The FDA is taking comments on label proposals until August 1 (see info at end of post).  Here’s mine on voluntary vitamin D labeling.

July 17, 2014

TO:  FDA

FROM:  Marion Nestle, Professor, New York University

RE:  Proposed revision to Nutrition Facts Panel: VITAMIN D

This is to argue against permitting food companies to voluntarily label added “Vitamin” D on the Nutrition Facts panel.  Doing so will not promote—and may possibly harm–public health.

Rationale

• “Vitamin” D is not a vitamin; it is a hormone synthesized by the action of sunlight on skin.  For this reason alone, it does not belong on the food label.
• Vitamin D fortification must be understood as a form of hormone replacement therapy.   As such, it raises questions about efficacy, dose, and side effects that should be asked about all such therapies.
• Fortification and supplementation provide hormone Vitamin D by the oral route.  This is not physiological.  Active vitamin D is synthesized in the body through a series of reactions that begin with the action of sunlight on skin.  Sunlight on skin produces ample Vitamin D, is regulated to promote synthesis as needed and avoid toxicity, and may lead to synthesis of other useful biological components; the unphysiologic oral route does not produce the same benefits.[i]
• As a hormone, Vitamin D is found naturally in very few foods (e.g., fish); in them, it is present in small amounts.  It is present in most foods as a result of fortification.
• Permitting Vitamin D to be listed on food labels will encourage fortification, undoubtedly of foods that would not otherwise necessarily be recommended.  To cite just one example: Yum Bunny Caramel Milk Spread fortified with vitamin D at 10% of the DV.  This product is half sugars by weight, marketed as “a good source of calcium and vitamin D,” and clearly aimed at children. See: http://www.yumbunny.com/about-us.   Whether such products should be considered “good sources” also deserves scrutiny.
• The U.S. Preventive Services Task Force concludes that evidence is insufficient to determine how Vitamin D supplementation (and, therefore, fortification) affects fracture incidence.[ii]^,[iii],[iv] 
• Data from the Women’s Health Initiative also are consistent with largely inconclusive findings about hormone Vitamin D supplements and bone health.[v]
• The Institute of Medicine (IOM) does not consider deficiency of Vitamin D to be a serious problem in the United States, except among certain population groups.  Instead, because of widespread fortification and supplementation, it is concerned about the possibility of adverse consequences from overconsumption through supplementation or fortification.[vi]
• Many scientific debates about hormone Vitamin D are as yet unresolved.[vii]^,[viii]  
• The lack of compelling research has permitted Vitamin D to become “trendy.”  It is advertised on boxes of fortified cereals, has its own pro-supplement advocacy group, and generates millions in annual supplement sales.[ix]

In the absence of stronger evidence for benefit from fortification, and some evidence for possible adverse consequences, the FDA should not contribute to further commercialization of this misnamed hormone by permitting it to be listed on food labels.

References

[i] Wacker M, Holick MF.  Sunlight and Vitamin D: A global perspective for health. Dermato-Endocrinology 2013;5(1):51–108.

[ii] Cranney A, Horsley T, O’Donnell S, Weiler H, Puil L, Ooi D, et al.  Effectiveness and safety of vitamin D in relation to bone health. Evidence Report/Technology Assessment No. 158. Rockville, MD: Agency for Healthcare Research and Quality. 2007.  http://www.ncbi.nlm.nih.gov/books/NBK38410. Accessed February 5, 2013.

[iii] Chung M, Balk EM, Brendel M, Ip S, Lau J, Lee J, et al  Vitamin D and calcium: a systematic review of health outcomes. Evidence Report/Technology Assessment No. 183. Rockville, MD: Agency for Healthcare Research and Quality. 2009.  http://www.ncbi.nlm.nih.gov/books/NBK32603/. Accessed February 5, 2013.

[iv] Chung M, Lee J, Terasawa T, Lau J, Trikalinos T. Vitamin D with or without calcium supplementation for prevention of cancer and fractures: an updated meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155(12):827-38.

