Food Politics is celebrating a birthday this year with the publication of a tenth anniversary edition in May. Today is actually its eleventh birthday. My department celebrated the occasion with a birthday cake!
The Lancet has just published a series of articles on non-communicable diseases (NCDs) the collective term for heart disease, type 2 diabetes, and other chronic conditions caused in large part by poor diets, lack of physical activity, or cigarettes or alcohol.
Since food politics is a big part of this discussion, these papers are worth a look. For example, as editor Richard Horton explains in his editorial:
So where are the global conferences on NCDs, the research meetings, the task forces, the grand challenges initiated by funders and foundations? They don’t exist. We, the global health community, understand that chronic diseases are a present danger to the health of our societies. Yet we are unable to translate that understanding into real political action. We cannot quite bring ourselves to put heart disease, stroke, cancer, chronic respiratory disease, diabetes, or mental ill-health, together with their associated risk factors, on an equal footing with childhood pneumonia and diarrhoea, preventable maternal death, or epidemics of AIDS, tuberculosis, and malaria. The disconnect between the reality of people’s lives in countries and the concerns of professional and political leaders has rarely been greater.
Here are the papers in this series. Read them and ponder.
Last week, First Lady Michelle Obama did a national tour to celebrate the third anniversary of her Let’s Move! campaign to end childhood obesity within a generation.
As explained in the White House press release, the tour was to focus on school lunches, physical activity, and getting businesses involved—“Healthy Families, Thriving Businesses.”
To that end, she visited a Walmart in Springfield, Missouri to congratulate the company on its pledge to open 300 stores in communities with limited access to affordable healthy foods, to reduce salt and sugars in its products, to make healthier food more affordable, and to put front-of-package logos on healthier foods.
As the press release explained (and as Walmart says in its own):
Walmart is one of many businesses across the country that is making healthy changes to support their customers, because they recognize that what’s good for their customer’s health is also good for their business. Following the tour, Mrs. Obama will deliver remarks about how supporting the health of American families is also good for business, and remind consumers that it’s up to them to continue demanding healthier options.
Did this mean that the new emphasis of Let’s Move! would be on personal responsibility? Mrs. Obama explained further in the Wall Street Journal:
Take the example of Wal-Mart. In just the past two years, the company reports that it has cut the costs to its consumers of fruits and vegetables by $2.3 billion and reduced the amount of sugar in its products by 10%. Wal-Mart has also opened 86 new stores in underserved communities and launched a labeling program that helps customers spot healthy items on the shelf.
The best reported account of this visit is by Eddie Gehman Kohan at Obamafoodorama. She points out that this particular Walmart is not located in an underserved community. She also did the math and calculated that the savings in the cost of fruits and vegetables work out to 16 cents per week per customer.
At this point, I thought it was time for a field trip.
I was in Ithaca, NY over the weekend and checked out its Walmart to see what its Let’s Move!-inspired actions looked like on the ground. I particularly wanted to see how its “Great for You” labeling program was working out. This, you may recall, identifies healthy products with this logo:
Although the labeling program was announced a year ago, I had to search hard to find any examples. Here are a couple in the produce section.
Only a few bins of produce were marked with those labels. There’s a tiny one in the picture below in front of some clementines from Honduras, but none of the other foods in that section had labels.
I could not find another such label anywhere else in the store.
How else was this Walmart promoting healthier eating? Its big in-store promotion that day was right along the produce section: a large display of Oreo Mega Stuf cookies (the ones with twice the filling and twice the calories of regular Oreos). A man was handing out free samples and dollar-off coupons. When I picked up a package to read the label he said “Don’t do that. Treat yourself.”
The Ithaca Walmart is a quarter of a mile from Wegmans, so I did some comparison shopping. I was surprised to find that the prices were remarkably close—about the same or only slightly higher (explaining why the Walmart price advantage is only a couple of cents a day).
But the people who shopped in Wegmans looked more affluent and healthier than Walmart shoppers.
Although the prices are similar—and the fresh foods at Wegmans are of higher quality—that Walmart is much less crowded, sparsely staffed by poorly paid employees, and somehow makes it more comfortable for very poor people to shop there.
My conclusions:
On this basis, does Walmart deserve this high level of White House praise and attention?
I don’t get it.
My monthly (first Sunday) column in the San Francisco Chronicle is now out, this time on the horsemeat scandal.
