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A reader who wishes to remain anonymous sent me an account of the development of the new Nordic Nutrition Recommendations, pointing out what they do not contain: a recommendation to reduce ultra-processed foods [Note: this is an updated and slightly corrected version of what was first posted on July 9].

Indeed, on pages 253-255 (this is a long report), you will find this statement:

The backstory here is one of effective food industry lobbying.

The Nordic Nutrition Recommendations do not say:  reduce consumption of ultra-processed foods.

The story begins with two authors who were asked to sum up the health effects of ultra-processed foods, and to advise the committee writing the recommendations.  They did so.  Their initial background paper concluded with these recommendations:

(1) Limit the consumption of ultra-processed foods.

(2) Choose less processed form of foods within each food group when possible.

(3) Cook at home and choose freshly prepared foods when eating out.

The committee revised the background paper.  It omitted the three recommendations but concluded:

Recommendations to limit ultra-processed foods, and choose foods of lower processing level, when possible, may enhance and support several of the existing FBDGs [food-based dietary guidelines] and help individuals select more healthful foods that align with the overall NNR2022 [last years Nordic Nutrition Recommendations] guidelines within each food category. For example, such advice would support choosing plain, unsweetened yoghurt instead of flavored, sweet yoghurt; choosing oatmeal or muesli based on grains, nuts, and dried fruits over sweetened, refined breakfast cereals; and choosing chicken breast/thighs over chicken nuggets.

The revised document was opened for public comment and a hearing.  A great many representatives of food companies objected to saying anything negative about ultra-processed foods.  This Excel spreadsheet lists the 60 people who commented and their main objections.

After the hearing, the committee preparing the recommendations wrote a draft report based on the comments.  The section on ultra-processed foods is on pages 152-153.  It begins:

There is currently no consensus on classification of processing of foods, including UPFs. The dominating UPF classification (NOVA classification group 4) contains a variety of unhealthy foods, but also a number of foods with beneficial health effects.

It also says:

Health effects. Regular intake of UPF encourages over-eating and intake of foods in the UPF category of the NOVA classification has been suggested associated with increased risk of obesity, cardiovascular disease, type 2 diabetes, cancer, depression, and premature mortality …However, no qSRs [qualified systematic reviews] support these suggestions.

These negative views of the UPF concept differ from the views of the background document (however politely stated) and clearly were influenced by the overwhelmingly negative views of food industry representatives.

The draft report also was opened for public comment.  These comments also are listed in an Excel document. Some favor the changes benefiting the food industry; others—but many fewer—object to them (these last are summarized in yet another document).

The final Nordic Nutrition Recommendations are somewhat of a compromise between public health and food industry views, but generally favor the food industry position.  The new Nordic Nutrition Recommendations are less critical of the UPF concept, but do not say “reduce consumption of ultra-processed foods.”

The NOVA food classification system, which first defined ultra-processed foods, was published by Carlos Monteiro, a professor of public health at the University of São Paulo, and his colleagues in 2009.*  About the Nordic recommendations, my informant writes:

I have come to realize that this is not at all about evidence. It’s about power, and who gets to define what’s important in nutrition science. “The establishment” refuses to accept that someone from Brazil, a country they regard as inferior, should be allowed to tell them they have been wrong in their nutritionism-approach. They claim NOVA is based on ideology, not science….And now this is getting in the way of public health.

My take-home lesson:  The food industry came out in force on this issue and greatly overwhelmed the few comments of public health advocates.  The message here seems clear: public support for reduction of ultra-processed food needs to be widespread, clear, and forceful.

*Definition of ultra-processed foods

• Industrially produced
• Bearing no evident relationship to the foods from which they were derived
• Formulated to be irresistably delicious (if not addictive)
• Usually containing color, flavor, and texture additives
• Often high in salt, sugar, and fat (but these are culinary ingredients that do not in themselves make foods ultra-processed)
• Cannot be made in home kitchens (because they are industrially produced and contain ingredients unavailable to home cooks)

Addition

An additional document was sent to me after this post and the response from nutritionists involved in the NNR, which I posted the following week.  It is from the authors of the background document expressing their concerns about the changes made.

Chocolate for breakfast? Kellogg’s + Hershey’s collab takes cereal to new heights in IndiaThe breakfast cereal giant has joined forces with one of the largest chocolate manufacturers in the world to launch Kellogg’s Hershey’s Chocos on the Indian market…. Read more

When I saw this, I wondered what was new here.  We already have plenty of chocolate breakfast cereals, organic and not, most of them aimed at kids.

These, for example:

At best, these cereals have some cocoa in them, usually as the 5th ingredient or less.

