It's time to reconsider our approach and exchange avoidance messages for positive ones that emphasize what to eat and that highlight the nutritional benefit foods provide.
Consumers are bombarded with nutrition information on a daily basis—from food and beverage packaging as well as television, magazines and the Internet. Faced with a plethora of food choices and conflicting dietary advice, it’s a wonder that the average person can decipher enough to make the best decisions.
Because clients receive nutrition information from many sources, perceptions vary about what is considered “healthy.” To some, “healthy” means low in calories, trans fat and sugar. Others consider healthy foods to be fresh, local and organic. The concept of a nutritious food is often determined by personal opinion, preference or circumstance—living with heart disease, for example. Generally, healthful foods are defined by the absence of fat, sugar and sodium. This common view narrows the focus to a few nutrients instead of considering the total nutrient package a food may offer. It also defines a healthful food by what it doesn’t contain instead of by the beneficial nutrients it does provide.
Dietary recommendations have typically followed this avoidance approach as well. Messages like “Cut calories,” “Eat less fat” and “Reduce added sugar” are regularly used to persuade consumers to eat better. Are nutrition messages really effective if they are based on what to avoid rather than on what to include? Or has the spotlight on what foods don’t contain (instead of their benefits) created a public misperception that the fewer “bad” nutrients a food contains, the healthier it is? Some health experts are concerned that consumers’ hyperfocus on one specific characteristic has steered the public away from the big picture: the total nutrient package and the overall diet are what matter.
This article reviews current dietary recommendations and the shift toward guiding consumers to healthier food choices using the naturally nutrient-rich foods approach. It also helps fitness and wellness professionals make sense of the growing number of symbols and icons popping up on supermarket shelves.
With 66% of U.S. adults now either overweight or obese, it is safe to say that traditional avoidance messages used to communicate dietary recommendations are not working (CDC 2008). Even though the American diet is energy rich, it continues to be nutrient poor with magnesium, calcium, potassium and vitamins A, C and E topping the list of nutrients Americans don’t get enough of from food (USDA 2004; Moshfegh, Goldman & Cleveland 2005). Added fats, oils, sugars and grains provide more calories per day for the average American than more nutrient-rich food groups—dairy, vegetables or fruit (USDA 2008). In a time when the majority of people are overweight but undernourished and attention is fixated on reducing calories, it becomes even more important to focus messages on making those calories count.
A 2008 survey reports that despite the nutrition information on food packages, consumers are confused (IFIC 2008). They are overwhelmed and puzzled about who and what to believe, and they cite having to give up their favorite foods as a major reason for not making a change (IFIC 2008; ADA 2008). For years, people have learned how to eat by learning what not to eat. It’s hardly surprising that most are turned off by this negative approach. Forty-one percent of consumers don’t know or understand dietary guidelines, and more than half say they need more practical tips to help them eat right (ADA 2008).
The shift in thinking to get more nutrition from your calories is the cornerstone of the 2005 Dietary Guidelines for Americans (DGA), released by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture. The DGA recommend choosing nutrient-dense foods first—to provide the most vitamins and minerals—then permitting less nutrient-dense foods as calorie needs allow. The guidelines refer to these “leftovers” as discretionary calories. Everyone has a calorie budget to manage each day. If you spend wisely by choosing more nutrient-dense foods, you might have a small number of calories left to spend on foods with added sugar, fat or alcohol. Because Americans are “big spenders” of empty calories, most people don’t have discretionary calories to work with. Nevertheless, discretionary calories can be increased by choosing more nutrient-dense foods and increasing physical activity (USDA 2005). This is a recommendation that clients may be more open to because it provides a bit of freedom for personal food indulgences as individual calorie budgets allow.
Getting more nutrition from calories is a long-standing dietary principle, but its emphasis in the 2005 DGA speaks to the renewed interest among health professionals in effectively communicating the benefits of nutrient density. A scientifically agreed-on definition is still a work in progress, but the DGA define nutrient-dense foods as those with a naturally high nutrient-to-calorie ratio, providing substantial amounts of vitamins and minerals and relatively few calories. In other words, nutrient-dense foods give you the most nutrition bang for your calorie buck.
