If You Need Proof The Food Industry Doesn't Care About You, Look No Further Than Smucker's "No Sugar Added" Jam

So I was shopping the other day.

We were making a dish that included apricot jam in a sauce and I was having a peek at the various offerings on the shelves.

I grabbed Smucker's Apricot Jam and noted that the front of its package highlighted the "fact" that it had "no sugar added".

The label of course told a different story.

It told me that the second ingredient was "white grape juice concentrate", which is likely on the order of 60% sugar by weight.

So yes, sugar was added.

I expressed my indignation on Twitter and Smucker's responded to tell me that they appreciated my feedback, that the concentrated white grape juice was meant to add "fruit flavor" as well as serve as a sweetener, and that according to the letter of the law, it was legal for them to state that their product contained no added sugar.

We appreciate your feedback. White grape juice concentrate provides added fruit flavor, and acts as a sweetener as well. Please know, we follow all CFIA labeling guidelines, including full disclosure of the total grams of sugar in each product, as listed on the Nutrition Facts.

— Smucker's (@smuckers) May 1, 2018

Now the good news is that at least in Canada, the addition of white grape juice concentrate, which of course is just the addition of sugar, will soon preclude Smucker's front-of-package "No Sugar Added" claim.

But of course if Smucker's actually wanted to do right by its customers it wouldn't be waiting for the Canadian Food Inspection Agency's regulations to change.

But that's not what Smucker's is about. Smucker's, like pretty much all publicly traded food industry players, is about profit, and their "No Sugar Added" jams are great case studies in how we shouldn't wait for the food industry to do the right thing, because unless the right thing aligns with profits, they're not going to do it.

Canada, Where Dr. Feelgood Beer Sales Are Banned, But Vitamin Water's Are Allowed

What's wrong with this picture?

Last month the Liquor Control Board of Ontario banned the sale of Dr. Feelgood IPA on the basis that the snake encircling the hops paddle, coupled with the prescriptive looking ℞ in the D℞., would implicitly lead consumers to believe that the beer was a health food.

Yet Vitamin Water's liquid candy sales are just dandy (including of course in stores frequented by children). And so too are the hundreds, if not thousands, of packaged foods that explicitly purport to confer health benefits, not to mention an entire industry of supplements that promise health miracles.

It is so disappointing that Canada continues to allow the food industry to dupe consumers with impunity.

(And for the record, and not just because I enjoy IPAs, I think the LCBO is overreaching here, while Health Canada and the CFIA don't bother lifting any fingers at all)

Food Industry Furious With Health Canada's Front-of-Package Plans

If Health Canada takes Chile's lead, we too might see Frosted Flakes boxes change from looking like those on the left to looking like those on the right.

When industry is furious with a government proposal it's a safe bet that proposal is likely to affect their sales, and so when I learned that the food industry was incensed by Health Canada's front-of-package plan proposals (Aric Sudicky, a final year medical resident who was rotating through our office at the time, watched the recent roundtable style consultation hosted to discuss the implementation of what will be a Canada wide front-of-package program, via teleconference and reported to me that industry was none too pleased), I wanted to learn more.

Now this post isn't going to delve into whether or not those are the best 3 targets for front-of-package symbols, instead I want to focus on the lobbying and machinations of industry.

First though, a tiny bit of background.

In creating a new front-of-package symbol for Canadian consumers, what Health Canada doesn't want is a program that emphasizes so-called positive nutrients as 50 percent of Canadian package fronts already have those (put there by the food industry directly to help sell food), or one that requires a second step of thinking to interpret (eg studying the nutrition facts table) as that has been shown to lead to misunderstanding, or a hodgepodge of programs (as more than 150 front-of-package labeling programs have already been documented in Canada) .

What Health Canada does want is a single, standardized system, that involves a prominent symbol, that's consistently located, that doesn't require nutritional knowledge to understand, to help consumers identify products with high levels of nutrients that Health Canada deems are concerning to public health, that by itself provides the required interpretation for its meaning. Such a system would be consistent with the core recommendations made by the U.S. Institute of Medicine.

Breaking it down further, what Health Canada wants is a system that conveys simple to understand information, rather than one that presents data requiring interpretation.

Further still?

Health Canada wants warnings.

In their recent meeting, Health Canada presented their wants to food industry stakeholders, as well as the evidence they feel supports them, and invited them to submit their thoughts and suggestions for a symbol to fit Health Canada's 4 design principles:

1. Follow the "high-in" approach
2. Focus only on the 3 nutrients of public health concern (sugar, sodium, and saturated fat)
3. Be 1 colour (red) or black and white; and
4. Provide Health Canada attribution

As to what this might look like, here are some mockups put together jointly by the Canadian Cancer Society, Canadian Medical Association, Canadian Public Health Association, Diabetes Canada, Dietitians of Canada, and the Heart and Stroke Foundation.

Given that warning symbols aren't likely to be good for business, I was curious as to industry's response to the ask.

Suffice to say, industry is indeed unhappy.

The Retail Council of Canada wants Health Canada to implement instead an instruction for consumers to turn products around and study their nutrition facts tables, and they don't want Health Canada's name mentioned on the symbol. They are apparently worried that including Health Canada's name on the symbol might be misinterpreted as a government endorsement which in turn would lead consumers to eat more of the products with the warning labels. They're also apparently simultaneously worried that if the symbol utilized is already recognized to be a danger symbol, it could lead consumers to believe there is a food safety risk, and that if used, children, accustomed to seeing these symbols on foods, might lead them to think that cleaning supplies with danger symbols are safe to consume.

The Food Processors of Canada used bold to point out that, "the meeting didn't agree to anything", and that, "Health Canada has lost its way on the obesity issue". They think that what's needed is more public education, not a front-of-package warning program.