Q: It makes me sick to think that anyone could eat horsemeat. I don’t see how it could get into so many foods. Tell me how I can be sure I’m not eating it.
A: From this side of the Atlantic, the discovery of horsemeat in European hamburger and frozen dinners is the most riveting of scandals, replete with DNA technology, veterinary drugs, impossible-to-trace supply chains, smuggling, organized crime and outright fraud – not to mention the usual finger-pointing, cover-ups and protestations of shock that accompany food crises.
It is easy to explain how horsemeat got into vast amounts of hamburger and prepared meals. Horses are expensive to house and feed. Something has to be done with them when they are no longer wanted for farming, transport, racing or recreation. Horsemeat is edible, even delicious to some, and costs less than beef.
Complications
In Europe, the supply chains are exceptionally complicated, involving countless companies in more than 21 countries that process, transport or sell horses or horsemeat. The complexity makes it relatively easy to use horses to smuggle people or drugs, to label horsemeat as beef or to slip it into hamburger.
This would just be a matter of economic fraud if people didn’t care whether they ate horsemeat. But some Europeans, and most Americans, care very much. Like you, many people are appalled at the idea of eating any companion animal, let alone one symbolic of the rugged West.
Beyond cultural prohibitions, there are other reasons to avoid eating meat from horses not raised for food. Horses are routinely treated with veterinary drugs, legal and not. The drug traces found in European horsemeat may be too low to cause harm, but hardly seem likely to promote human health.
How long horsemeat has been passed off as European beef is unknown, as is why officials in Ireland decided to do DNA tests on supermarket meals in the first place. Whether done as routine testing or because of a tip, the results were startling. More than one-third of the tested “beef” samples contained horsemeat. Later tests in Great Britain identified “beef” meals made entirely from horsemeat.
This, as the Guardian’s writer Felicity Lawrence wrote in her guide to the scandal, can only be “industrial scale adulteration.”
The ensuing crisis forced many food companies and retailers to recall vast numbers of products, some intended for school meals. Nestlé (no relation) recalled pasta meals, but issued assurances that such products do not leave Europe and that none of its American products contains horsemeat-laden European beef.
What to make of this? In our food studies programs at New York University, we discuss food as a marker of cultural identity. People in other nations eat horsemeat. But like you, about 80 percent of Americans are appalled at the idea of eating horsemeat and oppose slaughtering horses for food or any other reason.
Yet horsemeat used to be eaten by Americans (and still is, by some), and even more so by pets. As Malden C. Nesheim and I wrote in our book about the pet food industry, “Feed Your Pet Right,” horse slaughterhouses created pet food companies to dispose of the meat. Through the 1940s, nearly all domestic horsemeat ended up in pet food.
Under pressure from horse lovers and animal welfare advocates, pet food companies replaced horsemeat with meat from other animals. Although horsemeat is permitted in pet food, and in theory could show up in rendered byproducts and meals, no American company would knowingly use it as an explicit item in an ingredient list. One can only imagine the uproar if it did.
Inspection issues
In 2007, Congress blocked the Department of Agriculture from inspecting slaughterhouses, effectively banning their use. As unintended consequences, the 140,000 or so unwanted horses each year had to be transported to slaughterhouses in Canada or Mexico, and populations of neglected and abandoned horses increased. As a result, Congress permitted horse slaughterhouses to reopen last year, but the USDA has yet to authorize inspectors to work in them.
Could American beef be contaminated with horsemeat? We had a similar scandal in the 1950s. But if U.S. officials are testing hamburger for horsemeat DNA these days, they aren’t saying.
Because horsemeat is not produced here, it won’t be in butcher shops or supermarkets – unless the stores imported it or acquired contaminated products before the recalls, or unless the USDA assigns inspectors and allows horse slaughterhouses to reopen. Right now, without DNA testing, you can’t be sure.
You find this alarming? Short of going vegetarian, you have an option: Buy kosher meat. Jewish dietary laws prohibit horsemeat – horses are not ruminants and do not have cloven hooves – and kosher slaughterhouses are diligent about excluding forbidden animals.
This gives the horsemeat scandal one clear winner: Sales of kosher meat are booming.
I spent a lot of time last week talking to reporters about the widely publicized study in PloS One that correlates sugar and diabetes.
The study is based on an econometric model of data food availability and diabetes prevalence in many countries. Such data are not particularly reliable, but the authors did the best they could with what they had. They are quite forthcoming about the limitations of their model and the data on which it is based [see addition below].
