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Electronic letters published:
![[Read eLetter]](/icons/misc/sectionDOWN.gif){kind=icon}
Re: Re: CMAJ Health Check Article
Scrap the Health Check Program
Rewarding mediocrity
Letter to the Editor, CMAJ
Health Check's Hollow Defense
Re-thinking Heart-Check labeling programs
RE: CHECKING UP ON HEALTH CHECK
Re: CMAJ Health Check Article
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Bill Jeffery National Coordinator, Centre for Science in the Public Interest
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jefferyb{at}istar.ca Bill Jeffery
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Front-of-pack “healthy-for-you” symbols have the potential to help hurried and inexpert grocery shoppers choose healthy foods and interpret Nutrition Facts. But, symbols based on weak nutrition criteria and sold beside more nutritious products that don’t carry the symbol may even have negative net effects on public health. The Heart and Stroke Foundation’s (HSF) nutrition criteria are certainly stricter than some major companies' healthy-logo standards. But, approaches developed by Yale and Oxford researchers and the 150-outlet US- based Hannaford Brothers grocery store suggest opportunities for improvement. Plainly, many Canadian shoppers construe the “Health Check”TM logo as flagging foods that are, in an absolute way, health- promoting. But the HSF concedes that sometimes so-labelled products are only relatively nutritious among non-nutritious products in the same product category. Worse, for example, of the 257 fruit and vegetable products enrolled in the program, 194 are fruit juices, fruit leather, and french fries—hardly nutritional superstars—and only 14 are fresh fruits and vegetables. In nine years, the HSF’s best efforts and goodwill helped enrol 1,500 products--impressive by NGO standards and compared to the American Heart Association’s Heart-Check program. But, at less than 3% of available groceries, they are too few to ensure a significant or even net positive effect on public health. Using stricter criteria, shelf-liners at the Hannaford Brothers chain credit 28% of its entire 25,500-product inventory with at least one of three “Guiding Stars.” (The other 72% don’t get any stars.) The time has come for Health Canada to mandate (and health advocates to promote) a standard “healthy-for-you” symbol, colour-coding or rating scheme for all eligible prepackaged (and restaurant) foods based on sound nutrition standards to usefully help Canadians separate the wheat from the chaff. As a first step, Health Canada should commission, perhaps with the US federal government, a National Academy of Sciences, Institute of Medicine study to help identify the best nutrition standards and most effective approaches to front-of-pack labelling. Bill Jeffery, LLB National Coordinator of the Centre for Science in the Public Interest, Ottawa Conflicts: None. Conflict of Interest:None declared |
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Eddie Vos maintains health-heart.org
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vos{at}health-heart.org Eddie Vos
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Heart and Stroke’s Health Check program(1) is underpinned by fat, cholesterol and salt phobias that are firmly rooted in decades old concepts we now know do not to improve longevity. For example: 1. There are absolutely no trials showing that avoiding ‘fat’ makes people healthier while the ‘low fat’ suggestion in the fish categories ignores consensus that omega-3's prevent cardiac deaths (2). The omnipresent ‘low fat’ recommendation forgets that most saturated and mono unsaturated fat below one’s belt may well have been self-made from excess carbs, while the sodium criterion that ‘oil’ should have <480 mg per 50 grams is bizarre, despite the 7 ‘expert’ Advisory Committee(1) looking at it, since no oils contain any sodium. Their suggestion to avoid coconut ignores the fact that the next best source of its main fatty acid, C12:0, is breast milk, as nature intended, and that this saturate appears entirely non toxic [Medline 7270479]. Moreover, the Heart and Stroke ‘food facts’ suggests zero omega-3 yet 70% omega-6 sunflower and safflower oils are “better for heart health”, a notion debunked decades ago by the Veteran’s Trial. 