Consumer Issues
Unfolding Case
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Paul Youngblood
Paul is a 58-year-old single man with mild developmental and cognitive impairments who has lived with his mother for his entire life. He has held the same part-time entry level position at a local hardware store for 40 years. His mother’s recent death means he will be living independently for the first time in his life. He has no life skills pertaining to shopping or cooking because his mother always took care of that.
Check Your Knowledge
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Learning Objectives
Upon completion of this chapter, you will be able to
1 Analyze a nutrition or health claim for credibility.
2 Explain how the new changes to the “Nutrition Facts” label will help consumers make better food choices.
3 Compare how the regulation and marketing of dietary supplements differ from regulation and marketing of drugs.
4 Advise clients of questions to consider before using a supplement.
5 Give examples of natural and manufactured functional foods.
6 Interpret labeling on organic products.
7 Discuss the benefits and disadvantages of consuming organic foods.
8 Teach clients about the four simple steps to keep food safe.
9 Debate whether genetically modified food is safe.
10 Explain the reason why some foods are irradiated.
The proliferation of cyberspace information—and misinformation—gives millions of Americans ready access to nutritional concepts. Advances in food technology have brought us functional foods, bioengineering, and food irradiation as well as new questions about food safety and optimal nutrition. The ever-evolving science of nutrition has progressed from three square meals a day and a well-rounded diet to MyPlate. This is an era that presents old and new challenges for health professionals.
This chapter focuses on a variety of consumer issues, including nutrition misinformation, food labels, dietary supplements, functional food, organic foods, foodborne illnesses, biotechnology, antibiotics in the food supply, and irradiation.
Functional Foods commonly (not legally) defined as foods that provide health benefits beyond basic nutrition.
Food Irradiation treatment of food with approved levels of ionizing radiation for a prescribed period of time and a controlled dose to destroy bacteria and parasites that would otherwise cause foodborne illness.
CONSUMER INFORMATION AND MISINFORMATION
The role of food has shifted from simply a means to prevent deficiency diseases to a tool for optimizing health, preventing chronic disease, and delaying aging. Several factors are driving this “food as medicine” paradigm, including
Consumers’ interest in managing their own health
Increasing age of the population
Escalating health-care costs
Technologic advances, such as biotechnology
The obesity epidemic
Evidence-based science that links healthy eating patterns to a reduced risk of chronic disease
Quick BiteWhen asked to identify their top two to three sources of information about food and food safety, consumers cited the following (International Food Information Council [IFIC], 2015a):
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Combating Misinformation
Nutrition misinformation abounds. “Breaking news” stories may be little more than “spin” (a favorable slant) or incomplete coverage of preliminary results from scientific studies, which are often discounted later as more research is completed. The distinction between correlation and causation may be blurred, and inappropriate conclusions may be made from study results. Features or articles that fail to identify how much or little of a food should be eaten, how often it should be eaten, or to whom the advice applies do not give consumers enough information to appropriately judge what the study means to them personally. Other types of media inaccuracy include generalizing a study to a broader population than was actually studied and overstating the size of the effect. And although the information available on the Internet is vast, there are no regulatory safeguards in place to ensure that the information is accurate. Junk science coexists with legitimate data. It is the responsibility of each individual consumer to evaluate the reliability of information (Box 9.1).
Quick BiteRed flags or “buzz words” signaling that a health or nutrient claim may be fraudulent include the following:
Breakthrough
Easy
Enzymatic process
Discovered in Europe
New
Mysterious
Quick
Secret
Absolutely safe
Miraculous cure
Ancient formula
All natural
Exclusive formula
Scientifically proven
Many people treat nutrition as a belief system rather than a science, formulating opinions in response to emotional appeals rather than scientific evidence. Others assume that anything that appears in print form (e.g., in a book, magazine, or newspaper)
is accurate and not everyone recognizes the shortcomings of the Internet. If clients’ beliefs are unsupported but harmless, you may risk alienating them for no reason by trying to convince them they’re misinformed. Determine how much of an emotional investment the client has in believing harmless misinformation. Be aware that casual or judgmental dismissal of misinformation can cause clients to become defensive and distrustful; clients may conclude that you are not as up-to-date as they are about nutrition, and they may reject you as a credible reference.
