According to my twitter feed I seem to be the only person who thinks the recent announcement* should be celebrated. As for the rest of you- all I hear is cynicism and complaining.

The Health Star Rating (HSR) system uses a star rating scale, like the energy stars on appliances, to help shoppers make informed and healthier food choices. Given how much people struggle to interpret food labels surely this is a step in the right direction?

Yeah, I hear you critics. Your points have merit- I’d just like to put them in perspective.

Firstly, yes there are anomalies. There always will be- no labelling system is perfect. Nope, not the Heart Foundation’s Tick nor the UK’s traffic lights. As a dietitian who has worked in food industry I have trialed a variety of nutrition-scoring systems and whenever you think you’ve found one that works you’ll stumble across another curve-ball product that damages the integrity of the system.

Secondly, food industry was involved in the advisory group. The calibre of this group, and the associated collaboration around this table is actually what I think should be celebrated the most. The majority of the group was made up of nutrition experts working in public health, academia and government. Five of the 11 members were from ‘food industry’.  I should hope that industry was involved. After all, they are the ones who work day in day out with product development, regulation and labelling. Their involvement gives me faith that the system is actually practical for companies to implement.

Thirdly, the system is currently voluntary. If you think all (if any) food companies are rolling in money you are delusional. Labeling changes are expensive and are done as infrequently as possible. Given that food companies are the ones footing the bill, not government; it is fair that companies should choose when and how they roll out the labelling changes.  Again, for those up in arms about the industry involvement in the advisory group, the fact that some of our biggest food companies are supportive of the system in a great start. Nestlé and Sanitarium have already publically pledged their support. Give them the chance to step up to the plate.

Don’t get me wrong- I have apprehensions about how it is all going to work, and what effect it will actually have on health outcomes.  But can we all just take a moment to acknowledge that with a little collaboration and faith we may have taken an extremely positive step.

* On 27 June 2014 the Minister for Food Safety, Nikki Kaye, announced that the Government will be joining with Australia’s (voluntary) Front of Pack Nutrition Labelling system. More information available here.

While there is a lot of great material in their call for action document Stop the Heartbreak 2014, I chose to speak about the three closest to my heart – which unsurprisingly are related to the food and nutrition space.

They are:

-  objective, good quality data

-  facilitation more communication and collaboration

-  addressing inequity.

My first point addresses the paucity of ongoing good quality data on what New Zealanders are eating and drinking. How can the government possibly form rational and evidence-based policy, programmes and guidelines on food and nutrition when they don’t have quality information about the food supply and what we’re actually eating? This lack of authoritative data has created a space that’s ripe for anecdotal evidence and opinion.

For example: We did once have nutrition surveys that collected gold standard information about our diet – comparable with the best national surveys internationally such as NHANES in the US and the NDNS series in the UK.  Sadly these have been replaced with comparitively inaccurate health and lifestyle questionnaires within the health survey which cannot possibly assess the complete nutritional status of the participants. If you want good quality policy, you must invest in good quality evidence gathering.

Which brings me to my second point of facilitating communication and collaboration.

Part of good leadership is to ensure everyone’s aligned, on the same page, and moving forward as one, to address an issue in the most efficient way possible.  This saves various unaligned factions from wasting time and doubling up on resources – or even worse – working against each other and ultimately achieving nothing.  Sadly the latter is often the case when you consider work being done by the food sector and health sector in New Zealand.

Health officials should have the mandate to communicate and engage with all stakeholders in the food and nutrition area.  In my view, food manufacturers and their suppliers, retailers and food outlets are key stakeholders in determining the food environment and thereby, to some degree, the nutritional health of the population.  But health officials do not communicate with this sector.

This precludes them from impartially recognising important areas of mutual agreement with which to facilitate genuine cross-sectorial engagement and action.  Already, some food manufacturers are driving some impressive health-related change with the programmes they’re implementing: breakfast programmes in schools, workplace health programmes, targeted lifestyle, activity and cooking skills programmes, and reformulation initiatives around nutritional content or serve size.

These types of initiatives shouldn’t occur in isolated pockets – they could be facilitated, coordinated and even partnered with academics and NGOs and other stakeholders to deliver maximum benefits to the population, with a combination of funding sources.