2. About the cholesterol phobia, we know that its intake does not significantly raise blood levels and we know that in older populations it is LOW serum cholesterol that predict early death(3). Health Check does not recognize when promoting cholesterol lowering fibre that oat and wheat bran provide a host of nutrients while other sources such as wood and psyllium fibre do not. 3. The only B vitamin considered is folate while we know that higher than common intakes of B6 and B12 are also needed to minimize homocysteine, an agreed protein corrosive, marker for sub-optimal micro- nutrient intakes, and risk factor for, or cause of, a host of diseases(4). Looking at just 2 recent trials, graphically depicted here: http://www.health-heart.org/HIPandHOPE.gif: the HOPE-2 trials showed a 25% reduction in stroke in late secondary prevention after 5 years of 3 B- vitamins that lowered homocysteine [Medline 16531613]. Then, in mean 71 year old stroke victims, a Japanese trial showed an 80% reduction of hip fractures from homocysteine lowering, using just 2 B vitamins for 2 years [Medline 15741530]. The Health Check program is fatally lacking if early- in-life prevention by (fortified) food and supplement selection has anything to do with evidence based prevention of diseases caused by one’s slowly degrading functional and structural proteins. The Health Check program is arguably the worst ever devised on a $m2.7/year budget and for which Canadians ultimately pay. Heart and Stroke should end this program; personally, I don’t think it can be fixed under the current management and paradigms: it misleads, confuses and likely harms Canadians. 1. http://www.healthcheck.org/en/nutritional-information/nutrient- criteria-grocery.html and http://www.healthcheck.org/en/nutrition-information/technical-advisory- committee.html 2. Leaf A. On the Reanalysis of the GISSI-Prevenzione. Circulation. 2002;105:1874. Medline 11997268. Free full text: http://circ.ahajournals.org/cgi/content/full/105/16/1874 3. Ulmer H, Kelleher C, Diem G, Concin H. Why Eve is not Adam: prospective follow-up in 149650 women and men of cholesterol and other risk factors related to cardiovascular and all-cause mortality. J Womens Health (Larchmt). 2004 Jan-Feb;13(1):41-53. Medline 15006277 4. http://www.health-heart.org/why.htm [or http://www.health- heart.org/why.pdf ] Conflict of Interest:None declared |
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Barry Dworkin Assistant Professor, Department of Family Medicine, University of Ottawa
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barrydworkin{at}rogers.com Barry Dworkin
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As a family doctor I depend on evidence-based information to provide the best information for my patients. On my national radio show, Sunday House Call, we interview scientists, researchers and clinicians who provide the basic science behind their research and how it leads to progress in other areas, sometimes with serendipitous results. Over the past four years and 800 interviews later, the reaction from our listeners is one of appreciation for providing credible information that uses the scientific method as an equalizing yardstick. On Sunday House Call we do not minimize the science and our guests are encouraged to use words that best describe their work and to define these words on the fly. The result has been an educated audience that has learned how to use the critical thinking tools required when presented with health claims or end-points of various studies. They enjoy the show because it does not promote or endorse a particular product nor is it paid by any sponsors that would have a vested interest in said promotion. If it were revealed that an interview with a clinician about the latest diabetes medication was sponsored by the maker of the medication (even if there was no communication made by the company regarding the content of the interview), the public's impression would be that this interview was tainted. It is the death knell of any public relations program. This introduction brings me to the Health Check program. While I appreciate the complimentary words of some of the contributors regarding the purpose of the Health Check program, one must look at the evidence to support this program. There are several problems with its methodology. If a claim is to be made that a particular Health-Check approved food is a better choice to make, it begs the question, "Compared to what?" The Health Check program only reviews those products submitted to them by interested companies that have something to gain from this recommendation or seal of approval. One only had to watch the reaction of shoppers on CBC's Marketplace when they found out that companies paid the HSF to review their products. It is immaterial that the HSF uses this money to fund