Communicating with the dietetics profession

In Mother Jones this week, Kiera Butler has a striking report about the food industry presence at a conference of the California Dietetic Association. The description of attendees consuming and discussing their free McDonald's salads makes the association seem careless with its valuable public image and credibility.

One might ask, how on earth could dietitians ally themselves with major fast food chains, instead of with advocacy groups -- or hard-hitting magazines -- that seek to better represent the public interest?

Part of the answer, surely, is that the food industry provides funding to the dietetics associations. This is the answer Mother Jones might emphasize.

Another part of the answer is that the food industry publicly endorses the best judgment of dietitians and nutrition scientists on the leading diet and health questions of the day. Actual products may not follow this judgment, but the industry's public communications are deeply respectful of the profession. Industry representatives endlessly tell the profession, "We listen to your advice, while those would-be do-gooders in the public interest community foolishly pursue one nutrition fad after another."

For example, consider the claim in the Mother Jones article that mounting scientific evidence shows that "high-fructose corn syrup prompts more weight gain than other sugars." The article links to this four year old 2010 press release from Princeton University, which imprecisely summarizes its supporting scientific journal article (.pdf), which in turn has been strongly criticized by NYU's Marion Nestle, who is quoted as a trusted authority in the same Mother Jones article (!), and who further links to a more detailed evisceration of this research.

It is fine to criticize high-fructose corn syrup (HFCS) along with sugar, because of strong evidence that both are associated with risk of weight gain. But the current evidence does not support Mother Jones' claim that HFCS prompts more weight gain than other sugars. That claim -- and more specifically the casual and uncritical link to the Princeton University press release -- plays into the industry's strategy for befriending dietitians.

Writers and advocates who care about the public interest really can persuade the dietetics profession to adopt a more independent and skeptical stance in its relationships with the food industry. We could begin by avoiding these failures in summarizing the best scientific evidence.

Recent activities of Dietitians for Professional Integrity

Andy Bellatti last month summarized in a column for Civil Eats the recent activities of Dietitians for Professional Integrity, an initiative to encourage the leading dietetics professional association, the Academy of Nutrition and Dietetics, to distance itself more clearly from its food and beverage industry sponsors.

For years, many of my colleagues and I have voiced our discontent that the professional organization that represents us takes money from and partners with the likes of Coca-Cola, PepsiCo, McDonald’s, and Hershey’s, supposedly to foster dialogue with the industry and help Americans get healthier. In reality, Big Food gets free press for feigning concern, while going about its usual business, and the registered dietitian credential gets dragged through the mud.

“Too often I’ve lost the trust of potential clients because, despite my rigorous education in nutrition, they only see the dietetics field as corrupted by big businesses,” says Matt Ruscigno, MPH, RD, one of Dietitians for Professional Integrity’s co-founders.

Over the past four months, Dietitians for Professional Integrity has shared many statements of concern from registered dietitians on its Facebook page, and helped raise awareness of Big Food’s influence on the Academy (from the world’s largest aspartame producer helping to fund the organization’s evidence analysis team on the artificial sweetener to Coca-Cola’s Academy-approved continuing education webinars which  teach dietitians that soda is unfairly vilified).

A key point is that Dietitians for Professional Integrity is not a "nanny state" initiative.  There are good reasons why it is sometimes difficult for government agencies to take strong public interest positions on key challenges to the healthfulness of the food and beverage industry.  Government institutions in a democracy frequently must represent the mainstream of public opinion.  They explicitly must be concerned both with public health and with encouraging a thriving economy.  When government agencies push too hard or are insufficiently deferential to individual preferences in guiding people toward healthy nutritional choices, the public worries about government overreach.

Because of these constraints on government activism, it is especially important that non-profit public interest organizations such as the Academy of Nutrition and Dietetics speak clearly, boldly, and without bias on the nutrition issues of the day.  I think Bellatti and Dietitians for Professional Integrity have a good point in encouraging this private-sector nutrition organization to be more independent from its corporate sponsors.  Sometimes, the Academy should have more courage to criticize food and beverage industry products and marketing practices that really do contribute to an unhealthy nutrition environment.

Interpreting science at #EB2013 in Boston

While enjoying the excellent sessions sponsored by the American Society of Nutrition (ASN) at the Experimental Biology 2013 meetings here in Boston this week, I was struck once again by the way actual nutrition science research results are filtered or digested into short memes of conventional wisdom before they reach the public.

This filtering process is necessary, unavoidable, and even healthy.  And yet it is a key step, which brings politics and interest into the process of producing nutrition policy and dietary guidance.

Here is a passage from my chapter on Dietary Guidance in Food Policy in the United States: An Introduction (Routledge/Earthscan).

Filtering is the process of reading a large body of research and concisely summarizing its relevant points. Because the scientific literature is so heterogeneous, its policy impact depends heavily on how the research is filtered.

Filtering may be biased toward certain types of conclusions. Food industry organizations hire scientists and public relations specialists to spread the good word about favorable studies, without mentioning unfavorable studies. The public relations specialists are evaluated according to their success in placing favorable stories in the mass media. Reporters do not purposely seek to serve as a vehicle for industry public relations, but they face intense pressure to generate buzz by reporting novel and surprising findings. Hence, even though the balance of evidence in the scientific literature changes only slowly, headlines each week tell the public that everything they previously believed about nutrition and health was a big fat lie.