Of course the Heart Foundation are one of the few agencies facilitating some sterling work in this space with food companies, through inititiaves such as HeartSAFE and Fuelled 4 Life. But there’s a huge amount more scope for this type of activity.  In fact there is some promising signs that the Government also recognise this in their initial material regarding the proposed Healthy Families Programme.

And lastly, the absolute MOST important thing which the Government could and should do to stop the Heartbreak is to seriously address the health inequity in our society.  Inequity refers to the uneven distribution of health determinants which may be unnecessary and avoidable as well as unjust and unfair.

Sadly it’s no longer affordable to eat what’s recommended for many people in this country.  While academics argue over whether 5+ or 7+ fruit and veg a day are better for you, people struggle to achieve anything close to 5+ a day. Regardless of Government advice, the main reason why most shoppers don’t pick healthy foods is that they are more expensive.  They’re also often harder to access in some areas.

To buy fruit and vegetables for a family of four costs thousands of dollars more per year than more convenient (and potentially less good for you) food options. When faced with the option of buying apples or sausages for the family within a very limited budget, it’s not surprising that the more filling sausages make it into the trolley.  Good intentions evaporate when faced with the option of paying the electricity bill or having another bag of frozen peas this week so that another serving of vegetables can be part of each meal.

Importantly though, I wouldn’t blame the sausage makers or the electricity companies for that.  Instead I’d question why people are forced to make this decision at all, since all items are necessary for health.

The Government need to intervene, to mobilise communities and make healthy eating more affordable and accessible to those who are faced with unfair choices.

In a country where someone dies from heart disease every 90 minutes – we could all do more to stop the heartbreak.

Food companies exist solely to make money, so they will sell whatever people will buy. Healthy food provides smaller margins, so they fill their food with cheap processed ingredients that lack nutrition.  And then they market these foods to appeal especially to the most vulnerable (eg, children).  This has caused the ‘toxic’ food environment and high rates of obesity and diabetes.

When you view the world through this lens, it’s certainly easy to find examples to illustrate it.  For example:

• It’s hard to find a reasonably priced wholemeal salad sandwich amongst the shelves of confectionery and chips at a convenience store or a petrol station.
• A sausage roll and fries is much cheaper than a chicken salad at most cafes.
• How many times have you been trapped behind a ‘back of the bus’ promotion for the latest lolly and cream-filled frappé offering? (It always happens to me when I’m driving a carload of hungry children, so I know the effect these ads have on kids.)

It’s true: healthy choices are often difficult choices – especially for those most stretched for time and money.  They often go against the yummiest or the cheapest option – and we all know that taste and price are the major drivers to purchase.

Regulation, marketing restrictions and taxes on foods and beverages are being proposed by some as the means to change this.  I propose they won’t change this because they won’t achieve the fundamental societal shift that’s needed to encourage people to willingly adopt the harder option.

There are many aspects of life in which the right choice is not the easiest choice, but regulations are not the best answer:

• Most people find it easier to spend money than to save it.  Does that mean we should all be denied access to retail outlets on certain days of the week?
• It is easier for parents to let children watch TV for entertainment rather creating more sociable entertainment, or ensuring the homework is done instead.  Does that mean parents should not be allowed to have television sets?

Why is food and health any different?

As a dietitian working with a range of food companies, I also see things through a different lens.  It is easy to paint food companies as faceless, profit-hungry global entities who don’t give a damn about the health of the planet or their consumers, and to blame the current food environment on them (and the government for letting them do it).  But the burden of proof placed on those companies to demonstrate how fictitious this is, is often too high to scale, especially considering the lack of reason and objectivity that exists in the debate around “Big Food”.

Food companies – and especially the global ones in my experience – take their obligations to their communities, employees, consumers, environment, suppliers, stakeholders and shareholders equally seriously.  That is how they succeed.  A company who purposefully harms the health of their consumers is not sustainably commercially successful.  So no: commercial success does not equal public health failure because true commercial success requires public health gain.