Nutrient rich was recently coined as a more consumer-friendly term to describe the concept of nutrient density. Responding to a call for action from the 2005 DGA advisory committee, the Nutrient Rich Foods Coalition (NRFC)—led by Adam Drewnowski, PhD, from the University of Washington—worked to define nutrient density and determine criteria for foods that would meet this definition. The NRFC is a partnership of leading scientific researchers, communications experts and 12 agricultural commodity groups representing the five food groups. Its goal is to help people enjoy healthier diets by getting more nutrition from their calories and by making it easier to identify and choose the foods that provide nutrient density.
Diane Quagliani, RD, a nutrition communications consultant in the Chicago area, has been involved in this effort. “The NRFC has conducted extensive research with consumers to determine the most useful ways to communicate [nutrient-rich foods]. This work is expected to be complete in 2009,” she says. “Whatever the end result, it will help consumers choose the most nutrient-rich foods within food groups and help them build more healthful diets overall.” The FDA is also interested in utilizing the “total-nutrient package” approach to replace the current single-nutrient criterion for health claims (e.g., fiber). It is also considering a universal score for food labels to help consumers select foods with the highest nutrient densities.
The nutrient-rich foods approach has the potential to help people improve the nutritional quality of their diets and maintain energy intake. This concept is already applied by those working with older adults. As people age, energy needs decrease and nutrient needs increase. The quality of calories becomes critical (Berner et al. 2002).
Conversely, and perhaps not surprisingly, the reported number of empty calories consumed by children and adolescents is influenced by the amount of nutrient-dense foods they consume from the five major food groups (Kant & Graubard 2003). Junk food is pushed out when more nutrient-rich foods are added.
Studies suggest that focusing on increasing nutrient-rich food intake is an effective strategy for weight loss and maintenance. In a family-based behavioral weight management program, the focus was on increasing intake of fruits, vegetables and low-fat dairy. The results: kids and parents achieved a significantly greater reduction in body mass index and percent overweight during a 2-year period than they did by reducing energy-dense (high-fat and high-sugar) foods (Epstein et al. 2008). The authors speculated that the shift from parental restriction of foods to an approach that empowered kids with positive examples of what to eat was one way a healthy-food emphasis resulted in greater weight loss. “Suggesting that people watch their calories is universal nutrition advice, but getting the most nutrients from those calories is also important for getting and staying fit,” explains Dayle Hayes, MS, RD, owner of Nutrition for the Future Inc. in Billings, Montana.
This is further supported by a recent study of 97 obese women, all of whom were avoiding high-fat foods. Half the women were instructed to increase their consumption of fruits and vegetables. By the end of 1 year, the women who were focused on adding fruits and vegetables lost an average of 17 pounds, 20% more than the women who were simply paying attention to fat consumption (Ello-Martin et al. 2007). The positive message to “increase fruit and vegetable consumption” balanced restrictive messages to consume less. Positive messages resulted in greater dietary changes (Epstein et al. 2001; Rolls, Drewnowski & Ledikwe 2005).
“The NRF [nutrient-rich foods] approach is a perfect fit for supporting portion- and calorie-controlled choices, because its basic tenet is to ‘get the most nutrition per calorie,’” says Quagliani. “If people are cutting calories to manage their weight, it’s more important than ever to maximize the nutrients in each bite.”
When people define foods as “good” based on what they don’t contain, and concentrate on what to give up rather than what to include, the result may be the diet mentality of “can and can’t have” and of “good food” versus “bad food.” “By focusing on NRF, health and fitness professionals can play a more effective role in educating clients about delicious eating styles for better health,” says Hayes.
While some factors, such as food prices (Maillot et al. 2007), may limit consumers’ ability to adopt a more nutrient-rich diet, Hayes maintains that helping clients embrace a more nutrient-rich lifestyle is easy. It requires going beyond telling people what to eat and helping them learn how to eat well. To begin, Hayes recommends teaching clients to shop the perimeter of the grocery store for colorful fruits and vegetables, whole and fortified grains, lean meats and low-fat or fat-free dairy products. Clients can add more nutrient-rich foods to meals and snacks without additional cost by shopping for produce in season, buying frozen fruits and veggies and dried beans, and choosing fat-free milk rather than whole milk, explains Quagliani.