its program. They lost the battle when the public's cynicism was tweaked by this revelation; the Health Check system lost credibility in their eyes. The methodology to evaluate, in this case, whether a food fulfills the requirements of the Health Check program, must include o broad range of similar items selected by the HSF and not submitted by a particular company. The inherent bias in product selection would not pass the first test of a clinical trial were it to be framed as such. It is not the way we apply the scientific method. This was all too evident, much to my chagrin, when I interviewed Stephen Samis , Director of Health Policy, Heart and Stroke Foundation of Canada and Terry Dean, General Manager of Health Check.. I asked them to defend their Health Check approval of Welch’s Grape Juice, Disney’s Complimentary Dinners, Slush Puppies and Milk Buddies on the basis of the science. Despite my many attempts to get them to respond off-script, they stuck to the 1992 Canada Food Guide as the basis of their claim that these foods met the criteria for servings of fruit, protein, fruit, and dairy respectively. They also made mention of some of the vitamins present in these products. When I asked, if I took some water, added grape flavouring, ten teaspoons of sugar, and the vitamins they mentioned whether this would receive a Health Check certification, the answer was no. I did not understand this given that the ingredients were the same as that found in the Slush Puppies. We talk about the salt content of foods and again there was the answer that efforts were being mace to reduce salt intake by 2020! Granted, the HSF was not behind this decision but it seems incongruous that an organization devoted to the health and well-being of the public should not come out and forcefully say that this is not good enough. Too many people will die because of this dawdling. To say that the program has good intentions is not good enough. The HSF has a high standard to keep because it is taking the responsibility to provide credible information to the public. The Health Check program is a flawed half-measure that will backfire on the HSF. Witness the reaction on CBC’s Marketplace and the viewer’s emails as a testament to the public anger of discovering how the program operates and uses the science. Many other evaluative systems apply the science in a sound and rational manner. They also encompass all foods and not select ones. They offer people choice. Health Check does not let a person choose the better between similar foods because it only includes those whose companies pay for the privilege. We use a food guide that is methodologically flawed compared to other systems like the ONQI system. The politics and credo that “we must support the King because he is the King” leads to a backlash against criticism. The public are capable of recognizing when politics get in the way of science. Unfortunately, the public will suffer for it as will the HSF’s credibility. I truly want the HSF to be in the forefront of cardiovascular health. Indeed, an organization that admits it made a mistake is more “human” in the eyes of the public than one that seeks to cover its mistakes by spinning its message. Conflict of Interest:None declared |
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Bretta M. Maloff Health Check
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bretta.maloff{at}calgaryhealthregion.ca Bretta M. Maloff
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As Chair of the Health Check™ program’s Technical Advisory Committee, I am very proud of the work done by the Health Check program to improve our food supply and guide consumers to products that can be part of a healthy overall diet – a diet that should obviously be focused primarily on fresh, whole foods but can be complemented by other foods. Processed and convenience foods are a fact of life in our society and are not going to go away. Ignoring this reality does not serve the health of Canadians. Over the last 10 years, we have worked with companies to change the Canadian food supply and remove substantial amounts of salt and harmful fats from foods. Companies must earn the right to display the Health Check symbol. Products submitted to Health Check are evaluated against nine different criteria: Total Fat, Saturated Fats, Trans Fats, Protein, Fibre, Sugar, Sodium, Vitamins (A & C & Folacin), and Minerals (Calcium and Iron), depending on the food category. Our criteria are based on Canada’s Food Guide and nutrient claims allowed by Health Canada − and have been recognized as the