Unlike the tobacco industry, the food industry is able to produce and promote healthier food and portion options – something many companies have been actively working on for decades.  Increasing the momentum of this change depends on consumer demand, and this is influenced by a huge range of societal influences, in which we all have a significant part to play. What do you think you could do?

Week after week books are published and media reports are issued focussing on finger pointing.  For the past six months in particular all fingers have been pointed at the food industry – in particular the “food giants” – for manipulating and addicting consumers to their products.  Prior to that – at least in New Zealand – experts have pointed to Government, for their lack of investment in preventative health and unwillingness to introduce regulatory taxes, bans and restrictions for certain foods and food marketing.  And any health-related association or sports group is now being criticised for working collaboratively with food companies because of the fear that food companies only associate with health-related associations as a fluffy PR exercise. It is not known what foundation there is for such fear, but it’s enough to make food companies throw in the towel on their numerous attempts to introduce healthier options and reformulate existing products, and just start doing exactly what they’re being accused of (if people are determined to think that anyway).

In the meantime is the population any better off?  When the average person spends less than a second deliberating over their supermarket choices and juggles food provision for their families with all of the other priorities in our busy lives, what is all this finger pointing achieving for them?

I would venture to say it’s doing more harm than good.  It’s causing even more confusion.  The bottom line is people have to eat and drink something to stay alive.  Dietary experts and food and nutrition guidelines largely make recommendations based on the four food groups, which actually don’t relate well to what the average person has to choose from when they’re in the supermarket or eating out these days. People also don’t have the lifestyles or incomes that enable them to grow their own foods or shop at farmers markets (wonderful as they are).  They simply buy and eat what they like/can afford/are familiar with – in that order.  So achieving the shift that motivates them to also vitally include in the purchasing mix “know is healthy for them” requires the following:

- Unity and clarity in scientific advice from Government and academics which relates to the current food supply, not the foods which Nana had to choose from when she shopped for her family back in the 1960s.

- No more contradictory, confusing, subjective and unsubstantiated messages or blanket statements which only result in people giving up and going back to what they know and like.

- Support and endorsement from the scientific/health community when food companies make positive nutritional changes, so that there is actually a demand for healthier products from the population.

- Dropping the blame game.  Truly collaborative implementation of solutions is the only way forward to deliver real benefits to the population.  This will involve significant compromise for all parties, who must commit to concrete actions and be held accountable to those in the long term.

Can’t we just get on with it?

Is food addiction the ever-elusive single cause of the obesity epidemic?  As a slightly pedantic sceptic, I must admit to finding this term somewhat illogical.

The official definition of addiction is: a persistent, compulsive dependence on a behaviour or substance.  To some degree aren’t we all persistently, compulsively dependent on food?  After all, unlike nicotine, gambling, alcohol and narcotics, we cannot live without it.  Preferably we need it at least three times a day, every day, for our whole lives.  Yet only a third of the population are supposedly at risk of having “food addiction”.   If broccoli was your preference, would that be labelled an addiction?

Don’t get me wrong – I’m not trying to belittle the justifiably valid concerns of those who feel completely out of control around food, and who legitimately see this as a reason for their own weight problems – I just don’t see these people being in the majority.  I was intrigued when I recently saw a notice on a bus advertising an Overeaters Anonymous meeting.  Perhaps this is something we will see more of, and hopefully, as with AA, it will be a very helpful framework for individuals in order to work though common issues towards recovery.

But does this loss of control around food (or more correctly, specific types of food) occur in isolation?  I’m no psychiatrist, but it would seem to me that underlying reasons for this type of behaviour would be multifactorial and complex.  Overeating is therefore a symptom, which sadly results in symptoms of its own, exacerbating a cycle of health problems.

I don’t think the complete loss of control around food, with a continuous drive to eat more and more around the clock is solely responsible for the obesity epidemic we face.  Most of us eat a little too much on a regular basis and are too inactive to balance
this intake of calories.  Over time this leads to a gradual increase in the waistline, until we are in a situation where more people are overweight than are normal weight within the population, and nearly the same proportion are obese.