[v] Prentice RL, Pettinger MB, Jackson RD, Wactawski-Wende J, LaCroix AZ, Anderson GL, et al.  Health risks and benefits from calcium and vitamin D supplementation: Women’s Health Initiative clinical trial and cohort study.  Osteoporosis Int.  2013;24(2):567-580.

[vi] Institute of Medicine.  Dietary Reference Intakes: Calcium, Vitamin D.  Washington, DC: National Academies Press, 2011.

[vii] Rosen, Clifford J,  Abrams, Steven A,  Aloia John F. et al.  IOM Committee members respond to endocrine society vitamin D guideline. J Clin Endocrinol Metab. 2012;97:1146-1152.

[viii] Holick, Michael F,  Brinkley Neil C, Heike, A et al  Guidelines for preventing and treating vitamin D deficiency and insufficiency revisited.  J Clin Endocrinol Metab. 2012;97:1153-1158.

[ix] Much growth in vitamin sales driven by vitamin D.  Nutr Business J. 2009;14(6/7):5.

Here’s how to file comments:

The proposed revisions are to:

• Nutrition and Supplement Facts Labels
• Serving Sizes 

The FDA makes it very easy to file comments. It provides:

• All necessary information in one place.
• A short guide and checklist

File comments here

• Nutrition and Supplement Facts Label: Docket FDA-2012-N-1210  Comment here now
• Serving Sizes: Docket FDA-2004-N-0258  Comment here now

Living in New York as I do, I miss the fun in Washington, DC, of which there was much yesterday related to the First Lady’s “Drink Up” campaign with the Partnership for a Healthier America.   Here’s one of ObamaFoodorama’s tweets on the event.

Listen to what the First Lady is saying in these selected quotes, some of which deal with the current furor over school meals:

• When the Drink Up campaign was launched last year, it had one simple goal – to get kids and families excited about drinking water.
• As Drink Up encourages more people to drink more water, we also want to help make choosing water an easier choice…water for more people wherever they are, whenever they want it, however they want it – be it tap, filtered or bottled.
• In a number of school districts, participation in the lunch program has actually risen. And there’s a simple reason for that: It’s because those districts actually put some effort into marketing the new meals to the kids. They didn’t just sit back and say, well, the kids like junk food so let’s just give them junk food.
• Instead, they embraced higher standards and more nutritious options, and they worked hard to get the kids excited about them. They did taste tests. They came up with new recipes. They did everything they could to make healthy eating fun.
• Today, we’re seeing the results, especially among younger kids…They’re getting used to healthier food, and they’re developing healthy habits early on that will stay with them for the rest of their lives. And that’s our job as adults… And no matter what, we don’t give up on our kids. And we don’t give up on their health and their futures.
• We need to keep pushing to market healthy products to children and families. We need to keep working together within industries and across industries to help our kids lead healthier lives.

Even better, The California Endowment announced that it will increase community access to water in South Kern County and the Eastern Coachella Valley by installing hundreds of taps and dispensers to fill reusable water bottles in schools and public places.

Let’s have more tap-water initiatives, please.

The more people drink tap water, the greater will be public support for maintaining the quality of municipal water supplies.

Addition, July 24:  The School Nutrition Association wrote the First Lady to complain that it found her remarks offensive.

 

 

The Times’ obituary for Dr. Albert J. (“Mickey”) Stunkard, who died last week at the age of 92, describes his work on the genetics of obesity and quotes Dr. Walter Willett’s comment that genetics accounts for only a small part of the “legions of the obese.”

Stunkard was writing about the lifestyle and environmental determinants of weight gain, long before most of us had a clue.

I learned this in 2000 when Michael Jacobson and I were writing a paper on public health policy approaches to obesity prevention.[i]   We were arguing that policies aimed at preventing weight gain focused almost entirely on personal behavior but needed to focus on fixing the environment of food choice.

A peer reviewer scolded us for missing Stunkard’s work.

At last, we discovered Stunkard’s groundbreaking work.  In the published paper, we wrote:

The most notable exception [to the focus on personal responsibility] was the report of a 1977 conference organized by the National Institutes of Health (NIH) to review research and develop recommendations for obesity prevention and management.

