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FDA Insight: A Closer Look at Nutrition

Dr. Shah welcomes Dr. Susan Mayne, Director of FDA's Center for Food Safety and Applied Nutrition, to discuss nutrition and chronic disease prevention, including health disparities.

FDA Insight: Episode 13 – Transcript

>> Anand Shah: Welcome back to another episode of FDA Insight. I'm Dr. Anand Shah, the deputy commissioner for Medical and Scientific Affairs here at the FDA. Thank you very much for joining us for another great episode. This week, we'll be discussing nutrition and chronic disease prevention, including health disparities. Joining me is Dr. Susan Mayne, director of the Center for Food Safety and Applied Nutrition here at the FDA. Dr. Mayne, welcome to FDA Insight.

>> Susan Mayne: Thank you for having me on the show.

>> Anand Shah: Last time, we talked about food on the podcast. We had Commissioner Hahn join us to discuss FDA's work to ensure food safety during the pandemic. Today, we'd like to switch gears a little and talk about nutrition. To start, Dr. Mayne, can you tell us why diet and nutrition are so important to public health?

>> Susan Mayne: Today, chronic diseases like heart disease and cancer are the leading causes of death and disability in the United States. Almost one out of three adults in the U.S. have high blood pressure, which is a leading cause of heart disease and stroke. And almost 40 percent of U.S. adults are obese. And if you add overweight to that statistic, it goes up to a staggering 70 percent. Among children and adolescents, almost one in five are obese.

Poor nutrition plays a role in these patterns of chronic and preventable disease. Nutrition-related chronic diseases can lead to increased healthcare costs, reduce productivity, and even potentially impact national security through reduced fitness and readiness of our military recruits. And we also know that in the context of the current pandemic, those with obesity and other chronic conditions are at greater risk for severe symptoms of COVID-19. And this is an important observation. It tells us that diet and nutrition are important in the setting of both chronic as well as infectious disease.

>> Anand Shah: In 2018, FDA announced its Nutrition Innovation Strategy to help reduce preventable death and disease related to poor nutrition. Can you tell us about the key components of this strategy?

>> Susan Mayne: Under Nutrition Innovation Strategy, we are finding new ways to use our tools and our authorities to both empower consumers with information and facilitate industry innovation toward healthier foods that consumers are seeking. Improvements in diet and nutrition offer us one of our greatest opportunities to have a profound generational impact on human health and reducing health disparities.

The key activities of our strategy, I'll number and walk you through them. First, implementing nutrition facts label and menu labeling. We updated the nutrition facts labels in 2016 based upon current science to provide more information to empower consumers to choose healthful diets. It is now on most food products. And as of May 2018, covered eating establishments across the country such as chain restaurants are required to provide consumers with consistent access to calorie and other nutrition information.

Secondly, our work on reducing sodium. Excess sodium in the diet results in high blood pressure, which increases the risk of stroke and heart attacks. And we are committed to a multi-pronged strategy to reduce sodium intake, including guidance for industry with voluntary short-term targets for sodium in various food categories.

The third part of it is modernizing claims. Claims are quick signals for consumers about what benefits of food or beverage they might have, and how they can also encourage the food industry to reformulate products to improve the healthy qualities of those foods. For example, we are developing a proposed rule to update the nutrient content claim "healthy" to align with current nutrition science and dietary recommendations. And we are also exploring a symbol to depict healthy on a food label.

Next, modernizing standards of identity. Standards of identity are mandatory requirements related to the content and production of certain food products like breads, jam, juices, chocolates. And we're taking a fresh look at standards of identity to, in part, provide flexibility to encourage manufacturers to produce more healthful foods. Additionally, there are rules for naming and describing products. Under the nutrition innovation strategy, we are examining the use of names of dairy foods such as milk in the labeling of plant-based products.

Fifth, modernizing ingredient labels. We are looking at ways to reevaluate the ingredient list on food packages to make it more consumer friendly. For example, we published a draft guidance for an alternate name for potassium chloride in food labeling. Potassium chloride is an ingredient that can partially replace sodium chlorine or salt in foods. The alternative name may help Americans better recognize potassium chloride as an alternative to salt in ingredient statements and support industry reformulation efforts to reduce overall sodium intake. We are now working to finalize that guidance.

And sixth, nutrition education. And this is a really key point is we need to teach consumers how to use food labeling to make healthy food choices. That's really critical to amplifying our overall public health impact, including reducing disparities. And for example, we launched a nutrition facts label education campaign in March of this year, March of 2020, which includes a variety of new education materials for consumers and health educators.

>> Anand Shah: Dr. Mayne, you mentioned that part of this strategy is implementing the updated nutrition facts label. Can you tell us more about why this update was needed, what was done, and the benefits of the new nutrition facts label?

