Your Food, Digested

Your morning bowl of cereal: An ounce of prevention, a pound of cure?

Consumers, manufacturers grapple with food packaging claims

Like most parents, Denise Devine, 49, a busy mother of two teenagers, cares about the food she feeds her family. Her main concern is to avoid foods, particularly cereals, that contain a lot of sugar. “I try to buy cereal that has fruit in it or isn’t too sugary,” she said. “Serving cereal has been a way I could get my daughter to drink milk, especially when she was younger. But too much sugar can make her agitated so I try to be careful.”

Denise Devine gears up to hit the aisles

Even though Devine is motivated to buy healthy cereal, she always doesn’t read the Nutrition Facts Panel or the list of ingredients because she just sees a string of long words that don’t mean anything. Instead, she makes buying decisions using the information on the front of the package or a recommendation from a friend. As Devine said, “Sometimes you just don’t want to see the list. You think, ‘What is that’?”

 

Health claims up front

Research suggests that Devine is not alone in how she reacts to front-of-package labels. Short health claims on packaged foods tend to lead time-pressed shoppers to disregard the longer and more complete information on the back. The average consumer may believe the front-of-package claims are sanctioned by the government and are somehow “true.” While health claims on food packages are officially regulated by the FDA, they are not consistently enforced. Messages on the fronts of packages tend to be eye-catching and positive, while those on the back look less inviting and may include some negatives about the food.

The cereal canyon at the local supermarket

The question is what can be done to help consumers make better food choices. Writing in the February 24, 2010, issue of the Journal of the American Medical Association, Marion Nestle, professor of nutrition at New York University, and David Ludwig, a professor of pediatrics at Children’s Hospital Boston summarized the problem: “Front-of-package labels may so thoroughly mislead the public that another option deserves consideration—eliminate all nutrition and health claims from the front of processed food packages while strengthening the Nutrition Facts Panel.”

Keep it simple

In early May 2012, the FDA released its Foods and Veterinary Medicines Strategic Plan for 2012-2016. Included in this plan is a goal to “provide accurate and useful information so consumers can choose a healthier diet and reduce the risk of chronic disease and obesity.” Part of this goal is to update the nutrition facts label so that serving sizes, daily values and important nutrients are easier to grasp. In addition, one key initiative of this plan is to “explore front-of-pack nutrition labeling opportunities.” These goals and initiatives have been met with guarded enthusiasm by some nutrition experts. As Nestle wrote on her Food Politics blog, “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?”

On October 20, 2011, a committee of the Institute of Medicine (IOM) issued a set of recommendations to create a single, standardized front-of-package labeling system that will make “healthier options unmistakable.” The key feature of this proposed system is a system similar to the Energy Star ratings, using a standard symbol placed in a consistent location on all products to represent calories “in common household measure serving sizes.” Also displayed on this symbol is a simple point system to rank foods, requiring no calculations or nutritional knowledge, based on amounts of three nutrients per serving: saturated and trans fats, sodium and added sugars. In addition, the recommendations include incorporating this system across all food products to allow comparisons across products.

One example of IOM proposed labeling

 

 

Criteria for a proposed point system for ranking packaged foods

The labeling jungle

All of this is a far cry from the current labeling landscape. Allowable health claims for immune system support, cardiovascular health and cancer prevention commonly appear on the fronts of food packages, the first point of engagement for consumers. Also on October 20, 2011, two food industry trade groups, the Grocery Manufacturers Association and the Food Marketing Institute, issued a joint statement launching Facts Up Front, a voluntary nutrition labeling system “to help busy consumers—especially parents—make informed decisions when they shop.”

Facts Up Front Icon

The statement goes on to say that Facts Up Front was created in response to consumer preference “to make their own judgments, rather than have government tell them what they should and should not eat. This is the guiding principle of Facts Up Front, and why we have concerns about the untested, interpretive approach suggested by the IOM committee.” Facts Up Front displays nutritional information on four required elements per serving: calories, saturated fat, sodium and sugars. Individual products may include additional nutrients. Outside the food industry this system has been criticized as a cynical end run around the IOM recommendations.