I can’t find an ingredient list for the cereal aimed at India, but I did find one for similar products sold in other countries.

Chocolate is the first ingredient!

Candy for breakfast!

Yum!

This absolutely superb—informative, eminently readable, compelling—book makes the strongest possible case for the benefits of not eating ultra-processed foods.

These, you may recall, are produced by industrial means, loaded with unfamiliar and questionable food additives, unable to be made in home kitchens, and designed deliberately to be irresistibly delicious, if not addictive, so as to make profits for food companies.

They also encourage people to eat more than they realize, and are consistently associated with poor health.

Van Tulleken is a British physician, scientist, and television star with his twin brother Xand.

Although I am thoroughly familiar with just about everything in this book having written extensively about these topics myself, I still found it to be a great read.

Van Tulleken tells stories really well.  I was hooked on page 30 with the description of Lyra, his 3-year-old daughter’s first encounter with a breakfast cereal aimed at kids.  He had decided to do a Morgan Spurlock  (Super Size Me!) experiment on himself and eat mainly ultra-processed foods for as long as he could stand it.  He began with a breakfast of Coco Pops cereal.

I had assumed that, having never tried Coco Pops, she [Lyra] wouldn’t have any interest in them.  But Kellogg’s had got her hooked before she’d had a mouthful.  She knew that here was a product designed with a three-year-old in mind.  Again, I told her no, so she collapsed on the floor crying and screaming with rage…My lingering doubts [about this cereal] were irrelevant ….Lyra had crawled out from under the table, filled her bowl and started to eat great fistfuls of dry Coco Pops, wide-eyed and ecstatic.  Defeated, I poured out the milk, and read the ingredients…Lyra put her ear to the bowl and shut her eyes, entranced. She then began to eat again.

And eat.  And eat.  As I watched her, it seemed she wasn’t fully in control…Lyra had hardly taken a breath.  I normally have to do a little cajoling at mealtimes, but the first bowl of Coco Pops had simply disappeared.  When I tried to suggest that one bowl was enough, the idea was immediately dismissed.  It felt like advising a smoker to stick to one cigarette.  Her eating wasn’t just mindless: it was trancelike.

This is just what ultra-processed foods are supposed to do.

Van Tulleken calls for government policies to be made without food company involvement, and for policies to restrict the marketing of such foods.

Yes!

The book is published today by Norton. I thought it was a great read.

 A few months ago, I wrote about the FDA’s proposal for allowing the use of the word “Healthy” on food labels.  I said:

If we must have health claims on food packages, the FDA’s proposals are pretty good. They require any product labeled “healthy” to contain some real food (as opposed to a collection of chemical ingredients or, as author Michael Pollan calls them, “food-like objects”), and for the first time they include limits on sugars…These proposed rules would exclude almost all cereals marketed to children.

Now, the Consumer Brands Association (formerly Grocery Manufacturers Association), which represents Big Food, and which objects to the FDA’s proposal, has proposed an alternative framework.

The CBA is clear about its objectives.  It worries that

consumers could second guess or even reject items that might no longer be qualified to bear the “healthy” claim that can bear the claim today…As it stands, the proposed rule would eliminate an inordinate number of packaged products from being considered “healthy.”

That, of course, is its point.

The CBA issued what I read as a clear threat:

FDA’s proposed changes to its “healthy” definition will contradict the current Dietary Guidelines, causing confusion among consumers and potentially inviting legal challenges for the agency.

In other words, if the FDA does not back down on this, CBA intends to go to court over it.

This was also clear from the CBAs 54-page set of comments to the FDA.  As quoted in the Washington Post, the CBA said:

We are particularly concerned by the overly stringent proposed added sugars thresholds. We appreciate FDA’s interest in assessing added sugars intake. We believe, however, that FDA’s restrictive approach to added sugars content in foods described as healthy is unwarranted and outside FDA’s authority given the lack of scientific consensus on the relationship between sugar intake and diet-related disease.

Ted Kyle, who writes the excellent newsletter, ConscienHealth, also quoted the CBA:

Manufacturers have the right to label foods that are objectively ‘healthy’ as such, based on a definition of ‘healthy’ that is truthful, factual, and non-controversial. We are concerned that limiting the truthful and non-misleading use of the word ‘healthy’ in product labeling could harm both the consumer and the manufacturer.

As Kyle put it, “If you did not catch it, this is a freedom of commercial speech argument. Any guesses how the current Supreme Court might rule on that one? Yep, corporations are people too.”