To summarize a complex scientific literature with less bias, scientists prefer to rely on systematic evidence reviews. In a systematic evidence review, an inter-disciplinary team establishes a protocol, a document that describes in advance the procedure for selecting relevant research studies, reducing the temptation to concentrate on studies that are favorable to the team’s prior expectations. For each selected study, the team evaluates the strength of the evidence, again using criteria established in advance.

Systematic evidence reviews do have some limitations. While they can avoid errors that stem from selective reading of just favorable parts of the scientific literature, systematic evidence reviews cannot fix misinterpretations that are widespread in the literature. Also, such reviews may not reflect recent improvements in scientific research. Still, because of their transparency and replicability, systematic reviews can clarify the state of the evidence on contentious scientific issues.

If you are attending the Experimental Biology 2013 meetings this week in Boston, the book itself is on display today at the CRC Press booth (#531 in the exhibition hall).  Please stop by the booth, and please share your thoughts on whether food policy is a worthy topic of study at a meeting of scientists.

An inter-disciplinary approach to U.S. food policy

An excerpt from the first chapter of Food Policy in the United States: An Introduction (Routledge/Earthscan).

The 2010 Dietary Guidelines for Americans, which is the federal  government’s most authoritative official statement on nutrition and health issues (discussed at length in Chapter 8), presents a social and ecological framework for food consumption and physical activity decisions (see Figure). Similar models are found in many other high-profile nutrition policy documents (Institute of Medicine, 2012). To analyze major national problems of obesity and chronic disease, this framework goes far beyond immediate causes such as food and beverage intake and physical activity. Like planetary orbits that are farther from the center, the outer layers list more distant influences on food choices.

The framework calls attention to important topics, including agriculture (Chapter 2), the food and beverage manufacturing industries (Chapter 5), the retailing and restaurant industries (Chapter 6), marketing and the media (Chapter 9) and socioeconomic factors  (Chapter 10). Once nutrition and public health professionals begin to explore these more fundamental influences on food and beverage consumption, they find themselves engaged with challenging topics in economics and political science.

At first, this engagement can be unnerving. When interacting with patients, professionals in medical fields are rightly proud of their ability to diagnose problems and prescribe an appropriate remedy. It is tempting at first to adapt this medical patient approach to food policy applications. For example, if expanding food portion sizes contribute to rising rates of obesity, it is tempting to say government agencies should prescribe smaller portion sizes. If nutrient-dense foods cost too much, it is tempting to say government agencies should prescribe a price ceiling for fruits and vegetables. It is disappointing if policy-makers reject such proposals as politically infeasible. It is downright frustrating if policy-makers say with a straight face that a well-intentioned nutrition policy prescription is unwise. Yet, except in special settings such as school meal programs, determining portion sizes may be a decision that people do not want to delegate to their government. A price ceiling for fruits and vegetables may have unintended consequences, such as reducing the incentives to grow fruits and vegetables.

The outer layers of the social ecological framework bring nutrition policy into contact with many other societal objectives, such as a thriving economy, a healthy environment, poverty alleviation and effective political governance. Powerful policy actors in these outer layers do not—and sometimes should not—behave as if food consumption and physical activity stood alone as the sun at the center of the social ecological solar system. Governments balance food and nutrition concerns against other considerations, just as individuals and families do.

As we explore more deeply the normative question of what food policies best serve the public good, it will appear necessary to discern which decisions should be delegated to governments and which decisions should be made by individuals interacting in economic markets. And, as we explore more deeply the positive question of what policies can win political support, it will appear necessary to anticipate how a variety of producer and consumer interests will respond to such proposals.

These inter-disciplinary explorations are more difficult than simply prescribing the right policy medicine, but ultimately they offer both sharper policy insight and greater potential for political success.

Source: Dietary Guidelines for Americans, 2010.

Dietitians discuss appropriate policies to govern corporate sponsorship at the Academy of Nutrition and Dietetics (AND)

The Hunger and Environmental Nutrition (HEN) practice group within the Academy of Nutrition and Dietetics (AND) has long been encouraging greater transparency about corporate sponsorship issues.  The AND (formerly known as the American Dietetic Association) serves as an influential advocate in U.S. nutrition policy and also as the professional association for registered dietitians.

My students and former students who are registered dietitians have worried about AND corporate sponsorships.  They send me a steady stream of awkward examples of ill-chosen sponsorships, for example with sugar sweetened beverage companies and meat checkoff programs.  One Friedman School graduate student, Ashley Colpaart (who for some years co-blogged here at U.S. Food Policy), has been proposing reforms for AND's corporate sponsorship practices for many years.

Other Friedman School graduate students conducted analyzed a survey of dietitians last year, noting that many dietitians share at least some of these concerns [small edit Feb. 3].  The article was an important source for Michele Simon's hard-hitting and highly critical report this week on AND corporate sponsorship.  The students, Lauren Adler, Alyssa Koomas, and Catherine Wright, wrote:

ADA’s corporate sponsorship program has become a topic of public discussion in recent years. A total of 370 HEN members were surveyed to shed light on member opinions of the corporate sponsorship program and whether our DPG approves or disapproves of the program. The majority of survey respondents appear to disapprove of the corporate sponsorship program, indicating that it negatively impacts their public image as food and nutrition professionals. Additionally, 61% of respondents were willing to pay higher ADA membership fees in order to decrease reliance on corporate sponsors.