If it helps people to examine what they’re eating and how active their lifestyle is to label themselves as a “food addict”, then so be it.  The only outcome I’m interested in is people getting healthier.  This involves solutions that enable all of us to take more ownership of our health and make wiser choices about what foods and drinks we choose to buy and consume, in what amounts, and how much we sit being inactive.  What do you think?

Image thanks to FreeDigitalPhotos.net

The universal call to increase the consumption of fruits, vegetables, higher fibre foods and seafood, coupled with tightening family budgets, means that a study published recently in the Journal for Nutrition and Food Sciences is highly relevant.

The study looked at the nutritional qualities and relative cost of canned foods, and reassuringly found that canned foods provide sound nutrition at an affordable price, in a convenient format.  Specifically much-needed key nutrients, such as fibre, protein, folate, vitamin C, and vitamin A were shown to be significantly preserved in a range of canned foods.

The nutritional findings are in line with research undertaken here in New Zealand about 10 years ago, but the latest study went an extra step by evaluating affordability on a price-per-serve basis against fresh, frozen and dried counterparts.  The affordability measures took into account preparing and cooking time, and also energy usage.

The study looked specifically at canned beans, corn, mushrooms, peas, pumpkin, spinach, tomatoes, peaches, pears and tuna; comparing then with their fresh counterparts.

Two examples of the findings were:

• Tomatoes – It is nearly 60 percent more expensive to obtain dietary fibre from fresh tomatoes as from the same portion of canned tomatoes.
• Corn – When looking at purchase price alone, fresh corn is less expensive than canned or frozen. However, when the cost of waste (most notably the cob) is factored in, as well as time to prepare, canned corn offers the same amount of dietary fibre with a 25 percent cost saving compared to fresh and the same amount of folate with a 75 percent cost saving compared to fresh.

The NZ Nutrition Foundation (NZNF) commented on the relevance of the findings, as they come at a time when many families are struggling to put healthy food on the table because of limited budgets. It also makes the point that canned foods ensure essential nutrients are more accessible to consumers, particularly those with limited storage, preparation facilities, limited time, skill or interest in preparing fresh foods.

I find this heartening, at a time when so many of our current foodie programmes put great emphasis on the use of fresh fruit and vegetables.  I fear this may be setting the bar too high for many kiwi families who are struggling to make ends meet.  We now know that canned foods do deliver the goods nutritionally and needn’t shy away from the limelight, in the informed kitchen.

It was a great opportunity to show what is happening in NZ and how we as a nation are faring in these tricky times and what the food industry and health sector are doing to address a global issue.

Not surprisingly, but no less disappointingly the piece was fairly one dimensional and single-mindedly focused on sugar and soft drinks.  What it did highlight, once again, was the limited lens through which so many people choose to examine the link between food and health, or rather food and disease as appears to be the main focus.

While I commend Sunday for attempting to help New Zealanders think about what they choose to eat (or in this case drink), the facts do not warrant the dramatic way in which this, and many other stories are presented.

It certainly makes for good TV to show a wheelbarrow full of sugar to represent how much we each consume annually, but this is somewhat misleading.  Likewise we each consume several Olympic-sized swimming pools of water annually, which also looks frightening.  In fact on a daily basis our median intake of sucrose when last measured in 2008/09 was just 48g.  And it’s on the decline (it was 53g in 1997).

Also, only 5% of our energy (as measured in 2008/09) came from non-alcoholic beverages.  And just 1.4% of energy was contributed by the sucrose in all non-alcoholic beverages (only part of which is sugary soft drink).  The rest, presumably, is contributed by fat, lactose, fructose, glucose and protein (remembering this group includes all non-alcoholic beverages other than plain milk).  So are the other foods and drinks which contribute 98-99% of our energy intake unimportant?  I think not.

In New Zealand, our intake of sugar (and particularly sugary soft drinks) differs significantly from countries like the United States, where much of the concern about sugar intakes stems from.

I don’t wish to trivialise the issue, as clearly the above figures are population medians, and some New Zealanders do over-consume.  I would like to propose however, that these individuals are unlikely to be over-consuming on sugary soft drinks alone, and are more likely to be part of the growing number of food-illiterate people who don’t understand what over-consumption is.