Their principal conclusion: for every 150 kcal/person/day increase in sugar availability (about one can of soda/day), diabetes prevalence increases by about 1%.
Because no other dietary, weight, or behavioral factor shows this kind of effect in their model, it is tempting to interpret the study as demonstrating that sugar is a risk factor for diabetes independent of calorie intake or body weight.
I’m not so sure. Take a look at the summary figures and decide for yourself.
Figure 1. Relationship between obesity and worldwide prevalence of diabetes.
Despite outliers, this figure shows an obvious and strong correlation between obesity and diabetes. Compare this to Figure 2.
Figure 2. Relationship of sugar availability to worldwide diabetes prevalence.
The correlation here is much less obvious. Without statistical tests, you could just as easily draw the line straight across the graph. The statistical significance is much weaker than that in Figure 1.
This means that these data cannot easily distinguish between several possibilities:
(a) Calories –> Obesity –> Diabetes
(b) Sugar –> Diabetes
(c) Sugar –> Calories –> Obesity –> Diabetes
While waiting for science to clarify these distinctions, the bottom line is the same for all of them.
As I explained in yesterday’s post, everyone would be healthier eating less sugar.
Addition: The authors have posted detailed comments about their methods.
Here’s another one of those occasional queries from Kerry Trueman. This one, posted at Huffington, is about FDA regulations for labeling sugars.
Trueman: I’ve just begun to sink my teeth into Michael Moss’s extraordinary food industry exposé, Salt Sugar Fat: How the Food Giants Hooked Us, a book you’ve rightly lauded as a “breathtaking feat of reporting.” As Moss points out, the FDA is happy to give us guidelines on how much salt and fat to include in our daily diets, but–as a glance at any nutritional label shows–they’ve declined to make any recommendation at all about sugar.
Does this mean that:
(a) It’s OK to eat as much sugar as you like, or:
(b) There may be an unsafe level of sugar consumption, but the FDA just doesn’t have the resources to figure out what that level is, or:
(c) The FDA knows how much sugar we can eat without harming our health, but the food industry won’t let them tell us.
How is the average American supposed to interpret this absence of information?
Nestle: Whoa. Slow down. Let’s back up a minute. The FDA sets nutritional standards for food labels, but the Institute of Medicine (IOM) sets nutritional standards for dietary intake. To understand what’s happening with the FDA and food labels, we have to talk about what the IOM used to call the Recommended Dietary Allowances (RDAs) but now calls Dietary Reference Intakes (which, confusingly, include RDAs and other standards, such as Upper Limits).
In 2002, the IOM set standards for total carbohydrates–sugars and starches (which are converted to sugars in the body). In its review of the evidence, the IOM set the RDA for total carbohydrates at 130 grams a day (roughly 4 ounces) to meet the needs of the brain for fuel. This amount is much less than typically consumed by adults.
As for sugars, the IOM noted that the average intake of sugars among adolescent males was 143 grams per day, and that the heaviest users were consuming 208 grams per day–much more than the amount of total carbohydrate needed.
Since sugars are not required nutrients, the IOM could not set an RDA. And although it did not have enough evidence to set an Upper Limit, the IOM suggested that the maximum level of intake of added sugars (as opposed to those naturally present in foods) should be a whopping 25% or less of calories.
Americans typically consume around 20% of calories from added sugars. Taken at face value, the IOM suggestion made it sound as if current intake levels were just fine. The sugar industry happily viewed 25% as a recommendation, not a maximum.
Before the sugar industry got after them, many countries recommended an upper level of sugar intake at 10% of calories. That’s what the U.S. Pyramid did in 1992.
The sugar industry does not like the 10% recommendation. It means, for example, that just one of Mayor Bloomberg’s 16-ounce sodas takes care of recommended sugar intake for the day.
Robert Lustig, who is largely concerned about what too much fructose does to us, thinks that 50 grams of sugar (sucrose or HFCS) is a reasonable Upper Limit for most people. This would provide 25 grams of fructose, which the body can handle with relative ease. What’s interesting about his cut point is that it means 200 calories a day, or 10% of calories for a 2000 calorie diet. So there we are at 10% of calories again.
If the FDA wanted to be helpful, it could do two things.
1. Require companies to list added sugars under the carbohydrate category on food labels.
2. Set a DV for sugars at 50 grams.
In the meantime, everyone would be healthier eating less sugar.
