Thursday, March 24, 2011

Ottawa Hospital finally follows through with cafeteria reform!

Yesterday, nearly 3 years after they first told the Ottawa Citizen they'd be initiating a nutrition labeling plan in their cafeterias, the Ottawa Hospital announced that point of service electronic calorie, sodium and fat content will be made available to customers.

They'll also be implementing their own version of Health Check whereby a little green apple will signify meals they deem of......well not really. Let me explain.

Only two criteria will determine whether or not a meal will get a little green apple. Those criteria? Sodium content and total fat.

Sodium content? That seems like a reasonable determinant to include, but unfortunately it would appear that the levels they adopted were those put forth by the Heart and Stroke Foundation's Health Check program. That means a large entree can have up to 960mg of sodium and a small 720mg. Given sodium's total recommended daily maximum is 1,500mg, that's an awfully generous "healthy" amount.

Total fat? Again, probably a consequence of not building criteria from scratch but rather from existing, underpowered programs like Health Check and EatRight Ontario, the hospital's adopted total fat as an important nutritional determinant. Problem there is that it's not. The notion that total fat in one's diet is in and of itself responsible for the development of chronic disease or obesity has been soundly refuted over the course of the past decade or so of nutritional research.

There's probably also risk in clinging to it.

Dr. Frank Hu, one of the world's leading obesity and diabetes researchers and professor of nutrition at Harvard was recently quoted as saying,

"The country’s big low-fat message backfired. The overemphasis on reducing fat caused the consumption of carbohydrates and sugar in our diets to soar. That shift may be linked to the biggest health problems in America today."
So while I recognize the safety of working within the context of established programs, unfortunately if the established programs aren't in fact evidence-based, up to date, or nutritionally sound, the outcomes, while perhaps politically safe, may not be particularly stellar.

I'm also confused by the notion of a check based on just two nutritional determinants of health. I'd argue that such a check is potentially worse than no check as it will undoubtedly confer a health halo to foods that may well be chalk full of calories, refined carbohydrates, sugar, and trans-fat.

Interestingly the hospital has already distanced itself from the suggestion that their apple check'ed choices are in fact "healthy". In an article published yesterday in the Ottawa Citizen, Frances Furmankiewicz, the hospital's Director of Nutrition and Food Services was quoted as stating,
"So we're not saying they're healthy, they're healthier"
And while that may be the glass-half full version of looking at things, my glass-half empty version still maintains that "less bad" is not the same as "good", especially given the lack of any real criteria to reflect even "healthier", and the inherent risks associated with outdated, blindly low fat messaging.

All that said, I'm thrilled there will be point of sale nutritional information provided, and that apparently there will be healthier options available.

Here's hoping that given their will to launch the program, they'll also have the will to improve upon it.

Stay tuned for a video tour over the coming few weeks, but for now, congratulations to the Ottawa Hospital for starting what I hope over time will prove to be a much more substantial initiative.

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  1. Do you really think that the governments sodium levels are based on any real science? With the exception of ones with a damaged kidney, sodium levels are well managed by the body, and eating a lot of sodium may either raise, or lower your blood pressure by just a few points.

    As well if you eat a diet full of real foods found in their natural forms, ie, real fruit, vegetables, meat, eggs, poultry, cheese, you will be eating a diet low in sodium.

    You are right about fat, fat in and of itself is not a concern. HOwever, fats that contain transfats like vegetable oils are harmful. But fats, like butter, lard, olive oil and coconut oil are beneficial.

    Sugar and Carbs are much more of a concern than fat is.

  2. I do believe sodium recommendations are built on solid science.

    The argument that's fairest against worrying about sodium levels is that by no means does everyone "respond" to sodium. Generally sodium levels matter most to those who already have a number of chronic medical conditions, heart disease foremost among them.

    That said, patterns of eating matter. Heart disease is far and away the number one killer out there and having people grow accustomed to lower levels of sodium in their diets may help them when ultimately they do develop a sodium responsive disease.

  3. I believe better to start somewhere than not at all...may it will begin a trend and other hospitals will follow. We can at least hope!