is accurate and not everyone recognizes the shortcomings of the Internet. If clients’ beliefs are unsupported but harmless, you may risk alienating them for no reason by trying to convince them they’re misinformed. Determine how much of an emotional investment the client has in believing harmless misinformation. Be aware that casual or judgmental dismissal of misinformation can cause clients to become defensive and distrustful; clients may conclude that you are not as up-to-date as they are about nutrition, and they may reject you as a credible reference.
BOX 9.1 Judging Reliability of Nutrition “News”
Who is promoting the message? Anyone who stands to benefit economically by promoting a food, supplement, or diet is not likely to be an objective resource.
What is the message? Generally, if it sounds too good to be true, it usually is.
When was the study conducted, the results published, or the website updated? Even seemingly legitimate information can become quickly outdated.
Where was the study conducted? Was the site a reputable research institution or an impressive-sounding but unknown facility? Internet addresses ending in.edu (educational institutions),.org (organizations), or.gov (government agencies) are more credible than those ending in.com (commercial), whose main objective may be to sell a product.
Why was the article written—to further the reader’s awareness and knowledge or to sell or promote a product? Question objectivity when the author or site has a financial interest.
Unfolding Case
Recall Paul. He is used to treating himself to fast-food meals and eating what food mom buys—without thought about nutrition and health. He is not capable of applying critical thinking to news about nutrition but in his eagerness to please, is easily directed. What points should a learning plan include to enable Paul to purchase and prepare food for himself?
Food Labels
Food labels provide a wealth of information consumers can use to make better food choices. Information provided on a label includes “Nutrition Facts” and an ingredient list; nutrient content claims, health claims, and structure/function claims may also be found.
Nutrition Facts
The “Nutrition Facts” panel has been required on food labels since 1993. With the exception of the addition of trans fat content in 2006, the original “Nutrition Facts” label was unchanged since its inception. In spring of 2016, the U.S. Food and Drug Administration (FDA) finalized approval of an updated “Nutrition Facts” panel that reflects current dietary recommendations, national survey data, and evidence on the role of eating patterns in health promotion and disease prevention (FDA, 2016a, 2016b). Most manufacturers will be required to use the new label by July 26, 2018. Figure 9.1 features the original “Nutrition Facts” label and the new version. Changes are summarized below.
Greater Understanding of Nutrition Science
To reflect what is currently known about nutrition and health, the new “Nutrition Facts” label
Percent Daily Value (%DV) Amount of nutrients to consume, or not exceed, which is used on both food and dietary supplement labels. The %DV refers to the percentage of the nutrient in one serving of food based on a 2000-calorie diet. The label indicates what percentage of the daily goal a serving of food contributes.
Requires declaration of added sugars in grams and as the percent daily value (%DV), based on the recommendation that the daily intake of calories from added sugars not exceed 10% of total calories consumed. Added sugars were previously not included.
Updates the DVs for sodium, dietary fiber, and vitamin D based on newer scientific evidence
Requires the actual gram amount and %DV of potassium and vitamin D on the label because they are nutrients of public health significance. Iron and calcium content will continue to be required. Vitamin A and C content will not be required because deficiencies of these nutrients in the general population are not common.
Removes “calories from fat” based on evidence that the type of fat consumed is more important than total fat intake
 Figure 9.1 ▲ “Nutrition Facts” label. (Source: U.S. Food and Drug Administration. [2016a]. Changes to the Nutrition Facts label. Available at http://www.fda.gov/food/guidanceregulation/guidancedocumentsregulatoryinformation/labelingnutrition/ucm385663.htm. Accessed on 9/19/16.) |
Updated Serving Sizes and New Requirements for Certain Package Sizes
To reflect how people currently eat and drink the new label
Updates serving sizes to correspond to the amount people actually eat now, not what was typically consumed in the early 1990s. By law, serving sizes must be based on amounts people eat, not what the “should” eat. For instance, the reference amount for a serving of soda is changing from 8 to 12 oz.