In a letter to AND leadership last year (.pdf), some Hunger and Environmental Nutrition practice group members recounted the common experience of having their own independence called into question by others who were aware of the Academy's corporate sponsorship relationships:

[R]egardless if they are real or perceived, the influence of Academy corporate  sponsors has not only sparked scrutiny among journalists, but has led to several conversations in which members have had to defend these relationships and the profession at national conferences and forums. These confrontations have led to rising humiliation and a growing discomfort while fulfilling the role as Delegates. In some instances, this has led to long-­‐time members leaving the organization. We urge the Academy to uphold more transparent and stricter guidelines on access of corporate  sponsors to Academy leadership and to remove their presence at meetings, such as HOD [the AND House of Delegates], in which decisions about the profession and/or the organization are made. This will avoid conflict of interest, advance transparency, maintain professional and organizational integrity, and establish a more credible national presence.

It is difficult for any professional association to find a business model that works, providing needed support for association activities without conflicts of interests.  For example, the HEN practice group itself last year sought to develop its own policies for sponsorships (.pdf), describing the ideal potential sponsors as companies with a combination of nutrition and environmental virtues. I wish them well finding such terrific sponsors, but, realistically, we should admit that giving up compromised sponsorships may imply accepting a smaller scale of operation and revenue for a professional association.

Even recognizing those difficulties, it would have been wise for AND to listen to the input from its own internal rank and file.  As an outsider to AND, nutrition policy advocate Michele Simon offers much harsher criticism of the Academy in her report this week. With hindsight AND leaders might wish they had listened more sympathetically to internal concerns before matters came to this point.

When Marion Nestle blogged about this issue yesterday, generally agreeing with Simon's report, some of the open comments from dietitians were defensive, while others agreed with the concerns about corporate sponsorship.  Nestle has a very good follow-up post today, responding to the discussion so far.  The New York Times also covered this issue, which is unlikely to just fade away any time soon.

A proposal for a global ban on trans fats

While labeling strategies provide a sound public policy response to some food ingredient dilemmas, in other cases it is simpler and more effective to make do without the ingredient altogether.  Some argue that trans fats fall into the category of ingredients that should just be eliminated (with the exception of the small amount of trans fat that occurs naturally in animal food products).  These fats replaced healthier traditional oils and fats just a few decades ago, and some countries have recently been rapidly shifting back away from their use without any major food system damage.

In a commentary this week for the World Public Health Nutrition Association, Vivica Kraak, Uriyoán Colón-Ramos, and Rafael Monge-Rojas recommend a near-complete global ban on trans fats.

This commentary presents a case for public health professionals, practitioners, academics, industry and government representatives, funders, public-interest non-governmental organisations and consumer advocates, to collaborate to support a global trans-fat ban. Coordinated actions to remove this harmful substance from our food and eating environments will be able to contribute to reducing chronic non-communicable disease mortality by 2025.

From nutrition scientists "on behalf of Corn Refiners Association"

Here is a newsletter I received today from an email account labeled oddly: "ASN on behalf of Corn Refiners Association."

Follow the link for the full web version of the email.

The ASN is of course the American Society for Nutrition.  "Experimental Biology 2012" is the most important annual meeting for nutrition scientists.

The tiny footer to the email's web page says:

This email is a paid advertisement sent by ASN on behalf of Corn Refiners Association. ASN occasionally promotes to its members the efforts of other organizations promoting products, services or events that advance ASN's mission: excellence in nutrition research and practice. ASN never releases members' email addresses to any third party. 

While this footer to the email discloses the advertisement, the newsletter's .pdf file from the link does not mention that it is an advertisement.  Clearly, the whole package is designed to look like a newsletter from a scientific association.  In the gentlest way, the newsletter defends fructose and corn sweeteners from criticism.

Does this type of advertisement cost the scientific association much in terms of independent authority and reputation?

Why Calories Count

Why Calories Count, the new book by Marion Nestle and Malden Nesheim, nicely bridges the world of food policy commentary and nutrition science. It offers a great counterpoint to the loud and untrustworthy bazaar of diet books, each blaming some simple villain for the obesity epidemic (too much carbs, too much fat, too little calcium, whatever).  Why Calories Count teaches a wealth of detail about how calories are measured and how their effects are studied.  It also tells great stories, from the history of nutrition science to the poignant service of wartime conscientious objectors who participated in a clinical study of human starvation.  If I were a graduate student in nutrition or public health, I would find this book inspiring as an eloquent and engaging secondary reading alongside a nutrition science textbook.  Strongly recommended.

Links: Jane Brody, Mark Bittman.

How can salt be reduced?

Following the long-awaited new Institute of Medicine (IOM) report on salt released this week, here's a quick summary of a debate that I would find awful tiresome.

Institute of Medicine: "FDA should regulate salt."

Critics: "Big brother should not tell me what to eat."

To me, the more interesting questions are: (1) Is it important for Americans to consume much less salt; and (2) if so, how can this reduction be achieved in an economically sensible way?

The IOM report explains clearly why sodium reduction is important for our health and even for the national economy. It is apparently a myth that salt reduction is only important for a small number of people predisposed to hypertension. If you still hold that view, we'll have to postpone arguing about it until another day. The rest of the post assumes the answer to question (1) is "yes, salt reduction is important." The food industry, which is pursuing some voluntary efforts to reduce sodium in the food supply, concedes this point.