  4. If you think salt recommendations are based on science, point us to the paper.

    I can find lots of papers that do not show the purpose of cutting salt, except for sodium sensitive people.

    A high carb diet forces re-uptake of sodium in the kidneys, so if I need to be low sodium, I should also keep my carb below 100 gm/day.

    But what do I know.

  5. Anonymous7:31 pm

    Not much.


    Yea sure...
    is an editorial, more opinions of one well educated doctor. Also not available to the public.

    That is what brought the USDA food pyramid, and just look how well that worked out.

  7. @Yoni Freedhoff

    Please post the evidence showing that sodium intake substantially affects blood pressure. As others have said that one reference was not a study but rather an opinion or editorial not based on anything

    Patterns of eating do matter. One that reduces the starch and the sugar in the diet naturally lowers blood pressure. Lower glucose levels prevent reabsorbtion of salt and lower fructose levels (by eating less sugar) affects uric acid levels, and lowers blood pressure that way too.

    It is much more effective to lower blood pressure by reducing the starch and sugar in the diet.

    My own blood pressure has been lowered eating this way.

    Here are a couple studies:

    High Fructose Diet Raises Blood Pressure in Middle Aged Men:

    Low Carb Diet Best for Lowering Blood Pressure:

  8. Citations of single studies do not help further any argument.

    While certainly there are many studies I can point to that support sodium reduction, there are others you (or Fred, or others) can point to that state otherwise. That's simply the nature of nutritional epidemiological research.

    If you'd like I can also point you to 3 separate randomized trials that demonstrated no benefit to smoking cessation on mortality rates.

    You're of course welcome to your own opinions as to whether or not sodium reduction is a useful public health strategy or whether or not it's based on evidence.

    My read of the literature is that it is and for a summary of references feel free to have a peek at Canada's Sodium Working Group's final report.

  9. Yoni - I appreciate your website and that you allow commenting and dissenting view on your website.

    I would also agree about your point on smoking cessation.

    It's true that single studies are not enough to prove a point, they must be repeated by others in properly done controlled studies.

    However there is a lot of clinical experience of thousands of people who have lowered their blood pressure by greatly reducing starch and sugar. There is also a lot of anecdotal evidence.

    I think though that fructose is pretty well understood and undisputed as to the mechanism that it lowers blood pressure.

    The sodium working group looks like a government committee to reduce salt, and a lot of the references seem to come from government sources too. I only skimmed the report so I may be wrong.

    You have to be careful not to believe government committees, because they are often not based on real science. ie Food Pyrmaid and Canada Food Guide.

    Please show me references to carefully done studies that show real improvement in blood pressure by more than a few points by reducing sodium.

    I think we would both agree that by eating real food, fruit, vegetables, meat, fish and eggs and not eating processed food, or food in packages you would naturally reduce your sodium intake.

    Please show me the three studies.

    And I would say don't believe the government unless they are basing their recommendations on real evidence.

    I appreciate you letting me disagree with you and not strictly moderating comments. I think we might have to disagree on this issue though I'm sure there are many issues we may agree on.



  10. Hi Michael,

    I certainly someone who welcomes opinion, whether it is in line with mine or not.

    Interesting too. Your last response mentioned that you wanted articles that reported a greater than a few point reduction due to sodium changes.

    Perhaps therein lies our differences in regard to sodium?

    A few points are in fact exceedingly significant in the grand scheme of population health.


  11. Hi Yoni,

    Thanks for your reply.

    I think we need to be aware of the law of unintended consequences. Food Industry will likely reduce the salt in some of their products. But likely they may replace the salt with MSG, added sugar, or some other known or unknown toxin. It's just like when they lowered the fat in their products they replaced the fat with sugar to keep the products palatable.

    Secondly lowering someone's blood pressure or rather as you say the whole nation by a few points won't do much to solve the problem of hypertension. Since hypertension is at least 20 points above normal. Often much more than that. A few points won't do anything.

    Why not encourage the population to eat real food, reduce sugar and starch. Then they can lower their blood pressure dozens of points, not just a few. In addition they may be able to get off their medications too, and lose weight!

    Those are just my thoughts on your point.