Oxfam America announced a new initiative this week—an accountability project it’s calling Behind the Brands.
Oxfam is an international relief and development organization. It is concerned about what the top ten global food companies—Associated British Foods, Coca Cola, Danone, General Mills, Kellogg, Mars, Mondelez, Nestlé, Pepsico and Unilever—are doing about social and environmental policies to:
Oxfam finds the Big Ten companies to rank from so-so to poor on these measures. The overall results?
Oxfam intends to monitor companies’ responses and to adjust scores accordingly. It will have plenty of work to do.
Does Oxfam think companies will voluntarily take actions that might reduce their bottom lines? Will its scorecard encourage voluntary action? I’m not optimistic.
The first company to respond, Associated British Foods, terms Oxfam’s charges “ridiculous.”
Malden Nesheim and I wrote an editorial for the Annals of Internal Medicine that has just gone online, and is likely to elicit plenty of discussion. We comment on the highly conservative, evidence-based recommendations of the U.S. Preventive Services Task Force for taking supplements of calcium and vitamin D as a means to prevent osteoporosis.
Our commentary: “To Supplement or Not to Supplement: U.S. Preventive Services Task Force Recommendations on Calcium and Vitamin D.” Here’s what we said:
In this issue, the U.S. Preventive Services Task Force (USPSTF) plunges headlong into ongoing debates about whether healthy adults—those who show no signs of vitamin D deficiency or osteoporosis—should be advised to take combined supplements of calcium and vitamin D to prevent bone fractures and, if so, at what level (1).
In terse statements unlikely to settle the debates, the Task Force states first that insufficient evidence makes it impossible to determine how supplementation affects fracture incidence in men or premenopausal women. Next, it deals with postmenopausal women. For this group, the Task Force says that evidence is insufficient to assess the effects of daily supplementation with greater than 400 IU of vitamin D3 and greater than 1000 mg of calcium. The Task Force’s unambiguous conclusion: Supplementation at or below those levels does not prevent fractures. Because supplementation at or below 400 IU of vitamin D3 and 1000 mg of calcium seems to convey a slightly increased risk for renal stones, the USPSTF recommendation for postmenopausal women is also unambiguous: “do not supplement.”
The Task Force based these decisions on 2 commissioned evidence reviews and a meta-analysis (2 – 4). More recent data from the Women’s Health Initiative also are consistent with inconclusive findings, except among a subgroup of long-adherent supplement recipients who experienced a reduced risk for hip—but not total—fractures (5).
The Task Force’s recommendations must be interpreted in the light of ongoing disputes about the most effective method for assessing vitamin D deficiency, whether calcium and vitamin D supplements are needed by a large portion of the population, and what level of supplementation might best maximize benefits and minimize risks.
In 2011, after reviewing more than 1000 studies, the Institute of Medicine (IOM) concluded that vitamin D and calcium are indeed critical to bone health but their role in other diseases—cancer, heart disease, diabetes, immune function, and reproductive health, for example—remains uncertain. The IOM did not consider deficiencies of either calcium or vitamin D to be serious problems in the United States, except among certain population groups. Instead, because of widespread fortification and supplementation, the IOM was concerned about the possibility of adverse consequences from oversupplementation (6).
With risks as well as benefits in mind, the IOM established the average adult daily requirement for calcium at 800 to 1000 mg depending on age, the Recommended Dietary Allowance (the amount needed to meet the needs of about 97% of the population) at 1000 to 1200 mg, and the safe upper level of intake at 2000 to 2500 mg. Its corresponding recommendations for vitamin D were 400 IU, 600 IU (800 IU for older adults), and 4000 IU, respectively. The IOM viewed these levels as sufficient to maintain blood levels of 25-hydroxyvitamin D at or above 20 ng/mL, a level it considered adequate to meet population-based needs regardless of amounts synthesized as a result of sun exposure.
Vitamin D, of course, is not a vitamin in the usual sense. It is a hormone produced in response to the action of sunlight on skin. Like other hormones, vitamin D has multiple roles in the body, not all of them well-understood. Vitamin D supplementation, therefore, must be considered a form of hormone replacement therapy. As such, it raises all of the questions about efficacy, dose, and side effects currently asked of such therapies.