What consumers can do

How can consumers make better food choices with the currently available labels? In a telephone interview, Alice Lichtenstein, a professor of nutrition at Tufts University and vice-chair of the IOM committee on Examination of Front-of-Package Nutrition Rating Systems, said that “consumers should focus on the Nutrition Facts Panel and what’s most important to them from a health perspective, for example, calories, sugars or sodium,” and pay special attention to ingredients and nutrients that are most relevant. She added that “it’s difficult to automatically or easily compare across cereals because they have different serving sizes. Lichtenstein herself does not buy many packaged foods, but when she does, she looks at the calories per serving and the position of whole grains in the list of ingredients.

Larry Cornick, marketing manager at New England Natural Bakers, a small organic food company in Western Massachusetts, agreed that “serving sizes drive the information on the nutrition facts panel,” adding that some manufacturers practice labeling deception, using serving sizes that might be better characterized as “snack” sizes in order to keep the calories per serving down. Cornick takes pride in his company’s conscientious approach to marketing, saying that the front-of-package health claim that the company’s Organic Antioxidant Superfruit Granola “supports the immune system” wouldn’t be there if it weren’t true.

Regulation past and present

Regulation of health claims on food packages in the U.S. has its roots in legislation from a century ago, beginning with the Pure Food and Drug Act of 1906, which prohibited statements that were “false or misleading in any particular.” For many years this wording was interpreted to mean that no health claims were allowed. By the 1960s, packaged foods had become much more common, and accurate labels more necessary. In the mid 1980s, Kellogg challenged this restriction by adding a health claim to its All-Bran cereal. This action was challenged by the FDA, but Kellogg fought, and won, the challenge, ushering in the era of allowable health claims on foods, as long as they were based on scientific evidence. The 1994 Dietary Supplement Health and Education Actfollowed, allowing, after food companies demanded it, foods to make the same labeling claims as dietary supplements could.

Kellogg’s Frosted Mini-Wheats

 

Kellogg has continued to push the health claim envelope, and was reprimanded by the FDA twice in recent years for claims on Frosted Mini-Wheats (attention improvement in children) and Rice Krispies (immunity in children). Today, three types of claims are allowed on food packages: health, nutrient content, and structure/function. As Cornick noted, “The big companies push the legislation.”

 

Health claims are not universally allowed on packaged foods. In the European Union, for example, health claims are not allowed on the labels until after they’ve been reviewed the European Food Safety Authority. Asked why this approach to labeling isn’t used in the U.S., Yoni Freedhof, a family physician and founder of Ottawa’s Bariatric Medical Institute, said by email that “there needs to be political will to make regulatory changes to labeling, and if politicians care more about ensuring the food industry’s interests are met than they do about the health of their constituents, then we certainly won’t see any changes.”

When Freedhof buys packaged foods he reads the fine print on the back, but pays little attention to front-of-package claims. “I use the nutrition facts panels to quickly scan for calories and sodium per serving, and front-of-package messaging to assume the food contained inside is one I ought to avoid, because if something needs to convince me it’s a healthy choice, it’s probably not. I’m not sure if any claim is more or less dangerous than any other, as all claims tend to influence the increased consumption of processed foods—something I think we should as a society be doing less of.”

In the end, are the health claims true? The answer might be a resounding, “sort of.” They generally seem to adhere to the letter, not the spirit, of the law, and are, after all, allowed by the country’s federal food and drug safety agency. One axiom common among nutrition experts is, “the front of the package is marketing, the back is truth.”

The New Label Readers

Meanwhile, Devine said she intends to try reading more of the Nutrition Facts Panel and ingredients lists, but really hopes something can be done to make it easier to understand the nutritional information and health effects. Her daughter is going off to college in the fall, and will be buying her own cereal—and probably ignoring the labels.

Photos: IOM recommendations; Facts Up Front Icon
All others by Susan Karcz
 

Prevent Alzheimer’s? You sure?

“Keep your brain healthy for the rest of your life,” reads the book jacket. If you’ve watched a family member or friend fade into dementia, this is one promise you wish with all your heart to believe even as doubt simmers on that back burner. Dr. Gary Small is on the book tour to promote The Alzheimer’s Prevention Program, and as accessible, positive, and reasonable as the program is, I still balk. Not that I think Dr. Small is selling snake oil or is otherwise untrustworthy. He’s a well-regarded neurologist who is recommending, based on evidence from research, a program of nothing more than regular exercise, good nutrition, stress management, and memory exercises to maintain brain health. Nothing harmful here, and nothing we haven’t heard before. And even if it doesn’t keep your brain sharp, his program might just help you avoid or delay heart disease or diabetes. So why not? And why don’t I feel a sense of unease when the talk is about preventing heart disease using similar methods?