Also, you can encourage clients to read nutrition facts panels for more than calories and fat and instead to examine the total nutrient content of foods. Additional strategies include featuring nutrient-rich foods in newsletters, teaching classes on healthful eating or conducting supermarket tours. “[Fitness professionals] can give away ‘goodie bags’ with nonperishable nutrient-rich food samples at fitness events or health fairs,” Quagliani adds. Examples include whole-grain cereal, nuts, trail mix, beef jerky and 100% fruit and vegetable juices.
The nutrient-rich foods approach can also be used to educate school staff when it comes time to determine food and beverage nutrition standards. Most approaches to setting school nutrition standards have focused on calorie and nutrient avoidance. Although these efforts have been a major leap forward in improving offerings for students, paying attention to the quality of foods is the next logical step.
Because the nutrient-rich shift likely requires more planning and food preparation and less dependence on processed foods, refer to the NRFC website (see the Resources sidebar) for user-friendly tips, shopping lists and recipes to help clients understand how to identify and enjoy more nutritious foods and beverages.
Choosing foods that maximize the nutrient-to-calorie ratio requires consumers to be able to identify and compare nutrient-rich foods within and across food groups. This is the intention behind food labels. The 2008 Food & Health Survey reports that nearly two-thirds of consumers use the nutrition facts label when deciding whether to purchase or consume a food product. Calories and fat top the list of elements they consider, with serving size and servings per package gaining ground (IFIC 2008). Nevertheless, consumers find several aspects of the label confusing, including serving size, the Daily Value (DV) footnote, %DV and the vitamin and mineral content evaluation (IFIC 2008).
Making it easier to compare the nutrient density of foods is essential for helping consumers make better choices. This is already an identified need, as indicated on food packages by a proliferation of nutrient symbols and marks designed to flag better choices within food and beverage categories. However, the problem is a lack of consistency among manufacturers, which ultimately risks confusing consumers more than helping them.
Many companies bombard consumers with too much information, which can leave people not knowing where to look first or what to look for. To avoid this, in 2007 the Center for Science in the Public Interest petitioned the FDA for a universal labeling system. In response, the FDA requested comments in consideration of a major food label overhaul. Since then, significant industry developments have taken place to make healthier food selection easier and faster with front-of-pack labeling.
Nutrient profiling ranks foods based on their nutrient content, and aims to help consumers make more healthful choices. The American Heart Association’s (AHA) heart-check mark was the first symbol to appear on food packages over 13 years ago. According to Rose Marie Robertson, MD, chief science officer of the AHA, approximately 800 heart-healthy food items now voluntarily bear the red and white heart-check mark. “Using the heart-check mark to identify foods low in saturated fat and cholesterol is an important first step to achieving an overall healthy dietary pattern,” says Robertson.
Another familiar third-party certification program is the Whole Grain Stamp, developed by the Whole Grains Council. For a product to be stamped “100% Whole Grain,” all of the grain ingredients must be whole grain, with a minimum of 16 grams per serving. Products with the basic stamp have at least a half serving (8 grams) and may contain some refined grain.
In the past 5 years, a growing number of food manufacturers have developed their own criteria and symbols to spotlight the “better for you” foods and beverages they offer. These programs include PepsiCo’s Smart Spot®, Kraft’s Sensible Solution and Unilever’s Eat Smart™ and Drink Smart™. Several supermarkets have also launched their own guidance systems (see below).
Food companies admit that logos like these do not necessarily represent nutrient-rich foods, but rather guide consumers toward healthier products within given food categories provided by their companies. “If you are looking for chips, you can easily identify the healthier choice in the chip aisle by looking for our Smart Spot symbol on the front of our packages,” says Dave DeCecco, spokesperson for PepsiCo in New York City.
Symbols can also be found on supermarket shelf-tags in thousands of grocery stores, mainly on the East Coast. Hannaford’s Guiding Stars® program, launched in 2006, ranks foods based on nutrients they contain as well as what they don’t contain. It assigns food and beverages a one-, two- or three-star rating (good, better or best). For example, whole milk does not get a star, while skim milk gets three stars. One limitation of this system is that it doesn’t allow for comparison across food groups. For example, three stars in the meat section is not equivalent to three stars in the cereal aisle, and 7UP® PLUS is given one star just like 2% milk. That said, there is evidence that the program has impacted consumer choices. Hannaford reports an increase in sales of packaged products with stars, compared with products without stars.