In that light, the 2011 recommendations of the Endocrine Society deserve special scrutiny (7). The Society approaches questions about vitamin D from a standpoint quite different from that of the IOM. It appointed its own task force to make recommendations based on the premise that vitamin D deficiencies are common among all age groups. The Society prefers 30 ng/mL of 25-hydroxyvitamin D as the target level for maximum benefits. By that criterion, virtually all U.S., Canadian, and European adults are deficient in hormone vitamin D and require daily supplements of 1500 to 2000 IU. For adults with demonstrated deficiency, the Society recommends treatment with 50 000 IU of the hormone once a week or daily supplementation of 6000 IU for 8 weeks, followed by 1500 to 2000 IU for maintenance.
This clinical endocrinology perspective differs from the nutrition science perspective of the IOM committee, whose members tend to interpret studies of single nutrients within the context of the diet as a whole. From this standpoint, the amount of hormone generated by the action of sunlight on skin (which ought to be more than adequate for people who spend time outdoors in latitudes as far north as Boston) is crucial to decisions about supplementation. The IOM and Endocrine Society debated their conflicting perspectives in an exchange published in 2012 (8 – 9). The insufficiency of research to resolve such arguments has permitted vitamin D to become “trendy.” It is advertised on boxes of fortified cereals, has its own prosupplement advocacy group, and generates millions in annual supplement sales (10).
The USPSTF’s recommendations can be understood as an attempt to clarify the present situation with respect to one specific outcome of supplementation. In doing so, its recommendations have a substantial advantage. They depend on hard end points—fractures—rather than on blood levels of 25-hydroxyvitamin D, at best an indirect measure of vitamin D adequacy. The USPSTF uses the same precautionary approach as did the IOM. In the absence of compelling evidence for benefit, taking supplements is not worth any risk, however small.
A previous attempt to sort through the various claims for vitamin D noted an urgent need for further research to answer fundamental questions about the risks and benefits of sun exposure, fortification, and supplements, and the hormone’s role in body functions beyond bone mineralization (11). The USPSTF plans to publish further recommendations on the role of vitamin D in cancer prevention. When it does, we hope it will keep in mind the value of making a single recommendation about vitamin D and calcium supplementation that will encompass all potential benefits and risks. Multiple recommendations by condition confuse practitioners and the public. While we wait for the results of further research, the USPSTF’s cautious, evidence-based advice should encourage clinicians to think carefully before advising calcium and vitamin D supplementation for healthy individuals.
References
1 Moyer VA; U.S. Preventive Services Task Force. Vitamin D and calcium supplementation to prevent fractures in adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2013. [Epub ahead of print]
2 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. Evid Rep Technol Assess (Full Rep). 2007:1-235. [PMID: 18088161]
3 Chung M, Balk EM, Brendel M, Ip S, Lau J, Lee J, et al. Vitamin D and calcium: a systematic review of health outcomes. Evid Rep Technol Assess (Full Rep). 2009:1-420. [PMID: 20629479]
4 Chung M, Lee J, Terasawa T, Lau J, Trikalinos TA. 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;155:827-38. [PMID: 22184690]
5 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. Osteoporos Int. 2013;24:567-80. [PMID: 23208074]
6 Institute of Medicine. Dietary Reference Intakes: Calcium, Vitamin D. Washington, DC: National Academies Pr; 2011.
7 Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al; Endocrine Society. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96:1911-30. [PMID: 21646368]
8 Rosen CJ, Abrams SA, Aloia JF, Brannon PM, Clinton SK, Durazo-Arvizu RA, et al. IOM committee members respond to Endocrine Society vitamin D guideline. J Clin Endocrinol Metab. 2012;97:1146-52. [PMID: 22442278]
9 Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al. Guidelines for preventing and treating vitamin D deficiency and insufficiency revisited. J Clin Endocrinol Metab. 2012;97:1153-8. [PMID: 22442274]
10 Supplements stand out as 2008 sales bright spot for U.S. nutrition industry. Vitamins: D still shines. Nutrition Business Journal. 2009;14(6/7):5. Accessed athttp://newhope360.com/research-and-insights/supplements-stand-out-2008-sales-bright-spot-us-nutrition-industry on 15 February 2013.
11 Brannon PM, Yetley EA, Bailey RL, Picciano MF. Overview of the conference “Vitamin D and Health in the 21st Century: an Update”. Am J Clin Nutr. 2008;88:483S-490S. [PMID: 18689388]
Here’s the first objection:
This session is on Practicing Food Studies. It will be at 5;00 p.m. Details to come.