Blog | Wednesday, November 16, 2011

'Nutrition guidance' from the IOM: the good, the bad and the ugly

A committee commissioned by the Institute of Medicine, with backing by the CDC, the FDA and the USDA, just released its report on front-of-pack nutrition guidance. The recommendations are good in that they may help prevent the food industry from doing bad. The recommendations are bad if they forestall the progress and implementation of superior approaches. And the recommendations are downright ugly in that ... well, we'll get to that.

The IOM began work on this issue in earnest, at the request of federal agencies, in the immediate aftermath of what can only be called the "Smart Choices debacle."

Smart Choices was a front-of-pack nutrition guidance system developed by food industry elements, which famously reached the conclusion that Froot Loops was a "smart choice" for breakfast. That, among other things, invited some federal wrath, and the threat of punitive action by Congress, state attorneys general or both, and the system was decommissioned. Food manufacturers had other front-of-pack systems prior, and have developed others since. Food industry elements, through the Food Marketing Institute and the Grocery Manufacturers Association, have recently rallied around "Nutrition Keys," which shifts back-of-pack information to the front.

Even as the food industry has attempted to regroup after Smart Choices, the IOM work on developing recommendations for consistent front-of-pack guidance has proceeded.

The report just issued is lengthy. Its bulk alone, and its many citations, might suggest it is more definitive than it actually is. The IOM committee charged with this task, and its consultants, conducted no new research, not even consumer focus groups. They cite prior literature with which all directly concerned with this field were already familiar. The large aggregation of studies cited attest to the fact that decisive evidence to indicate what nutrition guidance system is "best" has not yet been gathered. And thus the very report in which the IOM committee issues its recommendation makes clear that the recommendations are simply the opinion of a small group of people not based on directly relevant data.

The committee's recommendations are, in essence, to note calories on the front of packs, and to provide a scale to indicate the relative quantity of added sugar, sodium, saturated fat and trans fat. It is not clear whether all of these nutrients will be bundled together into that scale, or whether each will be scaled separately. They suggest a numerical scale, ranging from 0 to 3.

Starting with the fact that this recommendation is based on nothing other than opinion, let's consider what's potentially good, potentially bad and potentially ugly about it.

The Good:

The strength of the recommendation resides in its potential to constrain and unify the current efforts by food manufacturers to call out nutritional properties of their products to consumers. I fully respect that the business of business is business, and have no problem with food companies working to sell their food! But it is for that very reason that they should NOT be the ones to decide how to highlight nutritional quality, because they will inevitably accentuate the positive. Food sellers deciding how to inform consumers about nutritional quality is a classic case of the fox guarding the hen house, and results in feather-flying fiascos like Smart Choices.

The IOM recommendations tell manufacturers what is expected, and while compliance with the expectations is voluntary, the heavy hand of regulation looms if compliance is poor. So the IOM report does promise to rein in the diverse efforts of food sellers to tell consumers a cherry-picked version of the truth about nutrition that is more about promoting sales than providing insights. That's good.

The Bad:

As already noted, the new recommendations are not the product of new research. They are simply a new opinion of a new group based on a limited assessment of the research to date.

The group seemed to ignore the fact that the information they are proposing to put on the front of the pack is already on the back-of-pack in every case. Do we truly think that the fundamental limitation to consumers' ability to judge relative nutritional quality is their inability to turn the box around?

The group also seemed to ignore that a long history of efforts based on highlighting just negative nutrients have resulted in very poor food choices indeed. Warned against an excess of dietary fat, the public followed front-of-pack messages about "low fat" to such questionable choices as SnackWell cookies. While accounting for several nutrients at a time may make similar missteps a bit less likely, there is much missed by simply noting what "bad" stuff is or isn't in a food.

Whether or not the new recommendations are proposing a 0 to 3 scale for each of several nutrients, or the several nutrients bundled together, a 0 to 3 scale is ... bad. It is bad because the average supermarket offers some 50,000 food items, and the U.S. food supply offers a staggering variety of products, in the neighborhood of 800,000! These products range from marshmallows, jellybeans and fried pork rinds to spinach and kale. In between is everything from orange juice, kiwis, cauliflower, potatoes, salmon, chicken, beef, pizza, milk and margarine to milk chocolate, dark chocolate, avocado, walnuts, olives and blue cheese salad dressing.

A 0 to 3 scale, one nutrient at a time, or several bundled together, risks truly massive compression of such diversity. If thresholds for points on such a scale are placed reasonably high, to safeguard health, an enormous percentage of processed foods will all get the same low score. When a large number of products get the same score, the system in question is providing no guidance when choosing among such products!