As I am ever saying, food companies are not social service or public health agencies.  They are businesses whose first priority is returns of profits to shareholders, regardless of how their products affect health (or the environment, for that matter).

The pushback on the FDA’s seemingly trivial “Healthy” idea, is enought to make me think it might actually have some impact.

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The USDA is trying to improve nutrition standards for school meals.  I wish it the best of luck.

It is proposing over the next several years to:

• Limit added sugars in certain high-sugar products and, later, across the weekly menu;
• Allow flavored milk in certain circumstances and with reasonable limits on added sugars;
• Incrementally reduce weekly sodium limits over many school years; and
• Emphasize products that are primarily whole grain, with the option for occasional non-whole grain products.

This does not make it sound as if USDA is in much of a hurry.  Or that it is doing anything particularly radical.

Take the sugar proposals, for example.  Currently, the re are no limits on sugars in school meals, which means that any limits ought to be an improvement.  The USDA proposal sugar limits in two phases:

1. Product-based limits: Beginning in school year (SY) 2025-26, the rule proposes limits on products that are the leading sources of added sugars in school meals:
   1. Grain-based desserts (cereal bars, doughnuts, sweet rolls, toaster pastries, coffee cakes, and fruit turnovers) would be limited to no more than 2 ounce equivalents per week in school breakfast, consistent with the current limit for school lunch.
   2. Breakfast cereals would be limited to no more than 6 grams of added sugars per dry ounce. This would apply to CACFP [Child and Adult Care Food Program] as well, replacing the current total sugars limit.
   3. Yogurts would be limited to no more than 12 grams of added sugars per 6 ounces.
   4. Flavored milks would be limited to no more than 10 grams of added sugars per 8 fluid ounces for milk served with school lunch or breakfast. For flavored milk sold outside of the meal (as a competitive beverage for middle and high school students), the limit would be 15 grams of added sugars per 12 fluid ounces.
2. Overall weekly limit: Beginning in SY 2027-28, this rule proposes limiting added sugars to an average of less than 10% of calories per meal, for both school breakfasts and lunches. This weekly limit would be in addition to the product-based limits described above.

Sugary products will still be allowed.  And schools have 4-5 years to comply (by that time, today’s elementary school children will be in high school).

Why the pussy-footing?  The USDA must be expecting ferocious pushback, and for good reason.  Anything, no matter how small, that threatens sales of foods commonly sold in schools will incite fights to the death.

• The dairy industry is gearing up to complain about restrictions on chocolate milk, which accounts for substantial revenues.
• The industry-funded School Nutrition Association, which represents school food serrvice personnel, strongly opposes the proposals, deeming them “unachievable.”

This, of course, was  precisely the reaction to Obama Administration immprovements to school meals, most of which were implemented with little difficulty.  Even so, Congress yielded to lobbying pressure and caved in on rules about potatoes, ketchup (a vegetable!), and whole grains.

I will never understand why everyone isn’t behind healthier foods for kids, but I’m not trying to get them to eat junk food.

As for why school meals matter so much to kids’ health, see Healthy Eating Research: Rapid Health Impact Assessment on Changes to School Nutrition Standards to Align with 2020-2025 Dietary Guidelines for Americans.

• Download the full report here.
• Download the executive summary here.
• Read the Press Release.

As for the gory details of the USDA’s proposals, see:

• Details of the proposed standards
• Comparison Chart: Current Standards vs. Proposed Standards
• Infographic: Proposed Rule for School Meal Standards
• Infographic: Proposed Timeline for Implementation
• Infographic: The Road Ahead – Building Back Better with School Meals
• Media Toolkit

Care to say something about this? FNS encourages all interested parties to comment on the proposed school meal standards rule during the 60-day comment period that begins February 7, 2023.

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I’m working on a book chapter on pet food and was interested to hear from Phyllis Entis, author of TAINTED. From Farm Gate to Dinner Plate, Fifty Years of Food Safety Failures, who sent me this.

The study: Isabella Corsato Alvarenga, Amanda N. Dainton & Charles G. Aldrich (2021).  A review: nutrition and process attributes of corn in pet foods, Critical Reviews in Food Science and Nutrition, DOI: 10.1080/10408398.2021.1931020

Background: “Corn is one of the largest cereal crops worldwide and plays an important role in the U.S. economy. The pet food market is growing every year, and although corn is well utilized by dogs, some marketing claims have attributed a negative image to this cereal.”

Purpose:  “the objective of this work was to review the literature regarding corn and its co-products, as well as describe the processing of these ingredients as they pertain to pet foods.”

Findings: “Corn is well digested by both dogs and cats and provides nutrients…In conclusion, the negative perception by some in the pet food market may not be warranted in pet foods using corn and its co-products.”