Requires that packaged foods, including beverages, that are typically consumed in one sitting be labeled as a single serving; therefore, calories and nutrient information will be for the entire package. For instance, a 20-oz soft drink, typically consumed in one sitting, will be labeled as one serving, not more than one serving.
Requires “dual column” labels on certain larger packages that could be consumed in either one or multiple sittings, such as a 24-oz bottle of soft drink or a pint of ice cream. One column is per serving and one per package.
Refreshed Design
In order to ensure consumers have access to information they need to make informed decisions, the label has been redesigned. Changes to the design include
The iconic looks of the label remain but with subtle changes. The font size will increase for calories, servings per container, and serving size.
The number of calories and the serving size declaration will be in bold type to emphasize their importance in public health concerns such as obesity, diabetes, and cardiovascular disease.
In addition to the %DV, the gram amounts of required vitamins and minerals are included. Declaring the gram amount for other vitamins and minerals is voluntary.
An updated footnote more clearly explains the meaning of the %DV. It will read “The % Daily Value tells you how much a nutrient in a serving of food contributes to a daily diet. 2000 calories a day is used for general advice.”
Unfolding Case
Think of Paul. He has never thought about nutrition, never been in charge of taking care of himself or a household. He is overweight and takes five medications for blood pressure. What points about the “Nutrition Facts” label are important for Paul to learn?
Ingredient List
Ingredients are listed in descending order by weight. The further down the list an item appears, the less of that ingredient is in the product. This information gives the consumer a relative idea of how much of each ingredient is in a product but not the proportion. Manufacturers are required to clearly state if a food product contains any ingredients that contain protein from the eight major food allergens: milk, eggs, fish, crustacean shellfish, tree nuts, peanuts, wheat, and soybeans.
Nutrient Content Claims label descriptions of the amount of a nutrient or substance provided in a food or beverage.
Health Claim a statement that describes a relationship between a food, food substance, or dietary supplement ingredient and a reduced risk of disease or a disease-related condition.
Structure/Function Claims statements identifying relationships between nutrients or dietary ingredients and a body function.
FDA-Allowed Claims
The FDA allows three types of claims on food and dietary supplement labels: nutrient content claims, health claims, and structure/function claims.
Nutrient Content Claims
Terms such as “low,” “free,” and “high” describe the level of a nutrient or substance in a food. The terms are legally defined and so they are reliable and valid. Nutrient claims may also compare the level of a nutrient to that of comparable food with terms such as “more,” “reduced,” or “light.” Box 9.2 defines the terms used in nutrient claims.
BOX 9.2 Definitions of Terms Used in Nutrient Claims
Free means the product contains virtually none of that nutrient. “Free” can refer to calories, sugar, sodium, salt, fat, saturated fat, and cholesterol.
Low means there is a small enough amount of a nutrient that the product can be used frequently without concern about exceeding dietary recommendations. Low sodium, low calorie, low fat, low saturated fat, and low cholesterol are all defined as to the amount allowed per serving. For instance, to be labeled low cholesterol, a product must have no more than 20 mg cholesterol per serving.
Very low refers to sodium only. The product cannot have more than 35 mg sodium per serving.
Reduced or less means the product has at least a 25% reduction in a nutrient compared to the regular product.
Light or lite means the product has fewer calories than a comparable product or 50% of the fat found in a comparable product.
Good source means the product provides 10% to 19% of the daily value for a nutrient.
High, rich in, or excellent source means the product has at least 20% of the daily value for a nutrient.
More means the product has at least 10% more of a desirable nutrient than does a comparable product.