The Canadian Beverage Association expressed their, "deep concerns", and that though they were happy to have been included in the meeting, their definition of "deep and meaningful dialogue" with industry should include a process whereby industry participants would all discuss and agree upon what the program would entail.

Food and Consumer Products of Canada also wanted to express their disappointment that they weren't provided the opportunity to be more directly involved in crafting the proposal's criteria and their concerns about "the integrity and transparency of the consultation process". They sent a second note expressing their hope that the criteria still have room to evolve and that their preference is for traffic lights as they believe, "information – good and bad – builds on consumer literacy".

Dairy Farmers of Canada expressed their concern that the proposed warning system lacks the nuance required "to distinguish between nutrient-dense and nutrient poor foods" (sweetened milk will likely be slapped with a high in sugar warning), and that they'd be happy to support, especially, "if coupled with exemptions for nutritious dairy products", those programs that would provide data for consumers to study and interpret (like for instance the Facts Up Front program illustrated below).

There was however, one response from industry that was heartening. It was from Nestlé, whose representative reported being, "a little embarrassed" by how industry presented their views during the roundtable, and, "that Nestlé is not fully aligned to some of the comments that were made by some of our trade associations, and a few of us are feeling very frustrated."

Whatever comes of all of this, one thing's for sure. The food industry's near uniform opposition to Health Canada's proposed front-of-package warning label criteria is strong indirect evidence in support of their utility, as for the food industry, salt, sugar, and fat are the drivers of profitability and palatability, and they'll oppose anything they worry might limit their use.

So kudos to Health Canada for sticking to their guns, and also for honouring their pledge to make this process transparent by sharing with me industry's responses.

(and if you clicked on any of the industry letters to read, this is the post roundtable letter from Health Canada to which they're all referring).

Could Health Canada's Future Front-of-Package Stoplights Reform Deceptive Claims?

So on Monday I blogged about how there are plenty of foods of dubious nutritional quality with fronts-of-package claims that while legal, are deceptive.

Looking ahead, there is the chance that Health Canada will be implementing a national front-of-package food labeling program which in turn would highlight products' higher than desired nutrient contents (perhaps by way of stoplights for instance).

So here's my straightforward suggestion.

Regardless of the system implemented, if a product's ingredients score it a front-of-package warning from Health Canada, that product's packaging should be legally prohibited from including any front-of-package health claims or inferences (where inferences for example would be a package of Froot Loops shouting out to its inclusion of whole grains or Vitamin D, but without an actual functional health claim).

Though imperfect, this simple step might help tilt the playing field ever so slightly away from the food industry's current unfair advantage.

The Canadian Food Inspection Agency Asks For Examples of Deceptive Food Labels

Saw this tweet from the CFIA and so I decided to take a supermarket field trip and found plenty of what I would describe as deceptive food labels.

5 teaspoons of sugar per bar along with 210 calories 

31% more sugar cup per cup than Froot Loops

By weight, this product is 48% sugar

Cookie for cookie more than double the sugar of an Oreo

Drop for drop more sugar and calories than Coca-Cola

With 2.75tsp of sugar per "Twist", contains the sugar of 2.3 actual Twizzlers

Each popsicle contains the sodium found in 93/100ths of one single grain of table salt (along with 2 teaspoons of sugar)

But here's the problem, none of the products' labels above break any Canadian packaging laws, and if the labelling laws themselves explicitly permit deceptive labels, consumers don't stand a chance.

Why have a system where the onus is on the consumer to study the products' nutrition fact panels to determine if their healthy front of package claims are supported?

Guest Post: Public Health RD Questions Ontario's Calorie Labelling Rollout

Last week an RD who'd prefer to remain anonymous asked me if they could share their thoughts on Ontario's new calorie labelling initiative with my readers. I readily agreed, and I agree with much of this post. I'm strongly supportive of calorie labelling, but the rollout certainly could have been more thoughtful. And while I agree with all of this RD's closing points, I don't see calorie labelling vs. other changes as being either or - I'd like to see them all.

On January 1st of this year it became mandatory for restaurants with at least 20 locations in Ontario to post the calories on their menus. Many dietitians and other healthcare professionals rejoiced as this information would help people to make better, or at least more informed choices when eating out. Personally, I was a little more skeptical. From what I had seen from other places implementing similar legislation resulted in little if any change in eating habits. We are always talking about evidence-informed decision making in healthcare, yet this legislation from the Ministry of Health and Long-term Care seemed to be based more on appearances than on evidence.

There were problems from the start. Training for public health inspectors (who are responsible for enforcing the legislation) didn’t take place until just over a month before the legislation took effect. It was made very clear to the PHIs that they were to only ensure that eating establishments adhere to the legislation; i.e. that calories were posted in the appropriate places in large enough font and that the contextual statement was posted. They were not to question the calorie counts posted. Some of you might remember the time everyone got upset about Chipotles posting the calories for just the chorizo in a wrap, rather than for the entire wrap. Well, if something like this were to happen in Ontario, unless a complaint came from the public, the PHIs have no recourse. They might see calories posted that seem blatantly incorrect but they have been instructed not to question them. Restaurant owners and operators need only use means that they “reasonably believe” to determine the calorie counts. That means that calorie counts could be determined by a bomb calorimeter (accurate) or by myfitnesspal (questionable) as long as the owner believes it to be accurate. The Ministry declined to provide PHIs with any guidance as to what methods and tools would be appropriate so they are left to take restaurant owners at their word.

Framing this as an initiative to decrease childhood obesity was a huge mistake in my mind. Teaching children to calorie count is not healthy or helpful. Nor is simply providing calorie amounts to parents when caloric needs vary so much among children. Sometimes providing just a little information can be dangerous. I’m sure that the government meant well and they thought this would be a great visible way to show that they’re tackling childhood obesity while downloading the cost onto restaurant owners, win-win. However, this legislation should have been targeted toward adults only. Children should never be counting calories.