Maybe my attitude is emblematic of the Baby Boomer zeitgeist–we’re living longer, we’re fighting aging, and we’re scared to death we’ll exit this vale by staring off into space uncomprehendingly or “wandering off,” as some of our parents have already. I saw my mother gradually lose her engagement with daily life, her capacity to speak, her ability to eat, and, finally, her self, as she slipped steadily away from us. It just might be her shade that pulls me up short when I’m about to fully believe in prevention. I’m sure she’d want me to believe, much as she wanted me to believe in the Holy Trinity or transubstantiation, but it’s just not in me yet. I’ll gladly eat my fruits and veg, exercise to the point of injury, and OM with the best of them to keep heart disease, cancer, or diabetes at bay, but dementia? It can’t be that easy to save a soul, can it?

Brain Food: One Doctor’s Prescription for Preventing Alzheimer’s

Alzheimer’s disease, the bane of Margaret Thatcher and now Glenn Campbell, may be preventable, said Dr. Gary Small to a crowd of about 100 people at a church in Cambridge, MA, last night. Speaking about his new book, The Alzheimer’s Prevention Program, Small, director of the UCLA Longevity Center, challenged the notion that Alzheimer’s, the most common form of dementia, cannot be prevented. Small’s plan combines physical activity, nutrition, stress reduction and memory training to defend against Alzheimer’s.

Dr. Gary Small in Cambridge, Mass., February 2012

Paying attention to these four factors, Small believes, will help you delay or prevent the brain changes that may lead to Alzheimer’s. The same problems that are believed to contribute to heart disease—chronic inflammation and oxidation—may lead to the buildup of the plaques and tangles seen in the brains of people with the disease.

Despite the promise implicit in his book’s title, Small said he agreed with the substance of the National Institutes of Health 2010 Consensus Statement that there is not now enough evidence to associate the modifiable risk factors of his program with delaying or preventing the disease. The NIH statement also said that there is reason to continue research to discover ways to delay the onset of Alzheimer’s, if not prevent it.

Small’s book is accessible and energetic, and the program’s components boil down to behavior changes that many people find extremely difficult to make—exercise more, eat better and reduce stress. The audience, most of whom appeared over age 50, was animated and involved in the topic. Asked for a show of hands to gauge the level of personal connection to Alzheimer’s, about 95% responded. During the question-and-answer period, about 15 audience members approached the microphone with thoughtful and well-informed questions.

For example, one query asked whether people may be more motivated to follow his program to prevent Alzheimer’s over a similar one to prevent heart disease. Small’s response was that there is a fear factor, especially if one has watched a family member descend into dementia. The second is age. “As we get older we notice changes in ourselves,” he said.  “But there is something about Alzheimer’s that strikes at the core. Our identity—who we are, memories, cognition, define who we are.”

Small’s language in selling his program—“slam dunk” techniques to improve memory, for instance, and a bright, can-do style—could be interpreted as manipulative or overpromising. However, Small’s scientific credentials are solid, and he does cite evidence and acknowledges the limitations of his approach. Preventing or delaying onset of Alzheimer’s, or reducing the risk of contracting it, is a growing area of research, and is far from the fringe.

After Small’s remarks, the event moderator, Dr. Margaret O’Connor, director of Neuropsychology at Beth Israel Deaconess Medical Center, introduced the question-and-answer period with a question of her own. When should a person be worried about changes they notice in themselves? she asked. Small answered that people with mild cognitive impairment (MCI), a transitional stage from normal age-related changes to dementia, should get medical advice.

MCI is a stage of early dementia, when people are beginning to have some cognitive difficulties, but can still live independently. This is a stage where drug therapies may be most effective. However, once cognitive changes are observed, it is likely too late to do much to delay progression. For this reason, any attempts at prevention or delay should begin early—in one’s 30s or 40s.

So, can people with MCI manage a program such as Dr. Small’s? O’Connor, in a telephone conversation the next day, said that MCI and dementia are heterogeneous, meaning they affect people in different ways. Some are more affected in their multitasking skills, others in language. If an individual is not too memory-impaired, then he or she could probably manage such a program. Otherwise, O’Connor said, a caregiver would have to be very involved.

Gary Small, MD, spoke about his new book, The Alzheimer’s Prevention Program, as part of the “How We Live Today” series presented by the Cambridge Forum. For further information on Alzheimer’s disease, visit the Alzheimer’s Association.