The interesting question is how salt reduction can be achieved. In calling for FDA participation in salt reduction efforts, IOM explains the collective action problem that limits the effectiveness of voluntary measures:

Regulatory action is necessary because four decades of public education campaigns about the dangers of excess salt and voluntary sodium cutting efforts by the food industry have generally failed to make a dent in Americans' intakes, the committee said. The industry's voluntary efforts have fallen short because of lack of a level playing field for all products. Companies have feared losing customers who could switch to competing products or brands with higher salt content.

[Update Apr 26, 2010: This sentence has been toned down, because of the next update below.] Moreover, the food industry's imagination on salt reduction could be more ambitious. For example, the input of the Grocery Manufacturers Association on the federal government's revision of the Dietary Guidelines emphasizes the limited options for high-tech salt replacements and claims that consumers would not accept less salty foods:

[F]ood processors have no alternatives with which to replace the sodium, and must simply accept a less salty flavor in lowered sodium products. But the consumer will not accept such products.

[Update Apr 26, 2010: Although the link above is to the GMA site and seems to have today's date, a reader tells me that the letter is actually GMA's comments on the 2005 Dietary Guidelines. I regret my error in reading. To be more current, here is the corresponding passage from the GMA comments to the 2010 Dietary Guidelines Advisory Committee.

There is no perfect "salt substitute " currently available. Sodium reduction in foods is often a complex, highly technical, expensive and labor intensive task that must frequently be undertaken "silently" without consumer's knowledge.]

Contrast this assessment of the consumer's tolerance with the fascinating and quite well-written Chapter Three of the IOM report, which marshals the evidence for a more optimistic conclusion:

The food supply contains a vast array of commercially successful products and ingredients – fresh, prepared, and manufactured – whose sodium levels range from very high to moderate to very low. The fact that the same individual for example, might be fully satisfied with two snacks of widely varying sodium levels – one a fresh apple and the other a handful of salted pretzels – reminds us how dependent the sodium taste issue is on wider flavor contexts.... [T]he salt taste challenge might be as much a matter of reconsidering flavor options in recipe selection and menu development ... as needing to overcome technical challenges with salt substitutions.

[Update Apr 26: This sentence has been edited to remove an implication that the food industry didn't know these insights. The good food scientists probably recognize these points.] Here are some marketing insights that I draw from the IOM report (my paraphrase):

• Consumers can become happily acclimated to a lower sodium environment over time, just as it took time for them to become accustomed to the current strangely high-sodium environment.
• We could give consumers greater freedom of choice by reducing salt in processed foods and letting everybody use salt shakers; it turns out that people add only 20% as much sodium when they are free to make their own choices.
• There is a difference between "taste" and "flavor." Salt is a "taste." Real "flavors" can be used to make less salty foods delightful.
• Many foods can have less sodium without tasting less salty, by modifying the size of salt particles and their placement on the surface of a food.

Although consumers might eat less processed foods, and more real whole foods, we might enjoy life just fine with less sodium.

Salt policy

Some major food companies -- Kraft, ConAgra, Unilever -- have announced voluntary initiatives to reduce salt. In other countries, such as the United Kingdom, public policy plays a bigger role alongside voluntary measures. On WBUR's syndicated radio show Here and Now, host Robin Young today covers salt policy. She interviewed Cheryl Anderson at Johns Hopkins University and myself.

New York City is calling on the food industry to cut back on sodium. The plan is voluntary and its goal is to reduce the amount of sodium people eat by 25%. Recent research shows that a decrease in sodium would cut new cases of coronary artery disease by 60,000 a year. Our guest is Dr. Cheryl Anderson of Johns Hopkins University. We’re also joined by Parke Wilde of the Friedman School of Nutrition Science and Policy at Tufts University, who discusses the role of public policy in debates about diet.

New study on high-fructose corn syrup

A Princeton University research team is reporting that HFCS increases obesity in rats more than sucrose does. The research appeared in February in the Pharmacology, Biochemistry, and Behavior.

As always, no one study settles the argument on this type of debate. This study moves the needle five degrees toward showing that HFCS is metabolically different from equivalent amounts of table sugar.

The study appears in a refereed journal. It includes a strong research design, randomly assigning rats to a treatment (HFCS) group and two control groups.

[Update 3/23: part of the study includes two control groups, which received either plain sucrose or an ordinary rat food diet, so one can distinguish HFCS from sucrose; a comment says that another part of the study included only one control group, which received the rat food diet, so it is not possible to distinguish HFCS from sucrose].

On the other hand, studies in rats are just one element in an array of evidence. Other elements include human studies and describing a plausible biological mechanism. One mystery is how HFCS (55% fructose) could be much different from sucrose (50% fructuse). The conclusion section of the new article spends most of its time talking about the metabolism of fructose, mentioning but then somewhat breezing over the similarity in fructose content between HFCS and sucrose.

Given that sucrose is a disaccharide, which is metabolized to one fructose and one glucose molecule (Caspary, 1992), it has been argued that there is little difference between fructose and sucrose, since both provide about 50% fructose and 50% glucose in the blood stream; and until recently, there was no evidence that HFCS contributes to long-term weight gain beyond what sucrose contributes (Forshee et al., 2007). However, the present study suggests that HFCS and sucrose can have different effects on body weight and obesigenic measures.