The point of this legislation is ostensibly to help the public make informed choices. To that end, you would think that there would have been a public education campaign launched well in advance of the implementation of the legislation. You would be wrong. Despite numerous requests from public health dietitians, and assurances that public education was coming, it wasn’t until over a month after the legislation came into effect that any “education” was undertaken. As a dietitian, I was expecting information on how to use the newly available calorie postings to make better choices. Boy was I wrong. Instead, the Ministry released a series of ads that read more like fast food advertisements and essentially just say “calories are now on menus”.

Let’s fill our kids with ideas about eating right.

A post shared by Ontario Government (@ongov) on Mar 8, 2017 at 11:36am PST

The calories in your food are being revealed. Look for them on menus today. Depending on age and activity, an average of 2000 calories a day is recommended for teens.

A post shared by Ontario Government (@ongov) on Mar 28, 2017 at 1:44pm PDT

I see these and I think, “wow! Poutine and hash browns are so low in calories. They’re not as bad a choice as I thought.” Not at all the message that I think should be coming through this campaign. It’s embarrassing that the government used our tax dollars to pay people to come up with these terrible ads. Apparently they focus group tested them and the teens thought they were hilarious. Perhaps they can’t tell the difference between laughing with you and laughing at you? Regardless, there should have been someone working on this campaign who saw that it wasn’t sending the intended message (check out the comments). They should also realize that simply telling people that calories are posted on menus isn’t sufficient to aid them in appropriately using this information. As it stands, it only serves to help those who are already health conscious and who know roughly how many calories per day they should be consuming. They should have been giving people the information and tools to better understand and use the calorie counts.

Does putting calories on menus even work? There was a recent webinar by Health Evidence on this and they said that on average, it led to reductions of about 70 calories per day. Which sounds great except that the average caloric intake of people in the studies was about 3000 calories a day, about 1000 calories more than the recommended daily calories for an average adult. So, yes, putting calories on menus may lead some people to choose items with fewer calories but if they’re still consuming about 900 more calories than they need I’m not sure that’s anything to write home about.

Calories are only one piece of information and I worry about putting too much emphasis on it. Restaurant meals tend to be obscenely high in sodium but the calories won’t tell us anything about this. Calories also don’t tell us if a menu item is nutrient dense or nutrient void. It can make it appear that deep-fried foods are equal to salads.

Something else to consider, beyond the concerns I mentioned above about the accuracy of the methods used to determine the calorie counts, is the human factor. Even if the calories are accurately measured, that’s based on the sample as provided by the restaurant which you can bet is going to put that food in the best light possible. Do you really think that line cooks in a restaurant, or teenagers at Five Guys are concerned about portioning things so that meals contain the same number of calories as is posted on the menus? I doubt it. they’re probably using more oil on that stir-fry or scooping extra fries onto that plate. It’s pretty safe to assume that the actual number of calories in any given menu item is going to be higher than the number posted on the menu so take the number on the menu with a grain of salt.

I’m sure that there are people reading this thinking “but at least they’re doing something. What would you do?” I would bring back mandatory home ec in schools. I would help to ensure better access to and affordability of nutritious foods across the province. I would provide more support and funding for healthy eating and food literacy initiatives for all ages. Instead of accepting that people are going to eat out regularly, and assuming that providing calories on menus is going to make people healthier, we should be encouraging people to get in the kitchen.

Will Candy With 30% Less Sugar Just Make Matters Worse?

Once reformulated this candy will "only" be 36.5% free sugar by weight 

A few weeks ago I blogged about the new lower in sugar Kit Kat bar that contains 4 fewer calories than the old bar (with 0.7g less sugar). The front of its package doesn't shout out about lower sugars though, instead it hypes "extra milk and cocoa".

It was the first example I'd seen of the inevitable future of ultra-processed treats that are being designed and launched under the banner of sugar as our global, singular, dietary boogeyman.

While there's little doubt we over consume sugar, and that sugar is one of the primary drivers of hyper-palatability and obesity, if the marketplace sees an influx of "now with 30% less sugar" ultra-processed foods, I'm not sure they won't make matters worse.

And that's precisely the sort of thing we're going to see as evidenced by this new line of Nestlé candy which according to this news story, will be sold alongside the original candy "with a 30% less sugar banner on the packaging"

Sounds an awful lot like the early 1990s when we saw the launch of "Fat-Free" Snackwell cookies (and more of course).

Will the "Now With 30% Less Sugar" banner lead people to buy candy more often? To eat candy more frequently? To eat more candy at each sitting? To grudgingly give in to their naggy kids and pack it in their lunches because it's less bad? Or will it lead to an overall reduction in free sugars and calories consumed?

For the majority of folks, my money's on all of the former, and none of the latter.

New Reduced Sugar Kit Kat Bars And The Risks of Overly Simplistic Dietary Demons

One of the things that proponents of low-carb high-fat diets rage against, and probably rightly so, is how the overly simplistic demonization of dietary fats led to the rise of an ultra-processed market place of low-fat (but often high sugar) packaged foods.

And yet many of those same folks spend much of their time beating another overly simplistic drum these days - sugar.

While there's no argument from me that society's excessive consumption of sugar is a large raindrop in our flood of calories and chronic non-communicable diseases, if it becomes a singular focus, we may wind up with products like this new Kit Kat bar.

Nestlé is promoting their new bar on the basis of its reduced sugar content, and its packaging also infers it's "healthier" than before with it's large shout out to having "extra milk and cocoa".

As to the bar itself?

It contains 4 fewer calories than the Kit Kat bar it's replacing along with 0.7g less sugar.