most rigorous in Canada. We continually update the program’s criteria to reflect changes to evidence-based nutrition recommendations. Over the past year we have updated a number of our criteria to reflect revisions to Canada’s Food Guide, as in the case of sugar. While there are no evidence-based limits for sugar consumption used in North American dietary reference intakes, our expert committee took the step of adding sugar criteria to our program to reflect new directional messages in the Food Guide and to encourage food manufacturers to reduce the sugar content of foods. We know that consumers are confused by the myriad of choices and messages in the grocery store, so we welcome the growing discussion on front-of-pack programs. That is why the Heart and Stroke Foundation agrees with the House of Commons Standing Committee on Health’s recommendation to adopt a national front of pack program in Canada that is science-based, transparent, and uses objective criteria − the same principles on which Health Check is based. We believe Health Check is a good model worthy of consideration, but not the only model. The most important point is that with one national standard, consumers could compare products and make healthier choices more easily. We all share the goal of healthier eating for Canadians. Bretta Maloff, Registered Dietitian Director, Healthy Living, Calgary Health Region Chair, Health Check Technical Advisory Committee Conflict of Interest:Volunteer advisor to Health Check program |
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Yoni Freedhoff Bariatric Medical Institute
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drfreedhoff{at}bmimedical.ca Yoni Freedhoff
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Perhaps tellingly, in all of the comments made by the defenders of the Health Check program, none actually address any of the specific nutritional concerns surrounding the program but rather simply repeat kind platitudes that the Health Check program is a good one and that it follows the recommendations of Canada's Food Guide. This omission of a discussion of the supposed nutritional merits of Health Check is of course not a mystery. It simply reflects the fact that the Health Check program's actual recommendations are themselves indefensible. Blood Pressure Canada and the Canadian Cardiovascular Society, along with the Heart and Stroke Foundation were all signatories on the recent National Sodium Policy Statement which called for a reduction in sodium in Canadian diets from the currently recommended 2300mg daily to 1500mg daily by 2020. The recently revised Health Check criteria still allow for a tremendous amount of sodium. Health Check's new revisions allow up to 480mg of sodium per grain, vegetable, dairy and meat choice; up to 650mg per soup and vegetable juice choice; up to 720mg per store bought entrée; and up to 1300mg per restaurant entrée. Therefore the revised Health Check allows for products to contain, per item, between 21% and 57% of the current 2300mg maximal recommended daily sodium intake and between 32% and 87% of the 1500mg target endorsed by the National Sodium Policy Statement. The revised Health Check criteria also still allows for the consumption of incredible amounts of sugar. This despite the fact that the World Health Organization, in their Technical Report #916 Diet, Nutrition and the Prevention of Chronic Diseases, identified free sugar as a contributor to chronic disease and recommended that we aim to keep Calories from sugar at less than 10% of our daily totals. To illustrate how utilizing the Health Check can impact on an individual's daily sodium and sugar intake, I put together a dietary plan made entirely of Health Check'ed items. I did not choose the items highest in sodium and sugar or lowest in sodium and sugar but rather tried to choose foods that an individual worrying about their health and utilizing the Health Check for guidance might have chosen. I will itemize the diet below, but in summary, eating only Health Check'ed items, that trusting individual would have been guided by front-of-package Health Checks to consume an astonishing 4065mg of sodium and 190.5g of sugar (47 teaspoons), with sugar accounting for 30% of their day's total 2450 Calories. Doing the same thing for children yielded a day with 2285mg of sodium and 160g of sugar (40 teaspoons) with sugar again accounting for 30% of the child's daily caloric intake. So if Health Check is as valuable as the preceding letter writers suggest, why would using the Health Checks lead a person to consume almost