HFCS is different than sucrose in many ways. First, HFCS-55 has proportionately slightly more fructose than sucrose (White, 2008). Second, fructose is absorbed further down the intestine than glucose, with much of the metabolism occurring in the liver, where it is converted to fructose-1-phsophate [sic], a precursor to the backbone of the triglyceride molecule (Havel, 2005). Third, fructose is metabolically broken down before it reaches the rate-limiting enzyme (phosphofructokinase), thereby supplying the body with an unregulated source of three-carbon molecules. These molecules are transformed into glycerol and fatty acids, which are eventually taken up by adipose tissue, leading to additional adiposity (Hallfrisch, 1990). And fourth, HFCS causes aberrant insulin functioning, in that it bypasses the insulin-driven satiety system (Curry, 1989). Whereas circulating glucose increases insulin release from the pancreas,... fructose does this less efficiently, because cells in the pancreas lack the fructose transporter.... Typically, insulin released by dietary sucrose inhibits eating and increases leptin release (Saad et al., 1998), which in turn further inhibits food intake. As previously discussed, meals of HFCS have been shown to reduce circulating insulin and leptin levels (Teff et al., 2004). Thus, fructose intake might not result in the degree of satiety that would normally ensue with a meal of glucose or sucrose, and this could contribute to increased body weight.

In each passage above where it seems the authors plan to talk about a mechanism that is specific to HFCS, the subsequent detail turns out to be all about fructose.

I enjoyed hearing a talk earlier this month by Barry Popkin (author of The World is Fat). Though he has also speculated about a possible distinct effect of HFCS, he now emphasizes just the sweetness and food energy content.

And this brings me to the final point that I wish news coverage of this topic emphasized more heavily. HFCS is a large part of our food supply, perhaps 40% or more of all caloric sweeteners. In these quantities, a special metabolic effect for HFCS is really beside the point for policy purposes. It could well be true that HFCS is making Americans obese in any case, just because we consume so much of it.

Economics of Food Safety and Nutrition

Call for Nominations

The Best Economics Paper: Food Safety and Nutrition

To recognize excellence in research endeavors that advance knowledge of the economics of food safety and human nutrition, the Food Safety and Nutrition Section of the Agricultural and Applied Economics Association (AAEA) is pleased to invite nominations for the 5th Annual Award for the Best Economics Paper in the areas of food safety and human nutrition. Theoretical and applied research papers are equally acceptable. Reviewers will look for innovative original research with a high impact. Authors do not need to be members of AAEA or the Section to be considered.

In order to be eligible, a paper must have been published in an English-language peer-reviewed journal with a publication date of 2009. Nominations, including self nominations, should include a copy of the paper and a brief letter of nomination highlighting the contribution of the piece. Electronic nominations (with a pdf version of the paper) are preferred.

The award and plaque will be presented to the winning author(s) during the Food Safety and Nutrition Section meeting at the 2010 annual meeting of the AAEA in Denver, CO, July 25-27, 2010.

Please submit nominations by March 31st, 2010, to parke.wilde@tufts.edu.

Principles for front of pack scoring systems

Several front-of-pack or supermarket-shelf nutrition labeling programs use scoring systems to rate food products.

Examples include the Hannaford supermarket chain's Guiding Stars system ...
... and the NuVal system used by some other supermarket chains.
The computation of the scores seems fairly arbitrary to me. It might help to start with some basic mathematical principles. Here are three principles that I think a food scoring system should satisfy.

1) The score should not depend on the serving size. A major limitation of all such scoring systems is that our health really depends on how much of each food we eat, and in what combination. Unfortunately, the scores necessarily apply to each food as it sits on the supermarket shelf, not as we consume it. Because the creators of the score have no knowledge of how much we eat, the score should be treated as a description of the density of good and bad nutrients per unit of weight or food energy. The score should not depend on the serving size convention used or the number of servings in a package. I have seen some scoring systems that appear at first glance to be independent of the serving size, but on closer inspection have quirky limits on total daily nutrients per serving that contribute to the score.

2) The score should rate mixed foods in a consistent way. Take the example of a ham and cheese sandwich. Suppose the sandwich is, by weight or by calories, 40% bread, 30% meat, and 30% cheese. The score for a packaged ham sandwich in the supermarket should be the same as a weighted average of the scores for bread, meat, and cheese purchased separately:

SandwichScore = 40%*BreadScore+30%*HamScore+30%*CheeseScore.

Without this principle, the scoring system will be biased in favor of or against manufactured mixed foods in place of separate ingredients. I think a good scoring system would have no such prejudice.

3) The score should rate each good and bad nutrient independently. Suppose adding 20% more salt to a high-fiber food reduces the score by 20%. How much should adding 20% more salt change the score for a low-fiber food? Many of us would say the score should again change by 20%. Unfortunately, existing scoring systems may have strange interactions across the good and bad nutrients, so that the effect of one nutrient on the score depends on the value of other nutrients in a way that the authors probably did not intend.

Currently, the scoring systems seem to me to have an ad hoc quality that makes it difficult to take the quantitative scores very seriously. Broadly speaking, a scoring system may seem to work correctly in giving healthy foods a good score, and unhealthy foods a bad score, but consumers understood those broad outlines of their food options already even without a scoring system. The whole purpose of a scoring system is to add quantitative rigor to the information provided. They may have a long way to go.

In other recent reading on front-of-pack labeling, see the recent series by Timothy Lytton at the Fooducate blog. In general, Lytton suggests that FDA should not get into the business of developing its own front-of-pack system, but instead should just enforce existing rules against making implicit healthy claims for foods that fail to meet FDA's definition of "healthy." One exception to Lytton's hands-off recommendation is that he feels there may be a need for stronger regulation of the complex scoring systems.