At the end of the day there's a world of difference between "inconsequentially less awful" and "healthier", but that's a distinction that will likely be lost as new lines of ultra-processed foods are launched under the banner of lower sugars.

My Oldest Daughter Fixes Fronts of Packages - A Pictorial

For her science fair project, my oldest daughter looked at the impact of front of packages on consumer perceptions of health. As part of her study, she fixed up some package fronts with more realistic statements.

The Coca-Cola Company Supports Stricter Sugar Guidelines Than Health Canada

By Romain Behar

Last week Coca-Cola announced that they supported the World Health Organization's recommendation to limit added sugars to 10% of total daily calories.

Putting aside that it's difficult to limit that which you can't see or count, Health Canada recently announced that rather than recommend limits and listings to added sugars on food labels, they are going to do so only for total sugars.

Their rationale has been explained to me and others as being in part reflective of the fact that as a percentage of Canadians' total sugar consumption (the other was a regulatory concern that they couldn't identify added vs. intrinsic sugar by way of testing), added sugars make up roughly half of those, and therefore with Health Canada's proposed 100g limit to total sugars, and using simulated diets, they expect 50g of those to be free or added. Working off a 2,000 calorie diet (which itself may not be all that wise, but is the convention everywhere), that reflects the WHO's 10% recommended daily added sugar limit. Of course that's only if you follow Canada's Food Guide. And given that soda, candy, and what were once known as "other" foods, aren't part of the Guide, suggesting a total sugar value will serve as a useful surrogate will fail the vast majority of the population given studies have suggested  that 25% of the average Canadian's calories come from "other" foods.

Even if you put dietary reality aside for a moment, there's a big problem with the plan as more recent research calls Canadians' presumptive added sugar consumption into question. The research, spearheaded by PhD candidate Jodi Bernstein and working out of Dr. Mary L'Abbé's lab notes that prior guesstimates were based off data generated in part from the limited Canadian Nutrient File (CNF) - a database that according to Bernstein et al. lacks, "scheduled, systematic and comprehensive updating", and does not contain any brand specific data.

In the CNF's stead, Bernstein et al created their own database, the Food Label Information Program (FLIP) database, which they update every 3 years. The data was collected by way of boots on the ground in Toronto, Ottawa, and Calgary grocery stores representing 75% of the market share. There, researchers used a smartphone to scan and categorize every single item with a Nutrition Facts table (NFt). Next, an algorithm was utilized to calculate the products' free and added sugars.

Among their FLIP derived conclusions is that rather than the 50% derived from the CNF, 62% of consumed sugar in Canada is from free and added sources.

In turn that means that Health Canada's arguments in support of their much criticized plan to list simply total sugar on future NFts, are weak, and may underestimate added sugar consumption, and that if you consume 100g of total sugar, you'll be exceeding the WHO's recommended daily added sugar maximum by 24%.

It also means that The Coca-Cola Company may now be supporting stricter added sugar limits than Health Canada.

[I should note though, both the 50% and the 62% are best guess estimates. In turn I'd say that speaks to why we'd be far better off with an added rather than total sugar listing on our NFts.]

Is Health Canada About To Allow Wonder Bread To Market Itself As A Health Food?

Last month Health Canada announced their finalized version of the changes Canadians can expect to see, 5 years from now, on our nutrition fact panels.

And while some of the changes are laudable, the changes to how our labels report sugar appear confusing.

Rather than highlight the distinction between total sugars and added sugars, a distinction that the World Health Organization, Canada's Heart and Stroke Foundation, the American Heart Association, the American Academy of Pediatrics, the Institute of Medicine, and many other public health authorities believe to be the crucial distinction as would pertain to the impact of sugar on our development of chronic diet related diseases, Health Canada instead declined to add a line expressly highlighting a food's added sugar content. Instead, Health Canada elected to provide a line for total sugars, and to it attribute a %DV (percent daily value) measure derived from a recommendation of a total maximal daily limit of 100 grams of sugar (or 20% of total daily energy for a diet of 2,000 calories).

In a consultation that I participated in at Health Canada, they explained to us that their rationale for not having an "added" or "free" sugar line was regulatory in nature. They reported that it would be impossible for Health Canada to include a line on added sugars because if there were a regulatory challenge, a laboratory would be unable to differentiate between a product's sugar source and would only be able to report total sugar and not the percentage of sugar added to said product.

This strikes me as something of a cop out as not only do we currently have other labeling features that aren't testable in laboratory settings (Halal, Kosher, etc), but it is far from impossible to compare a product's total sugar and subtract that which would be expected to be intrinsic to a product's ingredients. It's also clearly not impossible as evidenced by the fact that America's Food and Drug Administration has announced that a line for added sugars will be rolled out to their nutrition fact panels (and required to be adopted in 2 years, rather than Health Canada's 5).

As to why this matters, beyond stepping away from the recommendations of other jurisdictions and public health authorities, it's deceptive.

For instance, if you were considering a 12oz can of Coca-Cola, if an added sugars %DV was set at 10% of total daily calories (as per pretty much everyone's recommendations), the can's label would tell you that it contained 78% of your recommended total daily value, but with Health Canada's new label, it'll tell you it contains a far less awful sounding 39% of your total daily sugar.

But there's more. And it's worse. There's a far more worrisome sugar labeling initiative being considered by Health Canada. In what will undoubtedly make matters worse for consumers, a "low in sugars" claim is being considered whereby the food industry will be allowed to market their products as healthful if they

"have no more than 5 grams sugars (a) per reference amount and per serving, (b) per 50 grams if the reference amount is small (i.e., 30 grams or 30 millilitres or less), or (c) per 100 grams if the food is a prepackaged meal."

On that basis Wonder Bread would be allowed to promote itself as "low in sugars", and so too will scads of other ultra-processed foods.