double the current maximal daily recommendation for sodium intake, almost triple the National Sodium Policy Statement's recommended daily sodium maximum and triple the WHO's recommended maximal amount of sugar? Given that the Heart and Stroke Foundation are now angling to become Canada's only officially endorsed front of package labeling program, it behooves us to stop being blinded by the fact that the Heart and Stroke Foundation is itself a wonderful organization and instead focus on what the Health Check program actually recommends. It would be tragic were the nutritionally hollow Health Check program be thrust upon an unsuspecting public. A tragedy too given the availability of robust front-of-packaging labeling alternatives with truly evidence based foundations such as the Overall Nutritional Quality Index, the Naturally Nutrient Rich Score and the Hannaford Guiding Stars program. It is time for our country to leave the stone-ages of belief based nutritional recommendations and enter the 21st century of evidence based medicine. Blind faith is dangerous. Dr. Yoni Freedhoff, MD CCFP Dip ABBM, Medical Director, Bariatric Medical Institute (To see how Health Check compares to the aforementioned, evidence-based front of label programs, please click here to watch CBC's investigative journalism program Marketplace compare Health Check to the Overall Nutritional Quality Index and the Guiding Stars program.) A Health Check'ed Adult Day Breakfast: 950mg Na, 26.5g sugar, 555 2 tsp Becel Light margarine: 60mg Na, 0g sugar, 35 Calories 100ml Egg Beaters Southwestern: 340mg Na, 0g sugar, 50 Calories ½ cup Minute Maid Simply Orange: 0mg Na, 12.5g sugar, 120 Calories 1 cup So Good Omega Vanilla: 130mg Na, 10g sugar, 130 Calories Snack: 30mg Na, 28g sugar, 130 Calories 1 Sun-Rype Fruit Source Plus Veggie Tropical Bar: 30mg Na, 28g sugar, 130 Calories Lunch: 1510mg Na, 22g sugar, 520 Calories 1 Dempster's Whole Grains 12 Grain Bagel: 520mg Na, 6g sugar, 300 Calories 1 cup Campbell's Santa Fe Sweet Corn with Chipotle Soup:650mg Na, 5g sugar, 160 Calories 1 cup V8 V-Plus High Fibre: 440mg Na, 11g sugar, 60 Calories Snack: 250mg Na, 18g sugar, 230 Calories 1 Compliments 5 fruit Museli Muffin: 250mg Na, 18g sugar, 230 Calories Dinner: 885mg Na, 56g sugar, 675 Calories Green Salad with 1.5 TBSP Compliments Caesar Dressing: 225mg Na, 3g sugar, 135 Calories Compliments Sicilian Chicken Farfalle: 670mg Na, 7g sugar, 270 Calories 1 cup Compliments Pomegranate and Sour Cherry 5 Juice Blend with Vitamin C: 20mg Na, 29g sugar, 150 Calories ½ cup Compliments Fudge Brownie Frozen Yogurt: 70mg Na, 17g sugar, 120 Calories Snack: 440mg Na, 40g sugar, 340 Calories 1 serving of Compliments Junior Rumbly Graham Oatmeal Cookies 140mg Na, 4g sugar, 130 Calories 1cup Natrel 1% Chocolate Milk: 300mg Na, 36g sugar, 210 Calories A Health Check'ed Child's Day Breakfast: 420mg Na, 48g sugar, 320 Calories1 glass Welch's 100% Red Grape Juice: 20mg Na, 42g sugar, 170 Calories 1 serving Compliments Junior Brekkie Bites Original Mini Waffles: 400mg Na, 6g sugar, 150 Calories Snack: 220mg Na, 28g sugar, 240 Calories 1 serving Compliments Junior Chocolate Chip Mickey Muffins: 210mg Na, 13g sugar, 180 Calories 1 Compliments Junior Sippy Cherry Cranberry: 10mg Na, 15g sugar, 60 Calories Lunch: 650mg Na, 44g sugar, 370 Calories 1 cup Campbell's Goldfish Pasta in Chicken Broth: 480mg Na, 1g sugar, 140 Calories 1 serving Compliments Junior Fruit Pic Mix Raisin Berry Cherry: 0mg Na, 21g sugar, 100 Calories 1 Compliments Junior Chocolate Milk Buddies: 170mg Na, 22g sugar, 130 Calories Snack: 210mg Na, 4g sugar, 70 Calories 1 serving Compliments Junior Dippities Baby-cut Carrots and Ranch Dip: 210mg Na, 4g sugar, 70 Calories 1 glass of water Dinner: 785mg Na, 36g sugar, 560 Calories 1 serving Compliments Junior Poolognese Pasta Bolognese: 550mg Na, 6g sugar, 230 Calories 1 serving Compliments Junior Alpha Taters: 55mg Na, 0g sugar, 110 Calories 1 Compliments Junior Vanilla Milk Buddies: 105mg Na, 22g sugar, 140 Calories 1 serving Compliments Junior Cool-It Chocolate: 75mg Na, 8g sugar, 80 Calories Conflict of Interest:None declared |
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Marion Nestle New York University
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marion.nestle{at}nyu.edu Marion Nestle