In one paper, A.J. Stunkard thoroughly reviewed social and environmental influences on obesity.[ii]  As a result, the conference report included an extraordinarily broad list of proposals for federal, community, and private actions to foster dietary improvements and more active lifestyles.

These ranged from coordinated health education and model school programs to changes in regulations for grades of meat, advertising, taxes, and insurance premiums. Some of the proposals cut right to the core of the matter: “Propose that any national health insurance program…recognize obesity as a disease and include within its benefits coverage for the treatment of it.” “Make nutrition counseling reimbursable under Medicare.” And “Fund demonstration projects at the worksite.”[iii]

He was far ahead of his time and will be greatly missed.

References

[i] Nestle M, Jacobson MF.  Halting the obesity epidemic: A public health policy approach.  Public Health Reports 2000;115:12-24.

[ii] Stunkard AJ. Obesity and the social environment: current status, future

prospects. In: Bray GA, editor. Obesity in America. Washington:

Department of Health, Education, and Welfare (US); 1979. NIH Pub.

No.: 79-359.

[iii] Stunkard A. The social environment and the control of obesity. In:

Stunkard AJ, editor. Obesity. Philadelphia: WB Saunders; 1980. p. 438-

 

Sheldon Krimsky and Jeremy Gruber, eds.  The GMO Deception: What You Need to Know about the Food, Corporations, and government Agencies Putting Our Families and Our Environment at Risk.  Skyhorse Publishing, 2014.

I did a blurb for this one:

GMO Deception brings together essays by specialists in a wide range of fields united in skepticism about the benefits of GMOs for reasons grounded in in biology, social science, politics, and ethics.  If you do not understand why there is so much opposition to GMOs, nationally and internationally, this book is the place to start.

Politico ProAg’s Helena Bottemiller Evich has been reporting on the School Nutrition Association (SNA) meeting in Boston this week (and see the video conversation with her editor, Jason Huffman, about the meeting).

One of her points: from the kinds of junk-food products exhibited, you would never know that the SNA was at war with the White House over USDA’s nutrition standards for school meals (see my previous posts).

As she explains, food companies have had no problem coming up with look-alike products that meet USDA standards:

More than 400 exhibitors showed off their innovations designed to meet the Department of Agriculture’s new regulations…PepsiCo, which owns Tropicana, Quaker and Lays, has a long list of products that meet the new rules, including Reduced Fat Doritos and Cheetos, Stacy’s Pita Chips and Munchies. Windsor Foods, which specializes in food service, has come up with whole grain-rich egg rolls that the company says kids love.

General Mills displayed a modified version of Chex Mix, a whole grain Betty Crocker cookie and a Cinnamon Toast Crunch cereal bar: “Snacks so good, kids won’t know they’re nutritious,” according to the marketing flyers.

…while the changes to lunch standards may be giving many school nutrition professionals fits, the food manufacturing industry is drooling over the opportunity to gain more sales inside what has been described as the nation’s largest restaurant: The school lunch program serves 30 million kids each day and represents a $30 billion per year market for the food industry, according to the Center for Science in the Public Interest.

…SNA benefits from the food industry’s enthusiasm in school lunches. The largest chunk of the group’s revenue is generated at its annual conference, which brought in $4.7 million in 2012. The association charges $15,000 to sponsor an education session track featuring a company representative and $20,000 to put company logos on hotel key cards.

Evich quotes Michele Simon, who also attended the meeting.

Walking through that hall, it’s very hard to see where the changes are,” she said. “It’s still pretty appalling to see the types of junk food that can pass as acceptable food for school meals. It seems like there’s a disconnect between the uproar over the improved guidelines and all these vendors who seem to have no problem meeting them.”

Michele sent me a photo of one such product.

 

For photos of other such items, see Michele Simon’s other images on Time Magazine’s site, and Nancy Huehnergarth’s collection of what she calls “The Good, the Bad and The Ugly Food Exhibits.”

To understand what this is about, take a look at the Public Health Advocacy Institute’s report on Copycat Snacks in Schools.  The “better for you” versions are sold in schools, but you can hardly tell the difference between those and the “not so good for you” commercial versions from the nearly identical packages.