Lean refers to meat or poultry products with less than 10 g fat, less than 4 g saturated fat, and less than 95 mg cholesterol per standardized serving and per 100 g.
Extra lean refers to meat or poultry products with less than 5 g fat, less than 2 g saturated fat, and less than 95 mg cholesterol per standardized serving and per 100 g.
BOX 9.3 Examples of Approved Unqualified Health Claims that Are Supported by Significant Scientific Agreement
Cancer Risk
Dietary fat
Fruits and vegetables
Fiber-containing grain products
Coronary Heart Disease Risk
Saturated fat and cholesterol
Fruits, vegetables, and grain products that contain fiber, particularly soluble fiber
Plant sterol/stanol esters
Soluble fiber, such as that found in whole oats and psyllium seed husk
Soy protein
Useful in Not Promoting Dental Caries
Dietary noncariogenic carbohydrate sweeteners (e.g., sugar alcohols such as xylitol and sorbitol and the nonnutritive sweetener sucralose)
Hypertension Risk
Sodium
Neural Tube Defect Risk
Folate
Osteoporosis Risk
Calcium
Calcium and vitamin D
Health Claims
A health claim proposes a relationship between a food or substance in a food and a disease or health-related condition. There are two types of health claims; they differ in the degree of scientific evidence that supports the claim. Unqualified health claims, also known as “authorized health claims,” are supported by significant scientific agreement (SSA) among experts who have examined the evidence (Box 9.3). Foods that make one of these claims also meet other requirements: (1) They do not exceed specific levels for total fat, saturated fat, cholesterol, and sodium and (2) they contain at least 10% of the Daily Values (DVs) (before supplementation) for any one or all of the following: protein, dietary fiber, vitamin A, vitamin C, calcium, and iron. Additional health claim criteria are specific for the claim made. For instance, the claim regarding calcium and osteoporosis is only allowed on foods that have at least 20% DV for calcium. These claims are referred to as unqualified health claims because they do not require a qualifying statement about the strength of evidence supporting the claim.
The FDA allows certain qualified health claims when the relationship between food, a food component, and a supplement is not strong enough to meet SSA or published authoritative standards. Specific FDA-approved labeling language must be used for qualified health claims, and companies must petition the FDA for prior written permission to make a qualified health claim. The weakest claim is as follows: “Very limited and preliminary scientific research suggests [health claim]. The FDA concludes that there is little scientific evidence supporting this claim.” Examples of qualified health claims are listed in Box 9.4.
Unqualified Health Claim A type of health claim supported by significant scientific agreement.
Daily Values (DVs) are reference values established by the FDA for use on food labels. For some nutrients (e.g., sodium), they are amounts that should not be exceeded; for others (e.g., fiber), they are amounts to strive toward. For nutrient intakes that are based on the percentage of calories consumed, 2000 calories is the standard used.
Qualified Health Claim A type of health claim that must be qualified by a statement that specifies the degree of scientific evidence that supports it. These claims are based on the weight of evidence but are not considered to be backed by significant scientific agreement.
Structure/Function Claims
Structure/function claims offer the possibility that a food may improve or support body function, which is a fine distinction from the approved health claims that relate a food or nutrient to a disease. An example of a disease claim needing approval is “suppresses appetite to treat obesity,”
whereas a function claim that does not need approval is “suppresses appetite to aid weight loss.” These structure claims had previously been used primarily by supplement manufacturers with the disclaimer that “These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.” Structure/function claims are now appearing on food labels and do not require a disclaimer. Unlike health claims that can only appear on foods that meet other nutritional criteria (e.g., they cannot be high in fat, cholesterol, sodium), structure/function claims can appear on “junk” foods. Structure/function claims do not require FDA approval, so there may be no evidence to support the claim. See Box 9.5 for structure/function claims that do not need prior approval.
whereas a function claim that does not need approval is “suppresses appetite to aid weight loss.” These structure claims had previously been used primarily by supplement manufacturers with the disclaimer that “These statements have not been evaluated by the FDA. This product is not intended to diagnose, treat, cure, or prevent any disease.” Structure/function claims are now appearing on food labels and do not require a disclaimer. Unlike health claims that can only appear on foods that meet other nutritional criteria (e.g., they cannot be high in fat, cholesterol, sodium), structure/function claims can appear on “junk” foods. Structure/function claims do not require FDA approval, so there may be no evidence to support the claim. See Box 9.5 for structure/function claims that do not need prior approval.