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I view front-of-package labeling programs as a slippery slope. They make it all too easy for food companies to reformulate products to make them conform to criterion cut-points. The fewer the criteria, the greater the potential for such manipulation. As I understand it, the Heart and Stroke Foundation’s Health Check program currently relies on few criteria, a method that permits the Foundation to endorse foods containing amounts of sodium and sugar than would be excluded by more comprehensive criteria, and lesser amounts of health-promoting ingredients. From the evidence I have seen, such labeling programs confuse consumers and distract them from making sensible food choices. Personally, I prefer food-based recommendations such as the mantra I describe in What to Eat: “eat less, move more, eat lots of fruits and vegetables, and don’t eat too much junk food.” By keeping highly processed foods to a minimum, people do not need to be overly worried about specific nutritional details and instead can simply enjoy what they eat. --Marion Nestle, Ph.D., M.P.H. Paulette Goddard Professor of Nutrition, Food Studies, Conflict of Interest:None declared |
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Norm RC Campbell University of Calgary
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ncampbel{at}ucalgary.ca Norm RC Campbell
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One of the major tools in our fight to reduce the prevalence of hypertension and improve hypertension control in this country is to reduce the amount of sodium added to our foods during processing. Recently it was estimated that we could eliminate hypertension in one million Canadians by reducing sodium additives to a level that would result in a healthy level of sodium consumption (1). But a reduction in sodium additives won’t happen overnight. A collaborative and progressive approach to reduce sodium consumption by 2020 was recently endorsed by 17 Canadian health organizations, including the Canadian Medical Association, the Heart and Stroke Foundation and Blood Pressure Canada. Education of the public is critical, and an important component of that is the ability for the public to easily identify foods with less sodium. The Heart and Stroke Foundation’s Health Check program is a major contributor to that process. Their efforts have already resulted in significant amounts of sodium being removed from many foods. Health Check’s work with Campbell’s Soup, for example, recently led to Blood Pressure Canada awarding them a certificate of excellence for sodium reduction. Health care practitioners, public health workers, dietitians, the food industry and health groups like the Heart and Stroke Foundation need to continue to work together to make a healthier diet a reality, and Health Check is an important program that is taking us toward that goal. Health advocates need to refocus their energies on the companies that continue to add large quantities of salt and other harmful substances to our foods rather than the organizations striving to make Canadians healthier. (2). Dr. Norm Campbell, MD, FRCPC, Canadian Chair in Hypertension Prevention and Control President, Blood Pressure Canada Joffres MR, Campbell NRC, Manns B, Tu K. Estimate of the benefits of a population-based reduction in dietary sodium additives on hypertension and its related health costs in Canada. Can J Cardiol. 2007;23:437-443 Checking Up On Health Check. CMAJ 2008;178:X-X Conflict of Interest:None declared |
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Dr. Lyall A. Higginson Canadian Cardiovascular Society
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president{at}ccs.ca Dr. Lyall A. Higginson
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As a practicing cardiologist, I know the critical role that a healthy lifestyle plays in the prevention of heart disease. An important part of that is a well balanced diet, based on Canada’s Food Guide. In a world where confusing nutrition advice and information is everywhere, helping people maintain good health and reduce their risk for chronic diseases such as heart disease is a vital role, and one that the Heart and Stroke Foundation ably fills. The Foundation’s Health Check program is a commendable part of that effort to provide balance and identify foods that can fit into an overall healthy eating plan. While we would all like to see Canadians make major changes to their diet over night, I can tell you that that doesn’t happen. Health Check is an important contribution to helping people make important changes to their diet over time and keeping them out of my office. Sincerely, Lyall Higginson, MD, FRCPC, President of the Canadian Cardiovascular Society Conflict of Interest:None declared |
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