Conflicted interests: “The authors are with the Department of Grain Science and Industry, Kansas State University, Manhattan, Kansas, USA.”

Funding: “This work was commissioned by the Kansas Corn Commission.”

Comment:  For the record, substantial research supports the ability of dogs and cats to digest and use the nutrients in corn.  This has been documented for a long time.  The purpose of this review is to reassure pet owners that it’s to feed corn-containing products to their dogs and cats.  Corn is the most prevalent ingredient in commercial complete pet foods.   Lots of pet owners believe that grain-free foods are bad for pets and are buying grain-free products.  These must be cutting into sales.  Once again, this is an industry-funded study with predictable results.

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Last week, STAT News asked if I would write something about the FDA’s definition of “Healthy” for them.  I agreed because I was planning a blog post on it anyway (posted here).

I wrote a draft and had a great time working with a STAT editor, Patrick Skerritt, to fill in some missing pieces.  Here’s how it came out (with a couple of after-the-fact embellishments).

First Opinion: FDA’s plan to define ‘healthy’ for food packaging: Better than the existing labeling anarchy, but do we really need it?   STATNews, Oct. 7, 2022

The FDA has announced the set of rules it proposes to enforce for manufacturers to claim that a food product is “healthy.” The proposed rules are a lot better than the labeling anarchy that currently exists. But here’s my bottom line: health claims are not about health. They are about selling food products.

The FDA says that a “healthy” product must meet two requirements: It must contain a meaningful amount of food, and it must not contain more than certain upper limits for saturated fat, sodium, and added sugars.

To illustrate the “healthy” claim, the FDA is also researching a symbol that food makers can use, and might be testing examples like these.

[Source: https://www.regulations.gov/document/FDA-2021-N-0336-0003]

Doing all this, the FDA says, would align “healthy” with the 2020-2025 Dietary Guidelines for Americans and with the Nutrition Facts label that is printed on food packages.

This action is the latest in the FDA’s attempts to simplify food label information so it’s easier for consumers to identify healthier food choices. It is also an attempt to head off what food companies most definitely do not want: warning labels like those used in Chile, Brazil, and several other countries. These have been shown to discourage purchases of ultra-processed “junk” foods, just as they were supposed to, a message understood even by children or adults who cannot read. No wonder food manufacturers will do anything to prevent their use.

If we must have health claims on food packages, the FDA’s proposals are pretty good. They require any product labeled “healthy” to contain some real food (as opposed to a collection of chemical ingredients or, as author Michael Pollan calls them, “food-like objects”), and for the first time they include limits on sugars.

Here’s an example given by the FDA: To qualify for the “healthy” claim, a breakfast cereal serving would need to contain at least three-quarters of an ounce of whole grains and could contain no more than one gram of saturated fat, 230 milligrams of sodium and 2.5 grams of added sugars.

These proposed rules would exclude almost all cereals marketed to children.

But do Americans really need health claims on food products? You might think that any relatively unprocessed food from a plant or animal ought to qualify as healthy without needing FDA approval, and you would be right. But health claims aren’t about health. They are meant to get people to buy food products, not real foods like fruit, vegetables, grains, nuts, meat, poultry, dairy, eggs, or fish.

Food companies love the term “healthy” because it gets people to buy food products.

 

The history of “healthy”

How did we get to where the FDA needs to require a product to contain real food to be considered “healthy”? Blame KIND bars.

In 2015, KIND (then a small private company, but now owned by Mars) advertised its bars as healthy because they contained whole foods like grains and nuts. But nuts have more fat than the FDA allowed at the time for products to be labeled as “healthy.” The FDA warned KIND that its bars violated the rules for health claims.

KIND fought back. It filed a citizens’ petition arguing that even though nuts are higher in fat than the FDA allowed, they are healthy. The FDA could hardly argue otherwise — of course nuts are healthy — and it backed off. It permitted KIND to use the term and said it would revisit its long-standing definition of “healthy.” That was good news for KIND.

At the time, the FDA’s definition of “healthy” set upper limits for fat, saturated fat, sodium, and cholesterol; required at least minimal amounts of one or more vitamins or minerals; and said nothing about sugars. So the new FDA proposals break new ground in simplifying the nutritional criteria and in putting a limit on sugars.

 

Front-of-package symbols

These, too, have a long history with the FDA. In the early 1990s, when the agency was writing the rules for Nutrition Facts labels on food products, it tested public understanding of several prototype designs. As it happened, nobody could understand any of the samples very well, so the FDA picked the one that was the least poorly understood. Soon afterward, food companies and health organizations developed symbols that would allow buyers to recognize at a glance which products were supposed to be good for them.