>> Susan Mayne: Sure. Since 1993, the nutrition facts label on food packages have provided information to consumers to aid them in making healthy food selections. In May of 2016, we published two final rules to update the label to reflect updated nutrition science and current dietary recommendations. This is the first major update to the nutrition facts label in more than 20 years.

The new nutrition facts label is now on many food products. And we retained the iconic look of the nutrition facts label, but many really important updates were made. And I'll walk you through a few of them. For example, we have increased prominence of the calorie declaration and the serving size information. That's probably the quickest way you can immediately recognize the new nutrition facts label. We've updated serving sizes. We've required for the first time the declaration of added sugars. We've required the declaration of vitamin D and potassium. These are nutrients that are underconsumed in our population. We've updated daily values and we've mandated per serving and per container nutrition labeling for certain food packages.

We've issued many guidance documents to assist manufacturers in complying with the new requirements. The updated nutrition facts label will help consumers maintain healthy dietary practices by better aligning the information provided on the nutrition facts label with scientific evidence on the relationship between nutrition and chronic disease and dietary recommendations. And also, improving the design and the content of the nutrition facts label to make the most relevant label information, more salient, and easy to understand so consumers can make informed decisions. Our education and outreach efforts are really key to amplifying the public health impact of this work.

>> Anand Shah: Having access to nutrition information when eating outside the home is important in helping consumers make healthy choices. Tell us more about what the FDA has done on menu labeling?

>> Susan Mayne: Certainly. In December of 2014, FDA published a regulation to implement the Patient Protection and Affordable Care Act or ACA menu labeling mandate. As of May of 2018, restaurants and similar retail food establishments, this would include places like supermarkets and convenience stores, that are part of a chain with 20 or more locations doing business under the same name and offering for sale substantially the same menu items.

What they are required to do is really three things as part of menu labeling. First, they must disclose the number of calories contained in standard menu items on menus and menu boards and on signs adjacent to food on display and self-service food. They must also provide upon request additional nutrition information, written nutrition information. For example, for nutrients like saturated fat and sodium for those standard menu items, and they must post a statement regarding the availability of that additional written nutrition information on menus and menu boards.

And third, they must post what we call a succinct statement on menus and menu boards concerning suggested daily calorie intake in a language that says, "2,000 calories a day is used for general nutrition advice, but calorie needs vary." So, those are the three things that these covered establishments must do.

We provided many guidance documents to industry to help assist with implementation. We also released some consumer facing menu labeling education materials in March of 2019 to help raise consumer awareness about calories on menus, and to encourage consumers to use calorie and nutrition information to help make more informed and healthier choices when they're dining out.

>> Anand Shah: You mentioned that calories are more prominent on the updated nutrition facts label and calories are also on certain menus now. Can you tell us why calories are highlighted in nutrition labeling?

>> Susan Mayne: As I know you know, calories refer to the total number of calories or the amount of energy that you get from all the sources. And that's carbohydrate, fat, protein, and alcohol in a serving of food or beverage. And to achieve or maintain a healthy body weight, it's important to balance the number of calories that people eat and drink with the number of calories that they use. Eating too many calories per day or positive energy balance is linked to overweight and obesity. And calorie needs depend on age, sex, height, weight and physical activity level.

As we discussed, calories are now displayed in larger and bolder font on the updated nutrition facts label and they are required to be declared on certain menus to make the information easier to find and use. And our own research at CFSAN indicates that while most consumers know their typical daily calorie needs, there are some distinct differences between demographic groups. And more specifically women, non-Hispanic Whites, and those with higher income and education level are more likely to estimate typical daily calorie needs accurately. In contrast, men were also four times more likely than women to indicate a lack of knowledge of daily calorie needs.

Our education materials include information to help consumers understand their calorie needs and use the information both on the nutrition facts label as well as through menu labeling to make the best choices for themselves as well as their families.

>> Anand Shah: When consumers look at the nutrition facts label, one thing that's listed is the sodium content of the food product. Why is sodium so important for public health?

>> Susan Mayne: Research shows a direct relationship between increased sodium intake and hypertension or high blood pressure, and between hypertension and cardiovascular disease. Over 800,000 people in the U.S. die annually from cardiovascular disease. That's about one in every three deaths. Americans are consuming almost 50 percent more sodium than recommended limits. So, we are consuming around 3,400 milligrams per day versus the limit which is 2,300 milligrams per day. And researchers have estimated that lowering U.S. sodium intake by about 40 percent over a decade could save 500,000 lives and nearly $100 billion in health care costs. Those are really big numbers, big impact.