This year, you and your clients may have the option to eat by numbers. A pilot launch of NuVal™ shelf-tag scores occurred last fall in Price Chopper stores in the Northeast and Hy-Vee stores in the Midwest. “We have over 15 retail chains committed to adopting the system in early ’09, including some of the larger U.S. chains,” says David Katz, MD, director of the Yale-Griffin Prevention Research Center in Derby, Connecticut. NuVal, a joint venture company between Griffin Hospital and Topco Associates, is projected to be in 5,000 or more stores by mid-2009.
The NuVal System scores foods on a scale from 1 to 100: the higher the number, the more nutritious the food. The score is based on the Overall Nutritional Quality Index numerator/denominator algorithm that takes into consideration 30 nutrients and other factors, including glycemic load. Because the NuVal System applies the same nutritional criteria to all foods, it allows consumers to compare the nutritional value of foods within and across food categories, according to Katz. “So, for instance,” he says, “if baby carrots, an apple, crackers, popcorn or a granola bar are all considered potential ‘snack’ choices, NuVal could be used to directly compare them and place them in rank order of overall nutritional quality.”
In an effort to provide consumers with consistent information in place of the current explosion of nutrient symbols, major food companies have combined their efforts to launch the new Smart Choices voluntary front-of-pack nutrition labeling program. In addition to displaying calories per serving and servings per container, foods that meet certain nutrition criteria for a given food category will have an identifiable green check mark and the Smart Choices logo. Centered on the industry’s “better for you” concept, the symbol identifies healthier choices within a given food category.
It sets nutritional guidelines for 18 categories, from desserts to main dishes. Products get the check mark and logo if the following apply:
- They meet limits for total fat, saturated fat, cholesterol, added sugar and sodium.
- They contain no less than 10% DV of at least one of the encouraged nutrients, like calcium and fiber.
- They contain at least half a serving of one of the encouraged food groups—fruits, vegetables, whole grains and fat-free/low-fat dairy.
The program also seeks to stimulate product innovations and reformulations to improve levels of undesirable nutrients in products. Roberta Anding, MS, RD, LD, spokesperson for the American Dietetic Association (ADA), adds, “It may encourage some manufacturers to qualify, for example, by reducing their sodium and increasing vegetables.”
Beginning mid-2009, you can expect to see the Smart Choices logo on some of your favorite brands, possibly replacing their own symbols. Likely implementers include General Mills, Kellogg, Unilever, Kraft, PepsiCo, Coca-Cola and ConAgra. This may become the industrywide standard for front-of-pack nutrition labeling.
Meanwhile, work is underway to develop, validate and test a more transparent profiling system that will rank individual foods according to the ratio of nutrients to calories. Hayes explains that the Naturally Nutrient Rich (NNR) Index Score is the only system that meets criteria established for the benefit of public health. Specifically, it takes into account a balance of naturally occurring nutrients and uses a simple, scientifically valid and published formula that reflects the best combination of nutrients to encourage and limit. It addition, it is linked to food labeling and based on consumer research (Drewnowski & Fulgoni 2008).
Scores will vary depending on the nutrient criteria used. After determining that a model including nine to 11 nutrients gave similar rankings to one that included 20 nutrients, Drewnowski and colleagues proposed an algorithm with nine nutrients to encourage and three to limit. They also reportedly recommended a simpler 1–5 nutrient-density scoring system, although work on this is still being finalized.
The ADA favors a scoring system, expressing concern that the yes-or-no approach of a symbol will lead consumers into the good food/bad food conundrum (ADA 2007). Nevertheless, there is a need for simple and quick labeling, and movement toward a universal system—whatever it may be—is a step in the right direction. “There are many voluntary programs to help consumers make healthy choices. If a voluntary program is to be successful long-term, it must be a unified approach so we don’t have nutrient confusion,” says Anding.
The million-dollar question is, Will a symbol or score influence consumer choice and quality of diet? Potentially, but this early in the game it will likely have a larger impact on manufacturers’ production decisions than on individual food choice.
The nutrient-rich foods approach is a refreshing way to guide consumers back to the basics of enjoying high-quality, nutritious foods without overconsuming calories. It will help your clients make food decisions based on the total nutrient package rather than solely on calories or which nutrients to avoid. As the saying goes: the whole is greater than the sum of its parts!