All this leaves me scratching my head and wondering whose interests are best served by these changes - the public, or industry?

If Health Canada Won't List Free Sugars, These Frustrated Researchers Will

Today's guest post comes from PhD candidate and RD Jodi Bernstein. The post covers her, and her supervisor Dr. Mary L'Abbe, the University of Toronto's Earle W. McHenry Professor and Chair Department of Nutritional Sciences', continued push for Health Canada to require free sugars to be included on Canada's nutrition fact panels.

The World Health Organization recommends that we limit free sugar intakes to a maximum 10% of calories a day. But there are many factors that hinder our ability to abide by these guidelines, far more than support it. First of all, it’s pretty difficult to picture what 10% of calories looks like. Sure I can tell you that for the average adult it’s about 50g or 12 teaspoons, but would that really help you all that much? Most of the free sugar we eat is coming from inside candies and sweets, cereal, beverages, and baked goods, so we can’t easily see how much free sugar is in the food. To abide by the World Health Organization’s recommendations, free sugar needs it to be included on the nutrition facts table.

The United States is planning to include the amount of added sugar (similar to free sugar) on their food label. But here in Canada, the latest proposal to change the nutrition label did not include free sugar on the label. In fact, we discussed the importance of including added sugar on Canada’s nutrition label in a previous blog post on Weighty Matters.

But in the meantime, we weren’t about to just sit around and wait. In light of this difficult predicament we took it upon ourselves to calculate the free sugar content of over 15,000 Canadian packaged foods and beverages, published it for open-access use, and found some interesting results along the way. Using the University of Toronto’s Food Label database, which has nutritional and ingredient information, we calculated the amount of free sugar in each product using a 6-step algorithm tailored for just this purpose. Here’s what we found:

1. A lot of foods have free sugar in them. Sixty-five percent to be exact. That means its probably harder to find a packaged food that doesn’t contain free sugars, although the proportion was a lot lower in certain food groups like vegetables, nuts and seeds, dairy products and cereals and grains and highest in desserts, sugars and sweets, and bakery products.
2. Free sugar accounts for 62% of total sugar. Although this was much higher for sweets, bakery products, desserts, and beverages and much lower for fruits and vegetables.
3. There is a wide range of free sugar in a food category. This means two things: 1) when choosing a product, there may be a similar one that has less free sugar available; and 2) successful reformulation is possible. Having similar items, some with less free sugar, acts as proof showing that, yes, this food can be made with less free sugar and consumers will still buy it!
4. There are 152 ways to say “free sugar” in the Ingredient List. It’s no wonder free sugar is considered a “hidden” source of calories. For instance, ‘table sugar’ was listed 40+ ways including all dehydrated, dried, granulated, concentrated, refined, coarse, evaporated, solid, powdered, and liquid variants of cane juice, sugar, and sucrose.
5. 1/5 of total calories come from free sugar. Of course this ranged between food groups, with the highest at 70% of calories coming from free sugar in beverages. Consuming foods that have more than 10% of calories from free sugar increases the likelihood of exceeding dietary recommendations.

We are hopeful that these results will support of interventions and policies (including labelling free sugar on the nutrition label!) to limit excess free sugar consumption. The detailed information we provided in this study can be used as a benchmark to monitor changes in free sugar contents overtime, identify areas and targets to focus reformulation efforts, direct educational messages, and can be linked to national nutrition surveys to evaluate free sugar consumption and monitor associated health outcomes.

Jodi Bernstein is a Registered Dietitian and has a Master’s in Public Health, specializing in community nutrition. She is currently a PhD Candidate in the Department of Nutritional Sciences at the University of Toronto. Her thesis focuses on sugars in the Canadian food environment.

Most recently, Jodi has developed an algorithm to estimate the free sugars contents of Canadian food and beverages. Results have since been used to populate One Sweet App, a mobile app that allows users to track their free sugars intakes and compare this to guidelines from the World Health Organization.

Dr. Mary L’Abbé is the Earle W. McHenry Professor and Chair of the Department of Nutritional Sciences, Faculty of Medicine, at the University of Toronto, where she leads a research group on Food and Nutrition Policy for Population Health. Dr. L’Abbé is an expert in public health nutrition, nutrition policy, and food and nutrition regulations, with a long career in in mineral nutrition research. Her research examines the nutritional quality of the Canadian food supply, food intake patterns, and consumer research on food choices related to obesity and chronic disease.

Dr. L’Abbé a member of several committees of the WHO including the Nutrition Guidance Expert Advisory Group on Diet and Health and the Global Coordinating Mechanism for NCDs; the former which recently released the WHO Guidelines on Sugars. Dr. L’Abbé was co-chair of the Canadian Trans Fat Task Force, led the Trans Fat Monitoring Program and served as Chair and vice-Chair of the Canadian Sodium Working Group. Before joining the University of Toronto, Dr. L’Abbe was Director, Bureau of Nutritional Sciences at Health Canada. Dr. L’Abbé holds a PhD in nutrition from McGill University and has authored over 180 peer-reviewed scientific publications, book chapters and government reports.

Ugh, McDonald's Hands Out Activity Tracker With Happy Meals

Though they only lasted a single day, it wasn't public cynicism over McDonald's latest scheme to excuse eating there that sunk them, it was skin rashes that ended their Happy Meal provision of fitness trackers.

But I bet they'll be back.

It's great business for the food industry to state directly (like Coca-Cola's Global Energy Balance briefly tried to) or indirectly that exercise excuses (or balances) a crappy diet.

Though exercise is the world's best drug, as I've noted, it's not a weight loss drug, and though exercise absolutely mitigates the risks of both weight and likely diet too, that McDonald's believes fitness trackers to be a Happy Meal draw is worrisome.