BOX 9.4 Examples of Qualified Health Claims
Cancer Risk
Green tea
Selenium
Antioxidant vitamins
Tomatoes and/or tomato sauce (prostate, ovarian, gastric, and pancreatic cancers)
Cardiovascular Disease Risk
Nuts
Walnuts
Monounsaturated fatty acids from olive oil
Omega-3 fatty acids
B vitamins
Unsaturated fatty acids from canola oil
Corn oil
Hypertension Risk (and Pregnancy-Induced Hypertension and Preeclampsia)
Calcium
Industry-Originated Labeling
Over the last decade, many food manufacturers and retailers have added a variety of nutrition symbols and rating systems to the front of food packages to show how nutritious they are. For instance, the American Heart Association Heart-Check utilizes a single symbol to guide consumers toward heart healthy choices. The Whole Grain Council’s Whole Grain Stamp is a front-ofpackage symbol used to indicate the presence of a food group or ingredient. Although intended to simplify choices for consumers, having too many types of front-of-package labels may actually increase confusion.
BOX 9.5 Structure/Function Claims that Do Not Need Approval
Improves memory
Improves strength
Improves digestion
Boosts stamina
For common symptoms of premenstrual syndrome (PMS)
For hot flashes
Helps you relax
Helps enhance muscle tone or size
Relieves stress
Helps promote urinary tract health
Maintains intestinal flora
For hair loss associated with aging
Prevents wrinkles
For relief of muscle pain after exercise
To treat or prevent nocturnal leg muscle cramps
Helps maintain normal cholesterol levels
Provides relief of occasional constipation
Supports the immune system
 Figure 9.2 ▶ Facts Up Front. |
The Grocery Manufacturers Association and Food Marketing Institute have created Nutrition Keys, a voluntary front-of-package labeling initiative known as Facts Up Front. In a standardized format, four basic icons provide information from the “Nutrition Facts” panel on calories, saturated fat, sodium, and sugar. All four basic icons must appear. Some products may add up to two optional icons of nutrients that have positive health benefits—namely, potassium, fiber, protein, vitamin A, vitamin C, vitamin D, calcium, and iron (Fig. 9.2). Smaller packages may limit the icon to just calories. The icon began appearing in the marketplace in late 2011. Facts Up Front is a complement to the “Nutrition Facts” label, not a replacement for it.
The FDA views the Nutrition Keys basic icons (calories, saturated fat, sodium, and total sugar content) and optional icons as nutrient content claims subject to all FDA requirements and regulations. However, the FDA intends to exercise enforcement discretion in regard to certain aspects of nutrition labeling regulations to facilitate implementation of the Nutrition Keys program in an effort to provide consumers ready access to nutrient content information (FDA, 2015).
CONSUMER-RELATED INTERESTS AND CONCERNS
As knowledge of nutrition in health and disease continues to grow, consumers interested in self-directed care look to food and nutrition-related strategies to ensure health and wellness. Some of those strategies may include using dietary supplements, choosing functional foods, and opting for organic foods. Consumer concerns include foodborne illness, biotechnology, antibiotics, and irradiation.
Dietary Supplements
Dietary supplements represent a broad range of products that contain one or more dietary ingredients, including vitamins and minerals; specialty supplements, such as amino acids, omega-3 fatty acids, fiber, and probiotics; herbal supplements, such as cranberry, garlic, and Echinacea; and sports nutrition/weight management supplements, such as whey protein, energy drinks, and hydration drinks. They are intended to add to (supplement) the diets of some people, not to replace a healthy diet. Supplements are taken by mouth as a capsule, tablet, lozenge, liquid, or tea. Labeling laws require the front label to state that the product is a dietary supplement. Figure 9.3 depicts a supplement label.