And the majority of sodium comes from sodium added to processed and restaurant foods, not sodium added during cooking or at the table. And that makes it difficult to meet recommended sodium intake with our current food supply even for people like me who are trained in nutrition. And so, FDA is working on a multi-pronged strategy to reduce sodium intake including working with the food industry to make reasonable reductions in sodium in a wide variety of foods.

>> Anand Shah: Dr. Mayne, do you have suggestions on how consumers can reduce their sodium intake?

>> Susan Mayne: Well, the nutrition facts label shows the amount in milligrams and the percent daily value of sodium per serving of the food. The daily value for sodium is up to 2,300 milligrams per day. So, if consumers want to reduce sodium, you can also look for the words light, low sodium, reduced sodium, or no salt on packaged foods; and of course, read those labels for sodium. You can also flavor foods with herbs and spices and no salt or low salt seasoning blends. Also, things like rinsing sodium-containing canned foods such as beans, tuna, and vegetables before eating. Those are all strategies that consumers can use to reduce sodium intake.

>> Anand Shah: Dr. Mayne, how can good nutrition keep Americans healthy and prevent chronic disease?

>> Susan Mayne: So, unhealthy diets are at least partially to blame for chronic diseases like heart disease, cancer, and diabetes. It's widely known that heart disease, cancer, diabetes, and other chronic diseases are the leading causes of death and disability in the United States. And poor nutrition is a major factor that keeps these numbers high. There is strong and consistent evidence that demonstrates that dietary patterns that are higher in vegetables, fruits, whole grains, low fat dairy, and seafood, and lower in red and processed meat with lower intakes of refined grains and sugar sweetened beverages that's associated with a decreased risk of cardiovascular disease relative to less healthy eating patterns.

However, what many consumers are eating is far from ideal. About three fourths of the population is a diet that's low vegetable, fruits, dairy, and healthier oils; foods that we know are good for our health. And at the same time, most Americans exceed the recommended intake of added sugars, saturated fats, and sodium, too much of which can adversely impact health.

And that's why our work under the Nutrition Innovation Strategy is so important. We're working hard to give consumers the information they need to make informed choices to build a healthy eating pattern, as well as encouraging industry innovation to create healthier products for an overall healthier food supply where healthier options are the norm.

>> Anand Shah: How does nutrition play a role in health disparities?

>> Susan Mayne: So, health disparity refers to a higher burden of illness, injury, disability, or mortality experienced by one group relative to another. And food and nutrition are powerful levers when it comes to reducing health disparities. And the work we are doing can make a difference. And because everyone eats, the total impact of small changes across the population can be really large.

We know that education level, in addition to income or access to healthy food, can play a prominent role in dietary habits. Those with limited educational and economic opportunity are more likely to suffer from poor nutrition. This in turn exacerbates the incidence of chronic illness. And the burden of chronic illness, with all of its associated costs and hardships, can exacerbate poverty or make it harder to work, creating a cycle of poor nutrition and chronic illness.

Our challenge is to help create a healthier food supply for all, along with more healthy choices. We want to foster innovation and competition that can also make these choices more accessible and affordable for all. We are making strides to help reduce health disparities under our Nutrition Innovation Strategy. For example, as I mentioned earlier, our own research reveals disparities and understanding calorie needs. Women, non-Hispanic Whites, and those with higher income and education levels are much more likely to estimate daily calorie needs more accurately.

An external research study on menu labeling estimated that even though menu labeling may translate into small reductions in calories ordered and consumed, when considered across the population, that can prevent tens of thousands of cases of cardiovascular disease, death, and type two diabetes. The benefits in the study were estimated to be greater in Hispanics, non-Hispanic Blacks, Americans with less education, those with lower income, and those who are obese, the populations most at risk for many of these diet-related chronic diseases. So, the overall policy is one being menu labeling may be one tool to help reduce health disparities by empowering consumers with information.

>> Anand Shah: With that, it's time to wrap up this episode. Dr. Mayne, thank you for taking the time to join us this week on FDA Insight. You've shared a ton of helpful information for our listeners. Thanks to you and our Center for Food Safety and Applied Nutrition colleagues for all that you do.

>> Susan Mayne: Thank you again for having me, and I hope listeners will take advantage of some of the materials we have on our website. Thank you.

>> Anand Shah: Thank you. In future episodes, we'll be discussing more topics including women's health. As always, we'll be providing you insight, in plain language, to help you understand the products that we regulate, the issues that we face, and the processes that we follow. We hope you enjoyed this episode of FDA Insight. Please subscribe on your favorite podcast app, such as Apple Podcasts, Google Podcasts, Spotify, and Pandora. Thanks for listening.

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