It's worrisome because McDonald's belief that kids and their parents would see the activity trackers as both incentive and permission to eat there suggests that society is well and fully bought into the notion that exercise trumps diet.

So too does the much lauded scheme floated a few months ago that foods fronts-of-packages be festooned with "activity equivalent labeling".

And this photo of an advertisement from a local community centre that I took just 2 days ago.

"HAVE YOUR CAKE AND EAT IT TOO! (We'll help you work it off!)"

Listen, for most of us (me included), life includes some junk food, but all this to say, I worry about the potential unintended consequences of continuing to dumb down exercise to calories burned as the one thing people today don't need are more reasons to believe that they deserve a break today.

Could Accurate Front-of-Package Food Photos Help People Eat Less?

Yesterday there was an interesting study published in Public Health Nutrition.

The study, "Frosting on the cake: pictures on food packaging bias serving size" explored four questions.

1. Do the calories of the foods pictured on fronts of packages exceed the calories stated on the package's per serving nutrition label?

Using cake mixes as an example the authors demonstrated that as pictured, with frosting, the slices of cake on the fronts of packages contained 134% more calories than the serving size calories published on the packages' nutritional facts panels.

2. Do people take extra ingredient calories into account when determining serving size?

Cornell undergrads were provided with two types of cake mix boxes and asked to estimate the "appropriate" number of calories per serving of cake.

One group of undergrads' boxes had photos of cake with frosting, while another group's boxes had photos of the same cakes unfrosted. The group with photos of cake with frosting were explicitly told that the frosting shown on the fronts of their packages' cakes was not included in the cake's back of box nutritional labeling. A third group was given boxes with photos of cake with frosting, but with no note regarding the frosting's calories not being included in the nutritional labelling.

The authors found that when there was no proviso about the frosting's calories not being included, the amount of calories that people believed were "appropriate" for a serving of cake rose dramatically.

3. Would clear front of package labelling about extra ingredients reduce serving size norms?

Using more undergrads, one group was provided with a box of cake mix that included a photo of cake with frosting and then asked to indicate what they thought would be a normal serving size, a second group was provided with boxes that included the frosting not included in calculations proviso, and the last group with boxes that included photos of frostingless cake. All groups used a series of cake slices that varied in size as determined by 100 calorie increments to make their selections.

The students who weren't told about the frosting, selected cake slices containing nearly double the calories of those told frosting calories were not included on the nutritional labelling.

4. Would labelling about extra ingredients reduce serving size norms in nutritionally savvy consumers?

Basically a repeat of question number 3, but with the participants being 44 food-service industry conference attendees.

With this group, despite being professional food service workers, when faced with the box without the proviso about frosting, though not nearly as significantly as with the undergrads, they too chose larger serving sizes.

Ultimately what this study suggests is that at least with cake, more accurate front of package food photography would influence how much consumers served themselves. The authors note that it is not at all uncommon for front of package food photos to include sauces, toppings and other supplemental extras that would not have been included in the product's labelling. There's also little doubt that in many (most?) cases, a boxed food's front of package photos are of servings much larger than the back panel's calculated serving size.

All of this to say that package reforms and legislative efforts need to consider more than just the nutrition facts panel, and that ensuring that front-of-package food photos accurately reflect both the panel's reported serving size, and that if there are extras, either they're accounted for on the panel, or a proviso is clearly provided stating that they're not, might influence that product's consumption.

[Reading the study my mind went immediately to cereal where serving sizes are usually in the neighbourhood of ½-¾ of a cup, and yet the bowls on fronts of boxes likely contain 2 cups or more.]

Guest Post: U of T's Chair of Nutrition Calls For Added Sugar Labelling

Today's guest post comes from PhD candidate and RD Jodi Bernstein. The post covers her, and her supervisor Dr. Mary L'Abbe, the University of Toronto's Earle W. McHenry Professor and Chair Department of Nutritional Sciences', recent call in the CMAJ (including this freely accessible CMAJ podcast) for Canada's new government to take the opportunity to ensure that added sugars are included on Canada's nutrition fact panels.

It has been nearly 15 years since the nutrition label in Canada has been revamped.

A lot has changed in the world of nutrition since then, particularly the evidence to limit our intake of free and added sugar.

But not all sugars are created equal when it comes to the health of Canadians and this should be reflected on our nutrition label.

Types of sugar
There are several ways to classify sugars according to where they come from and how they are consumed:

• Naturally-occurring sugars are sugars that are found in their natural and original source, like the sugar consumed as part of an apple or in a glass of milk. These sugars are obtained from sources that, for the most part, form part of a healthy, balanced diet.
• Free sugars are the sugars that have been removed from their natural source and are then consumed as is, or put back into foods and beverages, such as table sugar or fruit juice.
• Added sugars refer specifically to the free sugars and syrups that are added to foods and beverages.
• Total sugars that are on the current nutrition label is the amount of all the above combined.

Although all these types of sugars are chemically identical, free sugars and added sugars can be consumed in much larger quantities than naturally-occurring sugars. They can also be added into foods and beverages which would not normally contain any or as much sugar. Because of this, free and added sugars contribute to the increased health risks that accompany excess intakes of sugar.

Research on sugar and Health
In recent years, more evidence has emerged showing the adverse health effects associated with excess sugar intakes such as cardiovascular disease, obesity, diabetes and dental caries. A number of health organization including the World Health Organization, the United States Dietary Guidelines Committee, the UK Scientific Advisory Committee on Nutrition and the Heart and Stroke Foundation of Canada have all recommended limiting intakes of free or added sugars to a maximum of 5 to 10% of calories.