Calorie counts and serving sizes

A new study in the Journal of the American Dietetic Association shows that many grocery and restaurant foods understate their food energy (calorie) contents by 8% to 18% on average. Some restaurant items had double the stated calories.

The study, by Prof. Susan Roberts and several other colleagues here at the Friedman School of Nutrition Science and Policy at Tufts, concluded, "this phenomenon could hamper efforts to self-monitor energy intake to control weight."

For interesting coverage, see Marion Nestle, Time Magazine, Slate's Explainer, and Food Navigator.

Forbes sells the next best thing to snake oil

Forbes Magazine this month named Monsanto as "Company of the Year."

Monsanto's business model employs the company's monopoly on several lines of genetically modified crop seeds to extract an unusually large fraction of the producer surplus earned by corn and soybean farmers. The seeds grow corn and soybean plants, which have pesticidal properties or which can tolerate especially large applications of the chemical pesticide glyphosate (Roundup). Roundup, of course, is sold by Monsanto.

That business model is profitable, but it does not usually win praise from others. So, Monsanto's public relations folks spend endless hours promoting products that have not yet been marketed successfully, which some day may end world hunger, repair the environment, or reverse obesity and chronic disease.

Forbes credulously repeats these promises about future products as if they were already here, while burying its more skeptical coverage of Monsanto's main business lines.

The article focuses first of all on Monsanto's efforts to provide omega-3 fatty acids through genetically modified soybeans. These fatty acids are found naturally in fish oils. Citing a not-yet-refereed paper from a recent scientific conference, Forbes gushes: "Wouldn't that be a wonderful product to have for sale? Stops heart disease--and protects the environment, too. People could get their nutritional supplements without depleting fish stocks."

Stops heart disease? For starters, let us look for the statement on omega-3 fatty acids in the Food and Drug Administration's page about health claims that have significant scientific agreement. No wait, omega-3 and fish oil claims are not there, because the evidence is too weak. So, let us look on FDA's page about second-tier "qualified" health claims that have mixed scientific evidence, and which are permitted only because the Supreme Court restricted FDA's ability to regulate claims that might perhaps maybe come true. Here, we find that fish oil merits a qualified health claim. If Monsanto made this claim on a label, the company would have to state the claim's evidence base in "supportive but not conclusive research." Instead of such frankness, wouldn't it be nice for Monsanto if it could instead convince Forbes to carry the message that the product will "stop heart disease."

Even if you believe the fish oil health claim, which many people do, Monsanto's genetically modified technological marvel would achieve the same outcome that you already have available in a common dietary supplement.

Forbes' adoration of Monsanto is not the unanimous view of the business media. Here is Jim Cramer's more insightful summary last Fall of Monsanto's business and policy risks. I use this video in my teaching, in a class session on imperfect competition in the food industry.

CNN calls obese kids "coronary time bombs"

The top story on CNN online this morning has the headline: "Obese kids are coronary time bombs."

What is your opinion of that headline?

It is good to be frank about the health consequences of childhood obesity, to motivate a vigorous response from parents and policy-makers alike. At the same time, we should respect and support the quality of life for the many children who will be overweight for much of their lives.

It seems helpful to say, as an expert quoted in the body of the CNN article does, "Our study suggests that more of these young adults will have heart disease when they are 35-50 years old, resulting in more hospitalizations, medical procedures, need for chronic medications, missed work days and shortened life expectancy."

But it seems unhelpful to call obese kids time bombs. It's stigmatizing. As a metaphor or image, "time bomb" doesn't bring to mind a correct impression of the health consequences as a scientist would see them. The article seems at times to be concerned about the teasing that heavy kids get in school, but that nuance is not carried through consistently. The "coronary time bomb" language was not from any of the experts quoted or evidence cited, but was in the CNN author's own voice.

The article is supported by direct advertising for an anti-cholesterol drug, Vytorin. Clearly, the advertising is linked with the content of the article. The fear-enhancing message in the article text serves well to generate interest in the ad. The ad has the same color scheme as the CNN website, increasing the visual sense of linkage. The teaser for the ad is: "What are you doing about cholesterol and the Two Sources -- food and family?"

Here is information, which does not appear in the ad on CNN, but rather on the Zytorin website linked from the ad:

VYTORIN contains two cholesterol medicines, Zetia (ezetimibe) and Zocor (simvastatin), in a single tablet. VYTORIN has not been shown to reduce heart attacks or strokes more than Zocor alone.

Selected Important Risk Information About VYTORIN
VYTORIN is a prescription tablet and isn‘t right for everyone, including women who are nursing or pregnant or who may become pregnant, and anyone with liver problems.

Unexplained muscle pain or weakness could be a sign of a rare but serious side effect and should be reported to your doctor right away. VYTORIN may interact with other medicines or certain foods, increasing your risk of getting this serious side effect. So, tell your doctor about any other medications you are taking.

Baseball gets dietary supplement regulation back in the game

In part due to Major League Baseball, members of Congress are re-considering how the $25 billion U.S. dietary supplement industry is regulated.