Conversely, if the threshold for scaling is placed low enough so that a reasonable percentage of processed foods can "register" on the same scale as broccoli or spinach, then the ability to make distinctions at the high end of the scale is lost and products that are only moderately nutritious become indistinguishable from products that are really excellent.

There is no basis whatsoever in evidence for expressing the quality of nutrition for a supply of hundreds of thousands of foods across the limited expanse of 4 points. We don't get miles-per-gallon fuel efficiency ratings that way. We don't get wine quality scores that way. We don't score the SAT that way. Whenever there is a wide variation in a measure, a scale suitable to express it clearly and simply, but reliably, is warranted and routinely used. Efforts to date to express nutritional quality on a scale with just several values result in over 70% of all items in the supermarket getting the same score, meaning, 7 times out of 10, such a system fails to help you make a choice.

There is another problem as well with so compressed a scale. One item at the very bottom of the nutritional quality barrel will get a 0 it well and truly deserves. Another will be much better, and nearly but not quite good enough to get a 1. It, too, will get a 0 and the difference will be invisible. Another item may barely qualify for a 3 and look exactly comparable to, say, spinach, which is monumentally overqualified for that same 3! Again, a great deal of "lumping" that conspires against the informed point-of-purchase choices such a system is supposed to empower.

Also bad is the fact that the IOM report is not directly linked to real-world evidence about what nutrition guidance systems can actually influence consumer choices for the better. And even more important, the committee apparently did not consider whether the nutrition guidance system actually translates into "better" food choices!

The only true way to measure "better" food choices is to show that they correlate with better health outcomes, since that is what the definition of "nutritious" derives from, foods that are health-promoting, and "good" for us. Absent evidence that food "scoring" for nutrition correlates with health outcomes, it is unsubstantiated opinion that a given scale reliably measures nutritional quality at all.

Such evidence of the link between nutritional quality measurement and health outcomes has been published, but the IOM report, quite surprisingly, ignores the issue entirely. This is clearly bad. The very goal of good nutrition guidance at point-of-purchase is to empower better health by moving in the direction of a better diet, one well informed choice at a time.

The Ugly:

But none of what's bad cited above rises to the level of truly "ugly."

To get to truly ugly, we have to look at what ISN'T in the IOM recommendations! Fiber is not in the recommendations. Omega-3 oils are not in the recommendations. Antioxidant nutrients are not in the recommendations. Monounsaturated oils are not in the recommendations. Calcium is not in the recommendations. In fact, no beneficial nutrient, or nutrient property, is considered at all.

There is no historical evidence that a nutritional guidance system based on "negative" properties only is useful. The nutrition facts panel that is the mainstay of this space, developed during the tenure of Dr. David Kessler as FDA Commissioner, very explicitly includes positive and negative nutrients, and establishes a standard that should not be casually tossed aside.

Imagine trying to sum up the health of a person with a short list of "negative" characteristics only. If you knew someone didn't use tobacco, didn't use illicit drugs, didn't run out into traffic without looking first and wasn't an alcoholic. do you feel confident in your ability to say whether or not this person is actually healthy? I'm an expert in doing so, and I certainly don't, nor would any other short list of just negative traits allow me to do so. A comprehensive blending of both negative and positive traits, however, reliably does, and is the cornerstone of both all medical assessment, and the standardized Health Risk Appraisal.

Trying to sum up overall nutritional quality by looking only at a short list of negative considerations is silly to the point of ... ugly.

How ugly? Well, such a system would presumably have to give its highest commendation to a food that was free of all bad properties under consideration. Among the ranks of foods free of calories, added sugar, sodium, saturated fat, and trans fat, diet soda springs to mind. A system that recognizes diet soda as a "perfect" food is ... very ugly indeed.

And it is equally ugly in reverse. Walnuts are wonderfully nutritious, but contain a bit of saturated fat, and quite a lot of calories. Avocado is highly nutritious, but also high in calories. Nut butters are very nutritious, but high in calories. Milk, unlike diet soda, contains sodium, calories and, if not fat-free, varying amounts of saturated fat. If the IOM intended to encourage diet soda intake as opposed to intake of milk, that's ... ugly.

In Conclusion:

An IOM committee recommendation based on no new research, but just the opinion of one small group of advisors, is at best questionable, particularly when it is at odds with the conclusions reached by other groups of those at least as highly qualified.

But whether the report proves to be of net benefit or harm to the public health will depend on how it is used. It will be good if used to prevent potentially harmful distortions that arise when the food sellers generate their own nutrition standards. It will be bad if it interferes with judgments in the court of public opinion about far more comprehensive approaches developed by independent entities committed to public health. And if it propagates the perception that high-calorie walnuts and almonds and avocado and yogurt are less good than 0-calorie diet sodas ... it will take ugly to a whole new place.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.