Added sugars labelling
Right now, only total sugars are on the nutrition label. Health Canada has proposed including a benchmark, or %Daily Value, on the label for total sugars to help consumers understand the amount. They are also proposing that food manufacturers will have to group all sugar-based ingredients together in the Ingredient List. However, these changes still don’t tell consumers how much sugar is added to the food they are eating.

Meanwhile, the United States has proposed including added sugars on their nutrition label along with a benchmark based on 10% of calories, which aligns with healthy intake guidelines.

Without listing the added (or free) sugar content on the nutrition label, it will be virtually impossible for Canadians to follow guidelines to limit added and free sugar intake to no more than 5% to 10% of calories. Without such labelling, it will be hard for consumers to know how much sugar is added to their food and to compare the amounts in different foods.

This year Canadians have elected a new federal government that has mandated the new Minister of Health to improve added sugars labelling. Let’s not lose this rare opportunity to update our Nutrition Facts table to ensure that Canadians can achieve the maximum public health benefits possible that are in line with the most recent scientific evidence.

In the absence of added and free sugars on the label, Canadian consumers can utilize apps such as One Sweet App, to track their free sugar consumption compared to World Health Organization recommendations.

Jodi Bernstein is a Registered Dietitian and has a Master’s in Public Health, specializing in community nutrition. She is currently a PhD Candidate in the Department of Nutritional Sciences at the University of Toronto. Her thesis focuses on sugars in the Canadian food environment.

Most recently, Jodi has developed an algorithm to estimate the free sugars contents of Canadian food and beverages. Results have since been used to populate One Sweet App, a mobile app that allows users to track their free sugars intakes and compare this to guidelines from the World Health Organization.

Dr. Mary L’Abbé is the Earle W. McHenry Professor and Chair of the Department of Nutritional Sciences, Faculty of Medicine, at the University of Toronto, where she leads a research group on Food and Nutrition Policy for Population Health. Dr. L’Abbé is an expert in public health nutrition, nutrition policy, and food and nutrition regulations, with a long career in in mineral nutrition research. Her research examines the nutritional quality of the Canadian food supply, food intake patterns, and consumer research on food choices related to obesity and chronic disease.

Dr. L’Abbé a member of several committees of the WHO including the Nutrition Guidance Expert Advisory Group on Diet and Health and the Global Coordinating Mechanism for NCDs; the former which recently released the WHO Guidelines on Sugars. Dr. L’Abbé was co-chair of the Canadian Trans Fat Task Force, led the Trans Fat Monitoring Program and served as Chair and vice-Chair of the Canadian Sodium Working Group. Before joining the University of Toronto, Dr. L’Abbe was Director, Bureau of Nutritional Sciences at Health Canada. Dr. L’Abbé holds a PhD in nutrition from McGill University and has authored over 180 peer-reviewed scientific publications, book chapters and government reports.

Canada's Senate Set to Tackle the Food Industry

Last week saw the publication of the Canadian Senate's Report Obesity In Canada A Whole-of-Society Approach for a Healthier Canada. My friend and colleague Dr. Arya Sharma criticized the report for not recognizing the pervasive and damaging nature of weight bias in Canada, and on this he and I strongly agree.

But Dr. Sharma voiced more concerns, broadly, that the report did not focus sufficiently on the treatment or research of obesity, and that it's stuck in the "Eat-Less Move-More" paradigm.

On these two points we both agree and disagree.

On treatment, the primary challenge is that there simply isn't a gold standard non-surgical approach to champion. The secondary challenge is that even were there such an approach, there's a dearth of physicians and allied health professionals trained and interested in delivering it. To that end I was encouraged to see the report's recommendation calling for improved physician training in nutrition and exercise - a need I recently wrote about, and to promote the use of counselling to help (a call that may relate to remuneration).

On research, I wholly agree with Dr. Sharma, it was surprising not to see a call for investment in studies and research meant to inform future best practices, both in terms of obesity treatment, but also prevention and public policy.

On Eat-Less Move-More, here I can't fully agree with Dr. Sharma's concerns. Ultimately eating less is required if we're to see changes to weight, and moving more is required if we're to see health risks mitigated, and there is a role for education and support of the public eating less and moving more directly. And had the Senate's report focused solely on the individual as the driver of change, I would have been equally disappointed, but that's not what their report does.

Instead the Senate's report focuses primarily on the food industry's direct and indirect influences on consumer choice.

The report's recommendations include:

• Banning food and beverage advertisements to children (where food advertisements have been proven to increase kids' eating)
• A sugar sweetened beverage tax which in turn may help both to decrease consumption due to economic considerations, and potentially to raise funds that in turn might further healthful eating or obesity treatment/research (I would be very disappointed were a tax enacted without some mechanism to ensure at least some of the funds raised would be earmarked for health)
• Improving access to nutritious food in Canada's northern communities (places where the exorbitant costs of healthful foods may preclude their purchase)
• Revising Canada's Food Guide to adopt a meal based approach and to have the guide speak strongly against the consumption of ultra-processed foods (and in so doing lay the groundwork to remove front-of-package health claims and the notion that juice is a fruit equivalent)
• Ensuring that the revision of Canada's Food Guide excludes the direct involvement of food industry representatives (which will help to ensure the recommendations are evidence, and not interest, based, where food industry interest always favours increased, not decreased, consumption patterns)
• Ensuring that the revision of Canada's Food Guide looks specifically at the science (or lack thereof) underpinning its excessively saturated fat phobic stance and that it changes the serving based focus that both nutrition professionals and the public have deemed confusing and unhelpful.
• Reforming our current system of front-of-package health claims (which will help to reduce the health haloing of ultra-processed foods)
• Exploring the possibility of using a unified front-of-package rating system (which in turn has been shown with some systems to improve dietary choices)
• Adding menu board calories in chain restaurants (which will help to inform, but not dictate, consumer choice)
• Creating a public awareness campaign on healthy eating that specifically calls out ultra-processed foods and champions cooking (could there be a report on nutrition or obesity that didn't include a public education component?)