How can food and beverage companies get away with this?  This is the result of USDA’s setting nutrient-based, rather than food-based standards for school meals.  Setting nutrient standards allows food companies to tweak the formulas to give the USDA what it requires.

Is a slightly “better for you” option necessarily a good choice?  Surely, schools can do better.

The FDA is taking comments on its proposals to revamp the food label until August 1, 2014.

It has two sets of proposed changes:

• Nutrition and Supplement Facts Labels
• Serving Sizes

Here is the first of my comments on several food label items.  Feel free to copy, edit, or file your own (see directions below).

July 16, 2014

TO:  FDA

FROM:  Marion Nestle, Professor, New York University

RE:  Nutrition Facts panel: ADDED SUGARS

1.  Retain the line for Sugars but call it Total Sugars

2.  Add a line for Added Sugars

Rationale:

• Excessive intake of dietary sugars is well established to raise the risk of obesity and type-2 diabetes.[i]
• Americans on average twice as much as is generally recommended.[ii]
• The amount typically consumed comes close to the upper limit recommended by the Institute of Medicine on the basis of increased risk of nutrient deficiencies.[iii]
• Sugars intrinsic to foods are accompanied by nutrients; added sugars are not.
• Although there is no biochemical difference between intrinsic and added sugars, food and beverage companies know exactly how much sugar they add as part of the recipes for their products.
• Listing the amount of added sugars on food labels would inform consumers about how much sugars are added to the foods they buy.
• Randomized, controlled clinical trials to test the hypothesis that added sugars increase disease risk would violate ethical standards and, therefore, are impossible to conduct.

3.  Establish a Daily Reference Value for Added Sugars of 10% of total calories

Rationale:

• Since the 1977 Dietary Goals, health officials have consistently recommended an upper limit of 10 percent of calories from added sugars.[iv]
• The 1992 USDA Food Guide Pyramid suggested an upper limit of 6, 12, and 18 teaspoons of sugars, respectively, for daily diets of 1,600, 2,200, and 2,800 calories, respectively.  This works out to 7, 10, and 13 percent of calorie intake, respectively, for an average of 10 percent.[v]
• By 1992, health officials in several European countries had recommended much the same.[vi]
• The Institute of Medicine’s 2002 upper safety limit of 25% of calories was based on risk for nutrient deficiencies, not obesity and chronic disease.[vii]
• In 2009, the American Heart Association recommended that women consume no more than 100 calories per day from added sugars (25 grams), and men no more than 150 calories per day (38 grams).  These come to 5 percent and 7.5 percent, respectively, of a 2000-calorie daily diet.[viii]
• The 2010 Dietary Guidelines for Americans state that no more than 5 to 15 percent of calories should come from a combination of solid fats and added sugars.  This implies that added sugars should be less than 10% of calories.^[ix]
• Dr. Robert Lustig says that a “dose” of added sugars up to 50 grams a day poses little risk for metabolic or chronic disease.  This amounts to 200 sugar calories and 10% of a 2,000-calorie daily diet (he says twice that much, the amount commonly consumed by Americans, is toxic.[x]
• The World Health Organization in 2014 said that added sugars should make up less than 10 percent of total calories per day, and less than 5 percent would be even better,[xi] based on two research reviews, one on sugars and obesity[xii]  and one on sugars and tooth decay.[xiii]
• Added sugars as 10% of calories represents about half the amounts currently consumed and comes close to consensus.

References

[i] Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohttp://steinhardt.nyu.edu/nutrition/hort studies. BMJ 2012;345:e7492.  doi: 10.1136/bmj.e7492.

[ii] USDA.  Loss-adjusted food availability documentation.  March 11, 2014.  http://www.ers.usda.gov/data-products/food-availability-(per-capita)-data-system/loss-adjusted-food-availability-documentation.aspx#.UzlzcfldU6w.   USDA.  Food availability documentation: added sugar and sweeteners.  http://www.ers.usda.gov/data-products/food-availability-(per-capita)-data-system/food-availability-documentation.aspx#sugar.   The tables used to construct figure 3D are at: Refined Sugar, Corn Syrup, Other Sweeteners.