To Professor Rush’s point, there is some evidence that we feel less satiated when we drink kilojoules, compared with when we eat them (because our stomachs empty more quickly), but I think the issue of satiation is far broader than just blaming drinks for our obesity problem.  More and more New Zealanders seem to have become so accustomed to constant grazing on food and drink, to the point that many do not recognise the feeling of satiation, let alone the feeling of hunger.

What drives us to this?  Economic, cultural and social issues that shape the environment we live in and the choices we make.  Recently I read some research which found that most people no longer know what a calorie/kilojoule is.  Yes, sugar and sugary drinks provide kilojoules, but so does everything we eat.  In order to improve our health as a nation, individuals need a basic understanding of their own diet and how it relates to their own health; they need tools to help them make the best choices for them individually and they need to accept some individual responsibility for what they feed themselves and their families on a daily basis.

Yes, I do provide independent nutrition advice to a range of food companies, including NZ Sugar and Coca-Cola Oceania, so you may think my opinion is biased.  As a result though, I’ve been following this issue closely and am aware of the evidence, plus lack of evidence, surrounding it.  In my experience, it’s hard to get those without a vested interest in this issue to speak up – at least in New Zealand.  My personal view is to stick to the facts, and to address all of the issues with practical solutions, rather than pinpoint one possible contributor alone.  If there was a single silver bullet to address obesity, we would have found it my now, and we’d all be an ideal BMI.

Lessons from this ancient fable are just as relevant today when we evaluate how various scientific experts approach the totality of scientific evidence.  Recently we had a good example of this when one prominent scientist published his professional (and somewhat extreme) opinion on sugar in Nature, resulting in a media storm and “expert” slanging match across the globe.  Personally I thought Dr Arya Sharma’s commentary on this was one of the better ones.

The very essence of scientific endeavour is to prove or disprove hypotheses, and since research often raises more questions than it answers, further research is usually justified.  So individual researchers passionately chase logic down the path where their research leads them.  It’s hardly surprising that when they come up for air and see what other “descriptions of the elephant” exist, debates can get heated. People who “describe the animal in the same way” comfortably reference each other’s material, while desparately trying to disprove the findings of others who might describe the animal differently.  Hence many highly esteemed experts fight it out in the media and the general public become more confused and disenchanted than ever.

In the world of nutrition science nothing is black and white, as everything is highly dependent on a complex web of lifestyle variables and genetic make-up.  It is therefore difficult to make clear and meaningful recommendations on a population basis, and no wonder really that we usually wind up back at use-your-common-sense messages, such as “eat a variety of foods” and “a balanced diet” which can be waffly and confusing for people.

White hat scientists (and there are a lot of them), tend to take the approach that it won’t do anyone any harm , rather than the evidence-based approach.  There is an increasing school of thought that goes; since it takes so long to prove or disprove scientific theories on nutrition, we should just make recommendations which may not be effective but can’t do any harm.  The American Heart Association clearly states in its position paper on sugar that “research tools thus far have been insufficient to confirm a direct link” [between added sugar intake and weight gain]. Then they go ahead and make  prudent recommendations anyway.

Sadly this well-intended advice often serves to confuse and alienate the public further, as they reach for another chocolate bar and vow never to listen to another expert.  Judging by the comments on TVNZ’s Breakfast facebook page (Feb 24th) this is certainly what happened when the NZMJ published a viewpoint article listing 49 foods for obese people to avoid, and the media made a complete meal of it.  Yet again, the dietitians among us come out of it looking like the food police.

So, can we win?  Is practical, meaningful and evidence-based dietary advice the ever-elusive holy grail?  I’d love your views on this.

Lightbulbs went on in my head throughout the workshop, appropriately titled A conversation around compliance, motivation and the imperfect, irrational human being. Often health professionals wonder why people come to them for help, only to fail to follow the advice or treatment plan that’s provided.

This nonsensicality begins to make sense when  the complexity of our brain, emotions and thought-patterns are accessed (and when you bear in mind that to some extent, we are in fact all imperfect, irrational human beings).

As many of  us know breaking an old habit, is remarkably difficult. Of course there are cases where people have turned their lives around in an instant, but these are far outweighed by those of us who have tried every way to leave behind a habit, and still struggle to achieve lasting results. In fact often we can end up worse off than when we started.