Herbal Supplements supplements from plants or parts of plants used to alleviate health problems or promote wellness.
The National Institutes of Health, Office of Dietary Supplements (2016) estimates Americans spent $36.7 billion on dietary supplements in 2014. The top 10 selling herbal dietary supplements in food, drug, and mass marketing retail channels in the United States are summarized in Table 9.1.
Whereas the functions and requirements of vitamins and minerals are fairly well understood, scientific research is lacking for many herbal products. Many people mistakenly believe “natural” is synonymous with “safe.” They assume that herbs must be harmless because they come from flowers, leaves, and seeds. In truth, herbs are not guaranteed to be safe or effective.
The FDA began requiring dietary supplements be produced using current good manufacturing practices in 2007. For the first time, identity, purity, strength, and composition of dietary
supplements were required to be accurately reflected on the label. This was a significant step in protecting consumers by ensuring supplements
supplements were required to be accurately reflected on the label. This was a significant step in protecting consumers by ensuring supplements
 Figure 9.3 ▶ Supplement label. (Source: Council for Responsible Nutrition. [2014]. Dietary supplement labeling. Adapted from https://www.crnusa. org/sites/default/files/pdfs/DS-RegsLabel-0613.pdf. Accessed on 1/5/17.) |
Meet quality standards for manufacturing processes
Are free of contaminants or impurities such as natural toxins, bacteria, pesticides, glass, lead, or other substances
Are manufactured to ensure identity, purity, strength, and composition
Have an accurate listing of ingredients
Supplement Regulation
In their medicinal sense, herbs are technically unapproved drugs; approximately 30% of drugs used today originated from plants (e.g., paclitaxel, aspirin, digoxin). In the United States, dietary supplements are regulated by the FDA as foods, which means they do not have to meet the same standards as drugs and over-the-counter medications. Supplements differ greatly from conventional drugs in how they are marketed and regulated.
Safety and Effectiveness Are Not Proven
Before a drug can be marketed, the FDA must authorize its use based on the results of clinical studies performed to determine safety, effectiveness, possible interactions with other substances, and
appropriate doses. In contrast, the regulations regarding dietary supplements are lax. Supplement ingredients sold in the United States before October 15, 1994, are assumed to be safe and so do not require FDA review for safety before they are marketed. Dietary supplement manufacturers that want to market a new dietary ingredient must submit information to the FDA that supports their conclusion that reasonable evidence exists that the product is safe for human consumption. Manufacturers do not have to prove to the FDA that dietary supplements are safe or effective; however, they are not supposed to market unsafe or ineffective products and are required to report all serious dietary supplement adverse events to the FDA.
appropriate doses. In contrast, the regulations regarding dietary supplements are lax. Supplement ingredients sold in the United States before October 15, 1994, are assumed to be safe and so do not require FDA review for safety before they are marketed. Dietary supplement manufacturers that want to market a new dietary ingredient must submit information to the FDA that supports their conclusion that reasonable evidence exists that the product is safe for human consumption. Manufacturers do not have to prove to the FDA that dietary supplements are safe or effective; however, they are not supposed to market unsafe or ineffective products and are required to report all serious dietary supplement adverse events to the FDA.
Concept Mastery AlertFor clients with metabolic disorders who are on drugs to control that disorder, including drugs that lower cholesterol and blood pressure, as well as treat diabetes and heart disease, herbal supplements (such as cranberry) with few or no drug/supplement interactions are recommended. Supplements such as ginseng, St. John’s wort, and ginkgo biloba all have significant interaction potential.
Table 9.1 2012 Top 10 Selling Herbal Supplements in the United States*: What Science Says and Possible Side Effects and Cautions† | ||||||||||||||||||||||||||||||||||||
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