By 2010, more than 20 such symbols were on food packages. The FDA commissioned the Institute of Medicine to do studies of front-of-package labeling. The Institute’s first report on the subject examined the strengths and weaknesses of all of the symbols cluttering up the labels of processed foods, and recommended that the FDA develop a single symbol that would cover just calories, saturated fat, trans fat, and sodium. Why not sugars too? The Institute said calories took care of them.

But the Institute’s second report did include sugars. It recommended a front-of-package labeling system that would give food products zero, one, two, or three stars (or check marks) depending on how little they had of the undesirable nutrients.

This idea so alarmed food manufacturers that they quickly developed the Facts Up Front labeling system in use today.

This, in my view, is so obfuscating that nobody pays any attention to it. But this scheme, coupled with industry pushback, was all it took to get the FDA to drop the entire idea of a symbol that would tell people what not to eat.

Here we are a decade later with the FDA’s current proposal. This plan is strong enough to exclude huge swaths of supermarket products from self-identifying as “healthy.” Products bearing the “healthy” symbol will have to contain real food and be low in saturated fat, salt, and sugar, as called for by federal dietary guidelines.

The new rules won’t stop “healthy” products from being loaded with additives and artificial sweeteners. And the FDA won’t require warning labels for unhealthy products, which work better than other symbols. But these proposals are a marked improvement over the current situation.

And the FDA might do more. It could look into the idea of warning labels. It already promises to make a decision about the other ambiguous marketing term, “natural.” A decision on that one can’t come soon enough.

As for “healthy,” the FDA is seeking feedback on its proposals. Instructions for filing comments, which can be made until Dec. 28, 2022, are at Food Labeling: Nutrient Content Claims; Definition of Term “Healthy.”

I can’t wait to see what companies wanting to sell ultra-processed food products as “healthy” will have to say about this.

Marion Nestle is professor emerita of nutrition, food studies, and public health at New York University, author of the Food Politics blog, and author of the new memoir, “Slow Cooked: An Unexpected Life in Food Politics” (University of California Press, October 2022).

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The FDA has announced a proposed rule for a “healthy” claim on food packages.

It proposes to align “healthy” with the Dietary Guidelines for Americans, 2020-2025 and the Nutrition Facts label.

The proposal has two requirements for the “healthy” claim.  To make the claim, products must:

1. “Contain a certain meaningful amount of food from at least one of the food groups or subgroups (e.g., fruit, vegetable, dairy, etc.) recommended by the Dietary Guidelines.”
2. “Adhere to specific limits for certain nutrients, such as saturated fat, sodium and added sugars. The threshold for the limits is based on a percent of the Daily Value (DV) for the nutrient and varies depending on the food and food group. The limit for sodium is 10% of the DV per serving (230 milligrams per serving).?

Food comes first!  What a concept!  The FDA will only allow a “healthy” claim on foods, not ingredients.  It also will only allow the claim on foods that are quite low in saturated fat, salt, and sugars (with exceptions for real foods).

The press release gave an example.  To qualify,

A cereal would need to contain ¾ ounces of whole grains and contain no more than 1 gram of saturated fat, 230 milligrams of sodium and 2.5 grams of added sugars.

The FDA is also researching a symbol to illustrate the “healthy” claim.  In March, it proposed research to develop this symbol.  The proposal did not illustrate prototypes, but some examples were published by a law firm.  ConscienHealth also published them under the heading of “A new roadmap for marketing healthy-ish food”

I see several things going on here.

1.  Positive, not negative.  This says foods are healthy.  Choose this!
2.  It adds sugars to disqualifying ingredients.
3.  It heads off warning labels—“high in fat, sugar, salt”—like those in Chile, Brazil, and Israel (see, for example, a previous post).  Avoid those!
4.  It heads off ultra-processed warnings (although this will exclude most, if not all, ultra-processed products).
5.  It supersedes the FDA’s efforts in 2010 and 2011 to put zero, one, two, or three stars or check marks on products.

I love Ted Kyle’s “Healthy-ish.”  As I keep saying, health claims are not about health; they are about marketing.

Companies love health claims; they sell food products.  Everyone falls for them; it takes serious critical thinking to resist them.

The FDA’s proposal will make “healthy” claims difficult for many products currently marketed with a health aura (Antioxidants! Gluten-free! No carrageenan!).

The time for comments is now.  I can’t wait to see the ones from companies making ultra-processed foods.

Next from FDA: a definition of “Natural?”

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