Last week, the Senate Judiciary Committee Subcommittee on Crime and Drugs heard testimony on whether current laws and regulations are sufficient to protect consumers from ingredients that may appear in supplements, but not on their labels. The interest of Chairman Arlen Specter (Dem-PA) is due in part to the court case of Philadelphia Phillies pitcher J.C. Romero, who was suspended for 50 games this year after testing positive for a banned substance. Earlier this year, Romero sued the manufacturer of an over-the-counter supplement, blaming the company for his suspension on the claim that it misrepresented ingredients in its products.

Under current law, no government agency evaluates the contents of dietary supplements to confirm the presence of ingredients listed on the label (or to discover those unlisted). Furthermore, dietary supplement manufacturers do not have to prove the safety or efficacy of the product to gain Food and Drug Administration approval prior to marketing. Rather, companies must submit some evidence that the product has a history of use or benefit 75 days before selling it. The safety burden falls on the FDA: if it believes a supplement to be unsafe it must demonstrate the public health risk in court. NYU nutrition professor Marion Nestle covers the history of this issue in detail in her book, Food Politics, as well as on her blog.

In his testimony, Michael Levy, the Director of the Division of New Drugs and Labeling Compliance at the FDA, describes this as, “a painstaking investigative and analytical process to show that [the products] are violative.” He states that the process can take many months, during which the product in question remains on the market, limiting the FDA’s ability to effectively protect consumers.

The largest trade association for the natural products industry, the Natural Products Association, also supported stricter enforcement of supplement contents. However, rather than questioning the effectiveness of current procedures, Interim Executive Director Daniel Fabricant called for increased money and manpower to enforce current law. He argues that sufficient resources would enable the FDA to pursue a larger number of investigations and court cases.

Batting averages are not the only outcomes at stake in this regulatory debate. Use of steroid-like compounds has been associated with kidney failure, liver injury, and stroke.

It will be interesting to see how the debate unfolds. The Major League Baseball Players Association is reported to be lobbying Congress to require that a federally certified lab analyze all supplements to identify the ingredients that should be listed on the label. Professional athletes may hit a regulatory home run that consumer safety advocates have sought for more than a decade.

Written by Natalie Valpiani, a graduate student at the Friedman School of Nutrition Science and Policy at Tufts. Cross-posted from a University of North Carolina food seminar blog, Eats 101.

Setbacks for Smart Choices

The Smart Choices labeling program has created quite a stir.

Following a critical New York Times article earlier this month, which Ashley Colpaart discussed here, the story has been picked up by other major outlets. Rebecca Ruiz scrutinized the program's funding sources in Forbes magazine [update: sentence corrected 9/25/2009]. Mark Bittman shared his wit in a tour of a supermarket aisle on ABC's Nightline. Tom Laskawy at Grist called the program a dumb move.

My dean at the Friedman School at Tufts, Eileen Kennedy, who is a board member for the Smart Choices program, was quoted in the Times defending the inclusion of Froot Loops, which has become the poster child for questionable products included in the program. She has taken a lot of grief for this, including unfair emails and telephone calls. She argues, in person and in public, that the participating companies deserve credit for the social responsibility they showed in giving up their separate food labeling schemes and agreeing to the stricter "Smart Choices" standards. If Froot Loops meets well-defined standards, then wouldn't it be wrong to exclude the brand simply because one doesn't like its marketing associations?

The Froot Loops example highlights a weakness of the Smart Choices program, which seems to favor reformulated branded manufactured products over traditional simple healthy foods, such as fresh fruits and vegetables. Dean Kennedy responds that all fruits and vegetables without additives qualify for the program, a point that was omitted from the New York Times article.

The Smart Choices program would have been wise to anticipate the criticism that it favors highly processed foods. The program could have considered stricter criteria in some areas, such as sweetened cereals. More importantly, it could have achieved a different emphasis even with the program's current criteria. It could have more strongly highlighted fruits, vegetables, and whole grains, while giving a lower profile to products that have been slightly reformulated and artificially enriched to just barely meet the nutrient criteria. Then, reformulated Froot Loops might still have qualified, but the program would have been on stronger ground choosing a different poster child product -- any of thousands of simple, healthy, delicious, traditional foods.

Instead, the program's one-page fact sheet (.pdf) promotes plenty of manufactured packaged food brands but no traditional healthy foods. The program's board includes major manufacturers, but no producers or retailers of less processed fruits, vegetables, and whole grains.

The program should have anticipated criticism of its fee structure also. Although it has a sliding cost scale for food companies, with larger fees for products that have bigger sales, the low end of the scale is still too expensive for commodity producers (comparatively small-scale producers of a non-branded food product). If the program is not just a marketing ploy for food manufacturers, or a revenue stream for the non-profit program itself, then it should permit the seller of an apple without additives simply and freely to use the Smart Choices logo. If an apple automatically meets the program's criteria, it is difficult to see what type of review the program would undertake that would justify even a modest application cost. Currently, if you search for "apple" on the program's website, you find all about Apple Jacks and very little about apples.

Marion Nestle's blog has covered this issue with cutting insight. Advocacy groups have been having a field day. Change.org is running an email campaign, with thousands of signatories already. Somebody has apparently circulated an email list of people to contact that includes faculty like myself. I read every email with interest, even though there is not much mileage in lobbying me on this topic.

The Food and Drug Administration, which oversees federal policy on food labeling, wrote to the Smart Choices Program in August:

In the past five years, competing FOP [front-of-pack] symbols on food labels have proliferated. Consumer research suggests that these competing symbols, which are based on different nutrient criteria, are likely to confuse consumers. In this context, we recognize the potential value of a more standardized approach for FOP labeling.