[iii] Institute of Medicine (IOM) of the National Academies. “Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients), Chapter 6: Dietary Carbohydrates: Sugars and Starches”, Washington, DC: National Academies Press; 2002.

[iv] U.S. Senate Committee on Nutrition and Human Needs.  Dietary Goals for the United States, December 1977.

[v] USDA.  Food Guide Pyramid, 1992.

[vi] Cannon G:  Food and Health: The Experts Agree.  London:  Consumers’ Association, 1992.

[vii] USDA.  Is intake of added sugars associated with diet quality?  Nutrition Insights, Insight 21, October 2000.

[viii] Johnson RK, Appel LJ, Brands M, et al.  Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association.  Circulation. 2009;120(11):1011-1120.  doi: 10.1161/CirculationAHA.109.192627.

[ix] USDA and USDHHS.  Dietary guidelines for Americans, 2010.  http://www.cnpp.usda.gov/dgas2010-policydocument.htm.

[x] Lustig RH.  Fat Chance: Beating the Odds Against Sugar, Processed Food, Obesity, and Disease.  Hudson Street Press, 2012.

[xi] WHO.  Draft guideline: Sugars intake for adults and children, March 2014. http://www.who.int/nutrition/sugars_public_consultation/en/.

[xii] Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ 2012;345:e7492 doi: 10.1136/bmj.e7492.

[xiii] Moynihan PJ, Kelly SAM.  Effect on Caries of Restricting Sugars Intake. Systematic Review to Inform WHO Guidelines.  JDR 2014;93:8-18.  doi:10.1177/0022034513508954.

 

The FDA makes it easy to file comments. It provides:

• All necessary information in one place.
• A short guide and checklist
• Nutrition and Supplement Facts Label: Docket FDA-2012-N-1210  Comment here now
• Serving Sizes: Docket FDA-2004-N-0258  Comment here now

I know I live on another planet, and my kids are long grown, but is there really a void in the market that has to be filled by a half-juice, half-herbal tea drink in a box for kids?

According to Food Navigator, the CEO of Drazil (lizard spelled backwards) Kids Tea thinks this product

pinpoint[s] a void in the kids’ beverage marketplace for a naturally healthy, reduced-sugar ready-to-drink beverage line as US consumers started falling out of love with 100% juice….There’s a huge need for healthy beverages that actually appeal to kids, so I thought, why not tea?…“I’ve studied how habits are formed when doing product development,” she said. “How do you get more adult tea drinkers? You get them to start drinking it regularly when they’re young. Tea is perfect because it’s relatively inexpensive to brew, so healthy—all those antioxidants, nutrients. Why not develop those habits young?”

OK.  The concept is adorable.

But is tea really loaded with antioxidants and nutrients?  Not like fruit juices.  This product is a juice drink that dilutes juice and its nutrients by half.   Yes, it also dilutes the fruit sugars by half but the boxes are 6.75 ounces and that much 100% juice is not unreasonable for school-age kids.

What ever happened to tap water?

This product is about marketing, and marketing to kids and hooking them early at that.

As I said, I live on another planet.

Authors employed by the Food Packaging Forum Foundation, funded by the packaging industry but working “independently of donors’ special interests,” have produced a surprising analysis of chemical in food packaging that comes into contact with food during production, handling or storage.

Why surprising?  Because the results are indeed against donors’ special interests.

Such chemicals, the authors say, can contaminate food through migration from the packaging.  About 6000 such substances exist, some of which are associated with disease.  These are Chemicals of Concern (COCs).

This study identified chemicals used in packaging that are considered to be COCs.  It found 175 such chemicals in use.  Of these, 54 are “candidates for Substances of Very High Concern.”

From a consumer perspective, it is certainly unexpected and undesirable to find COCs [chemicals of concern] being intentionally used in FCMs [food contact materials], and thus it seems appropriate to replace substances case by case with inherently safer alternatives.

This comes from people in the industry.  I hope makers of packing materials—and food safety regulators—pay close attention.