Again, back to Dr. David Katz' sandbag analogy. We have a flood. To date, as a society, Canada has focused primarily on the encouragement of swimming lessons to fight the current, and while swimming lessons are always worthwhile (and indeed included in this Senate report as well), here we finally see an arm of government calling for the building of a levee against one of the flood's primary sources - the food industry.

Happy to see this, and it's about time.

Are Menu Board Calories a Flop?

A recently publicized study reports that 5 years on and menu board calories out of NYC haven't led to behaviour change.

I'm still a supporter.

Why?

Well, firstly we know that posted menu board calories only matter to those who care about calories, and given pre-order surveys of patrons in New York City (where the recent study was conducted) showed that only about 15% of folks care, it's not particularly surprising to learn that overall drops didn't occur. Speaking personally, and with my patients, and with folks online, there's no doubt that those who care do use the labeling.

Secondly, what no study of menu board calorie impact will ever measure are the calories not ordered by the patrons who decided consequent to menu board calories postings, to eat out in restaurants less frequently and hence weren't included in the study at all.

Thirdly the study looked at the impact menu board labeling had on exclusively fast food purchases. Of all venues, fast food restaurants don't strike me as the places where we'll see major changes. People go to fast food restaurants to get specific and "fast" foods. People know what they're going to order before they even step in the door. People go for their Big Mac's, their nuggets, their chicken buckets, etc. Fast food restaurants have far less variety, and likely, aren't frequented as often by folks who'd report caring about calories/nutrition in the first place.

And lastly, there is never going to be a singular intervention that'll do the trick, but that doesn't mean we should scrap the single interventions, especially ones that simply provide consumers with information that will help to inform their decisions.

As I've mentioned on this blog before, couple menu board calories with better nutritional education in schools, public health campaigns surrounding daily caloric needs as well as a call to action to bring back home cooking, the end to crop subsidies that allow fast food to be sold for pennies, an advertising and toy ban for fast food companies targeting children, and maybe we'll see some changes.

Why You Might Want To Step Away From The Kale Chips

I spotted these as I wandered around Whole Foods before heading to the movies.

The packaging screams out health. "Kale", "Air Dried, Not Fried", "GMO Free", "MSG Free", "Gluten Free", "Vegetarian"

Turn the package over however and you might be surprised to learn a few things.

The bag's 640 calories clock in at 16% more than a Big Mac's 549 (and more gram for gram than Doritos), and they're also packing the same amount of sodium gram for gram as Lay's potato chips (regular flavour).

The nutrition data is also a bit curious.

Looking at 28g of raw kale you'll notice that it contains 86% of your Vitamin A %DV and 56% of Vitamin C. And yet 28g of these dehydrated kale chips, which you might imagine would in fact represent more than 28g of raw given the dehydration, have 97% less vitamin A and 73% less vitamin C.

Putting aside the fact that if you're actually looking for the nutritive benefits of kale, at least as compared with Kaley's Kale Chips, actual kale's the way to go, some might say that I'm being too harsh. They might say that the bag isn't meant to be consumed in one sitting. But as you can see from the photo where I'm holding it, the bag's no larger than your average checkout aisle chip bag, and at least with chips, you won't for a moment convince yourself they're a healthful choice.

If you want kale buy kale. If you want chips buy chips. Simple.

We've Got a Serving Size Problem

Will posting more realistic serving sizes on packages help consumers make wiser choices?

I certainly used to think so.

The thinking was straightforward. If faced with the high calories (or sugar, or salt, or whatever an individual might themselves be focused on reducing) identified by a more realistically portrayed serving size, people might eat less.

Recent research however calls that thinking into question. A study published this year in the journal Appetite found that proposed changes to include more realistic serving sizes led those utilizing them, in laboratory settings, to serve themselves and others more, and that the serving sizes were perceived as amounts that people were supposed to eat.

What the study did not show was whether or not more realistic serving size postings would impact upon the frequency with which people ate a particular product, or whether they might lead them not to purchase certain products in the first place - behaviours which in turn would support the practice.

But those questions aside, the research was pretty clear in that the public's perception of "servings" including the erroneous notion that they were recommended amounts.

Makes me wonder whether or not having a dual column nutrition facts panel that includes a commonly consumed portion amount alongside the whole package coupled with the removal of the word "servings" would help (see up above)?

Future research for someone I'm sure.

Health Canada Giving Food Industry Nearly 7 YEARS to Adopt New Labels!

Whether or not you think Health Canada went far enough with their nutrition fact panel reforms (I don't), if you were wondering whose side Health Canada is on when it comes to nutrition - public health's or the food industry's - their labelling reform implementation plans are telling.

According to this piece by Trish Kozicka, the food industry will be given 5 years to implement the changes. 5 years? There's really no explanation for that kind of time frame beyond pandering to industry. Though industry pandering shouldn't come as a surprise. Much as Health Canada's stated mission is,

"to improve the lives of all of Canada 's people and to making this country's population among the healthiest in the world as measured by longevity, lifestyle and effective use of the public health care system",

at the end of the day Health Canada is an arm of government. That means that along with Health Canada's stated mission, are its unstated and genuine obligations to consider politics and the interests of the largest single contributor of the manufacturing sector to Canada's GDP - the food industry - when rolling out change.

As to why the headline reads nearly 7 years and not 5?

Kozicka explains,

.@YoniFreedhoff & the 5 years may not kick in for a while. @HealthCanada has 18 months after 75-day consults to publish final changes in CG2

— Trish Kozicka (@TrishKozicka) June 13, 2015

Too bad health isn't Health Canada's only concern.