But don’t despair – some helpful tips, gleaned from John’s workshop on this topic, included:

• When encouraging change, we must first ensure that in doing so, we don’t increase resistance to change. If we are confronted, a natural instinct is to resist, demonstrate reluctance or react. Often, objective, logical evidence is dismissed and any attempt to use logic and scientific argument can have the opposite effect that’s intended.
• We as humans are wired to loss aversion – meaning if you told me I need to give up chocolate biscuits, I may work to avoid this. Instead it is important to focus on what I would gain from giving up that box of chocolate biscuits each day.
• We have a commitment to our beliefs which is often difficult to terminate, even when things aren’t working. Evidence in support of a belief (such as, “no I don’t believe I need to exercise in order to lose weight”) may be lacking, but this belief has the power to create an immoveable force, leading us back to our old habits.
• Motivational interviewing is a common and effective technique used in all forms of counselling, including dietary counseling. Instead of confronting or persuading someone to change, this technique focuses on helping a person to mobilise their values and goals so that change becomes the bi-product of this. This is done using tactics such as practicing reflective listening, open-ended questioning, and summarising – then being able to identify and act on ‘change statements’ – i.e. acting when a person is actually ready to change. Changes statements include those which; recognise a problem, show concern, show an intent to change, or show optimism about changing.

While motivational interviewing is widely used by health professionals, I believe it can be applied to many areas of our day to day lives, and the way we communicate with each other. Without knowing it, I was constantly using this technique quite successfully when employed as a nanny. When the children resisted eating their vegetables, I would focus on what they’d immediately gain from eating them – which was having the freedom to leave the table and go and play on the trampoline again. And to a 12 year old this prospect was irresistible.

I’d be interested in hearing your thoughts on where you think this could be applied, whether it be with your children or partner, or even with colleagues or business associates.

But the real kicker is what’s happened to our waistlines, despite all this apparent healthy change.  There’s no doubt about it – we’re all getting fatter.  Sadly, as is often the case, this trend disproportionately affects certain groups in the population, with obesity rates amongst Maori and Pacific peoples in particular, starting to scale to dizzying proportions.

While everyone agrees the reasons are multifaceted, a number of experts have provided commentary in the past week as to why this dichotomy is being seen, including (and I’m paraphrasing for the sake of brevity):

1. “It’s because people under-report what they eat in surveys” (Rod Jackson)

Yes, this has been documented in the literature, but in comparing like methodology with like methodology are we really likely to be recording our food intake any less accurately now than we were in 1997?  Even with an interviewer in our homes and going through our cupboards?  I’m not sure this is the only explanation.

2. It’s partly because we’re less active than ever before and the survey did not assess activity levels.

Certainly the basic energy in: energy out equation loop isn’t completed without an assessment of physical activity levels.  There is no question that sedentary behaviour is the elephant in the room with respect to obesity.  No matter how much we idolise our sporting heroes as a nation, the majority of us are more likely to sit on our backsides for most of the day.  Every day.  But, are we likely to be even more sedentary now than we were in 1997?  The 2006/07 NZ Health Survey found no change in regular physical activity between 2002/03 and 2006/07.  However, according to Professor Grant Schofield, our levels of sedentary behaviour are likely to be on the increase, with more hours of TV viewing, more sedentary jobs and greater car ownership/distance travelled by car in the last 15 years.  I don’t think we’ve heard the last on just how dangerous sitting can be for our health.

3. “It’s because our environment is too jammed with easily available high fat, salt and sugar foods” Robyn Toomath.

This is where we start to go around in circles, because the dietary intake data on the whole indicate we’re actually eating less fat and sugar.  In fact the only source of sugar which is growing in our diets seems to be fruit.  And in our fear of fat we seem to be switching to low fat dairy at the expense of retinol intakes and cutting out red meat to the expense of our zinc and iron intakes.  So are we reporting our intakes correctly? (… and the circular nature of this dicussion goes on).

I would love to know what you make of all of this.  It would be great to get a discussion going.  Just insert a comment below (if there are no comments yet you need to click on the no comments box in order to make one).