – toasted oat cereal, oatmeal, orange juice, peanut butter and canned tomatoes, among them.

It also lists the kinds of products that would not qualify for stars, including animal crackers, breakfast bars, sweetened yogurt and chocolate milk.

So the industry argues that consumers “want simple and easy to use information and should be trusted to make decisions for themselves and their families … rather than have government tell them what they should and should not eat.”

But why, you ask, does any of this matter? I view front-of-package labels as a test of the FDA’s authority to regulate and set limits on any kind of food industry behavior. If the FDA cannot insist that food labels help the public choose healthier foods, it means the public has little recourse against any kind of corporate power.

Perhaps Facts Up Front will arouse the interest of attorneys general – just as the Smart Choices program did.

In the meantime, the industry’s pre-emption of FDA labeling initiatives is evidence that voluntary schemes don’t work. Labeling rules need to be mandatory.

Let’s hope the FDA takes the Institute of Medicine’s advice and starts rule-making right away.

Marion Nestle is the author of “Food Politics” and “What to Eat,” among other books, and is a professor in the nutrition, food studies and public health department at New York University. E-mail comments to food@sfchronicle.com.

The Institute of Medicine (IOM) just released its second report on front-of-package (FOP) labeling.  It tells FDA to allow only four items in any front-of-package evaluation scheme:

• Calories
• Saturated and trans fat
• Sodium
• Sugars

To display this, the IOM committee recommends a point system based on levels of saturated and trans fats, sodium, and sugars for evaluating food products.  The points are to be indicated with check marks or stars.  Here is an example of how stars might be used to indicate products that qualify for zero, one, two, or three points.

I’m guessing that anything this clear and understandable will elicit storms of protest.

Recall that food companies have been setting their own nutrition criteria for evaluating their very own products and identifying the “better-for-you” or “more nutritious” products with special front-of-package logos.  By company standards, many of their products qualify for the logos.

To deal with the multiplicity and absurdity of such schemes, the FDA asked the IOM to take a look at the various FOP logos that were out there and recommend how to clean up the mess.  The first IOM report said the FDA should allow FOP labels to state only calories, saturated and trans fat, and sodium, but not sugars (this last was a mistake, I thought).

But—while the FDA was waiting for the IOM to produce its next report, the Grocery Manufacturers Association (GMA) and Food Marketing Institute (FMI) jumped the gun.  Their preemptive logo included “positive” nutrients such as vitamins and fiber along with the “negatives.”  This scheme is already in use on food packages.

The IOM committee was faced with an impossibly difficult task: to come up with a front-of-package scheme that would reduce the overall nutritional quality of processed foods to the sum of a few key factors.

Given strong industry marketing pressures to retain front-of-package labels—and the lack of an option to remove them altogether—the committee did the best it could with an inherently bad idea.

Why a bad idea?  FOP labels are a tool for selling, not buying.  They make highly processed foods look healthier, whether or not they really are.

And whether slightly better-for-you processed foods assessed by this method will help anyone to make better food choices and to be healthier remains open questions.

Nevertheless, the IOM proposal is a huge improvement over what food companies are now doing.  I consider it courageous.

Why courageous?  Because the scheme makes it so easy to distinguish products that qualify for the various point levels.

For example, here are some products that qualify for stars:

• Toasted oat cereal
• Oatmeal, instant
• Milk, 1% fat
• Yogurt, plain nonfat
• Salad dressing, light
• Orange juice, 100%
• Grape juice, 100%
• Kidney beans, canned
• Peanut butter
• Tomato soup, “healthy”
• Tomatoes, canned

Examples of products that do not qualify:

• Animal crackers
• Graham crackers
• Breakfast bar
• Sweetened toasted oat cereal
• Oatmeal, instant with fruit, nuts
• Chocolate milk
• Yogurt, sweetened

I can’t wait to see the GMA and FMI press release on this report.

And the FDA must now take this report under consideration to begin its interminable rulemaking process.

Why, you might ask, does any of this matter?  Aren’t questions about what food companies put on package labels basically trivial?  Don’t FOP label fights divert attention from other, more important food issues?

Maybe, but I see this as a test of the FDA’s authority to regulate and set limits on any kind of food industry behavior.  If the FDA cannot mandate a label that might help consumers choose healthier food options or refuse to permit labels that mislead consumers, it means the public has little recourse against any kind of corporate power.

I think this matters, and I’ll bet food companies do too.

And now, sit back and watch the lobbying begin!

That did not take long:  Here’s the GMA press release—fairly tame all things considered:

The Institute of Medicine’s Committee on Examination of Front-of-Package Nutrition Rating Systems and Symbols report adds a perspective to the national dialogue about front-of-pack nutrition labeling.  In the meantime, food and beverage companies have developed a real-world program that delivers real value to real consumers in real time.

Consumers have told us that they want simple and easy to use information and that they should be trusted to make decisions for themselves and their families. The most effective programs are those that consumers embrace, and consumers have said repeatedly that they want to make their own judgments, rather than have government tell them what they should and should not eat.  That is the guiding principle of Facts Up Front, and why we have concerns about the untested, interpretive approach suggested by the IOM committee.

My translation: Consumers prefer to have the food industry’s “Facts Up Front” tell them what to eat?  I don’t think so.

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The Institute of Medicine released a report today on how to prevent obesity in children from birth to age 5: Early Childhood Obesity Prevention Policies.

The report is remarkable for its focus on policies for parents and child care providers, and its almost complete lack of attention to policies for improving the food environment in which parents and caregivers operate.

The report’s key recommendations for children from birth to age 5:

• Promote breastfeeding
• Monitor growth
• Increase physical activity
• Provide healthy foods in age-appropriate portions
• Ensure access to affordable healthy foods; educate caregivers and parents
• Limit screen time (all media) to less than 2 hours a day

That’s all? Nothing about keeping sodas and junk foods out of the house?  Only this about food marketing to kids?

The Federal Trade Commission, the U.S. Department of Agriculture, Centers for Disease Control and Prevention, and the Food and Drug Administration should continue their work to establish and monitor the implementation of uniform voluntary national nutrition and marketing standards for food and beverage products marketed to children.

As the IOM well knows from its 2005 report on Food Marketing to Children and Youth, parents and caregivers cannot do this on their own.  They need help, and that means policies to improve the food environment.  The report does say a little about farmers’ markets and green carts as a means to improve access, but that’s it.

It’s time for a follow-up to the 2005 report.  This doesn’t do it, alas.

 

 

 

 

http://www.iom.edu/Reports/2011/Early-Childhood-Obesity-Prevention-Policies.aspx