However, since products bearing the Smart Choices symbol are just beginning to appear in the market, we will need to monitor and evaluate the products as they appear and their effect on consumers' food choices and perceptions.

FDA and FSIS would be concerned if any FOP labeling systems used criteria that were not stringent enough to protect consumers against misleading claims; were inconsistent with the Dietary Guidelines for Americans; or had the effect of encouraging consumers to choose highly processed foods and refined grains instead of fruits, vegetables, and whole grains.

Of course, some of FDA's concerns would seem to apply equally well to other front-of-pack labeling programs, not just Smart Choices.

The Board of Directors page on the Smart Choices website formerly listed affiliations for directors with senior roles at the American Diabetes Association, Baylor University, and Tufts University, but these affiliations have been removed. In an August 5 press release, the American Society of Nutrition (ASN) seemed proud to "jointly administer" the Smart Choices program along with a non-profit organization called NSF International: "Together, ASN and NSF International are committed to ensuring that the Smart Choices Program is credibly implemented, governed, and monitored." Now, however, some of the references to the ASN role have been deleted from the Smart Choices site -- for example, they have been removed from the one-page fact sheet (.pdf). ASN has tried to clarify its role in the program in a letter to members: "ASN does not own the program and does not endorse the products under Smart Choices." I wonder if leading institutions in the nutrition profession are reconsidering the program.

Does obesity even matter?

Healthy food is about much more than obesity prevention. Yet, in its place, without obsession, obesity deserves a place on the list of nutrition concerns, not for cosmetic reasons, but because it is connected to diabetes, heart disease, and other chronic diseases.

The leading theory is that increasingly abundant and inexpensive and palatable food, combined with lower physical activity, has produced rising rates of overweight and obesity. If you just look at the changes in the food system, restaurant industry, sweeteners, sedentary lifestyles, and food advertising to children, it is entirely plausible that calorie balance explains the changes in obesity. In addition, there are a hundred theories about the one thing that obesity is "all about" -- maybe it's the insulin, or the HFCS, or the carbs, or the meat, or the fat, or the chemicals, or the lack of fiber, or the glycemic index, or the volumetrics. Proponents of each of these theories will admonish us to read "the science," by which they mean "just part of the science, please." My advice is to follow each of those theories as their evidence base develops, but don't throw your weight or authority to any of them yet.

A question (not just an answer): How much does a nutritious diet cost?

How much does a nutritious diet cost?

Some say that the high price of healthy food is making us obese and unhealthy. Others wonder how that could be so, because (even with recent inflation) food of all sorts has been comparatively cheap in the United States for many years, due to government policy and technological change in the food system.

The leading source of disagreement about the cost of an adequate diet is different definitions of "adequate," not different price estimates. Your estimate of the minimal necessary cost depends on your opinion on questions like the following:

• whether a high level of meat and dairy is necessary for an adequate diet,
• whether your vision of healthy food includes foods marketed as healthy (organic yogurt, low-fat cereal) or simple basic staples (whole grain rice, cabbage, carrots),
• whether diets should be judged by their adherence to USDA's Pyramid recommendations,
• whether diets should be judged by their adherence to the National Academies' nutrient recommendations, and
• whether you think low-income people can cook at home, or whether instead convenience and restaurant foods are central to your definition of adequacy.

More subtly, your estimate of minimal cost depends on your opinion about whether people can change their diets in order to meet cost and nutrition goals, or whether it is inevitable that any realistic diet closely resembles the current average diet.

Reasonable answers about the cost of a nutritious diet, corresponding to different definitions of nutritious, range from even less expensive than the federal government's Thrifty Food Plan to much more expensive.

No wonder this issue generates a lot of argument! Most people on all sides of this issue leave these key assumptions implicit and unstated. Yet, these assumptions strongly influence conclusions about minimal costs.

In a recent article in the Journal of Consumer Affairs (free abstract, pay site for full article), "Using the Thrifty Food Plan to Assess the Cost of a Nutritious Diet," Joseph Llobrera and I use USDA's Thrifty Food Plan (TFP) framework to clarify the relationship between assumptions and cost estimates for nutritious diets. Let me know by email if your library does not have the journal. There is a related seminar on the Friedman School website. If you would like to play around with these models yourself, see our Thrifty Food Plan calculator. In both the seminar and the calculator, I should have emphasized more strongly that all of the dollars are in 2001 dollars per adult in the household, not adjusted for inflation (if you didn't know this, the amounts would seem unrealistically low).

For some readers, the whole computation will seem beside the point. They may reason that is clearly wrong to set the TFP cost target too low, but harmless to set it too high, so why not just pick the highest estimate? For a number of reasons, I think better food assistance policy comes from trying to choose the right estimate for a minimal cost target, rather than padding the estimate too much.

In the article, we find that the USDA's Thrifty Food Plan cost level can purchase a nutritious diet if (1) you think nutrient constraints (adequate protein, for example) are more important than food category constraints (plenty of meat), or (2) if you think it is reasonable to expect people to drastically change their current consumption pattern. If, instead, you think substantial meat and dairy amounts are essential to an adequate diet and you defer to the current consumption pattern of low-income consumers, you will probably prefer a more generous TFP cost target.

Update: Slate's Daily Bread food business blog has a thoughtful post about this article (gently needling the online presentation as "a little geeky" -- ha!).